EDUCATIONAL ADVANCES
Multiple Encounter Simulation for High-acuity Multipatient Environment Training Leo Kobayashi, MD, Marc J. Shapiro, MD, Deborah C. Gutman, MD, MPH, Gregory Jay, MD, PhD
Abstract Patient safety interventions for multitasking, multipatient, error-prone work settings such as the emergency department (ED) must improve assorted clinical abilities, specific cognitive strategies, and teamwork functions of the staff to be effective. Multiple encounter simulation scenarios explore and convey this specialized mental work-set through use of multiple high-fidelity medical simulation (SIM) manikins in realistic surroundings. Multipatient scenarios reflect the work situations being targeted yet have the benefit of scripted control and instructor guidance to advance specific educational objectives. The use of two or more SIM patients promotes the exploration not only of multiple distinct clinical issues but also of interdependent processes pervasive in EDs. Cascading shortages of time, personnel, equipment, and supplies are re-created, thereby replicating process limitations at various levels, in a safe environment in which compensatory actions and adaptive behaviors can be learned. Distinguishing features of multipatient exercises include 1) broadened educational scope and expanded indications for SIM application, 2) enhanced scenario complexity, 3) controlled exposure to high workload environments, 4) expanded communication requirements, and 5) increased potential for reflective learning. Widespread and effective training in wellreplicated, carefully coordinated representations of complex multipatient work environments may strengthen educational interventions for personnel working in high acuity and work-overloaded settings such as the ED. The use of concurrent patient encounter SIM exercises to elicit calculated stressors and to foster compensatory staff behaviors is an educational advance toward this objective. The authors present SIM methodology using concurrent patient encounters to replicate these environments. ACADEMIC EMERGENCY MEDICINE 2007; 14:1141–1148 ª 2007 by the Society for Academic Emergency Medicine Keywords: teaching methods, educational technology, simulation, medical education, medical error, emergency medicine
stablishment of effective instructional interventions to reduce medical errors is difficult.1–3 Risk management conferences, chart reviews, and other traditional error reduction activities may lack bedside relevance, flexibility and impact, impartiality, or, most importantly, acceptance.4–6 To attend to select causes of medical error without incurring these shortcomings, fully interactive high-fidelity medical simulation
E
(SIM) manikins offer realistic environments wherein the precipitant conditions and progression of modeled ‘‘errors’’ can be precisely controlled.7 Preventive and compensatory actions can be taught at the site and time of error occurrence8; mediated reflective learning by debriefing participants is integral to this process.9–11 Patient endangerment and physician apprehension over medicolegal liability or culpability become nonissues.12
From the Departments of Emergency Medicine (LK, MJS, DCG, GJ) and Bioengineering (GJ), Brown Medical School, Providence, RI; and Injury Prevention Center, Lifespan (MJS), Providence, RI. Received March 8, 2007; revisions received May 6, 2007, and May 15, 2007; accepted May 30, 2007. Excerpts from the multiple encounter simulation scenarios (MESS) discussed in this article were presented as an Innovation in Emergency Medicine Education at the SAEM annual meeting, Orlando, FL, May 2004. This material is based on work supported by the Centers for Medicare and Medicaid Services (CMS), Office of Naval Research (ONR), and U.S. Army Telemedicine and Advanced Technology
Research Center (TATRC). SAFER Transportable Simulationbased Patient Safety Curriculum is work performed under CMS grant 18-P-92332/1-01. The Rhode Island Disaster Initiative is work performed under Chemical-Biological Information Analysis Center contract SP0700-00-D-3180, Task Number 128, Delivery Order # 0122 sponsored by the ONR. The Reserve Component Medical Skills Training Program is work performed under TATRC subcontract number RCMST-RIH-05-001. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of CMS, ONR, or TATRC. Contact for correspondence and reprints: Leo Kobayashi, MD; e-mail:
[email protected].
