Exploring error in team-based acute care scenarios: an observational study from the United kingdom

To investigate the errors made by junior doctors (first year after primary medical qualification) in simulated acute care settings, using (and, for some purposes, amplifying) a previously published generic error-modeling system (GEMS). Possible error types were skill-based slips and lapses, rule-based mistakes, knowledge-based mistakes, and violations.

In August 2010, 38 junior doctors participated in high-fidelity simulated acute care scenarios in NHS Lothian, Scotland. Each video-recorded scenario was immediately followed by an audio-recorded debrief that encouraged articulation of underlying cognitive processes. Two researchers used evidence from the scenario, debrief, and field notes to determine which errors were attributable to a single underlying cause. In such cases, the errors were coded by template analysis into the GEMS framework. Errors for which a single cause could be identified but which did not fit the framework were coded inductively.

A total of 243 errors were identified, with sufficient evidence available to identify a single cause in 190. Skill-based slips and lapses, rule-based mistakes, and knowledge-based mistakes were all clearly identified within the data. Two error types not originally included in the GEMS framework were identified: compound errors and submission errors.

Amplification of GEMS provides a valid framework for categorization of the errors made by junior doctors in simulated acute care contexts. In addition, the amplified framework may be transferable to other, team-based contexts. An improved understanding of the knowledge and skills that are most vulnerable to each specific type of error will allow tailored educational strategies to be developed.