Patient Safety Learning Program
Professors John Del Valle, M.D., Michael Lukela, M.D., Raj Mangrulkar, M.D., and Vikas Parekh, M.D. won the Provost's Teaching Innovation Prize in 2010 for their project, Patient Safety Learning Program.
Original Publication Year:
TIP Winner: Patient Safety Learning Program
John Del Valle
Despite efforts to improve patient safety over the last decade, medical errors continue to affect significant numbers of patients. Graduate medical education programs (i.e., residencies) present an excellent
environment for targeting this issue. As frontline providers, residents are well positioned to analyze adverse events and to devise solutions to prevent their recurrence, while integrating best practices into their clinical work.
Piloted in the internal medicine and medicine-pediatric residencies, the Patient Safety Learning Program (PSLP) pursues a three-pronged curricular approach to shifting the culture of medical error during doctors’ formative years. First, a foundational seminar series introduces conceptual models for untangling and addressing safety problems. Second, e-portfolios provide a confidential space for residents’ reflections upon their own experiences and near misses, as well as feedback from expert faculty on these entries. Third, teams of residents receive protected time for Patient Safety Improvement Projects, along with guidance from faculty members trained through the Academy of Patient Safety Mentors. After diagramming causes and effects of a problematic system or process, the teams craft recommendations, some of which have been implemented immediately.
“What my patient safety team taught me is that we canimprove the care of a far greater number of patients by addressing the systematic root cause of an impediment to optimal care instead of sidestepping the problem with a onetime workaround.”
“The Patient Safety Improvement Project is a structured opportunity for house staff to pursue a research project from start to finish, and to answer a question that has direct impact on their day-to-day operation.”
“Regardless of career choice or focus (research- or clinically- oriented) residents place value on solutions for problems that imped their clinical practice. I feel that this experience has definitely improved both my skills in research as well as my analytical methodology, working through a problem from beginning to end.”
“During medical school, I observed that fear of lawsuits, fear of losing a patient’s confidence, and a feeling of personal failure prevented reporting of medical errors… I now understand the importance of this issue in healthcare and also identify myself as personally responsible for improving processes that contribute to continued errors in the hospital. The change in medical culture to promote patient safety is undoubtedly a life-saving intervention and has made me a better clinician. Furthermore, I believe the introduction of patient safety should be a mandatory part of medical training within all medical specialties, not only internal medicine.”
Above photos from left to right:
John Del Valle (Internal Medicine)
Michael Lukela (Internal Medicine and Pediatrics)
Rajesh Mangruikar (Internal Medicine and Medical Education)
Vikas Parekh (Internal Medicine)