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A Peer Reviewed Publication of the College of Allied Health & Nursing at Nova Southeastern University |
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Correspondence:
C J Biddle, CRNA, PhD
Citation:
In the care of patients, accidents, lapses, mistakes and other undesirable actions often result from incomplete knowledge, unfamiliarity, stress, or simply occur as an inevitable consequence of humans traversing an inherently complex terrain. Virginia Commonwealth University has produced a number of patient safety vignettes (PSVs), which are brief, staged reenactments of actual patient misadventures that are visually displayed providing an evidence-based approach to error resolution and prevention. Based upon the concept of the “living laboratory,” a virtual setting where activity, improvisation, success and failure occur in the face of simulated patient and provider interaction, we produce PSVs that are realistic.1 In our Center for Research in Human Simulation, we have the flexibility that allows us to model virtually any situation from a healthcare venue (e.g., operating room, intensive care unit, patient’s hospital room, etc). PSVs are directed toward preventing and managing real world negative patient events that surface in practice but would be difficult or dangerous to reproduce using real patients. We have spearheaded a patient safety initiative to bring the power of simulation to any interested professional, even in the privacy of their home, in the form of high fidelity multimedia tools. One principle of adult learning is that humans often learn best from their own mistakes.2 We would add that humans also learn vicariously from the mistakes of others and as such, embrace the view that errors or negative outcomes are opportunities for us to learn and develop robust systems to prevent similar errors from befalling others.3,4 An enlightened view of error recognizes that simply punishing those involved, or reassigning them to other jobs does not prevent mistakes. Educating providers and building better systems are superior approaches to error prevention and error absorption. Imagine a nurse, with only good intentions in mind, severely burning a patient with a universally used warming blanket. Imagine a patient getting the wrong operation suffering an unnecessary amputation. Imagine a person having a superficial surgical procedure on their neck, yet leaving the hospital with arm paralysis due to improper positioning. We have produced a range of vignettes targeting blood transfusion errors, drug administration mistakes, and equipment malfunctions, just to name a few. All of these cases have three shared themes: 1) they are documented to have occurred frequently in hospitals throughout the United States, 2) they have catastrophic effect(s) on the patient, and 3) they are completely preventable. Organizations such as the military, the aviation and nuclear power industries manage potentially hazardous processes by creating a culture of safety that anticipate and plan for unexpected events and future surprises. Inherent in the incredible complexity of the healthcare landscape is the responsibility for each individual, even those at the bottom of the ladder, to be made aware of their importance in the overall process of health care delivery. Each task, even those of an ancillary nature, must be accorded the same attention and the same consideration. We believe that the power of vicariousness embedded in media is a most effective method to convey this message. This paper overviews our work with the PSV and includes preliminary outcome data suggesting that it may have meaningful and lasting impact as a patient safety intervention. Background of the PSV Our interest in employing media as an instructional method began with clinical faculty development, specifically in the realm of improving the quality of the dynamic between instructors and students in the patient care setting. This interest led to the use of trigger films (TFs), 2-4 minute long films that simulate a real-life situation, finishing abruptly, and not always committing to a particular course of action.5,6 This technique, pioneered in the 1960s, has been virtually ignored in health care. Initially our work was directed at using this approach to enlighten clinical faculty in using principles of adult education in dealing with common and not-so-common faculty/student interactions. Among these, are TFs dealing with students who were ill-prepared, argumentative, insubordinate, unconfident or overly timid. The use of these TFs in faculty development workshops is well received, with demand for workshops from university and clinical departments exceeding the capacity to deliver them. In 2000, the Institute of Medicine published a landmark report, To Err is Human, which profoundly influenced the direction of our clinical and research efforts. From this report we learned that medical and nursing error was exceptionally common, produced an enormous toll upon human suffering, and that an aggressive nationwide effort was needed to improve the situation.7 Our work and experience with TFs, as well as our longstanding interest in patient safety, became the framework for developing PSVs, The primary author (CB) has extensive experience in dealing with root cause analysis, evidence-based decision making, and medical closed claims research, affording a national access to cases of patient and provider misadventures.8-16 Initial PSVs were directed at events occurring exclusively in the operating room where complex decision making involving critically ill patients, often occurs in the setting of time and production pressure. Examples of these PSVs are listed in Table I. Table I: Examples of recently produced patient safety vignettes (PSVs)
