Re-imagining patient safety education: Global insights and practical pathways for implementation

To Err is Human’ by the Institute of Medicine in 1999 was transformational to healthcare, leading to awareness, with an emphasis on patient safety research, healthcare processes, and medical education.[1] Patient harm reported globally, relates chiefly to medication errors (one in every 30 patients), surgical errors (10% of all preventable healthcare harm events), patient misidentification errors (12.3% of all sentinel events), and diagnostic errors (10% of deaths). Multiple interconnected factors (system and organisational factors, technological, human factors and behaviours, patient-related and external factors) are implicated in unsafe practices and the extent of harm that results, with 80% of them being preventable.[2] There is paucity of data from resource poor settings on the prevalence of near misses and near fatal events, and these remain largely under-reported. This makes it hard for global initiatives and patient safety reforms to be designed and contextualised.[3] We discuss the current global patient safety frameworks and the need for patient safety strategies and educational initiatives to be suited for the diverse nature of healthcare settings. We outline an educational strategy to navigate the limitations in implementing the goal of safe healthcare and provide insights for integrating technology to enhance patient safety. PATIENT SAFETY IN HEALTHCARE SYSTEMS The World Health Organisation (WHO), by providing a broad overview, defines patient safety as “a framework of organised activities that creates cultures, processes, procedures, behaviours, technologies and environments in healthcare, that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make errors less likely and reduce the impact of harm when it does occur.”[4] Patient safety in healthcare systems is based on six core principles: error prevention, transparent reporting and learning, standardisation and best practice, technology and automation, patient engagement, and having an organisational culture of safety. The WHO Global Action Plan (2021–2030) advocates a six-step framework for enhancing patient safety that includes healthcare worker education, enhancing skills and safety.[5] PATIENT SAFETY EDUCATION: OVERVIEW AND COMPETENCIES There are existing frameworks of patient safety competencies that have been in place for more than a decade. The WHO patient safety curriculum, launched in 2009, was originally modelled based on the Australian Patient Safety Education Framework (APSEF) that outlines comparable patient safety goals.[6-8] This curriculum is designed to achieve the core patient safety knowledge, skills, and expected behaviours with levels ranging from foundational patient safety competencies (Level 1) to organisational competencies (Level 4). Entrustable professional activities (EPA) provide an operational construct for ascertaining competence and progression to individual clinical practice.[9,10] Common themes across the majority of frameworks include error prevention, risk management, patient safety culture, and communication [Table 1].Table 1: Summary of patient safety curricular frameworks and guidesThe Canadian Patient Safety Institute (CPSI) prioritises competencies for team safety by optimising human and environmental factors.[11] The European Network for Patient Safety [EUNetPaS] advocates emphasis on context specificity with patient centric and team oriented approaches.[12] The United Kingdom National Health Service (UK NHS) outlines a five-level multi-professional patient safety syllabus, articulating the steps for progression from essential to advanced patient safety.[13] For the developing nations, the priority would be error prevention and reducing communication breakdowns, especially in high acuity and high risk areas. Developed settings, having established a culture of safety, with systems and processes in place, need to be vigilant to identify threats to compliance. The system needs to empower teams to achieve progressively tiered patient safety competencies. For a healthcare system to adopt these patient safety frameworks, there needs to be a good understanding of the diverse nature of these settings and awareness of limitations in implementation. DIVERSE HEALTHCARE SETTINGS AND PATIENT SAFETY PRIORITIES The healthcare systems, even in the developed settings, seem to be variably equipped with a stark contrast between the wealthy metropolises and the impoverished cities. There is a relative sparsity of reforms, health, and manpower resources and supplies. In the undeveloped settings, the concept of patient safety and its implementations, as an integral part of the holistic care of patients, is frequently ill-defined.[14] Meticulously planned patient safety governance, implementation of care pathways, and patient safety systems are imperative. Championing patient safety through education and prevention of harm is vital in differentially resourced settings.