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 Table of Contents  
Year : 2020  |  Volume : 64  |  Issue : 3  |  Page : 277-284  

Patient safety in graduate curricula and training needs of health workforce in India: A mixed-methods study

1 National Professional Officer, Department of Health Systems, World Health Organization Country Office for India, New Delhi, India
2 Professor & Head, Department of Medical Care & Hospital Administration, National Institute of Health and Family Welfare, Munirka, New Delhi, India
3 MD Student, Community Health Administration, National Institute of Health and Family Welfare, New Delhi, India
4 Team Leader, Department of Health Systems, World Health Organization Country Office for India, New Delhi, India
5 Advisor (Public Health), Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, New Delhi, India
6 Professor & Head, Department of Epidemiology; (Formerly) Director, National Institute of Health and Family Welfare, New Delhi, India

Date of Submission27-Sep-2019
Date of Decision29-Oct-2019
Date of Acceptance15-Jun-2020
Date of Web Publication22-Sep-2020

Correspondence Address:
Chandrakant Lahariya
National Professional Officer- Health Care, Access & Protection, World Health Organization (WHO) Country Office for India, Room No. 536, A-Wing, 5th Floor, Nirman Bhawan, Maulana Azad Road, New Delhi - 110 011
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_482_19

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Background: Improving quality of health services and providing safe care require well-trained and skilled workforce. The inclusion of components of patient safety in graduate training curricula, followed by adherence to curricula in teaching programs, can improve the quality of health-care services. Objectives: To review the existing training curricula for five subgroups of health workforce (Allopathic doctors, nurses, laboratory technicians, pharmacists, and nurse midwives) and to document the components and identified variables of patient safety covered. Methods: A mixed-methods study was conducted during July 2017–March 2018. Data were collected through desk review, field visits, in-depth interviews, self-administered questionnaires, and focused group discussions (FGDs). A total of 24 variables were identified by the experts to review the training curricula. Results: Seven states, 28 institutes, and 42 health-care facilities were visited. A total of 516 staff from different health cadres participated in the study through 54 interviews, 156 self-administered questionnaires, and 24 FGDs. Of 24 patient safety variables considered, 16 were covered in the medical and nursing, 9 in laboratory technician and pharmacist, and 5 in midwives' curricula. The teaching material on the patient safety, for most categories of staff, was not available in consolidated form, and there was no standardization. Conclusion: There is a need for the development of comprehensive training material cum operational modules on patient safety, suitably adopted as per the learning needs of different subgroups of health staff. The need for strengthening patient safety has been further underscored as the health workforce is fighting the coronavirus disease 19 (COVID-19) pandemic. The initiatives on patient safety will contribute to improved overall quality of health services, which in turn would advance universal health coverage.

Keywords: COVID-2019, India, patient safety, quality of health services, universal health coverage, World Patient Safety Day

How to cite this article:
Lahariya C, Gupta S, Kumar G, De Graeve H, Parkash I, Das JK. Patient safety in graduate curricula and training needs of health workforce in India: A mixed-methods study. Indian J Public Health 2020;64:277-84

How to cite this URL:
Lahariya C, Gupta S, Kumar G, De Graeve H, Parkash I, Das JK. Patient safety in graduate curricula and training needs of health workforce in India: A mixed-methods study. Indian J Public Health [serial online] 2020 [cited 2022 Jan 21];64:277-84. Available from:

   Introduction Top

”First do no harm” or “Primum non nocere” is considered one of the core principles of health service delivery. Yet, a proportion of people seeking health care are at risk of one or other forms of harm.[1] The need for safe care is increasingly being recognized, with renewed attention on improving the quality of health services, as part of the global efforts to advance universal health coverage (UHC).[2],[3] Indian government has made commitment to provide quality health services in the National Health Policy 2017.[4] Patient safety is considered an integral part of overall quality improvement process,[4] and the Government of India released the National Patient Safety Implementation Framework (NPSIF) 2018–2025 to operationalize a series of interventions and strategies.[5] The NPSIF (2018–2025) of India is fully aligned with the “Regional Strategy for Patient Safety in the WHO South-East Asia Region (2016–2025)” endorsed in the 68th meeting of regional committee of WHO South-East Asia Region.[6] The training and capacity building of health-care workers has been identified as one of the important strategies under the NPSIF as well as in the WHO's regional strategy.[5],[6] The graduate education curricula are considered to have major influence on the content and quality of training imparted to various cadres of health workforce. The inclusion of the components of patient safety in graduate training curricula is one of the approaches to make health services safe and improve the overall quality of care. Therefore, this study was conducted to review the existing graduate training curricula for five subgroups of health workforce (Allopathic doctors, nurses, laboratory technicians, pharmacists, and nurse midwives), document the components of patient safety included, and propose appropriate policy solutions & interventions.

