Three Years of Experience in Teaching about Medical Errors: A Problem-Based Learning Approach

Presenter: Anne Caffee, Pharm.D., BCPS, Associate Professor

Institution: Shenandoah University

Introduction: The health care environment is under increasing scrutiny to monitor, acknowledge and correct errors. Ideally, monitoring of past errors and near misses will prevent future errors from reaching patients. As members of the health care team, pharmacists work to prevent and respond to medication errors. They understand and employ techniques used to analyze errors and apply corrections for individual patient situations as well as for medication delivery and use systems.

Methods: Within a Pharmacy Practice Laboratory class, all third year students participated in an Error Analysis Workshop. This two day workshop is introduced with a discussion of errors and their health impact, followed by definitions and examples of root cause analysis, and failure modes and effects analysis. Problem based learning then follows two phases. First, small groups are assigned an error case and perform a root cause analysis in a simulated "care-team", with each group getting a different case, and closing with a presentation of findings from each group to the class. Second, individual students have a simulated patient encounter which focuses on a medication dispensing error with or without harm to the patient. Encounters are videotaped for later self-assessment by the student. Each student prepares a consult letter to the Primary Care provider addressing the error and recommending or reporting a resolution.

Measures of effectiveness for this workshop include faculty assessment of the small group presentations and the consult letter for a student grade, and student self-assessment of videotaped encounter and student assessment of the workshop experience.

Results: Workshops have been well received for the past three years. Small changes made each year have brought improvements. Much of the introduction was in lecture format the first year. This is being replaced with a required reading, prepared notes of definitions of terms, and a videotape of professional experiences resulting from errors. This allows more time for "Hands On Learning" and small group discussion.

Small group discussion now has specific assigned roles for each team member to promote different perspectives. These include team recorder, patient, pharmacist, prescriber, and nurse or administrator. This prevents the myopia of pharmacist’s perspective and has resulted in less emphasis on blame assignment.

The Simulated Encounter has changed each year. The first two years were very successful, with "near miss" cases. The third year was less successful with error reaching the patient, as pharmacy students fixated on the clinical issues of potential toxicity rather than the issues of communication, and error correction. We will return to a near miss case to focus on systems issues and communication.

Discussion: Adjustments may be made in applying this curriculum to medical education. Larger classes may require more time allocation. Simulated encounter cases limited in scope are more likely to allow emphasis of errors issues over other patient management issues.