Patients worldwide are unintentionally but avoidably harmed as a result of their interactions with health care [1
]. A global campaign to highlight the patient safety problem and recommend potential solutions is being led by the World Health Organisation (WHO) [2
]. In the United Kingdom (UK), making patient care safer has been an explicit policy priority in the National Health Service (NHS) for over a decade [3
]. Until recently the predominant safety improvement focus was on acute hospital settings where there is well-established evidence of the scale and consequences of adverse health care events [4
]. In UK general medical practice comparable research and knowledge of the nature and impact of avoidable harm is growing, but is methodologically limited compared with secondary care [5
]. However, the emerging evidence from a range of international sources suggests that the safety of general practice may be compromised in a significant minority of cases [7
]. Specialty trainees are known to be involved in a proportion of these incidents largely because of a range of systems, knowledge, cognitive, training and behaviour based reasons.
In the NHS, a raft of interventions designed to make patient care safer are being implemented or are under development. For example: multi-centre collaborative programmes of safety improvement that aim to reduce harm in specific areas of acute hospital care and, more recently, primary care are currently underway [10
]; a high-profile and long-running campaign to minimize healthcare acquired infections is ongoing [11
]; while a concerted attempt to improve the reporting and learning from patient safety incidents has also taken place [12
From an educational perspective, it is now recognised that there is a need for patient safety education to be more explicitly integrated and prominently positioned within existing undergraduate and postgraduate training curricula for all health care professions [13
]. The UK Royal College of General Practitioners (RCGP) - which has responsibility for the content of the specialty training curriculum - has responded by developing a curriculum statement on ‘patient safety’ [14
] and defining specific learning objectives (Table
). However, it is left to individual GP educational supervisors to determine how the RCGP curriculum is best delivered and the related learning needs of trainees are identified and acted upon during the training period. The role of the postgraduate deaneries in this regard is to verify that the evidence provided by training practices to support the delivery of the patient safety element of the curriculum is of an adequate standard.
RCGP Curriculum Learning Outcomes (with examples) related to Patient Safety
Ensuring that all essential educational issues are identified, prioritised and satisfactorily covered during training is not straightforward given the complexity of the tasks to be undertaken and the high volume of topics to be addressed. Within the framework of the RCGP curriculum, GP educational supervisors currently guide the activities undertaken by the trainee using a combination of locally developed induction packs, nationally promoted learning interventions and assessments, and professional experience in the workplace to match across to RCGP curriculum competencies (Table
). However, it is currently unclear how the patient safety-related learning needs of trainees are specifically addressed when in the training environment. Given the lack of standardized guidance on how and what specific learning issues are to be covered, it is possible there is variation in GP educational supervisors’ interpretation and delivery of this safety-critical element of the curriculum at the ‘sharp end’ of frontline educational practice.
A list of the 12 RCGP Curriculum Competencies with descriptions (assessment scale: insufficient evidence; needs further development; competent; and excellent)
Overall there appears to be a paucity of evidence on how postgraduate training in general practice (or lack of) may have a visible and negative impact on the safety of patients – arguably it may be impossible to ever demonstrate clear causation. However, we know that a range of issues connected with the postgraduate training environment may act as proxy indicators of the safety of patient care being compromised unnecessarily and avoidably. For instance, medical educators may be involved in failures of, or inadequate, clinical supervision [15
]; or fail to respond appropriately to trainees’ seeking professional guidance [16
]; or conduct insufficient joint reviews of the management of complex clinical cases [17
]; or provide limited feedback on drug prescribing performance [18
]; and may let poorly developed attitudes and behaviour (such as lack of insight) continue unchecked [19
]. Other salient issues that are potentially safety-critical include trainees’ possessing different levels of clinical knowledge [20
] and an inability to prioritise their clinical workloads and manage time [17
]. The quality of the learning environment in which trainees are based may also affect the safety of patient care [21
], while doctors-in-training are known to be susceptible to medical errors [6
Given what is known about human error theory in the healthcare workplace [23
], and the marked differences in local safety cultures [24
] and the reliability of practice systems [5
], it is inevitable that variation in the quality of training provision exists and that some issues will be inadequately covered or even overlooked completely. If this happens with fundamental training topics which are considered to be safety-critical then there is a likelihood that the risk of patients being harmed and other quality of care issues arising could potentially increase.
Evidence is accumulating from healthcare safety and improvement initiatives that routine adherence to the adoption and use of checklist reminders can improve the overall reliability with which care processes and tasks are undertaken and so potentially mitigate future risks [25
]. Against this background, we aimed to identify and prioritise the most safety-critical issues to be addressed by educational supervisors and trainees in the first 12-weeks of specialty training in the general practice environment – the training period judged to be specifically high risk and beyond which trainees are given greater clinical freedom. In doing this we may help maximize early opportunities to address safety-critical issues proactively via a checklist reminder, which may lead to a reduced risk of patients being unintentionally harmed during and after the training period.