Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies

Why Simulation Matters: A Systematic Review on Medical Errors Occurring During Simulated Health Care

BACKGROUND

Over the past decade, the implementation of simulation education in health care has increased exponentially. Simulation-based education allows learners to practice patient care in a controlled, psychologically safe environment without the risk of harming a patient. Facilitators may identify medical errors during instruction, aiding in developing targeted education programs leading to improved patient safety. However, medical errors that occur during simulated health care may not be reported broadly in the simulation literature.

OBJECTIVE

The aim of the study is to identify and categorize the type and frequency of reported medical errors in healthcare simulation.

METHODS

Systematic review using search engines, PubMed/MEDLINE, CINAHL, and SCOPUS from 2000 to 2020, using the terms "healthcare simulation" AND "medical error." Inclusion was based on reported primary research of medical errors occurring during simulated health care. Reported errors were classified as errors of commission, omission, systems related, or communication related.

RESULTS

Of the 1105 articles screened, only 20 articles met inclusion criteria. Errors of commission were the most reported (17/20), followed by systems-related errors (13/20), and errors of omission (12/20). Only 7 articles reported errors attributed to communication. Authors in 16 articles reported more than one type of error.

CONCLUSIONS

Simulationists and patient safety advocates must continually identify systems-related errors and training deficits that can lead to inaction, improper action, and poor communication. Recent dialogs in the simulation community have also underscored the potential benefits of developing a registry of errors across simulation centers, with a goal of aggregating, analyzing, and disseminating insights from various simulation exercises.

Investigating Racial and Ethnic Disparities in Maternal Care at the System Level Using Patient Safety Incident Reports

BACKGROUND

Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports.

METHODS

The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated.

RESULTS

Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as "other" accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01-1.54).

CONCLUSION

Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

In Situ Simulation as a Quality Improvement Tool to Identify and Mitigate Latent Safety Threats for Emergency Department SARS-CoV-2 Airway Management: A Multi-Institutional Initiative

BACKGROUND

In situ simulation has emerged as a powerful quality improvement (QI) tool in the identification of latent safety threats (LSTs). Following the first wave of SARS-CoV-2 at an urban epicenter of the disease, a multi-institutional collaborative was formed to integrate an in situ simulation protocol across five emergency departments (EDs) for systems improvement of acute airway management.

METHODS

A prospective, multi-institutional QI initiative using two Plan-Do-Study-Act (PDSA) cycles was implemented across five EDs. Each institution conducted simulations involving mannequins in acute respiratory failure requiring definitive airways. Simulations and systems-based debriefs were standardized. LSTs were collected in an online database, focused on (1) equipment availability, (2) infection control, and (3) communication.

RESULTS

From June 2020 through May 2021, 58 of 70 (82.9%) planned simulations were completed across five sites with 328 unique individual participants. Overall LSTs per simulation (7.00-4.69, p < 0.001) and equipment LSTs (3.00-1.46, p < 0.001) decreased from cycle 1 to cycle 2. Changes in mean LSTs for infection control and communication categories varied among sites. There was no correlation between total LSTs or any of the categories and team size. Number of beds occupied was significantly negatively correlated with total and infection control LSTs.

CONCLUSION

This study was unique in simultaneously running a structured in situ protocol across numerous diverse institutions during a global pandemic. This initiative found similar categories of threats across sites, and the protocol developed empowered participants to implement changes to mitigate identified threats.

Leading change in practice: how "longitudinal prebriefing" nurtures and sustains in situ simulation programs

In situ simulation (ISS) programs deliver patient safety benefits to healthcare systems, however, face many challenges in both implementation and sustainability. Prebriefing is conducted immediately prior to a simulation activity to enhance engagement with the learning activity, but is not sufficient to embed and sustain an ISS program. Longer-term and broader change leadership is required to engage colleagues, secure time and resources, and sustain an in situ simulation program. No framework currently exists to describe this process for ISS programs. This manuscript presents a framework derived from the analysis of three successful ISS program implementations across different hospital systems. We describe eight change leadership steps adapted from Kotter's change management theory, used to sustainably implement the ISS programs analyzed. These steps include the following: (1) identifying goals of key stakeholders, (2) engaging a multi-professional team, (3) creating a shared vision, (4) communicating the vision effectively, (5) energizing participants and enabling program participation, (6) identifying and celebrating early success, (7) closing the loop on early program successes, and (8) embedding simulation in organizational culture and operations. We describe this process as a "longitudinal prebrief," a framework which provides a step-by-step guide to engage colleagues and sustain successful implementation of ISS.

Interventions Into Reliability-Seeking Health Care Organizations: A Systematic Review of Their Goals and Measuring Methods

OBJECTIVES

Within the last 2 decades, numerous interventions making use of high-reliability theory have been implemented to increase reliability in healthcare organizations. This systematic literature review first explores the concrete goals on which such interventions focus. Second, the review captures how the achievement of these goals, or alternatively a change, generally an increase in organizational reliability, is measured across different contexts.

