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Multidisciplinary Teamwork Education Improving Patient Safety Through Simulation Draft 2 October 29 1400.

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Presentation on theme: "Multidisciplinary Teamwork Education Improving Patient Safety Through Simulation Draft 2 October 29 1400."— Presentation transcript:

1 Multidisciplinary Teamwork Education Improving Patient Safety Through Simulation Draft 2 October

2 Scenario #3 Conflict Resolution and Mutual Support Reinforce Briefs for planning –Role clarity Mutual Support and Conflict Management Task-related support Effectively advocate for the patient –Two Challenge Rule –CUS –Advocacy/Assertion Awareness of impact of conflict on the team Provide timely and constructive feedback Creating Psychological Safety

3 Advocacy and Assertion Demonstrate advocacy and assertion when encountering viewpoints that don’t coincide with own. CUS words Discuss use of the “two-challenge rule” when initial assertion is ignored. Review constructive strategies for reaching conflict resolution –Advocacy/Assertion approach: Opening (eg. CUS) State concern Offer solution Obtain agreement –“I need clarity” –“I can only take direction from one consultant. Dr. “In Charge”, what would you like the team priorities to be?” SBAR communication to surgery consultant when he arrives late

4 KSA’sCritical EventsTargeted Responses 1.Leader briefing: establish role clarity 2.Conflict resolution 3.Situational Monitoring and Awareness 4.Shared Mental Model: Leader synthesizes all available data and formulates a treatment plan (goals); shares with team 5. Avoid fixation error 6.Closed-Loop Communication 7.SBAR reporting for updates RRT responds to patient with tachycardia, N+V, and some confusion. Poor SBAR report from Room RN (KSA 1,3, 7) 1.The RRT leader identifies him/herself leader, introduces team; ensures signs of life present. 2.Leader starts to help RN organize report. Primary service arrives before report and evaluation of patient completed and is abusive to RN. Insists B-blocker be given.(KSA2,4,5) 1.RRT uses conflict strategies to gain control of situation. 2.RRT prevents administration of B- blocker 3.Leader creates psychological safety and collects rest of story/assessment of patient RN reveals bleeding issue.(KSA3,4,6,7) If B-blocker given prior to recognition of bleeding; let team manage patient with fluid /blood and end scenario with transfer to ICU and persistent mild hypotension with HR- 80 (suppressed by drug). 1.Leader identifies bleeding as cause of deterioration. 2.Leader shares priority of management with team. Need for fluid, lab, possibly blood and transfer to full ICU.

5 KSA’sCritical EventsTargeted Responses 1.Leader briefing: establish role clarity 2.Conflict resolution 3.Situational Monitoring and Cross-monitoring 4.Shared Mental Model: Leader synthesizes all available data and formulates a treatment plan (goals); shares with team 5. Avoid fixation error 6.Closed-Loop Communication 7.SBAR reporting for updates If team does not give B- blocker and manages previous conflict well escalate scenario: Patient vomits again and becomes unresponsive, aspirates and sats/BP drop. (KSA 3.4.5) 1.Team stabilizes ABCs 2.Fluid x 2 L; uncrossed blood; adequate lines 3.Need for intubation; preparations started Attending arrives demanding report. (KSA 2,4,7) 1.RRT uses conflict strategies to gain control of situation. 2.Leader gives SBAR to attending and team all at once for SMM Patient clenching teeth, need for sedation /neuromuscular blockade to intubate. RN announces about to give succinylcholine (before etomidate) (KSA 3, 6 ) 1.Someone on team recognizes med error and shares with team. 2.Leader aware of med error and stops it; reorders drugs in correct sequence

6 Scenario #2 Communication and Situational Awareness Reinforce Role Clarity –Role of briefing Communication –Call outs and Checkbacks –TV voice –SBAR for report Situational Awareness –Characteristics of highly functional teams –Creating shared mental model –Avoiding Task Fixation Errors –Checklists –Cross monitoring

7 Role Clarity – Have a Plan x Trauma Cons. X Airway Provider X RT X EM Res X Recorder X Team Leader X Assisting Provider X Assessing Provider X Left Arm Nurse X Right Arm Nurse

8 KSA’sCritical EventsTargeted Responses 1.Leader briefing: establish role clarity 2.Situational Monitoring and Awareness 3.Shared Mental Model: Leader synthesizes all available data and formulates a treatment plan (goals); shares with team 4. Avoid fixation error 5.Closed-Loop Communication 6.SBAR reporting for updates Code team called for 72 yo man on diltiazem drip develops heart block and hypotension from inadvertent OD. (KSA 1, 2) 1.The code leader identifies him/herself as the team leader; ensures signs of life present. 2.Conducts brief to establish team (role clarity and psychological safety) Room nurse gives report and notes decreasing HR and BP, history of atrial fib and oral diltiazem; forgets to mention IV drip. (KSA2,6) 1.ALL QUIET for report. 2.Leader notes decline in HR and BP and delegates primary survey (just as patient becomes pulseless) CPR started.(KSA2, 3, 4, 5)1.Leader identifies PEA arrest and initiates CPR/rhythm check. 2.Leader shares priority of management with team. Need for airway management, fluid, possibly epi/atropine, and search for underlying cause. 3.Team member recognizes diltiazem drip running, dose (50 mg/hr instead of 5), drip discontinued. 4.Leader is aware of OD

