Patient Safety Attitudes and Behaviors of Graduating Medical Students

Abstract

As North American medical schools reformulate curricula in response to public calls for better patient safety, surprisingly little research is available to explain and improve the translation of medical students’ knowledge and attitudes into desirable patient safety behaviors in the clinical setting. A total of 139 fourth-year medical students at Virginia Commonwealth University, School of Medicine, 96% of the 2010 graduating class, completed the Attitudes toward Patient Safety Questionnaire and a self-report of safety behaviors. The students were exposed to informal discussions of patient safety concepts but received no formal patient safety curriculum. Most students recognized errors and responded with attitudes supportive of patient safety but desired behaviors were less common. In particular, errors went unreported, owing, in part, to the relationships of power and social influence undergirding the traditional authority gradient in the culture of medicine. A deeper understanding of patient safety attitudes, behavior, and medical culture is required to better inform instructional design decisions that influence desired patient safety behaviors and improve patient care.

Keywords

medical education medical student patient safety medical error curriculum

Among the most pressing needs for improved health care is shared responsibility that enables patient safety as a common cause for patients, health care providers, and researchers (Kirch & Boysen, 2010; Sammer, Lykens, Singh, Mains, & Lackan, 2010). Principles of a culture of safety include leadership that acknowledges health care as a high-risk environment, a shared value of learning from mistakes and recognizing errors as system failures, the use of health information technology, teamwork and communication across the health professions, residents teaching others about patient safety, and early engagement of health professions students (Kirch & Boysen, 2010; Lucian Leape Institute at the National Patient Safety Foundation (LLI), 2010; Sammer et al., 2010).

Core objectives, content areas, and theories of change have been recommended to drive curriculum and evaluation in patient safety for undergraduate medical education, but medical schools continue to be slow to integrate the recommendations into formal curricula and to evaluate students’ performance beyond satisfaction and knowledge acquisition (Alper, Rosenberg, O’Brien, Fischer, & Durning, 2009; Bell, Moorman, & Delbanco, 2010; Foy et al., 2011; Gunderson, Smith, Mayer, McDonald, & Centomani, 2009; Halbach & Sullivan, 2005; Kane, Branne, & Kern, 2008; Lucian Leape Institute at the National Patient Safety Foundation (LLI), 2010; Madigosky, Headrick, Nelson, Cox, & Anderson, 2006; Mayer, Klamen, Gunderson, & Barach, 2009; Moskowitz, Veloski, Fields, & Nash, 2007; Newell, Harris, Aufses, & Ellozy, 2008; Patey et al., 2007; Sanders, Baz, Mayer, Wass, & Vickers, 2007; Wong, Etchells, Kuper, Levinson, & Shojania, 2010). Evaluation that demonstrates the translation of medical student attitudes and knowledge into behaviors is particularly important, because medical students will soon serve as residents and practicing physicians who direct patient safety efforts and set the tone for development of teams, in a medical culture that is pursuing increased collaboration, justice, and improvement in quality (Committee on Quality of Health Care in America, 2001; Committee on the Health Professions Education Summit, 2003; Lucian Leape Institute at the National Patient Safety Foundation, 2010). One important patient safety behavior that can be evaluated is error reporting. Evidence suggests that patient safety error reporting by physicians and students is inadequate and may be a product of negative influences in the socially created customs, rituals, standards, and power relationships comprising medical culture (Hafferty, 1998; Kaldjian et al., 2008; Madigosky et al., 2006; O’Connor, Coates, Yardley, & Wu, 2010; Schwartz & Davis, 1981; Seiden, Galvan, & Lamm, 2006). During undergraduate medical education, the decision-making power of medical students is regulated by an “authority gradient,” the balance of decision-making power dispersed across a common hierarchy that includes fellow students, nurses, house staff, and attending physicians (http://www.psnet.ahrq.gov/popup_glossary.aspx?name=authoritygradient). For example, a medical student calling a faculty member to clarify an order or to report an error may encounter a steep authority gradient, based on the faculty member’s harsh tone of voice or a lack of openness to input from the student; a student more empowered by the tenet of shared responsibility may nonetheless continue to raise legitimate concerns, whereas a less empowered student might not (French & Raven, 2001; http://www.psnet.ahrq.gov/popup_glossary.aspx?name=authoritygradient). Because their authority is limited, students ordinarily are unable to act unilaterally on their personal knowledge of a patient (Christakis & Feudtner, 1993), but the preeminent value of shared responsibility in patient safety empowers students with an obligation to perform on behalf of the patient.