METHODS

Searches were conducted in PubMed, Academic Search Ultimate, Business SourcePremier, CINAHL, Communication Source, EconLit, ERIC, Medline, Political Science Complete, PsycArticles, APA PsycInfo, PSYNDEX, SocINDEX (via the resource hosterEbscoHost), and Web of Science (through November 22, 2021). Peer-reviewed, English language studies were included, reporting on the implementation of a concrete intervention to increase reliability in a medical context and referring to high-reliability theory.

RESULTS

The search first yielded 8896 references, from which 75 studies were included in the final sample. Important healthcare goals stated by the seminal report "Crossing the Quality Chasm" guided the analysis of the included studies. Most of the studies originated from the United States and report on interventions to increase reliability of either organizational units or whole organizations when aiming for safety (n = 65). Other goals reported on include effectiveness, and much less frequently timeliness, patient centeredness, and efficiency. Fifty-eight studies use quantitative measurement exclusively to account for the achievement of these goals; 7 studies use qualitative measurement exclusively, and 10 studies use a mixed-method approach. The operationalization of goals, including the operationalization of organizational reliability, and measurement methods do not follow a unified approach, despite claiming to be informed by a coherent theory. Instead, such operationalizations strongly depend on the overall objective of the study and the respective context.

CONCLUSIONS

Measuring the outcomes of high-reliability interventions into healthcare organizations is challenging for different reasons, including the difficult operationalization of partly overlapping goals, the complex, processual nature of achieving reliability, and the limited ability of organizations striving for more reliability if they are already performing on a high level. This review critically assesses the adoption of the goals stated in the seminal report "Crossing the Quality Chasm" and provides insights for organizations and funding providers that strive to evaluate more reliable service provision.

The Medical Resuscitation Committee: Interprofessional Program Development to Optimize Care for Critically Ill Medical Patients in an Academic Pediatric Emergency Department

ABSTRACT

Provision of optimal care to critically ill patients in a pediatric emergency department is challenging. Specific challenges include the following: (a) patient presentations are highly variable, representing the full breadth of human disease and injury, and are often unannounced; (b) care team members have highly variable experience and skills and often few meaningful opportunities to practice care delivery as a team; (c) valid data collection, for quality assurance/improvement and clinical research, is limited when relying on traditional approaches such as medical record review or self-report; (d) specific patient presentations are relatively uncommon for individual providers, providing few opportunities to establish and refine the requisite knowledge and skill; and (e) unscientific or random variation in care delivery. In the current report, we describe our efforts for the last decade to address these challenges and optimize care delivery to critically ill patients in a pediatric emergency department. We specifically describe the grassroots development of an interprofessional medical resuscitation program. Key components of the program are as follows: (a) a database of all medical patients undergoing evaluation in the resuscitation suite, (b) peer review and education through video-based case review, (c) a program of emergency department in situ simulation, and (d) the development of cognitive aids for high-acuity, low-frequency medical emergencies.

An in situ simulation program: a quantitative and qualitative prospective study identifying latent safety threats and examining participant experiences

OBJECTIVE

To explore the impact of in situ simulation training in regard to identification of latent safety threats and participant experiences.

DESIGN

A prospective study including quantitative and qualitative measures.

SETTING

A Danish hospital shifted from simulation training in centers outside the hospital to training where simulation was conducted where the situations normally took place and with the normal working teams.

PARTICIPANTS

A total of 58 local instructors were educated and subsequently conducted in situ simulations in own departments. After each simulation, a log file was completed containing information on location, the scenario, who took part, time, learning points and findings. Furthermore, interviews were conducted with leaders, instructors and simulation participants.

MAIN OUTCOME MEASURES

Identified latent safety threats and participant experiences.

RESULTS

From June 2017 until December 2018, 323 simulations were conducted representing 35 different wards. They consisted of 40 different scenarios and had both technical and non-technical learning goals. A total of 35 organizational issues were uncovered via the in situ simulation and practice was adjusted accordingly. A total of 11 interviews were conducted. Four themes emerged from the analysis: practice-orientation, endorsement, sense of security and additional impact.

CONCLUSION

Transferring simulation to in situ training resulted in a substantial number of organizational findings. The subsequent follow-up and changes in practice made awareness of what could be latent safety threats. Leaders, instructors and simulation participants experienced in situ simulation as relevant and profitable.

