Patient Safety – Hospitals take
Michael Moyer, PhD (ABD), MS, EMT-P
Formerly: Cincinnati Children’s Hospital Center
for Simulation & Research
Currently: TriHealth Hospital System Simulation
& Education Training Center
Changes to medical education – why?
Where did Patient Safety really start?
Discuss the populations involved
Look at Sim lab training vs. in-situ
Teamwork & Communication
How to measure
Scales to show improvements (or not)
Interactive wrap-up!
We can be set up to make
Incompetent people are, at most, 1%
of the problem. The other 99% are
good people trying to do a good job
who make very simple mistakes and
it's the processes that set them up to
make these mistakes.
Dr. Lucian Leape, Harvard School of Public Health,
Co-author of “To Err is Human”
Human Errors in High Risk Settings
Technicians were doing tests and shut off the
coolant. Chernobyl exploded in April 26, 1986. It
occurred at Unit 4 of the power at Chernobyl,
The accident destroyed the reactor and released
an incredibly large amount of radiation into the
environment. Because of this access to an 18
mile radius of the plant was closed.
Thirty-one people died in this explosion.
135,000 had to evacuate the area. The radiation
cloud spread all through out western Europe. It
took the cloud 1 week to spread all over Europe.
Human Errors
Normal safety guidelines were disregarded
Operator was unfamiliar with the reactor
Operator had not been trained enough
Not trained under normal and/or extreme
Two months after a double bypass heart operation
that was supposed to save his life, comedian and
former Saturday Night Live cast member Dana
Carvey got some disheartening news: the cardiac
surgeon had bypassed the wrong artery. It took
another emergency operation to clear the blockage
that was threatening to kill the 45-year-old
Responding to a $7.5 million lawsuit Carvey
brought against him, the surgeon said he'd made
an honest mistake because Carvey's artery was
unusually situated in his heart. But Carvey didn't
see it that way: "It's like removing the wrong kidney.
It's that big a mistake,"
Why Simulation?
Began in aviation – mail carriers;
preventable accidents; CRM
Crossed into medicine – anesthesia;
Moved into military battlefields and
Medicine & Patient safety
All as a result of improved training
Why still a problem/Why patient
safety initiatives in hospitals?
Same vial look-a-likes
Same name of drugs (sound a-likes)
70% of all errors originate out of
communication issues
Teamwork is a whole issue in of itself
Decision making is hampered by
communication and teamwork issues
Hospital’s New Focus
From counting failures
- to anticipating risks
From preventing error
- to anticipating
Disciplined teamwork
How we can identify
“team leaders” in
every situation;
Move away from
individual mental
models to team
mental models;
sharing our thoughts
before, during & even
after an event.
Goals for a Course
Improve teamwork / communication
Critical thinking
Practice new or not common procedures
Medication safety
Medication double-checks
Gauge higher workload effects for a given
team in a particular area
Your participants:
You know them!
Some are solid in their beliefs.
Some are open to change.
Traditional thinking of: Groups = Friends
= Teams (not really!)
Variety of personalities
Variable learning styles
Will be here as a requirement; you will
change that into a necessity
Obstacles to Change:
Employees must think of teamwork, as
opposed to simply “interacting” with coworkers…. Day-to-day interactions lead to
a false sense of confidence in response,
versus a structured teamwork model.
All team members must be “equal” in their
team membership…. All have a voice in
patient care.
Stigma of not reporting events or fear of
punishment must be eliminated.
Essential elements of TEAMS
Common Purpose and Shared Goals
(Painting a mental model that everyone on the
team shares)
Interdependent Actions
(We rely on each
other, not independent of one another)
(We are all accountable for our
Collective Effort
(Everyone shares in the
responsibilities and decisions, not just the team
Common Team factors affecting medical
Verbal communication
Written communication
Supervision and seeking help
Structure of the team
Team Improvement Objectives
Improve the performance of teams in following areas:
Communications (Team members share a common thought
process about a patient or procedure. What we call
sharing a “mental model”).
Leadership (One member oversees the big picture – but
all team members communicate with the leader).
Decision making ( team members are a part of the
decision; team members share the common mental model
and provide input to the decision making process)
Stress & fatigue management
Teamwork = success!
Concentrate on Two Areas
Latent threats
 Threats in an
environment which are
undetected, yet pose a
potential problem if
circumstances arise.
 Not having leads on a
monitor, but not
knowing it until you run
through a simulation
 Can also be Human
Factor related
Teamwork & Communication
Account for significant
amount of errors within
medical field; appears to
Not really one single
event or lack of
communication, rather a
cascade of events
How might we measure
TW and Comm? Can we
see improvements after
Latent threats
 Missing medications
 Missing equipment
 Lack of algorithms for
cognitive aids
 Medications in same
drawer are close in look
 Defibrillator has synch
button that blends into
the background
Teamwork /
 Lack of leader
 Closed-loop
 Proper roles
 No step-backs
 Not acting on “pinches”
 Authority gradients
 Assumptions drawn
First, Let’s look at the WHOLE training
Realistic scenarios. Many can be from actual
Can look at how things evolved in an actual
case and learn from it; or practice the correct
High risk settings. Practice those areas that
seldom see errors but have much risk!
Practice simple scenarios in prone areas.
Special areas receive training over
Cardiac Unit
Intensive care unit
Why these area?
Higher SSE
More difficult
procedures or steps in
carrying out tasks (ie,
calling time out;
authority gradient;
Key Points For Adult Learning
What’s in it for me?!
Would I ever use this?
How will I benefit?
Will others think I’m an idiot?
Learning Models
Principles of learning have changed from
pure didactic to experiential
Self-directed learning
Utilize classroom learning in “real-life”
“Rules of engagement” – learners are
participating in teams; not silo’s
Problem-based learning
Safe, non-threatening environment
Benefits to Simulation
Allows for more self-directed learning
Classroom theory is translated into clinical
Gives realism to an education scenario
The learner can become engaged in actual care
Provides for critical thinking – move into the
clinical area
Can visualize your efforts – simulators hold you
accountable for your actions!
Facilitation vs. Teaching
Debriefing is critical to success
Must be included in all simulations
Why debrief? How does facilitation create
Discuss non-technical and technical
behaviors…. Learning from each other
Use of videotape… be careful!
Secondary outcomes
(Specifically about teamwork)
Reinforce teamwork behaviors in clinical
“Speak up”
Role clarity
Frequent updates/shared mental model
Independent medication double checks
Overcoming authority gradient
Future Research
Impact on competence (eg = nurse
Is training better vs. traditional methods?
If so, in what area(s)?
Does this translate into clinical practice?
Can we build a better educational model
as a result of this research?
Focus on real world problems.
Relate learning to participants goal.
Allow debate and challenge of ideas.
Encourage participants to be resources
to you and to each other.
Mike Moyer, Ph.D. (ABD), MS, EMT-P
Director, Simulation and Education Training Center
Bethesda North Hospital
TriHealth Hospital System
Cincinnati, Ohio
[email protected]

Michael Moyer, Cincinnati Children`s Hospital