Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retention and Transfer of Central Venous Catheter Skills

Error Management Training and Adaptive Expertise in Learning Computed Tomography Interpretation: A Randomized Clinical Trial

Importance

Adaptive expertise helps physicians apply their skills to novel clinical cases and reduce preventable errors. Error management training (EMT) has been shown to improve adaptive expertise with procedural skills; however, its application to cognitive skills in medical education is unclear.

Objective

To evaluate whether EMT improves adaptive expertise when learning the cognitive skill of head computed tomography (CT) interpretation.

Design, Setting, and Participants

This 3-arm randomized clinical trial was conducted from July 8, 2022, to March 30, 2023, in 7 geographically diverse emergency medicine residency programs. Participants were postgraduate year 1 through 4 emergency medicine residents masked to the hypothesis.

Interventions

Participants were randomized 1:1:1 to a difficult EMT, easy EMT, or error avoidance training (EAT) control learning strategy for completing an online head CT curriculum. Both EMT cohorts received no didactic instruction before scrolling through head CT cases, whereas the EAT group did. The difficult EMT cohort answered difficult questions about the teaching cases, leading to errors, whereas the easy EMT cohort answered easy questions, leading to fewer errors. All 3 cohorts used the same cases.

Main Outcomes and Measures

The primary outcome was a difference in adaptive expertise among the 3 cohorts, as measured using a head CT posttest. Secondary outcomes were (1) differences in routine expertise, (2) whether the quantity of errors during training mediated differences in adaptive expertise, and (3) the interaction between prior residency training and the learning strategies.

Results

Among 212 randomized participants (mean [SD] age, 28.8 [2.0] years; 107 men [50.5%]), 70 were allocated to the difficult EMT, 71 to the easy EMT, and 71 to the EAT control cohorts; 150 participants (70.8%) completed the posttest. The difficult EMT cohort outperformed both the easy EMT and EAT cohorts on adaptive expertise cases (60.6% [95% CI, 56.1%-65.1%] vs 45.2% [95% CI, 39.9%-50.6%], vs 40.9% [95% CI, 36.0%-45.7%], respectively; P < .001), with a large effect size (η2 = 0.19). There was no significant difference in routine expertise. The difficult EMT cohort made more errors during training than the easy EMT cohort. Mediation analysis showed that the number of errors during training explained 87.2% of the difficult EMT learning strategy's effect on improving adaptive expertise (P = .01). The difficult EMT learning strategy was more effective in improving adaptive expertise for residents earlier in training, with a large effect size (η2 = 0.25; P = .002).

Conclusions and Relevance

In this randomized clinical trial, the findings show that EMT is an effective method to develop physicians' adaptive expertise with cognitive skills.

Trial Registration

ClinicalTrials.gov Identifier: NCT05284838.

Creating an Optimal Learning Environment in the Operating Room: Lessons From the Soccer Field

For trainees, the operating room (OR) often represents an educational sanctuary, where for a few hours they can focus on their craft, rather than on phone calls, pages, and the never-ending task of electronic health record documentation. The OR provides a unique opportunity for unfettered one-on-one time with an attending surgeon at their side, where they can learn the art of surgery without interruption. It is vitally important to maximize learning in the OR, yet evidence suggests that it is not always an ideal educational environment. Considering the recent excitement over the World Cup soccer tournament (full disclosure: the senior author is an Argentine immigrant and soccer fan), in this article, we provide evidence-based ideas and suggestions on how to optimize learning in the OR using some analogies from the soccer field.

A Deliberate Practice-Based Ultrasound Training Program for Fetal Palate Screening Using a Sequential Sector Scan Through the Oral Fissure

OBJECTIVES

To introduce an ultrasound training program for fetal palate screening by using a sequential sector scan through the oral fissure to train less experienced doctors and to investigate its effectiveness.

METHODS

Twenty doctors and several women at approximately 20-28 weeks of gestation with singleton pregnancies who provided informed consent were enrolled. The training program consisted of theory and practice training, several tests, and two surveys. Trainees were tested before training and immediately after training; for the latter, each item with a score that was less than 60% of the full score was again used for training with a reconstructed plan. Finally, a post-training test was completed.

RESULTS

The median theory scores, median practice scores, median language competence scores, and median self-assessment scores all increased significantly from the pre-training to post-training tests (P < .01). The median completion time for fetal palate scans decreased significantly from the pre-training to post-training tests (P < .01). The median questionnaire scores were 5.00 for pragmatism, 4.00 for content, 4.00 for scientific nature, and 5.00 for effectiveness.

CONCLUSIONS

The training program for fetal palate screening can effectively standardize and improve doctors' scans for fetal palates. In addition, the program feasibly allows for the incorporation of the scan sequence into fetal palate screening.

