Health Administration Press
Chapter 8: Simulation in Healthcare Quality and Safety
Chapter Outline
• Introduction to Simulation
• Applying Education Frameworks to Patient Safety
Simulation
• Simulation in the Patient Safety Landscape
• Conclusion
• Study Questions
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Health Administration Press
Simulation Terminology
• Level of “fidelity” in healthcare simulation
• Educational delivery models:
–Task trainers
–Standardized patients
–High-fidelity options
–Low-fidelity options
• Debriefing
–Supporting a dialogue to encourage reflection
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Health Administration Press
Healthcare Simulation: Evolution & History
• Early training models in training programs
• Parallels with the aviation industry
• Crew resource management (CRM)
• To Err Is Human
• Champions of simulation
• Professional societies and their development
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Health Administration Press
Skills Addressed with Simulation
• Clinical skills (e.g., physical examination)
• Procedural skills
• Communication skills
• Interprofessional skills
• Leadership skills
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Health Administration Press
Simulation and Educational Programming
• Undergraduate audience: medical school, nursing school
• Graduate audiences: postgraduate trainees
• Stakeholders: education and clinical leadership
• Theoretical frameworks and paradigm shifts
– “See one, do one, teach one”
– Experiential learning
– Deliberate practice
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Health Administration Press
Simulation Center and In-Situ Design
Center
In Situ
Environmental Fidelity
Control of Scenario
Less Stress on Educators & Learners
Logistical Control
Team & Systems Evaluation
Realism
Time
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Health Administration Press
Educational Frameworks
• Adult learning
• Learner-centered design
• Experiential learning
• David Kolb’s cycles of learning
• Ericson’s concept of deliberate practice
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Health Administration Press
The Core of Simulation: Debriefing
• Guided reflective dialogue
• Debriefing in-action vs. on-action
• Addresses the cognitive, affective, and psychomotor
domains of the simulation
• Focus on interprofessional conversation
• Address strengths and opportunities for learning
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Health Administration Press
Crew Resource Management and Simulation
Team Strategies and Tools to Enhance Performance and
Patient Safety (TeamSTEPPS)
• Leadership
• Communication
• Situational monitoring
• Mutual support
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Health Administration Press
Opportunities to Address Errors
• Systems errors
• Uncover and expose latent threats
• Walk-throughs and/or reenactments
• Failures mode and effects analysis (FMEA)
• Just-in-time training
• Mock codes and drills
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Health Administration Press
Simulation in Patient Safety
• Consider the following questions:
• What is the goal for the simulation?
• Does the simulation match the learning objectives desired for
participants?
• What task trainers or simulation modalities are needed?
• Where does the simulation need to be executed?
• Does this need to be in center?
• Would it be more effective if performed in the actual clinical environment?
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Health Administration Press
Conclusion
• Simulation is an effective education tool that can be linked
with patient safety and quality efforts.
• Simulation can address known patient safety threats, and
even identify latent threats.
• It is essential to match the appropriate simulation-based
tools and modalities to the patient safety training
programs being designed.
• Successful simulation training programs are those that are
interprofessional and involve leadership and stakeholders.
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Health Administration Press
Study Questions
1.
2.
3.
4.
5.
How would you select and implement one or more of the simulationbased approaches discussed at your institution?
What are some of the challenges with leveraging simulation into
educational interventions to improve health outcomes and support
change in the clinical landscape of your institution?
Identify three key questions and/or issues that need to be considered
when planning to integrate healthcare-based simulation into your
program and/or institution?
What are some simulation-based technologies that can be integrated into
educational and training programs that address some of the following
deficiencies: ineffective teamwork, lumbar puncture associated infection
rates, poor chest compressions during CPR, novice laparoscopic skills?
What are some quality improvement tools that are linked with
simulation-based education to augment training programs and/or
interventions?
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College of Healthcare Executives. Not for sale.
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Live Session
Module #7
Patient Safety & Outcomes:
Healthcare Errors
HCM520
Quality and Patient Safety
What is a Diagnostic Error?
►
►
►
Situations when the correct diagnosis is…
►
Wrong
►
Significantly delayed
►
Missed
Some situations are unavoidable
►
Masked or atypical symptoms
►
Current tests lack sensitivity
►
Early stages of particular diseases
Most situations are preventable
►
Breakdown exists somewhere in the diagnostic process
► Cognitive
► System-related
► Both
Course Code and Title
Cause and Outcomes of
Diagnostic Errors
Course Code and Title
How Do We Arrive at a Diagnosis?
►
►
Most are made from…
►
History
►
Physical exam
Synthesis (reasoning) phase is important
►
►
Most prone to cognitive errors
The process is known as clinical reasoning
►
Often described by the ‘dual process’ paradigm
Course Code and Title
Dual Process Paradigm
Course Code and Title
System I
►
Intuitive problem solving
►
►
►
Instantaneous decision by the brain of what the problem is
or if the problem has been seen before
If the problem is recognized…
►
Diagnosis is made rather quickly
►
Based on intuition
Error-prone, especially when non-experts use it
►
Jumping to conclusions
►
Context errors
►
Seeking confirmation only
►
Diagnostic inertia
Course Code and Title
System II
►
Applying deliberate, rational thought
►
Success depends on…
►
►
Depth of knowledge
►
Ability to use evidence-based medicine
►
Skill in reasoning
Requires more time, effort, attention than System I
Course Code and Title
How Common are Diagnostic
Errors?
►
In the US…
►
40,000-80,000 preventable deaths from misdiagnosis
►
10-15% of ALL diagnosis are incorrect
►
5% of people are misdiagnosed in outpatient settings
►
Result in malpractice claims
►
Cause harm
►
Errors lead to delayed, unnecessary, inappropriate
testing and treatment
►
Increase in health costs
Course Code and Title
Factors Contributing to Error
►
Categories
► System-related
► All characteristics impacting safety/quality
► Distractions? Balanced workload? Adequate training?
Patient-centered?
► Cognitive
► Faulty knowledge
► No knowledge of disease, lacking the skills to diagnose
► Faulty data gathering
► Incomplete patient history, physical exam
► Faulty synthesis
► Most common
► ‘No fault’ (out of physician control)
Course Code and Title
Avoiding Diagnostic Errors
►
Thorough history and physical exam
►
Gather all relevant background
►
Watch out for context errors
►
Review some of the ‘high-risk’ situations
Course Code and Title
Cognitive-Related Interventions
►
Invoke analytical reasoning
►
Take a diagnostic ‘time-out’
►
Pause to reflect
►
How was the diagnosis established?
►
What else could it be?
►
Speak with peers
►
Obtain specialist insight if unsure
Course Code and Title
System-Related Interventions
►
Improve clinical workflow
►
Appropriate training and supervision
►
Specialist consultations
►
Providing medical hardware, software
►
Robust electronic medical record system
►
►
More effective discharge planning
►
►
Include a built-in decision support software
Follow up with patients
Clinician examples to learn from
Course Code and Title
Involving Patients
►
Should be partners
►
Should be educated on what to do if symptoms persist
or get worse
►
Clinicians should keep an open mind
►
Listen to the patients
Course Code and Title
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