   Materials and Methods Top

Study design

The mixed-methods approach[7] with quantitative and qualitative data collection followed by analysis.

Study period

July 2017 to March 2018.

Study tools and approach

Desk review, field visits, focused group discussions (FGDs), in-depth interviews (IDIs), and self-administered questionnaires.

Criteria for assessment of patient safety curricula

Five group of health workforce and graduate training curricula were considerer for inclusion in this study. These were Allopathic doctors (MBBS), Bsc Nursing, BSc Medical laboratory technicians, Bachelor of Pharmacy, and Auxiliary Nurse Midwives. The contents of training curricula were reviewed against 24 identified variables on patient safety. These variables included 10 of the 11 variables in the WHO multi-professional curriculum guide:[8] eight variables proposed by the expert group constituted by the MoHFW for the development of NPSIF[9],[10] and six variables specifically developed to fulfill the objectives of this study.

Sample size and sample selection

For the review of curricula, information was proposed to be collected through the official websites of the concerned ministries and the regulatory councils of the respective professional groups. It was proposed to make personal contacts with the officials in MoHFW as well as in the regulatory councils to get additional documents and information, not available on the websites. To validate the information generated from the desk review, the field visits were proposed. Based on the time and resources available for the field work, 6 to 7 states were initially proposed. Geographical repressiveness was a key factor in the selection of the states for the field visits. On this basis, Delhi, Assam, Maharashtra, Madhya Pradesh, Tamil Nadu, Uttar Pradesh, and West Bengal were selected for field visits. The “maximum variation purposive sampling” was used for selection of states, facilities within the states, and people to be interviewed at each of the facility.[11] The assumption behind “maximum variation purposive sampling” was that the curricula are implemented uniformly across the states, under respective state council regulations, and unlikely to vary by the institutes. In each of the identified states, a government medical college, nursing college, hospital (preferably attached with medical college), and one private hospital were visited. A total of 28 hospitals/institutes were included from different settings/levels in the study states. These institutions were run by union and state government, autonomous bodies, Employee State Insurance Corporation, private organizations, etc. At each of the identified institution, in addition to the departments and units delivering patient care, the blood bank and laboratory facility as well as community health centers were also visited.

Study participants

The senior administrators; mid-level managers such as head of the departments, in-charges of various units, and nursing supervisors; and different group of health personnel such as medical doctors/general practitioners, specialists, nursing personnel, laboratory staff/technician, and housekeeping, sanitary, and security staff of the health facility were included as study participants. The representatives of different professional councils; principals, deans, medical superintendents of medical and nursing colleges and hospitals; heads of the departments of the medical and paramedical departments; senior and junior medical and paramedical staff; and nursing interns were also interviewed.

Data collection

As a first step of the desk review, various guidelines/study materials available on the official websites of government agencies were searched. Special attention was paid that the content from the MoHFW, Medical Council of India, Pharmacy Council of India, Nursing Council of India, National Health Mission, National Health Systems Resource Centre, the National Institute of Health and Family Welfare, medical institutions, professional associations, and National Accreditation Board for Hospitals and Healthcare Providers is included. Alongside, the reports and publications on various patient safety interventions in the context of teaching and training curricula, both in print copies and electronic version, were searched and reviewed. The print and online reports and publications on patient safety were also searched and read and information was synthesized. The focus of this study was on “planned or proposed content” in these curricula, which was reviewed at all stages of the study. However, during the field visits, IDIs, and FGDs, attempts were made to elicit information on “delivered content” as well.

