Clinical Simulation and Patient Safety

Paul Bradley

Director of Clinical Skills

Peninsula College of Medicine and Dentistry

Scottish Clinical Skills Network

University Campus Hamilton

September 27th, 2007

Patient safety – how big is the problem? So what does clinical simulation have to offer? How can we go about this?

Patient safety – how big is the problem?

Why Patient Safety

“To err is human” in the USA “An organisation with a memory” in the UK

Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000

Department of Health. An organisation with a memory. London: Stationery Office; 2000

The size of the problem 400 die/seriously injured in adverse events involving medical

devices ~10,000 people experienced serious adverse reactions to

drugs ~1,150 suicides in people with recent contact with mental

health care ~28,000 written complaints about clinical treatment in

hospitals NHS pays £400 million a year settlement of clinical

negligence claims Potential liability of around £2.4 billion Hospital acquired infections cost nearly £1 billion.

The size of the problem

850,000 adverse events in the UK per year 10% of all hospital admissions In the USA estimated 44,000 – 90,000 deaths per

year – that’s equivalent to 15-30 September 11ths 1 million extra hospital days in USA 12.9% of all hospital admissions in NZ

5th NPSA Report - 2005

Analysis of the 1,804 serious incidents resulting in death. Reducing to 576 deaths that could be interpreted as

potentially avoidable and related to patient safety issues. 425 occurred in acute/general hospitals.

71 related to a range of diagnostic errors 64 related to patient unrecognised deterioration 43 involved a problem with resuscitation after cardiac

arrest.

National Patient Safety Agency. The fifth report from the Patient Safety Observatory - Safer care for the acutely ill patient: learning from serious incidents. London; 2007.

Recommendations - deterioration

Better recognition of patients at risk of, or who have deteriorated

Appropriate monitoring of vital signs Accurate interpretation of clinical findings Calling for help early and ensuring it arrives Training and skills development Ensuring appropriate drugs and equipment are

available

Recommendation - resuscitation

Improving communication Better situation analysis Regularly risk assessing resuscitation processes

locally Training and skills development Ensuring appropriate equipment is available

“These are not new concerns and, in spite of much high

quality work over many years, still more energy and commitment towards

improvement is needed.”

It isn’t history

26: Emergency support in surgical units: Dealing with haemorrhage

Issued: 10 Sep 2007

Following the death of a patient, the National Patient Safety Agency is warning that surgery should not be commissioned or delivered in facilities which lack the systems and equipment to manage emergencies safely.   In a recent incident a patient died following routine laparoscopic surgery exacerbated by no blood being available, a lack of critical resuscitation devices such as central venous catheters and an absence of surgical equipment such as abdominal packs and vascular sutures. 

So what does clinical simulation have to offer?

Simulation

“The technique of imitating the behaviour of

some situation or process (whether

economic, military, mechanical, etc.) by

means of a suitably analogous situation or

apparatus, especially for the purpose of

study or personnel training.”

The Oxford English Dictionary – Online 2006

Simulation in medical education – is not new

Too dangerous

Chess – 6th Century War games Weapons simulations

Too costly Space exploration Mission training

Too important

Civil and military aviation Nuclear power industry

Simulation in skills educationPart task trainers

Simulated patients and

role plays

Hi- and intermediate fidelity simulation

Haptic/VR simulators

1950 1960 1970 1980 1990 2000

Resuscitation movement

The movements in modern medical simulation

1950 1960 1970 1980 1990 2000

The movements promoting modern medical simulation

Åsmund LærdalResuscitation movement

Resuscitation movement

1950 1960 1970 1980 1990 2000

The movements promoting modern medical simulation

Stephen AbrahamsonSim One

Sim-One

“It breathes; has a heart beat, temporal and carotid pulse (all synchronized), and blood pressure; opens and closes its mouth; blinks its eyes; and responds to four intravenously administered drugs and two gases (oxygen and nitrous oxide) administered through mask or tube. The physiologic responses to what is done to him are in real time and occur ‘‘automatically’’ as part of a computer program.”

Abrahamson S, Denson JS, Wolf RM. Effectiveness of a simulator in training anesthesiology residents. Qual Saf Health Care 2004;13(5):395-397.

1950 1960 1970 1980 1990 2000

The movements promoting modern medical simulation

CASE (Comprehensive Anesthesia Simulation Environment) - Stanford

GAS (Gainesville Anesthesia Simulator)Florida

Patient simulator

1950 1960 1970 1980 1990 2000

The movements promoting modern medical simulation

Patient simulator

Features of modern simulators Complete human body Capable of “speech” Complete integrated

physiology/pharmacology model (high fidelity)

