Facilitators and Barriers to Safe Medication Administration to Hospital Inpatients: A Mixed Methods Study of Nurses’ Medication Administration Processes and Systems (the MAPS Study)

Context

Research has documented the problem of medication administration errors and their causes. However, little is known about how nurses administer medications safely or how existing systems facilitate or hinder medication administration; this represents a missed opportunity for implementation of practical, effective, and low-cost strategies to increase safety.

Aim

To identify system factors that facilitate and/or hinder successful medication administration focused on three inter-related areas: nurse practices and workarounds, workflow, and interruptions and distractions.

Methods

We used a mixed-methods ethnographic approach involving observational fieldwork, field notes, participant narratives, photographs, and spaghetti diagrams to identify system factors that facilitate and/or hinder successful medication administration in three inpatient wards, each from a different English NHS trust. We supplemented this with quantitative data on interruptions and distractions among other established medication safety measures.

Findings

Overall, 43 nurses on 56 drug rounds were observed. We identified a median of 5.5 interruptions and 9.6 distractions per hour. We identified three interlinked themes that facilitated successful medication administration in some situations but which also acted as barriers in others: (1) system configurations and features, (2) behaviour types among nurses, and (3) patient interactions. Some system configurations and features acted as a physical constraint for parts of the drug round, however some system effects were partly dependent on nurses’ inherent behaviour; we grouped these behaviours into ‘task focused’, and ‘patient-interaction focused’. The former contributed to a more streamlined workflow with fewer interruptions while the latter seemed to empower patients to act as a defence barrier against medication errors by being: (1) an active resource of information, (2) a passive information resource, and/or (3) a ‘double-checker’.

Conclusions

We have identified practical examples of system effects on work optimisation and nurse behaviours that potentially increase medication safety, and conceptualized ways in which patient involvement can increase medication safety in hospitals.     

Medication Errors in Vietnamese Hospitals: Prevalence,Potential Outcome and Associated Factors

Background

Evidence from developed countries showed that medication errors are common and harmful. Little is known about medication errors in resource-restricted settings, including Vietnam.

Objectives

To determine the prevalence and potential clinical outcome of medication preparation and administration errors, and to identify factors associated with errors.

Methods

This was a prospective study conducted on six wards in two urban public hospitals in Vietnam. Data of preparation and administration errors of oral and intravenous medications was collected by direct observation, 12 hours per day on 7 consecutive days, on each ward. Multivariable logistic regression was applied to identify factors contributing to errors.

Results

In total, 2060 out of 5271 doses had at least one error. The error rate was 39.1% (95% confidence interval 37.8%- 40.4%). Experts judged potential clinical outcomes as minor, moderate, and severe in 72 (1.4%), 1806 (34.2%) and 182 (3.5%) doses. Factors associated with errors were drug characteristics (administration route, complexity of preparation, drug class; all p values < 0.001), and administration time (drug round, p = 0.023; day of the week, p = 0.024). Several interactions between these factors were also significant. Nurse experience was not significant. Higher error rates were observed for intravenous medications involving complex preparation procedures and for anti-infective drugs. Slightly lower medication error rates were observed during afternoon rounds compared to other rounds.

Conclusions

Potentially clinically relevant errors occurred in more than a third of all medications in this large study conducted in a resource-restricted setting. Educational interventions, focusing on intravenous medications with complex preparation procedure, particularly antibiotics, are likely to improve patient safety.     

City Level of Income and Urbanization and Availability of Food Stores and Food Service Places in China

Objective

The contribution of unhealthy dietary patterns to the epidemic of obesity has been well recognized. Differences in availability of foods may have an important influence on individual eating behaviors and health disparities. This study examined the availability of food stores and food service places by city characteristics on city level of income and urbanization.

Methods

The cross-sectional survey was comprised of two parts: (1) an on-site observation to measure availability of food stores and food service places in 12 cities of China; (2) an in-store survey to determine the presence of fresh/frozen vegetables or fruits in all food stores. Trained investigators walked all the streets/roads within study tracts to identify all the food outlets. An observational survey questionnaire was used in all food stores to determine the presence of fresh/frozen vegetables or fruits. Urbanization index was determined for each city using a principal components factor analysis. City level of income and urbanization and numbers of each type of food stores and food service places were examined using negative binomial regression models.

