Incident-Trajectory Simulation for Excellence in Safety: Illustration in Healthcare

8/13/2019 Incident-Trajectory Simulation for Excellence in Safety: Illustration in Healthcare

1/7

International Journal of Advanced Computer Science, Vol. 3, No. 8, Pp. 381-387, Aug., 2013.

ManuscriptReceived:

14,Apr., 2013

Revised:

25,May, 2013

Accepted:

29,Jun., 2013

Published:

15, Jul., 2013KeywordsHealthcare,

Safety,

Simulation,

System

Trajectory.

Abstract High Reliability Organizations

maintain low adverse incident rates over a

sustained period of time. It is well recognized

that the core concepts, applicable in a whole

variety of complex risk-prone enterprises

such as healthcare, are: (1) Sensitivity to

operations; (2) Reluctance to simplify

interpretations; (3) Pre-occupation with

failure; (4) Deference to expertise; and (5)

Resilience. A highly transferrable training

methodology and the tools that help inculcate

leadership, systems thinking, communication,

situational awareness, teamwork,

consensus-based problem solving and

decision-making, as well as adaptive

responsiveness are presented. Proposed

methods of assessment of resulting individual

and team competencies and formative

assessment of the approach are described.1

1.

IntroductionHarm to patients in the healthcare settings, according

to the US Center for Disease Control and Prevention, is thethird leading cause of mortality, following heart disease and

cancer. This lack of reliability in the healthcare system hasbeen well articulated over the past several years [1],[2]. In a

July 2000 JAMA report, Starfield estimated a total of225,000 deaths per year from iatrogenic causes [3]. The USCenter for Disease Control estimates that 1.7 millionhospital-acquired infections occur every year (i.e., 4.5infections for every 100 admissions). According to someestimates, this nation experiences 1.5 million incidents of

harm per year due to medication errors alone [2]. These arejust a few examples of the huge chasm that has beendocumented to exist between the potential and the actualquality of care delivered in the U.S.

The United Nations World Health Organization isworking toward making patient safety a Basic Human Right[4]. Despite many efforts at all levels of the healthcaresystem, it cannot be stated that patients in the US aresignificantly safer today than they were 10 years ago [5].

The world needs a system that both prevents errors and

This work was supported by the US AHRQ

Ranjit Singh, Vice-Chair Dept. of Family Medicine Assoc. Professor and

Assoc. Director; Don McLean, Safety Associate; Ashok Singh, SafetyAssociate; Gurdev Singh, Director UB Patient Safety Research Center,

State University of New York at Buffalo. USA.

[email protected]

learns from them when they occur. Development of such asystem requires, first, a commitment by all stakeholders to aculture of safety.

The overarching goal of the authors interdisciplinaryresearch team is to provide value through

quality-improvement and waste-reduction by applyingsafety principles and invoking Improvement Science [6].In the work presented here, we respond to the need for

improved education for health professionals in patientsafety by using a novel simulation-based curriculum thatapplies concepts from high reliability organizations(HROs) to healthcare.

A High Reliability Organizations (HROs)

HROs were once considered peculiarities, but during the1990s researchers in organisational behavior began to

understand the cultural factors at the core of the success ofthese organizations and recognized that these factors could

have applicability in whole variety of complex, risk-proneenterprises such as healthcare. The core concepts that arethought to underlie the excellence in high reliability

organizations, first described by Weick and colleagues [7] in1999 are: (1) Sensitivity to operations; (2) Reluctance tosimplify interpretations; (3) Pre-occupation with failure; (4)Deference to expertise; and (5) Resilience. Figure 1illustrates our adapted conceptual framework for creatingsafety.

The essential thrust of these concepts is that allworkers should understand: (a) the complexity of the

systems within which they work and (b) the proneness ofsuch systems to fail, leading to adversity/ies. They shoulddevelop situational awareness of possibilities forincidents and should report them promptly, even if noadversity occurs. Decision-making should incorporate

expertise from whoever has it, regardless of hierarchy, andstaff should be prepared to handle adverse outcomes whenthey occur.

B Formation of Culture of Safety

Figure 2 portrays different stages of development in

safety-based culture in organizations.HRO concepts overlap with those underpinning a

culture of safety. Creation of a culture of safety is acritical step for organizations that wish to improve qualityand safety. Culture is a set of beliefs and norms of behaviorresiding in individual team members and in the interactionsbetween them. As shown in Fig. 3, error reporting is one of

a number of important factors that contribute to safetyculture.