Formalizing the Hidden Curriculum of Performance Enhancing Errors

Despite its inevitability, error remains an uncomfortable topic for discussion amongst surgeons. There are a range of reasons cited for this; significantly, there is an inextricable link between a surgeon's actions and their patient's outcomes. Attempts to reflect on error are often unstructured and without a defined end point, and modern surgical curricula lack content to guide residents' learning on recognizing and reflecting on sentinel events. There is a need to develop a tool to guide a standardized, safe, and constructive response to error. The current educational paradigm revolves around error avoidance. However, there is an evolving evidence base surrounding the inclusion of error management theory (EMT) into surgical training. This method explores and incorporates positive discussions surrounding errors, and has been demonstrated to improve long-term skill acquisition and training outcomes. We must harness the performance enhancing effects of our errors in the same way we do our successes. Implicated in all surgical performance is human factors science/ergonomics (HFE) - the interface between psychology, engineering, and performance. Developing a national HFE curriculum in the context of EMT would provide a common language to facilitate objective reflections regarding surgeons' operative performance and manage the stigma associated with fallibility.

The concept of errors in medical education: a scoping review

The purpose of this scoping review was to explore how errors are conceptualized in medical education contexts by examining different error perspectives and practices. This review used a scoping methodology with a systematic search strategy to identify relevant studies, written in English, and published before January 2021. Four medical education journals (Medical Education, Advances in Health Science Education, Medical Teacher, and Academic Medicine) and four clinical journals (Journal of the American Medical Association, Journal of General Internal Medicine, Annals of Surgery, and British Medical Journal) were purposively selected. Data extraction was charted according to a data collection form. Of 1505 screened studies, 79 studies were included. Three overarching perspectives were identified: 'understanding errors') (n = 31), 'avoiding errors' (n = 25), 'learning from errors' (n = 23). Studies that aimed at'understanding errors' used qualitative methods (19/31, 61.3%) and took place in the clinical setting (19/31, 61.3%), whereas studies that aimed at 'avoiding errors' and 'learning from errors' used quantitative methods ('avoiding errors': 20/25, 80%, and 'learning from errors': 16/23, 69.6%, p = 0.007) and took place in pre-clinical (14/25, 56%) and simulated settings (10/23, 43.5%), respectively (p < 0.001). The three perspectives differed significantly in terms of inclusion of educational theory: 'Understanding errors' studies 16.1% (5/31),'avoiding errors' studies 48% (12/25), and 'learning from errors' studies 73.9% (17/23), p < 0.001. Errors in medical education and clinical practice are defined differently, which makes comparisons difficult. A uniform understanding is not necessarily a goal but improving transparency and clarity of how errors are currently conceptualized may improve our understanding of when, why, and how to use and learn from errors in the future.

Why an IPE Team Matters… Improvement in Identification of Hospital Hazards: A Room of Horrors Pilot Study

Purpose

To evaluate student performance in a simulation-based interprofessional learning activity that focused on identifying patient safety hazards in a simulated patient's hospital room.

Participants and Methods

Students from nursing, occupational therapy, physiotherapy, radiography, social education, social work, biomedical laboratory science, dental hygiene, and medicine participated in this two-phased study. In the first phase, students worked alone to identify safety hazards. In the second phase, students worked in interprofessional teams. Following each phase, students completed a structured questionnaire to report their findings. In addition, following the first phase, each student wrote down the hazards they identified in an unstructured essay format.

Results

Out of 48 intended hazards, individual students identified 10.7% on the open essay and 42.6% on the questionnaire, and interprofessional teams identified 90.1%.

Conclusion

The number of hospital hazards identified increased considerably when working in interprofessional teams. A room of horrors exercise expands participants' observational skills. With some modifications, this pilot study can be implemented on a wider scale with the goal of increasing interprofessional students' awareness of hospital hazards.

Effects of patient deterioration simulation using inattentional blindness for final year nursing students: A randomized controlled trial

BACKGROUND

Patient deterioration should be detected early and responded appropriately for patient safety. It is necessary to strengthen situational awareness regarding patient deterioration. Inattentional blindness is a major factor that hinders situational awareness about patient deterioration in the clinical setting.

OBJECTIVES

To analyze the impact of patient deterioration simulation using inattentional blindness (PDS-IB) on situational awareness and patient safety competency-attitude among final year nursing students.

DESIGN

A randomized controlled trial.

PARTICIPANTS

Final year nursing students at a university in South Korea.

METHODS

Students were randomly assigned to an experimental or control group. The experimental group (n = 47) was given a PDS-IB. The control group (n = 44) received a simple patient deterioration simulation. Situational awareness and patient safety competency-attitude were measured at baseline, post intervention, and at 2 weeks follow-up. Data were analyzed using a two-way repeated measures ANOVA.

RESULTS

There were statistically significant group effects, time effects, and group and time interaction effects in situational awareness and patient safety competency-attitude.

CONCLUSION

PDS-IB is an effective educational strategy that increases situational awareness and patient safety competency-attitude in final year nursing students.

A Theoretical Model of Transition to Practice for Athletic Trainers

CONTEXT

The transition to practice of newly credentialed athletic trainers (ATs) has become an area of focus in the athletic training literature. However, no theoretical model has been developed to describe the phenomenon and drive investigation.

OBJECTIVE

To better understand the lived experience of the transition to practice and develop a theoretical model of transition to practice for ATs.

