In-Situ Simulation: Exposing Hidden Risks to Advance Patient Safety

Podcast Transcript

Announcer: Hello and welcome to MedEd Thread, a Cleveland Clinic education podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano: Hello, welcome to today's episode of MedEd Thread, an education podcast, exploring the essential role of In-Situ simulation in mitigating blatant threats as an integral part of education focused on promoting and optimizing patient safety. I'm your host, Dr. Tony Tizzano, director of Student and Lerner Health, here at Cleveland Clinic in Cleveland, Ohio.

Today, I'm very pleased to have Dr. Eduardo Mireles, director of both the simulation and advanced skills center and Medical Intensive Care Unit at Cleveland Clinic, along with Kim Sherry, program manager and simulation education specialist, along with Dr. Matt Olivero, emergency medicine physician and core faculty within this clinic simulation and advanced skills center here to join us.

Eduardo, Kim and Matt, welcome to today's podcast.

Kim Sherry: Thank you.

Dr. Matt Olivero: Thanks for having us.

Dr. Eduardo Mireles: Thank you.

Dr. Tony Tizzano: To get us started, would each of you please tell us a little bit about yourselves, your educational backgrounds, what brought you to Cleveland and your roles here at Cleveland Clinic? Eduardo, can we start with you?

Dr. Eduardo Mireles: Thank you, Tony. My road to simulation and my role here started from my training in pulmonary and critical care, which I did here at the Clinic. And my first entrance into simulation was actually when I got to University of Arkansas, which was my first job after fellowship. And that's where I learned about simulation and how to implement it.

And it was an amazing entry into that job. And as I started becoming more ingrained into the operations, I, we started using simulation to help us train the team and to overcome some of the issues that we were finding. So that's how I ended up here.

And now, years later, I'm directing along with Kathy Mau, the Simulation Center. And that's why I am talking to you today. So thank you.

Dr. Tony Tizzano: Thank you very much. And Kim.

Kim Sherry: So I am actually a nurse by trade. I started my career as a nurse here at Cleveland Clinic, which was 25 years ago. So been here quite a, quite a while. But I also was an instructor for the American Heart Association courses, and that is actually a form of simulation as well. Been doing that for 20 of those 25 years.

And as we started expanding and growing and recognizing a need we instituted a mock code program and I started off as a facilitator for the mock code program, which gradually evolved into a program coordinator, and then as we continued to grow a program manager and then now a simulation education specialist as well.

Dr. Tony Tizzano: Perfect. And finally, Matt.

Dr. Matt Olivero: Yeah, so I started medical school at Ohio University in Cleveland at our South Pointe Hospital, and I was introduced to simulation there, and I started conducting procedure labs for my fellow medical students. Continued that through residency with trauma training and procedures and case development.

And then I decided to go to a medical simulation fellowship at Indiana University School of Medicine, where I spent a year in the sim center training fellows, residents, medical students, pharmacists, et cetera, and learning how to debrief, learn about medical education and learning theory.

And then took a spot here at the Simulation Center as core faculty and I help oversee a lot of the nuts and bolts that happen, especially focused on our In-Situ program and all the sims we do throughout the enterprise.

Dr. Tony Tizzano: Well, I thank you all. I can't tell you, looking back at my own education at Ohio State, when the only simulation we really had was recus an Annie, which Kim you probably know about. I mean, that's where we've learned how to do CPR. It is so incredibly sophisticated now and the ability to look at things that we don't get to see very often and to polish our skills.

In today's segment, we'll explore how Cleveland Clinic is employing cutting edge insight to simulation, to educate caregivers about how to recognize and mitigate latent threats and ultimately advance patient safety in clinical areas across the enterprise by evaluating system competence and identifying latent or underlying conditions that predisposed to active medical errors.

So Kim, if you could give us a sense of latent and active errors that are terms that our listeners may not be familiar with. Could you help us with some definitions and examples?

Kim Sherry: Certainly. So a latent error or a latent safety threat are either hidden or less apparent conditions or system level failure within the organization.

These can contribute ultimately to patient errors, and they often go unnoticed until a harmful event or a patient safety event would occur. Kind of considered accidents waiting to happen. These can be equipment issues, they can be process issues, anything along those lines.

