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Developing a Platform for Learning from Mistakes: changing the culture of patient safety amongst junior doctors.

ABSTRACT: Junior doctors commonly make mistakes which may compromise patient safety. Despite the recent push by the NHS to encourage a "no blame" culture, mistakes are still viewed as shameful, embarrassing and demoralising events. The current model for learning from mistakes means that junior doctors only learn from their own errors. A survey was designed by the author for all the Foundation Year 1 doctors (FY1s) at Yeovil District Hospital to understand better the culture surrounding mistakes, and the types of mistakes that were being made. Using the results of the survey and the support of senior staff, a "Near misses" session has been introduced for FY1s once a month at which mistakes that have been made are discussed, with a consultant present to facilitate the proceedings. The aims of these sessions are to promote a culture of no blame, feedback information to clinical governance, and share learning experiences. 100% of the FY1s had made a mistake that could compromise patient safety. 63% discussed their mistakes with colleagues, 44% with seniors, and only 13% with their educational supervisor. Barriers to discussing mistakes included shame, embarrassment, fear of judgement, and unapproachable seniors. 94% thought a "Near misses" session would be useful. After the third session 100% of the FY1s agreed that the sessions were useful; 53% had changed their practice as a result of something they learned at the sessions. After discussing errors as a group we have worked with the clinical governance department, enacting strategies to avoid repetition of mistakes. Feedback from the junior doctors has been overwhelmingly positive and we have found these sessions to be a simple, inexpensive, and popular solution to cultural change in our organisation.

SUBMITTER: Millwood S

PROVIDER: S-EPMC4949613 | biostudies-literature | 2014

REPOSITORIES: biostudies-literature

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Developing a Platform for Learning from Mistakes: changing the culture of patient safety amongst junior doctors.

Millwood Sinead S

BMJ quality improvement reports 20140807 1

Junior doctors commonly make mistakes which may compromise patient safety. Despite the recent push by the NHS to encourage a "no blame" culture, mistakes are still viewed as shameful, embarrassing and demoralising events. The current model for learning from mistakes means that junior doctors only learn from their own errors. A survey was designed by the author for all the Foundation Year 1 doctors (FY1s) at Yeovil District Hospital to understand better the culture surrounding mistakes, and the t ...[more]

PMID: 27493733

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Project description:Introduction Writing a case report increases one's knowledge about a particular disease condition, demonstrates intellectual curiosity and commitment to scientific inquiry and the ability to follow through on scholarly projects. Despite several articles and journal-specific instructions published concerning case report writing, none have been evaluated by their intended audience. The aim of this study was to get junior doctors to evaluate an online presentation as part of the process of developing a beginner's guide to writing a clinical case report. Materials and methods In response to our previous studies an online presentation concerning how to write a clinical case report was provided for junior doctors. Junior doctors were invited by email to look at the online presentation and complete an online evaluation form thereafter. The questions were adapted from the Evaluation Form for Teaching and Presentations provided by the Joint Royal Colleges of Physicians Training Board. Data was analysed both quantitatively and qualitatively. Results Sixty-five doctors looked at the presentation and completed the online evaluation form. All agreed that the objectives of the presentation were identified and met. Sixty-four (98.5%) agreed that it was effective and clear. Sixty percent indicated that they found the information and instructions useful. An additional 13.85% found the whole presentation useful without specifying any aspect. Eight percent found the summary slide useful, 4.62% found the case selection criteria slide to be useful and 4.62% found the permission and patient consenting slide useful. Twenty percent would like the inclusion of examples of good abstracts and case reports, 13.85% would like more teaching sessions, and 13.85% would like improvements to the slide-presentation format. Overall, 64 junior doctors (98.46%) remarked that the presentation was good, very good or excellent. Conclusions This study has demonstrated the importance of evaluation of teaching material by junior doctors while developing a beginner's guide to writing a clinical case report. Once the above action points and limitations have been taken into account, further repeat evaluations by junior doctors need to be undertaken while developing a robust beginner's guide to writing a clinical case report.

Project description:ObjectivesSimulation is widely employed to teach a range of skills, across healthcare professions and is most effective when embedded within a standarised curriculum. Although recommended by many governing bodies, establishing a national programme of simulation presents many challenges. Successful implementation requires a clear understanding of the priorities and needs of those it seeks to serve yet there are limited examples of how best to do this. This study aimed to develop an integrated national simulation-based educational programme for junior doctors in Scotland through a structed, multistep prioritisation process.DesignA series of action research cycles were undertaken to develop and evaluate a national simulation programme. This paper describes cycle 1, which employed a six-step structured approach to understand and prioritise learner needs.SettingThe study considered the educational needs of Scottish junior doctors in the UK Foundation Programme (UKFP).ParticipantsMultiple stakeholder groups were involved in each stage of the process including recent Scottish UKFP graduates, clinical educators, UKFP programme directors and postgraduate deans.ResultsKey stakeholders reviewed the 370 competencies in the UKFP curriculum and identified 18 initial competency areas. These 18 areas were subsequently prioritised through the analytical hierarchy process, resulting in a carefully ordered list of 12 competencies from which a targeted simulation-based educational programme could be developed.ConclusionsTo our knowledge, this is the first study to outline the methods of competency prioritisation to create a simulation curriculum that is integrated within a national curriculum in the medical education context. As well as demonstrating the practical steps of such a process, key implications for practice are identified. This robust approach to educational design also resulted in unexpected benefits, including educator and clinician acceptance and programme funding sustainability.

Dataset Information

Developing a Platform for Learning from Mistakes: changing the culture of patient safety amongst junior doctors.

Publications

Developing a Platform for Learning from Mistakes: changing the culture of patient safety amongst junior doctors.

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