Simulation- March 2012



Simulation – Monthly Update



March 2012

Welcome to the March bulletin on Simulation being produced by the HEFT Library Services. This bulletin is produced to support Simulation training carried out in the Harry Hollier Simulation Centre at Good Hope. This issue will highlight evidence published in the previous 4 weeks. Full text articles can be accessed via your HEFT Athens ID.

Human factors

Title: Managing alarm fatigue in cardiac care

Citation: Progress in Pediatric Cardiology, January 2012, vol./is. 33/1(85-90), 1058-9813 (January 2012) Author(s): Solet J.M., Barach P.R.

Abstract: The article states that ‘alarm fatigue’ has led to delayed or failed alarm responses and deliberate alarm deactivations. Addressing alarm fatigue requires regulators, manufacturers and clinical leaders to recognize the importance and context of human factors and staff behaviour, with design and evaluation of devices accomplished through clinical simulations and rigorous usability testing. The authors finally review steps clinicians and managers can take to minimize nuisance alarms and maximize the safety and effectiveness of clinical monitors.


Medical errors and patient safety

Title: Enhancing patient safety with intelligent intravenous infusion devices: Experience in a specialty cardiac hospital

Citation: Heart and Lung: Journal of Acute and Critical Care, March 2012, vol./is. 41/2(173-176), 0147-9563;1527-3288 (March 2012) Author(s): Wood J.L., Burnette J.S.

Abstract: The objective of the study was to evaluate patient safety, increase nursing satisfaction, and affect economic factors through implementation of intelligent intravenous (IV) infusion devices in a specialty cardiac hospital. Intelligent IV infusion devices have been shown to decrease medication errors associated with inpatient infusions.


Title: Stepping out further from the shadows: Disclosure of harmful radiologic errors to patients

Citation: Radiology, February 2012, vol./is. 262/2(381-386), 0033-8419;1527-1315 (February 2012) Author(s): Brown S.D., Lehman C.D., Truog R.D., Browning D.M., Gallagher T.H.

Full Text: Available in fulltext at EBSCOhost EJS; Note: 12 month embargo Available in print at Heartlands Staff Library


Title: A multifaceted program for improving quality of care in intensive care units: IATROREF study

Citation: Critical Care Medicine, February 2012, vol./is. 40/2(468-476), 0090-3493;1530-0293 (February 2012) Author(s): Garrouste-Orgeas M., Soufir L., Tabah A., Schwebel C., Vesin A., Adrie C., Thuong M., Timsit J.F.

Abstract: The objective of the study was to test the effects of three multifaceted safety programs designed to decrease insulin administration errors, anticoagulant prescription and administration errors, and errors leading to accidental removal of endotracheal tubes and central venous catheters, respectively.

Full Text:  Available in fulltext at Ovid


Title: Designing a safer radiology department

Citation: American Journal of Roentgenology, February 2012, vol./is. 198/2(398-404), 0361-803X;1546-3141 (February 2012) Author(s): Johnson C.D., Miranda R., Osborn H.H., Miller J.M., Prescott S.L., Aakre K.T., Krecke K.N., Broderick D.F.

Abstract: Patients presume safety in radiologic services, but the potential to do harm exists in every area of imaging. Radiology department personnel need to understand basic regulatory requirements for safety and how to promote and improve safety in the future.


Title: When bad things happen: Adverse event reporting and disclosure as patient safety and risk management tools in the neonatal intensive care unit

Citation: American Journal of Perinatology, 2012, vol./is. 29/1(65-69), 0735-1631;1098-8785 (2012) Author(s): Donn S.M., McDonnell W.M.

Abstract: The Institute of Medicine has recommended a change in culture from name and blame to patient safety. This will require system redesign to identify and address errors, establish performance standards, and set safety expectations. This approach, however, is at odds with the present medical malpractice (tort) system. The current system is outcomes-based, meaning that health care providers and institutions are often sued despite providing appropriate care.


Title: Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report

Abstract: In response to requests from hospitals interested in comparing their results with those of other hospitals on the Hospital Survey on Patient Safety Culture, the Agency for Healthcare Research and Quality (AHRQ) established the Hospital Survey on Patient Safety Culture comparative database. The 2012 user comparative database report displays results from 1,128 hospitals and 567,703 hospital staff respondents. This report also includes a chapter on trending that presents results showing change over time for 650 hospitals that administered the survey and submitted data more than once.

Full text: Available in fulltext here.


Title: Learning from near misses: from quick fixes to closing off the Swiss-cheese holes.