So we use simulation to identify some of these conditions and they can be missing and broken equipment or supplies. They can be paging system issues, inadequate staff training on some medical procedures, anything along those lines.

Latent safety threats are kind of considered the blunt end of the healthcare system as opposed to an active error, which is maybe an actual medical error that occurs at the patient bedside in the moment, then that would be considered the sharp end.

Dr. Tony Tizzano: Okay. Very well. You know, I think it's really important for us to realize that what we do is very complex and the only way you can stay, you know up with current information and on the curve is to be able to practice and we'd like to think we can practice without having to practice on patients.

So I think this idea of simulation in the, and the work that you've done, and I love the fact that there are multiple people at different points in nursing, physicians, technicians, because it really requires the whole team to polish these efforts, would you say?

Kim Sherry: Absolutely. We, we focus actually on that interprofessional education. So we, we try to get as many of our different caregivers involved in these as possible, and it's always highly encouraged. And as we're getting more and more buy-in, that's becoming a more prevalent condition where it's not just nurses, it's not just physicians, everybody's working together as a team.

Dr. Tony Tizzano: Perfect. Eduardo with this idea, this definition in mind please help frame today's topic by providing listeners with some context around how In-Situ simulation has become an essential component in our efforts to educate our caregivers to recognize and manage these latent threats and improve safety.

Dr. Eduardo Mireles: Well, the way that we think about this is in terms of a system. How do we make the hospital the healthcare environment safer? And so when you start thinking about this, you're focused on the patient. You're trying to deliver care to that patient. And really there's kind of this tunnel vision that occurs that you can move through the hospital just focused on patient care and go and deliver until the error occurs.

What we do by implementing this In-Situ training to test the system to test not only our clinicians when they arrive and how they are gonna behave and how they're gonna address the medical issue, the educational issue.

But as we're doing that, then we also open our line of sight to see what other things in terms of operations of process of the environment are occurring that could pose threats or that could generate inefficiencies on the way that we deliver care. That's how this starts becoming a very relevant process.

So in the background, you're testing the system, you're testing the system for things that if you have not done this and you had an emergency in that room at that particular time, you would only have picked up when, when it happens.

And I will tell you, Tony, that the other part is that whenever there's a emergency in the, in the hospital or or a case or whatever, it happens, we are very good at adapting and solving and absorbing error. Because we are there, we say, okay, this is not working. Go run, fix this over there.

So sometimes because you were able to absorb it, people don't report it, and when they don't report it, it will remain there again, active towards the future. So creating an environment of everybody can speak up and catch those situations is key.

But this serves as a reinforcement to ensure that this will not happen and we don't have to deal and adapt to it.

Dr. Tony Tizzano: That's a really interesting point. So what you're saying is that, you know, error to a certain extent is essentially intrinsic to the complexity of what we do. And how can we have enough layers of processes in place that might lower the chance?

And, and that psychological safety that you mentioned to come forward and and speak up is really an enterprise wide sort of mantra that doesn't happen easily and it takes a lot of buy-in at at all levels.

So, Matt, when we think of In-Situ, I think that's a word that we should perhaps maybe expand upon for our audience and help us understand how these potential latent threats are identified and how you go about building an exercise to engage with that problem.

Dr. Matt Olivero: Absolutely, Tony. So when we talk about In-Situ, we're talking about running simulations in the natural environment where a provider would practice or be. So that could range anywhere from a medical office building, to an OR suite, to an emergency department. It could even happen in a stairwell or outside of an elevator in, in the J building. Anywhere where a patient encounter may occur.

And the reason we like to perform simulations where clinicians and patients are in their natural state is that it recreates an environment of realism. And it allows us to also not only critique or to sharpen the sword in our clinical skills, but also to reveal those environmental or latent safety threats within the system.

Because we can sit, you know, in the locker room, on the whiteboard and draw up the plays and how our processes should occur, but when we take it to the field or to the core and practice that's when our safety threats reveal, that's when providers feel more empowered, and that's when clinicians are able to practice in a real environment.

So it's very important that we do so in the clinical setting for all those reasons.

