Mistakes happen. After all, we’re humans, not robots. But for medical professionals, a single mistake — however small — can cost someone their life. Human error in the medical field results in an estimated 250,000 deaths and costs nearly $20 billion annually. This data differs from the Center for Disease Control and Prevention’s more conservative estimate (98,000 deaths). Even more, since the COVID-19 pandemic began, the 31% reduction in average central line-associated bloodstream infections (CLABSI) was reversed, and U.S. hospitals also saw an increase in catheter-associated urinary tract infections, ventilator-associated events, and methicillin-resistant Staphylococcus aureus bacteremia (Fleisher, et al., 2022). Despite best efforts, medical error rates are on the rise. So, how do organizations address the third most common cause of avoidable death in the U.S.?
Organizations know that hefty fees and penalties incur as a result of medical error. They also know the heavy emotional burden their healthcare professionals endure in the wake of an error. Evidence suggests clearly defined guidelines and policies can reduce medical error rates in hospitals. However, just as humans are prone to errors, the human mind is also prone to forgetting. As German philosopher Herman Ebbinghaus discovered in his late 19th century psychology studies, the nature of human forgetting can be illustrated through a curve. Memory rapidly degrades as soon as hours to a day after learning, and retention fades to about 20% after 30 days. However, certain learning strategies can disrupt this curve, improving retention of important information, as in the case of patient safety training. Therefore, coupling error prevention guidelines and policies with a way to offer continuous learning is a uniquely effective way to reduce errors.
For example, CLABSIs are often preventable, and rates can be reduced, if not eliminated, by adherence to evidence-based patient safety guidelines. One hospital in a large Colorado healthcare system was selected to pilot the idea that CLABSIs could be addressed with training. After implementing Amplifire’s online learning platform, they experienced a 79% reduction in CLABSIs. A reduction of this magnitude has a profound effect on patient wellbeing.
By implementing rigorous patient safety guidelines and policies as part of a larger “safety culture” and reinforcing them with an online learning solution that makes learning stick, organizations can tangibly achieve better patient outcomes and help their people reach their highest potential. Here’s how.
Creating a patient safety training program
While mistakes are a part of life, the stakes are higher in healthcare. In working to eradicate medical error, organizations are maintaining a culture of safety, based on clearly defined patient safety guidelines and policies, as well as establishing an effective learning solution to continuously fortify patient safety initiatives.
A culture of safety promotes the use of the Joint Commission Patient Safety Goals that supports institutions and healthcare professionals to create the safest environment for patients and providers. However, the Joint Commision’s guidelines are extensive, and the human brain is designed to naturally forget some things over time. Moreover, organizations often have their own policies and guidelines around patient safety and error protocol. So, as organizations strive to create a safety culture, they should also prioritize learning as well. Continuous training can help solidify these guidelines and policies and keep them fresh in employees’ minds.
Typically, training can be costly and time consuming. Training can also be ineffective if not implemented properly, or if it’s not personalized to learners’ prior knowledge. Guidelines and policies are not always the most exciting material to review, which is why non-engaging training won’t stick with learners, leaving safety culture efforts fruitless. When the stakes are high, introducing a training program that actively engages learners and makes learning stick is critical.
Confidence as a precursor to action
There are two main types of error. The first type of error is error of omission occur as a result of actions not taken. This can be remedied by continuous training. Information remains fresh in the minds of employees throughout their work, helping to combat any knowledge gaps, uncertainty, or stale practices that exist.
The second type of error is error of commission which occurs as a result of the wrong action taken. Because this type of error stems from an action, it indicates a particular type of cognitive risk exists in the minds of employees: confidently held misinformation (CHM). CHM is when a person believes they are correct when they are in fact wrong. CHM is particularly dangerous because it’s invisible until an active mistake has been made.
The world’s leading cognitive scientists recognized the real-world significance of this mental phenomenon, and their research is put to work in Amplifire’s adaptive learning platform. It finds and fixes CHM before mistakes happen. Where CHM would previously be invisible, Amplifire exposes it. Where there would eventually be a costly error from this CHM, the platform intervenes.
At a multi-hospital healthcare system, 2,385 physicians received an Amplifire course on safety in three modules: Safety Science, Culture of Safety, and Solving Safety Concerns. Amplifire discovered that nearly all of the physicians had some CHM or uncertainty in their knowledge base — which is concerning, but not necessarily surprising, since physicians are prone to mistakes, too. The special part of this training is that it spared these employees from potentially making a mistake — and preventing potential patient harm — based on that false information.
