Magnesium Toxicity and Medical Errors: A Multidisciplinary ... · BP 96/54 Lethargic Identify...
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Magnesium Toxicity and Medical Errors: A Multidisciplinary Simulation for Debriefing an Obstetric Emergency I Phillips, JM, Wolfe, M, Nelson, L, and Marko, K I George Washington University, School of Medicine and Health Sciences, Washington DC Conclusions We have designed a simple model that highlights the importance of: (1) communication during an obstetric emergency and (2) debriefing and evaluating errors from systems perspective. This model increased participant knowledge and comfort with magnesium toxicity and promoted a safe culture to discuss medical errors and practice debriefing. Case Scenario Objective Abstract Results Participants felt the simulation was: 1. a realistic scenario that allowed practice debriefing a medical error within a large multidisciplinary team 2. a place to practice high acuity care and communication 3. a safe place to receive and provide feedback “[I liked] practicing a scenario that we do not encounter very often in a realistic simulated environment” “[The simulation] allowed us to practice critical patient care and team-based communication skills” ”It was helpful to practice the steps of team debrief in a safe space where we could work through the cause of a medical error.” In general, participants (93%; N=14) felt like they learned advanced management of acute magnesium toxicity. All participants (100%; N=10) reported they would recommend this simulation to others in their profession. McDonnell, NJ, Muchatuta, NA, Paech, MJ. Acute magnesium toxicity in an obstetric patient undergoing general anesthesia for cesarean. Int J Obstet Anesth. 2010. 19(2) 226-231. To create a simulation that improves communication during obstetric emergency and promotes a safe learning environment to debrief and evaluate medical errors. Purpose: To create a simulation that improves communication during obstetric emergency and promotes a safe learning environment to debrief and evaluate medical errors. Background: Simulation is known to improve communication and comfort in obstetric emergency. Little data exist regarding simulation for enhancing expertise in debriefing and evaluating system errors. Methods: The simulation highlights an unresponsive patient shortly following a preterm delivery at 30 weeks gestation. The team discovers an accidental bolus of intravenous magnesium was given instead of postpartum oxytocin. Following conclusion of the simulation, participants were asked to lead a debrief session. Surveys were performed to assess participant comfort with magnesium toxicity, debriefing, evaluating a medical error, and communication during an emergency. Results: Participants felt the simulation was (1) a realistic scenario that allowed practice debriefing a medical error within a large multidisciplinary team, (2) a place to practice high acuity care and communication, and (3) a safe place to receive and provide feedback. On average, participants reported an increase in comfort with management of magnesium toxicity from little comfort (2/5) to moderate comfort(4/5). In general, participants (93%; N=10) felt like they learned advanced management of acute magnesium toxicity. All participants (100%; N=14) reported they would recommend this simulation to others in their profession. Discussion: We have designed a simple model that highlights the importance of (1) communication during an obstetric emergency and (2) debriefing and evaluating errors from systems perspective. This model increased participant knowledge and comfort with magnesium toxicity and promoted a safe culture to discuss medical errors and practice debriefing. Case: 28 yo G1P0101 delivered at 30 weeks gestation after precipitous onset of labor. She was on Magnesium for neuroprotection and given 2 doses of corticosteroids and antibiotics prior to delivery. She had increased bleeding after delivery and is receiving a bolus of Pitocin. There are several simultaneous deliveries and a new primary RN arrived to receive this patient for recovery. The patient calls out not feeling well. Her pregnancy was complicated by recurrent UTIs, on suppression with Macrobid Participants: Attending Physician, Resident Physician, Midwifery Provider, Labor and Delivery Nurses Results Figure 2. Magnesium Levels and Associated Toxicity Serum Magnesium mmol/L mEq/L mg/dL Effect 2-3.5 4-7 5=9 