Monthly Archives: June 2014

Feedback – More Than Just Debriefing


Too often in the designs of scenarios for simulation there is a lack of attention to the fact that there are many forms of feedback that occurs during a simulation than the debriefing. Debriefing is certainly an important part of any learning encounter, but in reality represents only one type of feedback.

As you think about sources of feedback I ask you to be both creative and attentive. I like to think of feedback in two broad categories, intrinsic and extrinsic. The latter being the more commonly thought of mechanisms such as debriefings, video reviews, and simulator log file reviews etc. with the former being the topic of this post.

What I find to be of significant interest as it related to the design of scenarios is the feedback that occurs intrinsically. That is clues, or changes that occur during the scenarios that are available to the participant to incorporate in their understanding of how their decisions, treatments, or lack thereof, are affecting the statues of the patient.

Many of you might be saying, what are you talking about???? Ha!!! Now on to my favorite part which is providing concrete examples to help explain myself further.  Let’s say you are simulating a pelvic fracture case with hypotension and shock. The vitals’ of the high technology simulator that you may be using for the case would likely show tachycardia and hypotension etc. Now lets say the participant(s) place a pelvic binding device and give a unit of blood. You may include changes in the vitals appearing on the monitor that indicated that there was mild to moderate improvement of the patient. Perhaps the tachycardia would decrease and the blood pressure may improve over a set period of time.

During the design process of the scenario many people may create the changes in the vitals thinking they are mimicking reality of what may occur.  More importantly I think those involved in the design of the scenario should realize that the changes in the vitals referred to above are a source of important intrinsic feedback. The participants should be able to make the observations and decide they are helping the patient to improve.

This can be powerful feedback that links together successful performance with particular behaviors or decisions that were made. It is self-discovery, it will help to guide further care and decisions if the scenario continues. If the designer of the scenarios recognizes this intrinsic feedback in the design phases, additional creative solutions can be implemented to reinforce the learning.

While my pelvic fracture example shows a positive change tin the patient based on correct actions, the converse example could be true if incorrect care is being rendered. Consider that if you have a heart attack case with hypotension and the patient is administered aspirin and nitroglycerin. You would likely worsen the shock from a physiological perspective. Seeing this change will provide intrinsic feedback to the learners(s).

This is not to say that it all has to do with fancy feedback from high technology simulators. The same could be accomplished with showing a worsening EKG on paper if treatment is incorrect or delayed, or conversely showing and improving EKG for the right treatment given within the appropriate time.

Approaching feedback from a deliberate perspective can be helpful in reinforcing learning. It should be recognized as a design tool and carefully integrated into the core deign of any scenario. Debriefing can be linked to these feedback areas in the scenario. This can provide valuable links or areas ripe for discussion to assist in accomplishing the learning objectives.

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Insitu Mock Codes Evaluate People Readiness and System Readiness – An Important Patient Safety Tool

CombinedTeamandEvaluationOver the last 20 years WISER has conducted hundreds of unannounced mock code evaluations at hospitals directly associated with our health system. Additionally we have assisted others with conducting and reporting on this important patient safety activity in hospitals both in the US and outside. As it is true in most things in simulation there is no binary answer on right versus wrong in the way simulation is carried out.

In situ mock codes bring a unique perspective that allows all of the effectiveness of simulation based education to be combined with human factors and systems testing that are crucial to ensure higher levels of patient safety for the increasingly ill patients who are being cared for in hospitals around the world. This is a patient population that is at well documented great risk for harm from errors that occur resulting from a myriad of causes ranging from human error to poorly design systems.

Mock codes in hospitals bring crucial insight into the care delivery that occurs episodically in high tempo, high stress unplanned situations in our hospitals. They can identify areas of deficiency that are not readily apparent. (Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes; Hunt et al. Pediatrics. 121(1):e34-43, 2008). We can gain unique perspectives such as where do we need to place AED’s? Is the hospital operator handling code requests in the most expedient fashion? Where in the hospital should responders respond from? It is these important system data points that can be understood from mock code data generation that are impossible to gain conclusive evidence from in the simulation lab, or in those mock codes that personnel know are of the simulated variety.

While we are able to do undeniable powerfully effective training in our simulation labs, it is the mock code and other insitu activities that help to bring true facts to factor into decisions that evaluate and ultimately improve patient safety. Do mock codes have the ability to lead to unintended harm or further error if not carefully planned carried out and monitored? Of course they do, and they must be regarded as such. But mopping the floor of the hospital also carries forth the increased possibility of hip fractures, yet it is a required element of infection control and with appropriate precautions and guidelines we make every attempt to minimize this potential risk.