The Use of in situ Simulation in Healthcare Education: Current Perspectives

In situ simulation is the practice of using simulated scenarios in a clinical environment itself rather than in training facilities to promote learning and improved clinical care. The use of in situ simulation has been increasingly used to train healthcare staff in dealing with emergencies, resuscitation and clinical skills. The aim of this study is to provide an overview of the themes, perspectives and approaches to in situ simulation for educational purposes with healthcare staff. The literature search included studies describing and evaluating in situ simulations with an educational component. We carried out a narrative synthesis and extracted data on the clinical setting, the simulation purpose, design, evaluation method and impact. In situ simulation has proved useful in a range of different specialties for skills improvement and team development. Simulation design ranges in terms of fidelity, duration and topic. No specific design has shown to be the most efficient. However, adopting a design that fits into the specific centers resources, educational needs and clinical demands is the most important consideration.

Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review

INTRODUCTION

Trauma resuscitation is a complex and time-sensitive endeavour with significant risk for error. These errors can manifest from sequential system, team and knowledge-based failures, defined as latent safety threats (LSTs). In situ simulation (ISS) provides a novel prospective approach to recreate clinical situations that may manifest LSTs. Using ISS coupled with a human factors-based video review and modified framework analysis, we sought to identify and quantify LSTs within trauma resuscitation scenarios.

METHODS

At a level 1 trauma centre, we video recorded 12 monthly unannounced ISS to prospectively identify trauma-related LSTs. The on-call multidisciplinary trauma team participated in the study. Using a modified framework analysis, human factors experts transcribed and coded the videos. We identified LST events, categorised them into themes and subthemes and used a hazard matrix to prioritise subthemes requiring intervention.

RESULTS

We identified 843 LST events during 12 simulations, categorised into seven themes and 38 subthemes, of which 23 are considered critical. The seven themes relate to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals' capacity, infection control and task-specific issues. The physical workspace theme accounted for the largest number of critical LST events (n=152). We observed differences in LST events across the four scenarios; complex scenarios had more LST events.

CONCLUSIONS

We identified a diverse set of critical LSTs during trauma resuscitations using ISS coupled with video-based framework analysis. The hazard matrix scoring, in combination with detailed LST subthemes, supported identification of critical LSTs requiring intervention and enhanced efforts intended to improve patient safety. This approach may be useful to others who seek to understand the contributing factors to common LSTs and design interventions to mitigate them.

Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process

OBJECTIVES

There is little knowledge about which elements of health care simulation are most effective in improving patient safety. When empirical evidence is lacking, a consensus statement can help define priorities in, for example, education and research. A consensus process was therefore initiated to define priorities in health care simulation that contribute the most to improve patient safety.

METHODS

An international group of experts took part in a 4-stage consensus process based on a modified nominal group technique. Stages 1 to 3 were based on electronic communication; stage 4 was a 2-day consensus meeting at the Utstein Abbey in Norway. The goals of stage 4 were to agree on the top 5 topics in health care simulation that contribute the most to patient safety, identify the patient safety problems they relate to, and suggest solutions with implementation strategies for these problems.

RESULTS

The expert group agreed on the following topics: technical skills, nontechnical skills, system probing, assessment, and effectiveness. For each topic, 5 patient safety problems were suggested that each topic might contribute to solve. Solutions to these problems and implementation strategies for these solutions were identified for technical skills, nontechnical skills, and system probing. In the case of assessment and effectiveness, the expert group found it difficult to suggest solutions and implementation strategies mainly because of lacking consensus on metrics and methodology.

CONCLUSIONS

The expert group recommends that the 5 topics identified in this consensus process should be the main focus when health care simulation is implemented in patient safety curricula.

Multiprofessional in situ simulation is an effective method of identifying latent patient safety threats on the gastroenterology ward

OBJECTIVE

In situ simulation (ISS) is an effective training method for multiprofessional teams dealing with emergencies in high pressured environments. A regular ISS programme was organised for the multiprofessional gastroenterology team with a primary objective of identifying, classifying and addressing latent patient safety threats and secondary objectives of improving team confidence and individual role recognition.

METHOD

22 unannounced ISS sessions (averaging approximately one session every 6 weeks and four participants per session) were conducted between February 2017 and August 2019 involving multiprofessional team members. The sessions centred around the following four common gastrointestinal emergency scenarios: massive upper gastrointestinal haemorrhage; biliary sepsis (cholangitis) and shock; postendoscopic retrograde cholangiopancreatography complications including perforation and cardiac arrest. Following the simulation, the faculty, which included nurses and doctors, facilitated a structured debrief session and action plan to identify and address latent errors.

RESULTS

96 participants from nursing, medical, physician associate and pharmacy backgrounds took part in the simulation programme. Analysis of collected latent safety threats identified the following four themes: education and training; equipment; medication and team working. Analysis of anonymously completed questionnaires identified that 95% of participants had a perceived better understanding of their role and 86% felt more confident in assessing an unwell patient. 96% of participants felt comfortable during the debrief.

CONCLUSION

ISS provides a unique opportunity to train the multiprofessional gastroenterology team in their own high-pressured environment, helping identify and address latent patient safety threats and improve perceived participant confidence and role recognition.

