Objective The purpose of this study is to co-evaluate resident technical errors and decision-making capabilities during placement of a subclavian central venous catheter (CVC). We hypothesize that there will be significant correlations between scenario based decision making skills, and technical proficiency in central line insertion. We also predict residents will have problems in anticipating common difficulties and generating solutions associated with line placement. Design Participants were asked to insert a subclavian central line on a simulator. After completion, residents were presented with a real life patient photograph depicting CVC placement and asked to anticipate difficulties and generate solutions. Error rates were analyzed using chi-square tests and a 5% expected error rate. Correlations were sought by comparing technical errors and scenario based decision making. Setting This study was carried out at seven tertiary care centers. Participants Study participants (N=46) consisted of largely first year research residents that could be followed longitudinally. Second year research and clinical residents were not excluded. Results Six checklist errors were committed more often than anticipated. Residents performed an average of 1.9 errors, significantly more than the 1 error, at most, per person expected (t(44)=3.82, p<.001). The most common error was performance of the procedure steps in the wrong order (28.5%, P<.001). Some of the residents (24%) had no errors, 30% committed one error, and 46 % committed more than one error. The number of technical errors committed negatively correlated with the total number of commonly identified difficulties and generated solutions (r(33)= −.429, p=.021, r(33)= −.383, p=.044 respectively). Conclusions Almost half of the surgical residents committed multiple errors while performing subclavian CVC placement. The correlation between technical errors and decision making skills suggests a critical need to train residents in both technique and error management. ACGME Competencies Medical Knowledge, Practice Based Learning and Improvement, Systems Based Practice

Introduction Urinary catheter insertion is a common procedure performed in hospitals. Improper catheterization can lead to unnecessary catheter associated urinary tract infections and urethral trauma, increasing patient morbidity. To prevent such complications, guidelines were created on how to insert and troubleshoot urinary catheters. As nurses have an increasing responsibility for catheter placement, resident responsibility has shifted to more complex scenarios. This study examines the clinical decision making skills of surgical residents during simulated urinary catheter scenarios. We hypothesize that during urinary catheterization, residents will make inconsistent decisions relating to catheter choices and clinical presentations. Methods Forty-five general surgery residents (PGY 2–4) in Midwest training programs were presented with three of four urinary catheter scenarios of varying difficulty. Residents were allowed 15 minutes to complete the scenarios with five different urinary catheter choices. A Chi Square test was performed to examine the relation between initial and subsequent catheter choices and to evaluate for consistency of decision making for each scenario. Results 82% of residents performed scenario A; 49% performed scenario B; 64% performed scenario C and 82% performed scenario D. For initial attempt for scenario A–C, the 16 French Foley catheter was the most common choice (38%, 54%, 50%, p’s<.001), whereas for scenario D, the 16 French Coude was the most common choice (37%, p<.01). Residents were most likely to be successful in achieving urine output in the initial catheterization attempt (p<.001). Chi-Square analyses showed no relationship between residents’ first and subsequent catheter choices for each scenario (p’s >.05). Conclusion Evaluation of clinical decision making shows initial catheter choice may have been deliberate based on patient background, as evidenced by the most popular choice in scenario D. Analyses of subsequent choices in each of the catheterization models reveal inconsistency. These findings suggest a possible lack of competence or training in clinical decision making with regards to urinary catheter choices in residents.

The residents did not perform as well as they anticipated when presented with more complicated bladder catheterization scenarios. Simulation can be used to identify and expose potential errors that may occur during complex presentations of basic procedures. This type of training and assessment may facilitate mastery.

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