Incident-Trajectory Simulation for Excellence in

Safety: Illustration in HealthcareRanjit Singh, Don McLean, Ashok Singh, & Gurdev Singh


2/7


International Journal Publishers Group (IJPG)

382

High Reliability Concepts General Orientation Impact on Process Ultimate Outcome

Res

ilien

ce

Sen

sitivitytoo

peratio

ns

High Reliability

Exceptionally Safe,

Consistently HighQuality Care

State of Mindfulness

Deferen

ceto

expertis

e

Reluctancetosimplify

interpretations

Pre-occupat ion w ith

fai lure

Capability toDiscover and Manage

Errors(

Fig. 1.Role of 5 HR Concepts for

Safety

Pathological: Why Bother about Patient Safety?

Reactive:Do something when we have an incident

Bureaucratic: We have system in place

Proactive:We are always on thealert/thinking about what might emerge

Safety-Cultured:We manage Safetyas an integral part of

everything we do

After Manchester PSF

Risin

gLe

vels

ofC

ulturalM

aturity

a fety

Dyna

micso

f

Succ

essfully

Man

aged

Chan

ge

Fig. 2.Rising Levels of Cultural Maturity

Fig. 3.Interactive Contributors to Culture of Safety in a Dynamic and Often Cascading Environment [8]


3/7

Singhet al.: Incident-Trajectory Simulation for Excellence in Safety: Illustration in Healthcare.


383

These factors interact in a cybernetic loop that creates andreinforces the culture. Leadership has an important role. Thepositive feedback, when reporting is used appropriately, canfurther drive the development of safety culture.

C Managing Errors for High Reliability

Detection, reporting, and meaningful interpretation ofincident reports are central to the creation and maintenanceof High Reliability Organizations. In healthcare settings,this concept is operationalized through the use of incident

reporting systems.

A study by Farley et al. [9] in more than 1600 UShospitals showed that most do not maintain effectiveincident reporting systems. Figure 4 presents a model thatillustrates the error reporting cycle in which team membersengage in error reporting, followed by analysis and feedbackof lessons learned, leading to system change that in turn can

provide positive feedback to team members, encouragingfurther reporting. This never-ending continuous cycle oflearningand system changeleads to error reduction and also

encourages further development of a culture of safety.Unfortunately, most errors and close calls (near misses) go

unreported. Potential reporters often have insufficientknowledge about available reporting systems and access tothem, do not know how to report adverse events, do notknow exactly what to report, and find reporting tootime-consuming, inconvenient and cumbersome [10].Differences and ambiguities in definitions cause confusion.The items marked with * in Fig. 4 are the barriers that we

expect will be most ameliorated by the Incident-Trajectory

Simulation Approach (ITSA), leading to increased incidentreporting, leading in turn to greater system learning. Thisapproach is presented in section 2.

2. Simulation Training Method

And ToolIncident Trajectory

Simulation Approach (ITSA)

The skills / competencies required of individuals andteams are complex and require considerable time and effortto develop. Simulation is a training methodology that is wellsuited to this field for the following reasons:

The subject matter is inherently risky to the staff andpatients involvedsimulation has the ability to re-createrealistic scenarios in a safe environment that is free fromrepercussions and blame.

The skills required are complex, including problemsolving, communication, and teamwork. These types ofskills are not readily acquired just through didactics butrequire experiential training, preferably in a controlledsetting such as a simulation.

Simulation as a training methodology has being widelyused with military personnel, business managers andteachers, and it is being increasingly used to train medical

professionals [11],[12]. It can replicate these situations andtrack how trainees respond. This is the prime reason why

disaster preparedness is being helped with simulation trainingon how to handle terrorism attacks, natural disasters,pandemic outbreaks, or other life-threatening emergencies. Itfacilitates learning of valuable lessons in a cost effective andsafeenvironment.

A Simulation For Inculcating High reliability Concepts

The authors propose an innovative approach in whichthey:1) use simulation to inculcate High Reliabilityconcepts; incorporating both individual and team-basedsimulations,2) use Reasons Incident Trajectory (aka AccidentTrajectory) as the key tool in the simulations, promptingstaff to analyze systems, understand causes of errors, andstrategies for their prevention, and include a patientadvocate in the team simulation.

In their work the authors simulate safety incidents and

the administrative response to events. All staff members in aspecific hospital unit are presented initially with simulatedincident reports in their organizations current reportingformat. The process of review and analysis of these reportsis designed to inculcate HRO concepts. Staff is engagedinitially at the individual level, and later in team meetings.In the latter, they simulate group discussion of safetyincidents so as to develop team skills around patient safety,

including deference to expertise and development ofteam-based solutions to safety issues.

