Uncovering the Informal Learning of Patient Safety in Undergraduate Clinical Rotations: A Qualitative Study of Patient Safety Specialists' Perspectives

Uncovering the Informal Learning of Patient Safety in Undergraduate Clinical Rotations: A Qualitative Study of Patient Safety Specialists' Perspectives | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Uncovering the Informal Learning of Patient Safety in Undergraduate Clinical Rotations: A Qualitative Study of Patient Safety Specialists' Perspectives Ikuo Shimizu, Kazumi Tanaka, Mikiko Kishi, Megumi Watanabe This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8480843/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Apr, 2026 Read the published version in BMC Medical Education → Version 1 posted 9 You are reading this latest preprint version Abstract Background Although the World Health Organization (WHO) emphasizes patient safety as a core competency, formal educational opportunities in clinical settings remain limited. This study aimed to clarify how medical students acquire patient safety competencies through informal learning during clinical rotations. Methods A descriptive qualitative study was conducted with 36 patient safety specialists at Japanese national university hospitals. Data were collected via an online open-ended questionnaire regarding safety-related behaviors students engaged in during clinical practice. The responses were analyzed using conventional content analysis. Results The analysis identified 14 learning categories situated within four clinical contexts: receiving instructions, invasive procedures, interprofessional communication, and incident response. These informally acquired competencies are closely aligned with the WHO Patient Safety Curriculum Guide. However, the learning related to quality improvement was notably limited. Participants proposed specific support measures such as utilizing incident reports for education and facilitating student participation in safety conferences to further enhance these informal learning opportunities. Conclusion Students acquire essential patient safety competencies through informal participation in clinical practice and complementing formal curricula. Clinical educators should recognize the value of these situated learning opportunities and intentionally facilitate informal learning environments to complement formal education. Clinical Clerkship Informal Learning Patient Safety Qualitative Research Quality Improvement Undergraduate Medical Education Background Patient safety and quality of care are increasingly recognized as critical issues in medical education [ 1 ]. In particular, how medical students learn about safety culture and acquire appropriate behaviors in clinical settings has attracted attention from the perspective of interprofessional and practice-based education [ 2 ]. The World Health Organization (WHO) has designated patient safety as an essential competency in the initial education of health professionals. It has emphasized the need for its systematic integration into curricula [ 3 , 4 ]. However, in many countries and institutions, patient safety education has not been sufficiently implemented. In particular, limited educational resources in clinical settings, constraints on faculty, and the lack of clear assessment indicators have hindered its incorporation [ 5 ]. Traditionally, patient safety education has been provided mainly through formal learning, such as lectures and simulation training; however, in the context of clinical clerkships, such opportunities are scarce and have not yet been systematically established [ 6 ]. At the same time, because patient safety is closely intertwined with clinical practice, the WHO curriculum notes that students learn about patient safety through their participation in clinical care, beyond intentionally planned learning activities [ 3 ]. In this context, the concept of informal learning has gained attention. Informal learning refers to learning activities that are not part of the official curriculum but occur with some degree of structure or intention and has been a focus, particularly in vocational training and adult education [ 7 ]. Werquin [ 7 ] defined informal learning as the acquisition of knowledge and skills that may not be formally recognized by institutions but are meaningful to learners and have social value. Thus, framing students’ learning about patient safety in clinical settings as informal learning may help elucidate the educational value that has previously been overlooked. Previous studies on patient safety education have primarily focused on evaluating the effectiveness of intervention-based programs using simulations or lectures [ 5 , 8 – 10 ]. Such education aims to impart specific knowledge and behaviors under formal educational designs. The WHO has also adopted a framework premised on formal learning, including modular lesson designs, learning objectives, and assessment methods. However, opportunities for such education are limited in clinical clerkship settings, where provision itself is often not systematically implemented at the organizational level [ 11 ]. Furthermore, the WHO Patient Safety Curriculum Guide [ 3 ] has a structural limitation in that it hardly considers the learning that naturally occurs in clinical settings, namely, informal learning [ 12 ]. Nevertheless, since patient safety is closely linked to clinical practice, students may acquire some form of learning through their participation in clinical care, and properly assessing its educational value is extremely important. However, few descriptive studies have examined how students' perceptions and behaviors regarding patient safety, which are formed implicitly and informally during clinical care, are structured as learning [ 13 , 14 ]. By focusing on informal learning, it is possible to visualize learning opportunities inherent in clinical settings and systematize practical knowledge that has not previously been considered an educational target [ 15 ]. Moreover, educators and curriculum designers provide practical clues to consciously support and complement unconscious learning. The structure of such learning aligns with the learning in communities of practice proposed by Lave and Wenger [ 16 ]. As peripheral participants in the clinical community, medical students acquire professional practice through experience in an informal, context-dependent manner, in which informal rather than formal learning plays a central role [ 17 ]. The purpose of this study is to elucidate how medical students acquire knowledge related to quality of care and patient safety through informal learning during clinical clerkships. It aims to descriptively capture naturalistic and context-dependent learning in practice settings, which cannot be fully addressed by traditional patient safety education based on formal learning. Specifically, this study surveyed certified patient safety specialists (general risk managers, GRMs) at university hospitals [ 18 ]. Although their primary focus is on student learning, GRMs possess a macroscopic view of systemic safety issues and incident trends, making them uniquely positioned to identify latent learning opportunities and behavioral expectations that students may not yet recognize. Through this approach, behaviors and situations related to the quality and safety that medical students may encounter during clinical clerkships were collected and qualitatively analyzed to reveal the structure of informal learning. Methods Study Design and Reporting This descriptive qualitative study aimed to elucidate the conditions of informal learning regarding patient safety experienced by healthcare students during clinical clerkships. The reporting of this study follows the Standards for Reporting Qualitative Research (SRQR) [ 19 ]. Participants and Data Collection Data were collected through an online survey with open-ended questions. Participants were GRMs affiliated with the Undergraduate Training Committee of the National University Hospital Council on Patient Safety. National university hospitals in Japan are premier institutions responsible for tertiary care, advanced research, and the education of medical students as part of a specialized hospital system [ 20 ]. All participants completed the government-certified training program for GRMs. The participants were recruited voluntarily through the committee. An explanatory document detailing the study's purpose, methods, and data handling procedures was presented during recruitment, and informed consent was obtained via a confirmation checkbox on an online questionnaire form. This study was exempt from ethical review by Chiba University Hospital, as it was classified as outside the scope of the "Ethical Guidelines for Medical and Health Research Involving Human Subjects" in Japan. Questionnaire Development The questionnaire items were newly developed through consensus among seven educators from medicine, nursing, and pharmacy, to broadly capture learning related to healthcare quality and safety. To identify the typical content of informal learning and the environmental factors supporting it during the clinical clerkship, the survey included two primary open-ended questions. Specifically, participants were asked to (1) list multiple actions taken by healthcare professionals during diagnosis and care that contribute to patient safety and (2) suggest support measures that medical safety departments could provide to promote patient safety learning in clinical settings. Although a pilot study was not conducted, the content validity of the questions was established through expert consensus of the multidisciplinary educator group. An English version of the questionnaire is provided as Supplementary file 1. Data Collection The survey was conducted in October 2023. A request for participation was sent to all 36 eligible GRMs. Data were collected electronically in an open-ended format, with no character limits or predefined options. To prioritize anonymity and encourage candid responses, demographic data such as years of experience were not collected; therefore, the variation in participants' professional backgrounds was not quantitatively assessed. Data