More recent work has extended into other areas of patient care including dealing with heparin-induced thrombocytopenia, neglected hand washing, electrocautery-ignition of a patient drape resulting in severe patient burn, and other misadventures. Description of the PSV Each PSV minimally exhibits the following attributes: 1) A 2-4 minute reenactment of an actual negative patient event employing domain-knowledgeable “actors” that simulate what took place to the best of our ability, 2) a brief pause, 3) a 2-4 minute follow-up vignette that demonstrates the salient, systematic events of the misadventure/calamity or that illustrates how another approach could have mitigated against the occurrence, 4) 2-3 minute evidence-based review of the relevant literature, and 5) evidence-based reference sources. Each PSV is staged and developed in a high-fidelity simulation laboratory with practice sessions preceding production. A highly skilled media crew is enlisted. Each PSV is then formatted in four modes: VHS, CD, DVD and web-site for video streaming. Early Outcome Analysis Institutional approval was obtained prior to developing our PSVs and exposing stakeholders to them. Our PSVs have been displayed at a number of national and regional symposia and conferences. Table 2 lists these meetings as well as the attributes of, and approximate number of the attendees at each. We have been carefully following up with attendees who have been exposed to the PSVs in a qualitative effort to measure their impact. Because our patient safety work is still in its infancy, and for a variety of ethical and logistical reasons, this preliminary data lacks the elements of a randomized trial. Thus any outcome analysis must be considered rudimentary and preliminary at this stage. In that context, we report our findings to date. Table 2: Audiences exposed to the Patient Safety Vignettes
Approximately 2,500 health care providers (nurses, physicians, technologists) and administrators (executive leadership, risk and quality management department members) have been exposed to a variety of PSVs but have seen at least the following two offerings: 1) wrong site surgery, and 2) peripheral nerve injury. Of these, contact information has been secured with 1,791 subjects in the form of e-mail or postal mailing addresses obtained at the time of experiencing the PSV. The breakdown of these 1,656 is as follows: 302 physicians (MD), 831 certified registered nurse anesthetists (CRNA), 249 registered nurses (RN), and 209 administrators (AD). As part of the actual follow-up, 5% of each cohort have been randomly contacted (ie, 15 MD, 42 CRNA, 13 RN, 11 AD). On follow-up at 6-12 months we observed the following:
As part of the ongoing study a comparison group of 15 MDs, 35 CRNAs, 15 RNs and 15 ADs were given 2 case reports to read from the FDAs MedWatch bulletin, one describing an inadvertent peripheral nerve injury due to malpositioning during an operative procedure, and one that detailed the events involved in a patient who experienced a wrong site surgery. These individuals were not exposed the PSVs. On follow-up at 6-12 months we observed the following:
This early data lends us to believe that
the cognitive imprint created with the PSVs is better in light of the
inconsistent and rather bleak imprint created with traditional reading of
published literature. We feel, and have indirect evidence to support our
belief that storytelling, especially in the framework of presenting
information in a believable, personally relevant manner has powerful
cognitive imprint qualities and potential. While we have not precisely
measured the actual weight of the role of vicariousness upon human learning,
we have long been impressed with the power of these multimedia presentations
to substantially imprint upon human cognition. Summary We report preliminary observations of our
ongoing program of research creating PSVs that target common, catastrophic
patient-related misadventures that occur in health care settings nationwide.
We believe that much can be achieved by learning from the mistakes that
others have experienced using the PSV instrument. As such we utilize the
tool of story telling. With this process we hope to spare ourselves (and our
own patients) from experiencing similar negative outcomes. Gleaning such
lessons, especially when rendered in a high fidelity multi-media format,
advantages the powerful human sense of vicariousness—with resultant high
cognitive imprinting. To view a sample film, in this case, a film on wrong site surgery, please go to: http://www.nrsa.vcu.edu/ps/WrongSurgery.htm References
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