In situ simulation: detection of safety threats and teamwork training in a high risk emergency department
TL;DR: Embedding in situ simulation as a routine expectation positively affected operations and the safety climate in a high risk clinical setting and to reinforce team training behaviours.
Abstract: Objective Implement and demonstrate feasibility of in situ simulations to identify latent safety threats (LSTs) at a higher rate than lab-based training, and reinforce teamwork training in a paediatric emergency department (ED).
Methods Multidisciplinary healthcare providers responded to critical simulated patients in an urban ED during all shifts. Unannounced in situ simulations were limited to 10 min of simulation and 10 min of debriefing, and were video recorded. A standardised debriefing template was used to assess LSTs. The primary outcome measure was the number and type of LSTs identified during the simulations. Secondary measures included: participants’ assessment of impact on patient care and value to participants. Blinded video review using a modified Anaesthetists Non-Technical Skills scale was used to assess team behaviours.
Results 218 healthcare providers responded to 90 in situ simulations conducted over 1 year. A total of 73 LSTs were identified; a rate of one every 1.2 simulations performed. In situ simulations were cancelled at a rate of 28% initially, but the cancellation rate decreased as training matured. Examples of threats identified include malfunctioning equipment and knowledge gaps concerning role responsibilities. 78% of participants rated the simulations as extremely valuable or valuable, while only 5% rated the simulation as having little or no value. Of those responding to a postsimulation survey, 77% reported little or no clinical impact. Video recordings did not indicate changes in non-technical skills during this time.
Conclusions In situ simulation is a practical method for the detection of LSTs and to reinforce team training behaviours. Embedding in situ simulation as a routine expectation positively affected operations and the safety climate in a high risk clinical setting.
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TL;DR: In this article, the authors describe the outbreak response measures of the anesthetic department staffing the largest (1,700-bed) academic tertiary level acute care hospital in Singapore (Singapore General Hospital) and a smaller regional hospital (Sengkang General Hospital).
Abstract: The coronavirus disease 2019 (COVID-19) outbreak has been designated a public health emergency of international concern. To prepare for a pandemic, hospitals need a strategy to manage their space, staff, and supplies so that optimum care is provided to patients. In addition, infection prevention measures need to be implemented to reduce in-hospital transmission. In the operating room, these preparations involve multiple stakeholders and can present a significant challenge. Here, we describe the outbreak response measures of the anesthetic department staffing the largest (1,700-bed) academic tertiary level acute care hospital in Singapore (Singapore General Hospital) and a smaller regional hospital (Sengkang General Hospital). These include engineering controls such as identification and preparation of an isolation operating room, administrative measures such as modification of workflow and processes, introduction of personal protective equipment for staff, and formulation of clinical guidelines for anesthetic management. Simulation was valuable in evaluating the feasibility of new operating room set-ups or workflow. We also discuss how the hierarchy of controls can be used as a framework to plan the necessary measures during each phase of a pandemic, and review the evidence for the measures taken. These containment measures are necessary to optimize the quality of care provided to COVID-19 patients and to reduce the risk of viral transmission to other patients or healthcare workers.
497 citations
TL;DR: R rudeness had adverse consequences on the diagnostic and procedural performance of the NICU team members and information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of Rudeness on procedural performance.
Abstract: BACKGROUND AND OBJECTIVES: Iatrogenesis often results from performance deficiencies among medical team members. Team-targeted rudeness may underlie such performance deficiencies, with individuals exposed to rude behavior being less helpful and cooperative. Our objective was to explore the impact of rudeness on the performance of medical teams. METHODS: Twenty-four NICU teams participated in a training simulation involving a preterm infant whose condition acutely deteriorated due to necrotizing enterocolitis. Participants were informed that a foreign expert on team reflexivity in medicine would observe them. Teams were randomly assigned to either exposure to rudeness (in which the expert’s comments included mildly rude statements completely unrelated to the teams’ performance) or control (neutral comments). The videotaped simulation sessions were evaluated by 3 independent judges (blinded to team exposure) who used structured questionnaires to assess team performance, information-sharing, and help-seeking. RESULTS: The composite diagnostic and procedural performance scores were lower for members of teams exposed to rudeness than to members of the control teams (2.6 vs 3.2 [ P = .005] and 2.8 vs 3.3 [ P = .008], respectively). Rudeness alone explained nearly 12% of the variance in diagnostic and procedural performance. A model specifying information-sharing and help-seeking as mediators linking rudeness to team performance explained an even greater portion of the variance in diagnostic and procedural performance ( R 2 = 52.3 and 42.7, respectively). CONCLUSIONS: Rudeness had adverse consequences on the diagnostic and procedural performance of the NICU team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.