Analysis The collected free-text data were qualitatively analyzed using the conventional content analysis approach [ 21 ]. An inductive approach was adopted, in which meaning units were extracted from the data without a predetermined framework. Importantly, data saturation was confirmed during analysis, as no new codes emerged from the final set of responses. All coding and analyses were performed in the original Japanese language to preserve the nuances of the participants' expressions. Meaning units were coded to derive subcategories based on descriptions of specific actions. Subsequently, these subcategories—representing specific behaviors—were semantically and functionally organized into higher-level "task categories" based on the nature of clinical practice. The final categories and representative concepts were then translated into English for publication. This process provided a structural description of the relationship between students' informal learning in clinical settings and specific healthcare tasks. Rigor and Trustworthiness Coding was performed independently by two researchers (IS and KT), both physician specialists in patient safety and actively involved in developing clinical education curricula. To ensure objectivity, the authors did not discuss the data during the initial coding phase. The coding results were subsequently compared and cross-checked, and discrepancies were resolved through discussion and consensus. When an agreement could not be reached, a third expert with extensive experience in medical education and clinical practice was consulted to finalize the codes and categories. Results A total of 169 free-text responses were obtained from 34 participants (response rate: 94.4%). The descriptions focused on the behaviors and perceptions related to medical quality and safety that medical students informally learn through their participation in clinical practice and care. Through qualitative analysis, the learning contents were classified into 14 subcategories. This learning contents were further mapped onto four distinct clinical contexts: (1) Involvement in Issuing and Receiving Instructions, (2) Participation in Invasive Procedures, (3) Interprofessional Communication and Exchange, and (4) Response to Patient Safety Incidents. Table 1 presents the categorization with representative descriptions of the student experience. Involvement in Issuing and Receiving Instructions This context highlighted fundamental safety communication. The most prevalent learning content was "Procedures for Receiving Instructions," in which students observed and practiced closed-loop communication techniques, such as read-backs, to ensure verbal orders were understood correctly. This was followed by "Patient Identification Protocols," which highlighted the internalization of strict verification practices using two identifiers. Additionally, students learned "Adherence to Guidelines/Manuals" and the importance of "Speaking Up," which involves assertiveness techniques to voice safety concerns regardless of hierarchy. Participation in Invasive Procedures In the context of invasive procedures, "Informed Consent Process" was the most frequently identified learning content. This suggests that students strongly perceived the ethical and legal necessity of explaining procedures and verifying patient understanding. Other key elements included "Privacy Management and Documentation" and "Briefing and Debriefing," where students learned the value of pre-procedural planning and post-event reflection. Students also engaged in "Risk Identification and Assessment" and "Patient Assessment and Monitoring," focusing on detecting early signs of patient deterioration. Interprofessional Communication and Exchange This context focused on how students learn to function within a medical team. "Teamwork and Collaboration" was a prominent theme, where students applied frameworks to understand role clarity and mutual monitoring. "Information Sharing and Handovers" was also frequently cited, reflecting the importance of structured communication during shift changes. "Team Decision Making" was a specific learning opportunity in which students witnessed the synthesis of diverse professional perspectives. Response to Patient Safety Incidents Regarding safety incidents, "Incident Response and Reporting" was the primary learning content, indicating that students are trained in non-punitive protocols for reporting errors to support organizational learning. Additionally, "Emergency Response (Call-out)" was identified, with students simulating scenarios that require immediate mobilization of rapid response teams. Although the results are presented in a clinical context for clarity, the analysis indicates that these categories are not mutually exclusive. Each learning content was observed across multiple settings, demonstrating that students learn patient safety practices intermittently and informally throughout the entire clinical process rather than in isolated modules. Strategies to Support Informal Learning The analysis also identified concrete proposals described by GRMs on how the Medical Safety Department can support informal learning. The respondents suggested that even without direct involvement in clinical supervision, GRMs can indirectly enrich safety education by facilitating the following opportunities: Educational Utilization of Incident Reports : Sharing incident reports relevant to a specific rotation site to help students contextualize accident prevention using real-world examples. Facilitation of Conference Participation : Actively arranging for students to attend multidisciplinary conferences, enabling them to discover and observe team dynamics and communication processes identified in the learning content. Provision of Practical Experiences : Specifying routine safety tasks (e.g., medication verification) that students should witness or perform, and encouraging ward staff to provide observation and practice opportunities. Inter-departmental Collaboration : Collaborating with the Medical Education Department to formally request clinical departments to actively involve students in the identified safety-critical tasks. Departmental Rotation : Introducing short-term rotations within the Medical Safety Department to expose students to specialized safety operations, such as the collection and analysis of incident information. Table 1 Clinical contexts and content for informal patient safety learning Clinical contexts (Categories) Learning contents (subcategories) (n) Representative quotes Involvement in Issuing and Receiving Instructions Procedures for Receiving Instructions 24 Students practice closed-loop communication techniques to confirm verbal orders and ensure instructions are understood correctly before action. Patient Identification Protocols 7 Students internalize the habit of verifying patient identity using at least two identifiers and physical gestures to prevent misidentification errors. Adherence to Guidelines/Manuals 5 Students learn to consult and strictly follow standard operating procedures and hospital manuals before executing clinical tasks. Speaking Up 5 Students are empowered with specific assertiveness techniques to voice safety concerns or question unclear orders, regardless of hierarchy. Participation in Invasive Procedures Informed Consent Process 22 Students observe and practice the ethical process of explaining procedures to patients and verifying their understanding to support valid decision-making. Privacy Management and Documentation 12 Students learn the legal requirements of accurate medical charting while strictly maintaining patient confidentiality and data security. Briefing and Debriefing 10 Students engage in pre-procedure planning to align team goals and post-event discussions to reflect on performance and areas for improvement. Risk Identification and Assessment 9 Students practice evaluating environmental and patient-specific factors to proactively identify safety risks, such as the potential for falls. Patient Assessment and Monitoring 9 Students learn to continuously observe vital signs and assess the patient's condition to detect early signs of deterioration or changes in care needs. Interprofessional Communication and Exchange Teamwork and Collaboration 15 Students apply teamwork frameworks to understand the importance of role clarity, mutual monitoring, and supporting colleagues to enhance safety. Information Sharing and Handovers 12 Students utilize structured communication frameworks to transfer critical patient information effectively during shift changes or inter-departmental transfers. Team Decision Making 3 Students participate in team conferences to witness how diverse professional perspectives are synthesized to determine the best course of treatment. Response to Patient Safety Incidents Incident Response and Reporting 15 Students are trained on the non-punitive protocols for reporting errors and adverse events to contribute to organizational learning and safety. Emergency Response (Call-out) 5 Students simulate emergency scenarios where they must vocalize critical information clearly to mobilize the rapid response team immediately. Discussion This study elucidated how healthcare students experience patient safety-related learning as a form of informal learning during their clinical clerkships. Analysis of open-ended responses identified 14 categories and four distinct clinical contexts. These findings suggest that students develop diverse behaviors and perceptions regarding patient safety during actual clinical tasks. Crucially, these learning experiences were not derived from formal educational interventions explicitly designed by educators but emerged naturally or informally in the practice of patient care. Consequently, this study prompted a reevaluation of the value of learning embedded within clinical clerkships, extending beyond the formal framework of patient safety education. The significance of informal learning in clinical settings is well supported by the existing literature. Dornan et al. described "experience-based learning" as the core of clinical education, wherein students acquire knowledge and attitudes by participating