Safety at the Sharp End: Simulation for Better Outcomes

1. Safety at the Sharp End: Simulation for Better Outcomes Dr. Kim Leighton, Dr. Maggie Allen, Dr. Aisha Aladab

2. As part of our extensive program and with CPD hours awarded based on actual time spent learning, credit hours are offered based on attendance per session, requiring delegates to attend a minimum of 80% of a session to qualify for the allocated CPD hours. • Less than 80%attendance per session = 0 CPD hours • 80% or higherattendance per session = full allotted CPD hours • Total CPD hours for the forum are awarded based on the sum of CPD hours earned from all individual sessions. ME Forum 2019 Orientation

3. Conflict of Interest The presenters in this session have no conflict of interest or disclosure in relation to this presentation.

4. Learning Objectives • At the end of this session, participants will be able to: • Identify common preventable causes of medical error • Discover the role of simulation for improving patient safety • Create ideas for how simulation can impact patient outcomes

5. Leading Causes of Death (US) • Heart Disease: 635,260 • Cancer: 598,038 • Accidents: 161,374 • Chronic Lower Respiratory Disease: 154,596 • Stroke: 142,142

6. Leading Causes of Death (US) • Heart Disease: 635,260 • Cancer: 598,038 • MEDICAL ERROR: 251,454 • Accidents: 161,374 • Chronic Lower Respiratory Disease: 154,596

7. 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

8. 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’ 20 TIMES SODIUM CHLORIDE DOSE IN IV

9. 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

10. Elective surgery; postop severe abdominal pain and distension Cold sweat, pain x 3 days Pulse ox alarm lowered Residents didn’t call attending Pain stops after 5 days BP with 12 different cuffs and machines ADULT DOSES OF KETOROLAC  RUPTURED DUODENAL ULCER

11. 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

12. Thirst, really thirsty Vomiting, diarrhea Temp 102 D/C central line - ? Infection Weak, lethargic Narcan  no more pain meds Anesthesia worried about withdrawal; reorders methadone

13. Instead of putting markers on the sofa, you will color the sky. . .

14. Why do YOU think these errors happened?

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

16. Learning Objectives: • At the end of this session, participants will be able to: • Understand a select group of human factors and how to apply them relevant to the healthcare setting • List a selection of human factors violations that contribute to error • List select interventions that can be used to minimize errors that are the result of the human factors interface

17. 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

18. HumanFactors in Incidents Latent Errors Active Errors Person Error s Violatio ns Development of an Organizational Accident (developedfrom J. Reason)

19. The Interaction of HumanFactors

20. Organizational Challenges • 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

21. What Can You Do to Help Maintain Situational Awareness? Huddles Briefings Debriefings Team communication Monitor the Baseline Use technology

22. What Can We Do to Address Human Factors Violations? Understand your processes View your processes through a human factors lens Chose the right strategy Proactively address human factors violations Human Factors Self Assessment

23. How Can Simulation Help?

24. 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--

25. 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

26. 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

27. Types of Simulation Urbanization Simulation Credit: Carrie Mattingly, Twitter

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

29. Credit: SWS Sydney

30. Credit: Inside Hook

32. Once is Not Enough . . .

33. 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?

34. Thank You! Dr Kim Leighton, KLeighton@hamad.qa Dr Maggie Allen, MAllen@hamad.qa Dr Aisha Aladab, AAladab@hamad.qa