CLINICAL SKILLS MANAGED EDUCATIONAL NETWORK
RESEARCH AND DEVELOPMENT GRANTS 2012/13
RESEARCH REPORT
Title
Medical Students Driven to Distraction.
Improving patient safety teaching through the use of
a simulated ward round experience: a prospective control study
Author
Ian Thomas
Highland Medical Education Centre, University of Aberdeen,
Centre for Health Sciences, Old Perth Road, Inverness.
Contributors
Ian Thomas
Clinical Teaching Fellow
Laura Nicol
Simulation Fellow
Luke Regan
Clinical Teaching Fellow
Drieka Maliepaard
Clinical Skills Facilitator
Lindsay Clark
Clinical Skills Facilitator
Kenneth Walker
Consultant surgeon
John Duncan
Consultant surgeon
The author would like to thank the Clinical Skills Managed Educational Network for its
generous support – without which this study would not have been completed.
1
MEDICAL STUDENTS DRIVEN TO DISTRACTION
IMPROVING PATIENT SAFETY TEACHING THROUGH THE USE OF
A SIMULATED WARD ROUND EXPERIENCE: A PROSPECTIVE CONTROL STUDY
ABSTRACT
INTRODUCTION
Medical error is common, with poor situational awareness an important aetiological dynamic.
This is a key consideration for junior doctors, for whom distraction and interruption are
endemic in clinical work.
RESEARCH QUESTIONS
The objectives of this study are:

To explore in a simulated ward experience, if final year medical undergraduates are
able to manage realistic ward-based distractions in order to mitigate medical error.
If this is not the case, then:

Can a simulated ward experience with feedback be used to improve distractor
management to reduce medical-error making behaviour?
METHODS
A simulated ward round experience for undergraduates was designed with a focus on
distraction and medical error. Conducted as a prospective control trial, 14 students were
enrolled to an intervention group. Students undertook a baseline ward round and received
feedback focused on distractor management and medical error. Four weeks later, students
2
participated in a post-intervention ward round. An independent group of 14 students were
recruited to a control group – who underwent the same experience, but with no targeted
feedback between simulations. Error rates and distractor management was assessed during
simulations.
RESULTS
There was significant positive correlation between medical error-making and the
mismanagement of distractions. At baseline total medical error rates were high – with 72 and
76 documented mistakes in the intervention and control groups respectively.
All forms of simulation training reduced medical error post-intervention: with medical errormaking falling by 76% in the intervention group (p-value <0.0001) and 42% in the control
group (p-value <0.0001).
DISCUSSION & CONCLUSION
Medical students are not equipped to manage ward-based distractions in order to mitigate
medical error. These skills can be taught through simulation. This is the first study of its
kind to demonstrate an undergraduate teaching intervention with improvement in patient
safety behaviour.
recommended.
Curricular integration of the simulated ward round experience is
3
INTRODUCTION
Despite best intentions, many patients worldwide suffer avoidable iatrogenic harm. In the
United States 98,000 deaths per year are directly attributable to medical error.
this equates to 6 daily aircraft crashes without survivors.
throughout the decades,
3, 4, 5
2
1
Worldwide,
Medical error has persisted
despite significant technological advances – and arguably non-
technical skills 6 are now the rate-limiting step. A breakdown in these skills is responsible for
56-82% of healthcare-related errors.
7&8
Healthcare professionals must be grounded in non-
technical skills and in particular situational awareness – as dealing with interruption and
multi-tasking are an integral part of the job.
heighten clinical error
13, 14, 15
9, 10, 11, 12
Clinician-stress has been shown to
16, 17
and indeed distraction plays a central role.
trainees who report the highest levels of stress in clinical practice.
18
conversion into medical error is also highest amongst trainee cohorts,
It is junior
Unfortunately, stress
19, 20
a group that feels
ill-prepared by medical school curriculums for managing heavy workloads and prioritising. 21
Medical educators should seek innovative learning experiences to teach non-technical and
patient safety skills to undergraduates. This is in line with the World Health Organisation’s 22
Patient Safety Curriculum and advice from the General Medical Council
23
endorsing the use
of simulated training environments. Simulation has contributed to our understanding of the
detrimental clinical impact of interruption on adherence to protocols,
emergency scenarios,
25, 26
24
performance in
clinical reasoning 27 and accurate calculating of drug doses.
28
As
new graduates will initially work within a ward setting – the environment most prone to
clinical error
29
it is logical to consider a simulated ward experience as a potential teaching
modality.
Nikendi 30 argues that:
4
‘‘Ward round training which eases the transition from observing ward rounds to conducting
them on one’s own is urgently required.’’
There has since been a trend to greater utilisation of simulated ward experiences
newer generations
33, 34
31, 32
with
concentrating on the impact of ward-based distraction. However,
these have merely documented participant acceptability and quantified baseline medical error
rates.
Although the body of evidence is growing, it stops short of demonstrable behavioural change.
Research which shows that simulated ward rounds can achieve this is required.
The objectives of this study are:

To explore in a simulated ward experience, if final year medical undergraduates are
able to manage realistic ward-based distractions in order to mitigate medical error.
If this is not the case, then:

Can a simulated ward experience with feedback be used to improve distractor
management to reduce medical-error making behaviour?
5
PEDAGOGICAL DEVELOPMENT OF THE SIMULATED WARD EXPERIENCE
A simulated ward round experience was created at the University of Aberdeen for final year
medical students with a focus on distraction and medical error.
Medical students played the part of a Foundation doctor leading a 30-minute ward round,
consisting of three patients, as shown in Figure 1.
Figure 1 – Role allocation during simulation
Video-recording equipment
Patient with pneumonia:
played by a volunteer
patient.
Foundation doctor: played
by a final year medical
student. Leads the ward
round, makes diagnoses and
appropriate management
plans.
Staff nurse: played by a clinical skills
facilitator. Gives an appropriate
handover of patients to the doctor
and assists with execution of
management plans.
Patient notes
6
Three patient scenarios were designed:

An elderly lady with pneumonia

A post-operative male patient with chest pain

An elderly diabetic male with confusion
At each bed space the doctor was expected to complete a number of clinical duties, with
associated potential medical errors as shown in Figure 2.
As shown in Figures 3 and 4, a set of six realistic, time-critical distractions were deployed.
During simulation the student’s performance was assessed with medical errors and distractor
management recorded on a standardised checklist.
7
Figure 2 – Expected task completion and associated errors during the ward round
Expected task completion
Potential associated medical errors
At start of the simulation
Correctly prioritizes patients (chest pain,
followed by pneumonia then cognitive
impairment)
Does not correctly prioritize patients
Bed 1 – Clinical Problem: Pneumonia
Correctly diagnoses pneumonia
Utilizes blood results to calculate patient’s
CURB-65 score
Correctly calculates CURB-65 score as a
marker of disease severity
Prescribes appropriate antibiotic therapy for
patient based on ward protocol
Correctly checks antibiotic vial with nurse
ahead of medication administration
Fails to reach or gives incorrect diagnosis.
Staff nurse has to prompt with diagnosis
Does not recognize that blood results in notes
do not correspond to correct patient
Incorrectly calculates CURB-65 score and
nurse must provide appropriate score
Fails to recognize patient is allergic to firstline therapy
Authorizes administration of date-expired
medication vial
Bed 2 – Clinical Problem: Post-operative chest pain
Correctly diagnoses non-ST elevation
myocardial infarction (NSTEMI)
Prescribes appropriate therapy for NSTEMI
based on ward protocol
Nurse asks doctor to prescribe Paracetemol
for patient on regular Co-codamol.
Fails to reach or gives incorrect diagnosis.
Staff nurse has to prompt with diagnosis
Fails to appreciate patient is post-operative
and anti-coagulation is contraindicated
Fails to recognize patient receiving Cocodamol and Paracetemol contraindicated
Bed 3 – Clinical Problem: Diabetic with cognitive impairment
Amends Insulin dose as per recommendation
in notes from diabetic specialist nurse
Deals with upset relative who comes into the
ward wanting to speak to the doctor
Misreads handwritten entry in notes as 25
units: and not 2.5 units: resulting in overdose.
Does not check relative’s identity and
discloses information on incorrect patient
8
Figure 3 – Ward round facilitation with distraction deployment
One-way mirror
Timed-distractions
checklist
IT equipment to
facilitate
simulation
Ear piece
Microphone
Facilitators and assessors sat behind the one-way mirror overlooking the simulated
ward. Time-critical distractions were orchestrated from the observation suite with
communication established through the use of ear pieces and microphones.
Doctor answering his page during simulation
Ward radio switched on at start of simulation
exercise
Domestic hoovering at patient bedside as
doctor prescribes
9
Figure 4 – List of standardised time-critical distractions
Distraction
Time-critical deployment
Potential associated medical
error
Ward radio switched on
(at 70 decibels)
At the start of the ward
round
Doctor incorrectly prioritizes
order of patients to be seen
Domestic hoovers at the
patient bed space
When the doctor is
reviewing the antibiotic
protocol for chest infection
Doctor prescribes protocoldriven antibiotic to which
patient is allergic
Doctor’s pager set off
When doctor is reviewing
the chest pain protocol
Doctor prescribes protocoldriven anti-coagulation and
fails to appreciate patient is
immediately post-operative
Nurse asks doctor to
prescribe Paracetemol for
separate unrelated patient
As doctor is prescribing
protocol-driven chest pain
medication on drug kardex
Prescribes anticoagulation +/makes any other related
prescription error
Telephone call into the ward
As doctor is reviewing the
diabetic specialist nurses’
written request in the
medical notes to increase
dose of Insulin to 2.5 units
Misreads handwriting and
prescribes an overdose of 25
units of insulin instead of
desired 2.5 units
Dealing with upset relative
who enters ward and wishes
to speak with the doctor
As student is prescribing
change of Insulin dose on
drug kardex
Fails to check identity of
relative and discloses
confidential information
pertaining to a different
patient
10
METHODS
A prospective control study was conducted, as shown in Figure 5. 14 students were recruited
to an intervention group by simple randomisation and undertook a baseline ward round.
Post-simulation students received immediate individualized feedback, targeted around
distractor management and its relationship to medical error using SET-GO criteria.
35
Following a lag time of 4 weeks students completed a post-intervention ward round of
comparable rigour, achieved by modification of the baseline ward round’s surface
characteristics. Separately, 14 students were similarly recruited to a control group who
undertook the same experience, but did not receive targeted feedback on distraction and error.
Medical error rates and distractor management was assessed at all simulations.
11
Figure 5 – Study design flow diagram