Citation: BMJ Qual Saf doi:10.1136/bmjqs-2011-000256 Published Online First 22 February 2012 Authors: Lianne Jeffs1,2,3, Whitney Berta4, Lorelei Lingard5,6, G Ross Baker4

Abstract: This is an exploratory study that was conducted to gain insight into the nature of, and contributing factors to, organisational learning from near misses in clinical practice.

Full text: Available in fulltext here. (Login with your Athens on before clicking on the link)


Title: System-related interventions to reduce diagnostic errors: A narrative review

Citation: BMJ Quality and Safety, February 2012, vol./is. 21/2(160-170), 2044-5415 (February 2012) Author(s): Singh H., Graber M.L., Kissam S.M., Sorensen A.V., Lenfestey N.F., Tant E.M., Henriksen K., LaBresh K.A.

Abstract: Diagnostic errors (missed, delayed or wrong diagnosis) have recently gained attention and are associated with significant preventable morbidity and mortality. The authors reviewed the recent literature and identified interventions that address system-related factors that contribute directly to diagnostic errors. Full Text: Available in fulltext at Highwire Press

Title: E-prescribing: E for error?

Commentary: Elisa W. Ashton, PharmD Published online on AHRQ website 2012.

Abstract: AHRQ website features a Spotlight Case involving an electronic prescription submitted in error by a nurse who, upon realizing the error, immediately deleted the order in the clinic’s computer. However, the cancellation did not occur at the pharmacy, and the patient took the medication until it was noticed at a follow-up appointment.

Full Text: Available in fulltext here.


Title: Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes.

Citation: BMJ Qual Saf. 2012 Mar 2. [Epub ahead of print] Authors: Mamede S, Splinter TA, van Gog T, Rikers RM, Schmidt HG.

Abstract: To explore the causes of faulty reasoning and the mechanisms through which reflection neutralises them by investigating the influence of salient distracting clinical

features on diagnostic decision-making.

Full Text: Available in fulltext here. (Login with your Athens on before clicking on the link)


Title: Identifying, understanding and overcoming barriers to medication error reporting

in hospitals: a focus group study.

Citation: MJ Qual Saf. 2012 Mar 2. [Epub ahead of print] Authors: Hartnell N, Mackinnon N, Sketris I, Fleming M.

Abstract: The under-reporting of medication errors can compromise patient safety. A qualitative study was conducted to enhance the understanding of barriers to medication error reporting in healthcare organisations.

Full Text: Available in fulltext here. (Login with your Athens on before clicking on the link)

Title: New Medication Reconciliation Tool Helps Hospitals Improve Patient Safety

Abstract: In support of Patient Safety Awareness Week (March 4–10), AHRQ offers hospitals a new toolkit to improve their medication reconciliation processes to reduce adverse drug events. The Medications at Transitions and Clinical Handoffs (MATCH) Toolkit provides step-by-step instructions on how to improve medication reconciliation, from planning—including how to get leadership support—to pilot testing, implementation and evaluation. Included is a workbook to help users implement the toolkit.

Full Text: To download a copy, go to:


Title: Health care system vulnerabilities: Understanding the root causes of patient harm

Citation: American Journal of Health-System Pharmacy, March 2012, vol./is. 69/5(431-436), 1079-2082;1535-2900 (01 Mar 2012) Author(s): Thompson-Moore N., Liebl M.G.

Abstract: This article explores potential vulnerabilities of the health care system as we track a patient’s movement from his arrival at the emergency department (ED) through admission and transfer to the intensive and acute care units and to the patient’s hospital discharge.

Full Text: Available in fulltext at EBSCOhost Available in fulltext at EBSCOhost




Title: US hospital incident reporting systems do not capture most adverse events.

Citation: BMJ, 2012, vol./is. 344/(e386), 0959-535X;1468-5833 (2012) Author(s): Roehr B

Full Text: Available in fulltext at Highwire Press


Medical debriefing

Title: Case-based simulation: Critical conversations surrounding resuscitation of the critically ill or injured patient

Citation: Journal of Pain and Symptom Management, February 2012, vol./is. 43/2(397-398), 0885-3924 (February 2012) Author(s): Lamba S.

Abstract: The authors discuss how to use clear/direct, closed-loop communication with interdisciplinary teams (simulated resuscitation). They explain a case-based simulated-resuscitation session which includes a didactic component to; reinforce closed-loop communication, introduce self-reflection as a tool for personal growth and highlight family-centered communication skills, including active listening, exploration of emotions, and appropriate non-verbal behaviours.


