Medical Simulation and Patient Safety
This audience is well-aware of the burden of adverse patient events and outcomes in healthcare: those preventable errors documented (Leape1994, Davis 2002) likely to be only a fraction of the true number/ cost of numerous minor errors, and no convincing evidence of overall improvement in the past 10 years. Some knowledge is also assumed of human fallibility and patterns of error, a systems approach to safety, and the swiss cheese model of analysing causes of system failure (Reason 2000).
The use of simulation in healthcare education and research is rapidly increasing in NZ and globally. Integration of simulation into clinical teaching is now an expectation in leading medical and nursing schools. Drivers for this include public expectation that healthcare providers acquire basic competencies before trying out their technical skills on patients, and simulation’s capacity to increase the quality and efficiency of learning by providing controlled exposure to key clinical situations, including those that are uncommon or potentially dangerous.
This paper highlights a broad role for simulation in reducing harm and cost associated with errors, and as a tool to mature and sustain a safety culture.
In other words, how can simulation assist to identify cheese slices and their holes (defence layers/ latent errors) and to evaluate strategies to improve defences?
Simulation has traditionally been used for learning technical skills – practising on fellow students, on simple physical objects and on an increasing range of skills trainers. Some behavioural (non-technical) skills have also been taught or assessed using simulation in the form of standardised patients /actors, or screen-based simulation.
As research has established the predictably major role of human factors in medical error, simulated scenarios have emerged as a useful means to improve communication among healthcare staff, decision-making and resource management. This is not to downplay the importance of competence in technical skills, but it is clear these are not enough on their own (Bromiley Report, www.chfg.org).
The facilitated debrief following a simulated scenario is the most valued part by participants of such an exercise. Debriefing is not simple feedback on errors; in contrast debriefing explores with participants why errors occurred or were avoided. Thus skilled debriefing addresses knowledge gaps but also assists learners to identify human factors and how to manage them at individual and team level. Scenarios routinely illustrate predictable perceptual problems in gathering information, predictable cognitive biases eg confirmation bias, barriers to asserting concerns, consequences of not sharing the mental model of the situation with the team, effects of assumptions - all human factors that even in retrospective chart reviews with their limitations, can be seen to be major contributors to adverse events. Specific teamwork strategies such as closed loop communication, briefing with an SBAR framework, structured handover, cross monitoring of team members, graded assertion of concerns, the Surgical Safety Checklist - these are layers of defence against error well-taught and evaluated using simulated scenarios (eg Flanagan 2004, Draycott 2008, Marshall 2009, Weller 2011).
Effective teamwork is one of our last defences – scenarios are also a method to address the contribution of systems to patient safety – identified as the major target (at least 30%) for interventions to prevent recurrence of adverse events (Davis 2002). This technique reaches its fullest potential to investigate, educate and try out interventions when scenarios are conducted in the clinical environment with real teams – “in situ” - with adequate debriefing by trained facilitators (Garden 2010, Riley 2010).
Perhaps less apparent is how conducting simulation in-situ can reinforce dimensions known to develop a safety culture: managerial commitment to overall continuous improvement, priority given to safety, education on a systems approach to error, an effective method of investigating and learning from incidents, open communication about safety issues, effective and well-received training methods, specific teamworking (NHS MaPSaF 2006). Getting healthcare from Safety Culture Level B or C (reactive and bureaucratic) to Level D and E (proactive and generative) is the goal. Mature safety culture is fundamental to refining defence layers, eradicating latent errors and managing active errors.
Finally the important role of simulation in research to improve patient safety must not be overlooked; investigating human factors, evaluating new equipment/ safety interventions or as a method to evaluate educational techniques.
Bromiley Report, www.chfg.org
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