Participation in a System-Thinking Simulation Experience Changes Adverse Event Reporting.

INTRODUCTION: System failures are contributing factors in the thousands of adverse events occurring in US healthcare institutions yearly. This study explored the premise that exposure to a simulation experience designed to improve system thinking (ST) would impact adverse event reporting patterns. METHODS: An intervention-control study was used to explore impacts of participation in a simulation designed to improve ST on adverse event reporting. Each summer Bachelor in Nursing Science students along with medical students participate in a week-long simulation-based interprofessional patient safety course. During the 2017 course, Friday Night in the ER, a table-top simulation designed to develop ST was included. As part of the school nursing's simulation program, students are asked to report adverse events observed or committed during simulation encounters into a simulated adverse event reporting system outside the simulation-based interprofessional patient safety course. Adverse event reporting system data were used to examine patterns of adverse event reporting in control and intervention groups studied. RESULTS: Findings demonstrated differences in proportions of reported adverse events. The proportion of reported adverse events by students with the second and terminal semesters of course work combined and the 2016 and 2018 control groups combined demonstrated statistically significant differences, P < 0.001. Additional analysis revealed that the intervention group reported more medication-related events, whereas the control group reported more failure to rescue and airway-related events. CONCLUSIONS: Exposure to a simulation designed to develop ST seems to impact adverse event reporting. These findings support the idea that ST may change safety monitoring behaviors.

Aspiration assessment and prevention in critically ill enterally fed patients: evidence-based recommendations for practice.

Providing nutrition to patients is a vitally important aspect of care. Enterally feeding even critically ill patients remains the method of choice for most prescribers; however, the decision to provide nutrition via the enteral route comes with the added concern of bronchopulmonary aspiration as a complication. The majority of the literature and research on enteral feeding is out of date and focuses primarily on ways to identify aspiration, rather then preventing it. Although much of this research and literature is not current, many valid and useful recommendations have been made that can be applied to current practice. These recommendations are synthesized in this article in an effort to improve the quality and safety of administration of enteral nutrition to critically ill patients. However, this compiled information is limited to the current resources. More research should be done to decrease the risk of aspiration in this delicate population.