Chuck Biddle CRNA, PhDChuck Biddle CRNA, PhD Professor Professor Virginia Commonwealth UniversityVirginia Commonwealth University

Staff AnesthetistStaff Anesthetist Department of AnesthesiologyDepartment of Anesthesiology VCU Medical CenterVCU Medical Center

Patient Safety Vignettes: Patient Safety Vignettes: Enhancing ClinicalEnhancing ClinicalCommunication & Patient SafetyCommunication & Patient SafetyIn The Hospital SettingIn The Hospital Setting

What is a Trigger Film?What is a Trigger Film?

Brief audio-visual vignette

Simulates real-life situation, finishes abruptly; may or may not commit to a particular course of action

Clinician reflects upon and analyzes real-life predicaments in a safe environment

Primary GoalPrimary Goal

Facilitate patient safety by modeling real-life adverse and catastrophic events while nurturing clinicians’ appreciation and response

LifeLifeAt TheAt TheSharp EndSharp End

Active errors / Latent Conditions

Active errorsActive errorsFrontline provider actionsFrontline provider actions

Frontline provider inactionsFrontline provider inactions

Latent conditionsLatent conditionsDysfunctional organizational structureDysfunctional organizational structure

Dysfunctional organizational policyDysfunctional organizational policy

Inadequate trainingInadequate training

Faulty communicationFaulty communication

•Inspire cultural change by storytellingInspire cultural change by storytelling

•Power of stories recognized by patient safety departmentsPower of stories recognized by patient safety departments

•Reenactments of adverse events & near misses viaReenactments of adverse events & near misses via story telling can raise and imprint awarenessstory telling can raise and imprint awareness

•Nothing more compelling than a well-told story?Nothing more compelling than a well-told story?

•An effective, low-tech approach An effective, low-tech approach

Trigger Film DevelopmentTrigger Film Development

Foundations

Based upon actual events

Evidence-based interventions

Vicariousness advantaged

“Ecological validity”

Hospital-level Patient Safety Indicators (20 Indicators) Hospital-level Patient Safety Indicators (20 Indicators) Complications of anesthesia (PSI 1) Death in low mortality DRGs (PSI 2)

Decubitus ulcer (PSI 3) Failure to rescue (PSI 4)

Foreign body left in during procedure (PSI 5) Iatrogenic pneumothorax (PSI 6)

Selected infections due to medical care (PSI 7) Postoperative hip fracture (PSI 8)

Postoperative hemorrhage or hematoma (PSI 9) Postoperative physiologic and metabolic derangements (PSI 10)

Postoperative respiratory failure (PSI 11) Postoperative pulmonary embolism or deep vein thrombosis (PSI 12)

Postoperative sepsis (PSI 13) Postoperative wound dehiscence in abdominopelvic surgical patients (PSI 14)

Accidental puncture and laceration (PSI 15) Transfusion reaction (PSI 16)

Birth trauma -- injury to neonate (PSI 17) Obstetric trauma -- vaginal delivery with instrument (PSI 18)

Obstetric trauma -- vaginal delivery without instrument (PSI 19) Obstetric trauma -- cesarean delivery (PSI 20)

““Center for Research in Human Simulation”Center for Research in Human Simulation” Virginia Commonwealth University

Richmond, Virginia

A virtual OR, ED, patient room, x-ray room, office waiting room,A virtual OR, ED, patient room, x-ray room, office waiting room,blood drawing suite,…………..etc.blood drawing suite,…………..etc.

High-Fidelity EnvironmentHigh-Fidelity Environment

Control roomControl room1-way mirror1-way mirror

Med Sim ManMed Sim Man ( virtual!)( virtual!)

Multiple cameraMultiple camera& audio devices& audio devicesthroughout roomthroughout room

Modern, real-world equipment

Easily Produced / EconomicalEasily Produced / Economical

--Easily Disseminated----Easily Disseminated--

Identify Problem AreasIdentify Problem AreasQA / RM officeQA / RM officeDepartmental databasesDepartmental databasesM&M conferences / Clinician inputM&M conferences / Clinician input

Target common themesTarget common themesTarget catastrophic themesTarget catastrophic themes

Model simulationsModel simulationsProduce TFsProduce TFs

Expose stakeholders Expose stakeholders To TFsTo TFs

Measure outcomeMeasure outcomecostcostefficacyefficacyalternativesalternatives

Efficacy???Currently exploring TFs in terms of:Currently exploring TFs in terms of:

•How do they impact safety?How do they impact safety?•Do they alter behavior over time?Do they alter behavior over time?•Better at prevention than remediation?Better at prevention than remediation?•Cost effectiveness?Cost effectiveness?

Current Projects UnderwayCurrent Projects Underway

Failure to properly consent for a patient procedureFailure to properly consent for a patient procedure

Failed hand-washing Failed hand-washing life-threatening infection life-threatening infection

““Error of the decimal” leads to cardiac arrestError of the decimal” leads to cardiac arrest

Blood harvesting / labeling error Blood harvesting / labeling error patient death patient death

Patient falls from gurney Patient falls from gurney severe internal injury severe internal injury

Transition of care Transition of care drug administration misadventure drug administration misadventure

Lahaye L, Biddle C. Errors in healthcare. Part I. Curr Rev Anesth. 2003;26:67-72

Lahaye L, Biddle C. Errors in healthcare. Part II. Curr Rev Anesth. 2003;26:79-86

Biddle C, Hartland W, Fallacaro MD. Patient safety vignettes: Preliminary observations.Internet Journal Health Sciences and Practice. http://ijahsp.nova.edu. ISSN 1540-580X.

Biddle C. Reducing error and morbidity in the healthcare setting. Curr Rev Anesth. 2006;29149-160

Coopsman V, Biddle C. Performance using a handheld, computerized, decision making aid duringcritical events: a randomized controlled trial. AANA JO. 2008;76:29-36

Hartland W, Biddle C, Fallacaro M. Audio-visual facilitation of clinical knowledge: A Paradigm basedon Paivio’s dual coding theory. AANA JO. 2008;76:194-198.

Partial bibliographyPartial bibliography