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 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 completionPotential 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

Method Prospective control study Intervention groupControl group N = 14 Pre-test WR Feedback on distraction management N = 14 Post-test WR Sept 2013 Oct 2013 N = 14 Pre-test WR No feedback N = 14 Post-test WR Nov 2013 Dec 2013

Baseline ward round Ward round parameter Post-test ward round Mrs Jones: Diagnoses pneumonia Utilises history and examination findings, notes, blood results, chest X- ray and sputum pot P ATIENT 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 Prescribes appropriate antibiotics based on ward- protocol Patient allergic to Amoxicillin Should be given Ciprofloxacin and not Tazocin The antibiotic vial is date-expired Checks antibiotic vial appropriately with staff nurse prior to drug administration The antibiotic vial is of incorrect dosage

Results 168 patient encounters and 28 hours of simulation DemographicInterventionControlP-value Participants Males Females 99 Average age Mean number of errors per student at baseline Mean number of distractions mismanaged per student at baseline

Spearman’s co-efficient = P-value = 0.01

76% < % 68% 33%

Simulation with feedback confers a 1.8 fold benefit in medical error making P-value =

2% improvement P-value % improvement P-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 = £ 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