Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies

Department of Health Policy & Management and Associate Dean, School of Public Health, University of Minnesota, Minneapolis, Minnesota 55455-0381, USA.
Quality and Safety in Health Care (Impact Factor: 2.16). 10/2010; 19 Suppl 3(Suppl 3):i53-6. DOI: 10.1136/qshc.2010.040311
Source: PubMed


In Reason's safety model, high-reliability healthcare organisations are characterised by multiple layers of defensive barriers in depth associated with increased levels of safety in the care delivery system. However, there is very little empirical evidence describing and defining defensive barriers in healthcare settings or systematic analysis documenting the nature of breaches in these barriers. This study uses in situ simulation to identify defensive barriers and classify the nature of active and latent breaches in these barriers.
An in situ simulation methodology was used to study team performance during obstetrics emergencies. The authors conducted 46 trials of in situ simulated obstetrics emergencies in two phases at six different hospitals involving 823 physicians, nurses and support staff from January 2006 to February 2008. These six hospitals included a university teaching hospital, two suburban community hospitals and three rural hospitals. The authors created a high-fidelity simulation by developing scenarios based on actual sentinel events.
A total of 965 breaches were identified by participants in 46 simulation trials. Of the 965 breaches, 461 (47.8%) were classified as latent conditions, and 494 (51.2%) were classified as active failures.
In Reason's model, all sentinel events involve a breached protective layer. Understanding how protective layers breakdown is the first step to ensure patient safety and establish a high reliability. These findings suggest where to invest resources to help achieve a high reliability. In situ simulation helps recognise and remedy both active failures and latent conditions before they combine to cause bad outcomes.

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    • "However, more recently, a new simulation modality, the 'in situ simulation' (ISS), has been introduced. ISS is described by Riley and colleagues [18] as “a team-based simulation strategy that occurs on the actual patient care units involving actual healthcare team members within their own working environment”. An unanswered question is whether ISS is superior compared with OSS with regards to simulation-based learning in obstetric emergencies? "
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    ABSTRACT: Unexpected obstetric emergencies threaten the safety of pregnant women. As emergencies are rare, they are difficult to learn. Therefore, simulation-based medical education (SBME) seems relevant. In non-systematic reviews on SBME, medical simulation has been suggested to be associated with improved learner outcomes. However, many questions on how SBME can be optimized remain unanswered. One unresolved issue is how 'in situ simulation' (ISS) versus 'off site simulation' (OSS) impact learning. ISS means simulation-based training in the actual patient care unit (in other words, the labor room and operating room). OSS means training in facilities away from the actual patient care unit, either at a simulation centre or in hospital rooms that have been set up for this purpose. The objective of this randomized trial is to study the effect of ISS versus OSS on individual learning outcome, safety attitude, motivation, stress, and team performance amongst multi-professional obstetric-anesthesia teams.The trial is a single-centre randomized superiority trial including 100 participants. The inclusion criteria were health-care professionals employed at the department of obstetrics or anesthesia at Rigshospitalet, Copenhagen, who were working on shifts and gave written informed consent. Exclusion criteria were managers with staff responsibilities, and staff who were actively taking part in preparation of the trial. The same obstetric multi-professional training was conducted in the two simulation settings. The experimental group was exposed to training in the ISS setting, and the control group in the OSS setting. The primary outcome is the individual score on a knowledge test. Exploratory outcomes are individual scores on a safety attitudes questionnaire, a stress inventory, salivary cortisol levels, an intrinsic motivation inventory, results from a questionnaire evaluating perceptions of the simulation and suggested changes needed in the organization, a team-based score on video-assessed team performance and on selected clinical performance. The perspective is to provide new knowledge on contextual effects of different simulation settings. NCT01792674.
    Trials 07/2013; 14(1):220. DOI:10.1186/1745-6215-14-220 · 1.73 Impact Factor
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    • "SA may provide the basis for complex decision making with limitations in SA associated with increased likelihood of error (i.e., poor performance) (Endsley, 1995, 1990; Klein, 2000). This has been demonstrated in the healthcare domain (Riley et al., 2010; Hogan et al., 2006). However, it is important to distinguish association from a causal link. "
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    ABSTRACT: The objective of this study is to determine the effects of environmental factors on physician situation awareness (SA) in an emergency department (ED) setting. An objective method of level 1 (i.e., perception) SA measurement and evaluation was developed and applied. Resident physician level 1 SA was measured using the Situational Awareness Global Assessment Technique (SAGAT). SAGAT question probes (i.e., sets of 10 questions) were generated randomly from a pool of questions and administered hourly. Questions were answered at a 7.4% false response rate. Environmental measures (i.e., patient information, physician information, temporal information, and workload) were collected concurrently. Mixed-effects modeling was used to determine the relationship between physician SA and environmental factors adjusting for potential correlation within physician observed, patients managed, and questions asked. Significant factors associated with decreases in SA include: patient hand-offs (Odds Ratio (OR): 1.67), resident physician in final year of training (OR: 0.49), and number of patients managed (OR: 1.17). Significant correlation within question was observed and adjusted for. Overall, this study demonstrates a novel approach toward diagnosing factors contributing to physician SA during patient care. SA studies in healthcare may provide evidence for interventions aimed at improving healthcare work environments and patient safety.
    04/2012; 2(2). DOI:10.1080/19488300.2012.684739
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