Background

Patient safety is the prevention of errors and adverse effects to patients associated with healthcare.1 In recent years, a clear direction has been set by the General Medical Council (GMC) and Health Education England to prioritise education and training as the means to improve patient safety across healthcare systems (compare the evolution of the GMC’s Outcomes for Graduates between 2015 and 2018.).2–4  Training doctors to make patient safety their highest priority is at the core of the GMC’s Promoting Excellence for Medical Education and training standards: ‘Just as good medical students and doctors make the care of their patients their first concern, so must the organisations that educate and train medical students and doctors’.5

Closely aligned is the concept of ‘human factors’, defined in healthcare as ‘enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings’.6 Human factors aid understanding of why error occurs and reduces the likelihood of future error through quality improvement and system redesign.7 An understanding of human factors is necessary for doctors to practise safely and allows professional development through participation in quality improvement activity.2 8 Understanding human factors is important for the shift in perspective it engenders as much as the theory taught—to understand error at a system rather than an individual level.9 10 Organisational efforts to improve patient safety using human factors principles are more effective if staff from all groups and levels of seniority are able to contribute, including medical students and newly qualified doctors.11–13

Problem

The WHO identifies 11 topics for patient safety curricula, including human factors, teamwork and communication.8 However, providing effective teaching to medical students can be difficult. Institutions can be slow to adapt to changing expectations of undergraduate curricula. Barriers to teaching patient safety include finding educators with the requisite expertise, enthusiasm and willingness to be open about their own experience, as well as the need to meaningfully integrate the subject into a busy curriculum.8 14 Another challenge is making the subject relevant to students, who may not yet recognise its importance to future practice.14 15

Consequently, curricula, teaching methods and time allotted to patient safety vary between institutions, with traditional classroom teaching remaining the most common approach.4 16 17 The soft skills required to contribute to improving patient safety are often assumed rather than explicitly taught, and students are not given opportunities to develop communication and teamwork skills.18 Though this variation is not unique to patient safety, it contributes to new graduates lacking confidence in their knowledge and skills and feeling unable to contribute to patient safety improvement.14 19

Some institutions have demonstrated success using experiential learning methods to engage students.15 20–22 Experiential learning presents learners with new experiences, encourages reflection on those experiences and conceptualises them into new ideas, which can be tested in the world.23 It facilitates rather than instructs, encourages learner autonomy and allows students to test and apply knowledge in practice.24 Experiential learning methods have proven effective for teaching patient safety; they are favourably received and impart knowledge which can be applied in the workplace.25

The highest-profile experiential learning intervention in healthcare is simulation—allowing learners to master skills in a risk-free environment by creating experiences designed to mimic real clinical encounters.26 27 However, simulation is often perceived as inaccessible due to cost or reliance on technology.4 In fact, simulation is most effective not when it succeeds in recreating a physical environment, but when the skills required to succeed in a task are faithfully reproduced.27

Method

We sought to overcome some of these challenges with a low-tech, low-cost, but engaging simulation through gamification of learning. This application of game design principles to learning increases immersion in the learning environment and participants’ engagement with concepts being taught, which in turn improves the learning experience.28 29 This approach has other benefits: games which encourage active participation and collaboration to achieve shared objectives build teamwork and communication skills.30 We aimed to create a learning environment which gaveto give students an appreciation of how the skills being taught are used in clinical settings to promote patient safety. We did this by creating an escape room.

Escape rooms are live-action team-based games where players work together to discover clues, solve puzzles and accomplish tasks to achieve a specific goal in limited time. Games are often set in fictional locations, incorporating storytelling elements to motivate players as the game progresses. Participation in escape rooms increases teamwork among clinicians.31 Adapting the escape room format for clinical scenarios is effective for teaching clinical skills due to the active participation required to complete tasks and ‘win’ the game.32–34 In this sense, escape rooms are simulations which aspire not to physical fidelity with the system being reproduced but create a high degree of the psychological fidelity required for students to learn and apply their knowledge.27

We created a session as part of a specialty choice module in patient safety for third-year medical students, delivered jointly by Imperial College London and Imperial College Healthcare National Health Service Trust. The module was offered 3 times over 1 year on a first-come-first-served basis. It was delivered to 19 students in groups of 6 to 7. A £90 cost was incurred for materials.

