Use of simulation to assess incoming interns’ recognition of opportunities to choose wisely

Intern Characteristics

One hundred twenty-five entering PGY1 interns participated in the simulation, representing 60 medical schools and 7 different specialty groups (Table 2). Thirty-five percent (44/125) were graduates from “Top 30” medical schools, and 8.8% (11/125) graduated from our own institution. Seventy-four percent (89/121) had received prior hospital safety training during medical school, and 62.9% (56/89) were satisfied with their training. A majority of interns (64.2%, 79/123) felt confident in their ability to identify potential hazards in a hospital setting, although confidence was much higher among those with prior safety training (71.9%, 64/89) compared to those without prior training or who were unsure about their training (40.6%, 13/32; P = .09, t test).

Identification of Hazards

The mean percentage of hazards correctly identified by interns during the simulation was 50.4% (standard deviation [SD] 11.8%), with a normal distribution (Figure 1). Interns identified a significantly lower percentage of low-value hazards than safety hazards in the simulation (mean 19.2% [SD 18.6%] vs 66.0% [SD 16.0%], respectively; P < .001, paired t test). Interns also identified significantly more room-based errors than chart-based errors (mean 58.6% [SD 13.4%] vs 9.6% [SD 19.8%], respectively; P < .001, paired t test). The 3 most commonly identified hazards were unavailability of hand hygiene (120/125, 96.0%), presence of latex gloves despite the patient’s allergy (111/125, 88.8%), and fall risk due to the lowered bed rail (107/125, 85.6%). More than half of interns identified the incorrect name on the patient’s wristband and IV bag (91/125, 72.8%), a lack of isolation precautions (90/125, 72.0%), administration of penicillin despite the patient’s allergy (67/125, 53.6%), and unnecessary restraints (64/125, 51.2%). Less than half of interns identified the wrong medication being administered (50/125, 40.0%), unnecessary Foley catheter (25/125, 20.0%), and absence of venous thromboembolism (VTE) prophylaxis (24/125, 19.2%). Few interns identified the unnecessary blood transfusion (7/125, 5.6%), and no one identified the unnecessary stress ulcer prophylaxis (0/125, 0.0%; Figure 2).

Predictors of Hazard Identification

Interns who self-reported as confident in their ability to identify hazards were not any more likely to correctly identify hazards than those who were not confident (50.9% overall hazard identification vs 49.6%, respectively; P = .56, t test). Interns entering into less procedural-intensive specialties identified significantly more safety hazards than those entering highly procedural-intensive specialties (mean 69.1% [SD 16.9%] vs 61.8% [SD 13.7%], respectively; P = .01, t test). However, there was no statistically significant difference in their identification of low-value hazards (mean 19.8% [SD 18.3%] for less procedural-intensive vs 18.4% [SD 19.1%] for highly procedural-intensive; P = .68, t test). There was no statistically significant difference in hazard identification among graduates of “Top 30” medical schools or graduates of our own institution. Prior hospital safety training had no significant impact on interns’ ability to identify safety or low-value hazards. Overall, interns who were satisfied with their prior training identified a mean of 51.8% of hazards present (SD 11.8%), interns who were not satisfied with their prior training identified 51.5% (SD 12.7%), interns with no prior training identified 48.7% (SD 11.7%), and interns who were unsure about their prior training identified 47.4% (SD 11.5%) [F(3,117) = .79; P = .51, ANOVA]. There was also no significant association between prior training and the identification of any one of the 12 specific hazards (chi-square tests, all P values > .1).

Intern Feedback and Follow-Up Survey

Debriefing revealed that most interns passively assumed the patient’s chart was correct and did not think they should question the patient’s current care regimen. For example, many interns commented that they did not think to consider the patient’s blood transfusion as unnecessary, even though they were aware of the recommended hemoglobin cutoffs for stable patients.

Interns also provided formal feedback on the simulation through open-ended comments on their ScanTron^TM (Tustin, CA) form. For example, one intern wrote that they would “inherently approach every patient room ‘looking’ for safety issues, probably directly because of this exercise.” Another commented that the simulation was “more difficult than I expected, but very necessary to facilitate discussion and learning.” One intern wrote that “I wish I had done this earlier in my career.”

Ninety-six percent of participating interns (120/125) completed an online follow-up survey 1 month after beginning internship. In the survey, 68.9% (82/119) of interns indicated they were more aware of how to identify potential hazards facing hospitalized patients as a result of the simulation. Furthermore, 52.1% (62/119) of interns had taken action during internship to reduce a potential hazard that was present in the simulation.

While many GME orientations include simulation and safety training, this study is the first of its kind to incorporate low-value care from Choosing Wisely™ recommendations into simulated training. It is concerning that interns identified significantly fewer low-value hazards than safety hazards in the simulation. In some cases, no interns identified the low-value hazard. For example, while almost all interns identified the hand hygiene hazard, not one could identify the unnecessary stress ulcer prophylaxis. Furthermore, interns who self-reported as confident in their ability to identify hazards did not perform any better in the simulation. Interns entering less procedural-intensive specialties identified more safety hazards overall.