International Journal of Advanced Computer Science, Vol. 3, No. 8, Pp. 381-387, Aug., 2013.

Incident-Trajectory Simulation for Excellence in Safety: Illustration in Healthcare

Ranjit Singh, Don McLean, Ashok Singh, & Gurdev Singh
Manuscript
Received: 14,Apr., 2013 Revised: 25,May, 2013 Accepted: 29,Jun., 2013 Published: 15, Jul., 2013

Keywords
Healthcare, Safety, Simulation, System Trajectory.

Abstract High Reliability Organizations maintain low adverse incident rates over a sustained period of time. It is well recognized that the core concepts, applicable in a whole variety of complex risk-prone enterprises such as healthcare, are: (1) Sensitivity to operations; (2) Reluctance to simplify interpretations; (3) Pre-occupation with failure; (4) Deference to expertise; and (5) Resilience. A highly transferrable training methodology and the tools that help inculcate leadership, systems thinking, communication, situational awareness, teamwork, consensus-based problem solving and decision-making, as well as adaptive responsiveness are presented. Proposed methods of assessment of resulting individual and team competencies and formative assessment of the approach are described.

learns from them when they occur. Development of such a system requires, first, a commitment by all stakeholders to a culture of safety. The overarching goal of the authors interdisciplinary research team is to provide value through quality-improvement and waste-reduction by applying safety principles and invoking Improvement Science [6]. In the work presented here, we respond to the need for improved education for health professionals in patient safety by using a novel simulation-based curriculum that applies concepts from high reliability organizations (HROs) to healthcare. A High Reliability Organizations (HROs) HROs were once considered peculiarities, but during the 1990s researchers in organisational behavior began to understand the cultural factors at the core of the success of these organizations and recognized that these factors could have applicability in whole variety of complex, risk-prone enterprises such as healthcare. The core concepts that are thought to underlie the excellence in high reliability organizations, first described by Weick and colleagues [7] in 1999 are: (1) Sensitivity to operations; (2) Reluctance to simplify interpretations; (3) Pre-occupation with failure; (4) Deference to expertise; and (5) Resilience. Figure 1 illustrates our adapted conceptual framework for creating safety. The essential thrust of these concepts is that all workers should understand: (a) the complexity of the systems within which they work and (b) the proneness of such systems to fail, leading to adversity/ies. They should develop situational awareness of possibilities for incidents and should report them promptly, even if no adversity occurs. Decision-making should incorporate expertise from whoever has it, regardless of hierarchy, and staff should be prepared to handle adverse outcomes when they occur. B Formation of Culture of Safety Figure 2 portrays different stages of development in safety-based culture in organizations. HRO concepts overlap with those underpinning a culture of safety. Creation of a culture of safety is a critical step for organizations that wish to improve quality and safety. Culture is a set of beliefs and norms of behavior residing in individual team members and in the interactions between them. As shown in Fig. 3, error reporting is one of a number of important factors that contribute to safety culture.

1. Introduction
Harm to patients in the healthcare settings, according to the US Center for Disease Control and Prevention, is the third leading cause of mortality, following heart disease and cancer. This lack of reliability in the healthcare system has been well articulated over the past several years [1],[2]. In a July 2000 JAMA report, Starfield estimated a total of 225,000 deaths per year from iatrogenic causes [3]. The US Center for Disease Control estimates that 1.7 million hospital-acquired infections occur every year (i.e., 4.5 infections for every 100 admissions). According to some estimates, this nation experiences 1.5 million incidents of harm per year due to medication errors alone [2]. These are just a few examples of the huge chasm that has been documented to exist between the potential and the actual quality of care delivered in the U.S. The United Nations World Health Organization is working toward making patient safety a Basic Human Right [4]. Despite many efforts at all levels of the healthcare system, it cannot be stated that patients in the US are significantly safer today than they were 10 years ago [5]. The world needs a system that both prevents errors and
This work was supported by the US AHRQ Ranjit Singh, Vice-Chair Dept. of Family Medicine Assoc. Professor and Assoc. Director; Don McLean, Safety Associate; Ashok Singh, Safety Associate; Gurdev Singh, Director UB Patient Safety Research Center, State University of New York at Buffalo. USA. rsl0@buffa1o.edu