The members of field visit teams attended a 2-day workshop cum training program in Delhi, and were given details on hands-on understanding of study design, data collection tools, and an overview of findings from the desk review. Six teams of two members each collected the data. Five teams had visited one identified state each, while one team had visited two states. The primary data in the form of interview with nodal officer/designated officer and secondary data in the form of published syllabus/curriculum and teaching and training material regarding different variables of patient safety were collected from all the sites visited. The study teams conducted IDIs on the pretested interview schedule, with the administrators for the training need of various health professional in relation to the patient safety.

Data analysis

The IDIs and FGDs were recorded with the consent of participants. These recordings were transcribed verbatim, if required, translated into English. The framework method[12] with attention on all steps, namely, transcription, familiarization, coding, charting, and interpretation, was followed for data analysis. An “inductive thematic approach” to analysis based on “grounded theory” was used.[13],[14] This approach focused on analyzing all IDIs and FGDs in their entirety and identifying concepts relevant to patient safety, the existing curricula, and “planned” as well as “delivered” content. The transcripts were then coded separately to assess similarities and differences between the participant groups. The coding process helped in the familiarization with the data, which was followed by open coding and then allocation of descriptive labels. The code and theme development were entirely data led and analyzed manually.[15] Microsoft Excel was used to organize participant codes. This was followed by category development until all transcripts had been coded. These were inserted into the spread sheet. Following coding, categories were grouped into subcategories and linked to the themes. The was followed by charting[12],[15] themes to create a framework matrix to insert quotes related to the corresponding and representative subcategory. This helped in visual representation of themes and facilitated the mapping and interpretation of the data.

The quantitative data were analyzed using Microsoft Excel 2016. The binary variables, especially on the inclusion of specific components of patient safety in training curricula, were quantified and tabulated. Information from various sources was triangulated and interpreted. The detailed responses and verbatim quotes collected as part of qualitative data were used for the full report prepared and submitted to the MoHFW. This article is based on a subpart of the full study and the data collected.

Ethical approval

This study was proposed by the expert group on patient safety,[9] which considered this as public health research for improving program performance. No human intervention was proposed as part of this study. Therefore, it was exempted from the approval by the ethics committee.

   Results Top

Seven states, 28 institutes, and 42 facilities were visited as part of this study. IDIs were conducted with 36 senior and mid-level officials. A total of 516 health staff from different health cadres participated in this study through 54 interviews, 156 self-administered questionnaires, and 24 FGDs. Six FGDs of doctors including senior and junior resident were conducted (one FGD in each selected state except Delhi, total participants = 48), and a total of 18 FGDs of nurses including full-time nurses and nursing interns (3 in each selected state except Delhi, total participants = 144) were conducted. Twenty-four variables of patient safety were reviewed, and the findings are presented in [Table 1].
Table 1: Patient safety variables covered under various curricula

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Of the 24 variables analyzed, 16 each were covered in the curriculum of doctors (MBBS) and nurses (BSc Nursing); 9 each in Bachelor of Pharmacy and BSc Medical Laboratory Technicians, and 5 in the curriculum of auxiliary nurse midwives. The variables such as biomedical waste (BMW) management, hand hygiene, effective communication, and the concept of effective team player were part of all the five curricula reviewed, whereas “the surveillance of healthcare-associated infection (HAI)” was not covered in any of the five curricula reviewed [Table 1].

A total of 36 mid-to-senior administrative officials were interviewed. It was noted that most of them were familiar with limited aspects of patient safety, mostly about HAI, quality control, and BMW management under patient safety. The thematic areas identified through FGDs as training needs for each of the group are listed in [Table 2]. A few of the variables emerged during the discussions with key stakeholders such as safety of dead body and nutritional safety. These were proposed to be included in the curriculum of MBBS and BSc Nursing. The nodal officers and the heads of departments identified a few key areas for capacity building for various groups of staff.
Table 2: Training needs identified for various groups (indicative list)

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  • For doctors: Effective communication skills (soft skills), triage, rational use of antibiotics, advanced cardiac life support and basic life support. Chemotherapy safety, infection prevention and control (IPC), record keeping, etc.
  • For nursing staff: Surgical safety, hand-over take-over, IPC, infusion safety, effective communication skills (soft skills), adverse drug reaction reporting, time management, medical record keeping, patient identification, etc.
  • For operation theater technician: Medical equipment safety
  • For housekeeping and nursing orderly: IPC, transport safety, effective communication skills (soft skills), BMW management, fall prevention, personal protective equipment etc.

