Using%20Simulation%20to%20identify%20Latent%20Safety%20Threats - PowerPoint PPT Presentation

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Using Simulation to identify Latent Safety Threats Steve Marks, RN, MS Operations Manager Mount Carmel Health System Kenny Hoffman RN, BSN, CEN, EMT-P – PowerPoint PPT presentation

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Title: Using%20Simulation%20to%20identify%20Latent%20Safety%20Threats


1
Using Simulation to identify Latent Safety Threats
Steve Marks, RN, MS Operations Manager Mount
Carmel Health System Kenny Hoffman RN, BSN, CEN,
EMT-P Simulation Coordinator Nationwide
Childrens Hospital
2
Introductions
3
Mount Carmel West Medical Center
4
Nationwide Childrens Hospital
5
Disclosures
  • Neither presenter has any conflicts of interest
    to report.

6
Objectives
  1. The learner will understand the benefits of
    conducting simulation for the new care
    environments.
  2. The learner will be able to outline the process
    for conducting simulation activities
    environments, including inter-agency
    participation
  3. The learner will understand how to structure
    simulation for identification of LSTs

7
What is a Latent Safety Threat?
  • Errors in design, organization, training, or
    maintenance that may contribute to medical errors
    and have a significant impact on patient safety.
  • Wetzel, et al. Jt Comm J
    Qual Patient Saf. 2013 Jun39(6)268-73.

8
Latent Safety Threats-not always apparent!
Small group exercise
9
Literature Review
10
Case study of identification of LSTs in labor and
delivery
  • OB delivery simulation on existing unit
  • Used combined standardized patient with a fetal
    heart tone simulator and baby high fidelity
    simulator
  • Simulated ruptured uterus requiring emergent
    C-section combined with fetal heart rate
    deceleration
  • Identified 6 environmental threats to safety,
    including communication, procedures, properly
    stocked medications, lack of familiarity with
    alarm systems to alert for assistance
  • Issues were able to be addressed with education
    and other policy and procedure changes.
  • Hammon, et al. (2009)
  • Hammon, et al. (2009)

11
Simulation to assess safety of new healthcare
teams in new facilities.
  • Institution opened satellite institution
    including pediatric ED
  • Objective was to define optimal staff roles and
    responsibilities to refine scope of practice and
    identify latent safety threats prior to opening
    the ED.
  • Performed 24 simulations over 3 months
  • Concluded that simulation can assist in
    determining provider workload, refine team member
    responsibilities, and identify latent safety
    threats
  • Geis et al.
    (2011)

12
Evaluating operational readiness of a childrens
hospital OB Unit
  • 3 simulations involving concurrent maternal and
    neonatal emergencies
  • Simulations identified multiple operational
    deficiencies including equipment and supply
    issues, staffing, and communication.
  • Ventre et al. (2014)

13
Mount Carmel Grove City
  • New free standing ED with ambulatory services
  • Objectives
  • Stress system
  • Walk ins and ambulance patients
  • Patient flow
  • Joint agency events

14
Simulation at MCGC
  • Video

15
The Process
  • Buy in with key stakeholders
  • Cost for staff salaries / overtime allowances
  • Planning
  • Implementation Team
  • Staff involved-Multi-disciplinary
  • How do you decide?
  • Resources / Assets needed

16
The Process (cont.)
  • Scenario Development
  • Keep an open mind and think outside of the box
  • What if?...
  • I wonder what would happen?...
  • Timing Crucial
  • Soon enough to allow adjustments
  • Not too soon that equipment is not available

17
The Process (cont.)
  • Evaluation
  • Measurement of event
  • Several raters from various stakeholder groups
  • Risk Management, Quality Improvement, Business
    Process Improvement
  • Nursing, physicians, respiratory, registration,
    lab, radiology, EMS, etc.
  • Video Recording
  • Debrief

18
The Process (cont.)
  • Now What??
  • What was learned?
  • Follow up
  • Corrective actions
  • Will be time and resource crucial
  • Some things imperative to correct immediately
  • Some things can wait