Dr. Tony Tizzano: And do you find, along with what you're saying, that once you begin to do a particular exercise, you might even expose other things that you will end up adding to your repertoire for that problem or that situation?

Dr. Matt Olivero: Absolutely. And I think probably the majority, like if we go in to test a system, because a safety threat was brought up to us, often, more times than not other latent threats are revealed that we weren't expecting. [Sure.]

You know, there may be, oh, you know, where was the stool for the provider when, when doing compressions? Well, it was buried under the crash cart. Oh, does this happen all the time? And then we test the system and notice that, yes, it does happen all the time. And then we standardize our crash carts and that's how it kind of happens often, spontaneously.

Dr. Tony Tizzano: Yeah. I remember once in residency I ended up having to do a C-section in the patient's room in bed, and they brought, what they had were the emergent instruments and I asked for the scalpel and they handed me the scalpel, but it didn't have a blade, and we hadn't put any blades in the set.

So they had to go run and get a blade when, when we were looking at seconds. So I could see how you think, oh yeah, we've got the scalpel handle, but someone forgot to add the blades.

For all of you, I'd be curious, how do you begin to establish the psychological safety for people to relax as they practice, but also in the real world, come forward and say, Hey, wait a minute, what about this? What about that? Because we all wanna do things just right for our patients.

Dr. Eduardo Mireles: I'll, I'll start from the leadership standpoint, Tony. I think that the key is that whenever error occurs it's a key opportunity for us to demonstrate that this is a fair environment, that you're gonna approach this in a non-punitive listen and going to the root cause event. Because it's easy to say it, but it's hard to contain the emotions that come and the judgment that comes when you hear about the event.

And so you have to learn and you have to model how to approach error or safety events in the clinical care with your team so that after that they will be more prone to saying, you know, I will not get eaten alive because of this happened. I will speak up and I know that I will be treated fairly, that this will come through. And, and I think that that is how you start changing the culture.

It's easy to say it and to post it, but it's hard to see leader respond and respond in a way that makes it constructive and it makes it a change to the environment. Thanks to you speaking up.

Dr. Tony Tizzano: Well said. So Kim and Matt, you know, you've got students working with you and you know, if there was a position in your training where you're the least psychologically safe, it's probably when you're a student, you know.

What can we do to make them feel from the outset that despite being new on the team, they can raise their hand and say, Hey, what about this? You know, because you don't wanna make a mistake even making a criticism. How do you set that stage?

Dr. Matt Olivero: So first off, I think just piggybacking off what Eduardo said, is setting up an environment. So our team in itself at the sim center is very empowering. It's really family oriented. There's not a hierarchy. Everyone is empowered to speak up at all times.

So when you create a culture within your own team of speaking up and sharing ideas and what methods you think you may wanna share with the group, that's a good starting point. When we start off our simulations or when we start a debrief or pre-briefing, it's always important to very much empower learners.

So just to tell them to speak up or during our debriefing process, if we notice something, for example, that came up an error in a protocol or a misstep, I simply will ask a medical student. Or ask a learner to speak up or what they thought about the process, how they could have done better.

Because when you empower those who may not be at the head of the hall or the lead to speak up, it again creates that environment of a team and they feel better about it.

Dr. Tony Tizzano: Well, I can appreciate that. Kim, do you have anything to add to that?

Kim Sherry: Sure, and again, kind of piggy back off of what Matt said is as part of the pre-brief, when we're doing these In-Situ simulations, we specifically say this is an educational opportunity, please feel free to speak up if you notice anything. If you see anything.

But we also stress that as a team of In-Situ simulationists, we're looking for those latent safety threats too. But those are the things that are keeping them from doing the best possible job they can for the patient.

It's, it's making their clinical practice better and by stating that and when they see that, that these things that they may have noticed in their clinical practice setting, and they may have noticed it for a long time and never said anything, but now they feel free to say, Hey, you know, these are things that we've come across in the past and we feel that it does prevent us from doing the right thing or, or the best possible job that we can.

And thank you for bringing it to the surface for us, and we're gonna escalate that and hopefully help you get these things fixed, you know, remedied, however, and we'll help mitigate that for you.

