Priorities Related to Improving Healthcare Safety Through Simulation.

STATEMENT: Improving healthcare safety is a worthwhile and important endeavor. Simulation-based activities can help with such a goal through research and training. In this manner, it can focus on education and training, assessment and metrics, process improvement, and culture change to help move forward both patient safety and quality of care.This article will address the following three main topics: (1) designing simulation-based activities to promote high reliability in healthcare, (2) developing simulation-based activities to foster resilience in healthcare systems, and (3) evaluating the impact of adverse events in healthcare and how simulation-based activities can be used to determine and potentially to prevent their cause. These topics will be treated sequentially, providing synopses of concepts and giving examples of research currently being undertaken. It will then highlight current priorities for simulation-based research in this domain by drawing from insights obtained and a targeted literature review.

Coordination patterns related to high clinical performance in a simulated anesthetic crisis.

BACKGROUND: Teamwork is an integral component in the delivery of safe patient care. Several studies highlight the importance of effective teamwork and the need for teams to respond dynamically to changing task requirements, for example, during crisis situations. In this study, we address one of the many facets of "effective teamwork" in medical teams by investigating coordination patterns related to high performance in the management of a simulated malignant hyperthermia (MH) scenario. We hypothesized that (a) anesthesia crews dynamically adapt their work and coordination patterns to the occurrence of a simulated MH crisis and that (b) crews with higher clinical performance scores (based on a time-based scoring system for critical MH treatment steps) exhibit different coordination patterns. METHODS: This observational study investigated differences in work and coordination patterns of 24 two-person anesthesia crews in a simulated MH scenario. Clinical and coordination behavior were coded using a structured observation system consisting of 36 mutually exclusive observation categories for clinical activities, coordination activities, teaching, and other communication. Clinical performance scores for treating the simulated episode of MH were calculated using a time-based scoring system for critical treatment steps. Coordination patterns in response to the occurrence of a crisis situation were analyzed using multivariate analysis of variance and the relationship between coordination patterns and clinical performance was investigated using hierarchical regression analyses. Qualitative analyses of the three highest and lowest performing crews were conducted to complement the quantitative analysis. RESULTS: First, a multivariate analysis of variance revealed statistically significant changes in the proportion of time spent on clinical and coordination activities once the MH crisis was declared (F [5,19] = 162.81, P < 0.001, eta(p)(2) = 0.98). Second, hierarchical regression analyses controlling for the effects of cognitive aid use showed that higher performing anesthesia crews exhibit statistically significant less task distribution (beta = -0.539, P < 0.01) and significantly more situation assessment (beta = 0.569, P < 0.05). Additional qualitative video analysis revealed, for example, that lower scoring crews were more likely to split into subcrews (i.e., both anesthesiologists worked with other members of the perioperative team without maintaining a shared plan among the two-person anesthesia crew). CONCLUSIONS: Our results of the relationship of coordination patterns and clinical performance will inform future research on adaptive coordination in medical teams and support the development of specific training to improve team coordination and performance.

How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?

BACKGROUND: A strong patient safety culture in the operating room (OR) and post-anesthesia care unit (PACU) is essential to promote safe care. METHODS: The Patient Safety Climate in Healthcare Organizations (PSCHO) survey was administered to employees at 30 Veterans Affairs (VA) hospitals. The survey consisted of 42 close-ended items representing 12 different dimensions of safety. We measured percent problematic response (PPR); higher PPR values reflect weaker safety culture. The "OR/PACU" and the "Other Work Areas" groups' item-specific, dimension-specific, and overall problematic responses were compared. RESULTS: The overall and dimension-specific PPRs were similar between the OR/PACU and the Other Work Areas group (overall: 20.2% and 18.1%, respectively; P = .41). When the 2 groups were compared on an item-by-item level, the OR/PACU staff reported more frequent witnessing of unsafe patient care (PPR 55.1% vs 43.2%; P = .01), and perceived less understanding by senior leadership of clinical care (PPR 28.3% vs 17.1%; P = .01) and less hospital interest in quality of care (PPR 20.4% vs 12.5%; P = .03). CONCLUSIONS: Specific areas of safety culture in the OR/PACU were found that should be targeted for improvement.

Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration.

Improving safety climate could enhance patient safety, yet little evidence exists regarding the relationship between hospital characteristics and safety climate. This study assessed the relationship between hospitals' organizational culture and safety climate in Veterans Health Administration (VA) hospitals nationally. Data were collected from a sample of employees in a stratified random sample of 30 VA hospitals over a 6-month period (response rate = 50%; n = 4,625). The Patient Safety Climate in Healthcare Organizations (PSCHO) and the Zammuto and Krakower surveys were used to measure safety climate and organizational culture, respectively. Higher levels of safety climate were significantly associated with higher levels of group and entrepreneurial cultures, while lower levels of safety climate were associated with higher levels of hierarchical culture. Hospitals could use these results to design specific interventions aimed at improving safety climate.

Improvement in coronary anastomosis with cardiac surgery simulation.

