Reducing errors: How simulations help improve high reliability and patient care
Health care is a very complex industry, in which every minute counts and split-second decisions are needed to save patients’ lives. Nowhere is this more true than in the operating room (OR).
Every day, Michigan Medicine faculty and staff provide life-saving treatment for hundreds of patients in ORs across the health system, but like any complex environment, breakdowns sometimes occur that can lead to patient harm.
When such breakdowns occur, the Patient Safety Event Team works to conduct a full review to determine a root cause and create an action plan to improve processes and minimize the risk of such an event occurring again in the future.
Simulating real life
Following a recent case in which a critical piece of equipment in the OR was inadvertently unplugged while a pediatric patient was undergoing cardiac surgery, a multidisciplinary team came together to conduct an event review.
“This case was a perfect example of the ‘Swiss cheese’ that is often used to describe patient safety events,” said Bridget Pearce, M.D., assistant professor of anesthesiology, who was involved in the event review. “We had an unstable pediatric patient undergoing a complex procedure that required the use of additional equipment in the OR, and this tense situation combined with gaps in our processes to create an environment in which team members were not communicating clearly with one another.”
The breakdown in communication led to the piece of equipment being unplugged, which affected the well-being of the patient.
“There were so many moving parts in this case but once we started peeling back the layers, we saw that the problems really boiled down to a disconnect — ultimately it all came back to a breakdown in communication,” said Pearce.
During the course of the event review, the team decided it would be beneficial to simulate the real event to gain better insight into the mindset of the team at the time, which would help them determine opportunities for improvement.
“Simulation is a great way to recreate the specific atmosphere and environment of a particular situation to objectively review the outcome,” said Elizabeth Putnam, MBBS, assistant professor of anesthesiology and director of simulation for pediatric anesthesiology. “In this instance we were able to replicate exactly what happened during the procedure because we conducted the simulation in the same OR instead of using the simulation center. This really put everyone in the shoes of the surgical team from that day and helped us come up with an improvement plan.”
Following the event review, several improvements were made, including establishing a “time out” process in the OR when outside personnel or equipment are being introduced, clearly labeling outlets so all team members can easily identify what equipment is plugged in, and efforts to streamline communication from the OR to outside areas when requesting assistance.
The importance of training and universal skills
Taking time to recreate a situation using simulation can help reinforce high reliability principles among teams and provide an opportunity for faculty and staff to practice universal skills, including communicating clearly, paying attention to detail and speaking up for safety.
“Using simulation as a learning technique is a great way to improve communication and teamwork, and provides a safe environment for every team member to speak up, encouraging an open dialogue,” said Putnam. “I encourage all faculty and staff to utilize simulation as a training tool. Don’t wait until after a safety event occurs — look for opportunities to incorporate this type of training into your team’s ongoing curriculum.”
Many of these high reliability principles are introduced during high reliability universal skills training, ongoing now. All employees will be required to undergo this training. Click here for more information.