gms | German Medical Science

GMS Journal for Medical Education

Gesellschaft für Medizinische Ausbildung (GMA)

ISSN 2366-5017

Pilot project "Patient-Safety" in Medical Education

project medicine

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  • corresponding author Michael Rosentreter - RWTH Aachen, Medizinische Fakultät, Institut für Geschichte, Theorie und Ethik der Medizin, Aachen, Deutschland
  • Dominik Groß - RWTH Aachen, Medizinische Fakultät, Institut für Geschichte, Theorie und Ethik der Medizin, Aachen, Deutschland
  • Gereon Schäfer - RWTH Aachen, Medizinische Fakultät, Institut für Geschichte, Theorie und Ethik der Medizin, Aachen, Deutschland

GMS Z Med Ausbild 2011;28(1):Doc12

doi: 10.3205/zma000724, urn:nbn:de:0183-zma0007246

This is the English version of the article.
The German version can be found at:

Received: July 22, 2009
Revised: October 27, 2010
Accepted: October 28, 2010
Published: February 4, 2011

© 2011 Rosentreter et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Since the summer term 2009 the study project „Patientensicherheit – Der klinische Umgang mit Patienten- und Eingriffsverwechslungen sowie Medikationsfehlern“ (Patient Safety – the clinical handling of patients – and mistaking of procedures as well as medication errors) is offered within the Modellstudiengang Medizin. Seminars on patient safety in Germany so far mainly address trained doctors and health economists. In contrast, this study project on patient safety should at an early stage contribute to a “culture of discussing and preventing mistakes” – an aspect that is little established in clinical medicine, but also in medical training. For this purpose, a broad variety of courses was developed, which – relying on problem-oriented learning – enables the students to analyse so-called adverse events (AE) and develop adequate prevention measures on the basis of the insights gained by this analysis. Therefore, theoretical lessons are complemented by discussing prototypical clinical cases. These discussions are moderated by experienced clinicians. After completing the seminar, students showed a significant increase (comparison of means) in the self-assessed qualifications „Wissen zu Patientensicherheit“ (Knowledge of Patient Safety) and „Wahrnehmung von Risikosituationen“ (Appreciation of Risk Situations). All in all, the students rated their training success with a grade of 1.5 (good).

Keywords: Undergraduate medical education, patient safety, adverse events, problem-based learning, medical education


Description of Problem and Demand

“Patient safety” is defined as “absence of Adverse Events” in relation to medical care [1]. The call to action contained in this definition implies the recognition and prevention of such events.

Investigations of high-risk sectors (e. g. aeronautics and space travel, nuclear energy) prove that up to 70% of mistakes made there can be traced back to human factors [8], [19]. This comparison is often made in discussing a medical safety culture. Besides, international studies of mistakes in health care are quoted; these studies conclude that individual negligence in relation to system errors can be considered as quantitatively low-ranking as a cause for health damages [4], [12], [13], [14], [15]. After all, Human Factors are “all physical, psychic and social characteristics of a human being, insofar as they influence their actions in and with socio-technological systems, or are influenced by them” [2]. In the individual fields of health care, people and technologies are organised as socio-technological systems in a certain way, in order to obtain the best possible state of health for their clients and patients.

The need of such a study project from the students’ point of view was evaluated in a poll (n=14) conducted at the start of the semester within the frame of a pilot seminar on that topic. Students were asked to rate, on a scale from 1 to 6 (6=very important), how important the issue of patient safety was to them, and which relevance the issue was given in their medical training, or how much it should be given, respectively. The issue was of high importance to the participants (mean m=5.67; standard deviation s=.651); and that in medical education it should be of high relevance (m=5.38; s=.650). At the same time the participants rated the current relevance as rather low (m=1.92; s=.954).

Current State

So far, a “Curriculum Patient Safety” does not exist in medical training in Germany. The curriculum worked out by the European Network for Patient Safety (EuNetPas) just went through reviewing; the guidelines of the German Agency for Quality in Medicine (AQUMED) (Ärztliches Zentrum für Qualität in der Medizin, ÄZQ) were conceptualised as a concept of further training full medical doctors. On 3 May 2010 the task force “Education and Training” came together for its constituting meeting under the aegis of the German Coalition for Patient Safety (Aktionsbündnis für Patientensicherheit, APS), with the aim to establish the issue of patient safety in compulsory medical training within the next five years.

