1. Patient Safety – Hospitals take heed!
Michael Moyer, PhD (ABD), MS, EMT-P
Formerly: Cincinnati Children’s Hospital Center for Simulation & Research
Currently: TriHealth Hospital System Simulation & Education Training Center

2. Objectives Changes to medical education – why?
Where did Patient Safety really start?
Discuss the populations involved
Look at Sim lab training vs. in-situ
Teamwork & Communication
How to measure
Scales to show improvements (or not)
Interactive wrap-up!

3. We can be set up to make mistakes…..
Incompetent people are, at most, 1% of the problem. The other 99% are good people trying to do a good job who make very simple mistakes and it's the processes that set them up to make these mistakes.
Dr. Lucian Leape, Harvard School of Public Health, Co-author of “To Err is Human”

4. Human Errors in High Risk Settings
Technicians were doing tests and shut off the coolant.  Chernobyl exploded in April 26, 1986.  It occurred at Unit 4 of the power at Chernobyl, Ukraine.
The accident destroyed the reactor and released an incredibly large amount of radiation into the environment.  Because of this access to an 18 mile radius of the plant was closed.
Thirty-one people died in this explosion. 
135,000 had to evacuate the area.  The radiation cloud spread all through out western Europe.  It took the cloud 1 week to spread all over Europe.

5. Human Errors Normal safety guidelines were disregarded
Operator was unfamiliar with the reactor
Operator had not been trained enough
Not trained under normal and/or extreme conditions

6. Two months after a double bypass heart operation that was supposed to save his life, comedian and former Saturday Night Live cast member Dana Carvey got some disheartening news: the cardiac surgeon had bypassed the wrong artery. It took another emergency operation to clear the blockage that was threatening to kill the 45-year-old comedian.
Responding to a $7.5 million lawsuit Carvey brought against him, the surgeon said he'd made an honest mistake because Carvey's artery was unusually situated in his heart. But Carvey didn't see it that way: "It's like removing the wrong kidney. It's that big a mistake,"

7. Why Simulation?
Began in aviation – mail carriers; preventable accidents; CRM
Crossed into medicine – anesthesia; ACRM
Moved into military battlefields and aeronautics
Medicine & Patient safety
All as a result of improved training methods…..

9. Why still a problem/Why patient safety initiatives in hospitals?
Same vial look-a-likes
Same name of drugs (sound a-likes)
70% of all errors originate out of communication issues
Teamwork is a whole issue in of itself
Decision making is hampered by communication and teamwork issues

10. Hospital’s New Focus
How we can identify “team leaders” in every situation;
Move away from individual mental models to team mental models; sharing our thoughts before, during & even after an event.
From counting failures - to anticipating risks
From preventing error - to anticipating complexity
Disciplined teamwork response.

11. Goals for a Course Improve teamwork / communication Critical thinking
Practice new or not common procedures
Medication safety
Medication double-checks
Gauge higher workload effects for a given team in a particular area

12. Your participants: You know them! Some are solid in their beliefs.
Some are open to change.
Traditional thinking of: Groups = Friends = Teams (not really!)
Variety of personalities
Variable learning styles
Will be here as a requirement; you will change that into a necessity

13. Obstacles to Change:
Employees must think of teamwork, as opposed to simply “interacting” with co-workers…. Day-to-day interactions lead to a false sense of confidence in response, versus a structured teamwork model.
All team members must be “equal” in their team membership…. All have a voice in patient care.
Stigma of not reporting events or fear of punishment must be eliminated.

14. Essential elements of TEAMS
Common Purpose and Shared Goals (Painting a mental model that everyone on the team shares)
Interdependent Actions (We rely on each other, not independent of one another)
Accountability (We are all accountable for our actions)
Collective Effort (Everyone shares in the responsibilities and decisions, not just the team leader) 14

15. Common Team factors affecting medical errors
Verbal communication
Written communication
Supervision and seeking help
Structure of the team
(Vincent,1998) 15

16. Team Improvement Objectives
Improve the performance of teams in following areas:
Communications (Team members share a common thought process about a patient or procedure. What we call sharing a “mental model”).
Leadership (One member oversees the big picture – but all team members communicate with the leader).
Decision making ( team members are a part of the decision; team members share the common mental model and provide input to the decision making process)
Stress & fatigue management
Teamwork = success! 16

17. Concentrate on Two Areas
Latent threats
Threats in an environment which are undetected, yet pose a potential problem if circumstances arise.
Not having leads on a monitor, but not knowing it until you run through a simulation
Can also be Human Factor related
Teamwork & Communication
Account for significant amount of errors within medical field; appears to snowball
Not really one single event or lack of communication, rather a cascade of events
How might we measure TW and Comm? Can we see improvements after training?

18. Examples Latent threats Missing medications Missing equipment
Lack of algorithms for cognitive aids
Medications in same drawer are close in look
Defibrillator has synch button that blends into the background
Teamwork / Communication
Lack of leader
Closed-loop communication
Proper roles
No step-backs
Not acting on “pinches”
Authority gradients
Assumptions drawn

19. First, Let’s look at the WHOLE training
Multidisciplinary.
Realistic scenarios. Many can be from actual patients.
Can look at how things evolved in an actual case and learn from it; or practice the correct methodology.
High risk settings. Practice those areas that seldom see errors but have much risk!
Practice simple scenarios in prone areas.

20. Special areas receive training over others?
Emergency
Perioperative
Cardiac Unit
Intensive care unit
Why these area?
Higher SSE possibilities
More difficult procedures or steps in carrying out tasks (ie, calling time out; authority gradient; hand-offs)

21. Key Points For Adult Learning
What’s in it for me?!
Would I ever use this?
How will I benefit?
Will others think I’m an idiot?

22. Learning Models
Principles of learning have changed from pure didactic to experiential
Self-directed learning
Utilize classroom learning in “real-life”
“Rules of engagement” – learners are participating in teams; not silo’s
Problem-based learning
Safe, non-threatening environment

23. Benefits to Simulation
Allows for more self-directed learning
Classroom theory is translated into clinical practice
Gives realism to an education scenario
The learner can become engaged in actual care
Provides for critical thinking – move into the clinical area
Can visualize your efforts – simulators hold you accountable for your actions!

24. Facilitation vs. Teaching
Debriefing is critical to success
Must be included in all simulations
Why debrief? How does facilitation create learning?
Discuss non-technical and technical behaviors…. Learning from each other
Use of videotape… be careful!

25. Secondary outcomes (Specifically about teamwork)
Reinforce teamwork behaviors in clinical setting
“Speak up”
Role clarity
Frequent updates/shared mental model
Independent medication double checks
Overcoming authority gradient

26. Future Research Impact on competence (eg = nurse readiness)
Is training better vs. traditional methods? If so, in what area(s)?
Does this translate into clinical practice?
Can we build a better educational model as a result of this research?

27. Summary Focus on real world problems.
Relate learning to participants goal.
Allow debate and challenge of ideas.
Encourage participants to be resources to you and to each other.

28. PLANNING FOR CLINICAL SIMULATION!
Mike Moyer, Ph.D. (ABD), MS, EMT-P
Director, Simulation and Education Training Center
Bethesda North Hospital
TriHealth Hospital System
Cincinnati, Ohio
PLANNING FOR CLINICAL SIMULATION!