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Simulation in health care creates a safe learning environment that allows researchers and practitioners to test new clinical processes and to enhance individual and team skills before encountering patients. Many simulation applications involve artificial "patients" that can show symptoms and respond to simulated treatment, analogous to flight simulators used by pilots.

The Agency for Healthcare Research and Quality (AHRQ) supports simulation research through its patient safety program.

Contents

Introduction
Project Descriptions
   Evaluation of the System for Teamwork Effectiveness and Patient Safety
   Simulation Training for Ultrasound-Guided Central Venous Catheter Insertion
   Preparing Rural and Urban Hospitals to Improve Safety Culture Through Simulation
   Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture
   Reducing Errors in the Diagnosis of Melanoma Using an Intelligent Tutoring System
   Evaluating the Clinical Impact of Simulation and Team Training on Obstetric Safety
   Emergency Department Simulation for Research and Training in Health Care Information Technology
   Simulation Training for Acute Coronary Syndrome Management for Rural Providers
   Clinical Decision-Support Simulations for Medication Administration Safety
   Acute Care Management Skills: An Assessment Program for Graduate Physicians
   Improving Patient Safety With Just-in-Time Pediatric Simulation Training
   In Situ Teamwork Training and Detection of Safety Threats in High-Risk Settings
   Improving Resuscitation Team Response to Inpatient Critical Events by Simulation
   In Situ Simulation to Detect and Prevent Near Misses During Critical Events
   Evaluating the Impact of Simulated Team Training on Patient Safety
   Immersive Simulation Team Training Impact on Rescue, Recovery, and Safety Culture
   Virtual Health Care Environments Versus Traditional Interactive Team Training
   Simulation-based Training Program to Augment Electronic Medical Record-Based Handoff Tool
   Simulation Training for Rapid Assessment and Improved Teamwork

Introduction

In 2006, AHRQ awarded more than $5 million for 19 new grants (select for press" release). These grants are 2-year cooperative agreements between the principal investigator and the Agency. The 19 projects focus on assessing and evaluating the roles that medical simulation can play to improve the safety and quality of health care delivery.

In a variety of clinical settings, simulation allows health care practitioners and teams to acquire valuable experience safely without placing patients at risk. The projects below will inform providers, health educators, payers, policymakers, patients, and the public about the effective use of simulation in improving patient safety.

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Project Descriptions

Evaluation of the System for Teamwork Effectiveness and Patient Safety
Principal Investigator: Shelia Chauvin, Ph.D., M.Ed.; Louisiana State University Health Sciences Center, New Orleans, LA.
Grant No.: RHS016680-01
Description: Operating rooms (OR) are characterized as dynamic, high-risk environments that place a premium on rapid response to change, clear communication, and skillful team performance. Several recent studies, however, have shown that OR teams often fail to perform in a highly " reliable manner, undermining patient safety.

Dr. Sheila Chauvin and her team are implementing, evaluating, and refining an interdisciplinary, simulation-based training model designed to improve teamwork and patient safety in OR environments. Known as the System for Teamwork Effectiveness and Patient Safety (STEPS), the approach entails a mobile mock operating room (MMOR) configuration that supports training with actual interdisciplinary teams in their own ORs, and enables development and implementation of change process strategies for enhancing teamwork and patient safety at the point of care. The MMOR-based simulations use realistic OR scenarios, specific team-based strategies, and reflective debriefings guided by video replay. The project assesses the extent to which STEPS, as a comprehensive simulation and change process strategy, impacts teamwork and a culture of patient safety. It also examines how individual and organizational factors influence transfer of training to on-the-job team performance.

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Simulation Training for Ultrasound-Guided Central Venous Catheter Insertion
Principal Investigator: Leigh Evans, M.D.; Yale University, New Haven, CT.
Grant No.: HS016725-01
Description: In the United States, physicians insert more than 5 million central venous catheters (CVCs) every year. While insertion of CVCs is common, it is an intricate procedure and not risk-free. Traditionally, inexperienced residents learn to insert CVCs on real patients under an apprenticeship model referred to tongue-in-cheek, as "see one, do one, teach one." Exposure to real patients is indispensable, but sub-standard performance can put patients at risk.

