Teaching patient safety in undergraduate courses: a bibliometric study


Natália GonçalvesI; Lillian Dias Castilho Siqueira II; Maria Helena Larcher CaliriIII

I Nurse. PhD in sciences. Adjunct professor, Department of Nursing, Federal University of Santa Catarina. Brazil. E-mail: nataliasjbv@gmail.com
II Nurse. PhD in sciences. Nurse at the University Hospital of the Federal University of Grande Dourados, Mato Grosso do Sul, Brazil. E-mail: ldcsiqueira@usp.br
III Nurse. PhD in nursing. Associate professor at the Ribeirão Preto College of Nursing, University of São Paulo. Brazil. E-mail: mhcaliri@eerp.usp.br

DOI: http://dx.doi.org/10.12957/reuerj.2017.15460




Objective: to identify the approach of scientific production on patient safety in undergraduate courses in the health field. Method: an online bibliometric search was conducted in the PUBMED, CINAHL and LILACS databases, for publications from 2010 to 2014. Results: 52 studies were identified for the final sample, most in PUBMED (27, 5.0%) and from the United States (35; 67.3%). The year with the highest number of publications was 2011, and the most frequent thematic categories were definition of patient safety and improvements in drug-related safety, on a quantitative approach (32; 61.5%). Twelve (36.4%) journals were specific to nursing. Conclusion: the results highlighted the importance of identifying scientific production on the subject and of spreading that knowledge.

Keywords: Patient safety; education; curriculum; bibliometrics.




In the last few decades, health care has become more complex and potentially dangerous because of its multiple activities, increasing technology, and high rates of interruption or discontinuation of care1. Since the publication of To Err Is Human: Building a Safer Health System, issued by the Institute of Medicine of the United States2 in 1999, the issue of patient safety has acquired enormous relevance. This report noted that approximately 100,000 people die every year in US hospitals from preventable adverse events2.

Unsafe care results in significant morbidity and mortality that can be avoided, as well as excessive spending on maintaining health systems 3. Estimates from developed countries have indicated that between 5% and 10% of patients admitted to hospitals acquire infections 3. In Brazil, a survey of three public hospitals in Rio de Janeiro identified an incidence of 7.6% of adverse events, of which 66.7% were avoidable4.

In this context, the Institute of Medicine pointed out that health professionals are not adequately prepared to provide high-quality care and patient safety. It further stated that health education needed a major overhaul, and professionals as members of interdisciplinary teams should be educated to provide patient-centered care, with an emphasis on evidence-based practice, approaches to quality improvement and informatics5, 6.

Faced with this reality, in 2011 the World Health Organization (WHO) launched a guide related to the development of curricula on patient safety, using a multidisciplinary approach, to assist in the creation of effective education on patient safety by academic health institutions. This guide presented, in a single publication, educational frameworks and a variety of concepts and methods for teaching and evaluating patient safety7.

In Brazil, the Ministry of Health established the National Patient Safety Program (NPSP), through Decree no. 529 of April 1, 2013. One of its specific objectives was "to promote the inclusion of the topic of patient safety in technical and undergraduate and postgraduate education in the area of health [...] "8:43, by "[…]coordination, with the Ministry of Education and the National Education Council, the inclusion of the subject of patient safety in the curricula of technical, higher and post-graduate health education courses [...]"8:43

For nursing, Florence Nightingale introduced the term "do not cause harm" to patients, as a basic assumption of the profession9. Nurses play a key role in promoting patient safety and providing quality health care. There is evidence that these professionals detect, intercept and correct potential adverse events, from decision making to interventions in direct patient care10,11.

Considering the WHO recommendations, students in all areas of health should be prepared to provide safe care; they also need to learn how to manage challenges, understand the impact of systems on the quality and safety of health care, and know how poor communication can lead to adverse events. As future leaders and providers of health care, it is vital that they be well-informed and skilled in applying principles and concepts related to patient safety7 and that they be capable of implementing a fair, transparent culture with a focus on educational measures to tackle failures in care12.

The purpose of the present study is to identify the approach to scientific production related to the teaching of patient safety in undergraduate courses in the health area, discussing the findings according to the assumptions presented in the WHO curriculum guide.



A descriptive, quantitative study of the bibliometric type allows measurement of the diffusion of scientific knowledge and the course of information under different approaches13. Bibliometrics is statistical analysis of written publications and the evolution of scientific disciplines through the calculation and analysis of multiple characteristics of that material13.

A bibliographic survey was carried out in June 2014 in the following databases: Latin American and Caribbean Health Sciences Literature (LILACS); National Library of Medicine (PubMed); and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The descriptors used were a combination of patient safety, education and curriculum, in English and Portuguese, according to the database used. These descriptors were identified through the Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH). The cross-over between each of the controlled descriptors with their (uncontrolled) synonyms was performed using the OR operator, separately. Subsequently, each controlled descriptor, as well as its synonyms, were crossed using the search operator AND.

The search of the PubMed and CINAHL databases was done using Endnote TM Software; for LILACS, the search was performed directly on the website of that database. This process was carried out separately by two researchers. After the studies were obtaining, they were compared to identify duplications, and then analyzed according to the criteria established for selecting the final sample.

The following inclusion criteria were used: original research articles in Portuguese and English, published between January 2010 and June 2014, and located in virtual libraries in electronic format. The exclusion criteria were: literature review articles and theoretical reflections.

The variables considered in the study were: total number of references included, databases, main themes of the studies, number of descriptors, most cited descriptors, number of articles per year of publication, number of articles published, periodicals chosen for publications, countries of publication, and types of study.

Each variable was recorded in a Microsoft Excel spreadsheet and analyzed by simple descriptive statistics: absolute frequency and percentage. The classification of the type of article was carried out based on the reading of the title and article summaries.



From the keywords selected in the databases, 279 articles published between 2010 and 2014 were identified. Using the exclusion criteria, 227 were eliminated. Thus, 52 (100%) publications were included in the final sample.

As for the year of publication, the results are displayed in Figure 1. An increase in the number of publications in 2011 can be observed, compared with 2010. In 2012, there was a decrease, followed again by an increase in 2013. The increase in 2011 may be related to the publication of the WHO Patient Safety Curriculum Guide, whose development began in January 2010 and was based on the Curriculum Guide for Medical Schools, published in 20097.

FIGURE 1: Percentage distribution of publications per year, 2010-2014.

The largest number of articles came from the PubMed database - 27 (51.9%), followed by CINAHL - 24 (46.2%) and LILACS (01; 1.9%). The databases used in this study were of international and national scope. Databases are important tools for identifying scientific productions in various countries, helping in the dissemination of studies for continuous training of professionals14. The themes addressed by the studies are presented in Table 1.

TABLE 1: Main themes found in the publications evaluated, 2010-2014.

(*)These studies addressed more than one theme category

The thematic variable of the studies presented a diversity of subjects addressed and was based on the WHO Patient Safety Curriculum Guide 7. Published in 2011, this comprehensive multidisciplinary guide aims to assist in the construction of education on patient safety. It provides educational structures and presents a variety of concepts and methods for teaching patient safety, applicable in different cultures and contexts.

The themes that stood out included the definition of patient safety, safety improvements related to medications, understanding of systems and the effects of complexity on patient care, and methods to improve care, as shown in Table 1. Four studies addressed more than one topic, such as defining patient safety and safety enhancements related to medications, and therefore have been classified into a new category.

The definition of patient safety encompasses the description of evidence of harm and suffering caused by adverse events. Safety enhancements are related to drug therapy and involve identifying the factors that lead to errors and knowledge of steps to minimize them, considering all the relevant factors related to prescription, dispensing, administration, and monitoring of drug effects. The comprehension of systems and the effect of complexity on patient care show that patient care includes multiple steps and many relationships, and requires an understanding of how the actions of professionals in a continuous process determine care outcomes. Methods related to improvement in quality of care provide examples of methods for measurement and improvement of clinical care7.

Still in relation to the main themes of the studies, there is a reduced focus on the categories related to risk management, patient and caregiver involvement, and teamwork. However, ensuring patient safety also means establishing teaching plans considering communication, teamwork, and involvement of family members and patients during the care process 15.

In this sense, teaching the topic of patient safety must encompass the entire curricular structure and focus on aspects related to risks of and preventive measures for harm in the various healthcare settings. Furthermore, curricula must be developed based on teaching-learning actions that ensure safe performance throughout training and are also sustained in the course of professional activities16.

The inclusion of the topic of patient safety in undergraduate curricula is of paramount importance for the quality and safety of the health care 17-19 provided by health professionals, but the present study found only topics related to clinical practices and competencies, such as medications and surgical procedure.

Considering the methodological approaches, it was observed that 32 articles (61.5%) used quantitative methods and 16 (30.8%), qualitative methods. Four (7.7%) studies applied both approaches. The descriptors found in the references investigated totaled 190. There were an average of 3.65 descriptors per published study, and those most cited by the articles were: curriculum, patient safety, students medical, medical errors, medical education, prevention and control, education nursing baccalaureate methods and attitude of health personnel. Health descriptors help in the use of common terminology for research20, and the identification of key descriptors in health in the field for patient safety and education can facilitate the development of subject searches and further research.

The titles of the journals found in the selected studies are listed in Table 2. Of the 33 journals, 12 (36.4%) were specific to nursing, includingCritical Care Nurse, Nursing Education Research and the Journal of Advanced Nursing, which are not in the table and each yielded one publication. These professionals stand out for being involved in direct patient care throughout their careers in health systems and being responsible for errors, but they also help in the dissemination of concepts about patient safety. Nurses adopt strategies to strengthen safe and quality nursing care through development of and cooperation between health and education institutions21. Also noteworthy is the significant number of articles in periodicals related to pharmaceutical education and safety/quality, which have been priority issues in health in the last few decades. This reflects the search for scientific evidence for a risk-free care and care that causes no harm, also evidenced by the second-most addressed topic in the articles, drug safety. Similar to the results of the present study, data from a recent review showed that studies on medication errors were predominant among a sample of adverse events in an intensive care unit22.

Nursing teams are inserted in scenarios where medication errors occur because of the high numbers of drugs prescribed and administered daily to patients, especially those who are hospitalized23,24. In Brazil, often the focus is on teams as causing these errors, even though it is known that not only individual factors, but also structural and systemic factors, contribute to this situation24-27.

TABLE 2: Titles of the most used journals for publications, 2010-2014.

The countries with the highest number of publications were the United States - 35 (67.3%), followed by the United Kingdom - 10 (19.2%) and China - 2 (3.8%). Canada, Taiwan, Germany, Brazil and Australia presented only one publication (1.9%) each.

As observed, research in Brazil that critically analyzes curriculum perspectives and changes is scarce, although there is a growing interest in curriculum innovation for patient safety. Moreover, curricular changes are slow and occur mainly through regulations28.

Improvements related to patient safety at the national level require the effective implementation of the safety concepts indicated by WHO and the development of studies, including the implementation of protocols, 29,30 for the improvement of teaching methods, student satisfaction and services, and applicability of skills, such as reduction of hospital infections and falls, and improvement of communication.



According to the assumptions presented by the WHO curriculum guide, the present study points out trends for specific topics, such as a focus on safety improvements in drug therapy and description of the negative effects of adverse events. The publications presented reduced focus on the teaching of teamwork, risk management, involvement of patients in their own care and learning from mistakes, which are all essential elements for patient safety.

In view of the importance of the subject matter of the present study, teaching of patient safety in undergraduate courses in the health field is considered to still be incipient, with emphasis on the lack of research in the Brazilian context. To overcome this reality, it is necessary to invest in dissemination of knowledge, development of new investigations, and training of professionals, based on the inclusion of the subject of patient safety in the curricula of the schools of the various health professions.

Bibliometric analysis is an important methodological resource for unveiling and identifying perspectives and trends in research development. The present study contributed to the nursing field by presenting information from outstanding journals in the production of knowledge on the subject at the international level, besides providing support for further scientific production.



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