Charts for Simulations of 6 April & 11 May 2006 Created: 30 August 2006.
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Charts for Simulations of 6 April & 11 May 2006 Created: 30 August 2006
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Transcript of Charts for Simulations of 6 April & 11 May 2006 Created: 30 August 2006.
Charts for Simulations of6 April & 11 May 2006
Created: 30 August 2006
1.
MEDICAL CODES
(time axis to scale)
1 4
71
58
2 2
0
2 4
1
3 1
13
16
3 3
2
4 2
4
5 9
5 3
5
5 5
3
6 4
9
7 2
8
7 4
5
8 2
7
8 5
90
6 5
7
7 5
5
8 3
4
10 1
10 3
2
1065
51
1180
96
1403
63
1614
60
1912
6319
6990
2119
74
2644
47
3091
13
3346
45
3530
95
4085
35
4477
20
4648
70
5069
79
5390
75
4171
97
4749
40
5143
17
6014
93
6324
48
1311
98
1816
93
2 1
1
V
B2
A1
C2C3
E3
B6
S3
C1
C4C5
B1
B3B4
A2A3A4
E2E1
S2S1
MI/PH
ID/R
S4S5S6S7
B5
C6C7
S8
D1D2D3
Part 1 6-Apr-2006
AIR
WA
YB
RE
AT
HIN
GC
IRC
UL
AT
ION
DIS
AB
.S
EC
ON
DA
RY
SU
RV
EY
EX
PO
S.
TL
JR
PNR
REC
CCT
ATP
RT
EMS
Other
X-ray
14 4
4
10 3
2
10 4
7
11 2
7
10 5
2
12 2
12 4
8
13 3
3
13 5
0
15 3
2
16 2
6
16 4
9
17 9
15 5
4
11 4
2
17 3
8
18 4
4
18 2
8843
43
7222
72
7676
01
8132
19
8303
77
9323
40
9864
50
1008
756
1029
445
9544
58
7016
33
1057
857
1123
894
1082
087
18 5
4
19 1
7
20
1134
101
1156
994
1199
524
6865
77
V
B2
A1
C2C3
E3
B6
S3
C1
C4C5
B1
B3B4
A2A3A4
E2E1
S2S1
MI/PH
ID/R
S4S5S6S7
B5
C6C7
S8
D1D2D3
AIR
WA
YB
RE
AT
HIN
GC
IRC
UL
AT
ION
DIS
AB
.S
EC
ON
DA
RY
SU
RV
EY
EX
PO
S.
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
SR
Other
6516
22
6324
48
6470
35
Part 2 6-Apr-2006
20
20 1
1
21 9
21 4
9
22 1
1
22 2
4
22 5
4
24 4
2
25 8
25 5
0
26 4
0
1199
524
1211
161
1269
095
1308
872
1343
580
1374
281
1435
902
1482
412
1508
399
1550
234
1600
005
1235
653
1330
985
20 3
6
V
B2
A1
C2C3
E3
B6
S3
C1
C4C5
B1
B3B4
A2A3A4
E2E1
S2S1
MI/PH
ID/R
S4S5S6S7
B5
C6C7
S8
D1D2D3
AIR
WA
YB
RE
AT
HIN
GC
IRC
UL
AT
ION
DIS
AB
.S
EC
ON
DA
RY
SU
RV
EY
EX
PO
S.
23 5
6
Part 3 6-Apr-2006
18 5
4
19 1
7
20
20 3
6
21 9
21 2
9
20 1
1
21 4
9
22 1
1
22 2
4
22 5
4
24 4
2
TL
JR
PNR
REC
CCT
ATP
RT
ANST
SR
X-ray
Other
23 5
6
18 4
4
?
25 8
Part 3
V
B2
A1
C2C3
E3
B6
S3
C1
C4C5
B1
B3B4
A2A3A4
E2E1
S2S1
MI/PH
ID
S4S5S6S7
B5
C6C7
S8
D1D2D3
?
1 2
1
1 5
1
2 2
1
2 4
4
3 2
6
6 2
2
6 5
2
7 2
2
7 4
9
8 3
1
8 3
9
9 1
3
10 7
0
9 5
1
2 7
1114
76
1270
09
1405
90
1639
39
2059
44
2372
543
57
3091
625
9
3414
985
41
3823
06
4122
91
4423
54
4688
30
4799
518
5108
16
5188
25
5527
37
5914
87
6073
19
V
B2
A1
C2C3
E3
B6
S3
C1
C4C5
B1
B3B4
A2A3A4
E2E1
S2S1
MI/PH
ID/R
S4S5S6S7
B5
C6C7
S8
D1D2D3
AIR
WA
YB
RE
AT
HIN
GC
IRC
UL
AT
ION
DIS
AB
.S
EC
ON
DA
RY
SU
RV
EY
? ?