To help avoid the risk of harming today's patients while training tomorrow's practitioners, Dr. Leigh Evans and her team focus on evaluating the efficacy of a structured simulation training protocol using ultrasound-guided CVC insertion for resident physicians. The project compares the failure rate of CVC insertion, the number of attempts at venous cannulation, and the rates of technical errors on actual hospitalized patients between residents who have completed a structured, hands-on simulation training protocol (intervention group) with those who are trained according to the traditional, bedside apprenticeship model (control group).

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Preparing Rural and Urban Hospitals to Improve Safety Culture Through Simulation
Principal Investigator: David Gaba, M.D.; Stanford University, Stanford, CA.
Grant No: HS016630-01
Description: Simulation is making inroads in academic hospitals, even though it has yet to realize its full potential for improving teamwork and safety culture. Little penetration has occurred with rural and community hospitals. According to Dr. David Gaba and his team, more needs to be known about the obstacles that need to be overcome in both rural and urban hospitals to achieve adoption and how simulation can be used to foster culture change in these settings.

Starting with a baseline safety culture assessment in three diverse hospitals, the Gaba team developed three distinct, 2.5-day simulation training programs for each site's multidisciplinary team. Members of the research team are currently assisting their client hospitals in designing and conducting their first simulation scenarios. Further mentoring occurs with conference calls, site visits, review of videotaped exercises and debriefings, and review of online participant evaluations. By allowing participants to enact teamwork knowledge, skills, and attitudes, the likelihood of a sustained improvement in team behavior and safety culture is considered greater.

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Using Team Simulation to Improve Error Disclosure to Patients and Safety Culture
Principal Investigator: Thomas Gallagher, M.D.; University of Washington, Seattle, WA.
Grant No.: HS016658-01
Description: Talking about harmful errors that patients experience and disclosing these errors to patients is not easy for physicians and nurses. Most providers have not received any training in error disclosure, and there is sometimes confusion regarding providers' roles with respect to disclosure. Yet transparency is a cornerstone of a positive patient safety culture.

With an innovative use of both standardized patients and standardized team members, Dr. Thomas Gallagher and associates aim to improve both the team discussions that occur as teams prepare and plan for disclosing errors to patients and the conduct of the disclosure. Each of the teams consists of a physician, nurse, and standardized team member (trained actor). The teams first discuss and react to what happened, plan the disclosure, and then conduct the disclosure with standardized patients. A "disclosure coach" also assists with the planning and conduct of the disclosure with probing questions and feedback. A structured debriefing occurs after the simulation. Performance of the disclosure teams is then compared to that of a control group with respect to pre- and postmeasures from a Web-based assessment of communication knowledge, skills, and attitudes. In addition to extending the use of trained actors as a form of simulation, the work of the Gallagher team is helping to fill a significant communication void among providers and between providers and patients.

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Reducing Errors in the Diagnosis of Melanoma Using an Intelligent Tutoring System
Principal Investigator: Dana Grzybicki, M.D., Ph.D.; University of Pittsburgh School of Medicine, Pittsburgh, PA.
Grant No.:> HS016657-01
Description: Skin cancer is the most common of all cancers. Malignant melanoma accounts for only about 4 percent of skin cancer cases but causes a large majority of skin cancer deaths. Previous studies have estimated that approximately 10 percent of all pigmented lesions examined are associated with a clinically significant false-negative error rate " related to melanoma, resulting in harm to patients.