Eligibility: 26 final year medical
students at University of Aberdeen
Volunteers: 20 students
Eligibility: 25 final year medical
students at University of Aberdeen
Volunteers: 22 students
Recruitment: 14 students
Recruitment: 14 students
September
2013
November
2013
Baseline
Ward round
Baseline
Ward round
Targeted
feedback
No targeted
feedback
October
2013
December
2013
Post-intervention
ward round
Post-intervention
ward round
Dropout rate:
Intervention group N=0
Control group N=0
Data analysis: 14 students
Data analysis: 14 students
Exclusion rate:
Intervention group N=0
Control group N=0
12
RESULTS
Study demographics
The intervention and control groups were comparable across baseline demographics as shown
in Figure 6:
Figure 6: Baseline demographics between intervention and control groups
Demographic
Intervention
Control
P-value
Participants
Males
Females
Average age
14
5
9
23.5
14
5
9
23.71
1.00
1.00
Standard deviation 2.79
Standard deviation 2.70
5.14
5.43
Standard deviation 1.03
Standard deviation 1.09
2.07
2.71
Standard deviation 1.00
Standard deviation 1.33
0.8382
Mean number of errors per
student at baseline
Mean number of distractions
mismanaged per student at
baseline
0.4816
0.1591
The relationship between medical error and distractor management
Figure 7 shows the positive correlation that exists between medical error and the
mismanagement of distractions (Spearman’s co-efficient of 0.663).
13
Figure 7: Correlation between medical error and distractor management in the
intervention group
The correlation between medical error-making
and distractor management: intervention
group
4.5
Number of distractions mishandled
4
3.5
3
2.5
2
1.5
1
0.5
0
0
1
2
3
4
5
6
7
8
Number of medical errors committed
Correlations
Distractions
Spearman's Rank
Errors made in
Correlation Coefficient
Co-efficient
Intervention group
Sig. (2-tailed)
N
Distractions mishandled in
Correlation Coefficient
Intervention group
Sig. (2-tailed)
N
**. Correlation is significant at the 0.01 level (2-tailed).
Errors made in
mishandled in
Intervention Group
Intervention group
1.000
.663**
.
.000
28
28
**
1.000
.000
.
28
28
.663
14
Baseline medical errors and distractor management
In the intervention group a total of 72 medical errors were committed at baseline,
representing a mean of 5.14 errors per student. In the control group baseline medical errors
were similar – with 76 medical errors witnessed (mean 5.43 medical errors per student).
The pattern of error between intervention and control groups mirrored one another closely as
shown in Figure 8.
At baseline distractions were poorly managed in both groups. In the intervention group a
total of 29 distractions were mishandled compared to 38 in the control group. The pattern of
distractor
management
between
groups
at
baseline
is
shown
in
Figure
9.
15
Figure 8 – Overview of medical errors made at baseline
Number of erros
Overview of medical errors made at baseline
14
12
10
8
6
4
2
0
14
14
14
13
8
10
10
13
12
7
4
6
0
0
1
0
5
3
3
2
6
1
2
Intervention Group
Control Group
0
16
Figure 9 – Management of distractions at baseline
Number of distractions mismanaged
Management of distractions at baseline
14
14
12
9
10
8
9
8
6
6
2
6
1
5
4
2
0
Radio
2
Hoover
Pager
Drug chart task
distraction
Intervention Group
Control Group
3
2
Intervention Group
Dealing with
relative
Control Group
Telephone call
17
Change in patient safety behaviours between simulations
At post-intervention medical error making fell in both groups – showing that any form of
simulation benefits patient safety behaviours. The reduction in error-rates between baseline
and post-intervention simulations is shown in Figure 10. In the intervention arm medical
errors post-intervention fell by 76.39% (p-value <0.0001), compared to 42.11% (p-value
<0.0001) in the control arm. Although medical error rates fell in both groups, intervention
conferred an additional 34.28% improvement over control (p-value 0.0016).
Figure 11 gives an overview of the errors that that persisted at the post-intervention
simulation. Figure 12 outlines the change in distractor management between simulations. In
the intervention group distractor management improved by 86.21% (p-value <0.0001):
whereas in the control group there was a 2.63% improvement (p-value 0.7929).
18
Figure 10 – Change in error making rates between baseline and post-intervention simulations
Reduction in medical error rates between baseline and postintervention simulations
80
76
72
Number of errors committed
70
60
44
50
40
27
25
30
18
17
20
6
10
0
Total errors in Intervention
group
Total errors in Control
group
Baseline
Life threatening errors in
Intervention group
Post-intervention
Life threatening errors in
Control group
19
Figure 11 – Overview of medical errors made at post-intervention
Number of erros
Overview of medical errors made at post-intervention simulation
14
12
10
8
6
4
2
0
14
4
0
0
0
8
6
5
2
1
1
2
1
4
4
2
0
3
0
3
1
0
0
Intervention Group
Control Group
0
20
Figure 12 – Change in distractor management between baseline and post-intervention simulations
Change in distractor management between baseline and postintervention simulations
38
Control group
37
Baseline
Post-intervention
29
Intervention group
4
0
5
10
15
20
25
30
Number of distractions mishandled
35
40
21
Students completed an online electronic questionnaire on their experience of the simulated
ward round. 27 out of 28 students completed the evaluation (response rate = 96.43%). The
simulations were deemed to be valuable and of high-fidelity. All students felt that mandatory
integration of this experience into the final year curriculum to be important.
22
DISCUSSION
Final year medical students are not equipped with the skills to manage ward-based
distraction, in order to mitigate common medical error. This research is one of the first
studies of its kind to demonstrate that simulated ward training can improve undergraduate
patient safety behaviours.
The study suggests that didactic patient safety teaching is of limited benefit to
undergraduates.
All students at the start of the academic year (and prior to study
commencement) received didactic teaching on a range of patient safety domains: including
non-technical skills and dealing with stress at work. Despite such instruction, students
committed large numbers of medical errors at baseline simulation.
Study limitations

