Patient Safety Tip of the Week
September 25, 2007
Lessons from the National Football League
A couple of weeks ago Buffalo
Bills’ tight end Kevin Everett suffered a life-threatening spinal cord injury
during a football game. Though his ultimate prognosis remains unknown, he has demonstrated
some early neurological improvement that may be due at least in part to the
rapid response of the emergency medical personnel and team physicians,
including use of induced hypothermia which apparently had never been used this
early in a human spinal cord injury. The ambulance/emergency medical technician
team at the stadium had, in fact, met with team physicians Drs. John Marzo and
Andrew Cappuccino a week before the first home game to go over procedures to be followed in
the event of a suspected spinal injury. That training included the possible use
of induced hypothermia by intravenous infusion of cold saline. The ambulance
was also specially equipped with a backboard designed to accommodate a player's
helmet and pads. At other NFL stadiums,
physicians and emergency medical response teams simulated how they would
respond to similar incidents.
Use of simulation in healthcare has
become popular as a tool to help promote teamwork. Its roots are from Cockpit
Resource Management training (also known as Crew Resource Management training)
in the aviation industry (see our May 15, 2007 Tip of the Week). It’s most
often used for teams, such as operating room teams, to improve communication
skills and decision-making capabilities. Some simulators involve expensive
hardware and software that allows life-like clinical situations and allows for
“complications” or “unexpected circumstances” to be programmed into the
simulation scenarios.
But simulation does not have to use
expensive laboratories and equipment. Simulation could and should be part of
your FMEA (Failure Mode and Effects Analysis) activities. Our September 11, 2007 Tip of the Week
discussed the RCA on an unintentional chemotherapy overdose. Some of the issues
addressed in the RCA dealt with the response and management of the patient
after the patient had received the high dose of chemotherapy much more rapidly
than planned. We wonder how many organizations that utilize such chemotherapy
protocols (or a variety of other protocols, for that matter) have ever
simulated such an unintended incident. Most often in a FMEA, one might simply
note that someone would have to look up the effects of the chemotherapy
toxicity and the clinical management of the patient. But an actual simulation
in the above case may have surprised people when the paucity of published
information on fluorouracil overdosage was discovered. Findings from such a
simulation could certainly lead to a refinement of the protocol.
So a good simulation activity
should include not only what steps are expected to be taken under certain
circumstances but also anticipate what things might go wrong and how you would
respond under those additional circumstances. Actually acting out the situation
can sometimes produce surprises that lead to constructive changes. Think about
adding that step when you do your next FMEA activity.
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