DESIGN

Qualitative study.

SETTING

Telephone interviews.

PATIENTS OR OTHER PARTICIPANTS

Fourteen professional master's athletic training students (7 men, 7 women, age = 25.6 ± 3.7 years, from 9 higher education institutions) in the first year of clinical practice as newly credentialed ATs.

DATA COLLECTION AND ANALYSIS

Participants completed semistructured phone interviews at 3 timepoints over 12 to 15 months. The first interview was conducted just before graduation, the second 4 to 6 months later, and the third at 10 to 12 months. The interviews were transcribed and analyzed using a grounded theory approach.

RESULTS

We developed a theoretical model to explain the causal conditions that triggered transition, how the causal conditions were experienced, the coping strategies used to persist through the first year of practice, and the consequences of those strategies.

CONCLUSIONS

The model provides a framework for new athletic training clinicians, educators, and employers to better understand the transition process in order to help new clinicians respond by accepting or adapting to their environment or their behaviors.

Piloting the FIRE: A Novel Error Management Training Simulation Curriculum for Fasciotomy Instruction

BACKGROUND

Multiple studies have demonstrated poor performance of lower extremity fasciotomy (LEF), highlighted by missed and/or inadequately released compartments. Incorporating error management training (EMT) into surgical simulation has been promoted as a way to gain deeper understanding of procedural errors and overall performance. The purpose of this study was to evaluate LEF performance using a Fasciotomy Improvement through Recognition of Errors (FIRE) simulation training curriculum to train novice surgical trainees.

METHODS

A mastery learning-based EMT curriculum was developed, and surgical residents were enrolled and pretested with a multiple-choice question (MCQ) written test, and a simulated fasciotomy using a lower leg model. Each trainee then watched a 15-minute narrated presentation followed by 2 rounds of fasciotomy error recognition and management training exercises to a mastery standard. During each round, trainees performed hands-on assessment of unique premade fasciotomy leg models containing a variable number of procedural errors. They were required to identify and propose corrective action for all errors. Serial rounds of remediation were implemented until the mastery standard was attained on both error identification rounds. All trainees were post-tested with the same MCQ and another simulated fasciotomy.

RESULTS

All 14 residents had minimal experience with only 0.3 ± 0.6 fasciotomies performed prior to instruction. There were 3 ± 1.6 missed or inadequately released compartments on the pretest. Residents examined 14 ± 2.5 legs, including 2 ± 2.5 legs during remediation to attain mastery. All residents demonstrated significant improvement following the FIRE of Error curriculum for the MCQ (57% ± 16% vs 78% ± 13%; p = 0.01; Cohen's d = 1.4), fasciotomy score (10 ± 7.1 vs 28 ± 1.9; p < 0.001; Cohen's d = 3.6), and achieving a complete fasciotomy (14% ± 36% vs 93% ± 27%; p < 0.001; Cohen's d = 2.5). Only a single cumulative compartment was missed on post-testing.

CONCLUSIONS

Implementation of a mastery learning-based EMT curriculum for fasciotomy simulation training results in significant improvement in fasciotomy technique without reliance on repeated procedure performance nor clinical fasciotomy exposure. This curriculum is a highly effective option for surgical trainees lacking fasciotomy training during residency.

A Training Program for Real-Time Ultrasound-Guided Catheterization of the Subclavian Vein

PURPOSE

To develop and implement a comprehensive program to train providers to place subclavian central venous catheters (CVCs) using real-time ultrasound guidance.

STUDY DESIGN

Simulation-based prospective study at an academic medical center. Of 228 anesthesia providers and intensivists eligible to participate, 106 participants voluntarily enrolled. The training program consisted of a didactic module, hands-on instruction and practice using a CVC simulator and a standardized patient. The success of the program was measured by pre and post knowledge tests and direct observation during the hands-on sessions.

RESULTS

Of 106 participants who enrolled, 70 successfully completed the program. Out of 20 possible procedure steps, an average of 17.8 ± 2.9 were correctly performed in the simulated environment. The average time to needle insertion, defined by positive aspiration of stained saline, was 3.35 ± 3.02 min and the average time to wire insertion with ultrasound confirmation was 3.85 ± 3.12 min.

CONCLUSIONS

Participants learned how to successfully perform ultrasound-guided catheterization of the subclavian vein. Since ultrasound-guided subclavian CVC placement is a useful clinical skill that many practitioners are unfamiliar with, increasing competence and comfort with this procedure is an important goal. Other centers could consider adopting an approach similar to ours to train their providers to perform this technique.

Medication error encouragement training: A quasi-experimental study

BACKGROUND

Medication errors are the most common clinical errors in healthcare practice and can lead to serious consequences. Medication error encouragement training (MEET) brings students face-to-face with potential errors in the medication process, in a safe environment where they are encouraged to understand both the error and the context in which it occurred.

OBJECTIVES

The study aimed to examine the effects of a MEET intervention on medication safety confidence among nursing undergraduates.

DESIGN

This was a quasi-experimental study with a nonequivalent control group design.