Therapeutic Range >3.5 >7 >9 Loss of Patellar Reflexes >5 >10 >12 Respiratory Paralysis >12.5 >25 >30 Cardiac Arrest Figure 1. Simulation Protocol Figure 3. Provider Comfort with (A) Magnesium Toxicity Diagnosis and Management and (B) Debriefing a Medical Error Before and After Simulation 0 1 2 3 4 5 6 7 8 1 2 3 4 5 Number of Providers Provider Comfort Level with Diagnosis and Management of Magnesium Toxicity Before Simulation After Simulation (1) Very uncomfortable/novice; (2) uncomfortable; (3) neither uncomfortable or comfortable; (4) comfortable; (5) very comfortable/expert (A) 0 1 2 3 4 5 6 7 8 1 2 3 4 5 Number of Providers Provider Comfort with Debriefing a Medical Error Before Simulation After Simulation (B) 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 After Sumulation Before Simulation Debreifing A Medical Error Magnesium Toxicity Figure 4. Average Provider Comfort with Magnesium Toxicity and Debriefing a Medical Error Before and After Simulation (1) Very uncomfortable/novice; (2) uncomfortable; (3) neither uncomfortable or comfortable; (4) comfortable; (5) very comfortable/expert Patient Vitals Patient Status Anticipated Action Scenario Trigger BP 108/60 Nauseated Perform History and Physical Exam Move to patient state #2 when: HR 96 Vomiting Recognize hypoventilation, Low SaO2 Discussing Differential Diagnosis T 98.4 Slurred Speech Begin supplemental O2, ask for labs, CXR RR 12 SaO2 91% Concerned family member Discuss differential diagnosis Patient State #1 Patient State #2 Patient State #3 Patient Vitals Patient Status Anticipated Action Scenario Trigger BP 96/54 Lethargic Identify magnesium toxicity Correct diagnosis à End Simulation, begin debrief HR 114 Minimally responsive Administer calcium gluconate Incorrect diagnosis à Patient State #3 T 98.2 Altered mental status Review laboratory values, Foley RR 6 SaO2 87% Hysterical family member Escalate O2 support (non-rebreather, bag mask ventilate) Patient Vitals Patient Status Anticipated Action Scenario Trigger BP --/-- Unresponsive Initiate ACLS protocol Begin Debrief HR -- Asystole Identify magnesium toxicity RR 0 Administer calcium gluconate SaO2 95% (if bagging /intubated) Magnesium Pitocin Non-rebreather Foley
Transcript of Magnesium Toxicity and Medical Errors: A Multidisciplinary ... · BP 96/54 Lethargic Identify...
Magnesium Toxicity and Medical Errors: A Multidisciplinary Simulation for Debriefing an Obstetric Emergency
I
Phillips, JM, Wolfe, M, Nelson, L, and Marko, KI
George Washington University, School of Medicine and Health Sciences, Washington DC
ConclusionsWe have designed a simple model that highlights the importance of:(1) communication during an obstetric emergency and (2) debriefing and evaluating errors from systems perspective.
This model increased participant knowledge and comfort with magnesium toxicity and promoted a safe culture to discuss medical errors and practice debriefing.
Case Scenario
Objective
Abstract Results
Participants felt the simulation was:1. a realistic scenario that allowed practice debriefing a medical error within a large multidisciplinary team2. a place to practice high acuity care and communication3. a safe place to receive and provide feedback
“[I liked] practicing a scenario that we do not encounter very often in a realistic simulated environment”
“[The simulation] allowed us to practice critical patient care and team-based communication skills”
”It was helpful to practice the steps of team debrief in a safe space where we could work through the cause of a medical error.”
In general, participants (93%; N=14) felt like they learned advanced management of acute magnesium toxicity. All participants (100%; N=10) reported they would recommend this simulation to others in their profession.
McDonnell, NJ, Muchatuta, NA, Paech, MJ. Acute magnesium toxicity in an obstetric patient undergoing general anesthesia for cesarean. Int J ObstetAnesth. 2010. 19(2) 226-231.
To create a simulation that improves communication during obstetric emergency and promotes a safe learning environment to debrief and evaluate medical errors.
Purpose: To create a simulation that improves communication during obstetric emergency and promotes a safe learning environment to debrief and evaluate medical errors.
Background: Simulation is known to improve communication and comfort in obstetric emergency. Little data exist regarding simulation for enhancing expertise in debriefing and evaluating system errors.
