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IMSH 2020

IMSH 2020 was a big success!

This was our first time hosting a booth at the International Meeting for Simulation in Healthcare. We had a steady stream of visitors to our booth; many of them were already using our safety labels. Others were using their own labels, and we discussed the advantage of a standardized label for easy recognition.

Although labels are the most visible aspect of our work, it is equally important to think about other aspects of simulation safety.  We had lots of conversations about possible risks. Ideally, simulation planning should include assessment of risks and mitigation strategies.

We presented a workshop:  First Do No Harm: Strategies to Prevent Simulation Accidents. After an introduction to the simulation safety concepts, workshop participants shared their examples of simulation mishaps and mitigation strategies.

Some examples:

  • Inadvertent activation of personnel/ resources: There were several examples of Code/Rapid Response Teams being summoned in error. These “false alarms” are a recurring problem, and they can disrupt clinical care. We have heard stories of blood transfusions ordered,  ECMO team and pediatric transport team being summoned to a simulation.
  • Keeping mannikins clean is challenging, and one team noted signs of mold growth despite usual cleaning procedures.  Cultures were sent to the lab, and they were dismayed to learn that the results were positive for Pseudomonas.  This is especially worrisome if mannikins are brought into patient care areas, which could be very risky for immunocompromised patients.
  • Despite instructions to the contrary, people give mouth to mouth ventilations to the mannikin.
  • Risks to standardized patients (SP) were described.  Allergic reaction to moulage have happened. Sometimes clinicians forget that the SP is not a real patient, and get “carried away” e.g. attempt IV or other invasive procedures.
  • Problems with medications are quite common.  Well-meaning donations of expired drugs can be a logistical challenge.  One program discovered narcotics in a storage closet, which had to be reported to authorities and required extensive follow up.
  • Expired supplies or procedure kits are saved for training purposes. Often these items are not quarantined or labeled, and could end up in patient care area.
  • Decommissioned equipment is sometimes used during simulations. These may not be up to current code, and can present risk of fire or shock.

Risk Reduction Strategies

Some programs install mechanical lift (Hoyer lift or other brand) for moving heavy mannikins.  This is also used for staff training.

Safety culture : encourage everyone to be empowered to speak up if they see any dangers and “stop the line”

Report accidents and near misses via incident reporting system.

Safety officer / safety observer. This person is assigned to watch for any unsafe conditions, and intervene. This is especially important during multi-patient simulations.

Q12020 - FHSS MASTER WORKSHEET

A Somber Anniversary

Five years have passed since we first heard this shocking news:

Adverse Events Associated with Administration of Simulation Intravenous Fluids to Patients

On December 23, 2014, the New York State Department of Health (NYSDOH) was notified of adverse health events in two patients who had been inadvertently administered nonsterile, simulation 0.9% sodium chloride intravenous (IV) fluids at an urgent care facility. ….

Source: Notes from the Field

This event was shocking and distressing. The thought that simulation could inadvertently cause harm to patients goes against our core values! Simulation educators provide a vital service to make healthcare safer, not to cause harm.

This incident was the catalyst for the formation of the Foundation for Healthcare Simulation Safety, and the 5 year mark seems like an appropriate time to think about the state of healthcare simulation safety, what has been accomplished, and plans for the future.

2019 in Review:

6000 Website visits from 66 Countries

71 Label orders fulfilled

441 Label templates downloaded from website

Spanish and Portuguese translations of the editorial: Simulation Safety First; An Imperative

Plans for 2020

IMSH workshop :  First Do No Harm: Strategies to Prevent Simulation Accidents. This is the 4th time we have presented this workshop; each time we hear more examples of simulation mishaps and mitigation strategies.

IMSH Booth This is our first time hosting a booth at the International Meeting for Simulation in Healthcare.  

 

 

 

2019 Year in Review

Over the last few years, the message of simulation safety has gained strength.  Thanks to all of our friends and colleagues for doing your part to keep sim safe!

6000 Website visits from 66 Countries

71 Label orders fulfilled

441 Label templates downloaded from website

Spanish and Portuguese translations of the editorial: Simulation Safety First; An Imperative

Simulation Safety was a featured topic on Simulcast Journal Club.  The online journal club discussed the Practically Saline article; a wide-ranging discussion followed.

Dr. Catherine Morse invited Ann Mullen to contribute a section on simulation safety to the article: The Changing Landscape of Simulation-Based Education, published in August 2019 in the American Journal of Nursing.

Plans for 2020

IMSH workshop:  First Do No Harm: Strategies to Prevent Simulation Accidents. This is the 4th time we have presented this workshop; each time we hear more examples of simulation mishaps and mitigation strategies.