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High Reliability Concepts

General Orientation

Impact on Process

Ultimate Outcome

Se ns it i vit yt Rel o uct op anc er e to inte ati rpr on eta sim pl s tion ify s
Pre-occupation with failure

Capability to Discover and Manage Errors (

State of Mindfulness

High Reliability

Exceptionally Safe, Consistently High Quality Care

e to renc Defe rtise e e p x e nc ie sil e R

Fig. 1. Role of 5 HR Concepts for Safety

D Su yna M cc mic an es s Le Sa agedsfull of ve ls fe C y of Cu ty han ge l tu ra lM at ur ity

Safety-Cultured:
We manage Safety as an integral part of everything we do

Proactive: We are always on the

alert/thinking about what might emerge system in place

Ri si ng

Fig. 2. Rising Levels of Cultural Maturity

Bureaucratic: We have

Reactive: Do something when we have an incident

Pathological: Why Bother about Patient Safety?
After Manchester PSF

Fig. 3. Interactive Contributors to Culture of Safety in a Dynamic and Often Cascading Environment [8] International Journal Publishers Group (IJPG)

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These factors interact in a cybernetic loop that creates and reinforces the culture. Leadership has an important role. The positive feedback, when reporting is used appropriately, can further drive the development of safety culture. C Managing Errors for High Reliability

disaster preparedness is being helped with simulation training on how to handle terrorism attacks, natural disasters, pandemic outbreaks, or other life-threatening emergencies. It facilitates learning of valuable lessons in a cost effective and safe environment. A Simulation For Inculcating High reliability Concepts The authors propose an innovative approach in which they: 1) use simulation to inculcate High Reliability concepts; incorporating both individual and team-based simulations, 2) use Reasons Incident Trajectory (aka Accident Trajectory) as the key tool in the simulations, prompting staff to analyze systems, understand causes of errors, and strategies for their prevention, and include a patient advocate in the team simulation. In their work the authors simulate safety incidents and the administrative response to events. All staff members in a specific hospital unit are presented initially with simulated incident reports in their organizations current reporting format. The process of review and analysis of these reports is designed to inculcate HRO concepts. Staff is engaged initially at the individual level, and later in team meetings. In the latter, they simulate group discussion of safety incidents so as to develop team skills around patient safety, including deference to expertise and development of team-based solutions to safety issues. B Use of Reasons Incident/Accident Trajectory as a Simulation Training Tool The training simulations are structured around the Accident Trajectory (aka Incident Trajectory) proposed by James Reason [13]. This describes how incidents result from a combination of situational factors and latent failures that predispose individuals to make mistakes (active failures). Only well designed safety barriers can intervene to prevent adversity. Figure 4 gives details of these four components. The authors have successfully piloted (and published) this construct in a number of out-patient offices and a hospital for stimulating systems thinking and team-based safety problem-solving. They are now planning to use it as a training tool to help staff and patient advocates in a variety of hospitals to analyze simulated incident reports in a safety training program, named Incident-Trajectory Simulation Approach (ITSA). Figure 5 illustrates the adapted concept and the structure of the Safety Journal which is an error/incident analysis tool developed by Singh et al [14],[15]. The Safety Journal is a document that healthcare workers can use to identify, describe and analyze safety incidents in a structured and logical way. It provides a visual portrayal of the relationship between the contributory factors and aids Root Cause Analysis and development of interventions for safety improvement. Figure 6 depicts the Safety Journal: Example Entry [15].
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Detection, reporting, and meaningful interpretation of incident reports are central to the creation and maintenance of High Reliability Organizations. In healthcare settings, this concept is operationalized through the use of incident reporting systems. A study by Farley et al. [9] in more than 1600 US hospitals showed that most do not maintain effective incident reporting systems. Figure 4 presents a model that illustrates the error reporting cycle in which team members engage in error reporting, followed by analysis and feedback of lessons learned, leading to system change that in turn can provide positive feedback to team members, encouraging further reporting. This never-ending continuous cycle of learning and system change leads to error reduction and also encourages further development of a culture of safety. Unfortunately, most errors and close calls (near misses) go unreported. Potential reporters often have insufficient knowledge about available reporting systems and access to them, do not know how to report adverse events, do not know exactly what to report, and find reporting too time-consuming, inconvenient and cumbersome [10]. Differences and ambiguities in definitions cause confusion. The items marked with * in Fig. 4 are the barriers that we expect will be most ameliorated by the Incident-Trajectory Simulation Approach (ITSA), leading to increased incident reporting, leading in turn to greater system learning. This approach is presented in section 2.