B Use of Reasons Incident/Accident Trajectory as aSimulation Training Tool

The training simulations are structured around theAccident Trajectory (aka IncidentTrajectory) proposed byJames Reason [13]. This describes how incidents result

from a combination ofsituationalfactorsand latentfailuresthat predispose individuals to make mistakes (active

failures). Only well designed safety barriers can intervene toprevent adversity. Figure 4 gives details of these fourcomponents. The authors have successfully piloted (andpublished) this construct in a number of out-patient officesand a hospital for stimulating systems thinking and

team-based safety problem-solving. They are now planningto use it as a training tool to help staff andpatient advocatesin a variety of hospitals to analyze simulated incidentreports in a safety training program, named

Incident-Trajectory Simulation Approach (ITSA). Figure 5illustrates the adapted concept and the structure of theSafety Journal which is an error/incident analysis tooldeveloped by Singh et al [14],[15]. The Safety Journal is adocument that healthcare workers can use to identify,describe and analyze safety incidents in a structured andlogical way. It provides a visualportrayal of the relationshipbetween the contributory factors and aids Root Cause

Analysis and development of interventions for safety

improvement. Figure 6 depicts the Safety Journal: ExampleEntry [15].


4/7


5/7



385

It is important to emphasize that this simulationprogram is highly adaptable and transferable to variousdomains outside the healthcare domain.

This tool is generalizable and can be used with eitherlow (paper-based) or high (web-based) technology. It has the4 attributes recommended by Miller for multidisciplinarysimulation-based healthcare education: practicality,feasibility, standardization and reliability. We believe,therefore, that this tool has particular potential to facilitate In

Situsimulation for training multidisciplinary teams [11],[12].

The authors propose an interactive type of multiplesimulated event-scenarios model along with the SafetyJournal as the means to inculcate the HRO concepts andobjectives.

3. ITSAGoals And Objectives

These were set and designed to inculcate individual andteam skills for 4 goals described below:

1. Sensitivity to operations: Training staff, with the aidof visual models [16],[17], to be aware of the systems and

processes in place and how these impact care, leading toidentification of risks, and reporting, in turn leading to

prevention. All participants are helped to understand theirrole within the system, how flawed systems and processeslead to error and harm, and their role in identifying andreporting events, including near misses.

2. Reluctance to simplify interpretations: Avoidingsimple explanations for events (e.g., blaming a mistake onstaff shortage) but instead look more thoroughly at causative

factors, especially underlying system failures that need to becorrected. Participants understand the role of Reasons

Adverse Event Trajectory in understanding complexcausality of safety events, understand the components of theAdverse Event Trajectory, and are able to identify situationalfactors, active failures, latent failures, and safety barriers insimulated safety event scenarios, and in real events.

3. Preoccupation with failure: All are encouraged toreport all safety events, including near misses. These reportsare important opportunities for learning. Participants learn

how and when to report safety events and understand theimportance of identifying and reporting near misses (even

though in a near miss there is no harm, it signals thepresence of risk that may cause harm in the future).

4. Deference to expertise: A culture is developed inwhich leaders and supervisors are willing to listen andrespond to the insights of staff at the front-line who know

how processes really work. Participants develop ability toparticipate effectively as part of a team in addressing patientsafety and employ appropriate communication strategies insafety discussions.

A Training Components for Individuals and Teams1. Didactic: Introductory session, led by Unit NurseManagers, with all staff and physicians and patient

advocate.

2. Simulation: Analysis of simulated event reports -participants are presented with a set of 5 simulated safetyevents (vignettes) in the organizations usual reportingformat. For each event, participants identify causativefactors according to the information presented and classify

the causative factors according to Incident Trajectory. Theteams are expected to put forward at least one proposal forsystem improvement.

3. Feedback:Within 1 week after each session,participants receive written individual feedback regarding

their individual and team performance (with respect to thecompetency measures outlined below).4. Repeat Simulation: Until a pre-determined level of

competency is reached by the individual (up to amaximum of 3 repeat simulations).The vignettes for the simulations are based on our

clinical experience (incorporating clinical input from

family medicine, geriatrics, pharmacy, nursing, and a

patient advocate), covering a variety of types of events,involving various systemic factors such as: medicationevents, testing events and events involving patientmistakes. They are tailored to unique hospital settings aswell as for team simulation events.

4. Individual and Team

Competency Assessment

Table 1 shows the competency and outcome measuresused inITSA with respect to the goals and objectives.

A Formative Evaluation of the ITSA ProgramFormative evaluation of the ITSA program has to be

carried out with respect to satisfaction, perceived utility,and perceived impact among participants in order toinform future development and generalizability of theprogram. Each participant needs to be invited to complete

brief ratings of the following (using Likert-type scaleresponses): (a) clarity of objectives, (b) extent to which

objectives were met, (c) format appropriateness andeffectiveness, (d) duration, level of engagement, (e)applicability to daily work, and (f) likelihood that they willchange their behavior as a result.

5. Concluding Remarks

ITSA is a highly transferable in situ simulation

methodology that helps inculcate the HRO concepts and theembedded objectives, at both the individual and team levels.One of the main advantages of the Incident Trajectoryformat is that it separates system problems from the activeand situational factors; focusing attention on these systemproblems can lead to sustainable solutions.


6/7



386

TABLE 1:

SUMMARY OF TRAINING OBJECTIVES,COMPONENTS,COMPETENCIES AND OUTCOME MEASURES

Fig. 6.The Safety Journal: Example Entry [15]


7/7



387

ITSA appears to create a safe environment for staff topractice discussing safety issues, become comfortabletalking in front of their superiors, receive non-punitivefeedback individually and as a group, and become moreeffective as a team. It is expected that these skills will

translate into staffs actual daily work leading to increase intheir own and patients satisfaction.

It is the authors experience that safety is not most

effectively taught through didactics but through engaginglearners in addressing real problems in their practices. In

situ simulation represents an important step toward this. Ourexperience suggests that further efforts are needed to findeffective ways to weave an emphasis on safety across thevarious threads of training so as to better facilitateinternalization (and hence application) of safety principles.

Acknowledgment

This work was supported by 2 grants from the USHealth Resource and Services Administration.

References

[1] Institute of Medicine. Committee on Quality of HealthCare in America. Crossing the Quality Chasm : A NewHealth System for the 21st Century. Washington, D.C.:National Academy Press; 2001.

[2] Aspden P, Institute of Medicine (U.S.). Committee onIdentifying and Preventing Medication Errors.

Preventing Medication Errors. Washington, DC:National Academies Press; 2007.

[3] Starfield B. Is Us Health Really the Best in the World?JAMA. 2000;284(4):483-485.

[4] WHO. World Health Alliance for Patient Safety.Forward Programme2005.

[5] Pronovost PJ, Colantuoni E. Measuring Preventable

Harm: Helping Science Keep Pace with Policy.JAMA. Mar 25 2009;301(12):1273-1275.

[6] Berwick DM. The Science of Improvement. JAMA.Mar 12 2008;299(10):1182-1184.

[7] AHRQ. Becoming a High Reliability Organization:Operational Advice for Hospital Leaders. Rockville,MD: Agency for Healthcare Research and Quality;2008.

[8] Singh G, Singh R, Thomas EJ, Fish R, Kee R,McLean-Plunkett E, Wisniewski AM, Okazaki S,

Anderson D. Measuring Safety Climate in PrimaryCare Offices. In: Henriksen K, Battles JB, Keyes MA,Grady ML, eds. Advances in Patient Safety: NewDirections and Alternative Approaches. Vol 2.Rockville, MD: Agency for Healthcare Research andQuality; 2008:59-72.

[9] Farley DO, Haviland A, Champagne S, Jain AK,

Battles JB, Munier WB, Loeb JM.Adverse-Event-Reporting Practices by US Hospitals:

Results of a National Survey. Qual Saf Health Care.Dec 2008;17(6):416-423.

[10] Uribe CL, Schweikhart SB, Pathak DS, Dow M,Marsh GB. Perceived Barriers to Medical-Error

Reporting: An Exploratory Investigation. Journal ofHealthcare Management. July/August2002;47(4):263-279.

[11] Fanning RM, Gaba DM. The Role of Debriefing inSimulation-Based Learning. Simul Healthc. Summer

2007;2(2):115-125.[12] LaVelle BA, McLaughlin JJ. Simulation-Based

Education Improves Patient Safety in Ambulatory

Care. In: Henriksen K, Battles JB, Keyes MA, GradyML, eds. Advances in Patient Safety: New

Directions and Alternative Approaches. Vol 3.Rockville, MD: Agency for Healthcare Research andQuality; 2008:213-232.

[13] Reason JT. Human Error. Cambridge [England] ;New York: Cambridge University Press; 1990.

[14] Singh R, Naughton B, Taylor JS, Koenigsberg MR,Anderson DR, McCausland LL, Wahler RG, Robinson

A, Singh G. A Comprehensive Collaborative Patient

Safety Residency Curriculum to Address the AcgmeCore Competencies. Med Educ. Dec2005;39(12):1195-1204. PMID: 16313578.

[15] Singh R, Naughton B, Singh A, Anderson DR, SinghG. The Safety Journal: Lessons Learned with an ErrorReporting Tool to Stimulate Systems Thinking. JPatient Safety. September 2007 2007;3(3):135-141.

[16] Singh R, Singh A, Fox CH, Taylor JS, Rosenthal TC,Singh G. Computer Visualization of Patient Safety in

Primary Care: A Systems Approach Adapted fromManagement Science and Engineering. Informatics inPrimary Care. 2005;13:135-144. PMID: 15992498.

[17] Singh R, Pace W, Singh S, Singh A, Singh G. A

Concept for a Visual Computer Interface to MakeError Taxonomies Useful at the Point of Primary Care.Informatics in Primary Care. 2007;15(4):221-229.PMID: 18237479.

Documents

Incident-Trajectory Simulation for Excellence in Safety: Illustration in Healthcare