The concept of errors in medical education: a scoping review

Abstract

The purpose of this scoping review was to explore how errors are conceptualized in medical education contexts by examining different error perspectives and practices. This review used a scoping methodology with a systematic search strategy to identify relevant studies, written in English, and published before January 2021. Four medical education journals (Medical Education, Advances in Health Science Education, Medical Teacher, and Academic Medicine) and four clinical journals (Journal of the American Medical Association, Journal of General Internal Medicine, Annals of Surgery, and British Medical Journal) were purposively selected. Data extraction was charted according to a data collection form. Of 1505 screened studies, 79 studies were included. Three overarching perspectives were identified: ‘understanding errors’) (n = 31), ‘avoiding errors’ (n = 25), ‘learning from errors’ (n = 23). Studies that aimed at’understanding errors’ used qualitative methods (19/31, 61.3%) and took place in the clinical setting (19/31, 61.3%), whereas studies that aimed at ‘avoiding errors’ and ‘learning from errors’ used quantitative methods (‘avoiding errors’: 20/25, 80%, and ‘learning from errors’: 16/23, 69.6%, p = 0.007) and took place in pre-clinical (14/25, 56%) and simulated settings (10/23, 43.5%), respectively (p < 0.001). The three perspectives differed significantly in terms of inclusion of educational theory: ‘Understanding errors’ studies 16.1% (5/31),’avoiding errors’ studies 48% (12/25), and ‘learning from errors’ studies 73.9% (17/23), p < 0.001. Errors in medical education and clinical practice are defined differently, which makes comparisons difficult. A uniform understanding is not necessarily a goal but improving transparency and clarity of how errors are currently conceptualized may improve our understanding of when, why, and how to use and learn from errors in the future.

Appendices

Appendix 1

Initial search performed on April 23rd, 2018, secondary search performed on May 8th, 2018, with the additional keyword: Omission. Third search performed on July 4th, 2018, and fourth and last search was performed on January 27th, 2021 before study submission.

Search strategy

Journals: Medical education journals.

Keywords and title/abstract search words: Error, Flaw, Mistake, Failure, Omission.

MESH search words; (OR) between each: Medical Errors, Medication Errors, Selection Bias, Truth Disclosure, Bias, Diagnostic Errors, Observer Variation, Knowledge of Results (Psychology), Guilt, Scientific Experimental Error.

((((("Medical teacher"[Journal]) OR (("Advances in health sciences education : theory and practice"[Journal]))) OR "Academic medicine : journal of the Association of American Medical Colleges"[Journal]) OR "Medical education"[Journal])) AND ((("Medical Errors"[Mesh] OR "Medication Errors"[Mesh] OR "Selection Bias"[Mesh] OR "Truth Disclosure"[Mesh] OR "Bias"[Mesh] OR "Diagnostic Errors"[Mesh] OR "Observer Variation"[Mesh] OR "Knowledge of Results (Psychology)"[Mesh] OR "Guilt"[Mesh] OR "Scientific Experimental Error"[Mesh])) OR (((((failure[Title/Abstract]) OR flaw[Title/Abstract]) OR mistake[Title/Abstract]) OR omission[Title/Abstract]) OR error[Title/Abstract])))

Journals: Clinical journals.

Title/abstract search words: Education, Learning.

Keywords: Error, Flaw, Mistake, Failure, Omission.

MESH search words; (OR) between each: Education, learning.

((((((("JAMA"[Journal]) OR "Journal of general internal medicine"[Journal]) OR "Annals of surgery"[Journal]) OR "British medical journal"[Journal])) AND (((Learning[Title/Abstract]) OR (("Education"[Mesh]) OR "Learning"[Mesh])) OR Education[Title/Abstract]))) AND ((("Medical Errors"[Mesh] OR "Medication Errors"[Mesh] OR "Selection Bias"[Mesh] OR "Truth Disclosure"[Mesh] OR "Bias"[Mesh] OR "Diagnostic Errors"[Mesh] OR "Observer Variation"[Mesh] OR "Knowledge of Results (Psychology)"[Mesh] OR "Guilt"[Mesh] OR "Scientific Experimental Error"[Mesh])) OR (((((failure[Title/Abstract]) OR flaw[Title/Abstract]) OR mistake[Title/Abstract]) OR omission[Title/Abstract]) OR error[Title/Abstract])))

See Appendix (Table 4)

Table 4 Study screening tool

Appendix 2: Data collection form

General data extraction
Manuscript ID
Authors
Title
Year of the study
Abstract
Journal
Rater initials (XX/XX)
Study score (Table 1, Appendix 1)