Results

Large-sized supermarkets and specialty retailers had higher number of fresh/frozen vegetables or fruits sold compared to small/medium-sized markets. High-income versus low-income, high urbanized versus low urbanized areas had significantly more large-sized supermarkets and fewer small/medium-sized markets. In terms of restaurants, high urbanized cities had more western fast food restaurants and no statistically significant difference in the relative availability of any type of restaurants was found between high- and low-income areas.

Conclusions

The findings suggested food environment disparities did exist in different cities of China.     

Multi-Morbidity in Hospitalised Older Patients: Who Are the Complex Elderly?

Background

No formal definition for the “complex elderly” exists; moreover, these older patients with high levels of multi-morbidity are not readily identified as such at point of hospitalisation, thus missing a valuable opportunity to manage the older patient appropriately within the hospital setting.

Objectives

To empirically identify the complex elderly patient based on degree of multi-morbidity.

Design

Retrospective observational study using administrative data.

Setting

English hospitals during the financial year 2012–13.

Subjects

All admitted patients aged 65 years and over.

Methods

By using exploratory analysis (correspondence analysis) we identify multi-morbidity groups based on 20 target conditions whose hospital prevalence was ≥ 1%.

Results

We examined a total of 2788900 hospital admissions. Multi-morbidity was highly prevalent, 62.8% had 2 or more of the targeted conditions while 4.7% had six or more. Multi-morbidity increased with age from 56% (65-69yr age-groups) up to 67% (80-84yr age-group). The average multi-morbidity was 3.2±1.2 (SD). Correspondence analysis revealed 3 distinct groups of older patients. Group 1 (multi-morbidity ≤2), associated with cancer and/or metastasis; Group 2 (multi-morbidity of 3, 4 or 5), associated with chronic pulmonary disease, lung disease, rheumatism and osteoporosis; finally Group 3 with the highest level of multi-morbidity (≥6) and associated with heart failure, cerebrovascular accident, diabetes, hypertension and myocardial infarction.

Conclusions

By using widely available hospital administrative data, we propose patients in Groups 2 and 3 to be identified as the complex elderly. Identification of multi-morbidity patterns can help to predict the needs of the older patient and improve resource provision.     

Implementation of Departmental Quality Strategies Is Positively Associated with Clinical Practice: Results of a Multicenter Study in 73 Hospitals in 7 European Countries

Background

Given the amount of time and resources invested in implementing quality programs in hospitals, few studies have investigated their clinical impact and what strategies could be recommended to enhance its effectiveness.

Objective

To assess variations in clinical practice and explore associations with hospital- and department-level quality management systems.

Design

Multicenter, multilevel cross-sectional study.

Setting and Participants

Seventy-three acute care hospitals with 276 departments managing acute myocardial infarction, deliveries, hip fracture, and stroke in seven countries.

Intervention

None.

Measures

Predictor variables included 3 hospital- and 4 department-level quality measures. Six measures were collected through direct observation by an external surveyor and one was assessed through a questionnaire completed by hospital quality managers. Dependent variables included 24 clinical practice indicators based on case note reviews covering the 4 conditions (acute myocardial infarction, deliveries, hip fracture and stroke). A directed acyclic graph was used to encode relationships between predictors, outcomes, and covariates and to guide the choice of covariates to control for confounding.

Results and Limitations

Data were provided on 9021 clinical records by 276 departments in 73 hospitals. There were substantial variations in compliance with the 24 clinical practice indicators. Weak associations were observed between hospital quality systems and 4 of the 24 indicators, but on analyzing department-level quality systems, strong associations were observed for 8 of the 11 indicators for acute myocardial infarction and stroke. Clinical indicators supported by higher levels of evidence were more frequently associated with quality systems and activities.

Conclusions

There are significant gaps between recommended standards of care and clinical practice in a large sample of hospitals. Implementation of department-level quality strategies was significantly associated with good clinical practice. Further research should aim to develop clinically relevant quality standards for hospital departments, which appear to be more effective than generic hospital-wide quality systems.     