PARTICIPANTS

Our sample was recruited from the nursing education department of a university, with 47 participants randomly assigned to the experimental group, and 50 to the control group.

METHODS

Both groups received theoretical training, followed by applied training. The experimental group received the MEET intervention developed specifically for this study, while the control group received traditional error avoidance training. Participants' medication administration confidence was measured pre- and post-intervention.

RESULTS

Following training, the experimental group's confidence was significantly higher than that of the control group. With regard to individual medication administration procedures, the experimental groups' medication safety confidence increased significantly after training compared to the control group in patient identification, drug information confirmation, and drug preparation.

CONCLUSIONS

Introducing MEET into nursing curricula could reduce medication errors and related complications in healthcare institutions. Further studies are needed to investigate the long-term effects of MEET interventions, as well as the generalizability of our findings.

From the simulation center to the bedside: Validating the efficacy of a dynamic haptic robotic trainer in internal jugular central venous catheter placement

BACKGROUND

The objective of this study was to validate the transfer of ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) placement skills from training on a Dynamic Haptic Robotic Trainer (DHRT), to placing US-IJCVCs in clinical environments. DHRT training greatly reduces preceptor time by providing automated feedback, standardizes learning experiences, and quantifies skill improvements.

METHODS

Expert observers evaluated DHRT-trained (N = 21) and manikin-trained (N = 36) surgical residents on US-IJCVC placement in the operating suite using a US-IJCVC evaluation form. Performance and errors by DHRT-trained residents were compared to traditional manikin-trained residents.

RESULTS

There were no significant training group differences between unsuccessful insertions (p = 0.404), assistance on procedure (p = 0.102), arterial puncture (p = 0.998), and average number of insertion attempts (p = 0.878). Regardless of training group, previous central line experience significantly predicted whether residents needed assistance on the procedure (p = 0.033).

CONCLUSION

The results failed to show a statistical difference between DHRT- and manikin-trained residents. This study validates the transfer of skills from training on the DHRT system to performing US-IJCVC in clinical environments.

Fasciotomy Improvement Through Recognition of Errors Course: A Focused Needs Assessment for Error Management Training for Lower Extremity Fasciotomy Performance

BACKGROUND

Many injuries from recent wars involve extremity trauma secondary to blasts, which predispose patients to developing extremity compartment syndrome. In military studies, 17% of fasciotomies required revision on arrival to a Role 4 hospital, and 41% of these had missed compartments, which is similar to that seen in civilian centers. While training has decreased this rate to 8%, this number is still too high. We conducted a focused needs assessment to guide the development of lower-extremity fasciotomy training.

METHODS

In a predeployment assessment, 42 military surgeons performed a 2-incision, 4-compartment, lower-extremity fasciotomy on simulated lower leg models. Models were assessed for standardized and objectively-assessed major (inadequate skin or fascial incisions, missed compartments) and minor (failure to make an H-shaped incision over the lateral compartments, division of the greater saphenous vein) errors based on joint Trauma System clinical practice guidelines and approved training curricula.

RESULTS

Four of 42 (9.5%) models contained no errors. Models averaged 4.3 ± 2.6 major and 0.3 ± 0.5 minor errors. 11 models (26.2%) had at least one missed compartment. The most common missed compartments were the deep posterior (17%) and anterior (14%). 29 (69%) had inadequate or poorly-placed skin incisions, with the most common being inadequate distal extension of the medial (10, 24%) and lateral (14, 33%) incisions, inadequate proximal extension of the lateral incision (6, 14%), medial incision too close to the tibia (7, 17%), and lateral incision over or behind the fibula (12, 29%). A total of 36 (86%) had inadequate fascial incisions. Inadequate fasciotomies were seen in the anterior (57%), lateral (55%), superficial (52%), and deep (34%) posterior compartments CONCLUSIONS: Performance on the models approximates what has been seen in military and civilian settings. This needs assessment will inform development of a simulation curriculum based on error-management and mastery learning theory to reduce the morbidity of lower-extremity compartment syndrome.

Rethinking high reliability in healthcare: The role of error management theory towards advancing high reliability organizing

US Healthcare, despite its exceptional technology and innovative treatments, is still unsafe and unreliable. It is estimated that medical errors account for an estimated 254,000 inpatient deaths a year and hold the distinction as the third leading cause of death in the US. Despite an aggressive national campaign set by organizations like the National Academy of Medicine, the Institute for Healthcare Improvement, the National Patient Safety Foundation, and the National Quality Forum, efforts to improve the quality and safety of US Healthcare have been unsuccessful, or at best, unsustainable at eliminating preventable patient harm. Historically, US Healthcare has turned to commercial aviation, nuclear energy, oil and gas, and other high reliability industries for lessons on how to avoid harm. In this paper, we join two pre-existing conceptual models: high reliability organizing and error management theory to propose a strategy for embedding and sustaining a preoccupation with failure and commitment to resilience within healthcare to advance a practical and disciplined focus to advance organizational high reliability.