	Item no.	Checklist item	Comments
Baseline characteristics
Specific information	1a	Study objectives and study aim
Specific information	1b	Study context, general
		1) Study population (i.e. participants like patients, written cases etc.)
		Number of patients/cases
		2) Study settings:
		Clinical setting: E.g. use of patients, inclusion and exclusion criteria. Number of patients involved
		Simulated setting: E.g. use of an ultrasound virtual reality simulator. Information about simulated cases and how they were selected
		Pre-clinical study settings: E.g. interventions in classrooms, at courses or at lectures. Use of cadavers, animals or cases. Description of intervention
		Number of settings used:
		One setting
		Two settings
		More than two settings used
		Description of settings and location:
		Clinical study design, (e.g. at XX Department, XX Hospital, XX Country)
		Simulated study design, (e.g. at XX Academy, XX Hospital, XX Country)
		Basic science/pre-clinical design (e.g. at XX University, XX City, XX Country)
Specific information	1c	Study intervention
		(Might include one or more different types of interventions, e.g. skills training, simulation training, observation of a procedure, massed/distributed practice, independent training/dual practice or group practice)
Specific information	1d	Outcome measures
		a)Primarily
		b)Secondary
Specific information	1e	Study participants
		Number of study groups (e.g. one, two, or more than two)
		Number of participants in the intervention group
		Number of participants in the control group
Specific information	1f	Other relevant information (not already specified under ‘other relevant information’)
Error practices
The following information will be noted from included studies when provided
Other relevant information:	2a	Identification of theoretical framework
		E.g. Error-Management Theory,
		Self-Regulated-Learning,
		Explorative learning,
		Active learning
		No learning theory or concept used
Other relevant information	2b	Errors in performance
		(How are errors investigated and used in the evaluation of performance)
		Technical and non-technical errors
		Technical errors: errors that happened from equipment handling, unsystematic approach, or lack of handling overall performance
		Mechanical errors
		Procedural errors
		Action errors
		Coordination errors
		Non-technical errors: Includes errors in communication, and cognitive errors
		Cognitive errors: Misinterpretation of procedures, wrong identification of anatomical structures, or wrong conclusion and diagnoses
		Informational error
		Strategy errors
		Diagnostic errors
Other relevant information	2c	Errors in the assessment of participants:
		How are errors measured:
		Raters: E.g. assessment scoring scheme, protocols, golden standards, task related questions
		Simulation-based ratings: simulation-based feedback metrics (passed/failed)
		Assessment errors might fall into several groups like
		Systematic errors
		Random errors
		Measurement error
		Diagnostic errors
Other relevant information	2d	Errors with relevance to contextual factors
		Including e.g. different settings, different cultures, educational characteristics, study task and participants
		Clinical context: Description or definition of errors such as: Not handling the situation or problem correctly, not following standard procedure, not able to realize or recognize a problem, not able to set correct diagnoses, unable to correct an identified problem, or errors in communication between team members
		Errors might fall into several groups like
		Communication
		Diagnostic
		Procedures
		Clinical handling
		Simulated context: Description or definition of errors in the simulated environment, such as: Not handling the problem (assessment task) correctly, not passing tasks or subtasks, not able to set correct diagnoses, not completing or passing predefined learning points, using too much time to complete a task, or incorrect handling of simulated equipment
		Errors might fall into several groups like
		Equipment handling (e.g. motor)
		Diagnostic (e.g. cognitive)
		Procedures (e.g. technical)
		Different cultures: (e.g. North American, European, Asian etc.)
		Educational characteristics: E.g. Undergraduate or postgraduate interventions
		Study participants (e.g. patients, doctors, medical students etc.)
		Study task/object of interest: e.g. performed on simulated patients, or written cases, real patients, mannequins or phantoms
Other relevant information	2e	Errors in relations to the learner (novice, experienced, expert)
		Definition of level of the study participants: Definition of level of the study participants:
		Novices: Less than 6 months of experience
		Experienced learners: Between 6 months and 10 years of experience
		Experts: > 10 years of experience
		Errors might fall into several groups like
		Subjective reactions: Reflections, feelings, thoughts
		Objective reactions: Handling, corrections, outcome measures
Other relevant information	2f	Error modelling
		Role of errors in the study methodology
		1) Errors are a part of the methodology, and errors are included in the outcome measures (e.g. comparing errors or performances between groups)
		a)Primary outcomes: The main outcome is to evaluate errors’ effect on learning
		b)Secondary outcomes: Errors are not investigated as part of the primary outcome but are found to possess relevance to either the main outcome or to other study results (e.g. discussed accordingly to differences in performances) OR errors are included in secondary outcomes
Other relevant information	2 g	Kirkpatrick level