Simulating the ‘Horrors’ of Overuse

In 2015, the University of Chicago Medical Center launched what would become an annual tradition for incoming medical interns. Each year during orientation, faculty at the University of Chicago create a simulation of patient safety hazards that has earned the term “Room of Horrors.”

Within the “Room of Horrors”’—usually a spare inpatient room—lies a hospital bed, a dummy patient and an assortment of artificial patient information. The room and dummy patient are staged with various “horrors”—ranging from improper IV fluids to faulty bed-rail positioning.

In the exercise, medical interns are asked to identify as many potential hazards as possible. Although the simulation involves the usage of mannequins rather than real patients, it is directly applicable to the clinical setting.

“Interns are often given lectures on patient safety hazards, but the Room of Horrors enables interns to operationalize this knowledge in a way that lectures do not,” said Dr. Vineet Arora, a board-certified internist and member of the American Board of Internal Medicine Board of Directors.

This year’s simulation was composed of an additional component. After reviewing Choosing Wisely recommendations on low-value care, faculty members chose four of these recommendations to incorporate into the module, including those around curbing the usage of unnecessary restraints, Foley catheters, blood transfusions and stress ulcer prophylaxis. During the simulation, each intern was given 10 minutes to identify as many of these hazards as possible.

“Interns seemed to have a more difficult time identifying low-value hazards compared to patient safety hazards,” said Dr. Arora. “Interns said it was harder to think about stopping a treatment or procedure that had already been started by someone else.”

The findings from this exercise seem to suggest that while low-value hazards may be easy to identify on paper, recognizing these hazards in real life is more of a challenge. Many interns assumed that if a treatment, such as a blood transfusion, had been started that the rationale behind the procedure was probably accurate.

“Identifying instances of low-value care requires trainees to exercise their mental muscles, training them to think a certain way,” Dr. Arora said. “It gives new interns an opportunity to practice recognizing low-value care in a clinical setting and develop situational awareness of these patient safety issues.”

Incorporating simulations such as the Room of Horrors into medical education curricula is particularly important for this reason, especially if high-value care is the desired result.

Dr. Arora and her colleagues hope to analyze yearly trends in hazard identification as the Room of Horrors expands. The simulation has already been modified for pediatrics, and the team is exploring further expansion to operating and ambulatory settings in the future.

“Using an actual, physical representation of low-value hazards is what makes the experience so different,” says Dr. Jeanne Farnan, a specialist in hospital medicine. “Physicians are able to make low-value hazards more tangible to the learner, which increases permanence.”