Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats.

BACKGROUND: Cardiac arrest resuscitation requires well-executed teamwork to produce optimal outcomes. Frequency of cardiac arrest events differs by hospital location, which presents unique challenges in care due to variations in responding team composition and comfort levels and familiarity with obtaining and utilizing arrest equipment. The objective of this initiative is to utilize unannounced, in situ, cardiac arrest simulations hospital wide to educate, evaluate, and maximize cardiac arrest teams outside the traditional simulation lab by systematically assessing and capturing areas of opportunity for improvement, latent safety threats (LSTs), and key challenges by hospital location. METHODS: Unannounced in situ simulations were performed at a city hospital with multidisciplinary cardiac arrest teams responding to a presumed real cardiac arrest. Participants and facilitators identified LSTs during standardized postsimulation debriefings that were classified into equipment, medication, resource/system, or technical skill categories. A hazard matrix was used by multiplying occurrence frequency of LST in simulation and real clinical events (based on expert opinion) and severity of the LST based on agreement between two evaluators. RESULTS: Seventy-four in situ cardiac arrest simulations were conducted hospital wide. Hundreds of safety threats were identified, analyzed, and categorized yielding 106 unique latent safety threats: 21 in the equipment category, 8 in the medication category, 41 in the resource/system category, and 36 in the technical skill category. The team worked to mitigate all LSTs with priority mitigation to imminent risk level threats, then high risk threats, followed by non-imminent risk LSTs. Four LSTs were deemed imminent, requiring immediate remediation post debriefing. Fifteen LSTs had a hazard ratio greater than 8 which were deemed high risk for remediation. Depending on the category of threat, a combination of mitigating steps including the immediate fixing of an identified problem, leadership escalation, and programmatic intervention recommendations occurred resulting in mitigation of all identified threats. CONCLUSIONS: Hospital-wide in situ cardiac arrest team simulation offers an effective way to both identify and mitigate LSTs. Safety during cardiac arrest care is improved through the use of a system in which LSTs are escalated urgently, mitigated, and conveyed back to participants to provide closed loop debriefing. Lastly, this hospital-wide, multidisciplinary initiative additionally served as an educational needs assessment allowing for informed, iterative education and systems improvement initiatives targeted to areas of LSTs and areas of opportunity.

Teaching medical students about medical errors and patient safety: evaluation of a required curriculum.

PURPOSE: To assess the effectiveness of a brief curriculum about patient safety and medical errors with third-year medical students. METHOD: From 2000-03, third-year medical students at New York Medical College, Valhalla, New York, were required to participate in a new curriculum on patient safety and medical errors during their family medicine clerkships. Five hundred seventy-two students participated in a four-hour curriculum that included interactive discussion, readings, a videotape session with a standardized patient, and a small-group debriefing facilitated by a family physician. Before and after participating in the curriculum, students were asked to complete questionnaires on self-awareness about patient communication and safety. Curriculum evaluations and follow-up surveys were also distributed. Responses to each statement on the before and after questionnaires were compared using the Wilcoxon signed-rank test for matched data. RESULTS: Five hundred eleven (89%) students reported that the opportunity to present an error to a patient increased their confidence about discussing this issue with patients, and 537 (94%) students reported that they strongly agreed or agreed that the standardized patient and feedback exercise was a useful learning experience. A total of 535 before and after questionnaires were used in the analysis. A comparison of before and after questionnaire data revealed statistically significant increases in the self-reported awareness of students' strengths and weaknesses in communicating medical errors to patients (p