Unannounced vs announced in situ simulation of emergency teams: Feasibility and staff perception of stress and learning

BACKGROUND

Simulation-based medical education, often used for teaching teamwork, can be conducted in different settings: off-site (simulation centers or other settings away from clinical units) or in situ (real clinical environment), where the latter can be either announced or unannounced. Simulation in general, but especially unannounced in situ simulation, has been described as stressful and stress can affect learning. The aim of this study was to evaluate feasibility and the perception of learning and stress.

METHODS

Sixteen standardized in situ simulations were planned in an emergency department on eight predetermined dates, with one unannounced and one announced simulation per day. Authentic ad hoc teams were formed based on the on-call staff and included doctors, nurses, radiographers, biochemist, porters, and secretaries. Data were collected using questionnaires and the State-Trait Anxiety Inventory.

RESULTS

Eleven of the 16 in situ simulations were completed. Self-perceived learning was "good" or "very good" for 27/47 (57%) participants and 33/50 (66%) in unannounced vs announced in situ simulation (P = 0.33). Two of 47 (4%) in unannounced in situ simulation "agreed or partly agreed" that in situ simulation was stressful or unpleasant vs 12/50 (24%) in announced in situ simulation (P = 0.06).

CONCLUSION

No significant difference was found between unannounced and announced in situ simulation among emergency department staff according to self-perceived learning and self-perceived stress. This is relevant for the future planning of simulation when considering what is to be achieved from implementing different designs for simulation-based medical education.

Effect of an in-situ simulation workshop on home birth practice in Australia

PROBLEM

Interprofessional training programs for obstetric emergencies have been introduced for up-skilling birth unit staff in hospitals but not frequently used in training midwives and paramedicine staff for home birth emergency.

BACKGROUND

Practical Obstetric Multiprofessional Training (PROMPT) has previously been described in the home birth setting using in-situ simulation training of home births for midwifery and paramedicine staff.

AIM

The aim of this study was to evaluate the benefit of the home birth simulation in clinical practice and to explore how the simulation program prepared the midwives for a birth-related emergency in a publicly funded home birth program.

METHODS

Midwives conducting home births, the midwifery educator and the simulated woman in labour (n=9) attended an interview that explored how the midwives' learning through simulation affected their home birth clinical practice. The simulated woman and the facilitator who conducted the simulation for more than six years were also interviewed to comment on the observed change in performance in simulation. The interview transcripts were thematically analysed.

FINDINGS

The themes that were identified and agreed upon, were applying learning to clinical practice, learning in teams, valuing realism, facilitating simulation based education and managing variation.

DISCUSSION

In-situ nature of simulation with home birth midwives and paramedical staff facilitated learning transfer and team-based approach to practice. The careful simulation design provided a breadth of experience in emergencies.

CONCLUSION

Applying learning to prepare for clinical emergency situations changed the midwives' approach in managing home births. This provided evidence for a change in behaviour (Level 3 Kirkpatrick's framework) and transfer of learning, leading to changed protocols (Level 4a Kirkpatrick's framework).

In Situ Operating Room-Based Simulation: A Review

OBJECTIVE

To systematically review the literature surrounding operating room-based in situ training in surgery.

METHODS

A systematic review was conducted of MEDLINE. The review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, and employed the Population, Intervention, Comparator, Outcome (PICO) structure to define inclusion/exclusion criteria. The Kirkpatrick model was used to further classify the outcome of in situ training when possible.

RESULTS

The search returned 308 database hits, and ultimately 19 articles were identified that met the stated PICO inclusion criteria. Operating room-based in situ simulation is used for a variety of purposes and in a variety of settings, and it has the potential to offer unique advantages over other types of simulation. Only one randomized controlled trial was conducted comparing in situ simulation to off-site simulation, which found few significant differences. One large-scale outcome study showed improved perinatal outcomes in obstetrics.

CONCLUSIONS

Although in situ simulation theoretically offers certain advantages over other types of simulation, especially in addressing system-wide or environmental threats, its efficacy has yet to be clearly demonstrated.

Design of simulation-based medical education and advantages and disadvantages of in situ simulation versus off-site simulation

BACKGROUND

Simulation-based medical education (SBME) has traditionally been conducted as off-site simulation in simulation centres. Some hospital departments also provide off-site simulation using in-house training room(s) set up for simulation away from the clinical setting, and these activities are called in-house training. In-house training facilities can be part of hospital departments and resemble to some extent simulation centres but often have less technical equipment. In situ simulation, introduced over the past decade, mainly comprises of team-based activities and occurs in patient care units with healthcare professionals in their own working environment. Thus, this intentional blend of simulation and real working environments means that in situ simulation brings simulation to the real working environment and provides training where people work. In situ simulation can be either announced or unannounced, the latter also known as a drill. This article presents and discusses the design of SBME and the advantage and disadvantage of the different simulation settings, such as training in simulation-centres, in-house simulations in hospital departments, announced or unannounced in situ simulations.