[15] LIMITATIONS IN IMPLEMENTATIONS OF PATIENT SAFETY EDUCATION AND CURRICULUM There are inherent difficulties in the implementation of patient safety education at varying levels. These include limited understanding of risk in healthcare and poor stakeholders’ buy in with implementation weaknesses in educational reforms. Suboptimal leadership commitment to patient safety education results in unstructured educational governance and poor curricular coordination and planning. There is limited agility to alter curricula to make them effective and contextually aligned. There is a lack of or insufficient role modelling of patient safety, medical, nursing, and allied health champions, with operational constraints and unfamiliarity of educators and faculty in teaching patient safety. There is limited availability of educators, mentorship, and continued training about evolving safety issues in healthcare.[15] Cultural barriers are a significant limitation to implementation. These include redundant and outdated practices with a resistance to change, or an aversion to newer evidence-based workflows. Socio-cultural practices such as strong hierarchical norms and beliefs affect societal behaviour and result in poor compliance or adherence to recommended safe practice initiatives. IMPLEMENTATION OF GLOBAL PATIENT SAFETY EDUCATION AND STANDARDS The approach to patient safety implementation and education needs to include multiple levels of oversight: government and regulatory bodies, hospitals, health services, and local stakeholders within the healthcare. This will ensure that the standard of care is continuously delivered. The factors or components that may influence patient safety implementation are outlined in Table 2.[13]Table 2: Outline of factors that influence the implementation of patient safety educational initiatives and educational strategiesKey strategies for patient safety education in the setting of clinical management and care include error prevention and management, patient empowerment, education and training, and patient safety administration. For educational interventions to be effective, there needs to be alignment between contextual needs and educational initiatives, with structured implementation in clinical settings, where the impact is meaningful and clinical educator role models are visible. PATIENT SAFETY CONTINUUM AND CONTINUOUS PROFESSIONAL DEVELOPMENT We propose a patient safety educational continuum, where principles of patient safety need to be introduced in foundational years and built upon subsequently [Figure 1]. Layering of past experiences and promoting conceptual learning is enabled with updated patient safety knowledge, skills, and behaviours to eliminate preventable harm that arises from evolving threats.[16]Figure 1: Patient safety education continuum and the various domains across the learning trajectory. Teaching and learning tools and assessment are an integral part of the overall portfolio-based demonstration of attainment of patient safety competencies. UG = undergraduate, PG = postgraduate, CPD = continuous professional development, Sim = simulation, PS = patient safetyThis ‘roadmap’ will help to guide the learner in understanding patient safety essentials while progressing to provide basic and advanced safe patient care. The range of educational tools (lectures, in-person and web-based resources, small-group interactive teaching methods, technology and game-based initiatives) and assessments offer learner-adjusted teaching modalities. These educational initiatives equip and enable error management (error recognition, reporting, mitigation, and prevention). A portfolio-based repository of learning, by embedding formative and summative assessments, self-reflections, and faculty feedback, will improve the effectiveness of patient safety educational endeavours.[17] TECHNOLOGY AND ARTIFICIAL INTELLIGENCE IN PATIENT SAFETY Technology has enhanced the quality of care through continued efforts to improve diagnostic accuracy, data management, robotics and minimally invasive surgeries, telemedicine, and care in remote settings. Enhancements in wearable technology, continuous monitoring systems, health information exchange, and functionalities that are enabled with Artificial Intelligence (AI) are in place. AI encompasses three approaches: deep learning (complex thinking), machine learning (repetitive tasks), and natural language processing (predictive intelligence from patterns in written language).[18] A review of the potential for AI in enhancing patient safety has shown that AI has the promise for improving outcomes when complex unstructured data are analysed. AI may provide accurate predictions for adverse drug events and diagnostic errors and for the prediction of decompensation and offering safety alerts.[19] AI-driven Clinical Decision Support Systems (CDSS) have shown enhanced quality of care with 30% improvement in medication errors.[20] The addition of sensors and wearables enhances fall for this review included paediatric for metabolic regulations (e.g. blood sugar), and provides a comprehensivew vital signs review. They enhance early predictions, preempt catastrophic events, and prompt the user for time sensitive corrective measures or actions. Introduction of ‘care robots’ when deployed for repetitive tasks like dispensing non-critical supplies and basic interviewing and monitoring has freed the trained professionals to perform complex interactions of caring that cannot be automated. There are inherent biases in AI technology with threats to reliability at the foundational input stage (non-diverse representative data). There are biases in the algorithm coding and construction stage (testing and training for validity) and at the end user human–computer interaction interface.