Seminars on the topic of patient safety are offered in the study courses Medical Technology (TU Ilmenau), Health Economy (University of Cologne) and Public Health Management (Dresden International University). Nonetheless, the need for educational programs on the systematic understanding of error emergence and a to-be-developed error culture, or better, safety culture, in medical training remains.

Description of Project

The idea of competence and educational aims

Central to the concept of the study project on patient safety are two essential dimensions: the personal dimension touches both the individual behaviour regarding patient safety and establishing a so-called error culture within the “Learning Organisation”; the temporal dimension refers to the prevention of errors and the creative handling of mistakes.

According to Klafki, competence is the all-round capability of finding solutions to problems in a variety of situations and using them self-responsibly. In order to do so, cognitive and psychosomatic knowledge and skills are needed, as well as the according motivation and will to act [11], [10]. An important aspect of this kind of self-organisation is the skill to judge individual possibilities realistically and not to expose oneself to (idealistic) over-strain [6].

For the sphere of activity of patient safety the study aims were formulated leaning on Bloom [3]:

1. Cognitive study aims

  • Knowledge of conventions and temporal sequences: Students should be able to discern different kinds of errors (terminological knowledge) and get an idea of legal aspects and economic relevance of patient safety (knowledge of criteria and categories). Knowledge of quality management and learning in organisations are also addressed.
  • Analysis and synthesis: Based on systematic understanding of error emergence the participants should be made capable of recognising and analysing any mistakes and damages, and to develop preventive measures based thereon.

2. Affective study aims

  • Developing understanding: Students of medicine should realise early that independent of medical competence, system errors like organisational or communication failures can have dire consequences. This includes a deepened understanding of organisational and communication processes.
  • Evaluate: The students should be aware of their own values and attitudes, as well as that of others, in order to be able to argue and act.

Localisation of the lecture “Patient Safety” at the Faculty of Medicine in Aachen

The Institute for History, Theory and Ethics of Medicine offers a qualification profile “Medicine and Ethics – Doctor, Patient, Society”, in which the Innovative Study Project “Patient Safety – the clinical handling of patients – and mistaking of procedures as well as medication errors” is located. The seminar is offered as a elective compulsory since the summer term 2009 and is financed by tuition fees.

Students and lecturers

The seminar is led by a medical sociologist with practical experience in anaesthetics and intensive-care medicine. The study project is conducted in cooperation with colleagues from clinics and practice. The clinical partners play an especially important part for practically-oriented content as experts and moderators. Experienced practitioners from different medical disciplines could be won for the case studies, who offer students an insight into the typical risk constellations of their fields. Altogether seven practitioners from clinics and health care are involved, additional to the project supervisor. Integral parts of the project are a guided tour through the Institute of Transfusion Medicine and an expert talk with an experienced nurse administrator on the topic “Violence against Patients”. The amount of coordination, despite the large number of participating tutors and mediators, is kept relatively low, as everyone already has relevant experience in the field and schooling lecturers can be left out but for a few arranged exceptions. The largest effort for the case studies is basically put into the timely coordination of appointments and into agreeing on case studies, which are suggested and prepared by the tutor. Acquiring new tutors and mediators for the successive extension of the thematic spectrum offered is more difficult. So far a network of especially committed practitioners and clinicians could be used.

All in all, 16 students in summer term 2009 and winter term 2009/10 enrolled for the study course Patient Safety, two of which cancelled in regard to further study engagements. It has to be noted here that besides the announcement in the prospectus, no further hint at the study course was given. The course in summer term 2010 was visited already by 14 students.

The average age of the participants was 24 years (s=4.21); on average they were in their fifth semester (s=1.46). Especially regarding the number of semesters and the clinical experiences already made, the variance was quite big – for example, two participants had worked as nurses for several years before studying. The ratio of female participants was 65%, which roughly conforms to the overall ratio of female medical students at RWTH Aachen University in 2010 (62.8%) [5].

