Sentinel Event Simulation Presentation
Skills or Simulation Laboratories
- Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as, work-arounds and dangerous abbreviations)
- Describe processes used in understanding causes of error and allocation of responsibility and accountability (such as, root cause analysis and failure mode effects analysis)
- Participate appropriately in analyzing errors and designing system improvements
- Engage in root cause analysis rather than blaming when errors or near misses occur
- Communicate observations or concerns related to hazards and errors to patients, families and the health care team
- Demonstrate effective use of strategies to reduce risk of harm to self or others
- Value the contributions of standardization/reliability to safety
- Appreciate the cognitive and physical limits of human performance
- Value own role in preventing errors
- Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team
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.
As this is a fairly time consuming project, various components are given due dates throughout the semester. Each project is worth 100 points total, with the presentation itself receiving 75 points. The presentation grade of 75 points is generated from a rubric with audience members "grading" 30% of the presentation points (using the grading rubric) and the course professor allocating 70% of the presentation grade. Students receive 5 points early in the semester for submitting one group detailed narrative description of the scenario and 20 points for completing a group Root Cause Analysis (RCA) and action plan.
The quality of the presentations has been dependent upon the amount of work invested in it. It became apparent after 2 semesters that students would benefit from having concrete due dates for discrete components of the presentation. As students have become increasingly proficient with technological innovation, the presentations have been moved to a "vodcast" or "podcast" format which markedly increases the number of potential audience members.
The presentations have been extremely well received as students developed a compelling, realistic "story line" that emphasized the human emotions experienced by both nurses and patients impacted by medical errors. The usage of simulation provides an element of realism and taped simulation "vignettes" embedded within the presentation offers the "best of both worlds" as students provide a rigorous analysis of a very realistic rendition of a patient safety situation.