ª 2007 by the Society for Academic Emergency Medicine doi: 10.1197/j.aem.2007.05.015
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Although educational uses of SIM are ongoing in a variety of medical fields,9,13–16 some workgroups may find the prototypical one-patient/one-provider-team SIM limiting. Unique cognitive and temporal demands arise in the emergency department (ED) from limited availability or inconstant reliability of information sources, incessant interruptions, distractors, dynamic and time-critical end points, patient surges, and understaffing.17–20 In this article, we discuss a SIM methodology featuring concurrent simulated patient encounters to replicate emergency medicine (EM) and disaster care work environments11,21 to better prepare health care providers for simultaneously managing multiple patients with varying acuities. MULTIPLE ENCOUNTER SIMULATION SCENARIOS Emergency medical personnel are frequently called upon to perform several life-saving duties simultaneously, thereby becoming mired in resource diversions, possibly associated with worse patient outcomes.22 Educational and patient safety interventions for multitasking, multipatient, error-prone work settings must help staff identify and improve an assortment of clinical abilities, specific cognitive strategies, and teamwork functions to be effective.23 Multiple encounter simulation scenarios (MESS) provide a setting for exploring these human factors through use of multiple SIM manikins in realistic surroundings. MESS scenarios reflect the work situations being targeted yet have the benefit of scripted control to advance specific educational objectives. Prior and Ongoing Multiple Patient SIM Programs Details of the experiences of several groups with simultaneous use of more than one SIM patient are available in the peer-reviewed literature. Small et al. have described two- and three-patient scenarios in EM SIM with standardized patients, SIM manikins, and combinations thereof.11 Multipatient Emergency Medicine Crisis Resource Management courses using teamwork and leadership principles from aviation and anesthesiology are ongoing.23 Results from an Emergency Team Coordination Course (Dynamics Research Corp., Andover, MA) research protocol revealed positive perceptions of multimanikin training environments and a trend toward enhanced teamwork in the intervention group.24 The military has constructed numerous SIM combat casualty care training facilities, including the Air Force’s ‘‘Simulated Medical Unit’’ inpatient hospital ward.25 Multipatient disaster medical management exercises featuring highfidelity manikin systems have also been reported.26–29 Educational and Training Opportunities Unique to Multipatient SIM Scenarios Teamwork lapses, breakdowns in communication, worker task overload, and time pressure have contributed prominently to patient safety failures.30–32 These cultural and institutional problems, highlighted in the Institute of Medicine report To Err is Human,33 are predictably magnified in ED and disaster environments. A multipatient scenario helps bring these issues to the forefront by creating the environmental conditions31,34 that facilitate and propagate medical errors. Table 1 provides distinguishing features of multipatient exercises, and Figure 1
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Table 1 Educational Focus Points for Multipatient Simulation Sessions Clinical Rapid triage of multiple patients with varied acuities Positive patient identification protocols (e.g., preprocedure timeouts) Institution of rapid evaluative + diagnostic approaches Institution of definitive/emergent therapeutic interventions Prompt formulation and flexible revision of treatment plan Efficient procedural performance Expeditious disposition Teamwork Establishment of visible leadership and team structure Task identification and delegation Effective communication of information within team Efficient communication of information to/from team Team cross-monitoring Performance of checkbacks on team member actions Workload assessment/resource allocation Effective collaboration with consultants Cognitive Process identification and prioritization Multitasking with controlled attention switching Debiasing of cognitive processes Continuous task reassessment/confirmation of task completion Maintenance of situational awareness Rapid recovery from errors/institution of corrective actions Rapid recovery from interruptions
provides an example of scenario construction and flow diagram illustration for a three-patient scenario. Broadened Educational Scope and Expanded Indications of SIM Every single-patient SIM scenario holds the potential to convey numerous teaching points, such as critical elements of clinical medicine and systems issues pertinent to bedside patient care.15 MESS expands on this by overlaying issues that arise when a simulated patient is placed into a complex system35 of health care with more than one simulated patient. High-acuity multipatient environment work conditions, such as cascading shortages of time, personnel, equipment, and supplies, are recreated in a safe environment in which compensatory actions and adaptive behaviors can be learned. Some of the cognitive skills required for effective functioning under such conditions are consonant with those highlighted by the triple-patient encounter oral examination cases administered during American Board of Emergency Medicine certification testing. SCENARIO DEVELOPMENT The following is a step-by-step description of multipatient scenario development. Scenario content has been extracted from actual completed sessions; suggested critical actions and timing of performance markers are included. Step 1: Select the Target Population of Learners and Teaching Objectives for Multipatient SIM Scenario Title: Three-patient scenario featuring hyperkalemia, asthma, and penetrating neck trauma, with scripted medication error.
