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Simulation and Integration into Patient Safety Systems
By Michael Moyer, Ph.D., MS, Program Director, Trihealth Simulation & Education Center
Human patient simulation (HPS) has made phenomenal strides in the healthcare industry since most medical facilities are now placing this training under the “clinical ladder” of their organizations hierarchy, where training of clinicians is readily available. This form of training has proven to be the golden standard in allowing multidisciplinary groups in any healthcare setting (for example) to practice simple to difficult medical scenarios. From everyday type illnesses or injuries to high-risk, but low acuity type occurrences; giving those medical providers the ability to be prepared for nearly all medical inconsistencies.
Just as important though are the reduction in patient safety events or medical errors that occur as a result of many variables. Patient safety systems within medical facilities can be effective in their own right; however, integrating medical simulation can push the limit in reducing the overall “abundance” of errors in hospitals and medical institutions. While early data in healthcare showed close to 98,000 errors in medicine annually, the push to find relevant statistical evidence for verifying this number actually showed that there was nearly three-times the number of medical errors; surprisingly making this the third leading cause of death in the United States alone. It also showed that what many thought about integrated patient safety systems in practice were not enough; that we needed to modify what we were doing in order to correct our current practices.
While experiential learning has been a proven concept in many fields, including healthcare, aviation was the impetus to introducing human patient simulation into medicine. The practice of the pilot being in charge of a commercial aircraft, while appearing the dominant and commanding methodology that one needed to ensure safe, effective leadership to take an aircraft from one destination to another, proved drastically wrong to this industries patient safety system. In fact, it doomed the industry for quite some time with many of the malfunctions of aircrafts a result of human error which clearly proved to be preventable. Other members of flight crews not speaking up, pilots and other members in the cockpit and service crew operating in “silos,” or were all working independently, afraid to speak up even if they saw a mistake or error.
This changed as a result of investigating how and why mistakes and crashes were continuing to increase, much in the way we are seeing this happen in medicine. Crew resource management (CRM) began to be a part of every training, which focused on using simulators in the airline industry as well as adding improved communication and teamwork skills.
When team members do not feel as though they are treating a real patient in a real environment, it takes away from the experience in many ways
It involved a better understanding that 70 percent of all errors resulted because of communication failures.
Soon, with the proof of where errors were originating in aviation, comparisons were being made in other high-risk settings, such as medicine, nuclear power plants, and even oil field services. Simulators that were being used in the aviation setting began showing up in many of these sites in order to practice not only avoiding errors, but understanding how errors occur; which meant that older practices of simply having “patient safety systems,” needed something more. This included simulation and better means to educate those working within these industries; a more productive way to take advantage of utilizing every member of the team’s experience. In other words, patient safety systems by themselves were not enough. High reliability organizations (HRO), which are known to avoid sentinel or catastrophic events, were beginning to use simulators and facilitation to explore patient safety. Simulations provided for hands on and realistic practice in actual or real environments, while facilitation proved to be much more constructive then “educating” those using simulation. Educating involved more lecturing from educators while facilitating involved those in lead education roles initiating a discussion between participants and allowing them to learn from each other rather than from a single educator. A facilitator turned out to be a much better alternative as one who guides the learning, not is the only provider to the learning.
One final concept that many HROs are continuing to use is in-situ training. An example often used is in the medical field. While there are a great number of simulation centers either in or outside of hospitals which are used by medical teams (emergency departments, intensive care Units amongst others), there is always some degree of non-reality; meaning that the simulation lab is not “exactly” set-up like a room in the environment trying to be portrayed. While beds, equipment, or even most supplies can be the same, clocks on the wall, crash carts or syringes may be different in some shape or form, which does not allow the team to reach what is referred to as a “suspension of disbelief.” When team members do not feel as though they are treating a real patient in a real environment, it takes away from the experience in many ways. In-situ training has become a very popular methodology in simulation whereby the simulation is carried out in the hospital, on the floor, in a room where the team actually works. This provides for a natural flow between providers, teams, and their regular environment, which then creates an almost natural provision of “belief” that the “patient” is real.
The power of introducing in-situ into the patient safety system of hospitals or any HRO has additional effects on patient safety programs. It allows for caregivers who are running simulations to use equipment within an actual patient room that can uncover any missing or broken equipment. This seems small but in fact is crucial, since it is found through simulation, rather than when or if needed on an actual patient, which could lead to a serious safety event or worse. Likewise, if inadequate equipment is found, it can be used as an alert to check other rooms or areas to ensure it is not a widespread problem versus one room concern. Finally, by providing opportunities for staff to work together and to actually use equipment that perhaps they have never used gives them empowerment to feel confident in the future, but it also points out weaknesses in staffing or inadequate areas of equipment placement that can be changed prior to an actual patient being in the room.
While patient safety systems have been defiant in many organizations, or as one might offer up, non-transparent, it is those organizations who are making the differences by not only changing how they report medical errors or sentinel events, but how they improve their safety systems altogether. It has been shown in many ways that HPS can be a useful tool in many ways as a secondary means to the patient safety system in many organizations. It is a way to be transparent and yet proactive in solving latent safety threats and preventing harm to patients prior to them even reaching their destination.