Dr. Dana Grzybicki and her team aim to improve the diagnostic accuracy of community generalist pathologists in the identification of malignant melanoma through the use of a cognitive simulation system. By modifying an existing cognitive simulator, the team is developing an "intelligent tutoring" system that will include difficult cases that have been frequently associated with false negative and false positive melanoma diagnoses. They will then conduct a controlled laboratory evaluation on generalist pathologist subjects to determine the effects of the intervention on decreasing false negative and false positive melanoma diagnostic errors. Once evaluated, the system can be used locally for proficiency testing and training and enhanced for use at national educational conferences.

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Evaluating the Clinical Impact of Simulation and Team Training on Obstetric Safety
Principal Investigator: Jeanne-Marie Guise, M.D., M.P.H.; Oregon Health & Science University, Portland, OR.
Grant No.: HS016673-01
Description: Many of the most frightening and lethal obstetric (OB) conditions occur in otherwise healthy, low-risk women at term, complicating up to 15 percent of all births. A review by the Joint Commission found that over two-thirds of sentinel OB events, in which the infant died or had severe brain damage, were attributed to poor communications and teamwork. It is also known that obstetrical care in rural hospitals lags behind that of urban hospitals.

With a focus on rural hospitals, Dr. Jeanne-Marie Guise and her team have developed a standardized Curriculum for Simulated Obstetric Emergency Response Drills and Safety that allows teams to rehearse OB emergencies. The simulation approach is based on principles from crew resource management (CRM) team training. Given that critical care personnel already are overextended, the Guise team is evaluating which elements of CRM training are associated with good teamwork at the "sharp end" of everyday routine and emergency OB care. They also are exploring which elements of CRM training are transferable, durable, and sustainable in the clinical environment over time and are developing a Web site for participating institutions to further promote patient safety culture.

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Emergency Department Simulation for Research and Training in Health Care Information Technology
Principal Investigator: Li Lin, Ph.D.; University at Buffalo (State University of New York), Buffalo, NY.
Grant No.: HS016672-01
Description:: Existing manual (e.g., white board) and electronic tracking systems in emergency departments (ED) play a critical role in communicating many patient-care factors that have a direct impact on patient safety. As information technology becomes better integrated into the health care system, EDs will undergo transitions to electronic systems. Simulation-based research can help ensure that as this technology is introduced, new opportunities for failure modes are identified and averted before patient safety is compromised.

In contrast to many training-based applications of simulation, Dr. Li Lin and his team utilize an immersive simulation-based laboratory environment to study caregiver interaction with patient-tracking systems. Their research demonstrates the use of simulation for usability testing, for iterative design improvement, and to help predict factors that have the potential to threaten patient safety. Information displayed on the patient tracking system is drawn from a real-time, interactive, discrete event simulation of an ED environment. Participant awareness, decisions, and actions are measured in two experiments that vary aspects of displays, ED demand levels, and caregiver types. The research helps inform the design and development of electronic patient-tracking systems.

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Simulation Training for Acute Coronary Syndrome Management for Rural Providers
Principal Investigator: John Messenger, M.D.; University of Colorado Health Sciences Center, Denver, CO.
Grant No.: HS016682-01
Description: Available data show low rates of adherence to guideline-based treatment of acute myocardial infarction (AMI) in many settings, particularly rural settings. Hospitals with low rates of adherence to guideline-recommended therapies have worse clinical outcomes than those with high rates of adherence.

Dr. John Messenger and his research team are assessing the current state of AMI care in rural hospitals in Colorado using chart abstractions and specific performance measures. Physicians and nurses in up to 10 rural hospitals are completing a 7-hour curriculum that focuses on recognition and guideline-based management of AMI using simulated clinical scenarios with a mobile simulator (SimSuite® Training System). AMI care before and after simulation training is evaluated; benchmarks are shared with other rural hospitals. The team hopes that exposure to best practices of care and the mobile use of simulation training will prove effective in responding to the unique needs of providers in rural settings charged with caring for AMI patients.

