using simulation to identify latent safety threats steve marks, rn, ms operations manager mount...

Using Simulation to identify Latent Safety Threats

Steve Marks, RN, MS Operations Manager

Mount Carmel Health System

Kenny Hoffman RN, BSN, CEN, EMT-P Simulation Coordinator

Nationwide Children’s Hospital

Introductions

Mount Carmel West Medical Center

Nationwide Children’s Hospital

Disclosures:

Neither presenter has any conflicts of interest to report.

Objectives

1. The learner will understand the benefits of conducting simulation for the new care environments.

2. The learner will be able to outline the process for conducting simulation activities environments, including inter-agency participation

3. The learner will understand how to structure simulation for identification of LST’s

What is a Latent Safety Threat?

Errors in design, organization, training, or maintenance that may contribute to medical errors and have a significant impact on patient safety.

Wetzel, et al. Jt Comm J Qual Patient Saf. 2013 Jun;39(6):268-73.

Latent Safety Threats-not always apparent!

Small group exercise

Literature Review

Case study of identification of LSTs in labor and delivery

• OB delivery simulation on existing unit• Used combined standardized patient with a fetal heart tone simulator and baby high

fidelity simulator• Simulated ruptured uterus requiring emergent C-section combined with fetal heart rate

deceleration• Identified 6 environmental threats to safety, including communication, procedures,

properly stocked medications, lack of familiarity with alarm systems to alert for assistance• Issues were able to be addressed with education and other policy and procedure changes.

Hammon, et al. (2009)

Hammon, et al. (2009)

Simulation to assess safety of new healthcare teams in new facilities.• Institution opened satellite institution including pediatric ED• Objective was to define optimal staff roles and responsibilities

to refine scope of practice and identify latent safety threats prior to opening the ED.

• Performed 24 simulations over 3 months• Concluded that simulation can assist in determining provider

workload, refine team member responsibilities, and identify latent safety threats

Geis et al. (2011)

Evaluating operational readiness of a children’s hospital OB Unit

• 3 simulations involving concurrent maternal and neonatal emergencies

• Simulations identified multiple operational deficiencies including equipment and supply issues, staffing, and communication.

Ventre et al. (2014)

Mount Carmel Grove City

• New free standing ED with ambulatory services

• Objectives– Stress system– Walk ins and ambulance

patients– Patient flow – Joint agency events

Simulation at MCGC

Video

The Process

• Buy in with key stakeholders– Cost for staff salaries / overtime allowances

• Planning– Implementation Team– Staff involved-Multi-disciplinary

• How do you decide?

– Resources / Assets needed

The Process (cont.)

• Scenario Development– Keep an open mind and think outside of the box• “What if?...• “I wonder what would happen?...

• Timing Crucial: – Soon enough to allow adjustments– Not too soon that equipment is not available

The Process (cont.)•Evaluation:– Measurement of event

• Several raters from various stakeholder groups• Risk Management, Quality Improvement, Business Process

Improvement• Nursing, physicians, respiratory, registration, lab, radiology, EMS, etc. • Video Recording

– Debrief

The Process (cont.)

•Now What??– What was learned?– Follow up – Corrective actions

•Will be time and resource crucial– Some things imperative to correct immediately– Some things can wait

Monday Jan 6th: 8am-12pm (snow day)

08:45 Registration of Standardized Patients to start and will progress over 90 minutes (total of 5 standardized patients as follows: vaginal bleeding, hyperglycemia, ankle injury, SOB, Abd pain)

09:45 Brain attack (to be worked up in ED only)

11:00 STEMI (walk in to ED) will need to be stabilized and transferred to MCW. Columbus Connection will handle the transfer.

12:00 Lunch and debriefing

1:00 Days events concluded (overview discussion for Dr. Williams, Dave, Chellee and Sim team).

Tuesday Jan 7th: 8am-11am

09:30 Walk in chest pain that progresses to cardiac arrest

09:45 EMS Run, cardiac arrest (EMS/walk-in simultaneous codes)

10:30 Events over Debrief

11:30 Lunch

Wednesday Jan 8th: 8am-12pm

08:30 Registration of standardized patients to start and progress over 60 min (Total of five standardized patients as follows: multiple complaints, chest pain, abdominal pain, medication refill, flank pain).

09:45 EMS run, Pediatric Respiratory difficulty progressing to arrest. Stabilization and transfer to NCH via EMS.

11:00 Events over. Debrief via conference call with NCH

11:30 Debrief with MCGC staff

12:15 Lunch

Outcomes/ROI• Mt Carmel examples:– Door size for EMS entry – Staffing– Communication to outside agencies

• Other examples:– Mock ICU Room (MCGC) – Signs (MCSA)

Mental Break !!

Nationwide Children’s Hospital Tower Transfer

• Moving from old tower hospital to new 427 bed hospital tower

• Transport of all patients from old tower to new tower, as well as ED move

Timeline of Training • November/December 2011, April/May 2012,

September 2012• Standardization of Nursing Orientation

• Orientation to responding to emergencies• Emergency call lights, interaction with a new

nurse call system, equipment location, defibrillators now on every patient unit

• Skill stations (added to sessions in April/May & September)

• BVM ventilation, Drawing up emergency medications, setting up a pull-push bolus system

• Total number we trained—725 Staff/94 hours/104 sessions

Outcomes

• Nationwide Children’s examples:– Height of squad entrance overhang– Equipment drop from cot during transit in hall– Clock mounting location– Bariatric lift system

Lessons learned for both

• Must work around construction deadlines and equipment/supply availability

• Work around marketing events• Trying to test too much, must be attainable plans• Working with entire multi-disciplinary care team • Test transport pathways

Acknowledgements• Jackson Township Fire Department, Grove City, Ohio– Captain Bill Dolby, Jackson Twp FD

• Mt Carmel Health Systems:– Dawn Prall, MD, Simulation Medical Director– Jarrod Williams, MD, MCGC Medical Director

• Nationwide Children’s Hospital– Tensing Maa, MD, Simulation Medical Director– DJ Scherzer, MD, Simulation Medical Director

Why we simulate!

Questions

Speaker Contact Information

Steve Marks RN, MSsmarks@mchs.comOffice: 614-234-3627

Kenny Hoffman RN, BSN, CEN, EMT-PKenneth.Hoffman@nationwidechildrens.orgOffice: 614-355-0667

References• Geis, G. L., Pio, B., Pendergrass, T. L., Moyer, M. R., & Patterson, M. D.

(2011, June). Simulation to assess the safety of new healthcare teams and new facilities. Society for Simulation in Healthcare, 6(3), 125-133.

• Hamman, W. R., Beaudin-Seiler, B. M., Beaubien, J. M., Gullickson, A. M., Gross, A. C., Orizondo-Korotko, K., & Fuqua, W. (2009, September). Using in situ simulation to identify and resolve latent environmental threats to patient safety: Case study involving a labor and delivery ward. Journal of Patient Safety, 5(3), 184-187.

• Ventre, K. M., Barry, J. S., Davis, D., Baiamonte, V. L., Wentworth, A. C., Pietras, M., & Coughlin, L. (2014). Using insitu simulation to evaluate operational readiness of a children's hospital-based obstetrics ward. Society for Simulation in Healthcare, 00(00), 1-9.