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Errors as allies: error management training in health professions education
  1. Aimee King1,2,
  2. Michael G Holder Jr1,3,
  3. Rami A Ahmed1,4
  1. 1Center for Simulation and Integrated Healthcare Education, Austen BioInnovation Institute in Akron, Akron, Ohio, USA
  2. 2Department of Psychology, University of Akron, Akron, Ohio, USA
  3. 3Department of Pediatric Emergency Medicine, Akron Children's Hospital, Akron, Ohio, USA
  4. 4Department of Emergency Medicine, Summa Akron City Hospital, Akron, Ohio, USA
  1. Correspondence to Dr Aimee King, Center for Simulation and Integrated Healthcare Education, Austin BioInnovation Institute in Akron, 47 N. Main Street, Akron, OH 44308, USA; aeking01{at}gmail.com

Abstract

This paper adopts methods from the organisational team training literature to outline how health professions education can improve patient safety. We argue that health educators can improve training quality by intentionally encouraging errors during simulation-based team training. Preventable medical errors are inevitable, but encouraging errors in low-risk settings like simulation can allow teams to have better emotional control and foresight to manage the situation if it occurs again with live patients. Our paper outlines an innovative approach for delivering team training.

  • Organizational theory
  • Medical error, measurement/epidemiology
  • Simulation
  • Team training

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Introduction

For better or worse, error is already our lifelong companion.

Surely, then, it's time we got to know it.

Kathryn Schulz1

Recent published reports estimate that as many as 200 000 Americans die each year from preventable medical mistakes.2 These errors also result in an additional $19.5 billion in cost to the healthcare system.3 In response to these and other alarming statistics, the healthcare community has focused considerable attention on the reduction of medical errors. Some efforts have centred on the development of outlets, such as autopsies and morbidity and mortality conferences, designed for the open discussion of error in the hope that others can learn from such mistakes. Such meetings, however, exhibit questionable success and can produce humiliation for those placing their mistakes under the scrutiny of others.4 Others have increased attention on high reliability organisations, which encourage development of systems that minimise the chance of error5 or on crew resource management, which is designed so that learners can avoid or mitigate threats of error.6 However, authors are beginning to argue that errors play a valuable role in medical training.7 In a recent literature review, Eva8 concluded that educators should be working to induce errors in learners and teams, leading them to ‘short term pain for long term gain.’ Admitting the inevitability of error and preparing for them leads to opportunities for growth.1 In other words, errors may be a necessary precondition for learning and behavioural change. The current paper seeks to identify mechanisms through which errors in a controlled setting can improve learning and provide new methods in which medical educators might capitalise upon those mistakes to improve team performance and patient safety. Specifically, we adopt training principles from the organisational psychology literature and integrate them within simulation-based training (SBT).

Making errors in safe settings

SBT involves immersing students in real-patient experiences that are created to replicate substantial effects of the real world in a fully interactive manner.9 The use of SBT to train teams has been touted as a powerful method to increase safety and effectiveness in healthcare.10 Training in this environment allows learners to develop skills to manage common as well as low frequency, high acuity events—all without risk to actual patients. Additionally, healthcare providers can operate in a setting that is safe to try new skills. As mistakes that occur within these settings do not result in patient harm, errors have the potential to elicit learning opportunities that would otherwise put patients at risk. Salas and colleagues11 note that simulation can be most effective when the content is highly relevant to the job (psychological fidelity), instructional features are embedded, there are numerous opportunities for measurement, and the learning experiences are integrated with strategically-designed scenarios and diagnostic feedback. Indeed, properly designed simulations have been found to improve performance with actual patients.12–14 Further, simulation is believed to have applications for professionals in all disciplines of healthcare.15 However, as noted by Salas and colleagues,16 simulation must be designed and delivered based on the science of training and learning to impact patient safety. The next section outlines how error management training (EMT) can be integrated within simulation to improve team performance and patient outcomes.

Integrating simulation and EMT

Trainee errors are often admonished in learning.17 Over 20 years ago, however, errors were proposed to be highly informative when learners discovered why such mistakes occurred and how they could be corrected.18 The benefit of error is also highlighted by the finding that people are more motivated to learn when things go wrong.19 Given that errors are inevitable within work settings, exposure to mistakes in a safe setting may be a beneficial learning experience. An investigation conducted at one medical centre found that nearly all students and residents reported ruminating on committing medical errors and that it caused significant stress.7 Thus, there is much value in training individuals to strategically and emotionally cope with such errors. Indeed, recent developments have indicated that errors can be beneficial in team training settings. EMT is a training method that incorporates active exploration and explicit encouragement for trainees to make errors during training and to learn from them.20 This training approach is based on the assumption that errors are a natural by-product of active learning. As learners take steps to explore their environment, errors will inevitably emerge. These errors, though, can play an integral role in trainee development. For example, errors can help trainees pinpoint where knowledge and skills need further improvement.