The current study expands upon prior findings by assessing the patient safety attitudes and behaviors of graduating medical students and by exploring the influence of medical culture at the student level. Specifically, the study, conducted at the conclusion of the fourth year after 2 years of immersed clinical training in the health care environment, includes assessments of the following: (a) students’ attitudes toward patient safety, (b) students’ error recognition and reporting behaviors, and (c) the role of power and authority within the culture of medicine, measured as students’ willingness to discuss an unsafe behavior within the traditional hierarchical reporting relationships of academic medicine.

Method

Participants

With approval of the Virginia Commonwealth University Institutional Review Board, all fourth-year medical students on the medical school main campus (n = 144) were invited to participate in the study during spring 2010 at a required educational activity. Students signed a written consent to participate; a researcher (A.W.) reviewed the consent form with the students, including the purpose of the study and confidentiality of responses. Students were advised that a unique identifier would be utilized to enable longitudinal tracking for potential future research questions. Students were provided class time, approximately 20 minutes, to complete the written questionnaire. Participation was voluntary.

During the preclinical years for these students, medical errors and the importance of error disclosure were discussed in classes on medical ethics; effects of fatigue and stress were discussed in classes on humanism. However, a comprehensive, formalized patient safety curriculum was not part of their educational program. During their clinical experiences, students were immersed in the culture of clinical medicine in two academic hospital systems and various other nonaffiliated outpatient settings, providing limited, supervised patient care in diverse interprofessional environments. The clinical opportunities ranged from collaborative interdisciplinary teams with less structured authority and less urgent medical care requirements, to acute response teams practicing in more urgent clinical situations with more highly structured authority (Retchin, 2008). Patient safety is a priority across the multiple health care delivery organizations in which students learn, but, because no overarching governance controls these areas, specific safety efforts to which the students were exposed could not be isolated, controlled, or otherwise accounted for. However, within the clinical environment, students were exposed to concepts including transitions of care and hand offs.

Measures

Recent studies and a check of the current Association of American Medical Colleges’ Graduation Questionnaire suggest limited availability of measures for medical student patient safety attitudes and error reporting behaviors (Committee on Quality of Health Care in America, 2001; Committee on the Health Professions Education Summit, 2003). As a result, medical student attitudes toward patient safety were assessed using the 26-item Attitudes toward Patient Safety Questionnaire (APSQ; Carruthers, Lawton, Sandars, Howe, & Perry, 2009). Based on a review of psychometrics by the lead author (A.W.), the APSQ was selected based on moderate evidence of a stable factor structure and internal consistency, measured by Cronbach’s α equal to .73 (Wetzel, 2011). Although not validated with U.S. medical students, an expert review of the items by a local patient safety expert and educator (A.D.) found the item content of the APSQ to be congruent with select medical school patient safety objectives for graduating students and recommended patient safety content areas for undergraduate medical education (Mayer et al., 2009; Sanders et al., 2007). The questionnaire includes items related to nine factors: Patient Safety Training Received, Error Reporting Confidence, Working Hours as Error Cause, Error Inevitability, Professional Incompetence as Error Cause, Disclosure or Reporting Responsibility, Team Functioning, Patient Involvement in Reducing Error, and Importance of Patient Safety in the Curriculum (Carruthers et al., 2009). Students responded using a 5-point Likert scale (1 = strongly agree to 5 = strongly disagree). For each item, data were recoded to determine the number of students who reported attitudes supportive of patient safety to enable identification of areas in need of curricular intervention. To determine the number of students who reported attitudes supportive of patient safety at the subscale level, the total number of students who reported the desired response for each item within the factor was summed and divided by the total number of respondents. The desired response was defined as “strongly agree” or “agree” except for the reverse-coded items (Items 11, 13–18, 25) for which “disagree” or “strongly disagree” was the desired response.

