Strategy Submission

The sentinel event simulation presentation has been developed as an immersive experience to integrate theoretical understandings about quality and safety in health care with the “lived experience” of those impacted by medical errors. The presentation is a mechanism that will provide a memorable, realistic (often emotional) high impact teaching tool about a particular sentinel event. Each group of students will receive one sentinel event description, which will be the topic of the presentation. Students are divided into groups of six or seven students. Each group is assigned a specific topic (wrong patient identity, aspiration of foreign objects, fatal medication error, etc.) from one of the safety bulletins from the Institute for Safe Medication Practices (ISMP).

Each presentation group is challenged with developing a very specific, very realistic adult medical-surgical scenario with potentially catastrophic results based on the safety alert topic assigned to the group.  After the scenario is fully developed, the group completes a Root Cause Analysis (RCA) of the scenario using the Root Cause Analysis form from the Joint Commission.

Students are challenged with using their nursing knowledge and clinical experience to develop realistic proximate factors representative off actors portrayed in the scenario.  Each presentation group is charged with researching and understanding all of the relevant medical and nursing facts in the scenario. The presentation group works in the simulation lab to videotape a reenactment of the scenario in a realistic and compelling way. The video clip is embedded into a PowerPoint for use during a presentation to an audience. Each presentation group provides relevant background on the scenario, proximate causes and an action plan that integrates evidence based practice.  While each scenario often highlights an individual error that occurs at the bedside with an individual patient, an emphasis is put on the completion of a systems analysis for relevant proximate causes that contributed to the individual error.  Students are challenged to become “change agents” and to generate pragmatic system’s based solutions to prevent similar incidents from ever occurring again.  The presentation concludes with two or three compelling and provocative discussion questions for audience members.