The information from FGDs and IDIs on training needs for various subgroups of health staff is summarized in [Table 3]. The BMW management and application of human factors were identified in these discussions as areas of training for all subgroups (doctors, nurses, blood bank staff, laboratory staff, as well as housekeeping and security staff) under study. The blood safety and quality of care, quality improvement, and assurance were considered important topics for majority of these subgroups.
Table 3: Training needs identified among different health-care cadres

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The study participants identified a few thematic areas and components as self-identified training needs as well as training need for specified group of health workforce. The second set of input was sought from hospital administrators, senior faculty members, and policymakers, who had a broader overview of the training needs. The training needs for self and others, categorized by staff subgroup and curriculum, are summarized in [Table 2].

   Discussion Top

This study provides systematic documentation on the components of patient safety for possible inclusion in the curriculum of various groups of health staff. The study noted that patient safety was not included in totality in planned content of any of the five curricula reviewed. The need and role to improve the culture of patient safety in clinical teaching and learning settings and training needs has been documented in the studies from other countries as well.[16],[17]

The exact magnitude of patient harm was not known to any of the officials/participants interviewed as part of this study. It is suggested that alongside capacity building, a system for regular reporting of medical errors, adverse events, “near-misses,” and “never events” with their regular review by the patient safety and quality control committee be established in India. The researchers in past have suggested[18] mechanisms such as national patient safety data repository, where records of all adverse events and medical errors maintained so that the epidemiology and burden of unsafe care can be documented and improvement measures can be initiated. Union and state governments in India may consider such mechanism on priority. This study noted that error identification and subsequent disclosure by physicians and nurses in India is often inhibited by several system factors, which require further studies and then, the learning be used for corrective measures. This approach has in past been adopted by others countries, and often publication of such information has resulted in establishing task forces and committees, which had subsequently resulted in improved patient safety measure.[19],[20],[21]

The early analysis of the findings from this study were made available to senior policymakers in the union MoHFW and contributed to finalization of NPSIF of India. The study findings and subsequent deliberations resulted in a recommendation to set up an expert group by the Government of India to collaborate with various institutes, for revision and update of curricula for health-care providers with inclusion of topics identified in this study. For the existing health-care staff, appropriate opportunities including professional development programs should be used to enhance capacity, through development of a training module and creating a pool of master trainers at national and state levels. These recommendations are in line with the strategic objective 6 of NPSIF (2018–2025) of India.

The quality of health care has received additional attention and a boost with release of three important reports in 2018, which included a joint publication of World Health Organization–World Bank and OECD titled as “Quality of healthcare, imperative for UHC; a report by National Academy of Medicine in United States of America, titled as “Crossing the Global Quality Chasm: Improving Health Care Worldwide” and another report of the Lancet commission on high-quality health systems.[2],[3],[22] These reports have synthesized the available evidence and provided a few new gap filling scientific evidence on various aspects of patient safety and quality of health care, along with the proposed interventions. Another commentary made a strong case for focus on quality of care for accelerated progress toward UHC[23] and concluded that while health-care providers may make errors, the same error should not be made again or repeated (the predictable error). Therefore, these “predictable” errors can be considered an indicative of a broken system. If this predictability is recognized and strategies are implemented at all levels, health-care delivery cost can be reduced and services can be made safe. It has been estimated that investing on improving quality of health care and stopping preventable errors can save up to 15% of health-care cost.[12],[24] As there is global discourse on UHC, attaining this goal is possible only with the quality health services.

There has been a number of initiatives in India to improve the quality of care and patient safety in the last 15 years, which have been listed elsewhere.[24] However, these initiatives need to be sustained and integrated to further improve the health outcomes in India. The Government of India, in 2019, had joined a WHO-led global patient safety collaborative (GPSC) initiative, to strengthen patient safety in the country.[24],[25] India is the only member state of WHO South-East Asia region to be part of this global collaborative, which will focus on developing leadership (including exploring to designate a “center of excellence”); training and capacity building; and research on the patient safety. The findings from this study will be useful as India embarks to implement NPSIF and roll out the activities under GPSC.