DISCUSSION

Non-randomised studies argue that in situ simulation is more effective for educational purposes than other types of simulation settings. Conversely, the few comparison studies that exist, either randomised or retrospective, show that choice of setting does not seem to influence individual or team learning. However, hospital department-based simulations, such as in-house simulation and in situ simulation, lead to a gain in organisational learning. To our knowledge no studies have compared announced and unannounced in situ simulation. The literature suggests some improved organisational learning from unannounced in situ simulation; however, unannounced in situ simulation was also found to be challenging to plan and conduct, and more stressful among participants. The importance of setting, context and fidelity are discussed. Based on the current limited research we suggest that choice of setting for simulations does not seem to influence individual and team learning. Department-based local simulation, such as simulation in-house and especially in situ simulation, leads to gains in organisational learning. The overall objectives of simulation-based education and factors such as feasibility can help determine choice of simulation setting.

Mitigating Latent Threats Identified through an Embedded In Situ Simulation Program and Their Comparison to Patient Safety Incidents: A Retrospective Review

OBJECTIVE

To assess the impact of service improvements implemented because of latent threats (LTs) detected during in situ simulation.

DESIGN

Retrospective review from April 2008 to April 2015.

SETTING

Paediatric Intensive Care Unit in a specialist tertiary hospital.

INTERVENTION

Service improvements from LTs detection during in situ simulation. Action plans from patient safety incidents (PSIs).

MAIN OUTCOME MEASURES

The quantity, category, and subsequent service improvements for LTs. The quantity, category, and subsequent action plans for PSIs. Similarities between PSIs and LTs before and after service improvements.

RESULTS

201 Simulated inter-professional team training courses with 1,144 inter-professional participants. 44 LTs were identified (1 LT per 4.6 courses). Incident severity varied: 18 (41%) with the potential to cause harm, 20 (46%) that would have caused minimal harm, and 6 (13%) that would have caused significant temporary harm. Category analysis revealed the majority of LTs were resources (36%) and education and training (27%). The remainder consisted of equipment (11%), organizational and strategic (7%), work and environment (7%), medication (7%), and systems and protocols (5%). 43 service improvements were developed: 24 (55%) resources/equipment; 9 (21%) educational; 6 (14%) organizational changes; 2 (5%) staff communications; and 2 (5%) guidelines. Four (9%) service improvements were adopted trust wide. 32 (73%) LTs did not recur after service improvements. 24 (1%) of 1,946 PSIs were similar to LTs: 7 resource incidents, 7 catastrophic blood loss, 4 hyperkalaemia arrests, 3 emergency buzzer failures, and 3 difficulties contacting staff. 34 LTs (77%) were never recorded as PSIs.

CONCLUSION

An in situ simulation program can identify important LTs which traditional reporting systems miss. Subsequent improvements in workplace systems and resources can improve efficiency and remove error traps.

Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interdisciplinary Teamwork Training, and Performance Feedback

OBJECTIVE

To improve safety practices and reduce adverse events in perinatal units of acute care hospitals.

DATA SOURCES

Primary data collected from perinatal units of 14 hospitals participating in the intervention between 2008 and 2012. Baseline secondary data collected from the same hospitals between 2006 and 2007.

STUDY DESIGN

A prospective study involving 342,754 deliveries was conducted using a quality improvement collaborative that supported three primary interventions. Primary measures include adoption of three standardized care processes and four measures of outcomes.

DATA COLLECTION METHODS

Chart audits were conducted to measure the implementation of standardized care processes. Outcome measures were collected and validated by the National Perinatal Information Center.

PRINCIPAL FINDINGS

The hospital perinatal units increased use of all three care processes, raising consolidated overall use from 38 to 81 percent between 2008 and 2012. The harms measured by the Adverse Outcome Index decreased 14 percent, and a run chart analysis revealed two special causes associated with the interventions.

CONCLUSIONS

This study demonstrates the ability of hospital perinatal staff to implement efforts to reduce perinatal harm using a quality improvement collaborative. Findings help inform the relationship between the use of standardized care processes, teamwork training, and improved perinatal outcomes, and suggest that a multiplicity of integrated strategies, rather than a single intervention, may be essential to achieve high reliability.

Study protocol for a framework analysis using video review to identify latent safety threats: trauma resuscitation using in situ simulation team training (TRUST)

INTRODUCTION

Errors in trauma resuscitation are common and have been attributed to breakdowns in the coordination of system elements (eg, tools/technology, physical environment and layout, individual skills/knowledge, team interaction). These breakdowns are triggered by unique circumstances and may go unrecognised by trauma team members or hospital administrators; they can be described as latent safety threats (LSTs). Retrospective approaches to identifying LSTs (ie, after they occur) are likely to be incomplete and prone to bias. To date, prospective studies have not used video review as the primary mechanism to identify any and all LSTs in trauma resuscitation.