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Figure 1. Scenario flow diagram system for scripting of multipatient simulation scenarios and their dynamic interactions. The vertical axis reflects the passage of time, starting at the top and moving downward with scenario progression. The horizontal axis is a visual analog of illness or injury severity, with the left side representing higher morbidity and mortality and rightward motion indicating clinical improvement. Simulated patients’ courses of illness/injury can be plotted with timed branch points to describe progressive changes in clinical status. The example depicts possible clinical progressions of a multiple encounter simulation exercise within an acute care hospital setting. Three patients (gray scale coded) arrive in quick succession, starting with critical medical patient 1 requiring emergent triage and treatment to avoid rapid demise. Patients 2 and 3 arrive soon after, initiating multipatient interactions revolving around allocation of personnel and equipment resources. Proper triage and treatment of each patient results in clinical improvement until a scripted drug swap error is introduced. Appropriate interventions and optimal teamwork behaviors result in a best-case outcome of three stabilized/improved patients. RN = nurse; Pt. = patient; SIM = high-fidelity medical simulation.
Target audience: EM trainees (program year 3+) and staff. Teaching Objectives
Cognitive: 1) Multitasking with controlled attention switching, 2) maintenance of situational awareness, 3) rapid recovery from error.
Global Clinical: 1) Rapid triage of multiple patients with varied acuities, 2) institution of rapid diagnostic approaches, 3) institution of emergent therapeutic interventions, and 4) efficient procedural performance. Teamwork: 1) Task identification and delegation, 2) workload assessment/resource allocation.
Manikin Patient 1: Primary, rapid recognition and treatment of hyperkalemia; secondary, medication error recognition and treatment. Patient 2: Primary, appropriate evaluation and treatment of asthma; secondary, ongoing reassessment of patient.
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Patient 3: Primary, rapid recognition and treatment of penetrating neck trauma; secondary, rapid sequence intubation; medication error recognition and treatment. Enhanced Scenario Complexity Each supernumerary manikin adds to the selection of potential patient presentations, indicated clinical actions, and medical decision branch points available in a multipatient exercise. Actions for one SIM patient could impact all other SIM patients, care providers, and available resources. These dynamic interfaces then contribute to replicating the complexity of working within a clinical setting.36 This capacity to generate a simulated health care ‘‘world’’ (akin to aviation ‘‘full mission SIM’’)37 can be a powerful tool for educators working in emergency and mass casualty medicine. Step 2: Select Background of Multipatient SIM Scenario MESS Setting. The learner is faced with three acutely ill patients who arrive within a brief period. Patient 1 arrives at the start of the scenario; two other patients arrive 6 minutes into the scenario. The two unstable patients have conditions requiring emergent treatment, and the third requires urgent treatment. Nursing and consultant resources are limited (see step 4). Timing and length of time (from start of scenario) until completion of critical actions will determine patient outcomes. A scripted drug swap medication error will be introduced. Step 3: Define Specific Markers of Performance Appropriate for Learner Level, with Consensus Input from Learner Educators, Supervisors, and/or Expert Consultation Critical Action Performance Markers (nonvalidated performance markers are not intended at this time for learner evaluation but solely for educational purposes) Global 1) Ability to triage patients and prioritize patient care (patients 1 and 3 to be triaged above patient 2), 2) ability to rapidly diagnose multiple life-threatening conditions (correct assessments of patient conditions while meeting scenario time requirements), 3) ability to rapidly treat multiple life-threatening conditions (correct life-saving interventions for patient conditions while meeting scenario time requirements). Manikin Patient 1: 1) Institutes efficient diagnostic plan for renal failure–related conditions causing confusion and widecomplex bradycardia (electrocardiogram [ECG], finger stick glucose, chemistry panel, computed tomography [CT] of the head ordered by 3 minutes), 2) implements efficient treatment plan for severe hyperkalemia (albuterol nebulizer, calcium infusion, insulin + dextrose infusion, sodium bicarbonate, nasogastric sodium polystyrene sulfonate ordered by 6 minutes), 3) reassesses patient for interval change (at least one recheck).