as members of a medical team, observing practice, and engaging in reflection [ 13 ]. Similarly, Seabrook highlighted how students absorb significant lessons from the educational atmosphere and culture of the workplace, underscoring the vital role of informal and situated learning in clinical environments [ 22 ]. From a vocational education perspective, Berger et al. emphasized that learning in informal fields of practice is central to the internalization of professional judgment and behavioral norms [ 23 ]. Furthermore, programs designed to help students consciously leverage informal learning, such as those that combine classroom introductions with workplace self-regulated learning tasks, have been shown to facilitate their adaptation to clinical settings [ 24 ]. The findings of this study align with these theoretical and empirical foundations, confirming the existence and significance of informal learning in clinical clerkships. Notably, the 14 learning categories identified in this study showed high consistency with the core learning objectives outlined in the WHO Patient Safety Curriculum Guide [ 3 ]. The guide defines key educational elements, such as fundamental patient safety principles, risk awareness, incident response, information sharing, teamwork, and speaking up, all of which correspond to the learning content identified in our study. It is particularly noteworthy that these competencies were fostered not through formal educational interventions but unintentionally within the context of clinical practice, often under the discretionary guidance of supervisors. This suggests that the learning objectives envisioned by the WHO curriculum are, to some extent, already being achieved within the context of informal learning. This finding implies that, even without exclusive reliance on formal learning, patient safety education can be effectively promoted when appropriate fields of practice and opportunities for participation are available. However, a distinct limitation was observed in quality improvement (QI), as descriptions in this category were scarce compared to those in other categories. This likely reflects the fact that QI activities are not yet fully integrated into clinicians’ routine tasks in many clinical settings. The literature suggests that QI is often perceived as the responsibility of specific departments or administrative bodies, and that there is a lack of a mature culture in which clinicians proactively engage in these activities [ 25 ]. As informal learning is inherently a process of learning from events within the environment, the absence of a pervasive QI culture makes it difficult for students to learn these concepts informally. This observation highlights the potential risk that informal learning can inadvertently reproduce the status quo. Although patient safety and QI are institutionally linked, they are often fragmented in educational curricula. Therefore, it is realistic to complement this with non-formal learning opportunities —defined as structured educational activities that occur outside the immediate clinical workflow— such as academic half-days or off-the-job training [ 26 ]. These structured settings allow students to systematically acquire the theoretical foundations of QI, ensuring they are equipped to engage in improvement activities even when the clinical environment is still maturing. To effectively leverage informal learning in education, D’Eon proposed three practical strategies: establishing interdisciplinary and service-based learning environments, promoting active participation in communities of practice, and ensuring continuous observation and feedback by faculty [ 27 ]. The concrete support measures proposed by the GRMs in this study, such as utilizing incident reports for education and facilitating student participation in safety conferences, align well with these theoretical strategies and offer a practical roadmap for implementation. The four identified clinical contexts—receiving instructions, invasive procedures, interprofessional exchange, and incident response—are also highly compatible with these elements. By intentionally designing these promoting factors in clinical clerkships, educators can effectively cultivate students' safety consciousness and teamwork competencies, deepening learning beyond the classroom. Furthermore, to ensure the consolidation of these informally acquired competencies, assessment practices must be utilized as a mechanism to foster learning [ 28 ]. By utilizing direct observation and providing formative feedback in clinical settings, educators can transform transient informal experiences into explicit learning outcomes, thereby bridging the gap between implicit practice and conscious competence. Limitations This study has several limitations. First, the analysis relies on the perspectives of GRMs, who serve as both educators and managers, rather than directly investigating students’ subjective experiences or perceptions, who are the primary subjects of learning. Consequently, the internal processes of what students actually internalized remained speculative from the data. Nevertheless, GRMs occupy a unique vantage point overseeing both medical safety management and clinical education. Their insights are therefore invaluable for objectively identifying the learning affordances inherent in clinical settings and defining the behavioral expectations of students as aspiring professionals [ 29 ]. Second, the data extracted in this study were limited to descriptions of observable behaviors and situations and did not assess whether these experiences translated into long-term retention or into transformation of knowledge, attitudes, and behaviors. This reflects a common challenge in the field, in which assessments of patient safety education programs often focus on lower levels of educational effectiveness, such as learner reactions or knowledge acquisition, rather than on behavioral changes [ 30 ]. To verify the impact of informal learning on the formation of professional identity, assessment methods that extend beyond mere behavioral observation are required. Third, the study participants were limited to specific national university hospitals, and the diversity of their professional backgrounds (e.g., years of experience) was not quantitatively assessed. Therefore, caution should be exercised when generalizing these findings to facilities with different organizational cultures or community medicine settings. Future research should employ a mixed-methods approach that combines student interviews, participant observation, and longitudinal tracking. A multifaceted verification of how students interpret clinical contexts and construct practical knowledge remains a critical task for future research. Conclusion This study aimed to elucidate how healthcare students experience learning related to patient safety during clinical clerkships from the perspective of informal learning, through a qualitative survey of General Risk Managers at national university hospitals. The findings revealed that students spontaneously acquire diverse behaviors and perceptions regarding patient safety, including patient identification, information sharing, incident response, and speaking up, as they engage in diagnostic and care processes. These learning experiences align with the core educational objectives of the WHO Patient Safety Curriculum, highlighting the inherent educational value of clinical settings that complement formal learning structures. Moving forward, educational designs that systematically capture, visualize, and support these informal learning structures must be introduced. Future research should incorporate student perspectives and examine the relationship between informal learning and actual learning outcomes to further clarify their educational significance. Ultimately, this study serves as a foundation for broadening the scope of patient safety education beyond formal learning, thereby opening new possibilities for diverse learning rooted in clinical practice. Abbreviations GRM General Risk Manager QI Quality Improvement SRQR Standards for Reporting Qualitative Research WHO World Health Organization Declarations Acknowledgements The authors express their sincere gratitude to the Japan National University Hospital Alliance on Patient Safety for their cooperation in facilitating this study. We also extend our deepest appreciation to the general risk managers at the national university hospitals who generously provided their time and valuable insights to complete the survey. Ethics approval and consent to participate This study was reviewed by the Ethics Committee of Chiba University Hospital and was determined to be exempt from ethical review, as it was classified as outside the scope of the "Ethical Guidelines for Medical and Health Research Involving Human Subjects" in Japan. However, ethical standards were strictly maintained. All potential participants received written information explaining the study’s purpose, the voluntary nature of participation, and data handling procedures. Submission of the completed survey constituted informed consent. Participants were assured of their right to withdraw at any time without penalty. All responses were collected anonymously via a secure online platform, and data were stored on password-protected servers accessible only to the research team. No financial compensation was provided. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional ethics committee and with the 1964 Declaration of Helsinki and its later amendments. Consent for publication Not applicable Availability of data and materials The datasets generated in this study are available from the corresponding author upon request. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Authors' contributions IS and KT conceived of and designed the study. IS and KT were responsible for data collection and analysis. MK and WM contributed to data interpretation. IS drafted the manuscript. All authors reviewed and approved the final version of the manuscript. References Lachman P, Runnacles J, Jayadev A, Brennan J, Fitzsimons J, editors. Oxford Professional Practice: Handbook of Patient Safety. Oxford University Press; 2022. Bowman C, Neeman N, Sehgal NL. Enculturation of Unsafe Attitudes and Behaviors: Student Perceptions of Safety Culture. Acad Med. 2013;88(6):802–10. World Health Organization. Patient safety curriculum guide: multi-professional edition. Geneva: World Health Organization; 2011. Wu AW, Busch IM. Patient safety: A new basic science for professional education. GMS J Med Educ. 2019;36(2):1–15. Kirkman MA, Sevdalis N, Arora S, Baker P, Vincent C, Ahmed M. The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review. BMJ Open. 2015;5(5):e007705. Nie Y, Li L, Duan Y, Chen P, Barraclough BH, Zhang M, et al. Patient safety education for undergraduate medical students: a systematic review. BMC Med Educ. 2011;11:33. Werquin P. Terms, definitions, models and taxonomies of informal learning. Recognition of non-formal and informal learning - country note: France. Paris: OECD; 2010. pp. 25–36. Ahmed M, Arora S, Tiew S, et al. Building a safer foundation: the Lessons Learnt patient safety training programme. BMJ Qual Saf. 2014;23:78–86. Cox KR, Scott SD, Hall LW, et al. Uncovering differences among health professions trainees exposed to an interprofessional patient safety curriculum. Qual Manag Health Care. 2009;18:182–93. Smith KL, Ashburn S, Rule E, et al. Residents contributing to inpatient quality: blending learning and improvement. J Hosp Med. 2012;7:148–53. Aldardeir N, Abdullah QK, Jones L. Patient safety education in undergraduate medical education through a global lens: a scoping review. BMC Med Educ. 2025;25:544. Parra Larrotta S, Hernández Rincón EH, Niño Correa D, Jaimes Peñuela CL, Romero Tapia AE. Effects of the Hidden Curriculum in Medical Education: Scoping Review. JMIR Med Educ. 2025;11:e68481. Dornan T, Boshuizen H, King N, Scherpbier A. Experience-based learning: a model linking the processes and outcomes of medical students' workplace learning. Med Educ. 2007;41(1):84–91. Wee CPJ, Ng M, Teunissen PW. How do factors in fixed clinical teams affect informal learning among Emergency Medicine Residents. TAPS. 2023;8(1):25–32. Ní Chroinin MN, O’Tuathail C, Cornally N. The influence of informal learning and learning transfer on nurses’ clinical performance during routine patient care: a quantitative study. Nurse Educ Today. 2019;79:15–20. Lave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge: Cambridge University Press; 1991. Ha MT, Siddiqui ZS. Understanding medical students’ transition to clinical training: a qualitative study of transformative learning and professional identity formation. BMJ Open. 2025;15(6):e098675. Ministry of Health. Labour and Welfare. Guidelines for the duties of medical safety managers and guidelines for creating training programs for their training. Tokyo: Ministry of Health, Labour and Welfare; 2020 Mar. [cited 2025 Dec 16]. Available from: https://www.mhlw.go.jp/content/10800000/000898761.pdf O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51. Ministry of Health, Labour and Welfare. Special functioning hospitals [Internet]. Tokyo: Ministry of Health, Labour and Welfare; [cited 2025 Dec 16]. Available from: https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000137801.html Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12. Seabrook MA. Clinical students’ initial reports of the educational climate in a single medical school. Med Educ. 2004;38(6):659–69. Berger AS, Niedra E, Brooks K, O’Keefe M. Teaching professionalism in postgraduate medical education: a systematic review. Acad Med. 2020;95(6):938–46. van Houten-Schat MA, Berkhout JJ, van Dijk N, Endedijk MD, Jaarsma ADC, Diemers AD. Self-regulated learning in the clinical context: a systematic review. Med Educ. 2018;52(10):1008–15. Pannick S, Davis R, Ashrafian H, Byrne BE, Beveridge I, Athanasiou T, et al. Beyond clinical engagement: a pragmatic model for quality improvement in healthcare. BMJ Qual Saf. 2016;25(9):716–25. Organisation for Economic Co-operation and Development. Recognition of non-formal and informal learning [Internet]. Paris: OECD. 2016 [cited 2025 Dec 21]. Available from: http://www.oecd.org/edu/skills-beyond-school/recognitionofnon-formalandinformallearning-home.htm D’Eon M. A blueprint for interprofessional learning. J InterprofCare. 2005;19(sup1):49–59. Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide 31. Med Teach. 2007;29(9–10):855–71. Stabel LS, McGrath C, Björck E, Elmberger A, Laksov KB. Navigating Affordances for Learning in Clinical Workplaces: A Qualitative Study of General Practitioners’ Continued Professional Development. Vocat Learn. 2022;15(3):427–48. Kim J, Lee M, Hong E. Evaluating the outcomes of patient safety education programs in nursing education: a scoping review. BMC Nurs. 2025;24(1):273. Additional Declarations No competing interests reported. Supplementary Files Supplementary1PSEinformal20260107.docx Cite Share Download PDF Status: Published Journal Publication published 30 Apr, 2026 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 09 Mar, 2026 Reviews received at journal 24 Feb, 2026 Reviews received at journal 24 Feb, 2026 Reviewers agreed at journal 20 Feb, 2026 Reviewers agreed at journal 18 Feb, 2026 Reviewers invited by journal 05 Feb, 2026 Editor assigned by journal 07 Jan, 2026 Submission checks completed at journal 06 Jan, 2026 First submitted to journal 06 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8480843","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587882562,"identity":"bf89929e-7e73-419f-8649-0dc4143eaf38","order_by":0,"name":"Ikuo Shimizu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYDACZiBmbGDgAZIPGD4AOWzsxGthNmCcAdLCTIxNQC0gzQbMPDBD8AG+47yHX/7ccVjG4EYym7TNr23yfMwMjB8+5uDWInmYL82a98xhHrCW3L7bhm3MDMySM7fh1mJwmMfMmLENpCX/mHRuz21GoBY2Zl4CWgx/tkFtsey5bU+MFuMHvDAtDD9uJxLUIgm0hZm3LZ1H8sxjZsvehtvJbcyMzXj9wnf+jPHHn23W9nzHkxlv/Phz23Z+e/PBDx/xaGE4wMAmAaIVDgAJxjYQExJN+LQwg5IJgzxY3R/8ikfBKBgFo2BkAgATVU+I0/Kq+gAAAABJRU5ErkJggg==","orcid":"","institution":"Chiba University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Ikuo","middleName":"","lastName":"Shimizu","suffix":""},{"id":587882563,"identity":"7c9eda4f-bfe7-47a4-a711-ce4c158d3e01","order_by":1,"name":"Kazumi Tanaka","email":"","orcid":"","institution":"Gunma University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kazumi","middleName":"","lastName":"Tanaka","suffix":""},{"id":587882564,"identity":"63563a4d-8275-4a2f-95bc-01a5da8ab3a3","order_by":2,"name":"Mikiko Kishi","email":"","orcid":"","institution":"Gunma University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mikiko","middleName":"","lastName":"Kishi","suffix":""},{"id":587882565,"identity":"db339828-7222-447c-b71c-7f9a89ad1b4d","order_by":3,"name":"Megumi Watanabe","email":"","orcid":"","institution":"Gunma University","correspondingAuthor":false,"prefix":"","firstName":"Megumi","middleName":"","lastName":"Watanabe","suffix":""}],"badges":[],"createdAt":"2025-12-30 11:38:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8480843/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8480843/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-026-09357-7","type":"published","date":"2026-04-30T15:57:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":108437609,"identity":"40994a22-e9dd-43ed-bc8c-3fbb6c20ab82","added_by":"auto","created_at":"2026-05-04 16:00:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":235357,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8480843/v1/466c2ea4-2f80-4b70-9fbf-1ee97f1a0d73.pdf"},{"id":102346284,"identity":"c45f3d01-022b-40e3-97d4-67c9e8e56b92","added_by":"auto","created_at":"2026-02-10 17:37:12","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":14214,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementary1PSEinformal20260107.docx","url":"https://assets-eu.researchsquare.com/files/rs-8480843/v1/194a1d98f5800c9790de8cf1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Uncovering the Informal Learning of Patient Safety in Undergraduate Clinical Rotations: A Qualitative Study of Patient Safety Specialists' Perspectives","fulltext":[{"header":"Background","content":"\u003cp\u003ePatient safety and quality of care are increasingly recognized as critical issues in medical education [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In particular, how medical students learn about safety culture and acquire appropriate behaviors in clinical settings has attracted attention from the perspective of interprofessional and practice-based education [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The World Health Organization (WHO) has designated patient safety as an essential competency in the initial education of health professionals. It has emphasized the need for its systematic integration into curricula [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, in many countries and institutions, patient safety education has not been sufficiently implemented. In particular, limited educational resources in clinical settings, constraints on faculty, and the lack of clear assessment indicators have hindered its incorporation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Traditionally, patient safety education has been provided mainly through formal learning, such as lectures and simulation training; however, in the context of clinical clerkships, such opportunities are scarce and have not yet been systematically established [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. At the same time, because patient safety is closely intertwined with clinical practice, the WHO curriculum notes that students learn about patient safety through their participation in clinical care, beyond intentionally planned learning activities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this context, the concept of informal learning has gained attention. Informal learning refers to learning activities that are not part of the official curriculum but occur with some degree of structure or intention and has been a focus, particularly in vocational training and adult education [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Werquin [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] defined informal learning as the acquisition of knowledge and skills that may not be formally recognized by institutions but are meaningful to learners and have social value. Thus, framing students\u0026rsquo; learning about patient safety in clinical settings as informal learning may help elucidate the educational value that has previously been overlooked.