Part 1 11-May-2006
EX
PO
S.
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
ORT
EMS
Other
8064
0
Team leader
Jr. resident
Primary nurse
Recorder
CCT
Attending
Respir. therap.
Anesthesia
Pharmacist
X-ray
Orthopedist
EMS
Other
V
B2
A1
C2C3
E3
B6
S3
C1
C4C5
B1
B3B4
A2A3A4
E2E1
S2S1
MI/PH
ID/R
S4S5S6S7
B5
C6C7
S8
D1D2D3
AIR
WA
YB
RE
AT
HIN
GC
IRC
UL
AT
ION
DIS
AB
.S
EC
ON
DA
RY
SU
RV
EY
EX
PO
S.
10 7
10 4
5
11 2
668
5688
7330
15
7567
19
7732
64
8023
16
12 1
3
12 3
7
12 5
3
13 3
9
1040
284
1009
159
9825
36
9495
05
9056
50
8385
70
8844
74
1066
677
1100
288
1121
992
1137
919
1159
350
1183
893
1202
412
1217
358
14 4
4
15 6
15 5
0
16 2
3
16 4
9
17 2
0
17 4
7
18 2
0
18 4
2
18 5
8
19 1
9
19 2
4
20 2
20 1
7
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
ORT
EMS
Other
Part 2 11-May-2006
6073
19
6446
74
2.
WORK FLOW CODES
(time axis to scale)
1 4
71
58
2 2
0
2 4
1
3 1
13
16
3 3
2
4 2
4
5 9
5 3
5
5 5
3
6 4
9
7 2
8
7 4
5
8 2
7
8 5
90
6 5
7
7 5
5
8 3
4
10 1
10 3
2
IR
MM
ASM
Q
SP
TO
GDM
JU
ED
INT
SET
RMT
TALK
RLY
CL
ACK
CO
GST
LTM
STM
MEXT
ENTER
EXIT
SEN
TA
TL
JR
PNR
REC
CCT
ATP
RT
EMS
Other
X-ray
1065
51
1180
96
1403
63
1614
60
1912
6319
6990
2119
74
2644
47
3091
13
3346
45
3530
95
4085
35
4477
20
4648
70
5069
79
5390
75
4171
97
4749
40
5143
17
6014
93
6324
48
1311
98
1816
93
OB
SE
RV
AT
ION
DE
CIS
ION
MA
KIN
GIN
TE
RV
EN
.
CO
MM
UN
ICA
TIO
NM
EM
OR
Y
2 1
1
Part 1 6-Apr-2006
14 4
4
10 3
2
10 4
7
11 2
7
10 5
2
12 2
12 4
8
13 3
3
13 5
0
15 3
2
16 2
6
16 4
9
17 9
15 5
4
11 4
2
17 3
8
18 4
4
18 2
IR
MM
ASM
Q
SP
TO
GDM
JU
ED
INT
SET
RMT
TALK
RLY
CL
ACK
CO
GST
LTM
STM
MEXT
ENTER
EXIT
SEN
TA
8843
43
7222
72
7676
01
8132
19
8303
77
9323
40
9864
50
1008
756
1029
445
9544
58
7016
33
1057
857
1123
894
1082
087
18 5
4
19 1
7
20
1134
101
1156
994
1199
524
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
SR
Other
6865
77
6516
22
6324
48
6470
35
OB
SE
RV
AT
ION
DE
CIS
ION
MA
KIN
GIN
TE
RV
EN
.
CO
MM
UN
ICA
TIO
NM
EM
OR
Y
WA
ITIN
G F
OR
AN
AS
TH
ES
IA
Part 2 6-Apr-2006
1 2
1
1 5
1
2 2
1
2 4
4
3 2
6
6 2
2
6 5
2
7 2
2
7 4
9
8 3
1
8 3
9
9 1
3
10 7
9 5
1
2 7
1114
76
1270
09
1405
90
1639
39
2059
44
2372
543
57
3091
625
9
3414
985
41
3823
06
4122
91
4423
54
4688
30
4799
518
5108
16
5188
25
5527
37
5914
87
6073
19
8064
0
0
IR
MM
ASM
Q
SP
TO
GDM
JU
ED
INT
SET
RMT
TALK
RLY
CL
ACK
CO
GST
LTM
STM
MEXT
ENTER
EXIT
SEN
TA
OB
SE
RV
AT
ION
DE
CIS
ION
MA
KIN
GIN
TE
RV
EN
.C
OM
MU
NIC
AT
ION
ME
MO
RY
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
ORT
EMS
Other
?
