Doctor, the patient's blood pressure is 80 over 60," says the nurse. But, focused on the patient's breathing difficulty, the doctor misses the blood pressure number and orders the nurse to inject a drug that may cause the blood pressure to drop even lower.
This example is only part of a clinical simulation scenario, but such miscommunications between members of a medical team during actual treatments can lead to bigger problems.
The Institute of Medicine estimates that medical errors are the eighth leading cause of death in the United States, and poor communication can be a major source of those errors. In an effort to reduce mistakes, several centers around the country are using clinical simulators to learn how to improve patient care.
The Clinical Simulation Center at Washington University School of Medicine and Barnes-Jewish Hospital in St. Louis is one of several new grant recipients involved in a federal initiative -- funded by the federal Agency for Healthcare Research and Quality (AHRQ) of the Department of Health and Human Services -- that hopes to improve patient safety by using simulators as research tools, rather than only as teaching aids.
Clinical simulators include a complex mannequin similar to the one that people might recognize from a CPR class. But unlike CPR dummies, the mannequins in simulators seem to breathe on their own, experience increases and decreases in blood pressure, have variable heartbeats, eyes that dilate and can even react to medications and medical procedures. The interactive devices allow doctors, medical students and other health professionals to receive hands-on training in realistic scenarios.
"The fidelity of the technology is so close to reality that we're able to implement a variety of training and assessment strategies for our medical students, residents and even for experienced physicians and specialists," says David J. Murray, M.D., professor of anesthesiology and director of the Clinical Simulation Center, a joint effort involving the School of Medicine and its Departments of Anesthesiology, Pediatrics and Surgery, and BJC Health System Inc., which operates Barnes-Jewish Hospital. "We're looking at ways to use simulation and implement programs on a hospital-wide and medical school-wide basis to improve practice standards for all health care professionals."
Murray and his colleagues have been using simulators to help assess and improve physician competence for more than a decade. This new project continues that training with medical residents, but it also researches how communication can break down between members of medical care teams during simulated acute-care events.
In a typical test of communication, most members of the team working in the simulation center will be scripted. They'll know what's wrong with the pretend patient and be coached to react in pre-determined ways. Unscripted team members then will be assessed, both for their competence in diagnosing and treating simulated problems and for their ability to communicate with the scripted members of the medical team. Murray believes this will reveal some of the common causes of communication failure.
"There is a substantial amount of data suggesting that problems arise in team communication and can endanger patients," Murray says. "Our goal is to assess that communication on a more individual level and figure out precisely where the actual failures may occur."
As specific problems are uncovered, he says researchers will quickly be able to design programs to improve communication and take them out of the simulation center and into the areas at Barnes-Jewish Hospital where teams work together to provide care.
"This grant from AHRQ recognizes that communication failure is an important patient safety problem," Murray says. "I think one of the major strengths of our approach is that we're going to use our clinical simulator as a tool to help develop and apply strategies to remediate those failures."
A total of 19 projects have been funded in 16 states. All deal with simulation technology and patient safety, but not all of the projects focus specifically on communication within the acute-care team. The Washington University project will focus mainly on resident physicians, but other centers will use simulators to work with specialists, nurses and other allied health professionals. The hope is that within two years, the research will lead to significant changes in the practice of medicine that improve patient safety.
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