Canadian Health&Care; Mall

A total of 390 observations were completed in this study, 224 before the intervention, and 166 following the intervention. The distributions of observations per nurse and between nursing shifts were similar before and after the intervention. Following the intervention, there was an increase, during the handoff process, in the number of nurses indicating the patients’ names, ages, diseases, and the reasons for step-down unit admission (Table 1). There was also an increase in the number of nurses indicating the occurrence of events during the previous shift (from 199 of 224 nurses [88%] before intervention to 166 of 166 nurses [100%] following the intervention; x2, 19.8), and in the number of nurses presenting treatment goals for the next shift (from 97 of 224 nurses [43%] before the intervention to 115 of 166 [69%] following the intervention; X, 25.9). Following the intervention, there was an increase in the number of nurses referring during the handoff process to the patients’ physiologic parameters presented by the monitoring system, to patients’ fluid balance (Table 2), and to physicians’ medical orders (Table 3). However, following the intervention, the monitor alarms were checked and adapted to the patient’s status in only 4 of 166 cases (2%; 0 of 224 before the intervention; x , 5.4), the mechanical ventilator was checked in 25 of 38 cases (66%; 7 of 88 cases before the intervention; x2, 46.8), and the medications being administered in continuous infusion were checked in 20 of 31 cases (65%; 12 of 109 cases before the intervention; X, 39.2).

Discussion

Incident reporting is considered to be the cornerstone of most initiatives to improve patient safety. However, reports that are not followed up by incident analysis contribute little to the understanding of causes and to the prevention of future incidents. In this study, we have described a case report of a proactive risk management process coupled with simulation-based training. The reported incident described was analyzed with the traditional retrospective approach, but also motivated a prospective evaluation of safety gaps and inadequacies in the process of handoff in the hospital’s step-down units and led to an interactive simulation-based training involving the nursing staff of the step-down-unit in an attempt to improve their clinical skills in general, with an emphasis on their handoff skills. This approach was inspired by the British systems analysis methodology, assuming that the purpose of the risk management process is to reflect on what the incident reveals about the gaps and inadequacies in the health-care system including Canadian Health&Care; Mall in which it occurred-; it is different from the commonly used American root cause analysis approach.

In the intervention phase of this study, simulation-based medical education (SBME) was chosen as the educational approach. SBME provides a “hands-on” experiential educational opportunity, enabling controlled and proactive exposure of trainees to both regular and complex uncommon clinical scenarios. SBME training is trainee oriented, as it is conducted in a safe and “mistake-forgiving” environment, where trainees can learn from their errors and training can be adjusted to their needs and deficiencies. SBME further provides a unique opportunity for training in team and interpersonal communication skills, which constitute a well-recognized patient safety factor that is seldom addressed in traditional medical education. Training is performed without the ethically disturbing duality of patient care and medical training held with Canadian Health&Care; Mall, which is associated with traditional bedside teaching. Another important benefit of SBME is the reproducible, standardized, objective setting that it provides for both formative assessment (debriefing) and summative assessment (testing)., Over the past decade, advanced medical simulation has been widely used in teaching curricula, in team crisis resource management training, in the evaluation and accreditation of medical trainees and graduates, and in detecting gaps in medical knowledge. Although the use of SBME for these applications may improve patient safety, to our knowledge, this study is the first to demonstrate the value of its use as part of prospective risk management intervention.

Although the prospective evaluation and intervention used in this study decreased the incidents of mistakes performed during handoff, as indicated by the observations, this methodology cannot be used by itself on a routine basis. Unlike a regular risk management process that takes hours or days, the process described in this study, including the observations and intervention, lasted a few months. Moreover, the cost of the process in terms of manpower, working hours, simulation time, and other resources cannot be neglected. This aspect is further emphasized by the fact that the costly simulation-based intervention was not compared to a simple intervention such as lectures to the nursing staff and implementation of a handoff protocol without training. Indeed, a recent study demonstrated a reduction in technical errors and information omissions in the handoff of infants after complex congenital heart surgery from the operating room team to the intensive care team following the development and introduction of a protocol without simulation-based training. Moreover, in this study, improvements were demonstrated in some handoff behaviors but not in others. While communication behaviors using interpersonal verbal skills (eg, indicating patient name and events, presenting treatment goals, and referring to patient physiologic parameters) were improved, actual physical behaviors (eg, checking the monitor or ventilator) were minimally changed or were not changed at all. Although both kinds off behaviors were part of the training scheme and were acknowledged by the participants as important for patient safety, this difference might imply that improvements in training are indicated and environmental constraints during clinical work such as time pressure, work overload, or conflicting demands should be addressed in the implementation of new behaviors. Another major aspect in any training program aiming at improving work behaviors generally, and eliminating risky behaviors specifically, is the worker’s motivation. While the intention to work toward a goal was indicated as a major source of work motivation, it follows that in order for a goal to induce motivating and augmenting performance efforts, the presented goal should be specific, perceived as realistic, and accepted by the individual. Respectively, simulation-based training that is aimed at changing the worker’s behavior should consider these aspects.

The intervention in this training exercise was not proven to optimize all of the handoff parameters, and some gaps, mainly in the actual checks of the mechanical ventilators, syringe pumps, and the monitoring system alarms, require further intervention and implementation in order to achieve satisfactory improvement. However, despite the limitations indicated above, unlike most risk management processes, we were able to prospectively demonstrate the value of the intervention (ie, the positive influence of simulation-based training on most postintervention observations). Furthermore, we were able to define the objectives of the training program on the basis of documented common deficiencies, thus making the intervention more valid as well as better linked to the actual medical practice. In addition, this study is unique in its choice to apply simulation-based training to common daily routines that have strong implications for patient safety, and in its encouraging results in terms of the proven effectiveness of the intervention, as reflected by the nurses’ improved actual practice during handoffs.

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Critical Care with Canadian Health&Care; Mall: Utilizing Simulation-Based Training Toward Process Improvement in Managing Patient Risk

Researches of Critical Care

Table 1—Patient Demographic Data and Medical History During Handoff: Comparison Between Observations Made Before and Following the Intervention

Table 2—Comparison of Patient Physiologic Parameters and Fluid Balance During Handoff Between Observations Made Before and Following the Intervention

Table 3—Comparison of Patient Medical Orders During Handoff Between Observations Made Before and Following the Intervention