513CHAPTER 43
Teaching Quality, Safety, and Process Improvement Through Root Cause Analysis Simulation
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
There is robust literature examining the use of both low- and high-technology simulation for learning in undergraduate and graduate nursing education. Most reports focus on the outcomes of simulation learning for increasing knowledge and improving clinical skills. However, there is a dearth of studies examining the use of simulation learning for graduate nurses preparing for nonclinical roles, such as nursing administration.
The use of multiple simulation modalities for clinical skills acquisition has increased in nursing education. This is due in part to increased student enrollment, faculty shortages, and limited clinical sites, as well as the understanding of the role of deliberate practice in education to ensure high-quality, safe care for patients. Sources contain frequent discussion of the advantages and disadvantages of the use of simulation in nursing education. Advantages include limited or no risk to actual patients, assurance of more opportunities to practice a variety of skills, enhanced knowledge, and immediate feedback by faculty. Disadvantages frequently noted are the high cost of time and equipment and the need for the technical knowledge and support inherent in this method (Hravnak, Tuite, & Baldisseri, 2005).
Many sources report on the efficacy of simulation use for student performance or confidence, both at a graduate and undergraduate level. Bremner, Aduddell, Bennett, and VanGeest (2006) reported on 615 undergraduate students and found improved performance and confidence in the assessment skills learned using simulation. Moule, Wilford, Sales, and Lockyer (2008) reported greater confidence in students exposed to simulation before starting their clinical experience. Other studies have found benefits to student-reported confidence or skills with the use of simulation, particularly when the learning is highly technical (Alinier, Hunt, Gordon, & Harwood, 2006; Brannan, White, & Bezanson, 2008; Feingold, Calaluce, & Kallen, 2004).
For graduate nurses and advanced practice nurses (APNs; nurse practitioners, clinical nurse specialists, nurse-midwives, and nurse anesthetists), the use of simulation is generally limited to acquiring various clinical skills or clinical management scenarios. Examples include advanced cardiac life support (ACLS) training, crisis management training, and clinical assessment skills acquisition (using standardized patients) in graduate APN education.
Hravnak, Tuite, and Baldisseri (2005) described teaching critical care technical skills to acute care nurse practitioners and clinical nurse specialists using high-fidelity patient simulators and reported positive student responses. Tiffen, Graf, and Corbridge (2009) evaluated low-fidelity 514simulation as compared with lecture and case study to teach cardiac and respiratory assessment to APN students. They found that the group using simulation achieved greater confidence in these skills than the group taught using a more traditional educational approach. Corbridge and colleagues (2008) and Haskvitz and Koop (2004) also found more self-reported confidence among graduate nursing students learning to manage complicated patient scenarios. Corbridge, Robinson, Tiffen, and Cobridge (2010) also reported a preference for simulation over a more traditional learning method for teaching mechanical ventilation to a group of nurse practitioner students. Two other reports described the use of simulated patient scenarios for teaching end-of-life and palliative care (Gillan, Jeong, & van der Riet, 2014) and may show promise for high-fidelity simulation scenarios (Shawler, 2011; Wakefield, Cooke, & Boggis, 2003).
Simulation is also being used in the health care field to promote team training (Murphy, Curtis, & McCloughen, 2016) and nontechnical skills such as teamwork, communication (Härgestam, Lindkvist, Brulin, Jacobsson, & Hultin, 2013; Tofil et al., 2014), collaboration, and leadership (Jankouskas et al., 2007). The use of simulation in nursing education continues to broaden. Decker, Sportsman, Puetz, and Billings (2008), among others, call for a continued assessment of simulation as a valid and reliable method for the acquisition and long-term retention of knowledge and skills. Recognizing the preference for simulation training by students and the reported increased learning and confidence in clinical skills, we attempt to expand the use of simulation beyond clinical and teamwork skills into the management and administrative courses of graduate nursing education. Although incorporating simulation into the root cause analysis (RCA) process and error identification is increasing, its use in undergraduate and graduate nursing education is still limited (Lambton & Mahlmeister, 2010; Simms, Slakey, Garstka, Tersigni, & Korndorffer, 2012).