Concepts and Contents

The aim of the study project and the topic itself imply a dual conception of theoretical and practice-oriented parts (see Figure 1 [Fig. 1]):

Initial conveyance of theoretical knowledge on patient safety and sensitisation towards connected problems;
Presentation and discussion of clinical cases for the evaluation of risks and special circumstances which lead to Adverse Events and errors.

Following this two-fold approach, the first theoretical part of the double lesson serves the conveyance of basic knowledge like definitions, terminology and legal aspects. Building on that in the project’s second phase, the institutional and social context of patient safety is assessed. Topics of this part of the seminar are the ethical dimensions of patient safety, culture of errors and organizational learning, guidelines of patient safety associations, and recent research results.

The second theoretical part of the respective unit is reserved for case studies. Experienced clinicians and practitioners from a broad variety of medical fields could be won as mediators for the case studies. The selection and preparation of typical examples from the respective internet-based Incident Reporting-Systems (paSOPS, jeder-fehler-zählt, cirsmedical, etc.) is done in coordination with the mediators. Questions concerning causes and complementary factors of error emergence, as well as possible prevention measures are attached to the written case introductions. Thereby, the students’ discussion is structured and the process of error analysis within the approach suggested by the German Coalition for Patient Safety is rehearsed. The spectrum of exemplarily shown risk situations ranges from General Practitioner Care to the large clinical fields up to aspects of locked-ward psychiatry. As representatives of their disciplines, the moderating doctors thus can immediately address the regularities of error emergence and the specifics of their fields.

Through this direct coordination of theory and practice, the participants can immediately use the theoretical terms and concepts introduced before, and check their relevance in practice themselves.

Important parts of the lectures offered are, in accordance to the theory of categorical training by Klafki [11], [10], the field trip to Transfusion Medicine for the exemplary depiction of basic problems of drug safety in practice and the expert talk for conveying an understanding of how violence towards patients can occur.

In the third phase, the students work out comprehensive groups of themes on the basis of socio-psychological, medico-ethical and sociological theories and results. Using topic such as communicative basics, social perception or personal handling of mistakes, the capability to introspection and self-criticism of the prospective doctors should be trained, in order to be able to face psychic pressure prior to or after Adverse Events adequately [18]. This means to become aware of one’s own values and attitudes, to critically check assisting offers and options (e. g. the work of the ethics committee and burnout-prevention measures) and to counter known phenomena like the faulty attribution of characteristics (prejudices and stereotypes) and a blurred perception through group-dynamic processes. The over-reaching aim of these topics is to consolidate the basics needed for medico-ethical decisions.

With the additional use of literary statements from doctors (P. Bamm, M. Bulgakow), an aesthetic level of learning should be addressed in the conveying of this serious and critical topic [16], [17].

To gain their ECTS-credits, students had to give a presentation or hand in a written case study.


Study success and results of evaluation

At the start of the semester (t0) the students were asked about previous knowledge, attitudes and self-assessed competences regarding patient safety [7], [9]. At the end of the term, a new poll was made with the same instrument, and changes were measured via a comparison of means (T-test at dependent samples). The operationalisation of the competence concept was exceedingly difficult due to the topic’s cross-sectional character. Lacking established instruments, factual and social competence in the field of patient safety were taken in as self-assessment of thematic knowledge, as recognition of risk situations and as information behaviour in unclear situations (compare Figure 2 [Fig. 2]). At the end of the semester students judged their knowledge of patient safety and their competence in recognising risk situations 1.7, respectively 2.7 steps, higher – and this significantly better – than at the start of the seminar. Only the aspect “Communication in Risk Situations” saw a weak and insignificant effect. However, from the beginning there was a high willingness within the group to gather further information in relevant situations.

To evaluate the studies, a questionnaire developed in a didactics seminar is used, which captures indexes for the conception, conduction and learning effects. This instrument can be easily applied to different study projects (e. g. the training aims of the case studies were clearly recognisable).