212 citations
TL;DR: The concept of a protected code stroke during a pandemic, as in the case of COVID-19, is introduced and a framework for key considerations including screening, personal protective equipment, and crisis resource management is provided.
Abstract: Background and Purpose- Hyperacute assessment and management of patients with stroke, termed code stroke, is a time-sensitive and high-stakes clinical scenario. In the context of the current coronavirus disease 2019 (COVID-19) pandemic caused by the SARS-CoV-2 virus, the ability to deliver timely and efficacious care must be balanced with the risk of infectious exposure to the clinical team. Furthermore, rapid and effective stroke care remains paramount to achieve maximal functional recovery for those needing admission and to triage care appropriately for those who may be presenting with neurological symptoms but have an alternative diagnosis. Methods- Available resources, COVID-19-specific infection prevention and control recommendations, and expert consensus were used to identify clinical screening criteria for patients and provide the required nuanced considerations for the healthcare team, thereby modifying the conventional code stroke processes to achieve a protected designation. Results- A protected code stroke algorithm was developed. Features specific to prenotification and clinical status of the patient were used to define precode screening. These include primary infectious symptoms, clinical, and examination features. A focused framework was then developed with regard to a protected code stroke. We outline the specifics of personal protective equipment use and considerations thereof including aspects of crisis resource management impacting team role designation and human performance factors during a protected code stroke. Conclusions- We introduce the concept of a protected code stroke during a pandemic, as in the case of COVID-19, and provide a framework for key considerations including screening, personal protective equipment, and crisis resource management. These considerations and suggested algorithms can be utilized and adapted for local practice.
197 citations
Cites background from "In situ simulation: detection of sa..."
...Simulation training, especially in-situ, can alleviate the anxiety of the situation and reduce safety threats.(8)...
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TL;DR: This article describes, from a pediatric perspective, the 2 main types of simulation-based research: studies that assess the efficacy of simulation as a training methodology and studies where simulation is used as an investigative methodology.
Abstract: As simulation is increasingly used to study questions pertaining to pediatrics, it is important that investigators use rigorous methods to conduct their research. In this article, we discuss several important aspects of conducting simulation-based research in pediatrics. First, we describe, from a pediatric perspective, the 2 main types of simulation-based research: (1) studies that assess the efficacy of simulation as a training methodology and (2) studies where simulation is used as an investigative methodology. We provide a framework to help structure research questions for each type of research and describe illustrative examples of published research in pediatrics using these 2 frameworks. Second, we highlight the benefits of simulation-based research and how these apply to pediatrics. Third, we describe simulation-specific confounding variables that serve as threats to the internal validity of simulation studies and offer strategies to mitigate these confounders. Finally, we discuss the various types of outcome measures available for simulation research and offer a list of validated pediatric assessment tools that can be used in future simulation-based studies.
181 citations
TL;DR: The number of studies on team interventions has increased exponentially and research tends to focus on certain interventions, settings, and/or outcomes, so the “evidence base” levels of the research are identified.
Abstract: A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design. To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the “evidence base” levels of the research. Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence. Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements. Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.
175 citations
Cites background from "In situ simulation: detection of sa..."
...…and videobased debriefing Intensive care Improvement in leadership, teamwork, and self-confidence skills in managing medical emergencies C Patterson et al. 2013a [146] Multidisciplinary in situ simulations Paediatric emergency Ability to identify latent safety C Table 1 Summary of…...
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...2013a [146] Multidisciplinary in situ simulations Paediatric emergency Ability to identify latent safety C Buljac-Samardzic et al....
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...…of results (Continued) Authors (year) Intervention Setting Outcome(s) GRADE with debriefing department threats, but changes in nontechnical skills Patterson et al. 2013b [147] Simulation-based training: introduction (lectures, videotapes of simulated resuscitations and case studies), simulation,…...
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References
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TL;DR: The longstanding and widespread tradition of the person approach focuses on the unsafe acts—errors and procedural violations—of people at the sharp end: nurses, physicians, surgeons, anaesthetists, pharmacists, and the like.
Abstract: The longstanding and widespread tradition of the person approach focuses on the unsafe acts—errors and procedural violations—of people at the sharp end: nurses, physicians, surgeons, anaesthetists, pharmacists, and the like. It views these unsafe acts as arising primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness. Naturally enough, the associated countermeasures are directed mainly at reducing unwanted variability in human behaviour. These methods include poster campaigns that appeal to people’s sense of fear, writing another procedure (or adding to existing ones), disciplinary measures, threat of litigation, retraining, naming, blaming, and shaming. Followers of this approach tend to treat errors as moral issues, assuming that bad things happen to bad people—what psychologists have called the just world hypothesis.
4,710 citations
TL;DR: Clinical experience in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities are described.
