May 14 16, 2014 Orlando 16th Annual NPSF Patient Safety Congress Guide to the Learning & Simulation Center OCEANS BALLROOM Center hours: Wednesday 4:00PM 6:00PM Thursday 12:00PM 1:30PM Thursday 4:00PM 6:00PM Friday 12:00PM 1:30PM The Learning & Simulation Center offers: Three Interactive Simulation Stations Innovative Solutions Providers* Research and Solutions Posters Receptions and Lunches Welcome Reception, Simulations, Exhibits, Posters, Prize Drawings Lunch, Simulations, Exhibits, Posters, Prize Drawings Networking Reception, Simulations, Exhibits, Posters, Prize Drawings Lunch, Simulations, Exhibits, Posters, Prize Drawings * See the Supporter & Exhibitor Guide for a full listing of solutions providers and their booth locations. npsfcongress.org Learning & Simulation Center supporter:
2014 Simulation Program Using Simulation to Improve and Enhance Patient Safety Simulation: Recreating Real World Experiences In the summer of 2013, a professional in risk management and patient safety at a large health care organization was diagnosed with breast cancer. What began as common treatment for noninvasive ductal carcinoma in situ soon became a series of adverse medical events. Throughout her experience, the patient wondered, How could this have happened to me, an experienced safety expert? Why has it been so hard for me to speak up? And, What could my providers and clinicians have done differently? We invite you to visit the three simulation booths in the Learning & Simulation Center to observe and record the events portrayed, to consider the patient safety issues that led to the complications experienced by this patient, and to identify the patient safety methodologies and solutions that could help prevent situations like this from occurring. This patient s story is true. The simulation scenarios you will observe are based on her experience; however, names and some specific details have been changed. Experiences and adverse events like those portrayed in these simulations occur every day in health care organizations throughout the world. We encourage you to observe how simulation, which can be done in any setting, large or small, provides an opportunity to practice individual and team skills, as well as being a highly effective medium for calling attention to potential and critical patient safety issues and lessons. Our Simulation Scenarios To illustrate the use of medical simulation as a patient safety tool, the National Patient Safety Foundation (NPSF) has created a series of simulated clinical experiences based on the above real patient story but portraying a fictional woman named Jamie Higgins. The three simulation scenarios follow one patient through several components of the continuum of care. The patient s first experience is set in a fictional health care facility called Sunshine Regional 2
Hospital. The two subsequent experiences are set in a second fictional facility called Everglades General Hospital System. The story behind the scenes you will see is true, and the patient safety problems that will be uncovered are real and pose serious issues to the delivery of safe and effective health care. As you explore and interact at each station in the NPSF Learning & Simulation Center, consider how Jamie s experiences are relevant to your own organization as you strive to provide safe care. Also consider how Jamie s story may inform your and your family s health care decisions. Use this booklet as a navigation tool as you follow Jamie Higgins. Each simulation will offer different opportunities for demonstration and discussion of pertinent patient safety issues. The Learning & Simulation Center strives to enhance learning, create a standard of care, and implement patient safety principles. Our demonstrations are designed to include active participation from all Congress attendees. We look forward to your involvement as an integral part of the learning experience. Simulation Program Objectives The Learning & Simulation Center is intended to provide examples of how simulation-based training and education can be applied in an organization for a broad variety of training and learning situations. Through observation and participation, conference attendees will be able to: Recognize how simulation and time for debriefing provide important task-training opportunities for clinicians and staff Identify how simulation can be used to practice effective communication between providers and between patients and families and their providers Discuss the importance of patient and family engagement and the difficulties associated with speaking up Gain familiarity with simulation equipment and meaningful use Identify critical opportunities for offering a disclosure and an apology 3
Patient Safety Applications As you follow Jamie s health care journey, you will notice that all of the simulation scenarios demonstrate real-world patient safety solutions. The practical solutions you will take away will be applicable to the following: Teamwork Communication System improvements Patient- and family-centered care Hand-off processes Goal-directed therapy Sepsis Checklists Simulation Facilitators Jared Kutzin, DNP, MS, MPH, RN, CPPS, Director, Simulation Center, Winthrop University Hospital Connie M. Lopez, MSN, CNS, RNC-OB, CPHRM, National Leader, Simulation and Risk Education, National Risk Management and Patient Safety, Kaiser Permanente Jeff Convissar, MD, Medical Director, Kaiser Permanente Care Management Institute Roxane Gardner, MD, MPH, DSc, Assistant Professor Ob/Gyn, Brigham and Women s Hospital; Director of the Labor and Delivery Program, Center for Medical Simulation Cate Nicholas, EdD, MS, PA, Director, Simulation Education and Operations, FAHC/UVM Clinical Simulation Laboratory, University of Vermont Robert Rupert, Jr., Program Development Education Specialist, Laerdal Medical Corp. NPSF extends its sincere thanks to the many individuals and organizations that have devoted their time and expertise to the design and development of this innovative simulation program, which would not have been possible without their insight, knowledge, and unwavering commitment to patient safety. 4
