Assessing System Thinking in Senior Pharmacy Students Using the Innovative "Horror Room" Simulation Setting: A Cross-Sectional Survey of a Non-Technical Skill.

System thinking is an important competency for all healthcare professionals as it is a required skill to provide safe patient care. However, the literature does not describe how students gain such a skill or the manner in which it is assessed. Purpose: This study aimed to assess pharmacy students' non-technical skills in the form of system thinking and error detection in a simulated setting. Results were correlated with the number of errors students were able to identify in a team-based simulation activity called the "horror room." Patients and methods: A cross-sectional survey was administered after completion of the "horror room" simulation activity to identify elements of system thinking and error detection. Survey respondents were senior students enrolled in a patient safety course. System thinking elements identified in the survey were then linked to the number of errors reported. Results: Sixty-six students participated in the activity. Their mean grade point average (GPA) was 4.72 (standard deviation (SD) 0.22), and the mean number of errors detected was 8 (SD 2). The average total system thinking score (STS) was 68 (SD 8.4). There was no association between the number of errors detected and STS; however, a positive association was found between GPA and STS (Spearman's correlation coefficient = 0.27, p = 0.030). The most common type of error detected was a medication safety error (100%). Conclusions: High STS showed that teaching theory is important for students to learn concepts; however, knowing the ideas associated with system thinking does not necessarily translate into practice, as evidenced by the low number of errors students were able to detect.