The scope of this study was to analyze the content of graduate training curricula and provide recommendations on the revision of these curricula. However, the revision and adoption of comprehensive curricula is only one of the first steps. Improving the quality of care and patient safety at service delivery level will be dependent on the adoption of new curricula for teaching and training (the delivery of content) and then practice of the skills by the providers, which should be actively promoted. Similarly, as the new approaches and models for strengthening primary health-care services are emerging,[26] it will be important that there is an explicit attention on strengthening patient safety at primary health-care facilities as well. Alongside, the role of communities and civil society organizations (CSO) in health services delivery is increasingly being acknowledged.[27] Therefore, the participation and engagement of community members and CSO in patient safety and improved quality of healthcare needs to be fully explored and suitably utilized.

This research study has focused on graduate training curricula and training need for five subgroups of health workforce. Globally, the role and significance of health research in advancing UHC is increasingly being highlighted.[28],[29] In India, there is a felt need to expand and support health research (including operational research), which is being reflected in increased annual allocation to the department of health research as well as proposed national knowledge platform and the already-established Health Technology Assessment India (HTAIn), among others.[30],[31],[32] As these institutional mechanisms evolve, it would be pertinent to expand the scope of operational research with inclusion of a broader range of health staff on quality of care; health systems strengthening; and for addressing the bottlenecks in access, financial protection, and service coverage (the three dimensions of UHC). These researches need to be actively promoted, financially supported, and conducted in partnership with the existing academic institutions and used for evidence-informed policy making. The medical colleges and public health professional association need to be actively engaged by the senior policymakers and program managers to achieve this common objective.

One of the recommendations following this study was to observe patient safety week in India for generating awareness and to emphasize the learning of its different aspects with involvement of patient and their caregivers. In this context, the World Patient Safety Day (WPSD) designated for 17 September of every year[33],[34] can be utilized as an important annual event to raise awareness.[24],[35]

In the early 2020, the coronavirus disease 2019 (COVID-19) pandemic affected the entire world. In responding to COVID-19 pandemic, health facilities and health workforce were at higher risk of infections while providing care for the sick and affected people. Across the world and in India, many health staff and people involved in providing care for COVID-19 were affected. The relevance and significance of patient safety in general and IPC in specific has, argubaly, never been recognised as it is during the COVID-19 pandemic. This is an opportunity to strengthen patient safety as well as making workplace safe for Health workforce. It is this backdrop in which “Health Worker Safety: A Priority for Patient Safety” has been made the theme for WPSD2020. The theme aims to bring focus on the interrelationship between health worker safety and patient safety. The slogan for WPSD2020 is “Safe Health Workers, Safe Patients”, which underscores the need for a safe working environment for health workers, as a prerequisite for ensuring patient safety.

   Conclusion Top

There are a number of components of patient safety not being covered in the planned content of the existing graduate curricula of various cadres of health workforce in India. Their knowledge on various aspects of patient safety is variable. There is a felt need for revision and update of graduate training curricula (planned content) for these cadre of health staff, followed by mechanisms to ensure that comprehensive patient safety content become part of teaching programs (delivered content). For the existing health staff, on-the-job trainings on patient safety through professional development program, seminars, workshops, and conferences need to be initiated. Improving quality of health services is high on the global health agenda and central to the discourse on UHC, as also envisaged in the National Health Policy 2017 of India. The COVID-19 pandemic has once again underscored the need for strengthening various components of patient safety including infection prevention & control as well as health workers safety. Advancing patient safety would contribute to improve the quality of health services, which in turn would advance and accelerate India's progress toward UHC.


The authors are thankful to Dr. NS Dharmashaktu, Former Advisor, Directorate General of Health Services, MoHFW, New Delhi, for his guidance for this study and Dr Rajneesh Mohan Siwan, then resident at Community Health Administration Deptt. at National Institute of Health and Family Welfare, New Delhi for his technical inputs on an early draft of this manuscript. The authors would also like to thank the officials of state govts. and other institutions and to the respondents in the study for sharing their valuable insights for successful completion of this work.

Financial support and sponsorship

This study was funded and technically supported through a grant by the World Health Organization Country Office for India to National Institute of Health and Family Welfare, New Delhi.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]

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