In addition to schools that use simulation for students, hospitals use simulation to train and educate clinical staff. The current, common focus of many simulation programs, especially hospital-based simulation programs, is on teaching clinical or interpersonal (teamwork and communication) skills. Such topics include shoulder dystocia skills and team training, cardiac arrest team training, and the breaking of bad news.
In addition, graduate faculty often advise simulation facilities that they cannot find ways of implementing simulation into their curricula or they do not see the utility in trying to bring this technique into their classes. However, some graduate faculty have long embraced standardized patients, a form of simulation, in the education of advanced clinical providers for specific skills training. This chapter discusses the implementation of a hybrid simulation program for nonclinical skills, which was implemented in a graduate nursing class focused on quality, safety, and process improvement.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA AND RELATED TO YOUR SPECIALTY
The program was initially implemented at the New York Simulation Center for Health Sciences (NYSIM), a New York University Langone Medical Center–City University of New York joint simulation center, located at Bellevue Hospital. The faculty initially involved with this program were associated with Hunter–Bellevue School of Nursing in New York City, which had access to the facility. Since the initial implementation, this program has been hosted at various hospital-based simulation facilities and national and regional conferences to demonstrate how simulation can be used to teach about quality, safety, and process improvement.
C. SPECIFIC OBJECTIVES FOR SIMULATION USE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
Initially, the simulation was included in a course that focused on how nurse leaders and other health care professionals work in integrated networks and apply leadership and management theories to patient safety and quality-of-care topics.
515Simulation was added to this course, which allowed the graduate nursing students to have an experiential learning opportunity focusing on the hazards that may lead to medical errors, how to identify the root causes of the error using specific analytic methods, and how to develop an action plan using process-improvement strategies that would permanently solve the root causes. Since the initial implementation, this course has been taught as a continuing-education program for licensed health care providers (nurses, physician assistants, physicians, etc.).
The scenario is designed for learners to interact with standardized participants (SPs) who play the role of health care providers involved with a medical error. When used as part of a graduate student curriculum, this activity takes place at the end of the semester after students have discussed the role of nursing management, oversight of regulatory agencies, and patient safety and quality.
D. INTRODUCTION OF SCENARIO
Setting the Scene
Before attending the simulation experience, learners should be familiar with the process of performing an RCA, including tools, such as fishbone diagrams and process mapping. Students typically spend about 2.5 hours learning and discussing the differences between RCA and failure mode effects analysis (FMEA), as well as specific tools used to improve health care quality, such as:
1. Pareto charts (Tagues, 2005)
2. Ishikawa diagrams (fishbone; Tagues, 2005)
3. Flow charts (National Patient Safety Foundation [NPSF], 2016)
4. The five-why’s method of reaching the root cause (Tagues, 2005)
5. Cause-and-effect diagrams (NPSF, 2016)
Through a variety of classroom exercises and discussions, students are taught why errors occur, how systems fail, the levels of harm that result from medical errors, and how health care attempts to identify and reconcile medical mistakes. Although originally taught in a traditional bricks-and-mortar classroom environment, using online educational modules (either homemade or publicly available), such as the Institute for Healthcare Improvement (IHI) open courses, can be substituted for traditional instructor-led training. Online education can be used to provide knowledge in preparation for an in-person simulation session focusing on conducting an RCA. In addition, both learners and faculty should review the NPSF’s (2016), RCA2: Improving Root Cause Analyses and Actions to Prevent Harm as a reference for how to conduct an RCA.
To begin the session, learners are positioned in small groups of five to seven, either in one large classroom or in separate small rooms. These teams are meant to simulate the teams that would conduct an RCA after a medical mistake has been identified. Each team is presented with a simulated incident report that gives high-level information regarding the case, such as the patient’s name, where the incident occurred, and what the reporting individual thinks happened. This can be tailored so that it accurately reflects the local institution’s format.
