Simulation as a toolkit-understanding the perils of blood transfusion in a complex health care environment

Simulation in the field of transfusion medicine: Scope and utility

Simulation in medical education has made significant inroads in most of the specialties in some form or the other. Transfusion medicine, as a branch, being a new specialty, is imbibing a few things from the world of simulation and provides immense scope for its utilization, given its broad applicability as well as necessity. In the current Indian scenario of transfusion medicine, wherein the transfusion process has undergone significant changes involving critical steps, with fewer but can be serious complications arising due to the transfusion process, it is desirable for students and the staff involved to practice on the simulators to attain the desired level of competency as it allows the practice of hands-on invasive procedures before performing the actual process. The principles, pedagogies, and educational strategies with their modalities used in health care simulation like case-based scenarios, physical models, computer systems, standardized patients, mannequins, virtual reality, and integrated simulators are all being used and the scope for improvisation is always in the fore with technical advancements. The transfusion and related activities include significant risks, so regular training is essential. The costs are also reasonably high, and focusing on being time-efficient is essential as many scenarios need immediate attention and management. Simulation in transfusion medicine has farsighted returns wherein there is the possibility of defining goals and objectives and ensuring that they could be adjusted to the individual learners as per their knowledge and skill level. The simulations can be set up that can train as well as assess cognitive, affective, and psychomotor domains simultaneously in transfusion using multiple modalities.

Harnessing system-focused simulation, debriefing and FMEA to inform healthcare blood transfusion safety and policy

Healthcare systems improvement using simulation and debriefing is an increasingly employed, yet underutilized quality improvement tool to enable user-centred design. This approach allows users to experience real-life systems and processes through simulation and then provide feedback on how a system supports them within their role. Understanding this interaction of people and their systems is critical to safe, quality, reliable and efficient care and bridges the gap between how we think a system is working and how it is working.

This novel project was collaboratively developed and led by simulation, human factors and patient safety experts and used existing organizational safety data to target further high-risk safety threats surrounding administering, cross-checking and labelling blood products for transfusion. A system-focused simulation-based approach was used to identify system issues for a large healthcare organization’s transfusion policy redesign. A Failure Mode and Effects Analysis (FMEA) was then used to apply a risk score to the findings from the simulation user feedback to inform a large high-risk policy redesign.

Multiple recommendations were provided to the participating units and policy and procedure redesign teams surrounding environmental issues, standards, interpretation and usability of the policy.

Our collaborative patient safety, simulation and human factors project was successful in proactively identifying both active and latent factors contributing to adverse events and identifying recommendations using FMEA methodology to improve patient safety, including revisions to the physical space within the lab, and the provincial blood transfusion policy and procedure.

Is in situ simulation in emergency medicine safe? A scoping review

OBJECTIVES

To provide an overview of the available evidence regarding the safety of in situ simulation (ISS) in the emergency department (ED).

DESIGN

Scoping review.

METHODS

Original articles published before March 2021 were included if they investigated the use of ISS in the field of emergency medicine.

INFORMATION SOURCES

MEDLINE, EMBASE, Cochrane and Web of Science.

RESULTS

A total of 4077 records were identified by our search strategy and 2476 abstracts were screened. One hundred and thirty full articles were reviewed and 81 full articles were included. Only 33 studies (40%) assessed safety-related issues, among which 11 chose a safety-related primary outcome. Latent safety threats (LSTs) assessment was conducted in 24 studies (30%) and the cancellation rate was described in 9 studies (11%). The possible negative impact of ISS on real ED patients was assessed in two studies (2.5%), through a questionnaire and not through patient outcomes.

CONCLUSION

Most studies use ISS for systems-based or education-based applications. Patient safety during ISS is often evaluated in the context of identifying or mitigating LSTs and rarely on the potential impact and risks to patients simultaneously receiving care in the ED. Our scoping review identified knowledge gaps related to the safe conduct of ISS in the ED, which may warrant further investigation.

GENESISS 2-Generating Standards for In-Situ Simulation project: a systematic mapping review

BACKGROUND

In-situ simulation is increasingly employed in healthcare settings to support learning and improve patient, staff and organisational outcomes. It can help participants to problem solve within real, dynamic and familiar clinical settings, develop effective multidisciplinary team working and facilitates learning into practice. There is nevertheless a reported lack of a standardised and cohesive approach across healthcare organisations. The aim of this systematic mapping review was to explore and map the current evidence base for in-situ interventions, identify gaps in the literature and inform future research and evaluation questions.

METHODS

A systematic mapping review of published in-situ simulation literature was conducted. Searches were conducted on MEDLINE, EMBASE, AMED, PsycINFO, CINAHL, MIDIRS and ProQuest databases to identify all relevant literature from inception to October 2020. Relevant papers were retrieved, reviewed and extracted data were organised into broad themes.