Healthcare students' perceptions and experiences of making errors in simulation: An integrative review

BACKGROUND

Research literature suggests that learning from mistakes facilitates news insights and leads to professional development. The significant growth in the use of simulation-based learning is premised on the understanding that in this context learners can make and learn from their errors without negatively impacting real patients. However, studies also suggest that making errors can be emotionally detrimental to learners. Given these contradictory findings, this literature review explores learners' views about this phenomenon.

OBJECTIVE

The objective of this integrated review was to explore healthcare students' perceptions of making errors during simulation-based learning experiences.

DESIGN

Whittemore and Knafl's framework for integrated reviews was used to structure this review.

DATA SOURCES

Five electronic databases MEDLINE, CINAHL, PsycINFO, ProQuest, and SCOPUS and the search engine Google Scholar were searched. The initial terms used were nursing students, medical students, health professionals, error*, mistake*, and simulation.

METHODS

The original search resulted in 2317 potential records. After screening against the inclusion/exclusion criteria, 11 articles were critically appraised using The Critical Appraisal Skills Program (CASP) checklist and were included in the review.

RESULTS

The two overarching themes to emerge from the analysis were the impact of errors on learners and the impact of errors on learning.

CONCLUSION

Despite the negative feelings experienced by some students regarding making mistakes in simulation, there were key factors that moderated the impact of these feelings and transformed the errors into learning opportunities. These included: the provision of a safe learning environment where constructive feedback was provided by skilled educators, and where students were supported to take responsibility for their mistakes. Although the findings suggest that making mistakes in simulation-based learning can be beneficial, optimising learning from mistakes requires a deliberate and thoughtful approach in which educators plan for and support learners to recognise, acknowledge and respond effectively to errors.

Challenges & Issues: Evidence-Based Clinical Skills Teaching and Learning: What Do We Really Know?

The recent programmatic focus on skills development in veterinary medicine means that many programs are devoting increased time to formal clinical skills teaching. This expansion makes it essential that we use the time as effectively as possible. This review examines current practices and veterinary training principles using the broader field of evidence-based motor skills learning as a lens. In many areas, current practices may be hindering learning. Proposed practices include using videos and discussions for pre-laboratory training, focusing on a single complex skill at a time, using more near-peer instructors rather than faculty, including assessments in each teaching or practice session, and encouraging supervised distributed practice by incorporating practice sessions into the formal curriculum. Ensuring mastery of a few core skills rather than exposure to many may be the new goal. Further research is urgently needed on block versus spiral curricula, optimum instructor-to-student ratios, learning and practice schedules, hours required for proficiency, and the benefits of exercise on motor skills learning.

Iatrogenic Critical Care Procedure Complication Boot Camp: A Simulation-based Pilot Study

BACKGROUND

Traditional medical education strategies teach learners how to correctly perform procedures while neglecting to provide formal training on iatrogenic error management. Error management training (EMT) requires active exploration as well as explicit encouragement for learners to make and learn from errors during training. Simulation provides an excellent methodology to execute a curriculum on iatrogenic procedural complication management. We hypothesize that a standardized simulation-based EMT curriculum will improve learner's confidence, cognitive knowledge, and performance in iatrogenic injury management.

METHODS

This was a pilot, prospective, observational study performed in a simulation center using a curriculum developed to educate resident physicians on iatrogenic procedural complication management. Pre- and postintervention assessments included confidence surveys, cognitive questionnaires, and critical action checklists for six simulated procedure complications. Assessment data were analyzed using medians and interquartile ranges (IQRs), and the paired change scores were tested for median equality to zero via Wilcoxon signed rank tests with p < 0.05 considered statistically significant.

RESULTS

Eighteen residents participated in the study curriculum. The median (IQR) confidence increased significantly by a summed score of 12.5 (8.75-17.25; p < 0.001). Similarly, the median (IQR) knowledge significantly increased by 6 (3-8) points from the pre- to postintervention assessment (p < 0.001). For each of the simulation cases, the number of critical actions performed increased significantly (p < 0.001 to p = 0.002).

CONCLUSION

We demonstrated significant improvement in the confidence, clinical knowledge, and performance of critical actions after the completion of this curriculum. This pilot study provides evidence that a structured EMT curriculum is an effective method to teach management of iatrogenic injuries.

Iatrogenic emergency medicine procedure complications and associated trouble-shooting strategies

PURPOSE

The purpose of this paper is to provide a consolidated reference for the acute management of selected iatrogenic procedural injuries occurring in the emergency department (ED).

DESIGN/METHODOLOGY/APPROACH

A literature search was performed utilizing PubMed, Scopus, Web of Science and Google Scholar for studies through March of 2017 investigating search terms "iatrogenic procedure complications," "error management" and "procedure complications," in addition to the search terms reflecting case reports involving the eight below listed procedure complications.

FINDINGS

This may be particularly helpful to academic faculty who supervise physicians in training who present a higher risk to cause such injuries.

ORIGINALITY/VALUE

Emergent procedures performed in the ED present a higher risk for iatrogenic injury than in more controlled settings. Many physicians are taught error-avoidance rather than how to handle errors when learning procedures. There is currently very limited literature on the error management of iatrogenic procedure complications in the ED.