19
Monday Jan 6th 8am-12pm (snow day) 0845
Registration of Standardized Patients to start
and will progress over 90 minutes (total of
5 standardized patients as follows vaginal
bleeding, hyperglycemia, ankle injury, SOB, Abd
pain) 0945 Brain attack (to be worked up in
ED only) 1100 STEMI (walk in to ED) will need
to be stabilized and transferred to MCW.
Columbus Connection will handle the transfer.
1200 Lunch and debriefing 100 Days events
concluded (overview discussion for Dr. Williams,
Dave, Chellee and Sim team).
20
Tuesday Jan 7th 8am-11am 0930 Walk in chest
pain that progresses to cardiac arrest
0945 EMS Run, cardiac arrest (EMS/walk-in
simultaneous codes) 1030 Events over Debrief
1130 Lunch
21
Wednesday Jan 8th 8am-12pm 0830 Registration
of standardized patients to start and progress
over 60 min (Total of five standardized patients
as follows multiple complaints, chest pain,
abdominal pain, medication refill, flank
pain). 0945 EMS run, Pediatric Respiratory
difficulty progressing to arrest. Stabilization
and transfer to NCH via EMS. 1100 Events over.
Debrief via conference call with NCH
1130 Debrief with MCGC staff 1215 Lunch
22
Outcomes/ROI
  • Mt Carmel examples
  • Door size for EMS entry
  • Staffing
  • Communication to outside agencies
  • Other examples
  • Mock ICU Room (MCGC)
  • Signs (MCSA)

23
Mental Break !!
24
Nationwide Childrens Hospital Tower Transfer
  • Moving from old tower hospital to new 427 bed
    hospital tower
  • Transport of all patients from old tower to new
    tower, as well as ED move

25
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26
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27
Timeline of Training
  • November/December 2011, April/May 2012, September
    2012
  • Standardization of Nursing Orientation
  • Orientation to responding to emergencies
  • Emergency call lights, interaction with a new
    nurse call system, equipment location,
    defibrillators now on every patient unit
  • Skill stations (added to sessions in April/May
    September)
  • BVM ventilation, Drawing up emergency
    medications, setting up a pull-push bolus system
  • Total number we trained725 Staff/94 hours/104
    sessions

28
Outcomes
  • Nationwide Childrens examples
  • Height of squad entrance overhang
  • Equipment drop from cot during transit in hall
  • Clock mounting location
  • Bariatric lift system

29
Lessons learned for both
  • Must work around construction deadlines and
    equipment/supply availability
  • Work around marketing events
  • Trying to test too much, must be attainable plans
  • Working with entire multi-disciplinary care team
  • Test transport pathways

30
Acknowledgements
  • Jackson Township Fire Department, Grove City,
    Ohio
  • Captain Bill Dolby, Jackson Twp FD
  • Mt Carmel Health Systems
  • Dawn Prall, MD, Simulation Medical Director
  • Jarrod Williams, MD, MCGC Medical Director
  • Nationwide Childrens Hospital
  • Tensing Maa, MD, Simulation Medical Director
  • DJ Scherzer, MD, Simulation Medical Director

31
Why we simulate!
32
Questions
33
Speaker Contact Information
  • Steve Marks RN, MS
  • smarks_at_mchs.com
  • Office 614-234-3627
  • Kenny Hoffman RN, BSN, CEN, EMT-P
  • Kenneth.Hoffman_at_nationwidechildrens.org
  • Office 614-355-0667

34
References
  • Geis, G. L., Pio, B., Pendergrass, T. L., Moyer,
    M. R., Patterson, M. D. (2011, June).
    Simulation to assess the safety of new healthcare
    teams and new facilities. Society for Simulation
    in Healthcare, 6(3), 125-133.
  • Hamman, W. R., Beaudin-Seiler, B. M., Beaubien,
    J. M., Gullickson, A. M., Gross, A. C.,
    Orizondo-Korotko, K., Fuqua, W. (2009,
    September). Using in situ simulation to identify
    and resolve latent environmental threats to
    patient safety Case study involving a labor and
    delivery ward. Journal of Patient Safety, 5(3),
    184-187.
  • Ventre, K. M., Barry, J. S., Davis, D.,
    Baiamonte, V. L., Wentworth, A. C., Pietras, M.,
    Coughlin, L. (2014). Using insitu simulation to
    evaluate operational readiness of a children's
    hospital-based obstetrics ward. Society for
    Simulation in Healthcare, 00(00), 1-9.
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