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Learning from mistakes


Today’s healthcare organizations need to improve patient safety, which includes effectively communicating information to nurses about safety incidents and how to address them. After all, frontline nurses are at the sharp edge of patient care—the last step before an error occurs. But communicating to staff in a large, academic, Magnet®-designated medical center can be challenging, to say the least. In this article we describe a new, engaging format—the Roving Patient of Errors— that keeps clinical nurses informed and educated about internal safety events.

Re-creating patient safety incidents

The Roving Patient of Errors uses an interactive, team-based approach to teach staff about actual patient safety incidents. It’s best described as a mobile simulation-based educational strategy that encompasses a series of specific steps.

A team of educators and facilitators:

• reviews recent internal patient safety incident reports

• identifies opportunities for improvement, based on internal trends and healthcare standards, such as The Joint Commission’s National Patient Safety Goals

• creates practice scenarios including appropriate orders, based on their review of real-life incidents

• outfits a manikin with props, such as medications, stretchers, and functioning medical equipment—creating a Roving Patient of Errors that can be used to effectively re-create real-life patient incidents; the team creates as many manikin-patients as needed

• deploys presenters to units; at each unit, presenters call a huddle and simulate patient care scenarios using the manikin and props.

The presenters:

allow staff to examine the manikin to identify errors

debrief and review all errors on the manikin, after each scenario

explain that the errors originated from recently reported internal incidents.

The team spends 10 to 15 minutes with each unit on average. Staff members complete a short evaluation to help monitor the effectiveness of each activity. Ongoing review of internal incident reports allows team members to identify trends that still need attention, recurring events, and new issues.

Simulation as a path to learning and motivation

Simulation-based education is at the heart of Roving Patient of Errors. Using simulation techniques fosters new knowledge, reinforces safety measures and clinical skills, helps shape attitudes, and ultimately, improves patient outcomes by providing a safe environment for nurses to learn from their mistakes. (See Why is learning from mistakes so effective?)

Roving Patient of Errors allows us to deliver education directly to clinical staff in their practice setting, rather than pulling them away to a classroom. An added benefit is that educators can cover more issues in a single session.

During each simulation exercise, nurses attempt to discover clinical errors. Participants get a second chance to learn from mistakes during debriefing when unrecognized errors are revealed. They can quickly deduce the effect on patient outcomes if they were to make the same mistakes and can better understand the significance of errors for their own practice.

Enhancing awareness through transparency

Most frontline staff members become aware of only a limited number of patient safety events—usually incidents occurring on their shift, unit, or department. This is due to the reality of silos within healthcare organizations and difficulties disseminating information.

According to research, the absence of transparency in healthcare organizations distorts collegiality, erodes patient trust, and inhibits healthcare professionals from learning from their mistakes. Lack of transparency is one reason why overall improvements in patient safety have been slow.

The Roving Patient of Errors method can be part of an organizational strategy to improve transparency. Simulation helps communicate organizational safety trends more effectively. Multiple reported incidents may be reviewed in a single learning session. During debriefing and review, several nurse participants were surprised to learn the errors depicted occurred at our organization. Greater awareness of clinical vulnerabilities helps nurses better understand the importance of being vigilant against errors. They come to realize they cannot assume everything is correct when they receive a patient. Facilitators encourage nurses to report safety incidents, since early identification of errors and near misses provides leadership with the opportunity to support needed safety improvements.

Minimal costs, maximal outcomes

Costs associated with the Roving Patient of Errors include the time invested to review internal patient safety reports as well as the time needed for staff to make presentations to units. The cost for outfitting the manikins was minimal; our organization already had manikins, and we used mostly expired equipment for props.

The Roving Patient of Errors approach achieved several positive outcomes at our facility:

• Four presenters working in teams of two were able to reach 256 staff members in 4 hours.

• 100% of participants said they would participate again.

• 100% of participants said that the activity increased transparency and awareness of patient safety issues.

• Using a scale of poor, fair, neutral, good, and excellent, 82% of participants rated this activity overall as excellent, and 18% rated this activity as good.

• Participants described the format as appreciated, novel, engaging, insightful, directly applicable, and relevant for staff in feedback.

People learn from their mistakes, but when nurses make mistakes, patients may be harmed. The Roving Patient of Errors model provides nurses with a safe and effective way to do what comes naturally to human beings—learn from mistakes. (See Key points about the Roving Patient of Errors.

Sonya Wood-Johnson is chair of the Quality and Patient Safety Core Council at the Hospital of the University of Pennsylvania in Philadelphia. Suzanna Ho is coordinator of patient safety and quality nursing at the Hospital of the University of Pennsylvania in Philadelphia. Melanie Rainford is professional development specialist at the Hospital of the University of Pennsylvania in Philadelphia.

Selected references

House S, Dowell S, Fox M, et al. Low-fidelity simulation to enforce patient safety. Clinical Simulation in Nursing. 2016;12(1):24-29.

Kornell N, Klein PJ, Rawson KA. Retrieval attempts enhance learning, but retrieval success (versus failure) does not matter. J Exp Psychol Learn Mem Cogn. 2015;41(1):283-94.

Phelps G, Barach P. Why has the safety and quality movement been slow to improve care? Int J Clin Pract. 2014;68(8):932-935.

Ziv A, Small SD, Wolpe, PR. Patient safety and simulation-based medical education. Med Teach. 2000;22(5):489-495.

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