Patient Safety – Hospitals take Patient Safety – Hospitals take heed!heed!

Michael Moyer, PhD (ABD), MS, EMT-PMichael Moyer, PhD (ABD), MS, EMT-PFormerly: Cincinnati Children’s Hospital Formerly: Cincinnati Children’s Hospital

Center for Simulation & ResearchCenter for Simulation & ResearchCurrently: TriHealth Hospital System Currently: TriHealth Hospital System

Simulation & Education Training CenterSimulation & Education Training Center

ObjectivesObjectives

Changes to medical education – why?Changes to medical education – why? Where did Patient Safety really start?Where did Patient Safety really start? Discuss the populations involvedDiscuss the populations involved Look at Sim lab training vs. in-situ Look at Sim lab training vs. in-situ Teamwork & CommunicationTeamwork & Communication

How to measureHow to measure Scales to show improvements (or not)Scales to show improvements (or not)

Interactive wrap-up!Interactive wrap-up!

We can be set up to make We can be set up to make mistakes…..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”

Human Errors in High Risk SettingsHuman 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.

Human ErrorsHuman 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

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,"

Why Simulation?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…..

Why still a problem/Why patient Why still a problem/Why patient safety initiatives in hospitals?safety initiatives in hospitals?

Same vial look-a-likesSame vial look-a-likes Same name of drugs (sound a-likes)Same name of drugs (sound a-likes) 70% of all errors originate out of 70% of all errors originate out of

communication issuescommunication issues Teamwork is a whole issue in of itselfTeamwork is a whole issue in of itself Decision making is hampered by Decision making is hampered by

communication and teamwork issuescommunication and teamwork issues

Hospital’s New FocusHospital’s New Focus From counting

failures - to anticipating risks

From preventing error - to anticipating complexity

Disciplined teamwork response.

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.

Goals for a CourseGoals for a Course

Improve teamwork / communicationImprove teamwork / communication Critical thinkingCritical thinking Practice new or not common Practice new or not common

proceduresprocedures Medication safetyMedication safety Medication double-checksMedication double-checks Gauge higher workload effects for a Gauge higher workload effects for a

given team in a particular areagiven team in a particular area

Your participants:Your participants: You know them!You know them! Some are solid in their beliefs.Some are solid in their beliefs. Some are open to change.Some are open to change. Traditional thinking of: Groups = Friends Traditional thinking of: Groups = Friends

= Teams (not really!)= Teams (not really!) Variety of personalitiesVariety of personalities Variable learning stylesVariable learning styles Will be here as a requirement; you will Will be here as a requirement; you will

change that into a necessitychange that into a necessity

Obstacles to Change:Obstacles to Change: Employees must think of teamwork, as Employees must think of teamwork, as

opposed to simply “interacting” with co-opposed to simply “interacting” with co-workers…. Day-to-day interactions lead to workers…. Day-to-day interactions lead to a false sense of confidence in response, a false sense of confidence in response, versus a structured teamwork model.versus a structured teamwork model.

All team members must be “equal” in their All team members must be “equal” in their team membership…. All have a voice in team membership…. All have a voice in patient care.patient care.

Stigma of not reporting events or fear of Stigma of not reporting events or fear of punishment must be eliminated.punishment must be eliminated.

Essential elements of Essential elements of TEAMSTEAMS

1.1. Common Purpose and Shared Common Purpose and Shared GoalsGoals (Painting a mental model that (Painting a mental model that everyone on the team shares)everyone on the team shares)

2.2. Interdependent ActionsInterdependent Actions (We rely on (We rely on each other, not independent of one another)each other, not independent of one another)

3.3. AccountabilityAccountability (We are all accountable (We are all accountable for our actions)for our actions)

4.4. Collective EffortCollective Effort (Everyone shares in the (Everyone shares in the responsibilities and decisions, not just the responsibilities and decisions, not just the team leader)team leader)

Common Team factors affecting medical Common Team factors affecting medical errorserrors

Verbal communicationVerbal communication

Written communicationWritten communication

Supervision and seeking helpSupervision and seeking help

Structure of the teamStructure of the team

(Vincent,1998)(Vincent,1998)

Team Improvement ObjectivesTeam Improvement Objectives

Improve the performance of teams in following areas:Improve the performance of teams in following areas:

CommunicationsCommunications (Team members share a common (Team members share a common thought process about a patient or procedure. What we thought process about a patient or procedure. What we call sharing a “mental model”).call sharing a “mental model”).

LeadershipLeadership (One member oversees the big picture – but (One member oversees the big picture – but all team members communicate with the leader).all team members communicate with the leader).

Decision makingDecision making ( team members are a part of the ( team members are a part of the decision; team members share the common mental decision; team members share the common mental model and provide input to the decision making process)model and provide input to the decision making process)

Stress & fatigue management Stress & fatigue management

Teamwork = success!Teamwork = success!

Concentrate on Two AreasConcentrate on Two AreasConcentrate on Two AreasConcentrate on Two Areas

Latent threatsLatent threats Threats in an Threats in an

environment which environment which are undetected, yet are undetected, yet pose a potential pose a potential problem if problem if circumstances arise. circumstances arise.

Not having leads on Not having leads on a monitor, but not a monitor, but not knowing it until you knowing it until you run through a run through a simulationsimulation

Can also be Human Can also be Human Factor relatedFactor related

Teamwork & Teamwork & CommunicationCommunication

Account for significant Account for significant amount of errors within amount of errors within medical field; appears medical field; appears to snowballto snowball

Not really one single Not really one single event or lack of event or lack of communication, rather communication, rather a cascade of eventsa cascade of events

How might we measure How might we measure TW and Comm? Can TW and Comm? Can we see improvements we see improvements after training?after training?

ExamplesExamples

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

First, Let’s look at the WHOLE trainingFirst, Let’s look at the WHOLE training

Multidisciplinary.Multidisciplinary. Realistic scenarios. Many can be from Realistic scenarios. Many can be from

actual patients.actual patients. Can look at how things evolved in an Can look at how things evolved in an

actual case and learn from it; or practice actual case and learn from it; or practice the correct methodology.the correct methodology.

High risk settings. Practice those areas High risk settings. Practice those areas that seldom see errors but have much that seldom see errors but have much risk!risk!

Practice simple scenarios in prone areas.Practice simple scenarios in prone areas.

Special areas receive training over Special areas receive training over others?others?

EmergencyEmergency PerioperativePerioperative Cardiac UnitCardiac Unit Intensive care unitIntensive 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)

Key Points For Adult LearningKey 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?

Learning ModelsLearning 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

Benefits to SimulationBenefits 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!

Facilitation vs. TeachingFacilitation 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!

Secondary outcomesSecondary outcomes(Specifically about teamwork)(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

Future ResearchFuture 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?

SummarySummary 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.

PLANNING FOR CLINICAL PLANNING FOR CLINICAL SIMULATION!SIMULATION!

Mike Moyer, Ph.D. (ABD), MS, EMT-PMike Moyer, Ph.D. (ABD), MS, EMT-P

Director, Simulation and Education Training CenterDirector, Simulation and Education Training Center

Bethesda North HospitalBethesda North Hospital

TriHealth Hospital SystemTriHealth Hospital System

Cincinnati, OhioCincinnati, Ohio

513.865.1169513.865.1169

michael_moyer@trihealth.com michael_moyer@trihealth.com