Abstract: Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common ‘‘critical language’’ to alert team members to unsafe situations. All too frequently, effective communication is situation or personality dependent. Other high reliability domains, such as commercial aviation, have shown that the adoption of standardised tools and behaviours is a very effective strategy in enhancing teamwork and reducing risk. We describe our ongoing patient safety implementation using this approach within Kaiser Permanente, a non-profit American healthcare system providing care for 8.3 million patients. We describe specific clinical experience in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities. Additionally, lessons learned as to effective techniques in achieving cultural change, evidence of improving the quality of the work environment, practice transfer strategies, critical success factors, and the evolving methods of demonstrating the benefit of such work are described.
2,000 citations
Book•
01 Jan 2001TL;DR: Weick and Sutcliffe as discussed by the authors introduced the concept of "mindfulness" and outlined five qualities of the mindful organization and the organizational skills needed to achieve them, each concept is clearly expressed in vivid case studies of organizations that demonstrate mindful practices in action.
Abstract: High reliability organizations (HROs) such as ER units in hospitals or firefighting units are designed to perform efficiently under extreme stress and pressure. Using HROs as the model for the 21st century organization, Karl Weick and Kathleen Sutcliffe show readers how to respond to unexpected challenges with flexibility rather than rigidity and to reduce the disruptive effects of change by using tools such as sensemaking, stress reduction, migrating decisions, and labeling. Introducing the powerful new concept of "mindfulness," the authors outline five qualities of the mindful organization and the organizational skills needed to achieve them. Each concept is clearly expressed in vivid case studies of organizations that demonstrate mindful practices in action. A Book in the University of Michigan Business School Series Voted Best HR Book of 2001 by HR.com
1,886 citations
TL;DR: The findings of the evaluation indicated that the ANTS system has a satisfactory level of validity, reliability and usability in an experimental setting, provided users receive adequate training.
Abstract: Background. Non-technical skills are critical for good anaesthetic practice but are not addressed explicitly in normal training. Realization of the need to train and assess these skills is growing, but these activities must be based on properly developed skills frameworks and validated measurement tools. A prototype behavioural marker system was developed using human factors research techniques. The aim of this study was to conduct an experimental evaluation to establish its basic psychometric properties and usability. Method. The Anaesthetists’ Non-Technical Skills (ANTS) system prototype comprises four skill categories (task management, team working, situation awareness, and decision making) divided into 15 elements, each with example behaviours. To investigate its experimental validity, reliably and usability, 50 consultant anaesthetists were trained to use the ANTS system. They were asked to rate the behaviour of a target anaesthetist using the prototype system in eight videos of simulated anaesthetic scenarios. Data were collected from the ratings forms and an evaluation questionnaire. Results. The results showed that the system is complete, and that the skills are observable and can be rated with acceptable levels of agreement and accuracy. The internal consistency of the system appeared sound, and responses regarding usability were very positive. Conclusions. The findings of the evaluation indicated that the ANTS system has a satisfactory level of validity, reliability and usability in an experimental setting, provided users receive adequate training. It is now ready to be tested in real training environments, so that full guidelines can be developed for its integration into the anaesthetic curriculum.
875 citations
TL;DR: A framework of risk factors is presented that aims to encompass the many factors influencing clinical practice and can be used to guide the investigation of incidents, to generate ways of assessing risk, and to focus research on the causes and prevention of adverse outcomes.
Abstract: Adverse events are incidents in which a patient is unintentionally harmed by medical treatment. Awareness while under anaesthetic, deaths during surgery, and missed cases of meningitis are tragic for both patients and staff, and may lead to complaints or litigation. Investigations usually focus on the actions of individual doctors and seldom examine the background to these events.
In a recent case of a patient whose bowel was perforated during surgery, examination of the medical records led to criticism of the surgeon. Only later did it emerge that the operation had been carried out in near darkness because of several equipment and power problems. Adverse events usually originate in a variety of systemic features operating at different levels—the task, the team, the work environment, and the organisation. We present a framework that aims to encompass the many factors influencing clinical practice. It can be used to guide the investigation of incidents, to generate ways of assessing risk, and to focus research on the causes and prevention of adverse outcomes.
The original model for accident assessment was developed for use in complex industrial settings such as offshore drilling platforms
#### Summary points
Adverse events in which patients are harmed by medical treatment are common
Investigations which consider only actions or omissions of individual clinicians are incomplete and misleading
Psychological research shows that liability to error is strongly affected by adverse conditions of work
These conditions include high workload, inadequate supervision, poor communication, rapid change within an organisation
A framework of risk factors allows a systematic approach to safety and error reduction
In spite of increased attention to quality, errors and adverse outcomes are still frequent in clinical practice.1 The risk of iatrogenic injury to patients in acute hospitals remains high, with studies reporting rates of 4-17%.2-4 A recent American observational study found that …
871 citations