METHODS AND ANALYSIS

A series of 12 unannounced in situ simulations (ISS) will be conducted to prospectively identify LSTs at a level 1 Canadian trauma centre (over 800 dedicated trauma team activations annually). 4 scenarios have already been designed as part of this protocol based on 5 recurring themes found in the hospital's mortality and morbidity process. The actual trauma team will be activated to participate in the study. Each simulation will be audio/video recorded from 4 different camera angles and transcribed to conduct a framework analysis. Video reviewers will code the videos deductively based on a priori themes of LSTs identified from the literature, and/or inductively based on the events occurring in the simulation. LSTs will be prioritised to target interventions in future work.

ETHICS AND DISSEMINATION

Institutional research ethics approval has been acquired (SMH REB #15-046). Results will be published in peer-reviewed journals and presented at relevant conferences. Findings will also be presented to key institutional stakeholders to inform mitigation strategies for improved patient safety.

The Tuscan Mobile Simulation Program: a description of a program for the delivery of in situ simulation training

Simulation has become a critical aspect of medical education. It allows health care providers the opportunity to focus on safety and high-risk situations in a protected environment. Recently, in situ simulation, which is performed in the actual clinical setting, has been used to recreate a more realistic work environment. This form of simulation allows for better team evaluation as the workers are in their traditional roles, and can reveal latent safety errors that often are not seen in typical simulation scenarios. We discuss the creation and implementation of a mobile in situ simulation program in emergency departments of three hospitals in Tuscany, Italy, including equipment, staffing, and start-up costs for this program. We also describe latent safety threats identified in the pilot in situ simulations. This novel approach has the potential to both reduce the costs of simulation compared to traditional simulation centers, and to expand medical simulation experiences to providers and healthcare organizations that do not have access to a large simulation center.

In situ simulation as a tool for patient safety: a systematic review identifying how it is used and its effectiveness

Background

In situ simulation is an emerging technique involving interdisciplinary teams working through simulated scenarios which replicate events encountered in healthcare institutions, particularly those which are either low frequency or associated with high risk to patients. Since it takes place in the clinical environment, it is ideally suited to improving patient safety outcomes.

Objective

To identify and appraise all studies assessing contribution of in situ simulation to patient safety, identify gaps in knowledge and areas for future research, as well as suggesting strategies for maximising its impact on patient safety within an institution.

Study selection

Three electronic databases (MEDLINE, PubMed and EMBASE) as well as the Cochrane Library were searched for articles relating to patient safety outcomes in in situ simulation. In addition a subject expert was approached to suggest any additional articles not identified by electronic searches. A total of 1795 abstracts were identified and screened, 35 full articles assessed for eligibility for inclusion and a total of 18 full articles included in the review after unsuitable articles were excluded.

Conclusions

In situ simulation can improve real-life patient safety outcomes, with 2 studies demonstrating improved morbidity and mortality outcomes following initiation of in situ simulation. There is good evidence to suggest that its implementation leads to improved clinical skills, teamwork and observed behaviours. Additionally, it is ideally suited to detecting latent safety errors (errors identified within a scenario which, if they had occurred in real life, could have led to a degree of harm occurring to a patient).

The use of in situ simulation to detect latent safety threats in paediatrics: a cross-sectional survey

Background

In situ simulation (ISS) has been reported as an innovative method to identify and mitigate latent safety threats (LSTs) in healthcare. Little is known about the current utilisation of ISS across academic simulation programmes.

Objective

This study aims to describe the use of ISS to identify LST across paediatric academic simulation programmes.

Methods

A 25-question cross-sectional survey was conducted at two simulation meetings in January 2014 to recruit leaders from paediatric simulation programmes. The total eligible sample was 82 individuals representing 48 distinct academic medical centres. The 25 survey questions were created to describe the constructs of: (1) utilisation of ISS (location, participants, cancellations and coordination) and (2) the outcomes of ISS (detection of and response to safety threats). Descriptive statistics were carried out using SPSS V.21.0 (IBM Corp released 2012).

Results

The response rate was 68% (56/82), representing 79% (38/48) of the eligible academic medical centres. The majority of respondents (52/56) reported that their programmes utilised ISS. ISS was most commonly conducted in acute care settings. Almost all respondents (48/52) detected an LST during ISS. More than half of the respondents (28/52) utilised a formal reporting process after ISS sessions to feedback the LST to other individuals within their institution. 23% (12/52) of respondents reported the detection of a serious LST in ISS that was not resolved and subsequently led to a safety event during real patient care.

Conclusions

The use of ISS to identify and mitigate LST is common in this cross-sectional survey of paediatric simulation programmes. Diverse processes and organisational structures exist for reporting and mitigating LSTs identified in ISS. A more integrated and systematic approach to ISS and LST could help ensure the mitigation of LSTs before they impact on patients.

