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

Advances in Simulation

Volumn 1, Issue 1, 2016, Pages

  Campbell, Douglas M ^a,b   Poost Foroosh, Laya ^a   Pavenski, Katerina ^a,b   Contreras, Maya ^a,b   Alam, Fahad ^b,c   Lee, Jason ^a,b   Houston, Patricia ^a,b  

^a ST MICHAEL'S HOSPITAL   (Canada)

^b UNIVERSITY OF TORONTO   (Canada)

^c SUNNYBROOK RESEARCH INSTITUTE   (Canada)

Author keywords

Blood transfusion; In situ simulation; Latent hazard; Medical error; Patient safety; Quality improvement; Simulation

Indexed keywords

EID: 85026802452     PISSN: None     EISSN: 20590628     Source Type: Journal    
DOI: 10.1186/s41077-016-0032-z     Document Type: Article

References (42)

1. Transfusion Transmitted Injuries Surveillance System (TTISS)—Public Health agency of Canada. http://www.phac-aspc.gc.ca/hcai-iamss/ttiss-ssit. Accessed 5 Nov 2015
2. Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York State: an anaylsis of 10 years’ experience. Transfusion. 2000;40(10):1207–13. DOI: 10.1046/j.1537-2995.2000.40101207.x
3. Murphy MF, Casbard AC, Ballard S, Shulman IA, Heddle N, Aubuchon JP, Wendel S, Thomson A, Hervig T, Downes K, Carey PM, Dzik WH. BEST Research Collaborative. Prevention of bedside errors in transfusion medicine (PROBE‐TM) study: a cluster‐randomized, matched‐paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check. Transfusion. 2007;47(5):771–80. DOI: 10.1111/j.1537-2995.2007.01189.x
4. Beyea SC, Majewski C. Blood transfusion in the OR—are you practicing safely? AORN J. 2003;78(6):1007–10. DOI: 10.1016/S0001-2092(06)60592-9
5. Lundy D, Laspina S, Kaplan H, Rabin Fastman B, Lawlor E. Seven hundred and fifty‐nine (759) chances to learn: a 3‐year pilot project to analyse transfusion‐related near‐miss events in the Republic of Ireland. Vox Sang. 2007;92(3):233–41. DOI: 10.1111/j.1423-0410.2006.00885.x
6. Maskens C, Downie H, Wendt A, Lima A, Merkley L, Lin Y, Callum J. Hospital‐based transfusion error tracking from 2005 to 2010: identifying the key errors threatening patient transfusion safety. Transfusion. 2014;54(1):66–73. DOI: 10.1111/trf.12240
7. Fastman BR, Kaplan HS. Errors in transfusion medicine: have we learned our lesson? Mt Sinai J Med. 2011;78:854–64. DOI: 10.1002/msj.20296
8. Burrows JM, Callum JL, Belo S, Etchells E, Leeksma A. Variable pre-transfusion patient identification practices exist in the perioperative setting. Can J Anesth. 2009;56(12):901–7. DOI: 10.1007/s12630-009-9180-0
9. Elhence P, Veena S, Sharma RK, Chaudhary RK. Root cause analysis of transfusion error: identifying causes to implement changes. Transfusion. 2010;50(12pt2):2772–7. DOI: 10.1111/j.1537-2995.2010.02943.x
10. Hogg G, Pirie ES, Ker J. The use of simulated learning to promote safe blood transfusion practice. Nurse Educ Pract. 2006;6(4):214–23. DOI: 10.1016/j.nepr.2006.01.004
11. Patronella G, Latocca R, De Vito G, D’Orso MI, Riva MA, Cesana G. Sentinel events for work-related stress in hospital and their monitoring in the decade 2001–2010. G Ital Med Lav Ergon. 2011;33(3 Suppl):3269.
12. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13 Suppl 1:i85–90. DOI: 10.1136/qshc.2004.010033
13. Yule P, Cooper RP. Express: a Web-based technology to support human and computational experimentation. Behav Res Methods Instrum Comput. 2003;35(4):605–13. DOI: 10.3758/BF03195540
14. Firth-Cozens J. Cultures for improving patient safety through learning: the role of teamwork. Qual Health Care. 2001;10(Suppl I):ii26–31.
15. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, Etchells E, Ghali WA, Herbert P, Majumdar SR, O’Beirne M, Palacios-Derflingher L, Reid RJ, Sheps S, Tamblyn R. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Can Med Assoc J. 2004;170(11):1678–86. DOI: 10.1503/cmaj.1040498
16. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. National Academies Press; 2000.
17. Murray WB, Foster PA. Crisis resource management among strangers: principles of organizing a multidisciplinary group for crisis resource management. J Clin Anesth. 2000;12(8):633–8. DOI: 10.1016/S0952-8180(00)00223-3
18. Salas E, Paige JT, Rosen MA. Creating new realities in healthcare: the status of simulation-based training as a patient safety improvement strategy. BMJ Qual Saf. 2013;22(6):449–52. DOI: 10.1136/bmjqs-2013-002112
19. Boet S, Bould MD, Fung L, Qosa H, Perrier L, Tavares W, Reeves S, Tricco AC. Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Can J Aneasth. 2014;61(6):571–82. DOI: 10.1007/s12630-014-0143-8
20. Shapiro MJ, Morey JC, Small SD, Langford V, Kaylor CJ, Jagminas L, Suner S, Sailsbury ML, Simon R, Jay GD. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care. 2004;13:417–21. DOI: 10.1136/qshc.2003.005447
21. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hamstra SJ. Technology-enhanced simulation for health professions education. A systematic review and meta-analysis. JAMA. 2011;306(9):978–88. DOI: 10.1001/jama.2011.1234
22. Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368:246–53. DOI: 10.1056/NEJMsa1204720
23. Nishisaki A, Keren R, Nadkami V. Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. Anesthesiol Clin. 2007;25(2):225–36. DOI: 10.1016/j.anclin.2007.03.009
24. Geis GL, Pio B, Pendergrass TL, Moyer MR, Patterson MD. Simulation to assess the safety of new healthcare teams and new facilities. Sim Healthcare. 2011;6:125–33. DOI: 10.1097/SIH.0b013e31820dff30
25. Kobayashi L, Overly FL, Fairbanks RJ, Patterson M, Kaji AH, Bruno EC, Kirchhoff MA, Strother CG, Sucova A, Wears RL. Advanced medical simulation applications for emergency medicine microsystems evaluation and training. Acad Emerg Med. 2008;15:1058–70. DOI: 10.1111/j.1553-2712.2008.00247.x
26. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Qual Saf. 2013;22:468–77. DOI: 10.1136/bmjqs-2012-000942
27. Cheng A, Grant V, Auerbach M. Using simulation to improve patient safety dawn of a new era. JAMA Pediatr. 2005;169:5.
28. Green R, Curry N. Simulation training improves clinical knowledge of major haemorrhage management in foundation year doctors. Transfus Med. 2014;24(6):379–84. DOI: 10.1111/tme.12161
29. Venture KM, Barry JS, Davis D, Baiamonte VL, Wentworth AC, Pietras M, Coughlin L, Barley G. Using in situ simulation to evaluate operational readiness of a children’s hospital-based obstetrics unit. Simul Healthc. 2014;9(2):102–11. DOI: 10.1097/SIH.0000000000000005
30. Cheng A, Eppich W, Grant V, Sherbino J, Zendejas B, Cook DA. Debriefing for technology-enhanced simulation: a systematic review and meta-analysis. Med Educ. 2014;48(7):657–66.
31. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth. 2003;90:580–8. DOI: 10.1093/bja/aeg112
32. Guise JM, Deering SH, Kanki BG, Osterweil P, Li H, Mori M, Lowe NK. Validation of a tool to measure and promote clinical teamwork. Simul Healthc 2008; Winter;3(4):217–23.
33. Berg BL. Qualitative research methods for the social sciences. Allyn and Bacon. 5th ed. Boston: Pearson; 2004.
34. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12. DOI: 10.1016/j.nedt.2003.10.001
35. Lincoln YS, Guba EG, editors. Qualitative Research Guidelines Project. Naturalistic Inquiry. Sage; 1985.
36. Liu D, Grudgeiger T, Sanderson PM, Jenkins SA, Leane TA. Interruptions and blood transfusion checks: lessons from the simulated operating room. Anesth Analg. 2009;108:1. DOI: 10.1213/ANE.0b013e318193597c
37. Morgan S, Rioux-Masse B, Oancea C, Cohn C, Harmon J Jr., Konia M. Simulation-based education for transfusion medicine. Transfusion. 2015;55(4):919–25.
38. Hilton G, Daniels K, Goldhaber-Fiebert SN, Lipman S, Carvalho B, Butwick A. Checklists and multidisciplinary team performance during simulated obstetric hemorrhage. Int J Obstet Anesth. 2016;25:9–16. DOI: 10.1016/j.ijoa.2015.08.011
39. Sellu DH, Davis RE, Vincent CA. Assessment of blood administration competencies using objective structures clinical examination. Transfus Med. 2012;22(6):409–17. DOI: 10.1111/j.1365-3148.2012.01192.x
40. Anders S, Miller A, Joseph P, et al. Blood product positive patient identification: comparative simulation-based usability test of two commercial products. Transfusion. 2011;51(11):2311–8. DOI: 10.1111/j.1537-2995.2011.03185.x
41. McCulloch P, Mishra A, Handa A, et al. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Safe Health Care. 2009;18(2):109–15. DOI: 10.1136/qshc.2008.032045
42. Nuttall GA, Stubbs JR, Oliver Jr WC. Transfusion errors: causes, incidence, and strategies for prevention. Curr Opin Anesth. 2014;27(6):657–9. DOI: 10.1097/ACO.0000000000000136