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Clinical Decision-Support Simulations for Medication Administration Safety
Principal Investigator: Jacqueline Moss, Ph.D., R.N.; University of Alabama at Birmingham, AL.
Grant No.: HS016660-01
Description: Medication administration errors continue to pose a significant threat to health care safety. While clinical decision-support systems have been useful in addressing a variety of medical errors, they are often difficult to integrate into the clinical workflow. End users cannot always articulate how the tools will work in the actual environment when asked for input regarding systems design.

Dr. Jacqueline Moss and her research team are developing a methodology and tools for the design of clinical decision-support systems to decrease the incidence of medication administration errors. Initially, they are modifying a simulated clinical information system to include a suite of decision-support tools for medication administration within intensive care. They are then engaging teams of intensive care unit nurses to participate in a protocol to identify how these tools can be customized for optimal decision support within their clinical environment. Finally, they are producing a detailed manual with instructions for customization across a broad range of settings and other support materials to enable general tool use in a contextually sensitive manner.

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Acute Care Management Skills: An Assessment Program for Graduate Physicians
Principal Investigator: David Murray, M.D.; Washington University School of Medicine, St. Louis, MO.
Grant No.: HS016652-01
Description: Graduate physicians need to acquire fundamental skills in managing acute care events to avoid harming patients. Yet there is evidence to suggest that considerable variation exists in the performance capability of medical students and interns to provide adequate, responsive care at a time when patients are most vulnerable.

To measure physicians' acute care management skills and establish performance standards for acute care events, Dr. David Murray and his team use a multiple event curriculum to assess and train acute care skills in conjunction with a full-scale mannequin. After reviewing participants' performance, an expert panel will derive attainable competency standards. The team also is designing simulation events to objectively measure physicians' communication skills with health care teams and nurses and will assess the" relationship between objective and subjective measures of communication. According to Dr. Murray, establishing an unambiguous, yet attainable, performance standard for graduate physicians will better equip them in acquiring the requisite acute care skills.

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Improving Patient Safety With Just-in-Time Pediatric Simulation Training
Principal Investigator: Vinay Nadkarni, M.D., M.S.; The Children's Hospital of Philadelphia, PA.
Grant No.: HS016678-01
Description: Safe and advanced pediatric airway management in the pediatric intensive care unit requires experienced and trained providers. Preliminary data suggests lack of experience is the reason why supervised physician trainees fail at their first attempts at tracheal intubation. Well-targeted simulation training that includes feedback improves performance; however, evidence demonstrating the transfer of this improvement to the clinical environment is limited.

Dr. Vinay Nadkarni and his team at the Children's Hospital of Philadelphia are evaluating the effects on teams of simulation overtraining versus no overtraining with respect to actual clinical performance in tracheal intubation and tracheal intubation-associated adverse events. The researchers are also investigating the impact of high fidelity (use of Laerdal's SimBaby with computerized feedback) versus low fidelity (use of SimBaby with human-standardized feedback) simulation on performance in simulation and clinical settings. If the findings support the use of simulation in this situation, the simulation techniques have potential to be adopted in other high-risk settings where the safety of ill and injured children is of major concern.

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In Situ Teamwork Training and Detection of Safety Threats in High-Risk Settings
Principal Investigator: Mary D. Patterson, M.D., M.Ed.; Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
Grant No: HS016615-01
Description: While emergency departments in hospitals are well known as high-risk areas, less is known about the magnitude of medical errors and special challenges associated with pediatric emergency medicine. The team of Dr. Mary Patterson at Cincinnati Children's Hospital Medical Center is acquiring a better understanding of the risks with an in situ research plan.

In addition to focusing on a vulnerable population in a high-risk clinical setting, the Patterson team uses the actual clinical environment to embed training of crew resource management, teamwork, and critical communication skills as a routine part of daily clinical practice. The researchers plan to stage training for trauma and emergency medical teams at their work locations. From simulation exercises and debriefings, researchers anticipate uncovering a richer account of latent safety threats and resource and system issues. Digital recordings of the simulations will allow evaluation of a team's success in meeting critical treatment goals. Resuscitations in the emergency department shock trauma bay also are to be digitally recorded, enabling evaluation of the transfer of skills learned from simulation exercises to an actual high-risk clinical procedure.