Methods: The simulation highlights an unresponsive patient shortly following a preterm delivery at 30 weeks gestation. The team discovers an accidental bolus of intravenous magnesium was given instead of postpartum oxytocin. Following conclusion of the simulation, participants were asked to lead a debrief session. Surveys were performed to assess participant comfort with magnesium toxicity, debriefing, evaluating a medical error, and communication during an emergency.
Results: Participants felt the simulation was (1) a realistic scenario that allowed practice debriefing a medical error within a large multidisciplinary team, (2) a place to practice high acuity care and communication, and (3) a safe place to receive and provide feedback. On average, participants reported an increase in comfort with management of magnesium toxicity from little comfort (2/5) to moderate comfort(4/5). In general, participants (93%; N=10) felt like they learned advanced management of acute magnesium toxicity. All participants (100%; N=14) reported they would recommend this simulation to others in their profession.
Discussion: We have designed a simple model that highlights the importance of (1) communication during an obstetric emergency and (2) debriefing and evaluating errors from systems perspective. This model increased participant knowledge and comfort with magnesium toxicity and promoted a safe culture to discuss medical errors and practice debriefing.
Case: 28 yo G1P0101 delivered at 30 weeks gestation after precipitous onset of labor. She was on Magnesium for neuroprotection and given 2 doses of corticosteroids and antibiotics prior to delivery. She had increased bleeding after delivery and is receiving a bolus of Pitocin. There are several simultaneous deliveries and a new primary RN arrived to receive this patient for recovery. The patient calls out not feeling well. Her pregnancy was complicated by recurrent UTIs, on suppression with Macrobid
Participants: Attending Physician, Resident Physician, Midwifery Provider, Labor and Delivery Nurses
Results
Figure 2. Magnesium Levels and Associated Toxicity Serum Magnesium
mmol/L mEq/L mg/dL Effect
2-3.5 4-7 5=9 Therapeutic Range>3.5 >7 >9 Loss of Patellar Reflexes>5 >10 >12 Respiratory Paralysis
>12.5 >25 >30 Cardiac Arrest
Figure 1. Simulation Protocol
Figure 3. Provider Comfort with (A) Magnesium Toxicity Diagnosis and Management and (B) Debriefing a Medical Error Before and After Simulation
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Provider Comfort Level with Diagnosis and Management of Magnesium Toxicity
Before Simulation After Simulation
(1) Very uncomfortable/novice; (2) uncomfortable; (3) neither uncomfortable or comfortable; (4) comfortable; (5) very comfortable/expert
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0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5
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Debreifing A Medical Error Magnesium Toxicity
Figure 4. Average Provider Comfort with Magnesium Toxicity and Debriefing a Medical Error Before and After Simulation
(1) Very uncomfortable/novice; (2) uncomfortable; (3) neither uncomfortable or comfortable; (4) comfortable; (5) very comfortable/expert
Patient Vitals Patient Status Anticipated Action Scenario Trigger
BP 108/60 Nauseated Perform History and Physical Exam Move to patient state #2 when:
HR 96 Vomiting Recognize hypoventilation, Low SaO2 Discussing Differential Diagnosis
T 98.4 Slurred Speech Begin supplemental O2, ask for labs, CXRRR 12SaO2 91%
Concerned family member
Discuss differential diagnosis
Patient State #1
Patient State #2
Patient State #3
Patient Vitals Patient Status Anticipated Action Scenario Trigger
BP 96/54 Lethargic Identify magnesium toxicity Correct diagnosis à End Simulation, begin debrief
HR 114 Minimally responsive Administer calcium gluconate Incorrect diagnosis à
Patient State #3
T 98.2 Altered mental status Review laboratory values, Foley
RR 6SaO2 87%
Hysterical family member
Escalate O2 support (non-rebreather, bag mask ventilate)
Patient Vitals Patient Status Anticipated Action Scenario TriggerBP --/-- Unresponsive Initiate ACLS protocol Begin Debrief HR -- Asystole Identify magnesium toxicityRR 0 Administer calcium gluconateSaO2 95% (if bagging /intubated)
Magnesium
Pitocin
Non-rebreather
Foley
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