During medical simulation, the inherent unpredictability of learners’ performances and decisions can make it challenging to consistently achieve desired learning objectives. The amount learned and the errors made can vary wildly between groups. Paradoxically, a stellar student can minimize the learning for the other providers if he or she takes over and effortlessly completes the case. Likewise, the visceral impact of seeing a case go horribly wrong can have tremendous teaching value.1
In addition to these challenges, the COVID-19 pandemic has introduced additional barriers to medical simulation training; physical distancing measures have resulted in limited or canceled simulation activities for most emergency medicine residency programs.
Name of the Innovation
This innovation is entitled the “Wednesday-Morning Quarterbacking” series. In this series, we produce carefully scripted simulated emergency medicine cases which are then recorded with providers as actors. The actors make intentional medical errors throughout the case. The videos are designed to demonstrate both the cause and the outcome of each error. During virtual residency conferences on Wednesday mornings, we screen the videos and challenge learners to identify the errors in real-time and recommend corrective actions.
Target learners include emergency medicine residents, attendings, advanced practice providers, and medical students.
This activity can be conducted in groups of nearly any size. Our study group ranged from 15-60.
This innovation requires:
- A high-fidelity medical simulation lab with equipment in which to record simulated cases
- Medically-trained volunteers to serve as actors
- Video recording equipment: An iPhone can be used to record the session. Purchasing a tripod costs less than $50 on Amazon, can improve video quality, and eliminate the need for an additional person to film. If filming outdoors, or if there is a need to film with a sweeping movement, consider purchasing an OSMO gimble handheld stabilizer, which costs around $150.
- Video editing software: Our team uses Mac’s iMovie, which is freely available on Apple computers.
Detailed Description of Activity and Background
This series consists of several cases. Two examples of cases are highlighted below.
Case 1: Critically ill patient with COVID-19
For this case, we identified the following overlying goals:
- Protecting health care providers from SARS-CoV-2 exposure
- Minimizing patient hypoxia
- Maximizing effective communication between team members to prevent medical errors
- Improving camaraderie
- Maximizing efficiency
We subsequently identified 40 potential errors related to these goals that could occur during a resuscitation, including the following examples:
- Failure to place a HEPA/viral filter inline on a bag-valve-mask
- Failure to place a mask on a patient with symptoms of COVID-19
- Unnecessary or overzealous bag-valve-mask ventilation during rapid sequence intubation
Case 2: Postpartum hemorrhage
For this case, we identified the following overlying goals:
- Demonstration of standard maneuvers for vaginal delivery
- Rapid identification of life-threatening postpartum hemorrhage
- Appropriate pharmacotherapy for hemorrhage
- Identification of the need for procedural intervention in an ED with no obstetrics support (Uterine Sweep, Bakri Catheter placement)
- Effective resuscitation of the critically ill neonate
Examples of featured errors included:
- Poor fundal massage technique
- Inappropriate intubation for age-appropriate hypoxemia in the immediate newborn period
- Failure to displace the gravid uterus on a presyncopal patient by placing her in a left lateral recumbent position
- Ordering magnesium sulfate for postpartum hemorrhage
- Ruling out significant maternal hemorrhage because of normal blood pressure
- Vaginal packing for a uterine hemorrhage
- Cutting instead of reducing a nuchal cord
For each case, we composed a script of an error-filled scenario and created a video using clinicians and actors. An advantage of the technique of pre-recording simulated cases included the ability to start and stop the action as well as incorporate close-ups and multiple angles. This allowed us to demonstrate each error with precision. This is in contrast to a live simulation, where many of the viewers and participants may not be able to directly visualize the error. Next, using editing software, we displayed sequential numbers in the video to designate the point at which the error should be identified.
During a live conference when possible and using video teleconferencing when not, learners were first instructed to take a blank sheet and number it. When the video was played, they were instructed to identify and record the error in real-time as the numbers appeared on the screen. The video was then played a second time. When a number appeared during the second viewing, the video was stopped and a learner was called on to share with the group their thoughts on the error. A brief discussion was held, and the video was restarted.
Cases available below:
Video 1: Errors in Resuscitation of High Consequence Respiratory Pathogen Patients
Video 2: Errors in the Management of Vaginal Delivery and Postpartum Hemorrhage
As expected, resident physicians were far more willing to openly identify and analyze the errors of the actors in the videos than to criticize their classmates who make errors during a live simulation. Additionally, during a live simulation, errors are either not caught or not acknowledged, such that potential areas for error in each case are not fully realized by the participants. By design, however, pre-recorded video simulation guarantees that the teaching points are delivered each time to all participants.
During virtual conference, the participants were more engaged and animated during the activity than during in-person conferences. Because every participant is proactively and randomly called upon by faculty members facilitating the session, they remain alert and ready to respond. Participants also can ask for help from classmates if they struggle to identify the error. This strategy helps mitigate some of the natural discomfort participants may feel to initiate speaking out loud on a large video conference call.
Educational theory behind the innovation
Our experience with teaching through errors was similar to the result of studies focusing on learning from erroneous examples Eichelmann, and Große found that
“incorrect solutions lead to enhanced learning outcomes if learners have favourable prior knowledge. Including errors in worked examples motivated these learners to explain what was wrong and why, and it fostered elaborations on the correct solutions. Their results underpin the positive relationship between transfer performance and the generation of self-explanations when learning with incorrect solutions.” 2,3
We have found that during simulation, calling attention to a few errors can be a useful strategy for teaching learners. However, when a resident makes multiple errors to the point of embarrassment, they may come to maladaptively believe that they are incompetent in the care of this particular condition.4 By placing the error on a third party, the actor, the residents are able to learn the lessons of devastatingly poor performance without creating an emotion of learned helplessness which could compromise their clinical performance. Although there is significant value in feeling the pressure of errors and overcoming them, the third-party viewer aspect of this teaching allows them to both dispassionately identify minor and catastrophic errors alike. They can learn from realizing which subtle errors that they missed, while remaining confident in their own competence.
References and Resources:
- Pelletier C, Kneebone R. Learning safely from error? Reconsidering the ethics of simulation-based medical education through ethnography. Ethnography and Education. 2016; 11:3, 267-282, doi: 10.1080/17457823.2015.1087865.
- Große CS, Renkl, A. (). Finding and fixing errors in worked examples: Can this foster learning outcomes? Learning and Instruction. 2007;17, 612–634. doi:10.1016/j.learninstruc.2007.09.008.
- Eichelmann A, NarcissS, Schnaubert L. Learning from errors through tasks-with typical-errors. 15th Biennial Conference of the European. 2013; 11:3, 267–282, http://dx.doi.org/10.1080/17457823.2015.1087865.
- Turton D, Buchan K, Hall-Jackson M, Pelletier C. Simulation: the power of what hurts. Med Educ. 2019; 53(4):326-328. PMID: 30690757
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