Effectiveness of room-of-error interventions for healthcare providers: a systematic review

Patient safety incidents account for a significant percentage of patient deaths [1], and preventing such incidents is a matter of grave concern for the healthcare system [2]. To become healthcare professionals, nursing students must learn how to manage potential patient safety incidents in clinical settings to reduce medical malpractice cases. However, clinical rotations offer students limited opportunities for hands-on experience in making decisions and directly addressing problems through effective communication and collaboration within the healthcare team [3].

The room-of-error (RFE) education program is a case-based educational program grounded in scenarios that encompass various medical errors that commonly occur in nursing practice. It allows nursing students to practice identifying and resolving medication or procedural errors within the given timeframe [4]. Through this approach, nursing students are exposed to potential problems that can occur in real-life situations with their groups and learn teamwork and communication skills. They can apply nursing interventions without causing actual harm to patients and engage in repeated learning through trial and error [5]. Moreover, studies have reported that a double-check approach, in which two individuals are paired for cross-checking, is more effective at detecting errors in real-life situations than a single-check method, in which only one individual makes the judgments [6]. Therefore, applying the knowledge acquired through such a case-based college curriculum to actual clinical practice can enhance not only knowledge and self-confidence but also practical competencies, fostering students’ abilities to provide high-quality nursing care [6].

In recent years, nursing education has increasingly utilized various forms of case-based teaching, gaining attention as an innovative alternative to address the limitations of clinical practicums. Notably, research on the RFE program has been expanding. However, a wide range of teaching methods, including lectures, simulations, debriefings, and role-playing, has been employed, potentially leading to inconsistent educational outcomes. Most programs emphasize error detection by nurses while also considering factors such as academic goals, learner characteristics, and the learning environment [7‐9]. Nevertheless, the impact of these varying teaching methods on learning outcomes remains unclear. This study aims to address this critical research gap by clarifying whether it seeks to resolve these differences or document them to provide a clearer understanding. To this end, we will conduct a comprehensive review of existing research and explore the context, mechanisms, and outcomes (CMOs) of RFE training programs designed for healthcare professionals and students. Furthermore, we plan to identify the facilitators and barriers to designing an error detection program based on real-life cases, using case-based learning (CBL) to help students apply theory to practice and develop critical thinking and problem-solving skills. The findings are expected to be useful for developing educational approaches for patient safety-related nursing education and as foundational data for practical education that assists nursing students and nursing professionals in adjusting to clinical practice.

This study is intended to (1) identify the CMOs of RFE training programs offered to healthcare practitioners (staff and students) and (2) apply these CMO configurations in explaining the successes and/or failures of these RFE training programs.

This systematic review study seeks to identify the CMOs of RFE education for healthcare providers. It was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines [7]. Two researchers independently performed literature selection, exclusion, data extraction, and data analysis, and disagreements between the two were resolved through discussion to finalize the selections.

This study conducted a systematic review to analyze the trends in RFE education programs that are aimed at promoting patient safety by analyzing the CMOs of RFE education programs for healthcare providers. A total of 2,447 studies were searched from the databases, and eight studies met the inclusion and exclusion criteria and were chosen for the analysis.

Most of the studies were published in or after 2015, indicating a growing interest in RFE education in recent years. It has also been shown that most RFE education programs were delivered to nurses. This can be attributed to the close involvement of nurses in continuously monitoring and predicting patient status as part of patient care [11]. In particular, RFE education for nurses predominantly addressed medication-related errors. This is understandable, as medication errors are the most common errors encountered by nurses, and nurses have the final opportunity to prevent errors throughout the entire process of prescription, preparation, and administration [12].

RFE programs were delivered in an environment with preset error scenarios. All eight studies (100%) used simulation-based education, with four studies (50.0%) incorporating prebriefing and three studies (37.5%) including debriefing. Simulation allows instructors to create desired scenarios without causing actual harm to patients and enables repeated learning [5]. Moreover, learners undergo situational awareness training during simulations, so simulations were most commonly chosen as the most appropriate approach for RFE education, where students detect and correct errors in a virtual error scenario.

