Training Situational Awareness for Patient Safety in a Room of Horrors: An Evaluation of a Low-Fidelity Simulation Method.


Journal

Journal of patient safety
ISSN: 1549-8425
Titre abrégé: J Patient Saf
Pays: United States
ID NLM: 101233393

Informations de publication

Date de publication:
01 12 2021
Historique:
pubmed: 5 1 2021
medline: 19 2 2022
entrez: 4 1 2021
Statut: ppublish

Résumé

To protect patients from potential hazards of hospitalization, health care professionals need an adequate situational awareness. The Room of Horrors is a simulation-based method to train situational awareness that is little used in Switzerland. This study aimed to evaluate (1) the performance of health care staff in identifying patient safety hazards, (2) the participants' subjective experiences, and (3) the group interactions in Rooms of Horrors. The study was conducted in 13 Swiss hospitals that implemented a Room of Horrors. Health care professionals participated as individuals or in groups and were asked to identify as many errors as possible within a certain time and to complete an evaluation questionnaire. Observations of group interactions were carried out in 8 hospitals. t Tests and χ2 tests were used to examine differences in performance between participants solving the task alone versus in groups. Data of 959 health care professionals were included in the analysis. Single participants identified on average 4.7 of the 10 errors and additional 10 errors and hazards that were not part of the official scenario. However, they also overestimated their performance, with 58% feeling the errors to be easy to find. Group observations indicated that participants rarely reflected on possible consequences of the hazards for the patient or their daily work. Participants feedback to the method was very positive. Our findings suggest that the Room of Horrors is a popular and effective method to raise situational awareness for patient safety issues among health care staff. More attention should be given to debriefing after the experience and to benefits of interprofessional trainings.

Sections du résumé

BACKGROUND
To protect patients from potential hazards of hospitalization, health care professionals need an adequate situational awareness. The Room of Horrors is a simulation-based method to train situational awareness that is little used in Switzerland.
OBJECTIVES
This study aimed to evaluate (1) the performance of health care staff in identifying patient safety hazards, (2) the participants' subjective experiences, and (3) the group interactions in Rooms of Horrors.
METHODS
The study was conducted in 13 Swiss hospitals that implemented a Room of Horrors. Health care professionals participated as individuals or in groups and were asked to identify as many errors as possible within a certain time and to complete an evaluation questionnaire. Observations of group interactions were carried out in 8 hospitals. t Tests and χ2 tests were used to examine differences in performance between participants solving the task alone versus in groups.
RESULTS
Data of 959 health care professionals were included in the analysis. Single participants identified on average 4.7 of the 10 errors and additional 10 errors and hazards that were not part of the official scenario. However, they also overestimated their performance, with 58% feeling the errors to be easy to find. Group observations indicated that participants rarely reflected on possible consequences of the hazards for the patient or their daily work. Participants feedback to the method was very positive.
CONCLUSIONS
Our findings suggest that the Room of Horrors is a popular and effective method to raise situational awareness for patient safety issues among health care staff. More attention should be given to debriefing after the experience and to benefits of interprofessional trainings.

Identifiants

pubmed: 33395018
doi: 10.1097/PTS.0000000000000806
pii: 01209203-202112000-00051
pmc: PMC8612898
doi:

Types de publication

Journal Article Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

IM

Pagination

e1026-e1033

Informations de copyright

Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.

Déclaration de conflit d'intérêts

The authors disclose no conflict of interest.

Références

Farnan JM. Situational awareness and patient safety. PSNet Patient Safety Network.
Endsley MR. Measurement of situation awareness in dynamic systems. Hum Factors . 1995;37:65–84.
Farnan JM, Gaffney S, Poston JT, et al. Patient safety room of horrors: a novel method to assess medical students and entering residents’ ability to identify hazards of hospitalisation. BMJ Qual Saf . 2016;153–158. doi: 10.1136/bmjqs-2015-004621.
doi: 10.1136/bmjqs-2015-004621
Wiest K, Farnan J, Byrne E, et al. Use of simulation to assess incoming interns’ recognition of opportunities to choose wisely. J Hosp Med . 2017;12:493–497.
Daupin J, Atkinson S, Bédard P, et al. Medication errors room: a simulation to assess the medical, nursing and pharmacy staffs’ ability to identify errors related to the medication-use system. J Eval Clin Pract . 2016;22:907–916.
Käppeli A. Patientensicherheit—Lustvoll lernen im «Raum des Horrors». Competence . 2018;1–2.
Zimmermann C, Schwappach D. Interaktives Lernen Im Room of Horrors. Manual . 2019. doi:10.13140/RG.2.2.15626.21445.
Zimmermann C, Schwappach D. Apprentissage Interactif Grâce à Une Chambre Des Erreurs. Guide d’utilisation ; 2019. doi:10.13140/RG.2.2.29047.98728.
Zimmermann C, Schwappach D. Apprendimento Interattivo Nella Stanza Degli Errori. Guida per l’utente ; 2019. doi:10.13140/RG.2.2.22337.10080.
Clay AS, Chudgar SM, Turner KM, et al. How prepared are medical and nursing students to identify common hazards in the intensive care unit? Ann Am Thorac Soc . 2017;14:543–549.
Korah N, Zavalkoff S, Dubrovsky AS. Crib of horrors: one hospital’s approach to promoting a culture of safety. Pediatrics . 2015;136:4–5.
Gregory A, Hogg G, Ker J. Innovative teaching in situational awareness. Clin Teach . 2015;12:331–335.
World Health Organization. Conceptual Framework for the International Classification for Patient Safety; Version 1.1. Available at: http://www.who.int/patientsafety/implementation/taxonomy/icps_technical_report_en.pdf?ua=1.:1-153 . Accessed December 1, 2020.

Auteurs

Chantal Zimmermann (C)

From the Swiss Patient Safety Foundation, Zurich.

Annemarie Fridrich (A)

From the Swiss Patient Safety Foundation, Zurich.

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