\u003c/p\u003e \u003cp\u003ePrevious studies on patient safety education have primarily focused on evaluating the effectiveness of intervention-based programs using simulations or lectures [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Such education aims to impart specific knowledge and behaviors under formal educational designs. The WHO has also adopted a framework premised on formal learning, including modular lesson designs, learning objectives, and assessment methods. However, opportunities for such education are limited in clinical clerkship settings, where provision itself is often not systematically implemented at the organizational level [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Furthermore, the WHO Patient Safety Curriculum Guide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] has a structural limitation in that it hardly considers the learning that naturally occurs in clinical settings, namely, informal learning [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, since patient safety is closely linked to clinical practice, students may acquire some form of learning through their participation in clinical care, and properly assessing its educational value is extremely important. However, few descriptive studies have examined how students' perceptions and behaviors regarding patient safety, which are formed implicitly and informally during clinical care, are structured as learning [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. By focusing on informal learning, it is possible to visualize learning opportunities inherent in clinical settings and systematize practical knowledge that has not previously been considered an educational target [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Moreover, educators and curriculum designers provide practical clues to consciously support and complement unconscious learning.\u003c/p\u003e \u003cp\u003eThe structure of such learning aligns with the learning in \u003cem\u003ecommunities of practice\u003c/em\u003e proposed by Lave and Wenger [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. As peripheral participants in the clinical community, medical students acquire professional practice through experience in an informal, context-dependent manner, in which informal rather than formal learning plays a central role [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe purpose of this study is to elucidate how medical students acquire knowledge related to quality of care and patient safety through informal learning during clinical clerkships. It aims to descriptively capture naturalistic and context-dependent learning in practice settings, which cannot be fully addressed by traditional patient safety education based on formal learning. Specifically, this study surveyed certified patient safety specialists (general risk managers, GRMs) at university hospitals [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although their primary focus is on student learning, GRMs possess a macroscopic view of systemic safety issues and incident trends, making them uniquely positioned to identify latent learning opportunities and behavioral expectations that students may not yet recognize. Through this approach, behaviors and situations related to the quality and safety that medical students may encounter during clinical clerkships were collected and qualitatively analyzed to reveal the structure of informal learning.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Reporting\u003c/h2\u003e \u003cp\u003eThis descriptive qualitative study aimed to elucidate the conditions of informal learning regarding patient safety experienced by healthcare students during clinical clerkships. The reporting of this study follows the Standards for Reporting Qualitative Research (SRQR) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Data Collection\u003c/h3\u003e\n\u003cp\u003eData were collected through an online survey with open-ended questions. Participants were GRMs affiliated with the Undergraduate Training Committee of the National University Hospital Council on Patient Safety. National university hospitals in Japan are premier institutions responsible for tertiary care, advanced research, and the education of medical students as part of a specialized hospital system [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. All participants completed the government-certified training program for GRMs.\u003c/p\u003e \u003cp\u003eThe participants were recruited voluntarily through the committee. An explanatory document detailing the study's purpose, methods, and data handling procedures was presented during recruitment, and informed consent was obtained via a confirmation checkbox on an online questionnaire form.\u003c/p\u003e \u003cp\u003e This study was exempt from ethical review by Chiba University Hospital, as it was classified as outside the scope of the \"Ethical Guidelines for Medical and Health Research Involving Human Subjects\" in Japan.\u003c/p\u003e\n\u003ch3\u003eQuestionnaire Development\u003c/h3\u003e\n\u003cp\u003eThe questionnaire items were newly developed through consensus among seven educators from medicine, nursing, and pharmacy, to broadly capture learning related to healthcare quality and safety. To identify the typical content of informal learning and the environmental factors supporting it during the clinical clerkship, the survey included two primary open-ended questions. Specifically, participants were asked to (1) list multiple actions taken by healthcare professionals during diagnosis and care that contribute to patient safety and (2) suggest support measures that medical safety departments could provide to promote patient safety learning in clinical settings. Although a pilot study was not conducted, the content validity of the questions was established through expert consensus of the multidisciplinary educator group. An English version of the questionnaire is provided as Supplementary file 1.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eThe survey was conducted in October 2023. A request for participation was sent to all 36 eligible GRMs. Data were collected electronically in an open-ended format, with no character limits or predefined options. To prioritize anonymity and encourage candid responses, demographic data such as years of experience were not collected; therefore, the variation in participants' professional backgrounds was not quantitatively assessed.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe collected free-text data were qualitatively analyzed using the conventional content analysis approach [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. An inductive approach was adopted, in which meaning units were extracted from the data without a predetermined framework. Importantly, data saturation was confirmed during analysis, as no new codes emerged from the final set of responses.\u003c/p\u003e \u003cp\u003e All coding and analyses were performed in the original Japanese language to preserve the nuances of the participants' expressions. Meaning units were coded to derive subcategories based on descriptions of specific actions. Subsequently, these subcategories\u0026mdash;representing specific behaviors\u0026mdash;were semantically and functionally organized into higher-level \"task categories\" based on the nature of clinical practice. The final categories and representative concepts were then translated into English for publication. This process provided a structural description of the relationship between students' informal learning in clinical settings and specific healthcare tasks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRigor and Trustworthiness\u003c/h2\u003e \u003cp\u003eCoding was performed independently by two researchers (IS and KT), both physician specialists in patient safety and actively involved in developing clinical education curricula. To ensure objectivity, the authors did not discuss the data during the initial coding phase. The coding results were subsequently compared and cross-checked, and discrepancies were resolved through discussion and consensus. When an agreement could not be reached, a third expert with extensive experience in medical education and clinical practice was consulted to finalize the codes and categories.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 169 free-text responses were obtained from 34 participants (response rate: 94.4%). The descriptions focused on the behaviors and perceptions related to medical quality and safety that medical students informally learn through their participation in clinical practice and care. Through qualitative analysis, the learning contents were classified into 14 subcategories. This learning contents were further mapped onto four distinct clinical contexts: (1) Involvement in Issuing and Receiving Instructions, (2) Participation in Invasive Procedures, (3) Interprofessional Communication and Exchange, and (4) Response to Patient Safety Incidents. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the categorization with representative descriptions of the student experience.\u003c/p\u003e\n\u003ch3\u003eInvolvement in Issuing and Receiving Instructions\u003c/h3\u003e\n\u003cp\u003eThis context highlighted fundamental safety communication. The most prevalent learning content was \"Procedures for Receiving Instructions,\" in which students observed and practiced closed-loop communication techniques, such as read-backs, to ensure verbal orders were understood correctly. This was followed by \"Patient Identification Protocols,\" which highlighted the internalization of strict verification practices using two identifiers. Additionally, students learned \"Adherence to Guidelines/Manuals\" and the importance of \"Speaking Up,\" which involves assertiveness techniques to voice safety concerns regardless of hierarchy.