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

Over 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.