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Asmaa F Sharif,1 Zeinab A Kasemy,2 Nada A Alquraishi,3 Kawther N Alshaikh,3 Anwar H Alfaraj,3 Eman A Alibrahim,3 Zainb M Alfarej,3 Hawra M Alawami,3 Fatma Alzahraa A Elkhamisy4,5 1Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt; 2Public Health and Community Medicine Department, Faculty of Medicine, Menoufia University, Shiben ElKoom, Egypt; 3College of Medicine, Dar Al-Uloom University, Riyadh, Kingdom of Saudi Arabia; 4Basic Medical Sciences Department, Faculty of Medicine, King Salman International University, South Sinai, Egypt; 5Pathology Department, Faculty of Medicine, Helwan University, Cairo, EgyptCorrespondence: Asmaa F Sharif, Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, 31527, Egypt, Tel +966 581639317, Email asmaa.sherif@med.tanta.edu.egPurpose: Team-based learning (TBL) is an interactive instructional strategy designed to enhance student engagement. Few studies reported that TBL needs to be more interactive, concerns were raised regarding the insufficient instructor feedback, and students feel that TBL gets less attractive with time. One method of boosting students’ interaction and performance is adding an element of challenge or positive stress. Therefore, we hypothesized that inserting an erroneous answer in the answer key would generate an observable improvement in the selected outcomes in terms of better satisfaction, interaction, interest in learning, better academic performance, and better development of competencies compared to traditional TBL.Methods: This randomized controlled trial aimed to determine if inserting an erroneous element in the answer key of a grouped team readiness assurance test (GRAT) would update TBL and whether this intervention would enhance students’ performance and satisfaction.Results: A total of 55 medical students were recruited (88.7% response rate). Erroneous elements were inserted in the answer key of the experimental group and students enrolled in traditional TBL were considered as controls. Compared to the control group (p < 0.001), the experimental group revealed significantly higher academic performances in GRAT and team evaluation test (TET). Analysis of students’ perception of the implemented TBL revealed better perception among the experimental group (33.7 ± 6.4) than the control group (30.1 ± 7.0). Moreover, significantly higher team dynamics were reported among the experimental group than the control group (33.0 ± 6.3 and 27.8 ± 7.6 for both groups, respectively; p = 0.005). The reported advantages were in-depth understanding, easier information retrieval, and development of problem-solving skills. Students considered time and effort as their main limitations.Conclusion: Adding a few erroneous answers in the GRAT is well perceived by students, enhances their learning competencies and overcomes some TBL challenges.Keywords: learning environment, motivation, instructional design, student’s interaction, academic performance, team-based learning