And we'll find then a lot of times in the debrief that then they speak up as well and they'll say other things that they've noticed.

Dr. Tony Tizzano: So this debriefing is really important. It surely makes sense. Thank you. So as program manager Kim and a, a simulation education specialist, what does that mean and what do you bring to the table to put this all together and make it work?

Kim Sherry: In kind of a unique position by having both of those titles. So my title is Simulation Education Specialist, and one of the main things that simulation education specialists do is ensure that simulation best practices are followed. And they also help strengthen patient safety through the support of different stimulation modalities.

As a program manager, I get to collaborate with enterprise leadership on when these safety events occur, getting these scheduled in different locations. When they see something, when they want to schedule these events, they can reach out to me.

And then they also know that I can assist with curriculum development, I can assist with helping to address any issues that they're seeing, any educational opportunities that they're seeing in their clinical practice area.

So it's, it's a very, very beneficial role. And then I also get to help, you know, foster education and simulation best practices as well as part of that role.

Dr. Tony Tizzano: How do you gauge, you know, the budget for this must be, can sometimes seem to be daunting. I mean, some of this is really complicated. You know, what kind of resources and how do you go about allocating these? If that's a question for you or anybody?

Kim Sherry: I am lucky enough to not have to deal with budget too much, but I have a very, very supportive department manager that I, I reach out to. And again, we go back to the simulation leadership, very supportive in what we need. They see the benefit with quality and patient safety, highly endorse the program.

And again, usually if there's any issues that come up, anything that we need, we go to our directors, whether that's Eduardo or Kathy or my department manager. And again, they do everything they can to help make sure that whatever we need happens, because they realize too, the impact that it's making.

Dr. Tony Tizzano: So you've got good support.

Kim Sherry: Absolutely.

Dr. Tony Tizzano: Eduardo, we are, we're more and more cognizant of the importance of systemness. How do these efforts contribute to that across all clinical sites within the enterprise?

Dr. Eduardo Mireles: That's the key part of, as this restructuring of the Cleveland Clinic, to ensure that the model replicates itself across each one of our sites, that we have repetition of if a patient gets admitted here or in Florida, that they would get the same pathway of care.

And when you start thinking about in that matter, then you can imagine the power of us doing an In-Situ here, or it's done in Florida or in Abu Dhabi or in London. And they recognize a latent safety threat in a system that is standardized and that we are following the same behaviors.

Just because you did it over there, there is a high likelihood when you are talking about systems that that may be occurring elsewhere. And that amplifies the effect of your training program. That amplifies the effect of your latent safety threat assessment program, because now you can expand this. And this has happened several times.

And Kim and Matt can talk about some of these examples and how this has amplified throughout. So I think as we think about a high reliability organization and we think about the restructuring, how we are trying to develop and mimic our secret sauce across and learn from each other.

This generates systems that become more lean and more efficient at repeating and we aren't having to do the same simulation, the same In-Situ, In-Situ elsewhere. And actually, if they do it elsewhere and they discover something else even better, you just continue to improve with this items and the system becomes better and more reliable.

Dr. Tony Tizzano: Yeah, that's a great point. And you know, I think that those efforts are actually contagious. You know, I look at, before we joined Cleveland Clinic in the multi-specialty group that I worked in in Wooster, we all of a sudden had all these resources. We had these care paths that we maybe talked about, but people did things differently here and did there.

And once we had this framework and we're required to report on our results and they would look at our information, even though we weren't in a Cleveland Clinic hospital, they said, well, you know, that's fine and good, but you need to be doing it this way when you're working for the Cleveland Clinic.

And that ended up raising the bar in our local hospital just by virtue of the fact that our results were beginning to shine. So there is actual measurable benefit that, you know, once you see it, you may say, ah, we don't need to do that. But once you see it work, you're more inclined.

Dr. Eduardo Mireles: This doesn't take away innovation. This actually, if anything fosters innovation in different areas and we learn from our different environments. What it does is it provides a framework for communication, um, to expand what we learn in each one of the sites.

