Oral Themed Presentation
Context: : Although rare, a serious patient safety threat than can occur in a hospital setting, is when an infant or child goes missing (Code Pink). This event can have catastrophic consequences for the child, caregiver and the institution where the event occurred. . Hospitals who care for children need to have plans in place to respond to these threats, and provide education and training for staff. Recognizing the need for such training, an academic pediatric medical center with an established simulation program, partnered with patient safety and security to overhaul the Code Pink drill process. Historically, the drills were conducted without the benefit of simulation, which offers more experiential learning. After observing an unannounced Code Pink drill with a poor outcome, the patient safety team performed a Root Cause Analysis and determined that the current Code Pink drill process was inadequate due to low engagement and poor response from staff. This inadequate response was deemed a patient safety threat.
Description: : The Code Pink drills were modeled after the simulation based curriculums utilized in the institution. Four Code Pink scenarios with learning objectives were created by simulation faculty. An embedded actor played the parent of the missing child, to add realism to the simulations. The simulations were piloted on an in-patient unit, before launching to the entire hospital. From October 9, 2017 to November 13, 2017, 43 Code Pink simulations were conducted. A total of 515 inter-professional participants attended the simulations. Each simulation had assigned observers who monitored the drill response for quality improvements that could be brought back to the patient safety committee for analysis. After every simulation, a simulation faculty member conducted a post event debriefing, utilizing a scripted debriefing tool .
Observation/Evaluation: : Data was gathered from the observations forms, and from the post simulation debriefings. A plethora of data was obtained from 160 observation forms returned, and the information was analyzed by the patient safety team for trends in opportunities for improvement. The data gathered during the Code Pink simulations were utilized to create a new Code Pink policy. Each drill was timed to monitor the speed of staff response. The time of the start of the simulation to the end or “All Clear”, decreased over time. This reflected increased staff engagement, and response when searching for a missing child following an overhead Code Pink announcement.
Discussion: : Partnering simulation based education with patient safety and security to overhaul the Code Pink drill process, has been a success. Utilizing simulation techniques such as; objective based scenarios, embedded actors, promoting realism and scripted debriefings, was key to this success. Important changes to the Code Pink process have been made as a result of the findings from the simulations, and are reflected in a new Code Pink policy. After the initial roll out of Code Pink simulations, drills are now conducted quarterly and monitored for quality improvements. Lessons learned from this project included ensuring inter rater reliability of the observers, benchmarking with peer institutions for best practices and discovering the need to perform Code Pink simulations in ambulatory and clinic settings. The Code Pink simulation project is relevant for all institutions which care for children. Simulating the complicated processes needed to respond to a report of a missing infant or child, is an important patient safety initiative.