integrasi patient safety ke dalam kurikulum keperawatan#uswatun uin jakarta

Teaching Patient Safety in Nursing Education: A Literature Review

Uswatun Khasanah, Ns., MNS1

Abstract

Patient safety is now gaining more attention not only in clinical setting but also in academic. The patient safety should be introduced since in the academic process. WHO is very concerned about the topic so they publish the WHO patient safety curriculum guide for medical school. However that guide also very useful for nursing education. The purpose of this paper is to find out the patient safety topics, give an idea of how to enter patient safety concepts into nursing education and provides examples of the patient safety learning activities.

A literature review approach is used to develop the paper. Literatures mostly is obtained from internet sources, however only literature from the credible sources is assessed.

As results are: there are 7 learning categories introduced by Australian Patient Safety Education Framework (a. communicate effectively, b. using evidence, c. adverse events, d. working safely, e. being ethical, f. learning and teaching, g. specific issues) and 11 major topics from WHO (1. what is patient safety?, 2. what are human factors and why is it important to patient safety?, 3. understanding systems and the impact of complexity on patient care?, 4. understanding systems and the impact of complexity on patient care? 5. being an affective team player, 6. understanding and learning from errors, 7. introduction to quality improvement methods, 8. engaging with patients and careers, 9. minimizing infection through improved infection control, 10. patient safety and invasive procedures, 11. improving medication safety). Those patient safety topics can be integrated into existing curriculum or as a standalone subject that could be gradually delivered start from year 1 up to 4. The patient safety can be delivered through lectures, skills laboratories, problem based learning, tutorial, clinical placement, or electronic learning.

As conclusions are teaching the patient safety involves modifications to curricula content, facilitation of multidisciplinary processes, and inclusion of theory and practice that reflect critical inquiry into healthcare and nursing education systems to ensure patient safety. Furthermore, patient safety

1 Lecture, School of Nursing Faculty of Medicine and Health Sciences, Syarif Hidayatullah State Islamic University Jakarta, Jln. Kertamukti Pisangan Ciputat 15419 Tangerang Selatan Telp. 021 7471678 Email: [email protected]

Teaching patient safety in nursing education: A Literature review# Uswatun Khasanah, Ns., MNS 1

mailto:[email protected]

should be introduced to the nurse student since in the beginning of education.

Keywords: Patient safety, nursing education, teaching strategy, nursing curriculum

IntroductionIn 1999, the Institute of Medicine (IOM) estimated that between 44,000

and 94,000 Americans die in hospitals each year due to medical error at a cost of over $29 billion (Effken & Carty, 2002). The center for Disease Control estimated that sepsis arising from the insertion of central venous line affects up to 250,000 patients a year in the United States, killing 15% or more (Freeth et al., 2005). Due that reason creating a culture of safety in health care systems is a goal of leaders in the patient safety (Neudorf et al., 2008).

The Institute of Medicine has brought public awareness to the growing issue of medical errors with its focused research on the extent to which errors occur in healthcare organizations. With the important of patient safety now is growing awareness so that many health institutions laid out a vision for how the healthcare system and related policy environment must be radically transformed in order to close the chasm between what we know to be good quality care and what actually occurs. When it comes to quality, we all know what a vital role nurses play – and the challenges they face – in providing safe, high-quality patient care (McKesson Corporation, 2004). Furthermore, McCutcheon et al. (2005) state as nurses constitute the largest segment of care providers within healthcare systems, the potential impact of nurse on patient safety is very large and Hughes (2008) nurses are the health care professionals most likely to intercept errors and prevent harm to patients.

The data below is shown on adverse events in health care from several countries. From the data indicate that actions to reduce adverse events are urgent for the health care systems.

Table 1: Data on adverse events in health care from several countries

No

Study Study Focus (date of admissions)

Number of hospital

admissions

Number of adverse events

Adverse event rate

(%)

1 United States(Harvard Medical Practice Study)

Acute care hospitals (1984)

30 195 1 133 3,8


No

Study Study Focus (date of admissions)

Number of hospital

admissions

Number of adverse events

Adverse event rate

(%)

2 United States(Utah-Colorado study)


14 565 475 3,2

3 United States(Utah-Colorado study)a


14 565 787 5,4

4 Australia (Quality in Australian Health Care Study)


14 179 2 353 16,6

5 Australia (Quality in Australian Health Care Study)b

Australia (Quality in Australian Health Care Study) (1992)