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Patient 2: 1) Completes rapid triage (patient 2 prioritization below patient 3, complete by 7 minutes), 2) institutes efficient diagnostic plan for moderate asthma flare (bedside peak flow, continuous pulse oximetry, chest radiography, ECG ordered by 25 minutes), 3) implements efficient treatment plan for moderate asthma flare (nebulized albuterol, intravenous corticosteroids, intravenous fluids ordered by 25 minutes), 4) reassesses patient for interval change (at least one recheck). Patient 3: 1) Completes rapid triage (patient 3 prioritization over patient 2, complete by 7 minutes), 2) institutes efficient diagnostic plan for posterior neck stab wound (assessment of wound location and platysmal violation by 8 minutes), 3) implements efficient treatment of unstable neck stab wound (airway management by 11 minutes, hemodynamic resuscitation, imaging and trauma consultation arranged by 15 minutes), 4) reassesses patient for interval change (at least one recheck). Step 4: Determine Needed SIM Elements Environment and Props. Lab Setup: 1) Level 1 trauma center/regional referral ED, 2) acute care/trauma areas (three patient ‘‘rooms’’). Manikin Setup + Props Patient 1: Intermediate- or high-fidelity manikin moulaged as older female patient in comfortable clothing. Assorted pill bottles, wide-complex bradycardia ECG, normal head CT, laboratory result printouts, medications for ED hyperkalemia treatment. Patient 2: Intermediate- or high-fidelity manikin moulaged as male patient in street clothing. Normal chest x-ray, medications for ED asthma treatment. Patient 3: Intermediate- or high-fidelity manikin moulaged as male patient in street clothing with posterior left neck stab wound. Normal chest x-ray, airway management equipment (including difficult airway kit), ED wound care, and blood product props. SIM Personnel and Assigned Roles. SIM personnel: 1) SIM scenario director/coordinator 1, 2) simulated patients (manikin controllers) 2–3, 3) facilitators and actors (see below), 4) audiovisual technician (optional). Facilitator and actor roles: 1) Family member of patient 1, 2) ED nurse 2, 3) ED technician 1 and/or respiratory therapist 1, 4) consultant physicians (intensivist 1 and trauma surgeon 1; both become available for consultation at 15 minutes into scenario). Controlled Exposure to High Workload Environments Clinicians in high-acuity multipatient settings carry significant workloads. Recovering from task fragmentation, continuously caring for and moving between patients in separated treatment areas, maintaining situational awareness (defined as ‘‘the ability to identify, process, and comprehend the critical elements of information about what is happening to the team with regards to the mission [plan of care]’’38), avoiding patient misidentification, and overcoming system inefficiencies are essential skills. Just as health care providers’ cumulative duties in a live clinical setting extend beyond direct patient care
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Table 2 Patient 1 Scenario Name/age/gender: S.B./87 years old/female Mode of arrival: Private vehicle, accompanied by daughter Chief complaint: [confusion]; minimal history due to dementia Past medical history: Moderate dementia, atrial fibrillation, type 2 diabetes mellitus, hypertension, renal failure, arthritis Medications/allergies: Glipizide, isosorbide dinitrate, lisinopril, vitamins/no known drug allergies Initial examination: Pulse 42 beats/min, blood pressure 167/94 mm Hg, respiratory rate 24 breaths/min, 92% oxygen saturation on room air, afebrile. Benign head examination, jugular venous pressure 5 cm elevated, rhonchorous breath sounds, regular heart sounds at 42 beats/min, benign abdomen, trace edema on extremities, nonfocal neurologic examination (conversant, confused, more so than baseline per family). Patient progression: Patient has missed dialysis for four days and has become increasingly confused due to uremia with accompanying hyperkalemia (K+ 7.0 mEq/L) and moderate hyperglycemia (382 mg/dL). Efficient diagnostic workup including ECG is required, as well as early intervention with potassium-lowering interventions before attending to other patients (patients 2 and 3). Multipatient scenario considerations: This patient arrives first and needs expeditious diagnosis and intervention, which will lead to temporary stabilization. Additionally, a drug swap error (omission of insulin) is scripted at a preset point in the scenario and will need to be addressed appropriately.