IMSH Booth This is our first time hosting a booth at the International Meeting for Simulation in Healthcare.  We hope to see you in San Diego! 

 

Simulation Safety at UAB

Our colleagues at the University of Alabama have embraced simulation safety!  During a recent visit to the Office of Interprofessional Simulation for Innovative Clinical Practice (OIPS), several examples of simulation safety practices were evident.

Medication Labels

The fake medications are clearly labeled. More importantly, the task of labeling is assigned to a specific person, who checks regularly to ensure that any new items are labeled “Not for Human Use, Education Only”

Policy for Actual Emergency

The center has a policy for managing real emergencies, which is clearly posted throughout the center. The simulation center looks like an authentic clinical environment, and if a learner or staff were to become ill or injured, there could be confusion or delay.  Clear instructions are posted with emergency phone numbers to summon help for real events.

In Situ Simulation 

In situ simulations are conducted regularly by the OIPS team. These drills are conducted to test the hospital system and to identify strengths, weaknesses, opportunities, and threats in clinical systems, the environment, or among teams.

The OIPS team presented a workshop on in situ simulation at the International Meeting on Simulation in Healthcare (IMSH) in January 2019.  The panel provided a comprehensive guide for implementing an in situ simulation program. April Belle, MSN, RN, Director of In Situ Simulations, provided many specific recommendations for reducing the risk to patients and staff during these drills.

The OIPS website section on in situ simulation features a photo of the team transporting a mannikin to a drill. The IV bag is clearly labeled with a FHSS safety label.  Many thanks to the team for their commitment to simulation safety!

Simulation Safety First: Portuguese Translation

We are happy to share another translation!

The simulation safety editorial is now available in Portuguese, thanks to the work of our colleagues from Brazil: Dr. Henrique Pierotti Arantes  and  Carolina Alexio.  Dr. Arantes is the coordinator of the IMEPAC Araguari – MG Medical Course in Araguari, Brazil.  More information about the IMEPAC Simulation Center can be found here.

Thank you Henrique for your time and talent!

The translated version is here: Juramento

Simulation Safety First: Spanish Translation

The  message of simulation safety is spreading to our Spanish-speaking colleagues!

We are so grateful to Priscilla Carmiol-Rodríguez for translating our editorial to Spanish. Priscilla teaches at at the University of Costa Rica’s Healthcare Simulation Center, and  has worked in healthcare simulation for over 7 years. The Simulation Center is located at the Nursing School, and is an SSH accredited center.

Our colleagues generously agreed to review the translation, and provided valuable feedback. Demian Szyld, MD is the Senior Director of the Institute for Medical Simulation at the Center for Medical Simulation in Boston.  José Mª Maestre, MD is the Director of Educational Innovation at Virtual Hospital Valdecilla in Santander Spain, and is on the faculty of  Institute for Medical Simulation, Center for Medical Simulation in Boston.

We thank Pricilla, Demian and José for your time and talent!

The translated version is here: Seguridad Primero

Journal Club: Simulation Safety Pledge

Simulation Safety was the topic of a recent Journal Club hosted by Darin Abbey, RN at the Centre for Interprofessional Clinical Simulation (CISCL) The journal club is a monthly event to engage in critical discussion of emerging practices related to clinical simulation education.

The session included discussion of each element of the Simulation Safety Pledge. Prior to the meeting, Darin asked the group to read the Pledge and consider the following:

  • Describe a safety hazard that you can imagine, or that your simulation program has experienced, which adherence to this pledge would mitigate.
  • What specific measures do you imagine your simulation program would have to undertake to fulfill the intention of this pledge item?

This format resulted in thoughtful discussion and examination of each item of the pledge.  The group shared their current practices and reflected on possible changes to their practices and how to engage their teams. The journal club is recorded and posted on the CICSL webpage. This journal club has covered lots of great topics; the link is here . They also discussed a safety checklist for in situ drills. This tool is on the FHSS website.

After listening to the journal club, we wanted to clarify some aspects of the the simulation safety pledge. There were some good discussions about whether certain items were applicable to every setting, as well as challenges to implementation and 100% compliance.  It was evident that the group examined each item seriously,  and they were open to expressing concerns about sections of the pledge. This is a positive thing; it would not be helpful to nod politely and accept the pledge without question! We offer the pledge as a list of sound practices, not as a command to be followed. This as a living document, and we are eager to hear input about revisions and additions.

We are so grateful to Darin for leading this discussion and for sharing with the FHSS. We look forward to further collaborations!