Part 1 11-May-2006
10 7
10 4
5
11 2
668
5688
7330
15
7567
19
7732
64
8023
16
12 1
3
12 3
7
12 5
3
13 3
9
1040
284
1009
159
9825
36
8385
70
1066
677
1100
288
1121
992
1137
919
1159
350
1183
893
1202
412
1217
358
14 4
4
15 6
15 5
0
16 2
3
16 4
9
17 2
0
17 4
7
18 2
0
18 4
2
18 5
8
19 1
9
19 2
4
20 2
20 1
7
6073
19
6446
74
IR
MM
ASM
Q
SP
TO
GDM
JU
ED
INT
SET
RMT
TALK
RLY
CL
ACK
CO
GST
LTM
STM
MEXT
ENTER
EXIT
SEN
TA
INT
ER
VE
N.
CO
MM
UN
ICA
TIO
NM
EM
OR
YO
BS
ER
VA
TIO
ND
EC
ISIO
N M
AK
ING
Part 2 11-May-2006
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
ORT
EMS
Other
9495
05
9056
50
8844
74
THE END
(Ignore the remaining slides!)
14
71
58
22
02
41
31
13
16
33
2
42
4
59
53
55
53
64
9
72
87
45
82
7
85
9
0 65
7
75
5
83
4
14
44
10
1
10
32
10
47
11
27
10
52
12
2
12
48
13
33
13
50
15
32
16
26
16
49
17
9
15
54
11
42
17
38
18
44
18
2
1 2
1
1 5
1
2 2
1
2 4
4
3 2
6
6 2
2
6 5
2
7 2
2
7 4
9
8 3
1
8 3
9
9 1
3
10 7
0
9 5
1
2 7
8064
0
1114
76
1270
09
1405
90
1639
39
2059
44
2372
543
57
3091
625
9
3414
985
41
3823
06
4122
91
4423
54
4688
30
4799
518
5108
16
5188
25
5527
37
5914
87
6073
19
IR
MM
ASM
TA
SP
TO
GDM
JU
ED
INT
SET
RMT
TALK
RLY
CL
ACK
CO
GST
LTM
STM
MEXT
ENTER
EXIT
SE
Q
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
SR
Other
OB
SE
RV
AT
ION
DE
CIS
ION
MA
KIN
GIN
TE
RV
EN
.
CO
MM
UN
ICA
TIO
NM
EM
OR
Y
10 7
10 4
5
6073
19
6446
74
11 2
668
5688
7330
15
7567
19
7732
64
8023
16
12 1
3
12 3
712
53
13 3
9
1040
284
1009
159
9825
36
9495
05
9056
50
8385
70
8844
74
1066
677
1100
288
1121
992
1137
919
1159
350
1183
893
1202
412
1217
358
1320
248
14 4
4
15 6
15 5
0
16 2
3
16 4
9
17 2
0
17 4
7
18 2
0
18 4
218
58
19 1
9
19 2
4
20 2
20
17
22
IR
MM
ASM
TA
SP
TO
GDM
JU
ED
INT
SET
RMT
TALK
RLY
CL
ACK
CO
GST
LTM
STM
MEXT
ENTER
EXIT
SE
Q
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
SR
Other
OB
SE
RV
AT
ION
DE
CIS
ION
MA
KIN
GIN
TE
RV
EN
.
CO
MM
UN
ICA
TIO
NM
EM
OR
Y
1 30 2 30 3 3 30 4 4 30 5 5 30 6 7 7 30 8 30 9 300 6 30 8 9 10 10 30
IR
MM
ASM
Q
SP
TO
GDM
JU
ED
INT
TALK
RLY
CL
ACK
TC
GST
RMT
LTM
STM
MEXT
SET
ENTER
EXIT
SEN
TA
OB
SE
RV
AT
ION
DE
CIS
ION
MA
KIN
G
INTERVEN.
CO
MM
UN
ICA
TIO
NM
EM
OR
Y
2
Part 1 6-Apr-2006
TL
JR
PNR
REC
ATP CCT
RT
EMS
Other
X-ray
1 30 2 30 3 3 30 4 4 30 5 5 30 6 7 7 30 8 30 9 306 30 8 9 1020
IR
MM
ASM
Q
SP
TO
GDM
JU
ED
INT
SET
RMT
TALK
RLY
CL
ACK
CO
GST
LTM
STM
MEXT
ENTER
EXIT
SEN
TA
OB
SE
RV
AT
ION
DE
CIS
ION
MA
KIN
GIN
TE
RV
EN
.C
OM
MU
NIC
AT
ION
ME
MO
RY
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
ORT
EMS
Other
?