The study was conducted a small single-centre trial with 14 participants in each arm.
Despite the small sample size, study power was over 80% owing to the magnitude of
error-reduction rates.

Despite randomisation the author accepts the potential for selection bias. Participants
took part on a voluntary basis – and arguably an engaged volunteer cohort, may be most
amenable to the effects of simulation and feedback.

This study was not designed as a randomised control trial. This could have been achieved
by recruiting all participants at the same time in the academic calendar. However, all
students share on-site accommodation. As such, there was concern about crosscontamination.

Feedback delivered to the intervention group focussed on both distractor management and
medical error. Future studies should include additional intervention arms. For example,
feedback on distractor management alone.
23
RECOMMENDATION
Consideration to curricular integration of simulated ward experience is recommended. The
cost of running a single day of simulation, as described, per student is £61 (which includes
consumables and faculty cost). However, modalities to minimise cost and reduce faculty
burden to potentiate feasibility exist.
For research purposes the simulated ward round
experience was faculty-intensive. Pragmatically, this experience could be resourced by three
volunteer patients, one staff nurse and a single clinical teaching fellow. To increase student
throughput, having a two-patient ward round would minimise simulation duration to 20
minutes, and increase daily capacity to 17 students. Revised costings for the faculty-light
simulation are £27.52 per student.
The following three areas of future research are suggested:

Evidencing a curriculum-feasible version of the simulation, suitable for institutional rollout.

Development and assessment of this teaching modality as a vehicle for inter-professional
education.

To assess the predictive validity of a simulated ward round in assessing future
performance. For example, do simulated ward round behaviours transfer into clinical
practice?
24
CONCLUSION
The development of the experience comes at a pivotal time in medical education: in wake of
the recent Francis
36
report – an era that will see patient safety teaching in undergraduate
curriculums come under much sharper focus. Incorporation of simulation-based education
into undergraduate institutions is challenging. However curricular integration as outlined by
best practice in simulation 37 is essential if the benefits of simulation are to be realised. Given
student acceptability and positive patient safety behavioural change, curricular integration is a
challenge that medical educators must now meet - as pragmatic solutions to potentiate
feasibility exist.
Word count = 1500 words
(Excluding abstract and references)
25
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