Patient Safety in Anticoagulation: Implementing Safety-II and FRAM in the Medical Curriculum
References
- World Health Organization. Global patient safety action plan 2021–2030: towards eliminating avoidable harm in health care. Geneva: World Health Organization; 2021.
- Provan DJ, Woods DD, Dekker SWA, Rae AJ. Safety II professionals: How resilience engineering can transform safety practice. Reliab Eng Syst Saf. 2020;195:
106740 . DOI: 10.1016/j.ress.2019.106740 - Verhagen MJ, de Vos MS, Sujan M, Hamming JF. The problem with making Safety-II work in healthcare. BMJ Qual Saf. 2022;31(5):402–8. DOI: 10.1136/bmjqs-2021-014396
- Payne R, Clarke A, Swann N, et al. Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis. BMJ Qual Saf. 2024;33(9):573–86. DOI: 10.1136/bmjqs-2023-016674
- Patterson M, Deutsch ES. Safety-I, Safety-II and Resilience Engineering. Curr Probl Pediatr Adolesc Health Care. 2015;45(12):382–9. DOI: 10.1016/j.cppeds.2015.10.001
- van Dijk LM, Meulman MD, van Eikenhorst L, et al. Can using the functional resonance analysis method, as an intervention, improve patient safety in hospitals?: a stepped wedge design protocol. BMC Health Serv Res. 2021;21:1–10. DOI: 10.1186/s12913-021-07244-z
- Damen NL, de Vos MS, Moesker MJ, et al. Preoperative Anticoagulation Management in Everyday Clinical Practice: An International Comparative Analysis of Work-as-Done Using the Functional Resonance Analysis Method. J Patient Saf. 2021;17(3):157–65. DOI: 10.1097/pts.0000000000000515
- Moesker MJ, de Groot JF, Damen NL, et al. How reliable is perioperative anticoagulant management? Determining guideline compliance and practice variation by a retrospective patient record review. BMJ open. 2019;9(7):
e029879 . DOI: 10.1136/bmjopen-2019-029879 - Leendertse AJ, Egberts ACG, Stoker LJ, van den Bemt PMLA, HARM Study Group. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Arch Intern Med. 2008;168(17):1890–6. DOI: 10.1001/archinternmed.2008.3
- Dreijer AR, Diepstraten J, Bukkems VE, et al. Anticoagulant medication errors in hospitals and primary care: a cross-sectional study. Int J Qual Health Care. 2019;31(5):346–52. DOI: 10.1093/intqhc/mzy177
- Jordan A. Why are anticoagulation exam questions such a hard nut to crack? Discrepancies in knowledge on anticoagulation pharmacotherapy between the curriculum of medical students from the Free University in Amsterdam and the core learning goals of the national pharmacotherapy exam. Master’s Thesis. Utrecht University: Utrecht. 2023.
- SSA Academy. LPAR Approach: SSA Academy. https://ssa.academy/resources/lpar-learn-practice-apply-review-approach/ (accessed 4 June 2025).
- Birkeli G, Lindahl AK, Hammersbøen ÅM, Deilkås ECT, Ballangrud R. Strategies and tools to learn from work that goes well within healthcare patient safety practices: a mixed methods systematic review. BMC Health Serv Res. 2025;25(1):
538 . DOI: 10.1186/s12913-025-12680-2 - Kelekar A, Afonso N. Evaluation of the effect of a new clinical reasoning curriculum in a pre-clerkship clinical skills course. Perspect Med Educ. 2020;9(2):123–7. DOI: 10.1007/s40037-020-00566-4
DOI: https://doi.org/10.5334/pme.2277 | Journal eISSN: 2212-277X
Language: English
Submitted on: Nov 19, 2025
Accepted on: Mar 6, 2026
Published on: Apr 9, 2026
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services
Publication frequency: 1 issue per year
© 2026 Lauren S. Baidjoe, Liselotte M. van Dijk, Mirjam Simoons, An Tran, Marieke J. H. A. Kruip, Jorie Versmissen, Floor van Rosse, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.