RESULTS

Sixty-nine papers were included in the mapping review. In-situ simulation is used 1) as an assessment tool; 2) to assess and promote system readiness and safety cultures; 3) to improve clinical skills and patient outcomes; 4) to improve non-technical skills (NTS), knowledge and confidence. Most studies included were observational and assessed individual, team or departmental performance against clinical standards. There was considerable variation in assessment methods, length of study and the frequency of interventions.

CONCLUSIONS

This mapping highlights various in-situ simulation approaches designed to address a range of objectives in healthcare settings; most studies report in-situ simulation to be feasible and beneficial in addressing various learning and improvement objectives. There is a lack of consensus for implementing and evaluating in-situ simulation and further studies are required to identify potential benefits and impacts on patient outcomes. In-situ simulation studies need to include detailed demographic and contextual data to consider transferability across care settings and teams and to assess possible confounding factors. Valid and reliable data collection tools should be developed to capture the complexity of team and individual performance in real settings. Research should focus on identifying the optimal frequency and length of in-situ simulations to improve outcomes and maximize participant experience.

Improving Transfusion Safety in the Operating Room With a Barcode Scanning System Designed Specifically for the Surgical Environment and Existing Electronic Medical Record Systems: An Interrupted Time Series Analysis

BACKGROUND

Manual processes for verifying patient identification before blood transfusion and documenting this pretransfusion safety check are prone to errors, and compliance with manual systems is especially poor in urgent operating room settings. An automated, electronic barcode scanner system would be expected to improve pretransfusion verification and documentation.

METHODS

Audits were conducted of blood transfusion documentation under a manual paper system from January to October 2014. An electronic barcode scanning system was developed to streamline transfusion safety checking and automate documentation. This system was implemented in 58 operating rooms between October and December 2014, with follow-up compliance audits through December 2015. The association of barcode scanner implementation with transfusion documentation compliance was assessed using an interrupted time series analysis. Anesthesia providers were surveyed regarding their opinions on the electronic system. In mid-2016, the scanning system was modified to transfer from the Metavision medical record system to Epic OpTime. Follow-up analysis assessed performance of this system within Epic during 2017.

RESULTS

In an interrupted time series analysis, the proportion of units with compliant documentation was estimated to be 19.6% (95% confidence interval [CI], 10.7-25.6) the week before scanner implementation, and 74.4% (95% CI, 59.4-87.4) the week after implementation. There was a significant postintervention level change (odds ratio 10.80, 95% CI, 6.31-18.70; P < .001) and increase in slope (odds ratio 1.14 per 1-week increase, 95% CI, 1.11-1.17; P < .001). After implementation, providers chose to use the new electronic system for 98% of transfusions. Across the 2 years analyzed (15,997 transfusions), the electronic system detected 45 potential transfusion errors in 27 unique patients, and averted transfusion of 36 mismatched blood products into 20 unique patients. A total of 69%, 86%, and 88% of providers reported the electronic system improved patient safety, blood transfusion workflow, and transfusion documentation, respectively. When providers used the barcode scanner, no transfusion errors or reactions were reported. The scanner system was successfully transferred from Metavision to Epic without retraining staff or changing workflows.

CONCLUSIONS

A barcode-based system designed for easy integration to different commonly used anesthesia information management systems was implemented in a large urban academic hospital. The system allows a single user with the assistance of a software system to perform and document pretransfusion safety verification. The system improved transfusion documentation compliance, averted potential transfusion errors, and became the preferred method of blood transfusion safety checking.

Lessons learned in preparing for and responding to the early stages of the COVID-19 pandemic: one simulation's program experience adapting to the new normal

Use of simulation to ensure an organization is ready for significant events, like COVID-19 pandemic, has shifted from a "backburner" training tool to a "first choice" strategy for ensuring individual, team, and system readiness. In this report, we summarize our simulation program's response during the COVID-19 pandemic, including the associated challenges and lessons learned. We also reflect on anticipated changes within our program as we adapt to a "new normal" following this pandemic. We intend for this report to function as a guide for other simulation programs to consult as this COVID-19 crisis continues to unfold, and during future challenges within global healthcare systems. We argue that this pandemic has cemented simulation programs as fundamental for any healthcare organization interested in ensuring its workforce can adapt in times of crisis. With the right team and set of partners, we believe that sustained investments in a simulation program will amplify into immeasurable impacts across a healthcare system.

Translational simulation: not 'where?' but 'why?' A functional view of in situ simulation

Healthcare simulation has been widely adopted for health professional education at all stages of training and practice and across cognitive, procedural, communication and teamwork domains. Recent enthusiasm for in situ simulation-delivered in the real clinical environment-cites improved transfer of knowledge and skills into real-world practice, as well as opportunities to identify latent safety threats and other workplace-specific issues. However, describing simulation type according to place may not be helpful. Instead, I propose the term translational simulation as a functional term for how simulation may be connected directly with health service priorities and patient outcomes, through interventional and diagnostic functions, independent of the location of the simulation activity.