RCN: Patient Safety and Human Factors
1
December 2012
Welcome to the Decemberbulletin on Simulation being produced by the HEFT Library Services. This bulletin is produced to support Simulation training carried out in the Harry Hollier Simulation Centre at Good Hope. This issue will highlight evidence published in the previous 4weeks. Full text articles can be accessed via your HEFT Athens ID.
Human factors
RCN: Patient safety and human factors
The RCN has launched a new patient safety and human factors resource. This area of the RCN website looks at the way certain “human factors” including communications and teamwork play a crucial part in day to day delivery of healthcare. The negative effects of these can be reduced by evidence-based tools and interventions. The website identifies the tools and how they are being used to develop more safety conscious health services. The website complements the online learning'Making sense of patient safety'that uses clinical scenarios to show the role nursing teams can play in protecting patients from harm
Title: Crisis Resources for Emergency Workers (CREW II): Results of a pilot study and simulation-based crisis resource management course for emergency medicine residents
Citation: Canadian Journal of Emergency Medicine, November 2012, vol./is. 14/6(354-362), 1481-8035 (November 2012)Author(s): Hicks C.M., Kiss A., Bandiera G.W., Denny C.J.
Abstract: The study describes the development, piloting, and multilevel evaluation of "Crisis Resources for Emergency Workers" (CREW), a simulation-based CRM curriculum for emergency medicine (EM) residents.
Full Text: Available from ProQuest in CJEM : Journal of the Canadian Association of Emergency Physicians
Title: Using human factors simulation training to improve emergency response to anaesthetic crises
Citation: Anaesthesia, October 2012, vol./is. 67/(38), 0003-2409 (October 2012)Author(s): Allen W., Smith T., Kandasamy G.
Abstract: Whipps Cross Hospital is a district general hospital in the north east of London. In 2010 a multi-disciplinary human factors training and simulation programme was introduced. Prior to this programme the accessibility of key emergency protocols was audited, and then reaudited with the programme ongoing eight months later.
Title: Healthcare management strategies: Interdisciplinary team factors
Citation: Current Opinion in Obstetrics and Gynecology, December 2012, vol./is. 24/6(445-452), 1040-872X;1473-656X (December 2012)Author(s): Andreatta P., Marzano D.
Abstract: Purpose of review: Interdisciplinary team factors are significant contributors to clinical performance and associated patient outcomes. Quality of care and patient safety initiatives identify human factors associated with team performance as a prime improvement area for clinical patient care.
Title: Patient safety & human factors training - A pilot project delivered by trainees, for trainees
Citation: Anaesthesia, October 2012, vol./is. 67/(27), 0003-2409 (October 2012)Author(s): Mistry R., Ho C., Shah M., Mukherjee K.
Abstract: Up to 70% of errors in healthcare errors are attributed to failures related to human factors. The Royal College of Anaesthetists [1] and WHO Patient Safety curricula [2] now recognise the need for training in Non-Technical Skills (NTS). Currently these skills are taught as part of non-mandatory simulation-based sessions which are not available to all trainees. As trainees, the author(s) we developed a program to deliver training in NTS that can be reproduced and applied to future clinical simulation training days.
Title: Human factors and operating room safety.
Citation: Surgical Clinics of North America, February 2012, vol./is. 92/1(21-35), 0039-6109;1558-3171 (2012 Feb) Author(s): ElBardissi AW, Sundt TM
Abstract: A human factors model is used to highlight the nature of many systems factors that affect surgical performance, including the OR environment, teamwork and communication, technology and equipment, tasks and workload factors, and organizational variables..
Full Text: Available from MD Consult in Surgical Clinics of North America, The; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.
Title:Real-time situation awareness assessment in critical illness management: adapting
the situation present assessment method to clinical simulation.
Citation:BMJ Qual Saf. 2012 Dec 4. [Epub ahead of print]Author(s):Shelton CL, Kinston R, Molyneux AJ, Ambrose LJ.
Abstract: Situation awareness (SA) is a human factor of critical importance to patient safety. Simulation training aims to examine and debrief human factors;however, SA cannot be directly observed. This has led to the development of SAmeasurement tools. The Situation Present Assessment Method (SPAM) measures SA in real-time without the need to pause the scenario. The SPAM process involves thedelivery of queries to the participant who must answer them accurately andquickly. The latency between the query being asked and answer being receivedrepresents SA.
Full text: Available in full text here.
Medical errors and patient safety
Title:Interventions for reducing wrong-site surgery and invasive procedures.
