A Simulated Lesson - part 2

Originally posted on 6-1-2010:
In my last entry I shared my experience with the IV pump simulation at the NPSF conference.  After learning some of the realities of nursing, I decided it would be worth attending another one of the simulations.  The next lab I went to was called the Patient Safety Risks Challenge. 

This setup was a patient simulator in a typical hospital bed setting.  The challenge presented to me was to find the 15 patient safety issues within five minutes.  The facilitator asked my background before I started, and I explained what I did working as a Human Factors Engineer for a pharmacy IT vendor.  He wished me luck as he stated that I should have no problem finding the "pharmacy issues" within the setup. No pressure...

Instead of looking at the situation holistically, I became overly focused on the flimsy 4 page paper chart in my hand to desperately find the pharmacy issues he mentioned.  I flipped back and forth, back and forth, to look at the medications recorded upon arrival and the current prescriptions.  I did find the aspirin missing and another med with the name changed on accident.  I felt pretty good getting those out of the way.  I also noticed some obvious errors - the "bloody" bandage that needed replacing, the overflowing box of sharps on the ground, and the urine bag literally under the wheel of the bed (please tell that is not based on a true story).  I ended up finding about 9 or 10 of the errors and figured my lack of clinical expertise would be the reasons I missed a few.

It turned out I did miss a few obvious safety issues.  The patient had a latex allergy, but did not have the band on his wrist indicating this.  I also learned that a patient that has a fall risk should not have one of bed rails down.  I will always wonder how I overlooked the pulse oximeter reading of 90 on the monitor.  The facilitator then pointed out that I had missed one of the pharmacy issues.  He simply stated, "you missed the dosing error."  I'm sure I had a stunned look on my face as I asked, "what dosing error?"  Flipping through the chart, he showed one of the admitting medications with a dose of 12.5 mg.  What showed up on the next page was 125 mg.  I can't remember the name of the drug, but I would have to guess this "death by decimal" error would be a serious one in a real setting.

I spent a good two minutes just staring at those pages to find an error like this, and it still slipped by me.  It provided another moment of enlightenment of just how easy it is to miss something so simple, yet potentially deadly.  Once again I was in the shoes of the nurse (or pharmacist), and I realized what hard shoes they are to fill.  As the facilitators pointed out, many hospitals still use paper charts similar to what was given to me.  I would like to think technology could have prevented me from missing that decimal point, however I have a feeling there is more to the root cause of my mistake.

I went into the conference already recognizing the value of simulation in healthcare.  These two sessions validated my feelings on the topic. Some thoughts I have from both experiences:

- New technology should be tested in a simulated environment to validate the technology fits into workflows of the clinicians in a safe, easy to use fashion.  Just testing the "sunny day" scenarios in a controlled environment will not validate the device will be safe and usable in a crisis situation.
- Simulation is a great way to train clinicians on new technology.  I would like to see hospitals go beyond a few hours of in service to really understand the tools they will be working with.  I have heard stories from friends in nursing that they have had to use technology for the first time with real patients.  I wonder if a few experts on the technology could be on call for such situations.
- I also think simulation can go beyond technology for healthcare.  I can see benefit in training staff on new procedures with no risk to a patient.  There was a third lab setup just to show clinicians the proper technique for central line insertions.
- I have gained even more respect for the clinicians on the front line of patient care.  I have a better understanding of what you are dealing with and how critical those situations are.  This all came from a few minutes of "playing" in a simulated environment.
- My final thought on the importance of simulators can be summed up like this: If you were flying on a plane, would you want the pilot to be completely unfamiliar with that particular plane?  They have those flight simulators for a reason.

I am curious to hear from those of you on the front lines.  Have you ever gone through clinical simulations such as this in your training?  If so, what were the scenarios you were trained in?  How are you typically trained when new technology is brought to your hospital?

A special thanks to the facilitators from the Center for Medical Simulation and the University of Miami - Jackson Health System for running these very educational simulation labs.