Those of us in healthcare who are directly involved in the care of patients as well as those who have roles in system oversight of the direct care of patients recognize that with every intervention, every therapy and every procedure there are risks and benefits. The same goes for the training we provide. The fact that someone in a simulation center may get shocked by a defibrillator or stuck by a needle during simulation training are potential harms that may occur secondary to the use of simulation based education. So we recognize these risks through failure mode effect analysis, learning from others at meetings such as the International Meeting for Simulation in Healthcare (IMSH), remaining informed by current literature and implementing solutions that attempt to minimize these risks.

While Raemer does a wonderful job of pointing out some of the potential possibilities of potential hazards associated with mock codes (Ignaz Semmelweis Redux?; Sim Healthcare 9:153-155, 2014), this personal opinion piece does not actually include an overall analysis of risk vs. benefit. Nor does he present any data that combines evaluation of training programs, professional readiness and systems design with a quantitative deliverable that allows such an assessment. With the latter information properly collected and analyzed those of us involved in designing future care delivery systems through policy, investments in training, staffing and equipment will be better prepared to make a difference in the safety of patients.

The reference to the Owen article is baffling. (Unexpected Consequences of Simulator Use in Medical Education: A Cautionary Tale; Sim Healthcare 9:149-152, 2014). Professor Owen authored a remarkably elegant piece in this month’s SIH journal that was inappropriately titled in my opinion. The title seems to be one that attempts to be provocative in an ability to gain ones attention in the simulation world.  (That part was effective I must admit, as I read the article immediately.) However the article and its title implies that the use of simulation CAUSED untoward outcomes in patients. From a root cause perspective in the information presented in the article, that is NOT THE CASE. The poor outcomes were associated with the lack of hand hygiene and the lack of knowledge associated with proper hand cleaning and infection transmission. It is analogous to saying that an automobile striking a pedestrian is the fault of the car.

I would estimate real codes occur in our healthcare system (of 20 hospitals/care facilities) roughly 50 times per day. So if we simply take 50 codes per day that is 18,250 codes per year. This is not a rare critical event; this is a common critical event that we still have much to learn about from a training perspective as well as a systems design perspective. We all know there are delays and errors associated with codes in general. My colleagues and I reported an enormous amount of medication administration errors during observations of REAL CODES (Medication errors during medical emergencies in a large, tertiary care, academic medical center; Resuscitation. 83(4):482-7, 2012 Apr) and that is just one element in the complex environment of actual codes.

Despite reams of paper trails, and gigabytes of data in the vaults of patient safety and risk management reports in the offices of hospitals, we still have very little insight into the actual root causes of the epidemic of harm to patients that occurs during hospitalization. The mock code, with its associated risks and POTENTIAL complications is an important tool in the armamentarium of patient safety probes that will ultimately save lives.


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Is Death Not Safe?

deadSimManToeTag_aAll of the discussion on the Sim Connect Community networking site of the SSH inspired me to expound a little on the topic of death during simulation.

A number of years ago we had a poster at IMSH reporting our results of a survey given to 224 professionals (Emergency Physicians, Flight Paramedics and Flight Nurses) who attended courses that had some scenarios that ended in death depending on how the cases were managed. Overall 48% of them had experienced death during the courses. These were courses that did not include objectives on death, family/patient communications or teamwork. Thus, there was no focus on the death during the debriefing.   PDF of Poster

They were asked a series of questions about experiencing death during the simulations. The four main conclusions that we reported were: 1) Participants disagreed that simulated death was distracting to the learning environment; 2) Participants strongly disagreed that students in their respective fields should be exempted from simulated death; 3) Participants strongly disagreed that experiencing simulated death would create a reluctance to participate in further simulation training; 4) Participants disagreed that a separate disclosure about the possibility of simulated death was necessary. On further analysis there was no difference in the perceptions of those who experienced simulated death and those who had not.

Bear in mind these are all practicing professionals and all from a high-acuity emergency profession. But, none the less this was their collective opinion. So maybe at times we should slow down and ask the participants their impression. I think many people take the phrase “safe learning environment” to extremes and try to make absolute rules that are very broad sweeping and thus become rate limiting steps in creating effective education.

Do I think that death in simulation is appropriate for all learners? Absolutely not! In the case of the learners participating in the courses we studied, it was the collective opinion of the subject matter experts involved in the design of the courses that it was appropriate. But importantly, it was a deliberate decision as part of the course design.

While there is significant passion, emotions, urban myths and beliefs surrounding this topic, like most things in simulation I think there is no one correct answer. I believe that those who profess to know “THE” way to do simulation and are unyielding in there methodology or offerings should be viewed with skepticism and doubt.

When programs carefully evaluate who their learners are, make realistic expectations, understand what is needed of the learner to provide the best patient care possible, remains attentive to the general emotional well being of the participants, and deliver the learning with well trained facilitators, I believe they are providing PATIENT CENTRIC SIMULATION. A concept which I believe is the most useful of all to the global healthcare community and will result in higher quality patient care.


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