14 179 1 499 10,6

6 United Kingdom Acute care hospitals (1999-2000)

1 014 119 11,7

7 Denmark Acute Care hospitals (1998)

1 097 176 9,0

Source: WHO, Executive Board 109th session, provisional agenda item 3,4,5 December 2001, EB 109/9

Reducing adverse events and improving the quality of health care for the community can be achieved with well-prepared health care workers who have the intention to and are ready to work safely. Health care workers who are educated and trained to work together can reduce risks to patients, themselves and their colleagues and when they manage incidents proactively and maximize opportunities to learn from adverse events and near misses. Organizations also have a responsibility to provide the appropriate systems and support to enable their workforce to learn and apply the skills and knowledge required for patient safety (ACSQHC, 2005).

The paragraph above indicates that patient safety is everybody’s business, this including the students such as medical student as well as nursing students (Seiden et al., 2006). Nursing students can be involved in events that contribute to the harm of a patient. Adverse events involving medications are common during students’ clinical learning experiences. Beginning students are surprised to learn that the healthcare system is experiencing a vulnerable system syndrome and students expect that illness and injury will be alleviated, not introduced, in healthcare settings (Neudorf et al. 2008).


According Neudorf et al. (2008) the nursing education system has a responsibility to alert nursing students to the realities of healthcare systems and to prepare them to practice with the competencies necessary to make surveillance, reporting, and analyzing common practice. This article will describes example how to integrating patient safety in the learning process for undergraduate nursing program, the patient safety topics, and patient safety teaching strategies.

The purpose of this paper is to find out the patient safety topics, give an idea of how to enter patient safety concepts into nursing education and provides examples of the patient safety learning activities. A literature review approach is used to develop the paper. Literatures mostly is obtained from internet sources, however only literature from the credible sources is assessed.

Patient Safety Concept

Patient safety is a relatively new discipline and producing any new material into existing medical curriculum is always challenging, this include what should be taught? Who should teach teach it? Where and how will it fit in with the rest of the curriculum? What does it replace? (WHO, 2009). The IOM (The institute of Medicine) define the patient safety is “the prevention of harm to patients” (Mitchell, 2008). Emphasis is placed on the system of care delivery that (1) prevents errors; (2) learns from the errors that do occur; and (3) is built on a culture of safety that involves health care professionals, organizations, and patients (Clancy in Mitchell 2008).

In line with Clancy’s definition of patient safety, the AHRQ (2001) define the patient safety as a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures. This definition is consistent with the dominant conceptual framework in patient safety, which holds that systemic change will be far more productive in reducing medical errors than will targeting and punishing individual providers. The definition’s focus on actions that cut across diseases and procedures also allowed the research team to distinguish patient safety activities from the more targeted quality improvement practices

WHO (2009) define that patient safety is a broad subject incorporating the latest technology such as electronic prescribing and redesigning hospitals and services to washing hands correctly and being a team player. Furthermore patients are not only harmed by the misuse of technology, they


can also be harmed by poor communication between different health-care providers or delay in receiving treatment.

Mitchell (2008) classified the type of errors and harm regarding domain of where the errors and harm occurred across the spectrum of health care providers and settings, they are:

1. Latent failure—removed from the practitioner and involving decisions that affect the organizational policies, procedures, allocation of resources

2. Active failure—direct contact with the patient3. Organizational system failure—indirect failures involving management,

organizational culture, protocols/processes, transfer of knowledge, and external factors

4. Technical failure—indirect failure of facilities or external resourcesIn conclusion is patient safety is an important component of high quality

health care. Nurses are having a critical role to the surveillance and coordination to reduce patient harm.

Contents of patient safety course

The Australian Council for Safety and Quality in Health Care published the National Patient Safety Education Framework (NPSF) (ACSQHC; WHO, 2009). The NPSF has been adopted by WHO in developing the curriculum guide on patient safety for medical school (WHO, 2009) and also useful for developing the curriculum for nursing education, and it has been used by the School of Nursing (Gregory, 2008; The Australian Commission on Safety and Quality in Health Care (ACSQH), 2005). NPSF published in 2005, the framework is a simple, flexible, and accessible template describing the knowledge, skills, and behaviors that all health-care workers need to ensure safe patient care. The framework is divided into level of knowledge, skills, and behaviors depending on a person’s position and clinical responsibility in an organization (WHO, 2009). The following are competencies in NPSF plus WHO topics in order to provide safe care:

Tabel 2: APSEF plus WHO topics

APSEF Topic Included in

curriculum

WHO Topic

Communicating effectively


APSEF Topic Included in

curriculum

WHO Topic

Involving patients and careers as partner in health care yes Topic 8Communicating risk yes Topic 6Communicating honestly with patients after an adverse event (open disclosure)

yes Topic 8

Obtaining consent no Highly likely already covered

Being culturally respectful and knowledgeable yes Topic 8Identifying, preventing and managing adverse events

and near missesRecognizing, reporting and managing adverse events and near misses

yes Topic 6,7

Managing risk yes Topic 6Understanding health care errors yes Topic 1,5Managing complaints yes Topic 6,8

Using evidence and informationEmploying best available evidence-based practice noUsing information technology to enhance safety no

Working safelyBeing a team player and showing leadership yes Topic 4Understanding human factors yes Topic 2Understanding complex organizations yes Topic 3Providing continuity of care Not directly

coveredManaging fatigue and stress yes Topic 2, 6Being ethicalMaintaining fitness to work or practice yes Topic 6Ethical behavior and practice yes Topic 1,6

Continuing learningWorkplace learning noWorkplace teaching no

Specific issuesPreventing wrong site, wrong procedure and wrong patient treatment

yes Topic 10

Medicating safely yes Topic 11Infection control (not part of Australian framework) yes Topic 9

Source: WHO (2009). WHO patient safety curriculum guide for medical schools


While NPSF divide the patient safety into 7 learning areas (categories), WHO (2009) divided the patient safety curriculum into 11 topics, those are:1. What is patient safety?2. What are human factors and why is it important to patient safety?3. Understanding systems and the impact of complexity on patient care?4. Understanding systems and the impact of complexity on patient care?5. Being an affective team player6. Understanding and learning from errors7. Introduction to quality improvement methods8. Engaging with patients and carers9. Minimizing infection through improved infection control10. Patient safety and invasive procedures11. Improving medication safety.

In addition to the framework above that published by WHO (2009) and NPSF (2005), the Canadian Patient Safety Institute (CPSI) propose the development of the Canadian Safety Competencies Framework. The draft Canadian framework consists of six domains, those are:1. Contribute to a culture of patient safety.2. Work in teams for patient safety.3. Communicate effectively for patient safety.4. Manage safety risks.5. Optimize human and environmental factors.6. Recognize, respond to and report adverse events.

Sandars et al. (2007) also identified the areas of patient safety topics are approaches to increase knowledge of patient safety including the causes and frequency, to develop willingness to take responsibility, to develop self awareness of the situation when patient safety is compromised, to develop communication skills especially inter-personal, and develop team working skills and Anderson et al. (2009) add topics about safe prescribing and procedures and skills for dealing with the outcomes of errors. The topics of safe prescribing may be more appropriate for the medical students. Topics mentioned above can be a guide in developing curriculum related to patient safety.

Integrating the patient safety into curriculumThe early step in integrating the patient safety into curriculum is to

review the curriculum for patient safety learning. The steps in reviewing the curriculum are: 1) Identify the learning outcomes for patient safety, 2) know


what is already in the medical curriculum. Before new material is introduced into a curriculum it is important to know what curriculum already exist as well as student’s clinical experiences in the hospitals and/or the different clinical environment. Getting a picture of existing material in the medical curriculum is necessary to identify those opportunities for enhancing patient safety teaching. 3) Build on what is already in the curriculum. A good approach to patient safety education is to enhance existing parts of the curriculum or integrate the patient safety education into overall curriculum rather than see patient safety as a new subject to teach (Moamary, 2010; WHO, 2009).

The field of patient safety is also very broad. Given this breadth and the need for contextualizing patient safety principles, there are many opportunities to incorporate effective patient safety education into existing sessions (Moamary, 2010; Sandars et al., 2007). If the curriculum in the school is traditional, the knowledge and performance requirements of patient safety are best taught in later years when students have more knowledge of the clinical disciplines, exposure to patients and clinical skills training. The context for the knowledge and performance requirements should match the students ability to put into practice their new knowledge. Introductory patient safety knowledge can still be included in the early years in subject such as publich health, epidemiology, ethics or other behavioral science-based subjects (WHO, 2009).

There suggestion if the curriculum is integrated and students are taught clinical skills from the first year, then patient safety topics are best introduced early and vertically integrated throughout the entire course (Sandars, 2007). This provides opportunities to reinforce and build upon earlier learning. Furthermore any clinical discipline can potentially house of a patient safety topics if a sample care is part of the session and is relevant to that discipline. (WHO, 2009).

Many School of Medicine or School of Nursing already integrate patient safety into their curriculum, just for example is College of Medicine, King Saud bin Abdulaziz University of Health Sciences (KSAU-HS). This College of Medicine uses the WHO patient safety framework in their curriculum. They integrate the 11 topics of WHO patient safety in their curriculum (Moamary, 2010).

In College of Medicine KSU-HS, the early steps in implantation included identifying learning outcomes, mapping patient safety to existing curriculum and the assessing capacity within the faculty to deliver the patient safety curriculum and engaging in capacity building work. Decision regarding delivery of patient safety material will depend on the nature and content of


existing curriculum, which is matched to current educational formats. The number of topics covered is increased over time to ease implementation. Some aspect of patient safety linked in well with existing subjects and can be incorporated into existing sessions, patient safety in incorporated mostly in the professional development themes (Moamary, 2010).

A topic in patient safety may be taught not only in one subject, rather can be taught in several subjects. However, some areas of patient safety are relatively new to medicine and may not be easy to graft onto an existing sessions and hence are likely to need own time slot in the curriculum (WHO, 2009). Furthermore WHO (2009) suggest that broad knowledge of patient safety principles can still be effectively introduced in the early years. The topics that suitable for early introduction include (i) what is patient safety, (ii) introduction to human factors engineering, and (iii) systems and complexity in health care.

Patient Safety Education ActivitiesThe learning domain in patient safety including: knowledge, skills, and

behaviors (Mayer et al., 2009). May each topic in patient safety have different learning domain and also some of the topics may be already be covered in nursing curriculum. From the study of Seiden et al. (2006) shows the types of harm can be prevented by students included averting non-sterile conditions, missing medications, mitigating exposure to highly contagious patients, and respecting patients’ do not resuscitate” requests.

Patient safety education can be meaningful to students by placing the principle in the context with their current and future practical role, using relevant examples of safety and giving students an opportunity to practice their patient safety knowledge and skills. The experiences of College of Medicine KSAU-HS in patient safety education activities including lectures, ward round-based teaching, small group learning, case based discussion, independent study, patient tracking, role play, simulation, and undertaking improvement projects. Each of these has benefits and challenges and different methods are appropriate for different learning goals (Moamary, 2010)

Below are examples of education activities that can be used to deliver the patient safety topics:1. Lectures

A lecture is an oral presentation intended to present information or teaches people about a particular subject. Topic about the concepts is relevant in lecture. Any clinical discipline can potentially house a patient safety topic if a sample case is part of the session and is relevant to that


discipline (WHO, 2009). Although the main focus of the session is not a patient safety topic, elements of patient safety education are weaved into the session. For this to occur, session objectives should include an element of patient safety.

2. Clinical placementsClinical placement is very relevant to practice patient safety. Clinical placement may offer opportunities to practice performance elements of patient safety, it is important that good habits be developed early. As Seiden et al (2006) stated that the students often observe the error in clinical setting, so student should be educated with how to prevent error in the clinical setting. Clinical placement may provide opportunities for students to learn about and practice the following patient safety performance elements:

- Communicating risk- Asking permission- Accepting refusal- Being honest with patients- Empowering patients-helping patients be active participants in their

own care- Keeping patients and relatives informed- Hand hygiene- Patients-centered focus during history taking and physical

examination- Clinical reasoning-diagnostic error, consideration of risk benefit ratio

of procedures, investigation and management plans.3. Online activities

Online activities can be used to teach patient safety topics. The activities here can be assignments, searching the evident, or may be as a useful tool to discuss the patient safety topics with the resource person. Another example is students are assigned to identify learning needs of patients/clients she/he is assigned to that dayand to search for web sites that address that needs (Day, 2007). The patient safety issues can be included as the learning needs.

4. On ward activitiesTeaching that occurs in the context of ward rounds or in bedside teaching sessions. As the patient safety issues are everywhere in the clinical environment, thus this ward based teaching provides one of the best opportunities to teach and observe history and examination skills as well as communication and interpersonal skills. However often the teacher is


lack of time due to work pressure or lack of knowledge of how to incorporate patient safety topics into bedside teaching.

5. Small group discussionLearning done in the setting of a small group, usually with a tutor. The main feature is student participation and interactivity, used in relation to a particular problem, with student to be responsible for own learning (WHO, 2009).

6. Problem-based learning (PBL)Many topics on patient safety can be as a case to be discussed in problem-based learning. WHO (2009) suggests that the best learning occurs when the case study used reflects local experiences. For PBL session the clinical case needs to be written in a way that promotes curiosity and discussion relating patient safety. In addition to a well written case, clearly stated learning objectives help keep students’ discussion on the intended path.

7. Skills laboratoriesInvasive procedures have the potential to harm patients. Procedure can cause harm trough complications, pain, and emotional distress, not being effective and not being necessary in the first place. Integrating patient safety education with procedural skills training at an undergraduate level will help students to be mindful of their responsibilities to patients when embarking on invasive procedures. Some of the patient safety topics that relevant for all procedures (WHO, 2009): 1. The learning curve. Understand that an inexperienced clinician is more

likely to cause harm and/or fail a procedure compared to an experienced clinician. What strategies can be used to help minimize harm while still allowing for learning to take place: for example, the role of careful preparation, planning, background knowledge, observation of others performing the procedure, simulation, supervision, feedback and follow up patients.

2. What is the required background knowledge to acquire about a procedure before undertaking that procedure

3. Sterile precaution4. Communicating risk 5. Correct patient identification, correct site, correct patient6. Follow up of test result

And bellow is the patient safety knowledge and skills applied to performance of specific procedures:

1. Common problems/hazard/traps, trouble shooting


2. Common and serious complications and how to minimize3. Advice for patients regarding follow-up4. Equipment familiarity5. Specific application of broad patient safety topics

Below is the sample from the University of Florida College of Nursing, in how to integrate the patient safety into check list of skills laboratory.

Injection skill Students will check off individually and have 10 minutes to perform ONE of the injection procedure selected at random by the faculty: Verifies correct patient Introduction to the patient Washes hands (may verbalize) Inquires about history of

allergies

Insulin SQ injection Administration with mixed insulin: verifies order prior to administration demonstration sheath use (if syringe has sheath) verifies the 5 rights chooses correct site for administration (faculty choice) chooses correct syringe Dons clean gloves correctly prepares vial correctly cleanses site (circular motion from center) adds correct amount of air to both vials (NPH vial first) correctly administer injection withdraws correct amount of regular insulin first correctly disposes sharps and contaminated material withdraws correct amount of NPH insulin second verbalize the need to wash hands (does not contaminate NPH vial) correctly documents injection admin on MAR demonstrate safe recap

Need to retake YES NO* Drawing up incorrect dose= automatic check off failure* Injection incorrect site = automatic check off failure* Recapping used needle= automatic check off failure

Another example is using the patient simulation in teaching the patient safety. She explains that use of the patient simulator as an instructional strategy holds great promise for nursing education. Simulation can become an integral part of nursing education because of its ability to improve patient care and patient safety. No live patients are placed in jeopardy at the


expense of the learner. Simulation provides standardization of cases, promotes critical thinking, allows mastery of patient care, provides immediate feedback, and helps students integrate knowledge and experience. It is an ideal synthesis learning experience for patients safety (Durham & Alden, 2008). Those two writers also state that the use of simulation as a teaching strategy can contribute to patient safety and optimize outcomes of care, providing learners with opportunities to experience scenarios and intervene in clinical situations within a safe, supervised setting without posing a risk to a patient.

8. Project workA project work for students can be used to teach patient safety. The activities such as the teacher assigns student to observe the clinical setting regarding the patient safety issues.

9. SimulationSimulation is defined as an educational technique that allows interactive, and at times immersive activity by recreating all or part of clinical experience without exposing patients to the associated risks. A number of different simulation modalities are available, including (WHO, 2009):

- Screen-based computer simulators- Low tech models or mannequins used to practice simple physical

maneuvers- Standardized patients (patient actors)- Sophisticated computerized (realistic) full body patient mannequin

simulators- Virtual reality devices

10. Practical workshopPractical workshop can be designed for incorporating patient safety issues are the realistic situations that mirror many real-life challenges that can emerge from the scenario. WHO (2009) gives an example knowing what to do in an emergency situation is different from actually doing it, especially when working as part of a team. The real elements introduced are time pressure, stress, teamwork, communication, equipment familiarity, decision-making in action and knowing the environment.

11. Role PlayRole-play is learning how to best handle a situation by practicing interactions and trying out different approaches. Role play allows student to act out of roles of health care professional in particular situation. Students may act out situations, problems, and issues in a safe setting and develop skills that promote patient safety.


12. Interprofessional studyMayer et al. (2009) dan Sandars et al. (2007) emphasized that interprofessional education should be a cornerstone of curricula for health science students and that interprofessional education should be introduced early in the educational process Anderson et al (2009) stated although students more comfortable when study alongside other medical students, those who learned with other disciplines such as nursing students, gained added values from the interaction and were able to frame thinking more clearly within the context of safe interprofessional team working. In addition, students need to both understand and experience firsthand the fact that “interprofessional learning consists of more than just sharing the same learning environment: it involves acquiring an understanding of the knowledge based, values, and ethos of like-minded individuals and developing respects for each others’ contribution to the learning process so that the patients outcome are more likely to receive safe, quality care (Mayer, 2009, Gregory, 2008)

13. Independent studyStudy undertaken by the student on their own, e.g assignment work, essay

ConclusionAs conclusions are teaching the patient safety involves modifications to curricula content, facilitation of multidisciplinary processes, and inclusion of theory and practice that reflect critical inquiry into healthcare and nursing education systems to ensure patient safety. Furthermore, patient safety should be introduced to the nurse student since in the beginning of education.

ReferencesACSQHC The Australian Council for Safety and Quality in Health Care. (2005).

National Patient Safety Education Framework. Canberra: Australia. Retrieved July 25, 2010 from http://www.safetyandquality.org/framework0705.pdf

AHRQ- Agency for Healthcare Research and Quality. (2001). Making Health Care Safer: A Critical Analysis of Patient Safety Practices- Evidence Report/Technology Assessment No. 43. Rockville: U.S. Department of Health and Human Services. Accessed at 09 August 2010 from: www.ahrq.gov


http://www.ahrq.gov/

http://www.safetyandquality.org/framework0705.pdf

Anderson, E., Thorpe, L., Heney, D., & Peterson. (2009). Medical students benefit from elarning about patient safety in an interprofessional team. Medical Education. 43: 542-552.

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Durham, C. Integrating quality and safety (QSEN) content into skills and simulation curricula. The University of North Carolina at Chapel Hill.

Durham, C.F., & Alden, K.R. (2008). Enhancing Patient Safety in Nursing Education Through Patient Simulation in Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Ronda, G.H. (editor). Rockville: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services.

Effken, J.A., & Carty, B. (2002). The era of patient safety: Implications for nursing informatics curricula. Journal of Am Med Inform Assoc. 120-123.

Freeth, D., Hammick, M Reeves S. Koppel I, Barr H. (2005). Effective interprofessional education-Development, Delivery, and Evaluation. Oxford: Blackwell Publishing.

Gregory, D. (2008). Patient safety and the management of adverse health event education curriculum. A Background Paper Prepared for the Task Force on Adverse Health Events December 2nd 2008. Accessed at 8 August 2010 from http://www.gov.nl.ca/ahe/additions/index.html

Hughes, R.G. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ Publication No. 08-0043. Rockville: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services.

Mayer, D., Klamen, D.L., Gunderson, A., Barach, P. (2009). Designing a patient safety undergraduate medical curriculum: The Telluride interdisciplinary roundtable experience in Teaching and Learning in Medicine, 21 (1), 52-58.

McCutcheon, A.S., Macphee, M., Davidson, JM., Doyle-Waters M., Winslow, W. (2005). Evaluation of patient safety and nurse staffing. Canadian Health Services Research Foundation.


McKesson Corporation. (2004). Patient safety and Nursing: Transforming the Work Environment with Technology. A White Paper.

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Moamary, M. A. (2010). Integrating Patient Safety in Undergraduate Medical Curricula. 4th Medical Career Day Publication-No. 1. King Saud bin Abdulaziz University for Health Sciences. Mohamed Al Moamary (Edtr). Accesed at 20 July 2010 from www.mcd4.org

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Seiden, S.C., Galvan, C., Lamm, R. (2006). Role of medical students in preventing patient harm and enhancing patient safety in Quality and Safety in Health care 15: 272-276

University of Florida. Curriculum Components on Patient Safety. Accesed at 10 July 2010 from: medinfo.ufl.edu:8050/faculty/flc/nursing/nursing.ppt

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integrasi patient safety ke dalam kurikulum keperawatan#uswatun uin jakarta

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