2. Simulation Training Method And Tool Incident Trajectory Simulation Approach (ITSA)
The skills / competencies required of individuals and teams are complex and require considerable time and effort to develop. Simulation is a training methodology that is well suited to this field for the following reasons: The subject matter is inherently risky to the staff and patients involved simulation has the ability to re-create realistic scenarios in a safe environment that is free from repercussions and blame. The skills required are complex, including problem solving, communication, and teamwork. These types of skills are not readily acquired just through didactics but require experiential training, preferably in a controlled setting such as a simulation. Simulation as a training methodology has being widely used with military personnel, business managers and teachers, and it is being increasingly used to train medical professionals [11],[12]. It can replicate these situations and track how trainees respond. This is the prime reason why

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Fig. 4. The Error Reporting Cycle and Barriers Faced

Situational Factors/failures
Unlucky/Unforeseen Circumstances
Examples: * Very unusual workload * Distraction * 2 patients with the same name * Power supply failure at critical juncture

Situ

Latent Failures
AKA

Lat

Latent Failures

Lat

Blunt End failures - these present the greatest threat to safety

Design Operation Maintenance Organization Management

Latent errors are built into the system - They are difficult for staff to see because they may be hidden/dormant.
- They may facilitate/trigger an error/s or amplify the resulting adversity. Fixing of this latent source of errors yields the greatest improvement in safety.

These are errors in:

These factors put additional stress on the system and can thereby trigger Latent Failures that may have existed for many years without causing any adverse events.

They exist before the active error occurs.

Active Failures:
AKA Sharp End errors - made by workers in the processes of care

Act

Active Failures:
Examples
* wrong drug prescribed * wrong dose prescribed * wrong medication given * wrong patient * wrong site procedure * picking up wrong bottle from shelf * mislabeling of specimen missed allergy

Act

Safety Barriers:

Bar

Their effects are felt/observed relatively rapidly or immediately

They hinder humans from committing an active failure or absorb the effects of active failures before adverse event can occur.

Blame is often inappropriately focused here

They can be: Technical ( strong ) Administrative

: Policies and Procedures

( weak )

Safety Barriers: Technical ( strong ): examples

Bar

Safety Barriers:
standard protocols and procedures clear clinical pathways adequate credentialing requirements emergency drills, simulations double checks, teach-backs making processes transparent and visible adequate looseness in coupling autonomy to handle the unexpected non-hierarchical team culture

Bar

Safety Barriers:
Another useful way of looking at Barriers:

Bar

Administrative ( weak ): examples

plugs, sockets, connections incompatibility equipment failing to safe default state forcing functions informatics safe and distinct storage of drugs safe dosage packaging safety guards standardization of equipment layouts and displays intuitive equipment operation

TYPE Physical e.g. forcing functions, walls, locks etc Natural e.g. time and distance Information e.g. labels, alarms, signs etc Measurement e.g. measurements, inspections Knowledge e.g. training, work aids, checklists etc Administrative e.g. checklists, procedures, policies etc

Fig. 5. Four Components of the Reasons Trajectory International Journal Publishers Group (IJPG)

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It is important to emphasize that this simulation program is highly adaptable and transferable to various domains outside the healthcare domain. This tool is generalizable and can be used with either low (paper-based) or high (web-based) technology. It has the 4 attributes recommended by Miller for multidisciplinary simulation-based healthcare education: practicality, feasibility, standardization and reliability. We believe, therefore, that this tool has particular potential to facilitate In Situ simulation for training multidisciplinary teams [11],[12]. The authors propose an interactive type of multiple simulated event-scenarios model along with the Safety Journal as the means to inculcate the HRO concepts and objectives.