Blame the Patient,Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care

Objective

Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model.

Method

Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies.

Results

Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system.

Conclusion

Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.     

Moving towards Routine Evaluation of Quality of Inpatient Pediatric Care in Kenya

Background

Regular assessment of quality of care allows monitoring of progress towards system goals and identifies gaps that need to be addressed to promote better outcomes. We report efforts to initiate routine assessments in a low-income country in partnership with government.

Methods

A cross-sectional survey undertaken in 22 ‘internship training’ hospitals across Kenya that examined availability of essential resources and process of care based on review of 60 case-records per site focusing on the common childhood illnesses (pneumonia, malaria, diarrhea/dehydration, malnutrition and meningitis).

Results

Availability of essential resources was 75% (45/61 items) or more in 8/22 hospitals. A total of 1298 (range 54–61) case records were reviewed. HIV testing remained suboptimal at 12% (95% CI 7–19). A routinely introduced structured pediatric admission record form improved documentation of core admission symptoms and signs (median score for signs 22/22 and 8/22 when form used and not used respectively). Correctness of penicillin and gentamicin dosing was above 85% but correctness of prescribed intravenous fluid or oral feed volumes for severe dehydration and malnutrition were 54% and 25% respectively. Introduction of Zinc for diarrhea has been relatively successful (66% cases) but use of artesunate for malaria remained rare. Exploratory analysis suggests considerable variability of the quality of care across hospitals.

Conclusion

Quality of pediatric care in Kenya has improved but can improve further. The approach to monitoring described in this survey seems feasible and provides an opportunity for routine assessments across a large number of hospitals as part of national efforts to sustain improvement. Understanding variability across hospitals may help target improvement efforts.     

Retropupillary Fixation of Iris-Claw Intraocular Lens for Aphakic Eyes in Children

Purpose

To report outcome, complications and safety of retropupillary fixated iris-claw intraocular lenses in a pediatric population.

Design

Retrospective study.

Patients and Methods

Ten consecutive pediatric patients (15 eyes) underwent placement of retropupillary fixated iris-claw intraocular lenses between October 2007 and July 2013 at the Department of Ophthalmology, Medical University Graz and General Hospital Klagenfurt, Austria. Postoperative visual acuity and complications were analyzed.

Results

Median final best-corrected visual acuity improved by 0.12 logMAR from preoperative baseline. Mean postoperative spherical equivalent was -0.05 ± 1.76 D. No serious complications were observed intra- or postoperatively during the entire follow-up period of up to 40 months. One patient experienced a haptic disenclavation with IOL subluxation immediately after a car accident.

Conclusion

Our study demonstrates that iris-claw intraocular lens implantation behind the iris is safe in children with lack of capsular support and yields excellent visual outcome with low complication rate.     

Patient Characteristics Associated with Measurement of Routine Diabetes Care: An Observational Study

Background

Non-modifiable patient characteristics, including age, gender, ethnicity as well as the occurrence of multi-morbidities, are associated with processes and outcomes of diabetes care. Information on these factors can be used in case mix adjustment of performance measures. However, the practical relevance of such adjustment is not clear. The aim of this study was to assess the strength of associations between patient factors and diabetes care processes and outcomes.

Methods

We performed an observational study based on routinely collected data of 12,498 diabetes patients in 59 Dutch primary care practices. Data were collected on patient age, gender, whether the patient lived in a deprived area, body mass index and the co-occurrence of cardiovascular disease, chronic obstructive pulmonary disease, depression or anxiety. Outcomes included 6 dichotomous measures (3 process and 3 outcome related) regarding glycosylated hemoglobin, systolic blood pressure and low density lipoprotein-cholesterol. We performed separate hierarchical logistic mixed model regression models for each of the outcome measures.

Results

Each of the process measure models showed moderate effect sizes, with pooled areas under the curve that varied between 0.66 and 0.76. The frequency of diabetes related consultations as a measure of patient compliance to treatment showed the strongest association with all process measures (odds ratios between 5.6 and 14.5). The effect sizes of the outcome measure models were considerably smaller than the process measure models, with pooled areas under the curve varying from 0.57 to 0.61.