Citation:Cochrane Database Syst Rev. 2012 Sep 12;9:CD009404. doi:
10.1002/14651858.CD009404.pub2. Author(s):Mahar P, Wasiak J, Batty L, Fowler S, Cleland H, Gruen RL.
Abstract:OBJECTIVES: To evaluate the effectiveness of organisational and professional
interventions for reducing wrong-site surgery (including wrong-site, wrong-side,
wrong-procedure and wrong-patient surgery), including non-surgical invasive
procedures such as regional blocks, dermatological, obstetric and dental
procedures and emergency surgical procedures not undertaken within the operating
theatre.
Full text: Available in full text here.
Title:Attitude is everything?: The impact of workload, safety climate, and safety tools
on medical errors: A study of intensive care units.
Citation:Health Care Manage Rev. 2012 Oct 18. [Epub ahead of print]Author(s):Steyrer J, Schiffinger M, Huber C, Valentin A, Strunk G.
Abstract:On the basis of extantliterature and concepts on both safety management and organizational/safetyculture, this study investigates to which extent production pressure (i.e.,
increased staff workload and capacity utilization) and safety culture (consisting
of safety climate among staff and safety tools implemented by management)
influence the occurrence of medical errors and if/how safety climate and safety
tools interact
Title:Perceived causes of prescribing errors by junior doctors in hospital inpatients: a study from the PROTECT programme.
Citation: BMJ Qual Saf. 2012 Oct 30. [Epub ahead of print]Author(s):Ross S, Ryan C, Duncan EM, Francis JJ, Johnston M, Ker JS, Lee AJ, Macleod MJ,Maxwell S, McKay G, McLay J, Webb DJ, Bond C.
Abstract: This study aimed to investigate the perceived causes ofprescribing errors among foundation (junior) doctors in Scotland.
Full text: Available in full text here.
Title:Bar-code Verification: Reducing but not Eliminating Medication Errors.
Citation:J Nurs Adm. 2012 Dec;42(12):562-566.Author(s):Henneman PL, Marquard JL, Fisher DL, Bleil J, Walsh B, Henneman JP, Blank FS,Higgins AM, Nathanson BH, Henneman EA.
Abstract:Using observation, eye tracking, and clinical simulation with embedded errors, we
studied the impact of bar-code verification on error identification and recoveryduring medication administration. Data supported that bar-code verification mayreduce but does not eliminate patient identification (ID) and medication errorsduring clinical simulation of medication administration.
Title:Reducing Interruptions to Improve Medication Safety.
Citation:J Nurs Care Qual. 2012 Oct 23. [Epub ahead of print] Author(s):Freeman R, McKee S, Lee-Lehner B, Pesenecker J.
Abstract: Thisarticle describes a bundle of safety interventions that reduced the average
number of interruptions during medication administration by 2.11 interruptions
per encounter and decreased reported medication errors by a total of 28 incidents
over a 3-month period.
Medical debriefing
Title: The Emerging Role of Simulation Education to Achieve Patient Safety. Translating Deliberate Practice and Debriefing to Save Lives
Citation: Pediatric Clinics of North America, December 2012, vol./is. 59/6(1329-1340), 0031-3955;1557-8240 (December 2012)Author(s): Griswold S., Ponnuru S., Nishisaki A., Szyld D., Davenport M., Deutsch E.S., Nadkarni V.
Abstract: This article highlights emerging evidence that shows how simulation-based interventions and education contribute to safer, more efficient systems of care that save lives.
Full Text: Available from MD Consult in Pediatric Clinics of North America; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.
Title: A novel use of simulation: Medicolegal simulation
Citation: Annals of Emergency Medicine, November 2012, vol./is. 60/5(S182-S183), 0196-0644 (November 2012)Author(s): Smith M.D., Veitinger N., Disilvio M., Noeller T.P.
Abstract: Study Objective: We describe the use of simulation techniques to create a mock deposition that bolstered EM medicolegal curricula.
Full Text: Available from MD Consult in Annals of Emergency Medicine; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.
Simulation and medical training
Title: Evaluation of simulation-based training model on vascular anastomotic skills for
surgical residents.
Citation: Simul Healthc. 2012 Dec;7(6):334-8. doi: 10.1097/SIH.0b013e318264655e.
Author(s): Sigounas VY, Callas PW, Nicholas C, Adams JE, Bertges DJ, Stanley AC,
Steinthorsson G, Ricci MA.
Abstract: The study hypothesized that practice on surgical task simulators
would improve residents' technical performance of vascular anastomotic technique.
Full text: Available in Print from Harry Hollier Simulation Centre
Title: Using simulation to support doctors in difficulty.