tasks,39,40 multipatient SIM scenarios require learners to work harder than if separately attending to each of the manikin patients. MESS participants can be exposed firsthand in a constructive manner to situations requiring high-level operational skills such as controlled attention switching, task delegation with monitoring for completion, workload balancing, and error recovery. Leadership becomes more challenging, either through intensified duties for the team leader or through distribution of command across multiple individuals. Step 5: Develop Session Narrative and Detailed Timeline Case Narrative. Scenario: It is a busy afternoon in a Level 1 trauma center/regional referral ED. The facility has just been taken off diversion, with few open intensive care unit or floor beds. Nursing staff is limited, and backup staff have not yet arrived. The attending physician and resident staff from the previous shift are still in the ED but are busy with a difficult cardiac resuscitation. Learner role: Clinician coming onto shift for acute care/ trauma area of ED. Initial SIM parameters: One learner + two facilitators for one patient + one family member. Timeline (see Figure 1): Starting cues, patient arrivals, and multipatient interactions occur at preset times; deci-
sion branch points, see scenario flow diagram; ending cues, learner completion of all critical actions or 25 minutes of scenario. Step 6: Generate Individual Patient Scripts in the Context of Multipatient SIM Scenario The scripts for patients 1–3 are provided in Tables 2–4, respectively. Expanded Communication Requirements Patient safety principles such as positive patient identification, preprocedure timeouts, and sidedness checks41,42 can be overlooked in training configurations with only one patient present. Populating a SIM learning environment with a cohort of patients immediately generates the need for improved communications between participants. Real-life requirements to identify each patient explicitly and to collaborate with the appropriate care provider(s) become apparent. Tools such as Situation-BackgroundAssessment-Recommendation (SBAR)43 become valuable and reinforce communication responsibilities in conjunction with vital safety behaviors such as cross-monitoring, callouts, and task checkbacks.38,44 (A checkback is defined as ‘‘A communication strategy that requires a verification of information. The sender initiates the message, the receiver accepts it and restates the message, in return, the
Table 3 Patient 2 Scenario Name/age/gender: K.A./27 years old/male Mode of arrival: Private vehicle Chief complaint: ‘‘My asthma is acting up a little.’’ Past medical history: Asthma (no intubations, occasional steroids, unknown peak flow) Medications/allergies: Albuterol (ran out 3 days ago)/no known drug allergies Initial examination: Pulse 126 beats/min, blood pressure 102/74 mm Hg, respiratory rate 30 breaths/min, 94% oxygen saturation on albuterol nebulizer, afebrile. Moderate dyspnea, diminished but equal breath sounds with diffuse wheezing, rapid heart sounds, benign abdomen, warm extremities, and nonfocal neurologic examination. Patient progression: This stoic patient slowly becomes more dyspneic but does not draw attention to his worsening condition. He does not need airway management or mechanical ventilation but requires appropriate diagnostic workup and nebulized albuterol, intravenous corticosteroids, and fluids to be stabilized. Multipatient scenario considerations: Patient arrives simultaneously with another patient (patient 3). Both have similar vital signs, but patient 2 is less acutely ill and needs to be triaged, then evaluated and cared for (after patient 3’s stab wound). Although serving primarily as a ‘‘distractor’’ to shift the learner’s attention away from patients 1 and 3, the high potential for clinical instability has to be recognized; the learner can accomplish this by periodically monitoring patient 2 in person or through nurse facilitators.