Conclusions

Several non-modifiable patient factors could be associated with processes and outcomes of diabetes care. However, associations were small. These results suggest that case-mix correction or stratification in assessing diabetes care has limited practical relevance.     

Factors that Influence the Way Communities Respond to Proposals for Major Changes to Local Emergency Services: A Qualitative Study

Objective

According to policy commentators, decisions about how best to organise care involve trade-offs between factors relating to care quality, workforce, cost, and patient access. In England, proposed changes such as Emergency Department closures often face public opposition. This study examined the way communities respond to plans aimed at reorganising emergency services, including the trade-offs inherent in such decisions.

Design

Cross-sectional study involving in-depth interviews. Participants selected their priorities for emergency care, including aspects they might be prepared to have ‘less’ of (e.g. rapid access) if it meant having ‘more’ of another (e.g. consultant-delivered care). A thematic analysis was carried out, combining inductive and deductive approaches, drawing on theories about risk perception.

Setting

Two urban areas of England; one where changes to emergency services were under consideration (‘Greenville’), and one where they were not (‘Hilltown’).

Participants

28 participants in total. Greenville interviewees included more common emergency service users - parents of young children (n=5) and older people (n=6) - plus patient representatives and individuals campaigning against service closures (n=9). Hilltown interviewees (n=8) received outpatient care for Chronic Obstructive Pulmonary Disease, an important cause of emergency admission.

Results

Most participants, in both areas, were not willing to accommodate the trade-offs involved in consolidating emergency services, principally because of the belief that timely access is associated with better outcomes. Participants did not consider the proposed improvements as gains worth having; interviewees believed care quality would be adversely impact, partly because increased patient numbers would place staff under greater pressure and result in longer waiting times.

Conclusions

Visible clinical leadership and detailed explanation of the case for change were insufficient to overcome opposition to the reconfiguration in Greenville, challenging the assumption that communities can be persuaded by evidence. Commissioners should make explicit credible plans to accommodate changes in patient flows, as well as clarifying the roles played by key staff groups.     

Puumala Hantavirus-Induced Hemorrhagic Fever with Renal Syndrome Must Be Considered across the Borders of Nephrology to Avoid Unnecessary Diagnostic Procedures

Background

Nephropathia epidemica (NE), a milder form of hemorrhagic fever with renal syndrome, is caused by Puumala virus and is characterized by acute kidney injury and thrombocytopenia.

Methods

A cross-sectional prospective survey of 456 adult patients with serologically confirmed NE was performed.

Results

Of the 456 investigated patients, 335 had received inpatient treatment. At time of admission to hospital, 72% of the patients had still an AKI and thrombocytopenia was present in 64% of the patients. The 335 patients were treated in 29 different hospitals and 6 of which had nephrology departments. 10 out of 335 patients received treatment in university hospitals and 63% of patients admitted themselves to hospital. Initially, the patients were admitted to 12 different clinical departments (29% of the patients were referred to a nephrology department) and during the course of the disease, 8% of the patients were transferred to another department in the same hospital and 3% were transferred to a nephrology department at another hospital. Regarding diagnostic procedures, in 28% of the inpatients computed tomography to exclude pulmonary embolism or due to severe gastrointestinal symptoms, lumbar puncture to exclude meningitis, magnetic resonance tomography of the brain owing to suspected stroke because of visual disorders, gastroscopy, or colonoscopy due to gastrointestinal symptoms was performed at time of admission to hospital.

Conclusions

NE must be considered by physicians across the borders of nephrology to avoid unnecessary diagnostic procedures especially in areas where NE is endemic.     

Identifying Patients with Bacteremia in Community-Hospital Emergency Rooms: A Retrospective Cohort Study

Objectives

(1) To develop a clinical prediction rule to identify patients with bacteremia, using only information that is readily available in the emergency room (ER) of community hospitals, and (2) to test the validity of that rule with a separate, independent set of data.

Design

Multicenter retrospective cohort study.