As proposed by simulation theory [13], the outcomes of situation education include knowledge, skill performance, satisfaction, critical thinking, and self-confidence. Among the included studies, eight studies (100.0%) measured skills and critical thinking as the expected outcomes of RFE education, with three studies (37.5%) and one study (12.5%) also measuring satisfaction and knowledge, respectively. Given the nature of RFE education, trying to detect errors is expected to cultivate critical thinking, while efforts to correct and prevent the recognized error or risk are expected to enhance skill performance such as safe medication [15, 20], accurate application of medical devices [19‐20].

In terms of the content of RFE education, medication administration was the most common (five studies, 62.5%), followed by infection control (two studies, 25.0%), safe surgical procedure (one study, 12.5%), pressure injuries (one study, 12.5%), and falls (one study, 12.5%). These are pertinent to major patient safety incidents as proposed by the IPSG(International Patient Safety Goal) of JCI [14], and preventing risky situations is of utmost importance to enhancing the quality of patient care.

The findings of this study furnish foundational data for the pragmatic implementation of RFE education in clinical settings, thereby augmenting patient safety. It is anticipated that these findings will serve as the foundation for the broader application of RFE programs, catalyzing further investigative endeavors within practical healthcare domains. The CMOs delineated in this study offer a nuanced understanding conducive to the judicious integration of RFE education within authentic clinical scenarios. The proposition for standardized RFE education programs positions them as a structured and consistent approach applicable across diverse healthcare institutions.

This study advocates for the utilization of RFE programs beyond the educational realm, emphasizing their potential impact on tangible patient care practices. By highlighting the pivotal role of nurses in ensuring patient safety, this study propels the notion of interprofessional collaboration. It advocates for the integration of RFE programs to foster collaborative efforts among diverse healthcare providers, ultimately contributing to creating a comprehensive and integrated approach to patient care. Finally, it underscores the need for further research within practical fields, considering the dynamic nature of healthcare environments.

Overall, this study not only elucidates the efficacy of RFE education but also serves as a scholarly impetus for the practical implementation, ongoing investigation, and perpetual refinement of patient safety protocols within the healthcare milieu. In this study, most of the ‘detection of errors’ were the outcome variable of RFE. However, the studies included had different methods of ‘detection of errors’ (e.g., the number of errors, the time it takes to find errors). Because of the heterogeneity of these studies, the effectiveness of RFE could not be verified. Therefore, it is necessary to standardize RFE education methods and outcome variables. Future meta-analyses should utilize rigorous evaluation methodologies, considering that the effectiveness of RFE programs for elevating patient safety standards must be assessed continuously.

This study’s significance lies in its evaluation of the current level of research on RFE education programs, a promising educational approach for promoting the safety and quality of patient care in healthcare settings. Nevertheless, this study had a few limitations. First, we only analyzed articles derived from online databases. Second, we only included studies published in English and Korean, the main languages of the researchers. Thus, the findings of our study must be interpreted with caution.

Our review of RFE education highlights the key role of nurses in promoting patient safety within healthcare facilities and their suitability for RFE education. However, nurses alone cannot prevent medical errors. Therefore, it is important to develop RFE programs that involve various healthcare providers who share the common goal of patient safety through interprofessional education. Additionally, interprofessional RFE programs should extend beyond medication errors to encompass a variety of error prevention scenarios, and additional RFE education initiatives are needed to establish standardized RFE education programs. The standardized interprofessional RFE curriculum needs to be included in the nursing accreditation program as an essential curriculum for nursing education. If the curriculum accumulated, it would help develop guidelines for customizing interprofessional RFE content to institutional needs. Overall, this study not only sheds light on the effectiveness of RFE education but also catalyzes its practical application and the continuous improvement of patient safety practices in healthcare settings.