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipation in Invasive Procedures\u003c/h2\u003e \u003cp\u003eIn the context of invasive procedures, \"Informed Consent Process\" was the most frequently identified learning content. This suggests that students strongly perceived the ethical and legal necessity of explaining procedures and verifying patient understanding. Other key elements included \"Privacy Management and Documentation\" and \"Briefing and Debriefing,\" where students learned the value of pre-procedural planning and post-event reflection. Students also engaged in \"Risk Identification and Assessment\" and \"Patient Assessment and Monitoring,\" focusing on detecting early signs of patient deterioration.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInterprofessional Communication and Exchange\u003c/h2\u003e \u003cp\u003eThis context focused on how students learn to function within a medical team. \"Teamwork and Collaboration\" was a prominent theme, where students applied frameworks to understand role clarity and mutual monitoring. \"Information Sharing and Handovers\" was also frequently cited, reflecting the importance of structured communication during shift changes. \"Team Decision Making\" was a specific learning opportunity in which students witnessed the synthesis of diverse professional perspectives.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eResponse to Patient Safety Incidents\u003c/h2\u003e \u003cp\u003eRegarding safety incidents, \"Incident Response and Reporting\" was the primary learning content, indicating that students are trained in non-punitive protocols for reporting errors to support organizational learning. Additionally, \"Emergency Response (Call-out)\" was identified, with students simulating scenarios that require immediate mobilization of rapid response teams.\u003c/p\u003e \u003cp\u003eAlthough the results are presented in a clinical context for clarity, the analysis indicates that these categories are not mutually exclusive. Each learning content was observed across multiple settings, demonstrating that students learn patient safety practices intermittently and informally throughout the entire clinical process rather than in isolated modules.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrategies to Support Informal Learning\u003c/h2\u003e \u003cp\u003eThe analysis also identified concrete proposals described by GRMs on how the Medical Safety Department can support informal learning. The respondents suggested that even without direct involvement in clinical supervision, GRMs can indirectly enrich safety education by facilitating the following opportunities:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eEducational Utilization of Incident Reports\u003c/b\u003e: Sharing incident reports relevant to a specific rotation site to help students contextualize accident prevention using real-world examples.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFacilitation of Conference Participation\u003c/b\u003e: Actively arranging for students to attend multidisciplinary conferences, enabling them to discover and observe team dynamics and communication processes identified in the learning content.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eProvision of Practical Experiences\u003c/b\u003e: Specifying routine safety tasks (e.g., medication verification) that students should witness or perform, and encouraging ward staff to provide observation and practice opportunities.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eInter-departmental Collaboration\u003c/b\u003e: Collaborating with the Medical Education Department to formally request clinical departments to actively involve students in the identified safety-critical tasks.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDepartmental Rotation\u003c/b\u003e: Introducing short-term rotations within the Medical Safety Department to expose students to specialized safety operations, such as the collection and analysis of incident information.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical contexts and content for informal patient safety learning\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical contexts (Categories)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLearning contents (subcategories)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRepresentative quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eInvolvement in Issuing and Receiving Instructions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProcedures for Receiving Instructions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents practice closed-loop communication techniques to confirm verbal orders and ensure instructions are understood correctly before action.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient Identification Protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents internalize the habit of verifying patient identity using at least two identifiers and physical gestures to prevent misidentification errors.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdherence to Guidelines/Manuals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents learn to consult and strictly follow standard operating procedures and hospital manuals before executing clinical tasks.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpeaking Up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents are empowered with specific assertiveness techniques to voice safety concerns or question unclear orders, regardless of hierarchy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eParticipation in Invasive Procedures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInformed Consent Process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents observe and practice the ethical process of explaining procedures to patients and verifying their understanding to support valid decision-making.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivacy Management and Documentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents learn the legal requirements of accurate medical charting while strictly maintaining patient confidentiality and data security.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBriefing and Debriefing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents engage in pre-procedure planning to align team goals and post-event discussions to reflect on performance and areas for improvement.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRisk Identification and Assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents practice evaluating environmental and patient-specific factors to proactively identify safety risks, such as the potential for falls.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient Assessment and Monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents learn to continuously observe vital signs and assess the patient's condition to detect early signs of deterioration or changes in care needs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eInterprofessional Communication and Exchange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeamwork and Collaboration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents apply teamwork frameworks to understand the importance of role clarity, mutual monitoring, and supporting colleagues to enhance safety.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInformation Sharing and Handovers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents utilize structured communication frameworks to transfer critical patient information effectively during shift changes or inter-departmental transfers.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeam Decision Making\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents participate in team conferences to witness how diverse professional perspectives are synthesized to determine the best course of treatment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eResponse to Patient Safety Incidents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncident Response and Reporting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents are trained on the non-punitive protocols for reporting errors and adverse events to contribute to organizational learning and safety.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmergency Response (Call-out)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudents simulate emergency scenarios where they must vocalize critical information clearly to mobilize the rapid response team immediately.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study elucidated how healthcare students experience patient safety-related learning as a form of informal learning during their clinical clerkships. Analysis of open-ended responses identified 14 categories and four distinct clinical contexts. These findings suggest that students develop diverse behaviors and perceptions regarding patient safety during actual clinical tasks. Crucially, these learning experiences were not derived from formal educational interventions explicitly designed by educators but emerged naturally or informally in the practice of patient care. Consequently, this study prompted a reevaluation of the value of learning embedded within clinical clerkships, extending beyond the formal framework of patient safety education.\u003c/p\u003e \u003cp\u003eThe significance of informal learning in clinical settings is well supported by the existing literature. Dornan et al. described \"experience-based learning\" as the core of clinical education, wherein students acquire knowledge and attitudes by participating as members of a medical team, observing practice, and engaging in reflection [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Similarly, Seabrook highlighted how students absorb significant lessons from the educational atmosphere and culture of the workplace, underscoring the vital role of informal and situated learning in clinical environments [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. From a vocational education perspective, Berger et al. emphasized that learning in informal fields of practice is central to the internalization of professional judgment and behavioral norms [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Furthermore, programs designed to help students consciously leverage informal learning, such as those that combine classroom introductions with workplace self-regulated learning tasks, have been shown to facilitate their adaptation to clinical settings [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The findings of this study align with these theoretical and empirical foundations, confirming the existence and significance of informal learning in clinical clerkships.