In addition to adopting the standard set of APSQ attitude items, we developed 13 items to assess students’ self-reported behaviors during their clinical years of medical school. Students were asked whether they had observed a medical error during their clinical years. If a student answered “yes,” he or she was then asked to respond to additional questions about whether they discussed the error with a member of the health care team (e.g., faculty member, resident/intern, nurse, pharmacist, other) or reported the error via the anonymous formal error-reporting system of the institution. Students were also asked if they had observed a near miss, a medical error that almost happened. Again, if a student answered “yes,” he or she was asked to respond to questions about whether they discussed the near miss with a member of the health care team (e.g., faculty member, resident/intern, nurse, pharmacist, other). Although discussion of patient safety incidents between students and other members of the health care team may be desirable in many instances, for these 13 items, the desired behavior was defined as discussing the error or near miss with a resident/intern or faculty member, since these individuals supervise the student and bear direct responsibility for medical decision making for the affected patient. Data were dichotomized to reflect whether the desired behavior was reported.

In addition, students were surveyed to determine whether they had witnessed a member of the health care team deviate from safe medical practices (e.g., use of contact precautions or hand washing). To evaluate the influence of medical culture, specifically the role of authority in student disclosure behavior, we asked students four questions about their willingness to notify other health care personnel of hypothetical observations of deviations from safe medical practices. Using a 5-point Likert scale (1 = never to 5 = always), students indicated the frequency of their intention to inform an individual from each of four groups—fellow students, nursing staff, residents/interns, faculty members—of an observed deviation from safe medical practices. Finally, three demographic questions were included to gather data on gender, age, and health care experience prior to medical school.

Results

A total of 139 of 144 eligible students (96.5%) completed the questionnaire. In all 53% of respondents were female, and the majority (84.2%) under 30 years of age. Most students (59.7%) reported a small amount of health care experience prior to medical school (e.g., some physician shadowing, volunteer work); 23% of students indicated some experience (e.g., paid, short-term position); 9.3% reported a previous long-term, paid position or prior career in health care; and 7% reported no experience in health care prior to medical school.

Attitudes to Patient Safety

On average, 75.7% students reported attitudes supportive of patient safety on the APSQ. Table 1 displays the percentage of students reporting the desired attitude by item for the 26-item questionnaire and presents the percentage of students reporting the desired attitude by subscale. Results indicate 80.1% of students agreed or strongly agreed that patient safety curricula should be a priority at the undergraduate level, and 83.5% responded positively to items about the patient safety training they received. Approximately 9 of every 10 students (88.8%) recognized the contribution of multidisciplinary teamwork to error reduction. In addition, almost all (92.8%) students reported understanding of error inevitability. Finally, most students (87.4%) agreed that involving the patient in their care can reduce error.

Table 1.

Percentage of Fourth-Year Medical Students’ Responding With Desired Attitudes Using Attitudes to Patient Safety Questionnaire (n = 139)

Subscale	Percent Responding With Desired Attitude by Subscale^a (%)	Item	Percent Responding With Desired Attitude by Item^a
Patient safety training received	83.5	My training is preparing me to understand the causes of medical errors	87.7
		I have a good understanding of patient safety issues as a result of my undergraduate medical training	75.5
		My training is preparing me to prevent medical errors	87.1
Error reporting confidence	57.6	I would feel comfortable reporting any errors I made, no matter how serious the outcome had been for the patient	61.2
		I would feel comfortable reporting any errors other people had made, no matter how serious the outcome had been for the patient	42.5
		I am confident I could talk openly to my supervisor about an error I had made if it had resulted in potential or actual harm to my patient	70.6
Working hours as error cause	73.4	Shorter shifts for doctors will reduce medical errors	65.5
		By not taking regular breaks during shifts doctors are at an increased risk of making errors	71.2
		The number of hours doctors work increases the likelihood of making medical errors	83.5
Error inevitability	92.8	Even the most experienced and competent doctors make errors	97.1
		A true professional does not make mistakes or errors	89.2
		Human error is inevitable	92.1
Professional incompetence as error cause	64.0	Most medical errors result from careless nurses	73.4
		If people paid more attention at work, medical errors would be avoided	25.2
		Most medical errors results from careless doctors	77.0
		Medical errors are a sign of incompetence	80.6
Disclosure or reporting responsibility	65.7	It is not necessary to report errors which do not result in adverse outcomes for the patient	62.6
		Doctors have a responsibility to disclose errors to patients only if they result in harm	63.3
		All medical errors should be reported	71.2
Team functioning	88.8	Better multidisciplinary teamwork will reduce medical errors	94.2
Team functioning	88.8	Teaching teamwork skills will reduce medical errors	83.5
Patient involvement in reducing error	87.4	Patients have an important role in preventing medical errors	79.1
Patient involvement in reducing error	87.4	Encouraging patients to be more involved in their care can help to reduce the risk of medical errors occurring	95.7
Importance of patient safety in the curriculum	80.1	Teaching students about patient safety should be an important priority in medical students’ training	87.1
		Patient safety issues cannot be taught and can only be learned by clinical experience when qualified	55.4
		Learning about patient safety issues will enable me to become a more effective doctor	97.8

