clinical simulation and patient safety
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Clinical Simulation and Patient Safety
Paul Bradley
Director of Clinical Skills
Peninsula College of Medicine and Dentistry
Scottish Clinical Skills Network
University Campus Hamilton
September 27th, 2007
Patient safety – how big is the problem? So what does clinical simulation have to offer? How can we go about this?
Patient safety – how big is the problem?
Why Patient Safety
“To err is human” in the USA “An organisation with a memory” in the UK
Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000
Department of Health. An organisation with a memory. London: Stationery Office; 2000
The size of the problem 400 die/seriously injured in adverse events involving medical
devices ~10,000 people experienced serious adverse reactions to
drugs ~1,150 suicides in people with recent contact with mental
health care ~28,000 written complaints about clinical treatment in
hospitals NHS pays £400 million a year settlement of clinical
negligence claims Potential liability of around £2.4 billion Hospital acquired infections cost nearly £1 billion.
The size of the problem
850,000 adverse events in the UK per year 10% of all hospital admissions In the USA estimated 44,000 – 90,000 deaths per
year – that’s equivalent to 15-30 September 11ths 1 million extra hospital days in USA 12.9% of all hospital admissions in NZ
5th NPSA Report - 2005
Analysis of the 1,804 serious incidents resulting in death. Reducing to 576 deaths that could be interpreted as
potentially avoidable and related to patient safety issues. 425 occurred in acute/general hospitals.
71 related to a range of diagnostic errors 64 related to patient unrecognised deterioration 43 involved a problem with resuscitation after cardiac
arrest.
National Patient Safety Agency. The fifth report from the Patient Safety Observatory - Safer care for the acutely ill patient: learning from serious incidents. London; 2007.
Recommendations - deterioration
Better recognition of patients at risk of, or who have deteriorated
Appropriate monitoring of vital signs Accurate interpretation of clinical findings Calling for help early and ensuring it arrives Training and skills development Ensuring appropriate drugs and equipment are
available
Recommendation - resuscitation
Improving communication Better situation analysis Regularly risk assessing resuscitation processes
locally Training and skills development Ensuring appropriate equipment is available
“These are not new concerns and, in spite of much high
quality work over many years, still more energy and commitment towards
improvement is needed.”
It isn’t history
26: Emergency support in surgical units: Dealing with haemorrhage
Issued: 10 Sep 2007
Following the death of a patient, the National Patient Safety Agency is warning that surgery should not be commissioned or delivered in facilities which lack the systems and equipment to manage emergencies safely. In a recent incident a patient died following routine laparoscopic surgery exacerbated by no blood being available, a lack of critical resuscitation devices such as central venous catheters and an absence of surgical equipment such as abdominal packs and vascular sutures.
So what does clinical simulation have to offer?
Simulation
“The technique of imitating the behaviour of
some situation or process (whether
economic, military, mechanical, etc.) by
means of a suitably analogous situation or
apparatus, especially for the purpose of
study or personnel training.”
The Oxford English Dictionary – Online 2006
Simulation in medical education – is not new
Too dangerous
Chess – 6th Century War games Weapons simulations
Too costly Space exploration Mission training
Too important
Civil and military aviation Nuclear power industry
Simulation in skills educationPart task trainers
Simulated patients and
role plays
Hi- and intermediate fidelity simulation
Haptic/VR simulators
1950 1960 1970 1980 1990 2000
Resuscitation movement
The movements in modern medical simulation
1950 1960 1970 1980 1990 2000
The movements promoting modern medical simulation
Åsmund LærdalResuscitation movement
Resuscitation movement
1950 1960 1970 1980 1990 2000
The movements promoting modern medical simulation
Stephen AbrahamsonSim One
Sim-One
“It breathes; has a heart beat, temporal and carotid pulse (all synchronized), and blood pressure; opens and closes its mouth; blinks its eyes; and responds to four intravenously administered drugs and two gases (oxygen and nitrous oxide) administered through mask or tube. The physiologic responses to what is done to him are in real time and occur ‘‘automatically’’ as part of a computer program.”
Abrahamson S, Denson JS, Wolf RM. Effectiveness of a simulator in training anesthesiology residents. Qual Saf Health Care 2004;13(5):395-397.
1950 1960 1970 1980 1990 2000
The movements promoting modern medical simulation
CASE (Comprehensive Anesthesia Simulation Environment) - Stanford
GAS (Gainesville Anesthesia Simulator)Florida
Patient simulator
1950 1960 1970 1980 1990 2000
The movements promoting modern medical simulation
Patient simulator
Features of modern simulators Complete human body Capable of “speech” Complete integrated
physiology/pharmacology model (high fidelity)
Open/close mouth Trismus Realistic airway Pharyngeal oedema Respiratory chest (
abdominal wall) movements
Appropriate anatomical landmarks
Lungs capable of spontaneous, assisted or mechanical ventilation
consumption of O2, exhalation of CO2 and uptake of anaesthetic gases
Tongue swelling Difficult airways Synchronised breath sounds Bowel sounds
Features of modern simulators Monitoring Pulses palpable Synchronised with heart
sounds Blood pressure measurable Variety of physiological
outputs to standard monitors e.g. CVP Temperature
Pulse oximetry
Procedures Defibrillation Pneumothorax decompression Cardioversion Cricothyroidotomy External pacing Pericardiocentesis Venepuncture Chest drain insertion Cannulation Intramuscular injection Urinary catheterisation
1950 1960 1970 1980 1990 2000
The movements promoting modern medical simulation40.2 Skills objectivesa) basic clinical method
i. obtain and record a comprehensive historyii. perform a complete examination and
assess mental stateiii. interpret the findings obtained from the
history and examinationiv. reach a provisional assessment of patients’
problems and formulate with them plans for investigation and management
b) basic clinical procedures includingi. Basic and Advanced Life Supportii. venepunctureiii. insertion of an intravenous line
Medical education reform
1950 1960 1970 1980 1990 2000
Resuscitation movement
Medical education reform
Sim-One
The movements promoting modern medical simulation
Patient simulator
Cummulative growth in "simulation" publications
0
100
200
300
400
500
600
1963 1968 1973 1978 1983 1988 1993 1998 2003
Source: Boston Simulation Centre
BEME systematic review Providing feedback Allowing repetitive practice Integrating within curriculum Providing a range of difficulties Being adaptable; allowing multiple learning strategies Providing a range of clinical scenarios Provides safe, supportive learning environment Active learning based on individualized needs Defined outcomes Simulator validity as a realistic recreation of complex
clinical situations
Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher 2005;27(1):10-28.
The benefits of simulation Risks to patients and learners are avoided Undesired interference is reduced Tasks/scenarios can be created to demand Skills can be practised repeatedly Training can be tailored to individuals Retention and accuracy are increased Transfer of training from classroom to real situation is
enhanced Standards against which to evaluate student performance and
diagnose educational needs are enhancedMaran NJ, Glavin RJ. Low- to high-fidelity simulation - a continuum of medical
education? Medical Education 2003;37(s1):22-28
Potential application of simulation Routine learning and rehearsal of clinical and
communication skills at all levels Routine basic training of individuals and teams Practise of complex clinical situations Training of teams in crisis resource management Rehearsal of serious and/or rare events Rehearsal of planned, novel or infrequent interventions Induction into new clinical environments and use of
equipment Design and testing of new clinical equipment Performance assessment of staff at all levels Refresher training of staff at all levels
Responsibilities for patient safetyOrganisation
Institution
Individual
TeamPatientsafety
…and the place for clinical simulation
Patientsafety
Institution
IndividualTeam
How can we go about this?
Building on theories of learning
Medical education and clinical skills learning is a theory rich educational environmentBehaviourismConstructivismSocial constructivismReflective practiceSituated learningActivity theory
Bradley, P., & Postlethwaite, K. (2003). Simulation in clinical learning. Medical Education, 37(s1), 1-5.
Learning theories
Theories can inform our practise Models of teaching and learning can be
developed that best support our students Theories can be tested Theories can be revised
Activity theory
Subject Object Outcome
Community
Division of labour
Rules
Artefacts
From Engeström Y 2001 Expansive learning at work: toward an activity theoretical reconceptualization. Journal of Education and Work 14,2,133-156
Simulator Work in operating theatre
Object 1
Rules Community Division oflabour
Subject
Mediating artifacts
Object 1
CommunityDivision oflabour
Subject
Mediating artifacts
Rules
Object 2
Object 2
Object 3
Activity Theory
Aha
Aha
Research
Evidence to date has been weak and patchy Much published work is descriptive or at low level
of evaluation Despite this simulation has certainly established
itself as a major educational movement We cannot always wait for the results of empirical
research to address major issues Sound, robust research is still needed to address
key areas
A possible way forward Use multiple methods approaches
Encompass the interpretive paradigm
Make more targeted use of the scientific paradigm to capitalise upon its particular ‘range of convenience’
Strive for increased theoretical clarity with respect to learning theories
Together, these ideas could lead to rather different kinds of enquiry
Conclusions Clinical simulation can enable learning of institutions, individuals
& teams It can play an important part in addressing issues of patient
safety Has a role at all levels of seniority within and between
professional groups It exists as a spectrum of educational activities - it is not a
dichotomy of low and high fidelity, but a continuum Not just technological/computerised – include important human
interactions - may be one-to-one or within or between teams Clinical simulation can test and challenge systems, policies and
plans Evidence to date tends to be of a low level evaluative nature, to
be weak in methodology and to be of limited generalisability Robust research focussed on higher level outcomes is required
Responsibilities for patient safetyOrganisation
Institution
Individual
TeamPatientsafety
…and the place for clinical simulation
Patientsafety
Institution
IndividualTeam
…and the place for clinical simulation
Patientsafety
Institution
IndividualTeam
Simulators