Evaluation of peer teaching and deliberate practice to teach veterinary surgery

OBJECTIVE

To assess the impact of peer teaching and deliberate practice on surgical skills acquisition and retention in first- and second-year veterinary students.

STUDY DESIGN

Randomized, prospective, comparative study.

SAMPLE POPULATION

Eighteen first-year and 25 second-year students from 1 college of veterinary medicine who had previously demonstrated proficiency in basic surgical skills.

METHODS

Forty-three participants were divided into 3 groups: the test group (group A, n = 15), who participated in a structured peer-assisted learning program using deliberate practice; the time-practice control group (group B, n = 15), who participated in an unstructured peer-supported environment; and the assessment-only control group (group C, n = 13), who participated in the assessments. Participants performed a subcutaneous mass removal on a cadaver model and were assessed via a global rating system. Three assessment points were evaluated: pretraining, immediate posttraining, and retention.

RESULTS

The number of participants who achieved acceptable or excellent grand total scores in group A increased after training. Among all participants, 22% in group A, 35% in group B, and 38% in group C did not achieve an acceptable total score at the retention assessment.

CONCLUSION

The study population improved in skill level and retention through the use of standardized video and peer instruction with attention to effective learning strategies, particularly deliberate practice.

CLINICAL SIGNIFICANCE

Use and enhancement of the format introduced in this study could augment veterinary surgical education.

Investigating the Effect of Simulator Functional Fidelity and Personalized Feedback on Central Venous Catheterization Training

OBJECTIVE

To compare the effect of simulator functional fidelity (manikin vs a Dynamic Haptic Robotic Trainer [DHRT]) and personalized feedback on surgical resident self-efficacy and self-ratings of performance during ultrasound-guided internal jugular central venous catheterization (IJ CVC) training. In addition, we seek to explore how self-ratings of performance compare to objective performance scores generated by the DHRT system.

DESIGN

Participants were randomly assigned to either manikin or DHRT IJ CVC training over a 6-month period. Self-efficacy surveys were distributed before and following training. Training consisted of a pretest, 22 practice IJ CVC needle insertion attempts, 2 full-line practice attempts, and a posttest. Participants provided self-ratings of performance for each needle insertion and were presented with feedback from either an upper level resident (manikin) or a personalized learning system (DHRT).

SETTING

A study was conducted from July 2016 to February 2017 through a surgical skills training program at Hershey Medical Center in Hershey, Pennsylvania.

PARTICIPANTS

Twenty-six first-year surgical residents were recruited for the study. Individuals were informed that IJ CVC training procedures would be consistent regardless of participation in the study and that participation was optional. All recruited residents opted to participate in the study.

RESULTS

Residents in both groups significantly improved their self-efficacy scores from pretest to posttest (p < 0.01). Residents in the manikin group consistently provided higher self-ratings of performance (p < 0.001). Residents in the DHRT group recorded more feedback on errors (228 instances) than the manikin group (144 instances). Self-ratings of performance on the DHRT system were able to significantly predict the objective score of the DHRT system (R2 = 0.223, p < 0.001).

CONCLUSION

Simulation training with the DHRT system and the personalized learning feedback can improve resident self-efficacy with IJ CVC procedures and provide sufficient feedback to allow residents to accurately assess their own performance.

Informing the Revolution: A Needs Assessment of Ultrasound Knowledge and Skills Among Graduating Physician Assistant Students

PURPOSE

We performed a needs assessment to understand how existing physician assistant (PA) program curricula and clinical training affect students' ultrasound knowledge, skills, and competence and prepare students for performing ultrasound techniques in clinical practice.

METHODS

Students graduating from a PA program completed a 23-item questionnaire examining their ultrasound training experiences, their self-assessment of competency, and their demographics. Students also completed a 15-item ultrasound knowledge assessment.

RESULTS

Thirty-eight of 39 students (97%) completed the survey. Students received little hands-on ultrasound training, with the most hands-on training being offered during emergency medicine (44.7%), obstetrics and gynecology (42.1%), and inpatient internal medicine (39.5%) rotations. This lack of preparedness was reflected in a mean score of 47.1% (±16.4%) on the ultrasound knowledge assessment. Most students (84.2%) indicated that the ultrasound instruction they received during clinical rotations was insufficient to prepare them for clinical practice, and 84.2% desired a formal ultrasound training program in the PA program curriculum.

CONCLUSIONS

Existing PA program curricula are insufficient for developing critical skills related to ultrasonography.

The Development of a Novel Perfused Cadaver Model With Dynamic Vital Sign Regulation and Real-World Scenarios to Teach Surgical Skills and Error Management

The landscape of graduate medical education has changed dramatically over the past decade and the traditional apprenticeship model has undergone scrutiny and modifications. The mandate of the 80-hour work-week, the introduction of integrated residency programs, increased global awareness about patient safety along with financial constraints have spurred changes in graduate educational practices. In addition, new technologies, more complex procedures, and a host of external constraints have changed where and how we teach technical and procedural skills. Simulation-based training has been embraced by the surgical community and has quickly become an essential component of most residency programs as a method to add efficacy to the traditional learning model. The purpose of this paper is twofold: (1) to describe the development of a perfused cadaver model with dynamic vital sign regulation, and (2) to assess the impact of a curriculum using this model and real world scenarios to teach surgical skills and error management. By providing a realistic training environment our aim is to enhance the acquisition of surgical skills and provide a more thorough assessment of resident performance. Twenty-six learners participated in the scenarios. Qualitative data showed that participants felt that the simulation model was realistic, and that participating in the scenarios helped them gain new knowledge, learn new surgical techniques and increase their confidence performing the skill in a clinical setting. Identifying the importance of both technical and nontechnical skills in surgical education has hastened the need for more realistic simulators and environments in which they are placed. Team members should be able to interact in ways that allow for a global display of their skills thus helping to provide a more comprehensive assessment by faculty and learners.

Use of simulation-based medical training in Swiss pediatric hospitals: a national survey

BACKGROUND

Simulation-based medical training (SBMT) is a powerful tool for continuing medical education. In contrast to the Anglo-Saxon medical education community, up until recently, SBMT was scarce in continental Europe's pediatric health care education: In 2009, only 3 Swiss pediatric health care institutions used SBMT. The Swiss catalogue of objectives in Pediatrics does not acknowledge SBMT. The aim of this survey is to describe and analyze the current state of SBMT in Swiss pediatric hospitals and health care departments.

METHODS

A survey was carried out with medical education representatives of every institution. SBMT was defined as any kind of training with a mannequin excluding national and/or international standardized courses. The survey reference day was May 31st 2015.

RESULTS

Thirty Swiss pediatric hospitals and health care departments answered our survey (response rate 96.8%) with 66.6% (20 out of 30) offering SBMT. Four of the 20 hospitals offering SMBT had two independently operating training simulation units, resulting in 24 educational units as the basis for our SBMT analysis. More than 90% of the educational units offering SBMT (22 out of 24 units) were conducting in-situ training and 62.5% (15 out of 24) were using high-technology mannequins. Technical skills, communication and leadership ranked among the top training priorities. All institutions catered to inter-professional participants. The vast majority conducted training that was neither embedded within a larger educational curriculum (19 out of 24: 79.2%) nor evaluated (16 out of 24: 66.6%) by its participants. Only 5 institutions (20.8%) extended their training to at least two thirds of their hospital staff.

CONCLUSIONS

Two thirds of the Swiss pediatric hospitals and health care departments are offering SBMT. Swiss pediatric SBMT is inter-professional, mainly in-situ based, covering technical as well as non-technical skills, and often employing high-technology mannequins. The absence of a systematic approach and reaching only a small number of healthcare employees were identified as shortcomings that need to be addressed.

Defining and comparing learning actions in two simulation modalities: students training on a latex arm and each other's arms

AIMS AND OBJECTIVES

To explore, describe and compare learning actions that nursing students used during peripheral vein cannulation training on a latex arm or each other's arms in a clinical skills centre.

BACKGROUND

Simulation-based training is thought to enhance learning and transfer of learning from simulation to the clinical setting and is commonly recommended in nursing education. What students actually are doing during simulation-based training is, however, less explored. The analysis of learning actions used during simulation-based training could contribute to development and improvement of simulation as a learning strategy in nursing education.

DESIGN

A qualitative explorative and descriptive research design, involving content analysis of video recordings, was used.

METHODS

Video-supported observation of nine nursing students practicing vein cannulation was conducted in a clinical skills centre in late 2012.

RESULTS

The students engaged in various learning actions. Students training on a latex arm used a considerably higher number of learning actions relative to those training on each other's arms. In both groups, students' learning actions consisted mainly of seeking and giving support. The teacher provided students training on each other's arms with detailed feedback regarding insertion of the cannula into the vein, while those training on a latex arm received sparse feedback from the teacher and fellow students.

CONCLUSION

The teacher played an important role in facilitating nursing students' practical skill learning during simulation. The provision of support from both teachers and students should be emphasised to ensure that nursing students' learning needs are met.

RELEVANCE TO CLINICAL PRACTICE

This study suggest that student nurses may be differently and inadequately prepared in peripheral vein cannulation in two simulation modalities used in the academic setting; training on a latex arm and on each other's arms.

Imperfect practice makes perfect: error management training improves transfer of learning

CONTEXT

Traditionally, trainees are instructed to practise with as few errors as possible during simulation-based training. However, transfer of learning may improve if trainees are encouraged to commit errors. The aim of this study was to assess the effects of error management instructions compared with error avoidance instructions during simulation-based ultrasound training.

METHODS

Medical students (n = 60) with no prior ultrasound experience were randomised to error management training (EMT) (n = 32) or error avoidance training (EAT) (n = 28). The EMT group was instructed to deliberately make errors during training. The EAT group was instructed to follow the simulator instructions and to commit as few errors as possible. Training consisted of 3 hours of simulation-based ultrasound training focusing on fetal weight estimation. Simulation-based tests were administered before and after training. Transfer tests were performed on real patients 7-10 days after the completion of training. Primary outcomes were transfer test performance scores and diagnostic accuracy. Secondary outcomes included performance scores and diagnostic accuracy during the simulation-based pre- and post-tests.

