Harmful medical errors are all too common, and research indicates that most physicians are likely to be involved in a medical error at some point in their career. Yet throughout the course of physician training, too little instruction is offered on how to recognize a medical error and what steps to take when an error happens—including how to disclose the mistake to a patient.
An objective structured clinical examination (OSCE) for fourth-year medical students at the Donald & Barbara Zucker School of Medicine at Hofstra/Northwell aims to address these gaps. The OSCE involves a standardized patient encounter involving an error. Medical students get real-time feedback about their performance in handling the situation.
Rebecca Dougherty, MD, an associate professor of medicine at the medical school, helped to implement the OSCE on medical error and presented the results in a poster showcased at the AMA Health Systems Science Summit. She offered a few insights for students on how to recognize medical errors.
See something, say something
The importance of quality improvement extends across the spectrum of physician training. Still, Dr. Dougherty said that a major barrier to medical students recognizing medical error is that they do not feel comfortable speaking up.
Medical students may not feel “empowered to bring up an error that's seen” with their supervisors. “That depends on whether or not there is a high degree of psychological safety that's been created for the team where they feel like they can bring something up,” she said. “When students are challenged about what to do, they should remember that they need to be the voice of the patient,” Dr. Dougherty added. “They have to see their role as helping a person. If you feel less comfortable asking questions, approach a situation with a level of curiosity. You say, ‘I'm curious as to whether this was noticed.’ Sometimes it is easier to ask a question that way.”
In the OSCE simulation, the medical error was embedded in tasks the students are expected to perform. The majority of medical students in the simulation missed the mistake.
“They cited a variety of issues for not catching it,” Dr. Dougherty said. “They have a lot of tasks to perform. They're in a in a new environment. They're doing new things. Sometimes they noticed it, but they felt like they were making the mistake.”
To counter those issues, Dr. Dougherty offered a few potential measures, such as letting the team you are working with know that you are unfamiliar with the environment or slowing down the tempo if possible.
“Be mindful of times that are vulnerable for errors,” she said. You can say: OK, I right now have a lot of things happening, I need to recheck what I'm doing. A lot of it has to do to with slowing down and pausing and recognizing that they're in a very complex environment. It's important to be efficient, but you need to do things well.
As far as medical students not trusting their own judgment, Dr. Dougherty said it’s a common theme that needs to be overcome throughout medical training.
“Early on in our learning, we question ourselves, we have impostor syndrome,” she said. “We don't think we're doing the right thing, but it’s about trusting that they do have the skills and the knowledge that this is building off—foundational concepts that they have learned from day one and trusting that they could be accurate in picking something up.”
Students who took part in the OSCE expressed greater confidence in their ability to work with a supervisor to disclose a medical error to patients upon completing the exercise.
“They felt very comfortable introducing the topic, asking permission, creating the setting and apologizing,” Dr. Dougherty said.
If you are going to talk with patients, you also need to share a proactive plan, and students were caught off guard by that.
“They did struggle with sharing what was going to be done immediately to address the error and how they were going to change, what they were going to do kind of in a in a broader sense to make sure that an error like this didn't happen. Those are two key things that patients really want to hear, which is what are you going to do to immediately fix this and how are you going to make sure it never happens again.”
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