The incident report for this specific case states that the patient, Jane Dolan, was an inpatient, currently on hospital day 4 for the treatment of pneumonia, who suffered a cardiac arrest. The cardiac arrest team responded and provided treatment, including chest compressions and defibrillation. The patient was then found to be wearing a bracelet that indicated the patient had an active do not resuscitate (DNR) order. The resuscitation was stopped. However, the primary nurse indicated to the code team that she did not think the patient had a DNR. The team monetarily paused their efforts until clarification of the DNR status was obtained. The incident report was filed because of the treatment (possible delay or wrong care) 516provided to the patient. The teams are now tasked with identifying what occurred, why it occurred, and how to prevent such situations in the future.
Technology Used
To facilitate the scenario, a high-fidelity manikin should be in a patient bed. A saline lock should be placed in the patient’s arm. Vitals signs are heart rate (HR): 90 beats/minute, blood pressure (BP): 110/70 mmHg, respiration rate (RR): 20 breaths/minute, oxygen saturation (SpO2): 94% on 2 L oxygen via nasal cannula). The patient wristband identifies the patient as Jane Dolan. Standard telemetry monitors are in place, including a bedside electrocardiography (EKG) monitor, BP monitor, and pulse oximeter. A code cart stocked with standard medications and a defibrillator are available in the hallway as is a stool for chest compressions. Other equipment needed “off stage” include a patient chart and color-coded medical wristbands.
The learners can watch the scenario from a remotely located room via closed-circuit television, through a one-way mirror, or can even be in the simulation room watching as observers.
Objectives
At the conclusion of this program, learners should be able to:
1. Discuss the differences between RCA and FMEA
2. Conduct an RCA to identify the causes of the error
3. Develop an improvement strategy that will alter the outcome of the case
Description of Participants
Standardized participants (SPs) play the roles of a primary nurse, code team nurse (ICU nurse), code team doctor (team leader), code team medical student, and respiratory therapist (or anesthesiologist).
E. RUNNING OF THE SCENARIO
SPs play the role of the primary nurse and the code team and have rehearsed the scenario before the course. Rehearsing before the scenario not only allows the SPs to be familiar with how to run the scenario, but also allows them to accurately give responses and portray their characters during the interview process previously described. The SPs have been given a script of their respective roles and understand the frame of mind of their character. The complete scenario, including SP frames of mind, is available in Exhibit 43.1.
In summary, the scenario begins with the primary nurse entering the patient’s room to perform an initial assessment. The nurse recognizes that the patient is missing the appropriate identification bands to signify she has an allergy to a medication. The nurse retrieves what they believe to be the correct wristband (blue) and applies it to the patient. After administering an antibiotic and leaving the patient room, the patient suffers a cardiac arrest. The responding team sees the blue wristband and recognizes this as a DNR wristband. A conversation ensues during the cardiac arrest regarding the patient’s code status. It is subsequently found that the patient does NOT have a DNR and the nurse applied the wrong wristband. An incident report is filed, which leads to the present day and the teams of learners needing to complete an RCA.
Once all of the learner groups have had the opportunity to interview the SPs, they are provided with 20 minutes to complete their RCA and develop a root cause statement and complete their flowcharts, Ishikawa diagrams, or other tools they used to reach the root causes. While the groups are completing this, faculty advisors circulate and ensure that students are on track in reaching a plausible root cause. On reaching a root cause(s), they then work as a group to identify a solution to the root cause(s) they determined. Potential solutions include, but are not limited to:
Exhibit 43.1 Human Patient Simulation: Mrs. Jane Dolan
Time | Vital Signs | Participant Cues |
Time 0: 0 min | HR: 90 beats/minute sinus rhythm BP: 110/70 mmHg RR: 20 breaths/minute SpO2 94% 2 L | The patient has just been admitted and is resting comfortably in bed. At this time the patient has no specific complaints. The patient states her breathing is better after being treated in the emergency department. A nurse is in the room completing an admission assessment and implementing the plan of care, including making sure the patient identification bands (ID, allergy, and no blood draw) are placed on the patient, and then hangs the antibiotics (ceftriaxone). The nurse places a blue wristband, which he or she believes signals an allergy to penicillin, and a red wristband, signaling no blood draw, on the patient. The nurse completes the tasks, double-checks that the patient is comfortable, and exits the room. |
