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Improving undergraduate patient safety teaching using a simulated ward round experience
Mr Ian ThomasClinical 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
Focus is on medical error and distraction
Simulated ward round experience for final year medical students at the UoA
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
Staff nurse Accompanies ward round – handover of patients
Volunteer patients 3 patients with medical & surgical problems
Ward round has a number of error-prone tasks built in!
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-65 score
Does not recognize that blood results in patient notes do not correspond to correct patient and fails to ask for correct set
Prescribes appropriate antibiotic therapy for patient based on ward protocol
Fails to recognize patient is allergic to first-line therapy and does not prescribe suitable alternative
Correctly checks antibiotic vial with nurse ahead of medication administration
Does not correctly check vial with the staff nurse and authorizes administration of date-expired medication
Bed 2 – Clinical Problem: Post-operative chest pain
Prescribes appropriate therapy for non-ST elevation myocardial infarction based on ward protocol
Fails to appreciate patient is immediately post-operative and anti-coagulation should not be administered
Nurse asks doctor to prescribe Paracetemol for separate unrelated patient
Prescribes regular Paracetemol and fails to recognize patient is already receiving Co-codamol and hence contraindicated
Bed 3 – Clinical Problem: Diabetic with cognitive impairment
Amends dose of Insulin appropriately based on recommendation in notes from diabetic specialist nurse
Misreads poor handwritten entry in medical notes as 25 units: as opposed to desired 2.5 units - resulting in overdose.
Deployment of distractions
Number of medical errors and management of distractions recorded
MethodProspective control study
Intervention group Control group
N = 14Pre-test WR
Feedback on distraction
management
N = 14Post-test
WR
Sept 2013
Oct 2013
N = 14Pre-test WR
No feedback
N = 14Post-test
WR
Nov 2013
Dec 2013
Baseline ward round Ward round parameter
Post-test ward round
Mrs Jones: Diagnoses pneumoniaUtilises history and examination findings, notes, blood results, chest X-ray and sputum pot
PATIENT WITH SEPSISDemonstrates appropriate
diagnostic skills
Mrs Swan: Diagnoses urosepsisUtilises 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
Prescribes appropriate antibiotics based on ward-
protocol
Patient allergic to Amoxicillin
Should be given Ciprofloxacin and not Tazocin
The antibiotic vial is date-expiredChecks antibiotic vial
appropriately with staff nurse prior to drug
administration
The antibiotic vial is of incorrect dosage
Results168 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
Spearman’s co-efficient = 0.663P-value = 0.01
< 0.0001 < 0.0001 0.0001 0.0108
Simulation with feedback confers a 1.8 fold benefit in
medical error making
P-value = 0.0016
2% improvementP-value 0.7929
86% improvementP-value <0.0001
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
