Patient Safety

Fig. 9.1
CanMEDs Framework of medical competence from the Royal College of Physicians and Surgeons of Canada highlighting seven key competencies for physicians—medical expert, communicator, collaborator, manager, health advocate, scholar, and professional (Adapted from Ref. [16])

Through this chapter we will discuss, in turn, the use of healthcare simulation to improve patient safety through each of the above key competencies that are paramount in developing a healthcare professional capable of providing quality patient care.

The Medical Expert

The idea of the medical expert is an umbrella term that can be used to describe a competency that incorporates all aspects of the CanMEDS roles by applying medical knowledge, clinical skills, and professional attitudes to provide ­patient-centered care [16]. In addition, healthcare practitioners, as medical experts, must establish and maintain core clinical knowledge, possess sound diagnostic reasoning and clinical judgment, and acquire procedural skill proficiency [16].

As mentioned previously, a variety of simulation-based training techniques have been used in healthcare education. These techniques provide learners with a risk-free environment to allow deliberate practice, where mistakes can be made and learned from without compromising patient safety. The use of surgical simulators by trainees has been shown to allow surgeons to improve psychomotor skills such as speed, error, and economy of movement as well as procedural knowledge, which contribute to improved performance and confidence in the operating theater [12]. However, simulation-based training comes in a range of varieties.

Box Trainers and Simple Mannequin Simulators

Low-fidelity, inexpensive simulators of procedural skills exist, such as laparoscopic surgery box trainers and ­mannequins to simulate venipuncture, intravenous cannulation, central venous catheterization, and airway intubation, where learners can develop, practice, and refine skills using real instruments on simulated models. Barsuk et al. reported that residents who underwent training using the Simulan’s CentralLineMan central venous catheter (CVC) insertion simulation model displayed decreased complications in the form of fewer needle passes, arterial punctures, and catheter adjustments and had higher success rates during CVC insertion in actual patients compared to residents who trained using traditional methods [18]. In addition, Draycott et al. retrospectively compared the management of shoulder dystocia and the associated neonatal injury before and after introduction of a simulation-based training course using the prototype shoulder dystocia training mannequin (PROMPT Birthing Trainer, Limbs and Things Ltd, Bristol, United Kingdom) [19]. The results of the study concluded that, after training, there was improvement in management of shoulder dystocia and a reduction in neonatal injury [19]. In 2004, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed the Fundamentals of Laparoscopic Surgery (FLS) program [20]. FLS comprised of a box trainer in which laparoscopic skills can be practiced by performing various abstract tasks and has been previously validated numerously in literature [21, 22]. Subsequently, following endorsement by the American College of Surgeons, the FLS simulator training program has been adopted by the American Board of Surgery as a requirement for completion of general surgical training [22]. Sroka and colleagues conducted a randomized controlled trial to assess if training to proficiency with the FLS simulator would result in improved operating room performance [23]. It was reported that, after proficiency training on the FLS simulator, surgical residents’ performance scores during laparoscopic cholecystectomy were higher than the control group [23]. Furthermore, completion of a proficiency-based FLS simulator training curriculum and subsequent interval training on the FLS simulator was found to be associated with a very high level of skill retention after 2 years [24].

Cadaveric and Animal Tissue Simulators

Human cadaveric and animal tissue has also been used in healthcare simulation training of procedural tasks. In addition to anatomical dissection of human cadavers for medical students and surgical trainees, human cadavers have been used to practice many procedures including laparoscopy and saphenous vein cutdown [25, 26]. Animal models involve the use of either live anesthetized animals or ex vivo animal tissues. Such models have been incorporated in many surgical skills courses, for example, the Intercollegiate Basic Surgical Skills course by the Royal College of Surgeons England. Despite a lack of incorporation into discrete proficiency-based training curricula, various studies have used animal models for medical training and assessment of transferability of skills developed from simulation-based training [2729].

Virtual Reality and Computer-Based Simulation

Virtual reality (VR) simulation has been extensively studied for its ability to provide a safe, high-fidelity, and risk-free environment for healthcare training and assessment [12]. The validity of VR simulation in surgery has been, hitherto, widely demonstrated [12]. Unlike the subjective traditional methods of technical skill assessment, VR simulators provide a valid, objective, and unbiased assessment of trainees, using parameters that cannot easily be measured within the operating theater [30, 31]. Much research has focused upon optimizing the delivery of these benefits with development of repetition and time-based curricula [32, 33]. However, the rate at which a trainee learns may vary, and, as such, these models result in surgeons with varying levels of skill at the end of training period. Thus, proficiency-based training, in which expert benchmark levels are used as performance targets, has been suggested as best able to increase surgical performance to a standardized level of competency [12]. Such training curricula have been developed that allow a strategic methodology for training inexperienced surgeons resulting in a shortened learning curve and attainment of benchmarked expert levels of dexterity [3436].