Setting

To derive the clinical prediction rule we used data from 3 community hospitals in Japan (derivation). We tested the rule using data from one other community hospital (validation), which was not among the three “derivation” hospitals.

Participants

Adults (age ≥ 16 years old) who had undergone blood-culture testing while in the ER between April 2011 and March 2012. For the derivation data, n = 1515 (randomly sampled from 7026 patients), and for the validation data n = 467 (from 823 patients).

Analysis

We analyzed 28 candidate predictors of bacteremia, including demographic data, signs and symptoms, comorbid conditions, and basic laboratory data. Chi-square tests and multiple logistic regression were used to derive an integer risk score (the “ID-BactER” score). Sensitivity, specificity, likelihood ratios, and the area under the receiver operating characteristic curve (i.e., the AUC) were computed.

Results

There were 241 cases of bacteremia in the derivation data. Eleven candidate predictors were used in the ID-BactER score: age, chills, vomiting, mental status, temperature, systolic blood pressure, abdominal sign, white blood-cell count, platelets, blood urea nitrogen, and C-reactive protein. The AUCs was 0.80 (derivation) and 0.74 (validation). For ID-BactER scores ≥ 2, the sensitivities for derivation and validation data were 98% and 97%, and specificities were 20% and 14%, respectively.

Conclusions

The ID-BactER score can be computed from information that is readily available in the ERs of community hospitals. Future studies should focus on developing a score with a higher specificity while maintaining the desired sensitivity.     

A Clinical Trial to Introduce Voluntary Medical Male Circumcision for HIV Prevention in Areas of High Prevalence in the Dominican Republic

Background

Voluntary Medical Male Circumcision (VMMC) is an effective strategy to reduce the risk of HIV infection. Studies conducted in the Dominican Republic (DR) suggest that acceptability of VMMC among men may be as high as 67%. The goal of this clinical trial was to assess the acceptability, uptake and safety for VMMC services in two areas of high HIV prevalence in the country.

Methods

This was a single-arm, non-randomized, pragmatic clinical trial. Study personnel received background information about the risks and benefits of VMMC and practical training on the surgical technique. A native speaking research assistant administered a questionnaire of demographics, sexual practices and knowledge about VMMC. One week after the surgery, participants returned for wound inspection and to answer questions about their post-surgical experience.

Results

539 men consented for the study. Fifty seven were excluded from participation for medical or anatomical reasons and 28 decided not to have the procedure after providing consent. A total of 454 men were circumcised using the Forceps Guided Method Under Local Anesthesia. The rate of adverse events (AE) was 4.4% (20% moderate, 80% mild). There were no serious AEs and all complications resolved promptly with treatment. Eighty eight percent of clients reported being “very satisfied” and 12% were “somewhat satisfied” with the outcome at the one-week postoperative visit.

Conclusions

Recruitment and uptake were satisfactory. Client satisfaction with VMMC was high and the rate of AEs was low. Roll out of VMMC in targeted areas of the DR is feasible and should be considered.

Trial Registration

ClinicalTrials.gov NCT02337179     

Trends in Cardiac Biomarker Testing in China for Patients with Acute Myocardial Infarction, 2001 to 2011: China PEACE-Retrospective AMI Study

Objectives

To describe trends in the availability of biomarker testing in Chinese hospitals and how practice complies with established standards for the diagnosis of acute myocardial infarction (AMI).

Background

Cardiac biomarker testing is standard in high-income countries, but little is known about the availability and use of cardiac biomarker testing in low- and middle-income countries (LMICs) such as China.

Methods

Based on a nationally representative sample of Chinese hospitals in 2001, 2006 and 2011, we describe the temporal trends and regional differences in the hospital capability and rates of use of cardiac biomarker testing, as well as the variation in use across hospitals with testing capability, for patients labeled with the diagnosis of AMI.