Fortunately the students gave the seminar an overall good (1.5) rating. Conduction (grading the course supervisor) and learning effect were both rated with 1.5 by the participants (all values adjusted downwards; see Figure 3 [Fig. 3]).

The practical parts of the seminar, such as the case studies with experienced clinicians and practitioners, were also highly rated (Training aims of case studies were reached: 1.3; the case studies were helpful for the future medical job: 1.0), as were the excursion and the expert talk (Excursion and expert talk as a useful addition: 1.2).

The success of the case studies can be seen by looking at the answers to the open questions. The participants stated that the cases were well chosen to get across the topic of patient safety; that the expert talks were well suited to get an impression of the variety and the specific problems of errors in the individual disciplines; and that this combination of theory and practice was helpful to make clear immediate relations.

Not heeding the preference for seminar parts with a clear practical approach, the students several times expressed a huge interest in sociological topics without an immediate medical reference – like, e. g., social perception, communication and personal handling of one’s own mistakes. Terminating the seminar to 5.00 pm, however, was criticised.


Given the low number of cases, the results at hand have to be judged with care. Also, the evaluation is only based on the students’ satisfaction with conception, conduction and learning effect, as well as a self-assessment of the competences they gained. Thus the basic methodical problem is touched, how a learning success, for example in Prevention of Adverse Events, should be described positively, not to mention measured.

Handling Adverse Events in medical treatment and their prevention requires knowledge and experience, but also intuition and according personal mindsets. The study project described here addresses these requirements by medical, socio-psychological and organisation-psychological issues, as well as a close combination of theoretical content and clinical-practical experience.

Regarding the general acceptance of such learning contents from the field of socio-psychology, and facing the fact that the issue of patient safety experiences a growing social and health-political attention, lecture modules of that kind seem a concrete chance, to help students approach hitherto less studied issues and to hone their critical self-conception.

The unfortunate choice of time (5.00 pm) for the seminar underlines the dilemma of patient safety. On the one hand the topic is met with broad acceptance, on the other hand concrete measures can in practice often only be pulled through slowly with constant persistence; on the one hand, putting the seminar within regular working hours could lead to an enhanced awareness of the topic, on the other, this aspect makes the desired inclusion of clinics problematic. Likely, such difficulties are to some degree also due to the fact that patient safety is not yet one of the classic parts of the curriculum and can thus not be taught during core time.

Without exception, all participants agreed in the closing discussion that the topic should be worked into the core main curriculum of medical training. Different opinions emerged regarding the question how the topic could be integrated into the curriculum without assuming the character of an exam-relevant obligatory course, thus being taken only from extrinsic motivation. Seen realistically, a foundation of the subject Patient Safety within the core curriculum of medical education however will only be feasable that way.

Especially the clinical case studies made clear that errors mostly occur at the borders between systems and areas, and that an improvement of patient safety can only be reached through a joint effort of all occupational groups working in medical care.

It should be noted however that the seminar’s participants probably are a “selective” group that judges the issue of patient safety very highly and which in its interests and positive assessment probably is not representative for the collective of medical students. The decision to participate in the seminar is also dependent on external aspects, such as setting focuses in the qualification profile and alternative lectures.


The topic patient safety reaches far beyond the scope of one study project – it is de facto a life-long “project”, asking for the personal responsibility of everyone working in medical care. The more important is the timely conveyance, respectively the acquisition of the necessary knowledge and competences. The dynamics of medico-technological progress and health-political requirements leads to a higher complexity in organisational processes, which can only be controlled by an education closely linked with theory and practice. The sustainability of such lecture modules can only be evaluated in the long run on base of ample samples, i. e. changes in behaviour in favour of an improved patient safety would have to be measured especially compared to according outcomes in practice. The value of the presented concept thus mainly lies in showing that, respectively how, the students’ interest in patient safety can be woken and what a great potential the topic has in terms of didactics (both in teaching and job), but also regarding health politics. The fact that 85% of the participants said that they wanted to further study the topic of patient safety is a clear hint.

Competing interests

The authors declare that they have no competing interests.


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