9 KSA’sCritical EventsTargeted Responses 1.Leader briefing: establish role clarity 2.Situational Monitoring and Awareness 3.Shared Mental Model: Leader synthesizes all available data and formulates a treatment plan (goals); shares with team 4. Avoid fixation error 5.Closed-Loop Communication 6.SBAR reporting for updates 7.Leader invites input Diltiazem drip noted by confederate to airway person or pharmacy if team unaware (KSA 2,3,5) If still no awareness; confederate tells RN, then team leader as necessary 1.Leader and team made aware of diltiazem OD. 2.Leader gives order to stop diltiazem, and drip is correctly discontinued. 3.Clear closed-loop communication can be heard by all Cardiologist arrives and requests report( KSA 6) 1.Leader gives concise SBAR and shares it with whole team Patient remains pulseless (KSA 2,3,4,7) 1.Leader requests help from others/pharmacy if does not know “best managements”. 2.Appropriate interventions for diltiazem OD instituted: Ca/Glucagon/dopamine/ norepinephrine/insulin (at least 2 to get pulse back).

10 Scenario #1 Leadership and Role Clarity Skills/Strategies for leader and the team: Role Clarity and team structure agreement (constant for every trauma team) Brief: critical to organize the team 4 key team skills for leader to focus and create shared mental model –Articulate Goals (Know the plan; Share the plan) –Organize the team (delegation is key) –Seek Input (Empower team to speak up) –Resolve questions/conflict Mutual support of team for leader Closed loop communication

11 Scenario #1 Patient arrives with little warning, so team must organize on arrival. S – 33 yo male; high speed MVA; GCS 13 –VS: BP 80/40; HR 125; RR 26; Sats 96% on 15L B – Scene call, Unrestrained driver, hit on driver side by car –No known past medical history A – Responds to painful stimuli only; deformity to L ankle; tender abdomen (fluid on US RUQ) R – IV 500 cc bolus, O2 at high flow, splint L ankle, spinal precautions

12 Knowledge…Skills… Attitudes…(KSAs) Critical EventsTargeted Responses 1.Leader briefing: establish role clarity (based on established team structure agreement) 2.Leader observes and helps direct activities of other team members – focus on expeditious primary survey first 3.Leader synthesizes all available data and formulates a treatment plan (goals) 4.Leader shares plan with team 5.Leader seeks input from team 6.Focus on closed-loop communication 7.Mutual support of team organization by other members 33 yo trauma patient arrives with no warning. (KSA 1, 7) 1.The trauma leader identifies him/herself as the team leader 2.Conducts brief to establish team (role clarity) EMS starts giving report before team organized and quiet to listen. Confederate (recording nurse) interrupts report. (KSA 1, 2, 7) 1.Leader (with team support) asks EMS to hold report till team organized and all quiet. 2.EMS report begins at request of leader, ALL QUIET for report. Primary survey completed. (KSA 3, 4, 6, 7) 1.Primary survey identifies patient in shock, need for rapid fluids, followed by blood if unresponsive. Also note altered LOC, head CT/Cspine needed. 2.Leader shares this plan with the team - Secondary survey focused on identifying injuries to explain hypotension and altered LOC. 3.Support from team if leader struggling, or check-backs not occurring.

13 KSA’sCritical EventsTargeted Responses 1.Leader briefing: establish role clarity (based on established team structure agreement) 2.Leader organizes team – focus on EMS report and expeditious primary survey first 3.Leader synthesizes all available data and formulates a treatment plan (goals) 4.Leader shares plan with team 5.Leader seeks input from team 6.Focus on closed-loop communication 7.Mutual support of team organization by other members Trauma and ED Consultants enter room during primary survey. Only provide input if sought from leader for first 5 minutes. May provide active support for KSA 1-4 after that (KSA 5) 1.Team leader seeks help from consultants as needed. 2.Team leader accepts help and suggestions from consultants. Trauma consultant asks for SBAR report on patient after primary survey complete. (KSA 3, 4) 1.Team leader shares SBAR summary with entire team. 2.This summary report should not interrupt need for primary survey and IV fluid orders. 3.Team Leader seeks input from team (is there anything important I missed?) Patient desaturates after Primary Survey. Trauma consultant ensures intubation for altered LOC and RR/slight desat prior to CT. (KSA3,4, 6) 1.Check-backs and closed-loop communications for all meds and tasks during entire scenario

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15 Trauma Experience Identified 6 key behaviors to reinforce –Briefs for pre-arrival planning Role clarity PPE with names on front Plan based on EMS info Equipment set-up; where to find equipment that might be needed –4 key leadership behaviors –Check –backs (closed-loop communication) –“TV” voice (audible communication) –Crowd / Noise control –Primary surveyor accountability for “Positives”


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