RESULTS

A total of 56 participants completed the study. On the transfer test, EMT group participants attained higher performance scores (mean score: 67.7%, 95% confidence interval [CI]: 62.4-72.9%) than EAT group members (mean score: 51.7%, 95% CI: 45.8-57.6%) (p < 0.001; Cohen's d = 1.1, 95% CI: 0.5-1.7). There was a moderate improvement in diagnostic accuracy in the EMT group compared with the EAT group (16.7%, 95% CI: 10.2-23.3% weight deviation versus 26.6%, 95% CI: 16.5-36.7% weight deviation [p = 0.082; Cohen's d = 0.46, 95% CI: -0.06 to 1.0]). No significant interaction effects between group and performance improvements between the pre- and post-tests were found in either performance scores (p = 0.25) or diagnostic accuracy (p = 0.09).

CONCLUSIONS

The provision of error management instructions during simulation-based training improves the transfer of learning to the clinical setting compared with error avoidance instructions. Rather than teaching to avoid errors, the use of errors for learning should be explored further in medical education theory and practice.

Exploring Senior Residents' Intraoperative Error Management Strategies: A Potential Measure of Performance Improvement

OBJECTIVE

The study aim was to determine whether residents' error management strategies changed across 2 simulated laparoscopic ventral hernia (LVH) repair procedures after receiving feedback on their initial performance. We hypothesize that error detection and recovery strategies would improve during the second procedure without hands-on practice.

DESIGN

Retrospective review of participant procedural performances of simulated laparoscopic ventral herniorrhaphy. A total of 3 investigators reviewed procedure videos to identify surgical errors. Errors were deconstructed. Error management events were noted, including error identification and recovery.

SETTING

Residents performed the simulated LVH procedures during a course on advanced laparoscopy. Participants had 30 minutes to complete a LVH procedure. After verbal and simulator feedback, residents returned 24 hours later to perform a different, more difficult simulated LVH repair.

PARTICIPANTS

Senior (N = 7; postgraduate year 4-5) residents in attendance at the course participated in this study.

RESULTS

In the first LVH procedure, residents committed 121 errors (M = 17.14, standard deviation = 4.38). Although the number of errors increased to 146 (M = 20.86, standard deviation = 6.15) during the second procedure, residents progressed further in the second procedure. There was no significant difference in the number of errors committed for both procedures, but errors shifted to the late stage of the second procedure. Residents changed the error types that they attempted to recover (χ²₅=24.96, p<0.001). For the second procedure, recovery attempts increased for action and procedure errors, but decreased for strategy errors. Residents also recovered the most errors in the late stage of the second procedure (p < 0.001).

CONCLUSION

Residents' error management strategies changed between procedures following verbal feedback on their initial performance and feedback from the simulator. Errors and recovery attempts shifted to later steps during the second procedure. This may reflect residents' error management success in the earlier stages, which allowed further progression in the second simulation. Incorporating error recognition and management opportunities into surgical training could help track residents' learning curve and provide detailed, structured feedback on technical and decision-making skills.

Simulated settings; powerful arenas for learning patient safety practices and facilitating transference to clinical practice. A mixed method study

Poor teamwork is an important factor in the occurrence of critical incidents because of a lack of non-technical skills. Team training can be a key to prevent these incidents. The purpose of this study was to explore the experience of nursing and medical students after a simulation-based interprofessional team training (SBITT) course and its impact on professional and patient safety practices, using a concurrent mixed-method design. The participants (n = 262) were organized into 44 interprofessional teams. The results showed that two training sequences the same day improved overall team performance. Making mistakes during SBITT appeared to improve the quality of patient care once the students returned to clinical practice as it made the students more vigilant. Furthermore, the video-assisted oral debriefing provided an opportunity to strengthen interprofessional teamwork and share situational awareness. SBITT gave the students an opportunity to practice clinical reasoning skills and to share professional knowledge. The students conveyed the importance of learning to speak up to ensure safe patient practices. Simulated settings seem to be powerful arenas for learning patient safety practices and facilitating transference of this awareness to clinical practice.

The value proposition of simulation

BACKGROUND

Simulation has been shown to improve trainee performance at the bedside and in the operating room. As the use of simulation-based training is expanded to address a host of health care challenges, its added value needs to be clearly demonstrated. Demonstrable improvements will support the expansion of infrastructure, staff, and programs within existing simulation facilities as well as the establishment of new facilities to meet growing needs and demands. Thus, organizational and institutional leaders, faculty members, and other stakeholders can be assured of the best use of existing resources and can be persuaded to make greater investments in simulation-based training for the future.

METHODS

A multidisciplinary panel was convened during the 8th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes (Simulation Centers) in March 2015 to discuss the added value of simulation-based training. Panelists shared the ways in which the value of simulation was demonstrated at their institutions.

CONCLUSION

The value of simulation-based training was considered and described in terms of educational impact, patient care outcomes, and costs.