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Table 4 Patient 3 Scenario Name/age/gender: J.L./19 years old/male Mode of arrival: Emergency medical services, accompanied by emergency medical technicians, if available Chief complaint: ‘‘I got cut in the neck!’’ Past medical history: None Medications/allergies: None/no known drug allergies Initial examination: Pulse 128 beats/min, blood pressure 108/76 mm Hg, respiratory rate 28 breaths/min, 96% oxygen saturation on room air, afebrile, 2-cm stab wound to zone 2 lateral neck posterior to sternocleidomastoid, equal breath sounds, regular heart sounds, benign abdomen, warm extremities, and nonfocal neurologic examination. Patient progression: Rapidly becomes more dyspneic and hoarse, developing a progressively enlarging neck hematoma without pulsatile external hemorrhage in the first 2 minutes. Although tracheobronchial structures are intact, rapid sequence intubation with preparation for difficult airway management needs to be accomplished due to potential for impending airway compromise. Upon successful airway management, hemodynamic resuscitation, imaging studies, and trauma surgery notification for emergent intervention are required. Multipatient scenario considerations: This patient arrives simultaneously with patient 2, who is having an asthma flare. The learner needs to prioritize and treat the current instability of patient 3 while being aware of the imminent clinical instability of patients 1 and 2. Finally, this patient is scripted to inadvertently receive 10 U of patient 1’s intravenous insulin during a drug swap error of commission. Upon error recognition, the learner will need to order repeated blood glucose measurements and corresponding treatment due to the patient’s intubated state.
sender verifies that the restatement of the original message is correct, or amends if not.’’38) Increased Potential for Debriefing Key to any multipatient scenario debriefing is discussion of participants’ abilities and weaknesses with respect to projected performance at the bedside. The dialogue should incorporate accurate reconstruction of critical events, analysis for causation and sequence of events, and suggested changes for process improvement.38 Finally, a concept of provider function within an interdependent health care system should supplant the perception of isolated team members working in a disconnected manner. Step 7: Develop Debriefing Plan with Didactic Materials and Institution-specific Discussion Points Debriefing Plan Focus/content of Debriefing Multipatient management: 1) Overview of scenario progress and learner actions, 2) patient care prioritization/triage, 3) rapid diagnostic approaches (for confusion, dyspnea, and trauma), 4) emergent treatment approaches (for confusion, dyspnea, and trauma), 5) multitasking with procedural efficiency, 6) situational awareness and workload distribution, 7) patient reassessment. Patient evaluation, management, and disposition: 1) Hyperkalemia, 2) asthma, 3) penetrating neck trauma. Medical error: 1) Errors of commission (patient identification protocols), 2) errors of omission, 3) error recovery and follow-up. SIM faculty can design the concerted integration of several simulated patients into an SIM session for an educational experience that supplements traditional teaching methods and resonates with practitioners working in the ED or out-of-hospital environment. Although practicing the care of individual SIM patients within expertly constructed and guided acute care multipatient sessions
may sharpen clinical skills, continued medical education through alternative means should be encouraged.45 Although confirmation of SIM utility has not been mandatory in other high-risk fields,46 simulator-to-bedside knowledge transfer through medical SIM educational techniques has yet to be definitively substantiated. The complex interrelated activities conducted within the SIM space in a multipatient exercise may impede development of time-coded and timing-standardized metrics, thereby presenting challenges to objective performance assessment. Efforts to scientifically determine the value of multiple patient scenario training are ongoing. LIMITATIONS There are abundant caveats regarding the advancement of medical education with sophisticated medical SIM strategies. Florini may have best addressed one concern: ‘‘. . . the mere use of technology to deliver instruction does not imply that the instruction is high in quality.’’47 These considerations are especially relevant because the financial and technical resources necessary to organize a MESS event are substantial. The budget must account for training of SIM faculty and technical personnel, medical supplies, and financial or clinical incentives to recruit facilitators. With manikins priced upwards of $35,000 aside from maintenance costs, the expense of assembling an adequate cohort of SIM systems and patient actors may be difficult. Collaborative efforts between medical educators and SIM facilities with the expertise, personnel, and technical resources to coordinate multipatient exercises are called for. CONCLUSIONS Well-designed, carefully coordinated multipatient SIM scenarios may strengthen educational interventions that teach health care providers the compensatory behaviors and skills needed in high-acuity, stressful, and workoverloaded settings such as the ED.