Clarifying the learning experiences of healthcare professionals with in situ and off-site simulation-based medical education: a qualitative study

OBJECTIVE

To examine how the setting in in situ simulation (ISS) and off-site simulation (OSS) in simulation-based medical education affects the perceptions and learning experience of healthcare professionals.

DESIGN

Qualitative study using focus groups and content analysis.

PARTICIPANTS

Twenty-five healthcare professionals (obstetricians, midwives, auxiliary nurses, anaesthesiologists, a nurse anaesthetist and operating theatre nurse) participated in four focus groups and were recruited due to their exposure to either ISS or OSS in multidisciplinary obstetric emergencies in a randomised trial.

SETTING

Departments of obstetrics and anaesthesia, Rigshospitalet, Copenhagen, Denmark.

RESULTS

Initially participants preferred ISS, but this changed after the training when the simulation site became of less importance. There was a strong preference for simulation in authentic roles. These perceptions were independent of the ISS or OSS setting. Several positive and negative factors in simulation were identified, but these had no relation to the simulation setting. Participants from ISS and OSS generated a better understanding of and collaboration with the various health professionals. They also provided individual and team reflections on learning. ISS participants described more experiences that would involve organisational changes than the OSS participants did.

CONCLUSIONS

Many psychological and sociological aspects related to the authenticity of the learning experience are important in simulation, but the physical setting of the simulation as an ISS and OSS is the least important. Based on these focus groups OSS can be used provided that all other authenticity elements are taken into consideration and respected. The only difference was that ISS had an organisational impact and ISS participants talked more about issues that would involve practical organisational changes. ISS and OSS participants did, however, go through similar individual and team learning experiences.

Simulation-based multiprofessional obstetric anaesthesia training conducted in situ versus off-site leads to similar individual and team outcomes: a randomised educational trial

OBJECTIVE

To investigate the effect of in situ simulation (ISS) versus off-site simulation (OSS) on knowledge, patient safety attitude, stress, motivation, perceptions of simulation, team performance and organisational impact.

DESIGN

Investigator-initiated single-centre randomised superiority educational trial.

SETTING

Obstetrics and anaesthesiology departments, Rigshospitalet, University of Copenhagen, Denmark.

PARTICIPANTS

100 participants in teams of 10, comprising midwives, specialised midwives, auxiliary nurses, nurse anaesthetists, operating theatre nurses, and consultant doctors and trainees in obstetrics and anaesthesiology.

INTERVENTIONS

Two multiprofessional simulations (clinical management of an emergency caesarean section and a postpartum haemorrhage scenario) were conducted in teams of 10 in the ISS versus the OSS setting.

PRIMARY OUTCOME

Knowledge assessed by a multiple choice question test.

EXPLORATORY OUTCOMES

Individual outcomes: scores on the Safety Attitudes Questionnaire, stress measurements (State-Trait Anxiety Inventory, cognitive appraisal and salivary cortisol), Intrinsic Motivation Inventory and perceptions of simulations. Team outcome: video assessment of team performance. Organisational impact: suggestions for organisational changes.

RESULTS

The trial was conducted from April to June 2013. No differences between the two groups were found for the multiple choice question test, patient safety attitude, stress measurements, motivation or the evaluation of the simulations. The participants in the ISS group scored the authenticity of the simulation significantly higher than did the participants in the OSS group. Expert video assessment of team performance showed no differences between the ISS versus the OSS group. The ISS group provided more ideas and suggestions for changes at the organisational level.

CONCLUSIONS

In this randomised trial, no significant differences were found regarding knowledge, patient safety attitude, motivation or stress measurements when comparing ISS versus OSS. Although participant perception of the authenticity of ISS versus OSS differed significantly, there were no differences in other outcomes between the groups except that the ISS group generated more suggestions for organisational changes.

TRIAL REGISTRATION NUMBER

NCT01792674.

Women's Experiences with Neuraxial Labor Analgesia in the Listening to Mothers II Survey: A Content Analysis of Open-Ended Responses

BACKGROUND

Most women who give birth in United States hospitals receive neuraxial analgesia to manage pain during labor. In this analysis, we examined themes of the patient experience of neuraxial analgesia among a national sample of U.S. mothers.

METHODS

Data are from the Listening to Mothers II survey, conducted among a national sample of women who delivered a singleton baby in a U.S. hospital in 2005 (N = 1,573). Our study population consisted of women who experienced labor, did not deliver by planned cesarean, and who reported neuraxial analgesia use (n = 914). We analyzed open-ended responses about the best and worst parts of women's birth experiences for themes related to neuraxial analgesia using qualitative content analysis.

RESULTS

Thirty-three percent of women (n = 300) mentioned neuraxial analgesia in their open-ended responses. We found that effective pain relief was frequently spontaneously mentioned as a key positive theme in women's experiences with neuraxial analgesia. However, some women perceived timing-related challenges with neuraxial analgesia, including waiting in pain for neuraxial analgesia, receiving neuraxial analgesia too late in labor, or feeling that the pain relief from neuraxial analgesia wore off too soon, as negative aspects. Other themes in women's experiences with neuraxial analgesia were information and consent, adverse effects of neuraxial analgesia, and plans and expectations.

CONCLUSIONS

The findings from this analysis underscored the fact that women appreciate the effective pain relief that neuraxial analgesia provides during childbirth. Although pain control was 1 important facet of women's experiences with neuraxial analgesia, their experiences were also influenced by other factors. Anesthesiologists can work with obstetric clinicians, nurses, childbirth educators, and pregnant and laboring patients to help mitigate some of the challenges with timing, communication, neuraxial analgesia administration, or expectations that may have contributed to negative aspects of women's birth experiences.

Initial steps in designing a simulation center and program to support the opening of a new women and children's hospital in Qatar

Designing and building a simulation program and center is a complex endeavor. This is considerably compounded by the simultaneous planning and construction of new hospital in which it will be house. To support the opening of a new healthcare facility in Doha, Qatar, simulation was chosen as a primary educational solution for the required onboarding of an international workforce, and to help collect data on systems to ensure processes and systems are optimal for patient safety. The following article provides a high-level overview of some of the key considerations and solutions that were made to overcome the many variables that are inherent in the planning phase of designing a center and program for a new hospital.

'In situ simulation' versus 'off site simulation' in obstetric emergencies and their effect on knowledge, safety attitudes, team performance, stress, and motivation: study protocol for a randomized controlled trial

BACKGROUND

Unexpected obstetric emergencies threaten the safety of pregnant women. As emergencies are rare, they are difficult to learn. Therefore, simulation-based medical education (SBME) seems relevant. In non-systematic reviews on SBME, medical simulation has been suggested to be associated with improved learner outcomes. However, many questions on how SBME can be optimized remain unanswered. One unresolved issue is how 'in situ simulation' (ISS) versus 'off site simulation' (OSS) impact learning. ISS means simulation-based training in the actual patient care unit (in other words, the labor room and operating room). OSS means training in facilities away from the actual patient care unit, either at a simulation centre or in hospital rooms that have been set up for this purpose.

METHODS AND DESIGN

The objective of this randomized trial is to study the effect of ISS versus OSS on individual learning outcome, safety attitude, motivation, stress, and team performance amongst multi-professional obstetric-anesthesia teams.The trial is a single-centre randomized superiority trial including 100 participants. The inclusion criteria were health-care professionals employed at the department of obstetrics or anesthesia at Rigshospitalet, Copenhagen, who were working on shifts and gave written informed consent. Exclusion criteria were managers with staff responsibilities, and staff who were actively taking part in preparation of the trial. The same obstetric multi-professional training was conducted in the two simulation settings. The experimental group was exposed to training in the ISS setting, and the control group in the OSS setting. The primary outcome is the individual score on a knowledge test. Exploratory outcomes are individual scores on a safety attitudes questionnaire, a stress inventory, salivary cortisol levels, an intrinsic motivation inventory, results from a questionnaire evaluating perceptions of the simulation and suggested changes needed in the organization, a team-based score on video-assessed team performance and on selected clinical performance.

DISCUSSION

The perspective is to provide new knowledge on contextual effects of different simulation settings.

TRIAL REGISTRATION

ClincialTrials.gov NCT01792674.

In situ simulation: detection of safety threats and teamwork training in a high risk emergency department

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.

In situ simulation in continuing education for the health care professions: a systematic review

INTRODUCTION

Education in the health sciences increasingly relies on simulation-based training strategies to provide safe, structured, engaging, and effective practice opportunities. While this frequently occurs within a simulation center, in situ simulations occur within an actual clinical environment. This blending of learning and work environments may provide a powerful method for continuing education. However, as this is a relatively new strategy, best practices for the design and delivery of in situ learning experiences have yet to be established. This article provides a systematic review of the in situ simulation literature and compares the state of the science and practice against principles of effective education and training design, delivery, and evaluation.

METHODS

A total of 3190 articles were identified using academic databases and screened for descriptive accounts or studies of in situ simulation programs. Of these, 29 full articles were retrieved and coded using a standard data extraction protocol (kappa = 0.90).

RESULTS

In situ simulations have been applied to foster individual, team, unit, and organizational learning across several clinical and nonclinical areas. Approaches to design, delivery, and evaluation of the simulations were highly variable across studies. The overall quality of in situ simulation studies is low. A positive impact of in situ simulation on learning and organizational performance has been demonstrated in a small number of studies.

DISCUSSION

The evidence surrounding in situ simulation efficacy is still emerging, but the existing research is promising. Practical program planning strategies are evolving to meet the complexity of a novel learning activity that engages providers in their actual work environment.