Hospital Simulations Improve Patient Safety

CPT LeeAnna Daniel had to get the patient's blood pressure under control. But the patient was going into labor and getting frantic to push.

As an obstetrical nurse, Daniel knew a blood pressure of 170/100 placed the laboring mom in a high risk for serious or fatal complication.

The attending physician seemed aware of the high blood pressure but her efforts were focused on the patient's urge to deliver. To Daniel, delivering the baby now before controlling mom's blood pressure didn't make sense.

"Doctor, don't forget her blood pressure is high, we need to get that under control," Daniel said to the physician.

Who was Daniel to tell an experienced and respected physician what to do? If the physician were a higher ranking officer, would that have prevented Daniel? If the anesthesiologist sided with the physician's direction, would the team suppress Daniel's concern?

Hierarchical forces, cultural values and, sometimes, even personalities keep a well-meaning medical team from taking the right course of action. At the heart of most medical errors according to Phyllis Toor is a lack of communication.

"When I was a patient safety manager, I would do a roll up of all the safety reports to look for common causes. Time after time, the cause of medical errors was a lack of communication," Toor said. "A doctor would ask for Benadryl 25 and the typical response was, 'I've got it,' only to provide the wrong medicine or dose. TeamSTEPPS teach us to respond with, 'I am getting Benadryl 25.'"

Toor is the program director for Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) with the U.S. Army Medical Command. She oversees the implementation of TeamSTEPPS across all Army health readiness platforms.

On Sept. 12-15, Toor and other TeamSTEPPS trainers visited with the staff of Irwin Army Community Hospital to carry out simulation-based training.

"We invited the TeamSTEPPS trainers so our staff can learn how to develop scenario-based simulation training," said Col. John Melton, IACH commander. "The MEDCOM team is helping us to adopt best practices for rehearsing critical communication skills."

Even though he is not a clinician, Melton said he attained Master TeamSTEPPS Trainer status in 2012 due to his confidence in the program to standardize the delivery of healthcare.

He compares the format and structure of TeamSTEPPS to a 9 Line Medical Evacuation.

"A 9 Line is an effective way to accurately report a combat injury in the midst of a stressful and hectic situation. Similarly, TeamSTEPPS creates a structure for healthcare personnel to communicate in any situation," Melton said.

Dominant personalities sometimes get in the way of communication -- they tend to be the only ones who know what is going on. But TeamSTEPPS creates checks and balances to empower every individual in the operating room. The system validates everyone's input and upholds a shared understanding among all as the norm.

"Everyone on the team can speak up to say they don't understand. The worst thing that could happen is the doctor thinking one thing, the nurse thinking another, and the two assuming they are thinking the same thing," said Col. Charles "Rod" Pattan, the Deputy Commander for Clinical Services at General Leonard Wood Army Community Hospital, Fort Leonard Wood, Missouri.

Pattan was among the master trainers who ran simulations. He would observe nurses like Daniel and test her nerve in challenging a physician.

During the simulated high-stakes scenario, Daniel said she was able to voice her concerns even if it undermined the physician or the majority of the team.

"With TeamSTEPPS I have the power to say, 'I am still not comfortable and I need you guys to explain why you think this is going to be safe,'" she said. "No matter what's going or who's in the room, you should be able to say 'Stop for second, I am so lost, I need understand what's going on."

The hands-on training was a first for Irwin Army Community Hospital. Although all team members take a class version of TeamSTEPPS, simulation training has never been part of the curriculum until now.

"It's like trying to learn how to fire a rifle from a slide deck and never going to the range," said Amanda Gagnon, IACH Patient Safety Manager. "Going through the simulation creates the practice that individuals need to intervene in a real-life situation."

Part of the simulation training also prepared 24 master trainers who can run the simulations, evaluate the team members, and identify opportunities for improvement.

"IACH has been teaching TeamSTEPPS for many years but the fact that we are taking it to the next level demonstrates our leadership's commitment to delivering quality and safe care," Gagnon said.

TeamSTEPPS was developed by the Department of Defense's Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality.