INVITED COMMENTARY

Case-based Learning for Patient Safety: The Lessons LearntProgram for UK Junior Doctors

Maria Ahmed • Sonal Arora • Paul Baker •

Charles Vincent • Nick Sevdalis

Published online: 2 March 2012

� Societe Internationale de Chirurgie 2012

Nordquist et al. [1] report their experience with imple-

menting surgical case-based learning (CBL) at the Under-

graduate Medical Programme at Karolinska Institutet. A

series of CBL seminars were introduced in place of tradi-

tional lectures at one of four teaching hospital sites. The

intention was to stimulate higher levels of cognitive learning

among the students, to foster reflection and peer-learning,

and to help integrate theoretical knowledge with the clinical

context. Interviews held with a sample of teachers and stu-

dents at the pilot site highlighted various deficiencies in the

process of implementation of CBL rather than a fault in the

‘‘function’’ of CBL per se. Failure to engage faculty and

students; insufficient training/preparation, and a lack of

alignment with clinical rotations and assessment were some

of the factors that led to unsatisfactory implementation of

CBL. From these findings, the authors derived a checklist to

assist in the implementation of educational interventions

aimed at enhancing surgical teaching and learning.

Case-based learning is an adult learning approach that is

gaining popularity across healthcare specialties as a means

of enhancing workplace-based learning [2]. Authentic

cases stimulate the acquisition of knowledge, skills,

and attitudes in a safe learner-centered environment. This

team-based approach also promotes deeper understanding

through interaction and dialogue between learners, which

goes beyond passive attendance at a lecture, and ensures

building and exchange of thoughts [3]. The role of the

faculty is to facilitate learner dialogue and to support

understanding.

Our team has recently taken a very similar approach,

aimed at junior doctors in their first two years of clinical

practice (termed ‘‘Foundation trainees’’ in the UK)—a

population not dissimilar from that of Nordquist et al. In

collaboration with the training provider of North West

England (the North Western Deanery) we have implemented

an innovative case-based Patient Safety training program for

these junior doctors. Called Lessons Learnt: Building a

Safer Foundation, the program comprises monthly sessions

built into the Foundation teaching program. Foundation

trainees lead a structured peer-group discussion of a patient

safety incident (adverse healthcare event) encountered in the

workplace in order to analyze its contributing factors using a

validated framework (London Protocol [4]) and pose

potential solutions. Senior clinicians (Attendings) trained in

incident analysis facilitate the sessions.

As an emerging discipline within medical and surgical

education, the implementation of patient safety training

brings its own challenges. Various barriers to curricular

integration have been identified, including poor learner

engagement; lack of expert faculty; local institutional

culture; and a lack of evidence for the impact of such

training on healthcare [5]. Our approach to implementation

was to address each of these barriers to ensure sustainable

integration within the Foundation teaching programs across

16 hospital sites (hosting over 1,000 Foundation trainees)

beginning in January 2011.

The first step was to engage all stakeholders. Foundation

training directors, administrators, trainees, and prospective

facilitators were invited to a half-day ‘‘launch event’’ to

M. Ahmed (&) � S. Arora � C. Vincent � N. Sevdalis

Department of Surgery and Cancer, Imperial College London,

St. Mary’s Hospital, Wright Fleming Building, Norfolk Place,

London W2 1PG, UK

e-mail: maria.ahmed@imperial.ac.uk

N. Sevdalis

e-mail: n.sevdalis@imperial.ac.uk

P. Baker

North Western Deanery, 3 Piccadilly Place,

Manchester M1 3BN, UK

123

World J Surg (2012) 36:956–958

DOI 10.1007/s00268-012-1499-y

propose the initiative and seek feedback to inform imple-

mentation right from project initiation. An ‘‘expert faculty’’

was developed through the recruitment and training of

Attendings. Incentives for participation in the form of

professional accreditation of training and alignment with

the UK General Medical Council (regulatory body)

requirements of Good Medical Practice ensured successful

recruitment of over 60 Attendings across diverse clinical

specialties [6].

Foundation trainees were engaged through creating a

‘‘Lead’’ position at each site, empowering them to lead the

project locally through recruiting peers to present cases,

chairing the sessions and coordinating local evaluation.

Comprehensive Tutor and Lead Handbooks were

developed, and a proforma was provided to help structure

each case-based discussion (based on the validated London

Protocol for the analysis of adverse events) and ensure an

action plan. A shortened example of what a typical case

may look like when ‘‘worked up’’ in a session is presented

in Fig. 1. Participation of trainees was incentivized through

providing certificates of presentation and ensuring align-

ment of objectives to the Foundation training curricular

competencies [7].

Evaluation of the initiative was conducted in parallel to

implementation and aimed to assess all four levels of

Kirkpatrick’s evaluation model: Reaction, Learning,

Behavior/Skill, and Organizational performance [8]. Satis-

faction questionnaires were administered to all stakeholders

at academic year-end (June/July 2011). Knowledge, skills

and attitudes of trainees and facilitators were evaluated

through a combination of bespoke and validated evaluation

tools. Behavior change and organizational performance were

assessed through evaluating incident reporting among

trainees and identifying quality improvement projects that

had been initiated (and some already completed) as a result

of any case-based discussion. Provisional analyses show

favorable results [9].

Finally, all stakeholders were invited back for a Feed-

back Conference in September 2011 to share provisional

results of the initiative, to gain feedback, and to inform

ongoing dissemination of Lessons Learnt. This ensured that

participant engagement was maintained—in fact, the levels

of interest of Foundation trainees and also of senior

Foundation Program Directors within the 16 hospitals and

hospitals in other UK regions was such that Lessons Learnt

is now being implemented in other hospitals as a

Fig. 1 Lessons Learnt patient safety incident discussion proforma (truncated)

World J Surg (2012) 36:956–958 957

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sustainable, engaging educational intervention (the pro-

gram materials are available for non-commercial use from

the corresponding author).

The implementation of novel approaches to teaching and

learning invariably poses challenges to both faculty and the

intended recipients of such interventions. From our expe-

rience, stakeholder engagement, investing in faculty

development, learner ownership, and robust evaluation are

essential in helping to ensure both the success and sus-

tainability of a new training initiative. Case-based learning

is an exciting educational paradigm that we believe should

be integrated into surgical curricula. By providing in-situ

training with residents learning through their own cases,

this approach promotes clinical reflection and an under-

standing of patient safety within a contextualized setting—

thereby, ultimately, contributing to enhanced safety in

patient care.

Acknowledgments This work was funded through the (UK) NHS

North West Junior Doctor Innovation Award in Education and

Training and the National Institute for Health Research (NIHR). The

authors are grateful to the project team and all participants in the

study.

References

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00268-011-1396-9

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