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Improving Resuscitation Team Response to Inpatient Critical Events by Simulation
Principal Investigator: Jose Pliego, M.D.; Texas A&M Health Science Center College of Medicine, Temple, TX.
Grant No.: HS016634-01
Description: Rural and small community hospitals often do not have the coverage to respond to immediate crisis management events; therefore, training nonphysician providers in rapid response teams becomes a necessity. Dr. Jose Pliego and his team are evaluating whether training "sharp end" health care providers can improve organization-wide safety culture, enhance individual and group teamwork, and have a positive impact on real patient outcomes.

The study is located at Scott & White Hospital (Temple, TX), with 15 regional clinics scattered throughout central Texas, making it particularly suited to addressing underserved rural areas. By improving team coordination processes and teamwork knowledge, skills, and attitudes in resuscitation teams, Dr. Pliego and his team aim to decrease mortality rates in nonexpectant adult inpatients in nonintensive care unit settings, decrease code blue alerts, and decrease time spent initiating treatments in code and rapid response teams.

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In Situ Simulation to Detect and Prevent Near Misses During Critical Events
Principal Investigator: William Riley, Ph.D., University of Minnesota, Minneapolis, MN.
Grant No.: HS016728-01
Description: At times, perinatal units serve a variety of functions, such as critical care centers, surgical suites, and emergency departments. Due to this diversity, opportunities for inconsistent and inaccurate care arise frequently. Communication failure is a frequently occurring root cause in perinatal deaths and injuries.

Dr. William Riley and his team are using team-based, in situ simulations to identify and reconfirm "near misses" for perinatal care and examining in situ simulation assessment as a predictor of performance in real world emergent cesarean deliveries. They also are testing the effects of training to a criterion level of performance on near misses during real world emergent cesarean deliveries, and determining the impact of in situ simulation training on a variety of maternal and newborn patient safety metrics. Overall, Dr. Riley and his colleagues hope to demonstrate that in situ simulation training can foster a culture of safety, creating an environment consistent with the features of high-reliability organizations.

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Evaluating the Impact of Simulated Team Training on Patient Safety
Principal Investigator: Daniel Scott, M.D.; University of Texas Southwestern Medical Center, Dallas, TX.
Grant No.: HS016667-01
Description: Each year, life-threatening and often preventable complications occur in a significant percentage of surgeries, resulting in thousands of deaths and costing billions of dollars. Evidence-based practice recommendations with redundant safeguards have been shown to improve surgical safety.

To improve the safety of high-volume surgeries, Dr. Daniel Scott and his colleagues are using a crawl-walk-run strategy to hone individual skills in: a bench simulator lab setting (the crawl), immersive training to promote team skills in a virtual operating room environment (the walk), and direct observation of team and organizational practices during actual operations (the run). The training occurs in a large county hospital and focuses on two high-volume ambulatory surgery procedures: laparoscopic cholecystectomy and laparoscopic tubal ligation. By better defining and assessing outcomes, knowledge produced by this study potentially will serve as a template for wider implementation of standards and practices that enhance patient safety during surgical procedures.

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Immersive Simulation Team Training Impact on Rescue, Recovery, and Safety Culture
Principal Investigator: Stephen Small, M.D.; University of Chicago, IL.
Grant No.: HS016664-01
Description: Although a great deal of national attention has focused on team-based simulation training, there is little standardization of teams and curricula, sparse evidence of successful transfer of this type of simulation training to the real clinical environment, and few methods for understanding how interdisciplinary training should occur.

To help address these concerns, a research team spearheaded by Dr. Stephen Small is testing the effectiveness of immersive, simulation-based, interdisciplinary rapid response (emergency) team training on incident control and recovery skills. The research is being carried out in simulation settings by conducting in situ "crash dummy" simulations in actual rapid response team clinical units, examining self-reports by immersive team trainees with respect to nonroutine patient care events, and facilitating institutional spread and sustainability of simulation training. The research team also is studying the feasibility of using a new, advanced networking multimedia technology that enables telecollaboration to other simulation centers and monitoring organizations.

