Traditional Poster Round
Context: : Serious adverse incidents (SAI) are adverse events in healthcare that justify a heightened level of response as their impact on patients, staff or systems is so great (1). The UK National Health Service (NHS) has a framework for reporting of SAIs, including Never Events and near misses (2) and individual healthcare trusts are responsible for investigating these incidents and delivering recommendations to its staff to avoid recurrence of the incident (1). Often these recommendations include education of multiprofessional staff. High fidelity in-situ simulation is an effective interprofessional educational model (3) and our group believe it can be used to learn from incidents in the operating theatre.
Description: : To enhance the education and learning from reported SAIs within the operating theatre environment, our group devised a process wherein following closure of investigation, a multiprofessional in-situ simulation based on the SAI theme is performed. Initially we reviewed the previous five years of SAIs and identified recurring themes. These included;
• Prescription errors: Incorrect dosing, incorrect route, incorrect drug
• Documentation errors: Consent form errors, Title of procedure errors
• Equipment errors: Use of out of date materials,
The simulations are to be performed in-situ within the operating theatre with Gaumard Pediatric HAL, a high fidelity model. Each simulation will specifically be designed to be a straightforward case which has an inbuilt error (based on the SAI theme) which will be expected to be recognised and acted upon by staff with adherence to local protocols. Simulations are streamed to a separate site for group observation and learning.
Our hope is to initiate this programme at the start of 2019 and present our results at IPSSW in May.
Observation/Evaluation: : The candidates will not be primed to the SAI theme. The observing team will be made aware of the theme and each member is tasked with reviewing a particular aspect of the simulation; clinical decisions, communication and teamwork, systems errors.
A standardised system of formal debrief will e performed with the candidates separately and then with the observers. Likert Scale questionaries’ are used for reflection on learning and assessing participants’ self-reported knowledge of the subject and how likely they would be to recognise the error before and after the simulation. We also will ask if participants feel simulation was a useful way to learn from previous SAIs.
We have performed a multiprofessional staff survey to ascertain if they feel there is a need for this programme: 18/20 staff felt that SAI often recur and 17/20 felt that this was because no formal educational programme took place. 8/20 staff recalled receiving an email to highlight a previous SAI. 15/20 staff felt that simulation is an effective tool to enhance learning. 12/20 staff have noticed system changes take place already in response to an SAI.
Discussion: : This programme hopefully will allow our group to highlight not only human error but system error as the simulations are performed in-situ. Identification of learning needs of the candidates is performed not only by faculty but also the observers, allowing focused peer and group education. The simulations also will prompt investigation and revision of documentation systems, such as the WHO checklist, to adapt it for our environment. To further expand this process, in-situ simulation will be performed in our hospital outside of the operating theatre environment in response to additional SAIs.