Citation: The clinical teacher, October 2012, vol./is. 9/5(285-9), 1743-4971;1743-498X (2012 Oct)Author(s): Stirling K, Hogg G, Ker J, Anderson F, Hanslip J, Byrne D
Abstract: BACKGROUND: A small percentage of medical trainees will have performance concerns identified within their clinical practice. These trainees require specific interventions to address these concerns. The Postgraduate Ward Simulation Exercise (PgWSE) was developed as a joint collaboration between the University of Dundee and NHS Education for Scotland (NES).
Full Text: Available from EBSCOhost EJS in Clinical Teacher, The
Title:Unannounced in situ simulations: integrating training and clinical practice.
Citation:BMJ Qual Saf. 2012 Dec 4. [Epub ahead of print]
Author(s):Walker ST, Sevdalis N, McKay A, Lambden S, Gautama S, Aggarwal R, Vincent C.
Abstract:The authors discuss their experiences of 'in situ' simulation for unannounced
cardiac arrest training when the training is taken to the clinical environment.
Full text: Available in full text here.
Title: The perceived value of multidisciplinary simulation training in obstetric emergencies
Citation: Anaesthesia, October 2012, vol./is. 67/(29), 0003-2409 (October 2012)
Author(s): Patel P., Fox V., Kitching M., Kaskos H., Van Hoogstraten R., Calvin M., Sockalingam I.
Abstract: The authorspresent findings from regular simulation training of both obstetric and anaesthetic staff in management of obstetric emergencies.
Title: Acute care simulation training: Enhancing patient safety by improving non-technical skills
Citation: Anaesthesia, October 2012, vol./is. 67/(28), 0003-2409 (October 2012) Author(s): Patel P., Fox V., Kaskos H., Teh E., Sockalingam I.
Abstract: The authors present findings from acute care simulation training of Foundation doctors at their trust.
Title: Case-based simulation: Critical conversations around resuscitation of the critically ill or injured patient
Citation: Annals of Emergency Medicine, October 2012, vol./is. 60/4 SUPPL. 1(S149-S150), 0196-0644 (October 2012) Author(s): Lamba S., Nagurka R., Offin M., Compton S.
Abstract: Study Objectives: Educational module objectives to enhance communication with family: To practice skills of clear/direct, closed-loop communication with interdisciplinary teams (simulated resuscitation) To enhance skills and use appropriate behaviors (responding to emotion, comforting someone in emotional shock) when breaking bad news/delivering news of death to survivors (simulation/role-play) To foster skills of self-reflection in order to identify processes for improvement and manage emotional responses
Full Text: Available from MD Consult in Annals of Emergency Medicine; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.
Title:Effectiveness of a simulated training model for procedural skill demonstration in
neonatal circumcision.
Citation:Simul Healthc. 2012 Dec;7(6):362-73. doi: 10.1097/SIH.0b013e3182634aceAuthor(s):Roca P, Alvarado C, Stausmire JM, Farooq S, Hill-Engstler EA.
Abstract: The study improved the design of a low-fidelity penile modelconstructed of cocktail wieners following the one by Brill and Wallace (Fam Med2007;39:241-243) and attached it to a high-fidelity infant simulator. Providingsimulated movement and crying similar to what is encountered in routine newborncircumcisions create a more realistic training scenario.The study objectives wereto (1) evaluate the educational experience of a simulated skill training program as perceived by participants based on a comparison scale and (2) evaluate thefidelity of the simulated model.
Full text: Available in Print from Harry Hollier Simulation Centre
Title:Simulation training for improving the quality of care for older people: an
independent evaluation of an innovative programme for inter-professional
education.
Citation: BMJ Qual Saf. 2012 Dec 6. [Epub ahead of print]Author(s):Ross AJ, Anderson JE, Kodate N, Thomas L, Thompson K, Thomas B, Key S, Jensen H, Schiff R, Jaye P.
Abstract:This paper describes the evaluation of a 2-day simulation training
programme for staff designed to improve teamwork and inpatient care and
compassion in an older persons' unit.
Full text: Available in full text here.
Team training
Title:Building a culture of safety through team training and engagement.
Citation:BMJ Qual Saf. 2012 Dec 4. [Epub ahead of print] Author(s):Thomas L, Galla C.
Abstract:The goal of this study was to build a culture of patient safety within a structure that optimised teamwork and ongoing engagement of thehealthcare team. Teamwork impacts the effectiveness of care, patient safety andclinical outcomes, and team training has been identified as a strategy forenhancing teamwork, reducing medical errors and building a culture of safety inhealthcare. Therefore, the author(s) implemented Team Strategies and Tools to EnhancePerformance and Patient Safety (TeamSTEPPS), an evidence-based framework whichwas used for team training to create transformational and/or incremental changes;facilitating transformation of organisational culture, or solving specificproblems.