Time 1: | HR: 130 beats/minute sinus tachycardia BP: 90/50 mmHg RR: 28 breaths/minute, wheezing SpO2 92% RA | The nurse is summoned back into the room via patient monitor alarm and the patient calling out for the nurse. The patient complains of dizziness, lightheadedness, and a general feeling of “not feeling well.” The nurse calls out for help—looking for “local assistance,” but no one is available and no one responds to the request. The nurse reassures the patient and asks questions such as: “What are you feeling? When did it start? Describe it in more detail.” The patient answers with: “Trouble swallowing, difficulty breathing, can’t catch my breath. Started a few minutes ago with a funny feeling in my mouth and throat.” The nurse looks around the room, checks the medications, and stops the infusion (realizing this may be anaphylaxis). The nurse begins providing oxygen via nonrebreather mask for the patient’s difficulty breathing. |
Time 2: 2.5 min | HR: Ventricular tachycardia BP: 0/0 mmHg RR: 0 breaths/minute SpO2 88% | The patient becomes unresponsive. Nurse again calls for help, this time by calling a code—pushing the code button, speaking with a unit coordinator, calling on a phone, and so on. The nurse puts the head of the bed down and begins prompt CPR. |
Time 3: 3.5 min | HR: Ventricular tachycardia BP: 0/0 mmHg RR: 0 breaths/minute SpO2 88% | The code team arrives with the code cart and defibrillator from the hallway and begins caring for the patient. The primary nurse turns over care to the code team by giving a verbal report. The primary nurse provides the code team with the situation (S), background (B), and assessment (A): S—Patient is in cardiac arrest. B—Patient was admitted for IV antibiotic for pneumonia. Patient has a history of CABG × 2, diabetes, HTN. A—IV antibiotics were infusing when patient became tachycardic, tachypneic, and then developed a pulseless ventricular tachycardia arrest. 518Code team begins to provide resuscitation. Junior MD begins compressions. ICU RN places defibrillation pads on the patient and turns defibrillator on (on direction from code leader). RRT or other member begins using BVM and securing an airway with appropriate devices (oral airways, intubation). Code team leader says to make sure the IV medication infusion is stopped, defibrillator pads are attached quickly, and asks that epinephrine 1 mg IV be made ready. The code leader has an intense focus on making sure the defibrillator is used quickly. He or she continually states, “Get the defibrillator on. Is it ready? Make sure the defibrillator is hooked up.” |
Time 4: 5 min |
| Two cycles of CPR are completed—code team nurse prepares to administer epinephrine and, before administration, notices a blue wristband signifying “DNR” on the patient’s wrist. The ICU nurse calls everyone’s attention to this by asking, “Is this patient DNR?” The code team asks the primary nurse for confirmation and the primary nurse, who is standing in the corner of the room, hesitantly states, “I … I don’t believe the patient to is DNR…. I don’t think so.” The code team asks the nurse to get the chart to confirm the code status while they debate whether they should continue resuscitation (compressions can be continued, but defibrillation is delayed, and medications are held while the patient status is confirmed). |
Time 5: 6 min | HR: Asystole BP: 0/0 mmHg RR : 0 breaths/minute SpO2 as indicated by actions of code team | While the code team debates whether they should continue and while the primary nurse is out looking for the chart, the patient deteriorates to asystole. The nurse returns a few moments later with the chart, which identifies the patient as a full code—the nurse is flipping through the chart and does not find DNR paperwork and states as such. The code team double-checks with the nurse by asking, “Are you sure the patient is a full code?” The primary nurse confirms the patient’s status and the resuscitation is continued after the delay. The code team can no longer provide defibrillation because the rhythm has changed to asystole. The resuscitation continues for two additional rounds of CPR (2–3 minutes) before being stopped and the patient is pronounced dead. An alternative to this ending, for those organizations not wanting to have the patient die, is to have a delay in defibrillation, but the heart rhythm remains in ventricular tachycardia (a shockable rhythm). The conclusion of the case can have the patient be successfully resuscitated with the patient being transferred to the ICU, however, because of the delay in defibrillation, the patient experiences irreversible brain damage (harm). |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
