Animated stories of medical error as a means of teaching undergraduates patient safety: an evaluation study

The need to emphasize patient safety within undergraduate medical curricula has been advocated by regulatory bodies across the world, including the World Health Organization [1]. Yet, a recent systematic review of undergraduate curricula found a lack of research addressing teaching interventions in this area [2].

To date, efforts to improve patient safety education have tended to adopt a systems-level approach [3]. In a professional context, some redress to this ‘top-down’ approach has materialized with the dissemination of Schwartz Centre Rounds, whereby healthcare providers share experiences from difficult cases to enhance the personal connections they make with colleagues and patients [4]. However, the use of storytelling for the specific purpose of disseminating learning from medical error remains underexplored, representing a significant missed learning opportunity as evidence from the field of applied psychology suggests learning from stories of error is more effective than learning from perfect examples [5].

A purely systems-based approach to medical error also discounts the potential for narrative to effect desirable behaviour change. Evidence from social sciences supports the power of stories in challenging preconceived beliefs versus the use of statistics alone [6] and mounting evidence has demonstrated the successful application of ‘narrative interventions’ to effect health behaviour changes [7]. One article describes how in a sample of 404 ‘college-age’ women, those exposed to expert-peer narrative videos about human papilloma virus vaccination were twice as likely to have sought out vaccination at 2 months compared with controls [8]. Its application in healthcare education has also been documented; a systematic review of digital storytelling for healthcare professions finds an ‘eclectic’ range of purposes for this approach, with the majority of studies identified applied in a nursing context [9]. This review found evidence of self-reported learning and behaviour change but highlighted the need for further research in the use and impact of digital storytelling in healthcare education and noted a minority of studies explored this approach in medical cohorts [9].

This study sought to explore innovative means of disseminating experiential insights from cases of medical error to undergraduates in a ‘Storytelling’ format. Owing to shame often associated with medical error, [10] it was recognized it would be challenging to recruit speakers. As such, the medium of animation was considered; educational research has highlighted its capacity to ‘allow visualization of subjects and scenes that could never be captured on camera’ [11].

It was hypothesized stories of medical error could facilitate learning about patient safety and that animated videos could allow a large audience to be reached whilst promoting engagement.

The primary objective was to evaluate to what extent hearing personal stories of medical error impacts on medical students’ reactions, perceptions and beliefs about patient safety, with a secondary objective to evaluate the impact of animation on communicating stories of medical error to medical students.

A total of 104 students out of the 200 who attended the sessions completed the evaluative questionnaire and 83 provided free-textbox feedback.

Mirroring disparate applications of allegorical approaches in healthcare, [7, 8] this study confirmed that undergraduate learners respond positively to personal stories of medical error, as a means of learning about patient safety. The use of animation served to enhance engagement and comprehension.

Key benefits demonstrated of the storytelling approach included its ability to engage learners and its potential to impact behaviours. These findings may be explained by Rose et al.’s [15] conclusions, in their meta-narrative review of storytelling in healthcare, that stories aid sense-making and ‘are uniquely primed to elicit empathy and compassion.’ The emotional impact of the stories may be key to their influence. A literature review examining the role of emotion in learning and transfer of clinical skills found ‘emotion influences how individuals identify and perceive information, how they interpret it, and how they act on the information’ [16]. Similarly, a review of digital story-telling in healthcare details examples where digital stories engender empathy to a particular subgroup and alter attitudes and behaviours [9]. The authors of this review describe examples of co-creation of stories between healthcare professionals and patients, [9] and particularly in the setting of patient safety, the inclusion of patient voices may enrich narrative-based learning.

As with practising clinicians, [10] an important finding from the study was the positive response of medical students to open, constructive discussion of error. Exposing students to clinicians speaking about mistakes may stand to enculture an attitude of openness before entering clinical practice where students risk acquiring negative behaviours for dealing with error [17]. Again, the narrative approach, using near-peers, may have heightened the impact of discussing and reflecting on error by facilitating a form of role-modelling [18]. Small group sizes, skilled facilitated discussion and use of near-peer experiences may help ensure such sessions achieve reflection and learning.

As demonstrated in this study, animation videos represent a powerful medium for communicating stories of medical error to wider audiences. Removing the need for the presence of a clinician circumvents the challenge of recruiting speakers from within a culture that is struggling to enact principles of candour [10] and may allow greater openness and more objective deconstruction of cases of medical error. One key advantage of using animation was its ability to engage learners and aid comprehension. Within the literature, studies have mainly focused on animation as a tool for patient education and have been shown to be an effective means of distilling complex information [19, 20]. For example, Hermann [20] randomized patients undergoing thyroidectomy to either receive written information or a 3D computer animation, prior to the surgery, explaining the procedure and possible complications. Understanding of the procedure and complications as well as trust in the treatment was significantly better in the group who watched the animation [20]. Analogously, the positive response to the animated videos in this study may reflect their ability to encourage learners to visualize the complexities of the clinical environment.

In contrast to a dominant focus on systems-level teaching in patient safety, this evaluative study confirmed that undergraduate students consider personal stories of medical error from near-peers an engaging and effective means of learning about patient safety. The use of animation served to enhance the storytelling approach. Further exploration would need to be undertaken to examine if similar sessions could improve safety behaviours in practice.