Note. Desired attitude = 1 or 2 except for reverse-coded items (11, 13–18, 25).

^a Scale: 1 = strongly agree, 2 = agree, 3 = neither agree nor disagree, 4 = disagree, 5 = strongly disagree.

Results for several attitudinal subscales highlight areas for potential improvement. A number of students reported beliefs that professional incompetence (35.9%) and working hours (26.6%) serve as causes of error. Similar results were seen for disclosure or reporting responsibility (34.3%) and error-reporting confidence (41.9%).

Self-Reported Reporting Behaviors

The desired behavior (i.e., reporting to a resident/intern or faculty member) was displayed, on average, by 65.2% of students who were involved in an error or near miss (See Table 2 ). A total of 109 (78.4%) participating students indicated they observed a medical error during the clinical years of medical school. Of these, six (5.5%) reported the observed error using the anonymous formal hospital reporting system. A total of 71 (65.1%) students who observed an error discussed it with an individual responsible for patient care. Specifically, 65 (91.6%) discussed the observed error with a resident/intern, 22 (31%) with a faculty member, 7 (9.9%) with a pharmacist, 5 (7%) with a nurse, and 3 (4.2%) with another individual responsible for the care of the patient.

Table 2.

Percentage of Fourth-Year Medical Students Responding With Desired Behaviors (n = 139)

Desired Behaviors	%
Recognition of near miss (n = 72/139)	51.8
Discussion of near miss with someone responsible for patient care (n = 49/72)	68.1
Discussion of near miss with faculty (n = 14/49)	28.6
Discussion of near miss with resident/intern (n = 42/49)	85.7
Recognition of medical error (n = 109/139)	78.4
Discussion of medical error with someone responsible for patient care (n = 71/109)	65.1
Discussion of medical error with faculty (n = 22/71)	31.0
Discussion of medical error with resident/intern (n = 65/71)	91.6
Reporting of medical error through anonymous formal hospital reporting system (n = 6/109)	5.5
Total reporting desired behavior	65.2

A total of 72 (51.8%) students reported observing a near miss during the clinical years. Similar to error-reporting behaviors, 49 (68.1%) students reported they discussed the near miss with an individual responsible for patient care. Again, a similar distribution is seen, 43 (85.7%) students discussed the near miss with a resident/intern, 14 (28.6%) with a faculty member, 4 (8.2%) with a nurse, 3 (6.1%) with a pharmacist, and 3 (6.1%) with another individual responsible for the care of the patient.

Self-Reported Willingness to Inform Others of Deviation From Safe Practice

A substantial number of students (n = 119, 85.6%) reported observing health care personnel deviate from safe medical practices (e.g., use of contact precautions or hand washing); however, the minority of students indicated they would always or often inform members of the health care team of this deviation from safe practices. Results appear consistent with the authority gradient—fellow student (46%), nurse (24.5%), resident/intern (17.8%), and faculty member (10.3%; see Figure 1 ). In addition, the percentage of students who would never inform a health care team member of an unsafe medical practice reflected the gradient (2.2% for fellow students, 7.2% for nurses, 5.8% for residents/interns, and 25.4% for faculty members).

Figure 1.

Fourth-year medical students’ self-reported willingness to inform health care personnel of deviation from safe medical practices (n = 139). *Scale: 1 = never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = always.