In our portable, suitcase-based escape room students work together to solve a series of challenges in order to diagnose and treat a patient within a 30 minute time limit. Progressing through the escape room requires students to complete a series of clinical tasks: making a diagnosis; calculating a National Early Warning Score (NEWS); looking up treatment in the British National Formulary; completing a drug chart to prescribe medication—all contained within the suitcase. These are familiar concepts to third-year medical students, though this experience using them is likely their first. Students seek advice from a hospital registrar and are prompted to use the situation, background, assessment, recommendation (SBAR) structured communication tool to deliver an assessment of the patient’s condition. Correctly completing challenges allows students to progress through the scenario by obtaining a series of codes which open padlocks to suitcase compartments containing the next task. Codes entered incorrectly act as a source of feedback on ‘clinician error’. Students were not prevented from making errors during the game but were provided with feedback to help them self-correct, an important aspect of this type of learning.24 27 The escape room is won when the patient is treated without suffering avoidable harm.

Following the escape room, trainers facilitate an After Action Review (AAR) in which students are asked to reflect on their expectations of the escape room and compare these with the experience of taking part. AAR allows students to reflect as a group on their experience, explore the factors which contributed to their successful (or otherwise) progression through the game and identify their own learning points.35 Classroom teaching is used to recap clinical and communication tools, using learning points from the AAR to motivate the need for good teamwork and communication. Students receive an introduction to the principles of human factors in healthcare and are asked to consider the avoidable errors which may have occurred during the escape room as well as strategies to prevent these in the future.

Results

Students evaluated the session using a feedback form containing two outcome measures: ‘did you gain new knowledge, skills or insights today?’, and ‘how confident do you feel that you will be able to apply what you learnt today in the future?’ They were invited to comment on what they liked about the session, and what they would change.

All students (n=19) completed an evaluation form. The session was overwhelming positively received: 100% of students agreed or strongly agreed they gained new knowledge and skills and insights. 100% felt confident or very confident they would be able to apply what they had learnt in the future.

When asked what they liked about the session, every student chose the escape room, describing it as ‘really enjoyable’, ‘interactive and engaging’ and ‘a good way to think about emergency situations in a low-pressure environment’. Suggestions for improvement focused on the latter parts of the session, with a strong desire to maintain the interactivity and teamwork of the escape room.

Discussion

Participants’ positive reaction to the session and agreement it had helped them to learn in a way that could be applied in future shows the potential of escape rooms as an experiential learning tool for teaching patient safety and human factors to medical students. The desire to win the escape room helped to build intrinsic motivation for tasks being simulated, which in turn builds a connection with the subject matter. Making links between students’ experience in the escape room (including the experience of identifying and correcting errors) and the patient safety concepts being taught increased their appreciation of the importance of the subject.

The escape room has the potential to address the challenge identified in the literature of building students’ motivation for this subject and recognising its value to future practice. The need for participants to work together to succeed allows students to develop communication and team working skills—something identified as a limitation of classroom teaching. The opportunity to practice in a risk-free environment which simulates the thinking and skills of a real scenario was received favourably by participants, and the confidence students reported may mitigate concerns about participating in patient safety improvement in future.

Central to the success of this intervention is AAR. Without the opportunity to reflect and to bridge the gap between experience and the concepts being taught, we do not learn as effectively.23 Students responded positively to the escape room in part because they had structured time to debrief following their shared experience and to identify their learning points as a group. Opening the session with the escape room and AAR set an open, interactive tone to the session, and this made it easier to have more difficult conversations about human factors and clinician error later on.

Conclusion

Our findings are in line with existing evidence demonstrating the success of experiential learning interventions for teaching patient safety to medical students. Where the escape room has the potential to add value is the use of game elements to engage learners with the experience being recreated despite its simplicity as a simulation.

A more thorough evaluation of larger pilots is required to explore effectiveness in comparison with other teaching methods, including longitudinal follow-up of retention of knowledge and confidence gained. Adapting the intervention for practising clinicians would allow easier assessment using higher levels of Kirkpatrick’s framework, behavioural change in practice and impact on patient care.