Dr. Tony Tizzano: So, Matt, previously you and I discussed this idea of normalization of deviance. Please explain this concept and how it might be addressed in an In-Situ simulation and debriefing exercise.

Dr. Matt Olivero: Yeah, that's a great topic. So the normalization of deviance. Imagine a provider at a certain clinical site. And like Eduardo was talking about earlier, sometimes we get into our routine of our day.

We get focused. We're going from task to task. We're doing a procedure, maybe a procedure or a task that we've done a thousand times. We pick up habits along the way. We pick up habits in our training from our attending physicians to nursing education leaders, and we develop our own practice as providers.

But sometimes parts of that practice is not best practice. And at the Cleveland Clinic, we like to encourage best practices because they're research based. And again, because they prevent poor patient outcomes and they encourage safety.

So you may have one process at a location that kind of you continue to do, but may not be in best practice. And that can spread in a culture and kind of this idea of, well, I've always done it this way and it's worked for me in the past.

But anytime we stray away from what a best practice may be then that can kind of breed a ground of going back to latent safety threats. Whether it's just universal protocol before doing a procedure, whether it's how you sterilize and prep for a central line kit in the intensive care unit or emergency department, whether you're doing a timeout before a surgical case is when we are able to standardize across our system, what's best for the patient and how we go about it and kind of get away from a little bit of those old habits, it's overall greater.

And then off of that as Eduardo alluded to off of the standardization of best practices and procedures, then that can breed and foster a more positive learning environment, new ideas, and we just continue to grow.

Dr. Tony Tizzano: And the most simplified example, I think of handwashing and I remember H1N1 , which is gonna probably date me. Some of you may remember, we had this H1n1 flu. Everyone was afraid of it. Our screensavers talked about hand washing. We all became very, very good hand washers and by George, we had a great H1N1 result.

We didn't see the transmissibility that we were expecting, and maybe that had something to do with it. But now I find myself going back into practice and I tell my MA or my nurse, I said, if you do not see me wash my hands before I touch that patient, you just stop me right in the room. 'cause I always have a chaperone and I don't mind.

And I think it's important for the patients to see that we function as a team like that, it makes them feel confident that we're doing the very best we can each and every one of us.

So Kim, there's this enormous interplay between safety, recognizing it, speaking up. We have this online safety event reporting system, this SERS system, and this whole idea of root cause analysis as a source of potential topics for consideration for you and your In-Situ team.

Can you help us understand how you look at things that happen and, and then make something occur in simulation that might address it?

Kim Sherry: Certainly so, and actually that, that interplay is kind of multifaceted. First of all, we are very much ahead of the curve in the fact that we do report our latent safety threats through a standardized reporting system.

And we've seen nationally through going to some of our, our conferences that a lot of healthcare systems don't have that. So we are at a very, very unique position to kind of share some of those best practices with other hospitals across the country. That we, we do have a way to do that. And then we have a way to follow up on those safety event reports as well.

So any caregiver can report a safety event. But the fact that there was actually a category created specifically for latent safety threats and In-Situ simulation is huge. And then what ended up happening is as we, we grew this program, I was given the position of a file manager too, so I can actually see how those safety events are, are followed up on.

But additionally, as another facet of this is I sit on all the code review and critical response resuscitation committees, and there's rescue categorizations that happen with real code events where issues are identified, opportunities for improvement are identified. Depending on the rescue categorization serves filings are encouraged or maybe even mandated.

And as such, we're also brought in because simulation is actually integrated into all these code review committees and CRRC committees so that they may ask, say, Hey, we saw this opportunity that occurred, a SERS event was filed for this rescue categorization. We really think that that team could benefit from a In-Situ simulation or a mock code simulation.

And then depending on what that opportunity was, we can actually structure curriculum around whatever that specific safety event was. And then additionally, like our stakeholders and our leadership, whether it's a nurse manager, whether it's a physician, when they see those opportunities, they also know that they can reach out and ask for some, some education and some In-Situ simulations in their clinical practice areas as well.

Dr. Tony Tizzano: So this is fabulous. So what you're saying is that you actually monitor by reviewing various things that happened across the enterprise where there might be a area that needs some attention, at a particular site and can take the simulation there?

Kim Sherry: Absolutely.