\u003c/p\u003e \u003cp\u003eNotably, the 14 learning categories identified in this study showed high consistency with the core learning objectives outlined in the WHO Patient Safety Curriculum Guide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The guide defines key educational elements, such as fundamental patient safety principles, risk awareness, incident response, information sharing, teamwork, and speaking up, all of which correspond to the learning content identified in our study. It is particularly noteworthy that these competencies were fostered not through formal educational interventions but unintentionally within the context of clinical practice, often under the discretionary guidance of supervisors. This suggests that the learning objectives envisioned by the WHO curriculum are, to some extent, already being achieved within the context of informal learning. This finding implies that, even without exclusive reliance on formal learning, patient safety education can be effectively promoted when appropriate fields of practice and opportunities for participation are available.\u003c/p\u003e \u003cp\u003eHowever, a distinct limitation was observed in quality improvement (QI), as descriptions in this category were scarce compared to those in other categories. This likely reflects the fact that QI activities are not yet fully integrated into clinicians\u0026rsquo; routine tasks in many clinical settings. The literature suggests that QI is often perceived as the responsibility of specific departments or administrative bodies, and that there is a lack of a mature culture in which clinicians proactively engage in these activities [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. As informal learning is inherently a process of learning from events within the environment, the absence of a pervasive QI culture makes it difficult for students to learn these concepts informally. This observation highlights the potential risk that informal learning can inadvertently reproduce the status quo. Although patient safety and QI are institutionally linked, they are often fragmented in educational curricula. Therefore, it is realistic to complement this with non-formal learning opportunities \u0026mdash;defined as structured educational activities that occur outside the immediate clinical workflow\u0026mdash; such as academic half-days or off-the-job training [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These structured settings allow students to systematically acquire the theoretical foundations of QI, ensuring they are equipped to engage in improvement activities even when the clinical environment is still maturing.\u003c/p\u003e \u003cp\u003eTo effectively leverage informal learning in education, D\u0026rsquo;Eon proposed three practical strategies: establishing interdisciplinary and service-based learning environments, promoting active participation in communities of practice, and ensuring continuous observation and feedback by faculty [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The concrete support measures proposed by the GRMs in this study, such as utilizing incident reports for education and facilitating student participation in safety conferences, align well with these theoretical strategies and offer a practical roadmap for implementation. The four identified clinical contexts\u0026mdash;receiving instructions, invasive procedures, interprofessional exchange, and incident response\u0026mdash;are also highly compatible with these elements. By intentionally designing these promoting factors in clinical clerkships, educators can effectively cultivate students' safety consciousness and teamwork competencies, deepening learning beyond the classroom. Furthermore, to ensure the consolidation of these informally acquired competencies, assessment practices must be utilized as a mechanism to foster learning [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. By utilizing direct observation and providing formative feedback in clinical settings, educators can transform transient informal experiences into explicit learning outcomes, thereby bridging the gap between implicit practice and conscious competence.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, the analysis relies on the perspectives of GRMs, who serve as both educators and managers, rather than directly investigating students\u0026rsquo; subjective experiences or perceptions, who are the primary subjects of learning. Consequently, the internal processes of what students actually internalized remained speculative from the data. Nevertheless, GRMs occupy a unique vantage point overseeing both medical safety management and clinical education. Their insights are therefore invaluable for objectively identifying the learning affordances inherent in clinical settings and defining the behavioral expectations of students as aspiring professionals [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSecond, the data extracted in this study were limited to descriptions of observable behaviors and situations and did not assess whether these experiences translated into long-term retention or into transformation of knowledge, attitudes, and behaviors. This reflects a common challenge in the field, in which assessments of patient safety education programs often focus on lower levels of educational effectiveness, such as learner reactions or knowledge acquisition, rather than on behavioral changes [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. To verify the impact of informal learning on the formation of professional identity, assessment methods that extend beyond mere behavioral observation are required.\u003c/p\u003e \u003cp\u003eThird, the study participants were limited to specific national university hospitals, and the diversity of their professional backgrounds (e.g., years of experience) was not quantitatively assessed. Therefore, caution should be exercised when generalizing these findings to facilities with different organizational cultures or community medicine settings. Future research should employ a mixed-methods approach that combines student interviews, participant observation, and longitudinal tracking. A multifaceted verification of how students interpret clinical contexts and construct practical knowledge remains a critical task for future research.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study aimed to elucidate how healthcare students experience learning related to patient safety during clinical clerkships from the perspective of informal learning, through a qualitative survey of General Risk Managers at national university hospitals. The findings revealed that students spontaneously acquire diverse behaviors and perceptions regarding patient safety, including patient identification, information sharing, incident response, and speaking up, as they engage in diagnostic and care processes. These learning experiences align with the core educational objectives of the WHO Patient Safety Curriculum, highlighting the inherent educational value of clinical settings that complement formal learning structures.\u003c/p\u003e \u003cp\u003eMoving forward, educational designs that systematically capture, visualize, and support these informal learning structures must be introduced. Future research should incorporate student perspectives and examine the relationship between informal learning and actual learning outcomes to further clarify their educational significance. Ultimately, this study serves as a foundation for broadening the scope of patient safety education beyond formal learning, thereby opening new possibilities for diverse learning rooted in clinical practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGRM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Risk Manager\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eQI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuality Improvement\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSRQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandards for Reporting Qualitative Research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their sincere gratitude to the Japan National University Hospital Alliance on Patient Safety for their cooperation in facilitating this study. We also extend our deepest appreciation to the general risk managers at the national university hospitals who generously provided their time and valuable insights to complete the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed by the Ethics Committee of Chiba University Hospital and was determined to be exempt from ethical review, as it was classified as outside the scope of the \"Ethical Guidelines for Medical and Health Research Involving Human Subjects\" in Japan. However, ethical standards were strictly maintained. All potential participants received written information explaining the study’s purpose, the voluntary nature of participation, and data handling procedures. Submission of the completed survey constituted informed consent. Participants were assured of their right to withdraw at any time without penalty. All responses were collected anonymously via a secure online platform, and data were stored on password-protected servers accessible only to the research team. No financial compensation was provided. All procedures involving human participants were conducted in accordance with the ethical standards of the institutional ethics committee and with the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated in this study are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIS and KT conceived of and designed the study. IS and KT were responsible for data collection and analysis. MK and WM contributed to data interpretation. IS drafted the manuscript. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLachman P, Runnacles J, Jayadev A, Brennan J, Fitzsimons J, editors. Oxford Professional Practice: Handbook of Patient Safety. Oxford University Press; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowman C, Neeman N, Sehgal NL. Enculturation of Unsafe Attitudes and Behaviors: Student Perceptions of Safety Culture. Acad Med. 2013;88(6):802\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Patient safety curriculum guide: multi-professional edition. Geneva: World Health Organization; 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu AW, Busch IM. Patient safety: A new basic science for professional education. GMS J Med Educ. 2019;36(2):1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirkman MA, Sevdalis N, Arora S, Baker P, Vincent C, Ahmed M. The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review. BMJ Open. 2015;5(5):e007705.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNie Y, Li L, Duan Y, Chen P, Barraclough BH, Zhang M, et al. Patient safety education for undergraduate medical students: a systematic review. BMC Med Educ. 2011;11:33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWerquin P. Terms, definitions, models and taxonomies of informal learning. Recognition of non-formal and informal learning - country note: France. Paris: OECD; 2010. pp. 25\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed M, Arora S, Tiew S, et al. Building a safer foundation: the Lessons Learnt patient safety training programme. BMJ Qual Saf. 2014;23:78\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCox KR, Scott SD, Hall LW, et al. Uncovering differences among health professions trainees exposed to an interprofessional patient safety curriculum. Qual Manag Health Care. 2009;18:182\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith KL, Ashburn S, Rule E, et al. Residents contributing to inpatient quality: blending learning and improvement. J Hosp Med. 2012;7:148\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAldardeir N, Abdullah QK, Jones L. Patient safety education in undergraduate medical education through a global lens: a scoping review. BMC Med Educ. 2025;25:544.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParra Larrotta S, Hern\u0026aacute;ndez Rinc\u0026oacute;n EH, Ni\u0026ntilde;o Correa D, Jaimes Pe\u0026ntilde;uela CL, Romero Tapia AE. Effects of the Hidden Curriculum in Medical Education: Scoping Review. JMIR Med Educ. 2025;11:e68481.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDornan T, Boshuizen H, King N, Scherpbier A. Experience-based learning: a model linking the processes and outcomes of medical students' workplace learning. Med Educ. 2007;41(1):84\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWee CPJ, Ng M, Teunissen PW. How do factors in fixed clinical teams affect informal learning among Emergency Medicine Residents. TAPS. 2023;8(1):25\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eN\u0026iacute; Chroinin MN, O\u0026rsquo;Tuathail C, Cornally N. The influence of informal learning and learning transfer on nurses\u0026rsquo; clinical performance during routine patient care: a quantitative study. Nurse Educ Today. 2019;79:15\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLave J, Wenger E. Situated learning: legitimate peripheral participation. Cambridge: Cambridge University Press; 1991.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHa MT, Siddiqui ZS. Understanding medical students\u0026rsquo; transition to clinical training: a qualitative study of transformative learning and professional identity formation. BMJ Open. 2025;15(6):e098675.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health. Labour and Welfare. Guidelines for the duties of medical safety managers and guidelines for creating training programs for their training. Tokyo: Ministry of Health, Labour and Welfare; 2020 Mar. [cited 2025 Dec 16]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/content/10800000/000898761.pdf\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/content/10800000/000898761.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health, Labour and Welfare. Special functioning hospitals [Internet]. Tokyo: Ministry of Health, Labour and Welfare; [cited 2025 Dec 16]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000137801.html\u003c/span\u003e\u003cspan address=\"https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000137801.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeabrook MA. Clinical students\u0026rsquo; initial reports of the educational climate in a single medical school. Med Educ. 2004;38(6):659\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerger AS, Niedra E, Brooks K, O\u0026rsquo;Keefe M. Teaching professionalism in postgraduate medical education: a systematic review. Acad Med. 2020;95(6):938\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Houten-Schat MA, Berkhout JJ, van Dijk N, Endedijk MD, Jaarsma ADC, Diemers AD. Self-regulated learning in the clinical context: a systematic review. Med Educ. 2018;52(10):1008\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePannick S, Davis R, Ashrafian H, Byrne BE, Beveridge I, Athanasiou T, et al. Beyond clinical engagement: a pragmatic model for quality improvement in healthcare. BMJ Qual Saf. 2016;25(9):716\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganisation for Economic Co-operation and Development. Recognition of non-formal and informal learning [Internet]. Paris: OECD. 2016 [cited 2025 Dec 21]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.oecd.org/edu/skills-beyond-school/recognitionofnon-formalandinformallearning-home.htm\u003c/span\u003e\u003cspan address=\"http://www.oecd.org/edu/skills-beyond-school/recognitionofnon-formalandinformallearning-home.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eD\u0026rsquo;Eon M. A blueprint for interprofessional learning. J InterprofCare. 2005;19(sup1):49\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide 31. Med Teach. 2007;29(9\u0026ndash;10):855\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStabel LS, McGrath C, Bj\u0026ouml;rck E, Elmberger A, Laksov KB. Navigating Affordances for Learning in Clinical Workplaces: A Qualitative Study of General Practitioners\u0026rsquo; Continued Professional Development. Vocat Learn. 2022;15(3):427\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim J, Lee M, Hong E. Evaluating the outcomes of patient safety education programs in nursing education: a scoping review. BMC Nurs. 2025;24(1):273.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Clinical Clerkship, Informal Learning, Patient Safety, Qualitative Research, Quality Improvement, Undergraduate Medical Education","lastPublishedDoi":"10.21203/rs.3.rs-8480843/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8480843/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAlthough the World Health Organization (WHO) emphasizes patient safety as a core competency, formal educational opportunities in clinical settings remain limited. This study aimed to clarify how medical students acquire patient safety competencies through informal learning during clinical rotations.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA descriptive qualitative study was conducted with 36 patient safety specialists at Japanese national university hospitals. Data were collected via an online open-ended questionnaire regarding safety-related behaviors students engaged in during clinical practice. The responses were analyzed using conventional content analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analysis identified 14 learning categories situated within four clinical contexts: receiving instructions, invasive procedures, interprofessional communication, and incident response. These informally acquired competencies are closely aligned with the WHO Patient Safety Curriculum Guide. However, the learning related to quality improvement was notably limited. Participants proposed specific support measures such as utilizing incident reports for education and facilitating student participation in safety conferences to further enhance these informal learning opportunities.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eStudents acquire essential patient safety competencies through informal participation in clinical practice and complementing formal curricula. Clinical educators should recognize the value of these situated learning opportunities and intentionally facilitate informal learning environments to complement formal education.\u003c/p\u003e","manuscriptTitle":"Uncovering the Informal Learning of Patient Safety in Undergraduate Clinical Rotations: A Qualitative Study of Patient Safety Specialists' Perspectives","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 17:36:50","doi":"10.21203/rs.3.rs-8480843/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-09T06:42:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-24T17:55:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-24T09:40:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332631570191248040653800921437680588208","date":"2026-02-20T19:15:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"252272336987308682997162932645450000072","date":"2026-02-18T11:59:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T20:52:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-07T06:23:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-07T04:30:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-01-07T04:25:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d7189b46-66a9-4a81-816b-40cb217fd443","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T15:59:44+00:00","versionOfRecord":{"articleIdentity":"rs-8480843","link":"https://doi.org/10.1186/s12909-026-09357-7","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2026-04-30 15:57:09","publishedOnDateReadable":"April 30th, 2026"},"versionCreatedAt":"2026-02-10 17:36:50","video":"","vorDoi":"10.1186/s12909-026-09357-7","vorDoiUrl":"https://doi.org/10.1186/s12909-026-09357-7","workflowStages":[]},"version":"v1","identity":"rs-8480843","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8480843","identity":"rs-8480843","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}