Discussion of Curricular Implications

This study describes medical students’ patient safety attitudes and behaviors within the current medical culture experienced by students of one medical school participating in diverse academic health center and community-based inpatient and outpatient settings. The research builds upon previously reported peer-reviewed studies of medical students’ knowledge and attitudes, adding self-reported behavior to the knowledge base of performance in practice, a higher level evaluation according to the outcomes framework advanced by Moore, Green, and Gallis (2009). From our assessment of medical students’ patient safety attitudes and self-reported reporting behaviors, we better understand now the current role of students in patient safety; how existing medical culture may contribute to their attitudes and behaviors, including the influence of authority on student disclosure; and what opportunities exist for faculty development and curricular intervention, as we aim to succeed in further developing a culture of safety (Hafler et al., 2011).

In our study, a large majority of students reported attitudes supportive of patient safety on most measures. However, nearly a quarter of respondents did not demonstrate the desired attitudes on select subscales. Student responses in the Professional Incompetence subscale demonstrate that medical students in this sample hold a pervasive belief that individual failures are the primary root cause of errors; conversely, the science of patient safety tends to refute the belief that personal inattention is the main cause of most errors (Leape et al., 1999). Understanding that professional incompetence is not always at the center of safety incidents is an especially important concept since it underpins the interactions of justice, teamwork, and continuous quality improvement desired in modern health care (Sammer et al., 2010). Medical student education around the epidemiology of error and the concept that multiple systems failures lead to patient harm has been recently recommended and implemented at the undergraduate level (Mayer et al., 2009; Walton et al., 2010; Wong et al., 2010).

Desired attitudes around several behaviorally oriented subscales—Disclosure or Reporting Responsibility and Error Reporting Confidence—also showed low percentages. These findings highlight the need for instruction on disclosure guidelines to help students know when disclosure is appropriate and on the communication skills that support error disclosure and reporting. Development and assessment of communication skills may be strengthened with higher levels of evaluation including objective measures of specific student behaviors in clinical environments or simulated environments with standardized patients and simulated safety scenarios (e.g., Browning, Meyer, Truog, & Solomon, 2007; Stroud, McIlroy, & Levinson, 2009).

Equal in results of a prior study, 78% of our students, reported observing an error or near miss (White et al., 2008). Although our study did not differentiate between student- and supervisor-initiated discussions about these errors, the results indicate two thirds (65.2%) of students discussed near misses or errors with a resident/intern or faculty member. This finding is slightly higher than older reports of resident-initiated discussions with faculty (Wu, Folkman, McPhee, & Lo, 1991) and similar to hypothetical intentions of residents and students reported more recently (Bell et al., 2010). For our sample, a noteworthy new finding is that, when error discussions did occur, students engaged in them with residents (91.6%) rather than faculty (31.0%). Given that most house staff currently have limited formal training in how to discuss medical errors, this result supports current efforts to expand patient safety education at the graduate level (White et al., 2008). Furthermore, better preparing medical students during their formative undergraduate clinical periods to recognize and escalate error discussions should bolster improved performance as students become residents. Recent evidence suggests residents also fail to contact attendings for one third of critical patient events; however, residents reported that when contacted, attendings were open to discussions and discussions led to changes in patient management in one third of discussed cases (ElBardissi et al., 2009). Similarly, in our study, faculty members were involved in fewer than one third of these discussions and other health care team members in less than 1 in 10 of them. Student-driven error discussions provide an opportunity to improve communication and teamwork during authentic health care delivery. This finding underscores the importance not only of teaching information about patient safety and error reporting but also of faculty development for fostering a safer culture by modeling the knowledge and behaviors of patient safety, infused with both formal and explicit as well as informal and implicit learning dimensions, as they occur in the clinical setting (Christakis & Feudtner, 1993; Hafferty, 1998; Hafferty & Franks, 1994; Hafler et al., 2011).