Over the past decade, numerous studies have illustrated the benefits of VR simulation on patient safety. Seymour et al. conducted one of the principal studies to show that VR training improves operating performance [37]. In this randomized controlled trial, 16 surgical residents were randomized to either VR training or no VR training [37]. The VR-trained group completed training on the MIST-VR laparoscopic surgical simulator until expert criterion levels were attained. Following this, both groups performed a laparoscopic cholecystectomy, which was reviewed and rated by two independent blinded raters [37]. It was reported that the VR-trained group was faster at gallbladder dissection and six times less likely to make errors, and the non-VR-trained group were five times more likely to injure the gallbladder or burn non-target tissues during their first laparoscopic cholecystectomy [37]. Moreover, two studies reported that VR laparoscopic surgical training to proficiency resulted in significantly better performance when performing basic laparoscopic skills and laparoscopic cholecystectomies in the animate operating environment [2938]. A recent study by Ahlberg et al. investigated the effect of proficiency-based VR laparoscopic training on outcomes during the early part of the learning curve in the clinical environment [39]. The study showed that VR training to proficiency resulted in significantly fewer errors and a reduction in surgical time in comparison to the control group during the residents’ first ten laparoscopic cholecystectomies on actual patients [39]. This notable finding illustrated that the hazardous early part of the learning curve can be shortened and flatter after VR training, thus substantiating the role VR simulation in enhancing patient safety [39]. Most notably, a Cochrane review of the effectiveness of VR training in laparoscopic surgery, based on 23 trials involving 622 participants, confirmed that VR training decreased time taken, increased accuracy, and decreased errors in laparoscopic surgery [40].

The benefits of VR simulation training extend beyond the laparoscopic surgical domain. A pilot study by Sedlack and collaborators showed that computer-based colonoscopy simulation training resulted in a shortened learning curve during the initial 30 patient-based colonoscopies conducted by gastroenterology fellows [41]. Simulator-trained fellows were found to be safer, require less senior assistance, able to define endoscopic landmarks better, and reach the cecum independently on more instances than traditionally trained fellows during the initial part of the learning curve [41]. A further study by Sedlack et al. illustrated that computer-based endoscopy simulator training had a direct benefit to patients by improving patient comfort [42]. Additionally, a recent multicenter, blinded randomized controlled trial provided further evidence for the use of VR endoscopy simulation in reducing the learning curve and improving patient safety [43]. In this study, additional VR colonoscopy simulation-based training resulted in significantly higher objective competency rates during first year gastroenterology fellows’ first 100 real colonoscopies [43]. Moreover, as little as 1 h of prior training with a VR bronchoscopy simulator was found to improve the performance of inexperienced residents during basic bronchoscopy on patients compared to peers without similar training and produce a skill level similar to that of more experienced residents [44].

Patient Scenario Simulation

The advent of patient scenario simulation initially utilized a programmed patient paradigm, in which, most commonly, a lay individual would be taught to simulate a medical condition [11]. Harden and Gleeson, in developing the Objective Structured Clinical Examination (OSCE), incorporated this structure into a series of clinical stations comprised of actors performing as simulated patients [11]. Students would rotate through these stations in which aptitude in clinical skills such as history taking, clinical examination, procedural skills, and management plans were tested using a standardized objective scoring system [11]. Since its conception, the OSCE has been used by educational institutions as a valid and reliable method of assessment [17].

