Patient Safety – Hospitals take heed!

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. 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. Hospital’s New Focus

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)

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

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!

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. 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 Examples

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? Why these area? Higher SSE possibilities More difficult procedures or steps in carrying out tasks (ie, calling time out; authority gradient; hand-offs) • Emergency • Perioperative • Cardiac Unit • Intensive care unit

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 513.865.1169 michael_moyer@trihealth.com