OBJECTIVE: Cardiac surgery trainees might benefit from simulation training in coronary anastomosis and more advanced procedures. We evaluated distributed practice using a portable task station and experience on a beating-heart model in training coronary anastomosis. METHODS: Eight cardiothoracic surgery residents performed 2 end-to-side anastomoses with the task station, followed by 2 end-to-side anastomoses to the left anterior descending artery by using the beating-heart model at 70 beats/min. Residents took home the task station, recording practice times. At 1 week, residents performed 2 anastomoses on the task station and 2 anastomoses on the beating-heart model. Performances of the anastomosis were timed and reviewed. RESULTS: Times to completion for anastomosis on the task station decreased 20% after 1 week of practice (351 +/- 111 to 281 +/- 53 seconds, P = .07), with 2 residents showing no improvement. Times to completion for beating-heart anastomosis decreased 15% at 1 week (426 +/- 115 to 362 +/- 94 seconds, P = .03), with 2 residents demonstrating no improvement. Home practice time (90-540 minutes) did not correlate with the degree of improvement. Performance rating scores showed an improvement in all components. Eighty-eight percent of residents agreed that the task station is a good method of training, and 100% agreed that the beating-heart model is a good method of training. CONCLUSIONS: In general, distributed practice with the task station resulted in improvement in the ability to perform an anastomosis, as assessed by times to completion and performance ratings, not only with the task station but also with the beating-heart model. Not all residents improved, which is consistent with a "ceiling effect" with the simulator and a "plateau effect" with the trainee. Simulation can be useful in preparing residents for coronary anastomosis and can provide an opportunity to identify the need and methods for remediation.

Adaptive coordination in cardiac anaesthesia: a study of situational changes in coordination patterns using a new observation system.

Patient care in hospital settings requires coordinated team performance. Studies in other industries show that successful teams adapt their coordination processes to the situational task requirements. This prospective field study aimed to test a new observation system and investigate patterns of adaptive coordination within operating room teams. A trained observer recorded coordination activities during 24 cardiac surgery procedures. The study tested whether different patterns occur during different phases of and between different types of surgical procedures (two-way multivariate ANOVA with repeated measure). A statistically significant increase was found in clinical and coordination activities in phases of the operation with high task interdependence. The highest level of 'coordination via the work environment' (i.e. an implicit coordination mechanism) was recorded during the actual procedure on the beating heart. These findings prove the sensitivity of the observation system developed and evaluated in this study and provide insight into patterns of adaptive coordination in cardiac anaesthesia. This study furthers our understanding of adaptive coordination as a cornerstone of effective team performance in complex work environments. Using a new observation system, it describes patterns employed by health care professionals in response to changing task demands in an acute patient care setting.

Use of cognitive aids in a simulated anesthetic crisis.

We evaluated empirically the extent to which the use of a cognitive aid during a high-fidelity simulation of a malignant hyperthermia (MH) event facilitated the correct and prompt treatment of MH. We reviewed the management of 48 simulated adult MH scenarios; 24 involving CA 1 and 24 involving CA 2 residents. In the CA 1 group, 19 of the 24 teams (79%) used a cognitive aid, but only 8 of the 19 teams used it frequently or extensively. In the CA 2 group, 18 of the 23 teams (78%) used a cognitive aid but only 6 of them used it frequently or extensively. The frequency of cognitive aid use correlated significantly with the MH treatment score for the CA 1 group (Spearman r = 0.59, P < 0.01) and CA 2 group (Spearman r = 0.68, P < 0.001). The teams that performed the best in treating MH used a cognitive aid extensively throughout the simulation. Although the effect was less pronounced in the more experienced CA 2 cohort, there was still a strong correlation between performance and cognitive aid use. We were able to show a strong correlation between the use of a cognitive aid and the correct treatment of MH.

The risks and implications of excessive daytime sleepiness in resident physicians.

PURPOSE: To assess the levels of physiologic and subjective sleepiness in residents in three conditions: (1) during a normal (baseline) work schedule, (2) after an in-hospital 24-hour on-call period, and (3) following a period of extended sleep. METHOD: In 1996, a within-subjects, repeated-measures study was performed with a volunteer sample of 11 anesthesia residents from the Stanford University School of Medicine using three separate experimental conditions. Sixteen residents were recruited and 11 of the 16 completed the three separate experimental conditions. Daytime sleepiness was assessed using the Multiple Sleep Latency Test (MSLT). RESULTS: MSLT scores were shorter in the baseline (6.7 min) and post-call (4.9 min) conditions, compared with the extended-sleep condition (12 min, p =.0001) and there was no significant difference between the baseline and post-call conditions (p =.07). There was a significant main effect for both condition (p =.0001) and time of day (p =.0003). Subjects were inaccurate in subjectively identifying sleep onset compared with EEG measures (incorrect on 49% of EEG-determined sleep episodes). CONCLUSION: Residents' daytime sleepiness in both baseline and post-call conditions was near or below levels associated with clinical sleep disorders. Extending sleep time resulted in normal levels of daytime sleepiness. The residents were subjectively inaccurate determining EEG-defined sleep onset. Based on the findings from this and other studies, reforms of residents' work and duty hours are justified.