[18] We advocate robust regulatory measures that mandate better transparency in declaring development algorithms that embed AI-based predictive technology. We need legislation for the inclusion of diverse patient profiles and end-user education to reduce these biases. Safety systems, continued vigilance, periodic review of accuracy and quality of outputs of technology, and AI-enabled patient care environments are mandatory. PATIENT SAFETY LEADERSHIP AND EXCELLENCE Excellence in safe patient care requires dynamic leadership that is actively engaged, enabling a culture of safety with proactive problem-solving and resource allocation.[21] The leadership teams need to continuously engage all care facilities through active efforts such as patient safety walkabout programs that help to discover and relay realistic on-the-ground care concerns and operational issues, or resistance to change.[22] The WHO has established frameworks for training healthcare leaders to ensure effective patient safety outcomes. Improvements in patient safety can be achieved through impetus from political and regulatory bodies that enable policies, through institutional strategies for enabling a culture of safety, and by execution at the individual level. Establishing a local, regional, and national network of patient safety professionals, quality and safety specialists would help in steering towards wider acceptance and implementation of patient safety principles. Quality of care can be ascertained and periodically assessed through standards ensured by international (Joint Commission Internationale, JCI) and national accrediting bodies (National Accreditation Board for Hospitals and Healthcare providers, NABH). These ensure currency in high-quality patient-centred and process-driven safe standard of care that is on par with global benchmarks. We recommend regular accreditation exercises to be considered for healthcare settings. The preparation for achieving accreditation success improves the patient safety culture achieved through rigour in education and stringent quality control measures within the context. We need to encourage patient safety education and research collaboratives across international settings. The aim of this collaborative would be to achieve a repository of safety issues, critical incidents, and pattern recognition across diverse healthcare systems.[23] Stratifying the threats across healthcare systems, while developing and customising teaching and learning modalities, will help overcome knowledge deficits. These initiatives will offer opportunities to learn from untoward events, akin to how the international civil aviation organisation transparently publishes final reports of incidents.[24] Implementation research that provides data on the educational effectiveness of teaching and learning tools needs to evolve beyond the lower levels of Kirkpatrick’s grades (self-reported satisfaction and efficacy) towards translational outcomes of error prevention and reduction of patient harm and conservation of resources.[25] CONCLUSION The WHO patient safety educational initiatives have helped with the global patient safety curricular structure. There are contextual limitations to implementation resulting from disproportionate resources for clinical care, diverse care settings, and priorities. There is a paucity of educational impetus from organisations, leadership, and governing bodies in differentially resourced settings. An overview of the existing patient safety curricular guides and the need for an educational continuum from foundational years to individual and interprofessional clinical care is proposed. Technology and AI-enhanced clinical care are evolving to show clinical effectiveness, with an imperative for better regulation of design, development, inclusion, implementation, and vigilance. There is a need for involvement of all components of the healthcare environment (patient care, staff well-being, resource allocation, patient safety culture, environment, and leadership) for patient safety education to be effective. Establishing patient safety systems with local, regional, national, and international networks, inclusive of patient safety educators and researchers, will help align the priorities, actions, and outcomes. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Presentation at conferences/CMEs and abstract publication None. Study data availability Not applicable. Disclosure of use of artificial intelligence (AI)-assistive or generative tools The authors confirm that no AI tools or language models (LLMs) were used in the writing or editing of the manuscript, and no images were manipulated using AI. Declaration of use of permitted tools None used for this manuscript. The figure is created by the authors and is original and needs no additional copyright permissions. Authors contributions BA was involved in the conceptualisation, literature search, manuscript preparation, editing, review and approval; RN was involved in manuscript preparation, editing, review and approval; SA was involved in manuscript preparation, editing, review and approval of the final manuscript. Supplementary material None.