3/9/19 Leading Causes of Death (US) 1.Heart Disease: 635,260 - - PDF document

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Safety at the Sharp End: Simulation for Better Outcomes

• Dr. Kim Leighton, Dr. Maggie Allen, Dr. Aisha Aladab

Leading Causes of Death (US)

1.Heart Disease: 635,260 2.Cancer: 598,038 3.Accidents: 161,374 4.Chronic Lower Respiratory Disease: 154,596 5.Stroke: 142,142 Emily Jerry

• Yolk sac tumor in abdomen
• Surgery
• Several rounds of chemo
• MRI – cancer free!
• Celebrated 2nd birthday in

hospital

• One last dose of chemo ‘just to

be sure’

Emily Jerry Foundation

Lewis Blackman

• Elective surgery; postop

severe abdominal pain and distension

• Cold sweat, pain x 3 days
• Pulse ox alarm lowered

because keeping him awake

• Residents didn’t call attending
• Pain stops after 5 days
• BP with 12 different cuffs and

machines

Patient Safety Movement

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Josie King

• 18-months old
• 2nd degree burns over 60% of

her body

• Ventilator, central line, dressing

changes, skin grafts

• Two weeks and out of ICU;

close to discharge

• PCA d/c, started on methadone

to wean from narcotics

Josie King Foundation

• Thirst, really thirsty
• Vomiting, diarrhea
• Temp 102
• D/C central line - ? Infection
• Weak, lethargic
• Narcan à no more pain meds
• Anesthesia worried about

withdrawal; reorders methadone

Human Factors

”We can’t change the human condition, but we can change the conditions under which humans work.” James Reason

What are Human Factors?

Courtesy of Patrick O Connor and Ken Arnold Hazard Management and the Importance of Human Factors Presentation to the Marine Board

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Error s Violatio ns Development of an Organizational Accident (developed from J. Reason) Person

Human Factors in Incidents The Interaction of Human Factors

Unsafe Acts

Errors Decision Errors Skill Based Errors Perceptual Errors Violations Routine Exceptional

§ Improper work procedure § Misdiagnosed situation § Wrong response action § Exceeded ability/authority § Inappropriate maneuver § Poor decision making § Adverse mental state § Haste or task saturation § Situational awareness § Failed to use resources § Hiring the wrong person § Fail to track performance § Breakdown in visual scan § Failed to prioritize focus § Inadvertent use of controls § Omitted step in procedure § Omitted checklist item § Poor technique or ethic § Over reaction to controls § Inexperience or capability § Adverse physiological state § Physical or mental limitations § Inadequate safety training § Lack of intelligence/aptitude § Lack skills or qualifications § Misapplied skill set § Spatial disorientation § Visual illusion § Misunderstood task § Misunderstood rules § Poor work environment § Miscommunication § Tight time constraints § Personal readiness § Work/home distraction § Mental complacency § Inadequate reaction time § Inadequate rest breaks § Time pressures § Failed job requirements § Failed to follow direction § Lack of worker training § Breakdown communication § No supervisor oversight § Hazard not identified § Controls in-place not used § Substandard work practices § Pre-existing illness or injury § Failure of leadership to act § Failure to correct problem § Failed to enforce the rules § Failed to report unsafe acts § Lack of funding § Excessive cost cutting § No formal accountability § Poor equipment design § Unauthorized work § Exceeded authority § Over reaction § Lack of capability § Lack of qualification § Except very high risk § Poor planning § Lack of objectives § Unrealistic goals § Under manned/resourced

Organizational Challenges

• 1. Huddles
• 2. Briefings
• 3. Debriefings
• 4. Team communication
• 5. Monitor the Baseline
• 6. Use technology

What Can You Do to Help Maintain Situational Awareness?

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• 1. Understand your processes
• 2. View your processes through a human factors lens
• 3. Chose the right strategy
• 4. Proactively address human factors violations
• 5. Human Factors Self Assessment

What Can We Do to Address Human Factors Violations? What is Simulation?

“a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion” (Gaba, 2004, p. 2)

Gaba, D. (2004). The future vision of simulation in health care. Quality and Safety in Health Care, 13 (Suppl 1), 2-10. Nov 2012--

Why Simulation?

• Lack of Clinical Sites/Cases
• Patient Complexity
• Rules Limiting Skill Performance
• Limit on Number of Students per Site
• Faculty/Student Ratio on Clinical

The Value of Simulation

• Safe Environment
• Learn from Mistakes
• Repetition
• Enhance Teamwork & Collaboration
• Improve

– Critical Thinking & Clinical Judgment – Organization, Prioritization, & Communication

• Control Types of Patient Experiences
• Can Observe Learners More Closely

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26

Urbanization Simulation Credit: Carrie Mattingly, Twitter

Types of Simulation

27

Role Play Credit: Monash University Role Play Credit: The Doctors

28

Credit: SWS Sydney

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Credit: Inside Hook

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30 31

Once is Not Enough . . . Reflecting on Your Needs

• What patient did you think about ?
• Why did the medical error occur?
• What do you want practitioners to learn?
• How could simulation help?

Thank You!

• Dr Kim Leighton, KLeighton@hamad.qa
• Dr Maggie Allen, MAllen@hamad.qa
• Dr Aisha Aladab, AAladab@hamad.qa