The effect of emergency manuals on team performance during two different simulated perioperative crises: A prospective, randomized controlled trial.

Study Objective: Whether having an emergency manual (EM) available for use during perioperative crises enhances or detracts from team performance, especially for multi-factorial diagnostic situations that do not explicitly match a chapter of the EM.

Design: A simulation-based, prospective randomized trial based upon two perioperative crises, one involving a patient with a transfusion reaction for which the EM contains a specific chapter, and the other involving a patient with refractory hypotension progressing into septic shock for which the EM does not have a specific chapter.

Setting: 52 regularly scheduled 6-h courses at the Center for Medical Simulation in Boston, Massachusetts, USA.

Internal Medicine Residents' Exposure to and Confidence in Managing Hospital Acute Clinical Events.

Background: Internal Medicine (IM) residency graduates should be able to manage hospital emergencies, but the rare and critical nature of such events poses an educational challenge. IM residents' exposure to inpatient acute clinical events is currently unknown.

Objective: We developed an instrument to assess IM residents' exposure to and confidence in managing hospital acute clinical events.

Improving Anesthesiologists' Ability to Speak Up in the Operating Room: A Randomized Controlled Experiment of a Simulation-Based Intervention and a Qualitative Analysis of Hurdles and Enablers.

Purpose: The authors addressed three questions: (1) Would a realistic simulation-based educational intervention improve speaking-up behaviors of practicing nontrainee anesthesiologists? (2) What would those speaking-up behaviors be when the issue emanated from a surgeon, a circulating nurse, or an anesthesiologist colleague? (3) What were the hurdles and enablers to speaking up in those situations?

Method: The authors conducted a simulation-based randomized controlled experiment from March 2008-February 2011 at the Center for Medical Simulation, Boston, Massachusetts. During a mandatory crisis management course for practicing nontrainee anesthesiologists from five Boston institutions, a 50-minute workshop on speaking up was conducted for intervention (n = 35) and control (n = 36) groups before or after, respectively, an experimental scenario with three events. The authors analyzed videos of the experimental scenarios and debriefing sessions.

A behaviourally anchored rating scale for evaluating the use of the WHO surgical safety checklist: development and initial evaluation of the WHOBARS.

Background: Realising the full potential of the WHO Surgical Safety Checklist (SSC) to reduce perioperative harm requires the constructive engagement of all operating room (OR) team members during its administration. To facilitate research on SSC implementation, a valid and reliable instrument is needed for measuring OR team behaviours during its administration. We developed a behaviourally anchored rating scale (BARS) for this purpose.

The use of emergency manuals in perioperative crisis management: a cautious approach.

When an unexpected perioperative crisis arises, simulation studies have suggested that the use of an emergency manual (EM) may offset the large cognitive load involved in crisis management, facilitating the efficient performance of key steps in treatment. However, little is known about how well EMs will translate into actual practice and what is required to use them optimally. While EMs are a promising tool in the management of perioperative critical events, more research is needed to define best practices and their limitations.

Is clinical trial registration for simulation-based research necessary?

Summary statement: The International Committee of Medical Journal Editors requires that all clinical trials be prospectively registered before being considered for publication in their member journals. Clinical trial registries are Web-based databases of clinical trials, providing researchers, journal editors, and reviewers detailed study information to help inform trial results. What is unclear is whether clinical trial registration is required for simulation-based studies, where typically health care providers are the subjects and where the outcomes may be provider based or patient based.

Establishing a safe container for learning in simulation: the role of the presimulation briefing.

Summary statement: In the absence of theoretical or empirical agreement on how to establish and maintain engagement in instructor-led health care simulation debriefings, we organize a set of promising practices we have identified in closely related fields and our own work. We argue that certain practices create a psychologically safe context for learning, a so-called safe container. Establishing a safe container, in turn, allows learners to engage actively in simulation plus debriefings despite possible disruptions to that engagement such as unrealistic aspects of the simulation, potential threats to their professional identity, or frank discussion of mistakes.

Ignaz Semmelweis redux?

The story of Ignaz Semmelweis suggests a lesson to beware of unintended consequences, especially with in situ simulation. In situ simulation offers many important advantages over center-based simulation such as learning about the real setting, putting participants at ease, saving travel time, minimizing space requirements, involving patients and families. Some substantial disadvantages include frequent distractions, lack of privacy, logistics of setup, availability of technology, and supply costs.

Improving faculty feedback to resident trainees during a simulated case: a randomized, controlled trial of an educational intervention.

Background: Although feedback conversations are an essential component of learning, three challenges make them difficult: the fear that direct task feedback will harm the relationship with the learner, overcoming faculty cognitive biases that interfere with their eliciting the frames that drive trainees' performances, and time pressure. Decades of research on developmental conversations suggest solutions to these challenges: hold generous inferences about learners, subject one's own thinking to test by making it public, and inquire directly about learners' cognitive frames.

Methods: The authors conducted a randomized, controlled trial to determine whether a 1-h educational intervention for anesthesia faculty improved feedback quality in a simulated case.

A history of simulation-enhanced interprofessional education.