A further application of patient scenario simulation that has been investigated is within critical care and, particularly, within training responses to emergency scenarios. Needless to say, it is imperative that healthcare professionals are highly skilled and experienced to deal with these high-risk clinical situations that carry great morbidity and mortality. However, such situations occur with relatively low frequency to gain sufficient experience, and, often, junior members of the medical team, who lack such experience, are the first responders [45]. Therefore, simulation-based training is an attractive technique for medical professionals to practice management of these scenarios outside of the clinical environment. One such technique used in emergency situation training is the computer-controlled patient simulator, SimMan (Laerdal Medical Corporation, Wappingers Falls, NY). Mayo et al. utilized patient-based simulation training to investigate interns’ competence in emergency airway management. In this randomized controlled trial, participants were given training on the management of respiratory arrest using the SimMan computer-controlled patient simulator. Such training resulted in significant improvement in airway management skills in actual patient airway events [45]. Furthermore, simulation training using a human patient simulator resulted in improved quality of care provided by residents during actual cardiac arrest team responses [46]. This study illustrated that simulator-trained residents responded to actual cardiac arrest events with great adherence to treatment protocols than non-simulator-trained more experienced residents [46]. Importantly, the durability of the Advanced Cardiac Life Support skills acquired through simulation training was demonstrated by Wayne et al., which reported retention of skills at 6 and 14 months post-training [47].

The recognition of the ability of simulation to be used as a potent tool in healthcare education has resulted in its incorporation into various healthcare educational courses. For example, patient simulation has been integrated in many official acute medical event management courses, such as the worldwide Advanced Trauma Life Support (ATLS) course and the Detecting Deterioration, Evaluation, Treatment, Escalation and Communicating in Teams (DETECT) course in Australia [48].

The Communicator

Communication, written or verbal, is a key attribute that all healthcare professionals must excel at in order to optimize safe, holistic patient care. Not only must communication be effective between healthcare professionals and patients, but also to other healthcare professionals as well as the public as a whole. It is a vital skill that is imperative in every element of clinical practice, especially challenging scenarios such as breaking bad news. The CanMEDs 2005 Framework suggested that, as communicators, physicians must effectively facilitate the doctor-patient relationships enabling “patient-centered therapeutic communication through shared decision-making and effective dynamic interactions with patients, families, caregivers, other professionals, and other important individuals” [16]. A competent communicator must establish rapport and trust as well as elicit and convey relevant and accurate information from patients, families, and other healthcare professionals in order to develop a common understanding with a shared plan of care [16].

An astonishing statistic provided by the Joint Commission on Accreditation of Health Care Organizations demonstrated that poor communication was causative in two-thirds of almost 3,000 serious medical errors [49]. Compounding this, during a review of 444 surgical malpractice claims, 60 cases were identified as involving communication breakdowns directly resulting in harm to patients [50]. Of these cases of communicative errors, the majority involved verbal communications between one transmitter and one receiver, and the most common communication breakdown involved residents failing to notify attending surgeons of critical events and failure of attending-to-attending handovers [50]. This of course is wholly unacceptable.

Several studies have attempted to investigate methods to improve communication within healthcare practice, including the use of simulation. Correct and thorough communication of patient information during staff shift handover is vital in providing high-quality continued care over the increasingly shift-work-based culture in healthcare. Berkenstadt et al. recognized a deficiency existed within this domain and illustrated that a simulation-based teamwork and communication workshop increased the incidence of nurses communicating crucial information during shift handovers [51].

Moreover, studies have investigated the incorporation of training and assessment of communication skills alongside technical skill acquisition. Kneebone and colleagues developed the Integrated Procedure Performance Instrument (IPPI), which combines technical skills training using inanimate models, with communication challenges in a variety of clinical contexts using standardized simulated patients [52]. Each clinical scenario consists of a bench-top model of a procedural skill, such as wound closure, urinary cauterization, endoscopy, or laparoscopic surgery, and a fully briefed standardized patient [52]. Through such practice, skills to deal with difficult situations such as an anxious, confused, or angry patient can be rehearsed and developed in a safe environment with immediate objective feedback [52]. An extension on this innovative research in 2009 demonstrated that the IPPI format resulted in significantly improved communication skills in residents and medical students [53].

The Collaborator

The CanMEDs 2005 Framework highlights that, in order to deliver optimal patient-centered care, physicians must work effectively within a healthcare team [16]. Such profes­sionals should be competent in participating in an inter­professional healthcare team by recognizing roles and responsibilities of other professionals in relation to their own and demonstrate a respectful attitude towards others in order to ensure where appropriate, multi-professional assessment and management is achieved without conflict [16]. A recent review highlighted the close association between teamwork and patient outcomes in terms of satisfaction, risk-adjusted mortality, complications, and adverse events [54]. As such, techniques to develop and improve teamwork have been investigated.

Other high-risk organizations, such as the airline industry, have demonstrated the use of simulation to improve teamwork skills through Crisis Resource Management, and these techniques have been explored in enhancing patient safety (discussed in the previous chapter). Salas et al. conducted a quantitative and qualitative review of team training in healthcare [55]. They described the “power of simulation” as an effective training tool that creates an environment in which trainees can implement and practice the same mental processes and teamwork skills they would utilize in their actual clinical practice [55]. This review included simulation-based training as an integral aspect of their “eight evidence-based principles for effective planning, implementation and evaluation of team training programs specific to healthcare” (Fig. 9.2) [55]. In addition, simulation has been demonstrated as a key aspect of an education package within a framework for team training in medical education [56].


Fig. 9.2
Eight principles of team training required for production and implementation of an effective team training program as described by Salas et al. [55]

Through the collaboration between the Agency for Healthcare Research and Quality and the US Departments of Defense, the TeamSTEPPSTM curriculum was developed. The TeamSTEPPSTM initiative is an evidence-based simulation-based teamwork training system designed to improve patient safety by improving communication and other teamwork skills [57]. The underlying principles of TeamSTEPPSTM comprises of four core competencies that encompass teamwork: leadership, situation monitoring, mutual support, and communication (Fig. 9.3). Emphasis is placed on defining tools and strategies that can be used to gain and enhance proficiency in these competencies [58]. Incorporated within the core curriculum are sessions using patient scenarios, case studies, multimedia, and simulation [58]. Hitherto the TeamSTEPPSTM program has been implemented in multiple regional training centers around the USA as well as in Australia [59]. A recent multilevel evaluation of teamwork training using TeamSTEPPSTM by Weaver and colleagues demonstrated that such simulation-based training significantly increases the degree to which quality teamwork occurred in the operating room [60]. Trainees also reported increased perceptions of patient safety culture and teamwork attitudes [60].


Fig. 9.3
Core TeamSTEPPSTM competencies

The Manager

An important contributor to optimizing patient safety is by developing a safe, effective healthcare system. Healthcare professionals must play a central role in healthcare organizations and allocate scarce resources appropriately, as well as organize sustainable practices, in order to improve the effectiveness of healthcare [16]. This type of leadership is a key factor in promoting a safety culture, and it has been suggested that, unlike the nursing profession, physicians are yet to develop and utilize skills required for such leadership challenges [61].

As described above, there is evidence to show the positive results of simulation-based training on communication and teamwork of healthcare professionals. However, its use to train management skills has not been illustrated in literature thus far. Despite this, simulation-based training could have many implications in the training of challenging managerial situations. For example, healthcare professionals may be able to practice scenarios where one must apologize to a patient for a serious mistake or manage a situation where a colleague has behaved unprofessionally or unethically. By performing these difficult and uncommon situations in a simulated environment, managerial techniques can be learned, developed, and practiced. Furthermore, simulation-based training has been suggested as a viable method of training error reporting, disaster response, and assessment of hospital surge capacity [62].

The Health Advocate

As health advocates, clinical practitioners have a responsibility to use their expertise and influence to enhance the health of patients, communities, and the population as a whole [16]. Consequently, such advocates highlight inequities, potentially dangerous practices, and health conditions and have attempted to develop strategies to benefit the patient. Examples of the use of simulation in improving health advocacy are scarce. However, simulation-based training has been incorporated into an advocacy training program at Johns Hopkins’ Bloomberg School of Public Health in the USA [63]. This program, aimed at graduate students, is designed to develop media advocacy and communication through a multitude of didactic lectures, expert presentations, and ­practical skills training using a 90-min simulation group exercise [63]. During this exercise, students are divided into groups representing different constituencies, ranging from government to nonprofit organizations, concerned with a local public health issue [62]. Each group is given time to develop a policy position regarding the issues and advocacy strategies to advance its proposed policy improvement [63]. Following this, each participant is placed in a simulated television interview, where challenging questions are asked to help students learn to effectively communicate with advancing a health-policy position [63].

The Scholar

Continual lifelong learning is vital to optimize performance of all healthcare professionals. One must be able to use ongoing learning to maintain and enhance professional activities by reflecting on current practice and critically evaluating literature, in order to make up-to-date evidence-based decisions and make their practice safer [16]. Furthermore, healthcare professionals must facilitate the learning of students, patients, and the wider public as well as be able to contribute to the creation, dissemination, application, and translation of new medical knowledge and practices [16].

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May 30, 2017 | Posted by in Uncategorized | Comments Off on Patient Safety

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