Part 1 11-May-2006
1 30 2 30 3 3 30 4 4 30 5 5 30 6 7 7 30 8 30 9 306 30 8 9 1020
ASM
MM
IR
ENTER
EXIT
SEN
OB
SE
RV
AT
ION
SP
TA
TO
ED
GDM
TALK
GEST
Q
CL
RLY
ACK
TC
RMT
LTM
STM
MEXT
INT
JU
DE
CIS
ION
MA
KIN
G
INTERVEN.
?
Part 1 11-May-2006C
OM
MU
NIC
AT
ION
ME
MO
RY
SETUP
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
ORT
EMS
Other
Actors
0 1
4
0 4
7
2 2 1
6
2 3
1
4 1
0
4 4
7
5 2
2
6 9
7 3
1
8 1
8
8 4
6
8 5
9
1 7
1367
2
4723
7
6716
3
1196
36
1360
06
1510
70
1762
082
56
1927
743
13
2135
633
34
2497
74
2873
89
3219
73
3694
55
4214
14
4508
12
4976
62
5260
81
5389
69
7 1
9 1
455
4477
9 3
257
2469
10
5927
23
0
ASM
MM
IR
ENTER
EXIT
SEN
SP
TA
TO
ED
GDM
TALK
GEST
Q
CL
RLY
ACK
TC
RMT
LTM
STM
MEXT
INT
JU
SETUP
Part 1 7-Nov-2006
1 30 2 30 3 3 30 4 4 30 5 5 30 6 7 7 30 8 30 9 300 6 30 8 9 10 10 30
ASM
MM
IR
JU
GDM
TALK
GEST
Q
CL
TC
STM
INT
SET
ACK
RLY
SP
RMT
LTM
TO
MEXT
ED
ENTER
EXIT
SEN
TA
OB
SE
RV
AT
ION
DE
CIS
ION
MA
KIN
G
INTERVEN.
CO
MM
UN
ICA
TIO
NM
EM
OR
Y
2
Part 1 6-Apr-2006
TL
JR
PNR
REC
ATP CCT
RT
EMS
Other
X-ray
4 4 30 5 5 30 6 76 304 4 30 5 5 30 6 76 30
MEMORY
INTERVEN.
3 30 7 307 30 3 30
OB
SE
RV
AT
ION
DE
CIS
ION
MA
KIN
GC
OM
MU
NIC
AT
ION
ASM
MM
IR
SEN
JU
TA
GDM
TALK
NonVerbB
Q
CL
TC
STM
INT
SETUP
Simulation #2Simulation #1
4 4 30 5 5 30 6 76 304 4 30 5 5 30 6 76 30
MEMORY
INTERVEN.
3 30 7 307 30 3 30
OB
SE
RV
AT
ION
DE
CIS
ION
MA
KIN
GC
OM
MU
NIC
AT
ION
ASM
MM
IR
SEN
JU
TA
GDM
TALK
GEST
Q
CL
TC
STM
INT
SETUP
Simulation #2TL
ANST
JR
ORT
PNR
ATP
CCT
X-ray
REC
Other
Actors
Simulation #1
4 4 30 5 5 30 6 76 304 4 30 5 5 30 6 76 30
Simulation #2 Event #3
MEMORY
INTERVEN.
3 30 7 307 30 3 30
OB
SE
RV
AT
ION
DE
CIS
ION
MA
KIN
GC
OM
MU
NIC
AT
ION
ASM
MM
IR
SEN
JU
TA
GDM
TALK
GEST
Q
CL
TC
STM
INT
SETUP
TL
ANST
JR
ORT
PNR
ATP
CCT
X-ray
REC
Other
Actors
1.a) of 6 April 2006
MEDICAL CODES
(time axis not to scale)
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
ORT
Other
6 4
9V
1 4
7
B2
A1
1 5
8
C2
2 2
0
C3
2 4
1E3
B6
3 1
13
16
S3
C1
3 3
2C4C5
B1
B3B4
A2A3A4
E2E1
S2S1
MI/PH
ID
TL
JR
PNR
REC
CCT
ATP
RT
EMS
Other
X-ray
S4S5S6
4 2
4
5 9
5 3
5
5 5
3
6 5
7
7 2
8
S7
7 4
5
8 2
7
8 5
9
0Part 1
B5
C6C7
S8
D1D2D3
14 4
4
10 1
10 3
2
10 4
7
11 2
7
10 5
2
12 2
12 4
8
13 3
313
50
15 3
2
16 2
6
16 4
9
17 9
17 3
8
18 4
4
8 5
9
15 5
4
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
Other
18 2
Part 2
V
B2
A1
C2C3
E3
B6
S3
C1
C4C5
B1
B3B4
A2A3A4
E2E1
S2S1
MI/PH
ID
S4S5S6S7
B5
C6C7
S8
D1D2D3
18 5
4
19 1
7
20
20 3
6
21 9
21 2
9
20 1
1
21 4
9
22 1
1
22 2
4
22 5
4
24 4
2
TL
JR
PNR
REC
CCT
ATP
RT
ANST
SR
X-ray
Other
23 5
6
18 4
4
?