In EMT, participants are given only minimal guidance and otherwise are encouraged to actively explore and experiment on their own. EMT also involves explicit encouragement of errors. Trainees are given brief instructions that instruct them to expect errors while they work on the tasks and that emphasise the positive informational feedback of errors for learning.17 Positive statements might include, ‘The more errors you make, the more you learn!’ or ‘You have made an error? Great! Because now you can learn something new!’.21 During the training session, participants receive statements like these and are asked to reflect on errors whenever they happen. However, no further assistance is offered when an error occurs. Such emphasis on positive framing of errors is a distinct characteristic of EMT that sets it apart from purely exploratory or proceduralised training methods. Treating mistakes as ‘puzzles to be solved not crimes to be punished’22 is a central tenet of EMT. This approach differs from debriefing as debriefing sessions are conducted after the simulation, are led by a facilitator (vs self-directed learning of EMT) and do not typically focus on the positive aspects of errors made during the learning experience.

When training a team on procedural sedation, typical instruction involves providing an interprofessional team with a general checklist that must be followed. It provides them with a step-by-step action plan that must be adhered to in a sequential fashion. For example, teams are instructed to administer a specific amount of medication immediately after they have obtained intravenous access, placed the patient on a cardiac monitor and provided supplemental oxygen. Teams are rarely provided guidance on how to handle the situation if the medication is administered with an improper dose. When integrating EMT with this procedure, however, team members are encouraged to administer improper doses and/or administer doses at improper rates. As a result, they can encounter patients who exhibit oversedation and loss of protective airway reflexes, hypotension and cardiorespiratory arrest and learn the correct methods to manage these potential complications. In this way, practitioners will be more adept at managing on-the-job errors with strategic and emotionally-controlled responses.

The effectiveness of EMT has been well documented. Frese et al17 found that learners provided with instructions on managing errors performed better on difficult problems compared with groups that were instructed to avoid errors. Additionally, participants in error encouragement conditions learn more compared with groups in error avoid or control conditions.23 Others have also found that encouraging errors among trainees was a valuable instructional strategy.24 Additionally, a recent meta-analysis uncovered that error management is better than error avoidance or exploratory training.25 The success of EMT has been attributed to the fact that it encourages greater effort to learn, promotes a deeper understanding of tasks, and provides both strategic and emotional management tactics for handling on-the-job job errors.11

A recent review of the training literature11 led scholars to offer evidence-based recommendations and best practices for maximising training effectiveness. These recommendations include the incorporation of errors and simulation into training programmes. Indeed, EMT aligns with the active learning approach of SBT. Errors are more likely to be made over the long term when too few errors are induced during the learning experience.8 However, exposure to errors during the learning experience may reveal gaps in a learner's knowledge or skill base that may otherwise be concealed and uncorrected in the absence of clear feedback.8 In this way, errors serve an important feedback function. EMT should be applied to SBT programmes in circumstances in which emotions can potentially harm performance, as EMT stimulates self-regulation of emotions and cognitions.25 Thus, EMT will be most beneficial for emotionally-charged tasks in which providers must multi-task in dynamic environments. Such situations are exceedingly prevalent in the healthcare industry. Therefore, integrating errors within training can help improve transfer of training to real work settings and equip trainees to deal with challenges while on the job, ultimately impacting patient safety.

Application of EMT to team training settings can be beneficial for a number of reasons. EMT may help team learning and performance because it encourages communication about errors among team members. One study26 found that errors lead to learning because they facilitate communication and the development of new ideas and insights by incorporating the viewpoints of others. Communication, coordination and collaboration behaviours are fundamental teamwork competencies.27 Additionally, research has shown that junior members of teams find it difficult to point out errors committed by senior members.7 However, learning with these individuals in an environment that encourages the benefits of committing mistakes likely promotes more open discussion of actual errors. Errors and discussion of errors within teams can also help develop shared cognition among team members. Such shared knowledge networks enhance team performance.28 Finally, as EMT has been found to decrease negative feelings associated with errors, such training may allow healthcare practitioners to better manage both personal and others’ errors that will inevitably occur in medical settings. Having encountered errors previously, practitioners will be calmer and better adept to rectify similar situations.

Conclusions

In sum, we argue that the healthcare professions education industry can benefit by incorporating EMT into simulation-based team training scenarios. Encouraging errors in a low-risk setting may allow trainees and teams to develop better emotional control and foresight and provide better care to live patients. Integration of EMT into SBT can provide a better understanding of those conditions that induce or hinder learning. The extent to which we can build a solid conceptual framework for how errors might be integrated into SBT will impact the degree to which future innovations and research efforts can be facilitated in a productive direction. We hope that this review will help educators and practitioners think beyond the ‘bells and whistles’ of simulation11 and promote the investigation and further exploration of EMT and how it contributes to the design, development and effectiveness of SBT programmes.

References

Footnotes

  • Contributors Each author contributed to this manuscript via conception, drafting the article, making edits and providing final approval of the manuscript.

  • Funding None.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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