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The authors thank Anna C. Cousins for her assistance in manuscript preparation.
References 1. Berwick DM. A primer on leading the improvement of systems. BMJ. 1996; 312:619–22. 2. Leape LL, Berwick DM. Safe health care: are we up to it? BMJ. 2000; 320:725–6. 3. Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care. 2004; 13(Suppl 2):ii3–9. 4. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002; 347:1933–40. 5. Hofer RP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. 2002; 137:327–33. 6. Rosen AB, Blendon RJ, DesRoches CM, et al. Physicians’ views of interventions to reduce medical errors: does evidence of effectiveness matter? Acad Med. 2005; 80:189–92. 7. Blum R, Raemer DB, Carroll JS, Dufresne RL, Cooper JB. A method for measuring the effectiveness of simulation-based team training for improving communication skills. Anesth Analg. 2005; 100:1375–90. 8. Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg Med. 1999; 34:373–83. 9. Gaba DM, Howard SK, Fish KJ, Smith BE, Sowb YA. Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience. Simul Gaming. 2001; 32:175–93. 10. Bond WF, Deitrick LM, Arnold DC, et al. Using simulation to instruct emergency medicine residents in cognitive forcing strategies. Acad Med. 2004; 79: 438–46. 11. Small SD, Wuerz RC, Simon R, Shapiro N, Conn A, Setnik G. Demonstration of high-fidelity simulation team training for emergency medicine. Acad Emerg Med. 1999; 6:312–23. 12. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative. Acad Med. 2003; 78:783–8. 13. Gordon JA, Wilkerson WM, Williamson Shaffer D, Armstrong EG. ‘‘Practicing’’ medicine without risk: students’ and educators’ responses to high-fidelity patient simulation. Acad Med. 2001; 76:469–72. 14. Macedonia CR, Gherman RB, Satin AJ. Simulation laboratories for training in obstetrics and gynecology. Obstet Gynecol. 2003; 102:388–92. 15. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005; 27(1): 10–28. 16. Eppich WJ, Adler MD, McGaghie WC. Emergency and critical care pediatrics: use of medical simulation for training in acute pediatric emergencies. Curr Opin Pediatr. 2006; 18:266–71.
