In Situ Simulation Uncovers Hidden Hospital Hazards
by Michael Vlessides
San Diego—Although simulation testing in actual patient care settings has been well documented as a way to improve clinical knowledge, an observational pilot study by San Francisco researchers has revealed a lesser-known benefit: Latent threats to patient safety were uncovered that were related to missing, inappropriate or nonfunctioning equipment in the clinical care environment.
“Traditionally, simulation has been performed in a simulation center that’s removed from the hospital,” said Francis A. Wolf, MD, an anesthesia resident at the University of California Medical Center, in San Francisco. “We do what we call in situ simulation, in the actual place of patient care rather than in a simulation lab.”
An important feature of in situ simulation is that participants rely on the same resources they would use in a true patient emergency. “There’s an increased sense of realism and engagement for the participants,” Dr. Wolf said. “Moreover, you have the ability to look at your system itself. You can look at how your providers interact with the environment and resources, and look for defects in systems and processes of care.”
Using a portable, life-sized computerized mannequin, Dr. Wolf and his colleagues, Richard Fidler, CRNA, and senior author, Brian Cason, MD, conducted 10 sessions of in situ simulation over six months. Scenarios involved either an acute change in patient condition (e.g., shortness of breath, chest pain, cardiac arrest or respiratory arrest) or evacuation of a patient via the stairwell. Scenarios were conducted in a number of locations throughout the hospital, including the intensive care unit, emergency department, operating room and acute care rooms. Equipment-related hazards were recorded by an experienced observer through live observation and debriefing interviews.
Dr. Wolf’s team discovered five major equipment-related threats to patient safety as a result of their in situ simulations: a missing mask on a bag valve mask; missing suction components; nonfunctioning emergency power outlets in patient rooms; oversized evacuation stretchers that could not pass around stairwell corners; and the presence of obsolete cricothyrotomy supplies in surgical airway kits. Dr. Wolf presented the results at the 2010 annual meeting of the American Society of Anesthesiologists (abstract A383).
After identifying the hazards, the investigators conducted room-to-room and equipment inventory inspections to assess whether the problems were isolated or systemic. Their analysis revealed that each identified problem was a widespread, systemic deficiency and not isolated to one specific room, kit or stretcher.
The investigators reported their findings to appropriate department heads, which resulted in changes to equipment ordering, maintenance and testing. “The problems were all relatively easy to fix,” Dr. Wolf said.
“The point here is not to air our dirty laundry,” he said, “but rather to illustrate the concept that every hospital has hidden problems. None of these could have been discovered simply by doing simulation in a simulation lab; most would have remained hidden threats until intended use on an actual patient, which could have led to harm.”
Dr. Wolf said that his team realized from their study the importance of having good communication with those ordering equipment and to have scheduled inspections. “While these particular five problems are specific to our hospital, all hospitals will have hidden threats to patient safety, and it’s important to have a way of performing proactive risk assessment before an adverse event occurs,” he told General Surgery News.