I m Talking, Are You Listening? Using Sepsis to Infect Health Care Providers with Great Communication Skills BOOTH 101 Wednesday Thursday Friday 4:30PM 5:00PM 12:00PM 12:30PM and 4:30PM 5:00PM 12:00PM 12:30PM Setting: Emergency Department, Sunshine Regional Hospital Two weeks following her lumpectomy, Jamie was recuperating in a cabin in the mountains when she began to experience severe pain and developed a fever. Because she was four hours from home and there was no hospital along the route home, she asked her husband to take her to the closest emergency department (ED), which was at Sunshine Regional, a small rural hospital. In the ED, the attending doctor calls her home hospital to discuss treatment and is told she needs to be transferred by Emergency Medical Services (EMS) to her home hospital. Basic Life Support (BLS) transport is requested by the emergency physician to transport Jamie. Despite her family s reservations, Jamie is sent via ground ambulance to her home hospital. Observers are encouraged to identify missed signs of sepsis as well as important opportunities for communication that would have led to better outcomes. Learning Objectives Upon completion of this medical simulation session, participants will be able to: 1. Recognize the signs and symptoms of sepsis 2. Identify successful handoff communication techniques between providers 3. Support speaking up behaviors for both patients and providers Supplies and equipment for this simulation have been provided by: B-Line Medical Hospira Hospital Systems Inc. Laerdal Limbs and Things Stryker Medical 5
You re Speaking, but I Don t Hear You. Communication and Clinical Breakdowns in the ICU BOOTH 119 Wednesday Thursday Friday 5:00PM 5:30PM 12:30PM 1:00PM and 5:00PM 5:30PM 12:30PM 1:00PM Setting: ICU, Everglades General Hospital Jamie arrives at Everglades General via Basic Life Support (BLS) transport, lethargic and in critical condition. The medical team attempts to place an IV line, but has difficulty given her dehydration. Jamie s surgeon arrives and determines Jamie is suffering from septic shock and needs immediate surgery. The physician leaves to book an operating room while the advance practice nurse places a central line. The doctor returns to announce that they will perform the surgery in the ICU. Come observe this simulation and record patient safety issues that arise, as well as opportunities for improved communication between the patient s family and the provider. Learning Objectives Upon completion of this medical simulation session, participants will be able to: 1. Identify the importance of good communication between health care providers 2. Describe how medical simulations may be used to teach communication and technical skills 3. Discuss the importance of using a checklist for treating patients (both task checklists and criteria checklists) 4. Recognize the signs and symptoms of sepsis and septic shock 5. Review the appropriate goal-directed therapy for the septic patient 6 Supplies and equipment for this simulation have been provided by: Hospira Simulab Corporation Hospital Systems Inc. SonoSite Laerdal Stryker Medical Medline Industries Inc. Studiocode Business Group
I Hear You Now, We re Communicating. Disclosure and Apology in the Aftermath of Serious Clinical Adverse Events BOOTH 413 Wednesday Thursday Friday 5:30PM 6:00PM 1:00PM 1:30PM and 5:30PM 6:00PM 1:00PM 1:30PM Setting: Surgeon s Office, Everglades General Hospital This scenario takes place two weeks after Jamie s discharge from the hospital. Jamie had required surgery in the ICU and a prolonged stay in the hospital because her wound had not healed properly. Her surgeon was frustrated that Jamie s wound was healing poorly. Jamie interpreted the frustration as anger and had difficulty speaking up. This scenario portrays a discussion between Jamie and her surgeon that involves an apology and disclosure about the events that have transpired throughout Jamie s treatment. Participants are invited to observe the conversation and participate in the debriefing discussion. Learning Objectives Upon completion of this medical simulation session, participants will be able to: 1. Describe the value of open and honest communication with patients 2. List tips and describe techniques for effective communication with patients and families after serious clinical adverse events 3. Practice skills for apology and disclosure in the aftermath of medical errors or adverse events 4. Identify areas from this event where communication gaps lead to failures or areas for improvement. Supplies and equipment for this simulation have been provided by: B-Line Medical Laerdal MIDMARK 7
16th Annual NPSF Patient Safety Congress 2014 Simulation Times I m Talking, Are You Listening? Using Sepsis to Infect Health Care Providers with Great Communication Skills BOOTH 101 Wednesday 4:30PM 5:00PM Thursday 12:00PM 12:30PM and 4:30PM 5:00PM Friday 12:00PM 12:30PM You re Speaking, but I Don t Hear You. Communication and Clinical Breakdowns in the ICU BOOTH 119 Wednesday 5:00PM 5:30PM Thursday 12:30PM 1:00PM and 5:00PM 5:30PM Friday 12:30PM 1:00PM I Hear You Now, We re Communicating. Disclosure and Apology in the Aftermath of Serious Clinical Adverse Events BOOTH 413 Wednesday 5:30PM 6:00PM Thursday 1:00PM 1:30PM and 5:30PM 6:00PM Friday 1:00PM 1:30PM Learning & Simulation Center OCEANS BALLROOM 119 POSTERS 413 101 NPSF ENTRANCE