Results also indicate students rarely used the formal reporting method recommended by the medical center (5.5% of events). This outcome is similar to prior studies of medical student-reporting behavior and with descriptions of behavior reported for other health care practitioners (Cullen et al., 1995; Madigosky et al., 2006; O’Connor et al., 2010). Further, this finding is consistent with our attitudinal results, showing a lower percentage of desired attitudes related to disclosure or reporting responsibility and error reporting confidence. Based on these findings, instruction and assessment about error reporting have been incorporated into a recently introduced patient safety curriculum at Virginia Commonwealth University School of Medicine. Further research framed by a theoretical model of the relationship between attitudes and behaviors is needed to understand the predictive or relational nature of patient safety attitudes and subsequent error-reporting behavioral outcomes. Specifically, to understand low reporting rates, the contribution of process factors such as low awareness of formal reporting mechanisms and cumbersome reporting systems, and of cultural factors such as the value of reporting, expectations for reporting, and potential risks to professional relationships or status should be examined.

Our results on willingness to inform other health care personnel of deviations from safe medical practice suggest an influence of the authority gradient on behavior. More than a quarter of sampled students would never inform a faculty member if that faculty member engaged in an unsafe behavior. With our findings about faculty involvement in error reporting and discussion, these results suggest the traditional hierarchy of power remains a major barrier, as suggested in prior studies, to achieving a culture of safety (Feudtner & Christakis, 1994; Gaufberg, Batalden, Sands, & Bell, 2010). This hierarchy is reinforced by expert power, that which is conferred by a faculty position. It may be compounded by the power of reward and the threat of coercion that can accrue in the grading of students (French & Raven, 2001). If patient safety is to be prioritized further and sustained by open communication within health care teams, the influence of power must be better understood, in order to diminish the authority gradient in health care. Students, in particular, must be shown that: (a) errors are not synonymous with negligence, (b) errors can be reported without repercussions, and (c) faculty, despite their power status, respect the roles and contributions of all team members. Interventions that successfully achieve these outcomes need defining and likely include changes to system-level processes paired with targeted educational efforts. If health care providers integrate safety principles into their daily work, transparency will be supported and encouraged and students will feel more comfortable speaking up, even if that means challenging the authority gradient (Johnson et al., 2007).

Limitations of this study include the application of a recently developed attitudinal questionnaire with limited psychometric evidence from outside the United States. In particular, student responses for the item—“If people paid more attention at work, medical errors would be avoided”—are inconsistent with other responses for the Professional Incompetence as Error Cause subscale. This result may suggest a knowledge gap or an issue with the item content; cognitive interviewing with medical students is in process to determine whether this item should be revised or deleted from the instrument in future administrations. In addition, a new questionnaire was developed to assess student behavior around error recognition and reporting and lacks formal validation. This instrument was designed specifically to assess self-report of patient safety reporting behavior. Reporting represents only one patient safety behavior; therefore, these findings do not generalize to all patient safety behaviors. Both instruments rely on student self-report rather than observational measures in the clinical setting, with student self-report measures at-risk for social desirability bias. In addition, the posttest-only design does not enable evaluation of change in attitudes or behaviors. Finally, because graduating students were asked to reflect on past incidents from their clinical education across the third and fourth years of medical school, recall bias may be present. Although observation of student-reporting behavior in the clinical setting presents feasibility challenges, a repeated measures research design with more frequent data collection would decrease the recall time interval, may improve accuracy, and would create opportunities to test for change in attitudes or behaviors.

Conclusions

Our results describe the current state of medical students’ attitudes and behaviors toward patient safety at one U.S. medical school, select influences of medical culture on these attributes, and areas of focus for the design of patient safety curricula. Although most students hold the desired attitudes about patient safety education, the causes of error and the effects of long work hours on safety need greater curricular attention. Also, students’ skills and confidence in error-reporting and disclosure are lacking. These areas should be targeted with formal instruction with assessment of student behavioral outcomes. To expand on student self-report of error recognition and reporting, both process and cultural factors should be considered and standardized patients and simulated encounters may provide valuable data on the success of curricular interventions. Our findings provide further evidence of the influence of the authority gradient on patient safety reporting at the medical student level. Medical students, because they are at such a formative time in their professional development, represent an ideal learner group to target with patient safety education. By focusing patient safety education on identified needs and by measuring the impact on desired student attitudes and behaviors, effective instruction and assessment of students may be designed to provide safer health care and positively influence the culture of medicine.

Footnotes

The author(s) declared no conflicts of interest with respect to the authorship and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr. Mazmanian is supported by award number UL1RR031990 from the National Center for Research Resources and NIH Roadmap for Medical Research, National Institutes of Health.

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