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Virtual Health Care Environments Versus Traditional Interactive Team Training
Principal Investigator: Jeffrey Taekman, M.D.; Duke University Medical Center, Durham, NC.
Grant No.: HS016653-01
Description: Team coordination skills are believed to be most effective when opportunities for interactive practice in realistic environments exist, yet there is little evidence to assess and compare the impact of different forms of interactive training. Because of the vast need for teamwork training across the health care disciplines and the heightened costs associated with implementing it, a research team headed by Dr. Jeffrey Taekman is examining the impact of networked, three-dimensional, interactive virtual-reality team training (3DiTeams) compared to traditional interactive training.

By incorporating attributes from computer games and advanced learning technologies successfully used by the military to train large audiences, the Taekman team aims to pilot test 3DiTeams, compare experimentally participants' improvement in team knowledge and behavior to a traditional form of interactive team training, and evaluate the experimental data along with realistic cost estimates for designing and implementing team coordination training within the Duke University Health System. The research has longer-term implications for developing team coordination training that can be exported beyond a given institution or health system.

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Simulation-based Training Program to Augment Electronic Medical Record-Based Handoff Tool
Principal Investigator: John Vozenilek, M.D.; Evanston Northwestern Healthcare, Evanston, IL.
Grant No.: HS016640-01
Description: Inadequate communication of clinical information during the handoff of patient care responsibilities from one managing team to a new team is a particularly vulnerable area in hospital-based practice. Relatively little standardization exists among the various medical and nursing senders and receivers of information, leading frequently to errors of omission and commission.

In responding to the need for better standardization of patient care hand-offs, the research team of Dr. John Vozenilek is implementing an electronic medical record-based (EMR-based) tool for use by resident physicians in the emergency department. Concurrent with the introduction of the handoff tool, the team is conducting a 4-hour simulation-based training program using standardized patients and mannequins to instruct residents in the use of the tool and the fundamentals of communication. The effectiveness of the EMR handoff tool and the simulation-based communication training is assessed by pre- and post-implementation measures and the use of experimental and control groups, respectively. The team also is assessing the rate of learning decay by evaluating resident performance with the tool over time.

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Simulation Training for Rapid Assessment and Improved Teamwork
Principal Investigator: Matthew Weinger, M.D.; Vanderbilt University Medical Center, Nashville, TN.
Grant No.: HS016651-01
Description: As a crucial component of safe care, effective clinician communication is starting to receive the attention it deserves. Educational silos, authority gradients, role specialization, and incentives that favor individual rather than team performances are some of the structural barriers that underlie ineffective communication. The reduction of communication failures is a major challenge and is especially critical during transitions of care (handoffs) between clinicians.

Dr. Matthew Weinger and his team focus on the postanesthesia care unit (PACU) and aim to improve communication between physicians and nurses during transitions of care by using a newly designed simulation-based training intervention, Simulation Training for Rapid Assessment and Improved Teamwork (STRAIT). After an initial 2-month baseline of observations of actual patient handoffs, PACU-based clinicians receive the STRAIT intervention and are measured on four dimensions of handoff effectiveness: information transfer, use of best-evidence handoff strategies, interpersonal skills, and team behaviors. Pre- and postintervention ratings by trained observers are taken; clinicians also rate their own handoffs. By successfully demonstrating improved handoffs between anesthesia providers and the PACU staff, the Weinger team hopes to see dissemination of the methods to other critical handoff situations.

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Current as of June 2008

Internet Citation:

Improving Patient Safety Through Simulation Research. June 2008. Agency for Healthcare Research and Quality, Rockville, MD.
Courtesy: http://www.ahrq.gov/qual/simulproj.htm

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