Dr. Tony Tizzano: That, that is perfect. That's exactly what we would want to happen. Everyone listening would say, yeah, that's exactly what should happen. That's fabulous.

So what lies on the horizon for all of you? You know, what's next? Dr. Stoller talks about his magic wand. If you could have his magic wand, what would be the next thing? What are you looking at down the road?

Kim Sherry: We've got several things actually. I think our first and most important thing is the globalization and the standardization of our practices that we're sharing with all of our sites around the world. And we have a, a global advisory board that actually helps facilitate all of that and In-Situ simulation is actually gonna be part of the faculty development in that program.

We're also looking to expand the development and the recognition of latent safety threats to other areas of simulation and how it will be reported in the safety event reporting system. And then we're also looking at how we're categorizing these latent safety threats.

This is another thing and an opportunity again, nationwide, is how are latent safety events categorized and how do they fit into a, any kind of bucket? And there's some literature out there, but there isn't a lot of literature, and so we're actually looking at how can we categorize them to make them easier to mitigate, easier to address.

Dr. Tony Tizzano: Excellent. Other thoughts?

Dr. Matt Olivero: I think it's just very important to continue to foster for our learners, to empower them to speak up when, when we're not even there, but normal clinical practice, if they see an error or if they think of something or see something that could be done better to protect patients to report that in our safety event reporting system.

You know, it's anonymous. They can just report the error and try to categorize it for themselves, and then we go and look in. It's not, again, it's not nothing punitive. It's just to empower our teams and to improve patient safety.

And also, again, as, as Kim talked about, to share our knowledge and the breadth of everything that we've learned with our providers internationally in Florida and Abu Dhabi, in London. So we've made connections and we've all reached out and spoken to certain leaders, uh, in the simulation roles internationally, so we can keep it growing.

Dr. Eduardo Mireles: I, I wanted to make two pointed comments in terms of we are very lucky in many ways of having an amazing leadership that has supported us and that sees the value on the simulation operation and how we support and empower our learners and our teams to become safer.

And sometimes there may be this sensation one, one is hearing one of these top performing environments saying, where do I start? How do I get to do this? And I would put it into two buckets.

The first one is that there are things that we're doing already in terms of simulation in your organization, just thinking about the mock codes, for example, but any other type of, in which this is an incremental  item of work. It's another moment of reflection that we can add to work that it's already been done by your simulation teams to create an environment that is safer. It's just simply changing your viewpoint from just education of the learner to a process system safety environment. And that's a shift that it's incremental that many centers can achieve by themselves.

And the the second point that I would put here is the item, and you, you mentioned it about budgeting, Tony. And I think that one of the common things that we hear is simulation is expensive. And having the resources to, to do this is difficult. And allocating people to do it is hard.

But I think that in this day and age with our focus on safety and the stakes that we have with all the very sick patients that we're caring for, that when you do this type of work in which you are detecting latent threats, that could have caused an error with multiple economical disadvantages and, and cost for the institution and for the patient, and for everybody that when you start creating these systems, they pay for themselves.

It's very hard to demonstrate the economic impact that they have, but when you start thinking from the safety standpoint, their value becomes evident to the institution. So for the listeners out there and for administrators out there, simulation is a key part of what we need to implement in our environment, in our healthcare systems to make them safer.

Dr. Tony Tizzano: Yeah, I think that's very well said and and I do believe, I've always been impressed by what I see actually happen in building this culture of safety and the idea that e-, every level of leadership, whether you're the intern talking to the medical student or you're the CEO, talking to the entire group, this whole notion that look,

I know we're not perfect. I want to hear about these things when they happen. You will not be admonished for it. You know? I will respect anyone who comes forward and raises a hand and say, Hey, what about this right or wrong? I mean, that's the beauty of finally kind of pinning this down.

Well, thank you so much, Eduardo, Kim and Matt.

This has been a wonderfully insightful and thought provoking episode of MedEd Thread. To our listeners, if you'd like to suggest a medical education topic to us or comment on an episode, please email us @educationatccf.org. Thank you very much for joining, and we look forward to seeing you on our next podcast.

Have a wonderful day.

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