Full text: Available in full text here.
Title: Team performance in resuscitation teams: Comparison and critique of two recently developed scoring tools
Citation: Resuscitation, December 2012, vol./is. 83/12(1478-1483), 0300-9572;1873-1570 (December 2012)Author(s): McKay A., Walker S.T., Brett S.J., Vincent C., Sevdalis N.
Abstract: Following high profile errors resulting in patient harm and attracting negative publicity, the healthcare sector has begun to focus on training non-technical teamworking skills as one way of reducing the rate of adverse events. Within the area of resuscitation, two tools have been developed recently aiming to assess these skills - TEAM and OSCAR. The aims of the study reported here were:. 1.To determine the inter-rater reliability of the tools in assessing performance within the context of resuscitation.2.To correlate scores of the same resuscitation teams episodes using both tools, thereby determining their concurrent validity within the context of resuscitation.3.To carry out a critique of both tools and establish how best each one may be utilised.
Full Text: Available from Elsevier in Resuscitation; Note: ; Notes: You will need to register (free of charge) with Science Direct the first time you use it.
Title: Managing a surgical exsanguination emergency in the operating room through simulation: An interdisciplinary approach
Citation: Journal of Surgical Education, November 2012, vol./is. 69/6(759-765), 1931-7204;1878-7452 (November-December 2012)Author(s): Acero N.M., Motuk G., Luba J., Murphy M., McKelvey S., Kolb G., Dumon K.R., Resnick A.S.
Abstract: Objective: Operating room (OR) emergencies, such as fire, anaphylaxis, cardiac arrest, and exsanguination, are infrequent, but high-risk situations that can result in significant morbidity and mortality. An exsanguination scenario involving a pregnant trauma patient in the OR was developed for surgery residents with the objectives of improving overall team performance when activating an emergency response system, identifying a team leader, initiating an exsanguination protocol, following advanced cardiac life support guidelines, and recognizing the mother as the first patient.
Title: Be SMARTT about trauma: An interdisciplinary educational approach to improving teamwork in the trauma bay
Citation: Annals of Emergency Medicine, November 2012, vol./is. 60/5(S172-S173), 0196-0644 (November 2012)Author(s): McDowell C.M., Roberts N.K., Sutyak J., Griffen D., Wall J., Schwind C., Williams R.G.
Abstract: Patient care outcomes are adversely affected by poor teamwork. Trauma teams are particularly prone to communication problems and an absence of overt leadership. The objective of the study was to improve leadership behaviors and communication in ad hoc trauma teams.
Full Text: Available from MD Consult in Annals of Emergency Medicine; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.
Title: Technology-assisted trauma case review conference-combining simulation and audience response
Citation: Annals of Emergency Medicine, November 2012, vol./is. 60/5(S182), 0196-0644 (November 2012)Author(s): Dorfsman M.L., Phrampus P.E.
Abstract: The objective of the study was to develop a unique way to present trauma or morbidity and mortality cases, actively involving each resident, medical student, and faculty member attending the conference.
Full Text: Available from MD Consult in Annals of Emergency Medicine; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.
Title: The simulation Olympics: A resuscitation-based simulation competition as an educational intervention
Citation: Canadian Journal of Emergency Medicine, November 2012, vol./is. 14/6(363-368), 1481-8035 (November 2012)Author(s): Dagnone J.D., Takhar A., Lacroix L.
Abstract: The Department of Emergency Medicine at Queen's University developed, implemented, and evaluated an interprofessional simulation-based competition called the Simulation Olympics with the purpose of encouraging health care providers to practice resuscitation skills and foster strong team-based attitudes.
Full Text: Available from ProQuest in CJEM : Journal of the Canadian Association of Emergency Physicians
Title: Speaking up is related to better team performance in simulated anesthesia inductions: An observational study
Citation: Anesthesia and Analgesia, November 2012, vol./is. 115/5(1099-1108), 0003-2999 (November 2012)Author(s): Kolbe M., Burtscher M.J., Wacker J., Grande B., Nohynkova R., Manser T., Spahn D.R., Grote G.
Abstract: Our goal in this study was to test the relationship between speaking up-i.e., questioning, correcting, or clarifying a current procedure-and technical team performance in anesthesia.
Full Text: Available from Free Access Content in Anesthesia and Analgesia
Available from Ovid in Anesthesia and Analgesia
Title: Impact of an open-chest extracorporeal membrane oxygenator model for in situ simulated team training: A pilot study