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17. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians ‘‘interrupt-driven’’ and ‘‘multitasking’’? Acad Emerg Med. 2000; 7:1239–43. 18. Chisholm CD, Dornfeld AM, Nelson DR, Cordell WH. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med. 2001; 38: 146–51. 19. Spencer R, Coiera E, Logan P. Variation in communication loads on clinical staff in the emergency department. Ann Emerg Med. 2004; 44:268–73. 20. Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Hospital-based Emergency Care: At the Breaking Point. Washington, DC: National Academy Press, 2006. 21. Shapiro MJ, Simmons W, Wears R, Perry S, Morey JC. ED prototype simulation scenarios. In summary white paper for human engineering: emergency medical team performance (MedTeams) phase III, Development of the Emergency Team Coordination Course supported by high fidelity simulation training to improve team performance (ETCC-S), Army Research Laboratory Contract #DAAL01-96-C-0091, Aberdeen Proving Grounds. Subcontracted through Dynamics Research Corp., Andover, MA, 2001. 22. Fishman PE, Shofer FS, Robey JL, et al. The impact of trauma activations on the care of emergency department patients with potential acute coronary syndromes. Ann Emerg Med. 2006; 48:347–53. 23. Reznek M, Smith-Coggins R, Howard S, et al. Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine. Acad Emerg Med. 2003; 10:386–9. 24. Shapiro MJ, Morey JC, Small SD, et al. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care. 2004; 13:417–21. 25. Eaves RH, Flagg AJ. The US Air Force Simulated Medical Unit: a teaching strategy with multiple applications. J Nurs Educ. 2001; 40:110–5. 26. Berkenstadt H, Ziv A, Barsuk D, Levine I, Cohen A, Vardi A. The use of advanced simulation in the training of anesthesiologists to treat chemical warfare casualties. Anesth Analg. 2003; 96:1739–42. 27. Kyle RR, Via DK, Lowy RJ, Madsen JM, Marty AM, Mongan PD. A multidisciplinary approach to teach responses to weapons of mass destruction and terrorism using combined simulation modalities. J Clin Anesth. 2003; 16:152–8. 28. Decker SI, Galvan TJ, Sridaromont K. Integrating an exercise on mass casualty response into the curriculum. J Nurs Educ. 2005; 44:339–40. 29. Kobayashi L, Suner S, Shapiro MJ, et al. Multipatient disaster scenario design using mixed modality medical simulation for the evaluation of civilian prehospital medical response: a ‘‘dirty bomb’’ case study. Simul Healthcare. 2006; 1(2):72–8. 30. Helmreich RL. On error management: lessons from aviation. BMJ. 2000; 320:781–5.
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31. Reason J. Human error: models and management. BMJ. 2000; 320:768–70. 32. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000; 320:745–9. 33. Kohn LT, Corrigan JM, Donaldson MS (eds). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999. 34. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003; 133:614–21. 35. Kernick D, Sweeney K. Post-normal medicine. Fam Pract. 2001; 18:356–8. 36. Hamman WR. The complexity of team training: what we have learned from aviation and its applications to medicine. Qual Saf Health Care. 2004; 13(Suppl 1): i72–9. 37. Beaubien JM, Baker DP. The use of simulation for training teamwork skills in health care: how low can you go? Qual Saf Health Care. 2004; 13(Suppl 1): i51–6. 38. Department of Defense. TeamSTEPPS: Team Strategies & Tools to Enhance Performance and Patient Safety. Developed by the Department of Defense and published by the Agency for Healthcare Research and Quality. AHRQ Publication No. 06-0020-0. Rockville, MD: Agency for Healthcare Research and Quality, 2006. Available at: http://www. ahrq.gov/qual/teamstepps/ and http://www.usuhs. mil/cerps/teamstepps.html. Accessed Nov 15, 2006.
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39. Potter P, Wolf L, Boxerman S, et al. Understanding the cognitive work of nursing in the acute care environment. J Nurs Adm. 2005; 35:327–35. 40. Willis K, Brown CR, Sahlin I, Svensson B, Arnetz BB, Arnetz JE. Working under pressure: a pilot study of nurse work in a postoperative setting. Clin Nurse Spec. 2005; 19:87–91. 41. Parisi LL. Patient identification: the foundation for a culture of patient safety. J Nurs Care Qual. 2003; 18(1):73–9. 42. Joint Commission on Accreditation of Healthcare Organizations. 2004 national patient safety goals adapted for programs. Jt Comm Perspect. 2004; 24(3):1–5. 43. Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006; 32: 167–75. 44. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004; 13(Suppl 1):i85–90. 45. Casarett D, Helms C. Systems errors versus physicians’ errors: finding the balance in medical education. Acad Med. 1999; 74:19–22. 46. Gaba D. Improving anesthesiologists’ performance by simulating reality. Anesthesiology. 1992; 76:491–4. 47. Florini BM. Communications technology in adult education. In: Galbraith MS (ed). Adult Learning Methods. Malabra, FL: Krieger, 1990.