25 8
Part 3
V
B2
A1
C2C3
E3
B6
S3
C1
C4C5
B1
B3B4
A2A3A4
E2E1
S2S1
MI/PH
ID
S4S5S6S7
B5
C6C7
S8
D1D2D3
?
Old Slides for Simulationof 6 April 2006
Created: 25 July 2006
V
1 4
7
B2
A1
1 5
8
C2
2 2
0
C3
2 4
1E3
ORT
B?
3 1
13
16
S3
C1
3 3
2
CIR
C4C5
Bwl
B1
B3B4
A2A3A4
E2E1
S2S1
MIID
TL
JR
PNR
REC
CCT
ATP
RT
EMS
Other
X-ray
S4S5S6
PTN
4 2
4
F
5 9
5 3
5
5 5
3
6 5
7
7 2
8
S7
7 4
5
8 2
7
8 5
9
0Part 1
14 4
4
V
B2
A1
10 1
C2
10 3
2
C3
10 4
7E3
ORT
B?
11 2
7
10 5
2
S3
C1
12 2
CIR
C4C5
D2
B1
B3B4
A2A3A4
E2E1
S2S1
MI
ID
TL
JR
PNR
REC
CCT
ATP
RT
ANST
PHRM
X-ray
S4S5S6
PTN
12 4
8
F
13 3
313
50
15 3
2
16 2
6
16 4
8
S7
17 9
17 3
8
18 4
4
8 5
9
15 5
4
M
Other
18 2
Part 2
V
B2
A1
18 5
4
C2
19 1
7
C3
E3
ORT
B?
20
S3
C1
20 3
6
CIR
C4C5
D2
B1
B3B4
A2A3A4
E2E1
S2S1
MI
ID
S4S5S6
PTN
21 9
F
21 2
9
20 1
1
21 4
1
22 1
1
S7
22 2
4
22 5
4
24 4
2
M
TL
JR
PNR
REC
CCT
ATP
RT
ANST
SR
X-ray
Other
23 5
6
18 4
4
? ??
?
?
??
?
?
?
25 8
Part 3
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Count of lines an actor appears in transcript of Event #3, per minute (values range: 0 – 15)Endotracheal intubation
Primary survey
Accident reporting
Instrumentation setup
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Count of lines an actor appears in transcript of Event #3, per minute (values range: 0 – 15)
Primary survey
Accident reporting
Instrumentation setup
Endotracheal intubation
Temporal occurrence of errors - Randy
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Count of lines an actor appears in transcript of Event #3, per minute (values range: 0 – 15)
Endotracheal intubation
Primary survey
Accident reporting
Instrumentation setup
Omission errorsCommission errorsSelection errors
Temporal occurrence of errors - Meredith
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Count of lines an actor appears in transcript of Event #3, per minute (values range: 0 – 15)
Endotracheal intubation
Primary survey
Accident reporting
Instrumentation setup
Other:
Omission errorsCommission errorsSelection errors
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Primary survey
Instrumentation setup
Endotracheal intubation
Incident reporting
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 20 Time (minutes)
Primary survey
Instrumentation setup
Endotracheal intubation
Incident reporting Error of omissionError of commissionError of selectionCommunication error
16.67
Omission errorsCommission errorsSelection errorsCommunication errors
CCT
TL
PNR
JR
REC
ANES
ATP
Other
Omission Commission Selection
TL
CCT
PNR
JR
CE
REC
Other
ANES
ATP
16.67
0.1
1
10
100
2 4 6 9 11 14 16 18 21 23 25 28 30 32 35
Utterances
Errors
Time (min)
Attending physician
Team leader
Anesthesiologist
Junior resident
Primary nurse
Recorder
Technician (CCT)
EMS
0 5 10 15 Time (minutes)
0.1
1
10
100
2 4 6 9 11 14 16 18 21 23 25 28 30 32 35
Utterances
Errors
Time (minutes)(a) (b)