Recognizing CHM as a risk factor is a proactive way to prevent medical error, just as is creating a culture of safety and learning from clearly defined guidelines and policies. But not all training methods to execute these safety initiatives are created equally.
Patient safety training checklist
Amplifire’s platform not only detects and corrects knowledge gaps, instances of uncertainty, and misinformation, but it also does so in an adaptive, personalized manner that’s specific to each learner’s knowledge level. This degree of personalization is essential to creating a well-received culture of learning that respects employees’ time and expertise, while also ensuring everyone has the information they need to maintain the highest degree of safety. As an organization, there are qualities like time to completion, flexibility, and efficacy that factor into a training program’s viability.
Here are some features that made learning stick for healthcare employees at the multi-hospital healthcare system we mentioned above:
The Amplifire platform’s adaptive algorithm watches each learner’s starting levels of knowledge, uncertainty, and misinformation and adjusts which areas they need to focus on. The learning experience is rigorously personalized with adaptive functionality. It treats each learner as an individual with their own unique mix of mastery, misinformation, uncertainty, and information gaps so their learning time is used efficiently. By adapting to their knowledge level, trainees don’t waste time relearning things they already know. Instead, they spend more time only on subjects they demonstrate struggle with.
In the case of the healthcare system, it cut patient safety training from four hours to only 63 minutes. Learners also benefit from a virtual instructional coach, VIC, who encourages, cajoles, and prompts learners with guidance.
Brain science principles
Choosing a learning platform that uses science-based techniques is important not only because it makes learning more effective, but also because it is a better experience for the learner. The Amplifire platform is built on cutting-edge brain science discoveries from our Science Advisory Board (SAB) — some of the world’s leading experts in neuroscience and cognitive science. It is built to work with the way the mind naturally learns, so learners can spend less time learning and actually retain more than traditional methods.
Science-based learning is also a more engaging experience. Over twenty cognitive triggers — identified by the SAB — are coded into the platform to guide people on their personal path to mastery. Cognitive triggers such as priming, metacognition, feedback, spacing and more create a learning experience that has a gamification feel to it. Triggers increase learning and retention by switching specific brain circuits on so that it can be recalled at a future point in time. Some of the most effective triggers work by creating engagement through emotion and attention — two powerful influences on memory. These triggers have been identified to form rapid, long-lasting memory that sticks. And when learning sticks, employees perform better, and organizations prosper.
No need to start from scratch. Choose from (or modify) proven-effective courses developed by industry experts, members of Amplifire’s Healthcare Alliance — a collaborative group of health systems, hospitals, physicians, and nurses working to raise the bar on knowledge, judgment, and performance.
Some courses include:
- CAUTI Prevention
- CLABSI Prevention
- Sepsis: Recognizing and Managing
- Patient Safety – Science of Safety, Culture of Safety, Solving Safety Concerns
- Preventing Patient Falls
- Prevention of Pressure Injuries
- And more
Data is good, but actionable data is better. Amplifire reveals where individuals struggle and with what topics. This specific information can help instructors or team leaders intervene for at-the-elbow coaching. For example, in the case of the Colorado health system, implementing patient safety courses with Amplifire, all physicians showed CHM or uncertainty, but there was a wide variation in degree. Most learned quickly, but others needed more support. For individuals who struggled to learn, Amplifire generated individual action plans.
Depending on how many people struggle with certain questions, it can also help inform learning and development teams’ content strategy. If certain questions just aren’t landing with learners, it may be time to reconsider the question content.
Training comes full circle when organizations can also use learning data to see evidence of mastery when their people complete Amplifire courses, ensuring they can operate to the highest standards. This is how the quality of a trainee’s learning experience is directly correlated to your organization’s success. Every detail matters when lives are at stake, too. Amplifire’s platform helps you ensure their learning experience is positive and effective, so everyone wins.
By the end of training, all physicians that completed the Amplifire courses demonstrated 100% proficiency. And while we can’t generate a concrete metric to illustrate what errors would have been made but weren’t, the system was able to achieve tangible training results in less time for more physicians.
Amplifire helps organizations achieve patient safety goals by showing leaders how knowledge is arrayed in the minds of employees. This highest degree of transparency is not possible without the data analytics from Amplifire’s adaptive learning platform. Without the ability to see what’s really going on, organizations, healthcare professionals, and patients are at risk for preventable errors.