Open/close mouth Trismus Realistic airway Pharyngeal oedema Respiratory chest (

abdominal wall) movements

Appropriate anatomical landmarks

Lungs capable of spontaneous, assisted or mechanical ventilation

consumption of O2, exhalation of CO2 and uptake of anaesthetic gases

Tongue swelling Difficult airways Synchronised breath sounds Bowel sounds

Features of modern simulators Monitoring Pulses palpable Synchronised with heart

sounds Blood pressure measurable Variety of physiological

outputs to standard monitors e.g. CVP Temperature

Pulse oximetry

Procedures Defibrillation Pneumothorax decompression Cardioversion Cricothyroidotomy External pacing Pericardiocentesis Venepuncture Chest drain insertion Cannulation Intramuscular injection Urinary catheterisation

1950 1960 1970 1980 1990 2000

The movements promoting modern medical simulation40.2 Skills objectivesa) basic clinical method

i. obtain and record a comprehensive historyii. perform a complete examination and

assess mental stateiii. interpret the findings obtained from the

history and examinationiv. reach a provisional assessment of patients’

problems and formulate with them plans for investigation and management

b) basic clinical procedures includingi. Basic and Advanced Life Supportii. venepunctureiii. insertion of an intravenous line

Medical education reform

1950 1960 1970 1980 1990 2000

Resuscitation movement

Medical education reform

Sim-One

The movements promoting modern medical simulation

Patient simulator

Cummulative growth in "simulation" publications

0

100

200

300

400

500

600

1963 1968 1973 1978 1983 1988 1993 1998 2003

Source: Boston Simulation Centre

BEME systematic review Providing feedback Allowing repetitive practice Integrating within curriculum Providing a range of difficulties Being adaptable; allowing multiple learning strategies Providing a range of clinical scenarios Provides safe, supportive learning environment Active learning based on individualized needs Defined outcomes Simulator validity as a realistic recreation of complex

clinical situations

Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher 2005;27(1):10-28.

The benefits of simulation Risks to patients and learners are avoided Undesired interference is reduced Tasks/scenarios can be created to demand Skills can be practised repeatedly Training can be tailored to individuals Retention and accuracy are increased Transfer of training from classroom to real situation is

enhanced Standards against which to evaluate student performance and

diagnose educational needs are enhancedMaran NJ, Glavin RJ. Low- to high-fidelity simulation - a continuum of medical

education? Medical Education 2003;37(s1):22-28

Potential application of simulation Routine learning and rehearsal of clinical and

communication skills at all levels Routine basic training of individuals and teams Practise of complex clinical situations Training of teams in crisis resource management Rehearsal of serious and/or rare events Rehearsal of planned, novel or infrequent interventions Induction into new clinical environments and use of

equipment Design and testing of new clinical equipment Performance assessment of staff at all levels Refresher training of staff at all levels

Responsibilities for patient safetyOrganisation

Institution

Individual

TeamPatientsafety

…and the place for clinical simulation

Patientsafety

Institution

IndividualTeam

How can we go about this?

Building on theories of learning

Medical education and clinical skills learning is a theory rich educational environmentBehaviourismConstructivismSocial constructivismReflective practiceSituated learningActivity theory

Bradley, P., & Postlethwaite, K. (2003). Simulation in clinical learning. Medical Education, 37(s1), 1-5.

Learning theories

Theories can inform our practise Models of teaching and learning can be

developed that best support our students Theories can be tested Theories can be revised

Activity theory

Subject Object Outcome

Community

Division of labour

Rules

Artefacts

From Engeström Y 2001 Expansive learning at work: toward an activity theoretical reconceptualization. Journal of Education and Work 14,2,133-156

Simulator Work in operating theatre

Object 1

Rules Community Division oflabour

Subject

Mediating artifacts

Object 1

CommunityDivision oflabour

Subject

Mediating artifacts

Rules

Object 2

Object 2

Object 3

Activity Theory

Aha

Aha

Research

Evidence to date has been weak and patchy Much published work is descriptive or at low level

of evaluation Despite this simulation has certainly established

itself as a major educational movement We cannot always wait for the results of empirical

research to address major issues Sound, robust research is still needed to address

key areas

A possible way forward Use multiple methods approaches

Encompass the interpretive paradigm

Make more targeted use of the scientific paradigm to capitalise upon its particular ‘range of convenience’

Strive for increased theoretical clarity with respect to learning theories

Together, these ideas could lead to rather different kinds of enquiry

Conclusions Clinical simulation can enable learning of institutions, individuals

& teams It can play an important part in addressing issues of patient

safety Has a role at all levels of seniority within and between

professional groups It exists as a spectrum of educational activities - it is not a

dichotomy of low and high fidelity, but a continuum Not just technological/computerised – include important human

interactions - may be one-to-one or within or between teams Clinical simulation can test and challenge systems, policies and

plans Evidence to date tends to be of a low level evaluative nature, to

be weak in methodology and to be of limited generalisability Robust research focussed on higher level outcomes is required

paul.bradley@pms.ac.uk

Responsibilities for patient safetyOrganisation

Institution

Individual

TeamPatientsafety

…and the place for clinical simulation

Patientsafety

Institution

IndividualTeam

…and the place for clinical simulation

Patientsafety

Institution

IndividualTeam

Simulators