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Patient Safety Awareness Week 2019

March 10-16

Virtually everyone has played the telephone game once in their life. Players form a line, and the first player comes up with a message and whispers it to the ear of the second person in the line. The second player repeats the message to the third player, and so on. Once the message gets to the last player, the message is typically distorted. With enough players, by the end of the line, the message may bear no resemblance to the original at all.

Imagine now that as the message is passed down the line, a patient is passed along with it. And, imagine that the message contains the information necessary for the next person to administer safe immediate care. What would the results be for the patient?

If you have been thinking about how to design your next simulation scenario, we hope that the telephone game comes to your mind as a possible opportunity. The root cause of 70% of sentinel events reported to the Joint Commission have been found traceable to communication failure.1 And, to the point of the telephone game, 80% of patient harm is traceable to a teamwork and communication failure occurring during patient hand-offs.2

This week marks Patient Safety Awareness Week sponsored by the Institute for Healthcare Improvement (IHI). We join with the IHI in encouraging everyone to take a fresh look at the topic of Patient Safety, focusing on how improving Patient Safety is fundamentally a teamwork and communications endeavor.

Using Simulation to Build High Performance Teams


Narrow the curricula focus on multidisciplinary team training

Many medical schools are now teaching the importance of teamwork and communications to doctors-in-training. Similarly, nursing schools have been integrating Quality and Safety Education for Nurses (QSEN) in their curricula. Some organizations are taking team training a step further by bringing varying healthcare disciplines (doctors, nurses, and anesthesiologists, for example) together to conduct multidisciplinary exercises. Research shows that this type of multidisciplinary team training leads to better outcomes, especially in emergency situations.

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Use simulation to improve team performance and patient outcomes

Industries like aviation and the military have long-relied on simulation to build effective teams. They’ve seen improvements in team effectiveness, reductions in risk, and better results overall. In healthcare, simulation can yield the same results. Didactic learning alone is generally an insufficient foundation for practice. Even observational learning can fall short. Simulation training can better prepare a team to respond to orchestrated team care, especially emergency care. This, ultimately, leads to better patient outcomes. 

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Amplify the learning experience with in situ simulation

Simulation conducted on location in your team’s own care setting, otherwise known as in situ simulation, can greatly enhance the realism of a scenario. Once learners become confident in their ability to complete tasks in isolation, in situ simulation offers them an opportunity to reinforce their problem-solving skills as part of an entire care system. Learners can test their team and communication skills in an environment representative of the real-world they are about to enter. In situ simulation builds team confidence and cohesion.

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