Results

We sampled 175 hospitals (162 participated in the study) and 18,631 AMI admissions. 14,370 patients were included in analysis of biomarker use. The proportion of hospitals with biomarker testing capability was 57.4% in 2001 (25.0% troponin and 32.4% creatine kinase MB fraction (CK-MB) only) and 96.3% (81.4% troponin and 14.9% CK-MB only) in 2011. The proportion of hospitals with troponin testing capability in 2011 was significantly higher in urban compared with rural hospitals (96.8% vs. 71.4%, p< 0.001). In 2011, only 55.9% of hospitals with troponin testing capability (71 out of 127 hospitals) used the assay for more than 80% of their patients with AMI. Among hospitals with either biomarker testing capability, there was marked variation in use in both rural (from 7.1% to 100.0% of patients) and urban hospitals (from 57.9% to 100.0% of patients). In 2011, 36.1% of the patients with AMI did not have troponin tested and 4.9% did not have either biomarker measured.

Conclusions

The recommended biomarker tests for AMI diagnosis are not universally available and the testing is not consistently applied when it is available in China.

Trial Registration

ClinicalTrials.gov NCT01624883     

The Menace of Schistosomiasis in Nigeria: Knowledge,Attitude, and Practices Regarding Schistosomiasis among Rural Communities in Kano State

Background

Schistosomiasis is one of the most common neglected tropical diseases, especially in the developing countries in Africa, Asia and South America, with Nigeria having the greatest number of cases of schistosomiasis worldwide. This community-based study aims to evaluate the knowledge, attitude and practices (KAP) regarding schistosomiasis among rural Hausa communities in Kano State, Nigeria.

Methods

A cross-sectional study was carried out among 551 participants from Hausa communities in five local government areas in Kano State, North Central Nigeria. Demographic, socioeconomic and environmental information as well as KAP data were collected using a pre-tested questionnaire. Moreover, faecal and urine samples were collected and examined for the presence of Schistosoma mansoni and S. haematobium eggs respectively.

Results

The overall prevalence of schistosomiasis was 17.8%, with 8.9% and 8.3% infected with S. mansoni and S. haematobium respectively, and 0.5% had co-infection of both species. Moreover, 74.5% of the participants had prior knowledge about schistosomiasis with 67.0% of them how it is transmitted and 63.8% having no idea about the preventive measures. Three-quarters of the respondents considered schistosomiasis a serious disease while their practices to prevent infections were still inadequate, with only 34.7% of them seeking treatment from clinics/hospitals. Significant associations between the KAP and age, gender, education and employment status were reported. Multiple logistic regression analysis revealed that age, gender, history of infection and educational level of the respondents were the most important factors significantly associated with the KAP on schistosomiasis among this population.

Conclusions

Schistosomiasis is still prevalent among Hausa communities in Nigeria and participants’ knowledge about the disease was poor. Mass drug administration, community mobilization and health education regarding the cause, transmission and prevention of schistosomiasis and education about good personal and sanitary hygiene practices should be considered in order to significantly reduce the prevalence and morbidity of infection within these communities.     

Field Test of the World Health Organization Multi-Professional Patient Safety Curriculum Guide

Introduction

Although the importance of training in patient safety has been acknowledged for over a decade, it remains under-utilized and under-valued in most countries. WHO developed the Multi-professional Patient Safety Curriculum Guide to provide schools with the requirements and tools for incorporating patient safety in education. It was field tested with 12 participating schools across the six WHO regions, to assess its effectiveness for teaching patient safety to undergraduate and graduate students in a global variety of settings.

Methods

The evaluation used a combined prospective/retrospective design to generate formative information on the experiences of working with the Guide and summative information on the impacts of the Guide. Using stakeholder interviews and student surveys, data were gathered from each participating school at three times: the start of the field test (baseline), soon after each school started teaching, and soon after each school finished teaching.

Results

Stakeholders interviewed were strongly positive about the Guide, noting that it emphasized universally important patient safety topics, was culturally appropriate for their countries, and gave credibility and created a focus on patient safety at their schools. Student perceptions and attitudes regarding patient safety improved substantially during the field test, and their knowledge of the topics they were taught doubled, from 10.7% to 20.8% of correct answers on the student survey.

Discussion

This evaluation documented the effectiveness of the Curriculum Guide, for both ease of use by schools and its impacts on improving the patient safety knowledge of healthcare students. WHO should be well positioned to refine the contents of the Guide and move forward in encouraging broader use of the Guide globally for teaching patient safety.