This article explores the evolution and history of interprofessional education (IPE) using healthcare simulation (HCS). The evolution described here demonstrates an achievement of patient safety efforts as a consequence of the historical roots of healthcare and highlights HCS as a progressive method synergistic with IPE. This paper presents a descriptive review that covers the HCS and IPE literature, indicating factors that led to the use of HCS in IPE.

Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

Objective: To test the feasibility of implementing a standardized teamwork training program with full operating room teams in multiple institutions, driven by malpractice insurer support and incentives.

Background: Failures in intraoperative teamwork are among the leading causes of preventable patient injury and death in surgical patients. Teamwork training, particularly using simulation, can be an effective intervention but is difficult to scale.

We know what they did wrong, but not why: the case for 'frame-based' feedback.

Background:   Actionable feedback targeted to the learner's needs is one of the strongest predictors of improved performance in learning. Unfortunately, when a trainee makes an error, although instructors may understand what a trainee has done wrong, they can erroneously assume they know why.

Context:   There is a growing recognition that cognitive biases impede clinical diagnosis, however, the same biases can also undermine accurate and effective feedback.

The effect of an olfactory and visual cue on realism and engagement in a health care simulation experience.

Introduction: Fidelity has been identified as an important element in a subject's perception of realism and engagement in learning during a simulation experience. The purpose of this study was to determine whether an isolated visual and olfactory sensory change to the simulation environment affects the subjects' perceptions of realism during simulation cases.

Methods: Using an electrosurgical unit applied to bovine muscle tissue, we created a model to simulate the characteristic operating room smoke and burning odor that occur during many procedures.

Mixed-realism simulation of adverse event disclosure: an educational methodology and assessment instrument.

Introduction: Physicians have an ethical duty to disclose adverse events to patients or families. Various strategies have been reported for teaching disclosure, but no instruments have been shown to be reliable for assessing them.The aims of this study were to report a structured method for teaching adverse event disclosure using mixed-realism simulation, develop and begin to validate an instrument for assessing performance, and describe the disclosure practice of anesthesiology trainees.

Curriculum and cases for pain medicine crisis resource management education.

Medical crises that may occur in the setting of a pain medicine service are rare events that require skillful action and teamwork to ensure safe patient outcome. A simulated environment is an ideal venue for both acquisition and reinforcement of this knowledge and skill set. Here, we present an educational curriculum in pain medicine crisis resource management for both pain medicine fellows and attending physicians as well as the results of a successful pilot program.

Speaking across the drapes: communication strategies of anesthesiologists and obstetricians during a simulated maternal crisis.

Introduction: Organizational behavior and management fields have long realized the importance of teamwork and team-building skills, but only recently has health care training focused on these critical elements. Communication styles and strategies are a common focus of team training but have not yet been consistently applied to medicine. We sought to determine whether such communication strategies, specifically "advocacy" and "inquiry," were used de novo by medical professionals in a simulation-based teamwork and crisis resource management course.

Educational program in crisis management for cardiac surgery teams including high realism simulation.

Introduction: Cardiac surgery demands effective teamwork for safe, high-quality care. The objective of this pilot study was to develop a comprehensive program to sharpen performance of experienced cardiac surgical teams in acute crisis management.

Methods: We developed and implemented an educational program for cardiac surgery based on high realism acute crisis simulation scenarios and interactive whole-unit workshop.

Research regarding debriefing as part of the learning process.

Introduction: Debriefing is a process involving the active participation of learners, guided by a facilitator or instructor whose primary goal is to identify and close gaps in knowledge and skills. A review of existing research and a process for identifying future opportunities was undertaken.

Methods: A selective critical review of the literature on debriefing in simulation-based education was done.

Design and evaluation of simulation scenarios for a program introducing patient safety, teamwork, safety leadership, and simulation to healthcare leaders and managers.

We developed a training program to introduce managers and informal leaders of healthcare organizations to key concepts of teamwork, safety leadership, and simulation to motivate them to act as leaders to improve safety within their sphere of influence. This report describes the simulation scenario and debriefing that are core elements of that program. Twelve teams of clinician and nonclinician managers were selected from a larger set of volunteers to participate in a 1-day, multielement training program.

Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety.

Introduction: Residents train in a historically hierarchical system. They may be compelled to question their teachers if they do not understand or disagree with a clinical decision, have a patient safety concern, or when treatment plans are unclear. We sought to determine whether a debriefing intervention that emphasizes (1) joint responsibility for safety and (2) the "two-challenge rule" (a rubric for challenging others) using a conversational technique that is assertive and collaborative (advocacy-inquiry) can improve the frequency and effectiveness with which residents "speak up" to superiors.

Anesthesiologist management of perioperative do-not-resuscitate orders: a simulation-based experiment.

Introduction: This study was performed to assess perioperative reevaluation of Do-Not-Resuscitate (DNR) orders by practicing anesthesiologists.

Methods: As part of an Anesthesia Crisis Resource Management course, an anesthesiologist interviewed a patient-actor with prostate cancer and bone metastases scheduled for a central venous catheter placement. The chart included a properly documented DNR order and the patient-actor's scripted responses emphasized that he would accept resuscitative efforts only "if the adverse clinical events were believed to be both temporary and reversible.