3. ITSA Goals And Objectives

These were set and designed to inculcate individual and team skills for 4 goals described below: 1. Sensitivity to operations: Training staff, with the aid of visual models [16],[17], to be aware of the systems and processes in place and how these impact care, leading to identification of risks, and reporting, in turn leading to prevention. All participants are helped to understand their role within the system, how flawed systems and processes lead to error and harm, and their role in identifying and reporting events, including near misses. 2. Reluctance to simplify interpretations: Avoiding simple explanations for events (e.g., blaming a mistake on staff shortage) but instead look more thoroughly at causative factors, especially underlying system failures that need to be corrected. Participants understand the role of Reasons Adverse Event Trajectory in understanding complex causality of safety events, understand the components of the Adverse Event Trajectory, and are able to identify situational factors, active failures, latent failures, and safety barriers in simulated safety event scenarios, and in real events. 3. Preoccupation with failure: All are encouraged to report all safety events, including near misses. These reports are important opportunities for learning. Participants learn how and when to report safety events and understand the importance of identifying and reporting near misses (even though in a near miss there is no harm, it signals the presence of risk that may cause harm in the future). 4. Deference to expertise: A culture is developed in which leaders and supervisors are willing to listen and respond to the insights of staff at the front-line who know how processes really work. Participants develop ability to participate effectively as part of a team in addressing patient safety and employ appropriate communication strategies in safety discussions. A Training Components for Individuals and Teams 1. Didactic: Introductory session, led by Unit Nurse Managers, with all staff and physicians and patient advocate.

2. Simulation: Analysis of simulated event reports participants are presented with a set of 5 simulated safety events (vignettes) in the organizations usual reporting format. For each event, participants identify causative factors according to the information presented and classify the causative factors according to Incident Trajectory. The teams are expected to put forward at least one proposal for system improvement. 3. Feedback: Within 1 week after each session, participants receive written individual feedback regarding their individual and team performance (with respect to the competency measures outlined below). 4. Repeat Simulation: Until a pre-determined level of competency is reached by the individual (up to a maximum of 3 repeat simulations). The vignettes for the simulations are based on our clinical experience (incorporating clinical input from family medicine, geriatrics, pharmacy, nursing, and a patient advocate), covering a variety of types of events, involving various systemic factors such as: medication events, testing events and events involving patient mistakes. They are tailored to unique hospital settings as well as for team simulation events.

4. Individual and Team Competency Assessment

Table 1 shows the competency and outcome measures used in ITSA with respect to the goals and objectives. Formative Evaluation of the ITSA Program Formative evaluation of the ITSA program has to be carried out with respect to satisfaction, perceived utility, and perceived impact among participants in order to inform future development and generalizability of the program. Each participant needs to be invited to complete brief ratings of the following (using Likert-type scale responses): (a) clarity of objectives, (b) extent to which objectives were met, (c) format appropriateness and effectiveness, (d) duration, level of engagement, (e) applicability to daily work, and (f) likelihood that they will change their behavior as a result. A

5. Concluding Remarks
ITSA is a highly transferable in situ simulation methodology that helps inculcate the HRO concepts and the embedded objectives, at both the individual and team levels. One of the main advantages of the Incident Trajectory format is that it separates system problems from the active and situational factors; focusing attention on these system problems can lead to sustainable solutions.

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Fig. 6. The Safety Journal: Example Entry [15]

TABLE 1: SUMMARY OF TRAINING OBJECTIVES, COMPONENTS, COMPETENCIES AND OUTCOME MEASURES

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ITSA appears to create a safe environment for staff to practice discussing safety issues, become comfortable talking in front of their superiors, receive non-punitive feedback individually and as a group, and become more effective as a team. It is expected that these skills will translate into staffs actual daily work leading to increase in their own and patients satisfaction. It is the authors experience that safety is not most effectively taught through didactics but through engaging learners in addressing real problems in their practices. In situ simulation represents an important step toward this. Our experience suggests that further efforts are needed to find effective ways to weave an emphasis on safety across the various threads of training so as to better facilitate internalization (and hence application) of safety principles.

[11]

[12]

[13] [14]

Acknowledgment
This work was supported by 2 grants from the US Health Resource and Services Administration.

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