Intended for healthcare professionals

Feature Patient Safety

Putting safety on the curriculum

BMJ 2009; 339 doi: (Published 15 September 2009) Cite this as: BMJ 2009;339:b3725
  1. Oliver Ellis, Clegg scholar
  1. 1BMJ, London WC1H 9JR
  1. oellis{at}

    WHO wants patient safety to be included from the start of medical education, Oliver Ellis reports

    The idea that health care actually harms patients has been around for some time, but until now little has been done to educate future doctors about the problem. However, the World Health Organization hopes that this will change with the publication of its curriculum guide next year. The new curriculum, currently being piloted, will detail how medical schools should teach patient safety to undergraduate doctors.

    The publication builds on growing concerns that medical errors have high human and financial costs. Back in 2000, the Institute of Medicine’s Committee on Quality of Health Care in America found that in the US alone up to 98 000 deaths a year could be attributed to medical error, costing between $17bn (£10bn; €12bn) and $29bn. It concluded that: “The status quo is simply not acceptable and cannot be tolerated any longer.”1

    Despite this, many medical students have found their training on safety to be wanting: a 2004 survey of American graduates reported that 45% considered their training on quality assurance “insufficient.”2 Since then, medical educators have made several calls for patient safety to be made a focus of undergraduate training. In 2007 the Association of Medical Education in Europe recommended that patient safety should be integrated into the curriculum from the first year,3 but there have been no international guidelines on what form it should take.

    The new WHO curriculum is largely based on the Australian Council for Safety and Quality in Health Care’s 2005 patient safety education framework, which covers 22 topics on patient safety and is aimed at all workers who deal with patients, from housekeeping staff to hospital managers.4

    The WHO curriculum identifies 11 areas relevant to improving safety (box).5 As well as infection control, surgery, and medication, it includes sections on how errors are reported and reducing blame culture; practical ways of analysing mistakes; and a system of investigating the fundamental cause of errors that arise. It is presented as a comprehensive resource for educators containing background information on patient safety as well as a detailed undergraduate curriculum and sample exam questions.

    WHO curriculum on patient safety5

    • What is patient safety?

    • What is human factors and why is it important for patient safety?

    • Understanding systems and the impact of complexity on patient care

    • Being an effective team player

    • Understanding and learning from errors

    • Understanding and managing clinical risk

    • Introduction to quality improvement methods

    • Engaging with patients and carers

    • Minimising infection through improved infection control

    • Patient safety and invasive procedures

    • Improving medication safety

    Science of safety

    Safety, as a discipline, has largely been developed in high risk industries such as aviation and mining. And the WHO report acknowledges that some doctors and medical educators may be resistant to the science of safety. They may dislike the importation of “management consultancy style interference” or there may be “a reluctance to address knowledge that originates from outside medicine such as systems thinking and quality improvement methods.”

    The authors are nevertheless adamant that safety is a vital part of a doctor’s training and that by targeting training at undergraduates, the curriculum will influence medics before they become entrenched in prevailing opinion.

    The authors expect that much of the material will be integrated into existing educational modules. Merrilyn Walton, director of patient safety at Sydney Medical School and lead author of the report, says: “Many components can be easily incorporated through further development of existing subjects or topics. Areas such as health law, clinical and medical ethics, and healthcare communication are all appropriate for integration of patient safety concepts and principles.”

    She also said that medical schools have been keen so far: “There has been great enthusiasm for the patient safety curriculum. Because it is new, the universities do not have a lot of capacity to develop a curriculum themselves. This guide gives them a leg-up in terms of content and teaching to all levels of undergraduates.”

    Early promise

    Preliminary reactions have been broadly positive. Stefan Lindgren, president of the World Federation for Medical Education, said that the curriculum is a good idea as long as topics are presented in the context of real medical practice. He says that patient safety “is a core attitude and thus needs to be introduced early and then reinforced throughout postgraduate education and continuing professional development.”

    Chair of the BMA Medical Students Committee, Tim Crocker-Buqué, thinks anything that improves patient safety is a good idea. “Medical students should have some consideration of patient safety about the time that they start to come into contact with patients, which currently is lacking.” He is more guarded about the practicalities of implementation, however, as he thinks that the curriculum is necessarily unspecific so that it is applicable worldwide. “It depends on the curriculum in that particular medical school. In the UK it needs to be considered and implemented within the current content of the curriculum.”

    The curriculum is currently being tested at 10 medical schools in different countries. Each school has implemented at least three of the 11 topics and will use focus groups and questionnaires to judge student and staff reactions to the material. According to Benjamin Ellis, the curriculum programme manager for WHO, the schools’ reactions have been largely positive. “However, we realize that only through conducting a high quality evaluation will we be really be able to understand what we can do to make this curriculum guide even better.” WHO will review the results, along with feedback from other interested parties, in spring 2010; the final document could be published as soon as the end of that year, with curriculums for other healthcare professions shortly following.

    Medical schools piloting WHO curriculum

    • School of Medicine, Cardiff University

    • University of Aberdeen Medical School

    • College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

    • Sydney Medical School, Australia

    • Sackler Faculty of Medicine, Tel-Aviv University, Israel

    • School of Medicine, del Salvador University, Buenos Aires, Argentina

    • Patan Academy of Health Science, Kathmandu, Nepal

    • Hawassa University College of Health Science, Faculty of Medicine, Ethiopia

    • Maulana Azad Medical College, New Delhi, India

    • Faculty of Medicine, University of Manitoba, Winnipeg, Canada


    Cite this as: BMJ 2009;339:b3725


    • Competing interests: None declared.


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