Improving undergraduate patient safety teaching
using a simulated ward round experience
Mr Ian Thomas
Clinical Teaching Fellow
Background
•
•
•
•
•
Medical error is common
Most occur on hospital wards
As a result of human factors
Distractions play a major role
Ward rounds have lost their importance
Innovation
Simulated ward round experience for final year
medical students at the UoA
Focus is on medical error and distraction
Why is this important?
• Potential to improve patient safety.
• New doctors do not feel prepared for graduation.
• Currently we teach non-technical skills
didactically rather than practically.
• Simulation is the only safe way to practically
train undergraduates in these skills.
• The WHO and GMC are calling for this style of
training.
• First study to assess change in patient safety
behaviours in medical undergraduates.
Student = FY1
 Lead the ward round: diagnosis & management plans
Ward
round
has
a
number
of
Staff nurse
 Accompanies
ward roundtasks
– handover
of patients
error-prone
built
in!
Volunteer patients
 3 patients with medical & surgical problems
Expected task completion
Potential associated medical errors
At start of the simulation
Correctly prioritizes patients on terms of SEWS score (i.e.
chest pain patient first, followed by patient with
pneumonia and finally patient with cognitive impairment)
Does not correctly prioritize patients
Bed 1 – Clinical Problem: Pneumonia
Utilizes patient blood results to calculate patient’s CURB- Does not recognize that blood results in patient notes do
65 score
not correspond to correct patient and fails to ask for
correct set
Prescribes appropriate antibiotic therapy for patient based Fails to recognize patient is allergic to first-line therapy
on ward protocol
and does not prescribe suitable alternative
Correctly checks antibiotic vial with nurse ahead of Does not correctly check vial with the staff nurse and
medication administration
authorizes administration of date-expired medication
Bed 2 – Clinical Problem: Post-operative chest pain
Prescribes appropriate therapy for non-ST elevation Fails to appreciate patient is immediately post-operative
myocardial infarction based on ward protocol
and anti-coagulation should not be administered
Nurse asks doctor to prescribe Paracetemol for separate Prescribes regular Paracetemol and fails to recognize
unrelated patient
patient is already receiving Co-codamol and hence
contraindicated
Bed 3 – Clinical Problem: Diabetic with cognitive impairment
Amends dose of Insulin appropriately based on Misreads poor handwritten entry in medical notes as 25
recommendation in notes from diabetic specialist nurse
units: as opposed to desired 2.5 units - resulting in
overdose.
Number of medical errors and management of distractions
recorded
Deployment of distractions
Method
Prospective control study
Intervention group
Sept
2013
N = 14
Pre-test WR
Control group
Nov
2013
Feedback on
distraction
management
Oct
2013
N = 14
Post-test
WR
N = 14
Pre-test WR
No feedback
Dec
2013
N = 14
Post-test
WR
Baseline ward round
Ward round
parameter
Post-test ward round
Mrs Jones: Diagnoses pneumonia
Utilises history and examination
findings, notes, blood results, chest Xray and sputum pot
PATIENT WITH SEPSIS
Demonstrates appropriate
diagnostic skills
Mrs Swan: Diagnoses urosepsis
Utilises history and examination
findings, notes, blood results,
urinalysis and urine specimen pot
The blood results in the notes do not
belong to Mrs Jones
Checks identity of all test
results
The blood results in the notes do not
belong to Mrs Swan
Calculates a CURB-65 score
Calculates sepsis score as
marker of disease severity
Calculates a urosepsis score
Patient allergic to Penicillin
Should be given Erythromycin and
not Amoxicillin
The antibiotic vial is date-expired
Prescribes appropriate
antibiotics based on wardprotocol
Checks antibiotic vial
appropriately with staff
nurse prior to drug
administration
Patient allergic to Amoxicillin
Should be given Ciprofloxacin and
not Tazocin
The antibiotic vial is of incorrect
dosage
Results
168 patient encounters and 28 hours of simulation
Demographic
Intervention
Control
P-value
Participants
14
14
1.00
Males
5
5
1.00
Females
9
9
Average age
23.5
23.71
0.8382
Mean number of errors per
student at baseline
5.14
5.43
0.4816
Mean number of distractions
mismanaged per student at
baseline
2.07
2.71
0.1591
Number of distractions mishandled
The correlation between medical error-making
and distractor management: intervention group
4.5
Spearman’s co-efficient = 0.663
P-value = 0.01
4
3.5
3
2.5
2
1.5
1
0.5
0
0
1
2
3
4
5
6
7
Number of medical errors committed
8
Number of erros
Overview of medical errors made at baseline
15
14
8
10
5
0
14
10
10
14
13
12
7
13
6
4
0
0
1 0
3
5
3
2
Intervention Group
Control Group
6
2
1
0
Number of distractions mismanaged
Management of distractions at baseline
14
15
9
6
6
10
9
8
2
5
5
0
Radio
Hoover
Pager
3
2
2
Drug chart
task
distraction
Intervention Group
1
Dealing
with
relative
Telephone
call
Control Group
42%
70
60
50
44
40
68%
30
27
25
33%
80
76
72
76%
Number of errors committed
Reduction in medical error rates between
baseline and post-test simulations
17
20
6
10
< 0.0001
< 0.0001
0.0001
0.0108
0
Total errors in
Intervention group
Total errors in
Control group
Baseline
Life threatening
errors in
Intervention group
Post-test
Life threatening
errors in Control
group
18
Number of errors committed
Reduction in medical error rates between
baseline and post-test simulations
80
76
72
Simulation with feedback
confers a 1.8 fold benefit in
medical error making
70
60
44
50
P-value = 0.0016
40
30
17
20
10
0
Total errors in
Intervention group
Total errors in
Control group
Baseline
Life threatening
errors in
Intervention group
Post-test
Life threatening
errors in Control
group
Change in distractor management between
baseline and post-test simulation
38
2% improvement
P-value 0.7929
Control group
Intervention
group
29
86% improvement
P-value <0.0001
4
0
37
10
20
30
Number of distractions mishandled
Baseline
Post-test
40
Student acceptability
• 27/28 students completed electronic
questionnaire on the experience.
• Highly acceptable and valued.
Survey Monkey 2013
Discussion
• Medical students are not inherently equipped
to manage distractions to mitigate error.
• These skills are required for safe foundation
doctor practice.
• Didactic teaching fails to teach these skills to
students.
• These skills can readily be taught through
simulation.
• Simulation with feedback is critical to gain
most benefit.
Recommendation
• Consider integrating this experience into
the final year curriculum
• Cost of 1 day of simulation = £100 – 400
• Cost of simulation/student = £7.14 - 28.50
• Arguably cost-effective teaching tool
• Modalities to increase student capacity &
reduce faculty burden exist
• Further research opportunities exist and
should be explored
Thank you for your attention