Title: Using a simulation lab to deliver pediatric bad news

Citation: Journal of Pain and Symptom Management, February 2012, vol./is. 43/2(341), 0885-3924 (February 2012) Author(s): Komatz K., Zayas J.

Abstract: The article discusses how to utilizing live-actors in a simulation lab to engage with adult learners and the development of pediatric-casebased scenarios when delivering bad news.


Simulation and medical training

Title: Simulation in obstetric anesthesia

Citation: Anesthesia and Analgesia, January 2012, vol./is. 114/1(186-190), 0003-2999 (January 2012) Author(s): Pratt S.D.

Abstract: Simulation can be used to teach technical skills, to evaluate clinician performance, to help assess the safety of the environment of care, and to improve teamwork. Each of these has been successfully demonstrated in obstetric anesthesia simulation.

Full Text: Available in fulltext at Ovid


Title: Evaluation of simulation training in cardiothoracic surgery: The Senior Tour perspective

Citation: Journal of Thoracic and Cardiovascular Surgery, February 2012, vol./is. 143/2(264-272), 0022-5223;1097-685X (February 2012) Author(s): Fann J.I., Feins R.H., Hicks Jr. G.L., Nesbitt J.C., Hammon J.W., Crawford Jr. F.A.

Abstract: The study objective was to introduce senior surgeons, referred to as members of the "Senior Tour," to simulation-based learning and evaluate ongoing simulation efforts in cardiothoracic surgery.

Full Text: Available in fulltext at Ovid


Title: Venous endovascular simulation training-initial observations

Citation: Journal of Vascular Surgery, January 2012, vol./is. 55/1(298), 0741-5214 (January 2012) Author(s): Mattos M.A., Rits Y., Rubin J.R., Baigorri B., Brown O.

Abstract: Endovascular simulation training has been advocated as a method to improve the endovascular skills of interventional trainees but only procedures involving arteries have been reported. The authors describe their experience in venous endovascular simulation training for performance of diagnostic venography and inferior vena cava (IVC) filter placement. Full Text: Available in fulltext at Ovid

Title: Early Use of Simulation in Medical Education.

Citation: Simul Healthc. 2012 Feb 28. [Epub ahead of print] Author(s): Owen H.

Abstract: This article describes the history of simulation in medical practice.

Full Text: Available in Print from Harry Hollier Simulation Centre.

Title: External Validation of Simulation-Based Assessments With Other Performance Measures of Third-Year Anesthesiology Residents.

Citation: Simul Healthc. 2012 Feb 28. [Epub ahead of print] Author(s): Mudumbai SC, Gaba DM, Boulet JR, Howard SK, Davies MF. 

Abstract: There has been interest in the use of high-fidelity medical simulation to evaluate performance. The authors hypothesized that technical and nontechnical performance in the simulated environment is related to other various criterion measures, providing evidence to support the validity of the scores from the performance-based assessment.

Full Text: Available in Print from Harry Hollier Simulation Centre.


Title: Successful Implementation of the American College of Surgeons/Association of Program Directors in Surgery Surgical Skills Curriculum via a 4-Week Consecutive

Simulation Rotation.

Citation: Simul Healthc. 2012 Feb 27. [Epub ahead of print] Author(s): Mittal MK, Dumon KR, Edelson PK, Acero NM, Hashimoto D, Danzer E, Selvan B, Resnick AS, Morris JB, Williams NN.

Abstract: Increased patient awareness, duty hour restrictions, escalating costs, and time constraints in the operating room have revolutionized surgery education. Although simulation and skills laboratories are emerging as promising alternatives for skills training, their integration into graduate surgical education is inconsistent, erratic, and often on a voluntary basis. The authors hypothesize that, by implementing the American College of Surgeons/Association of Program Directors in Surgery Surgical Skills Curriculum in a structured, inanimate setting, they can address some of these concerns.


Title: Training using medical simulation

Citation: Archives of Disease in Childhood, March 2012, vol./is. 97/3(255-259), 0003-9888;1468-2044 (March 2012) Author(s): Grant D.J., Marriage S.C.

Abstract: By mapping simulated scenarios to the Royal College of Paediatrics and Child Health Curriculum for General Paediatric Training at Level 1, the authors have developed two complementary courses aimed at preparing the general paediatric trainee for progression to the middle grade role. It is hoped that such approaches will become integral to paediatric training in the future.

Full Text: Available in fulltext at Highwire Press


Title: Simulation-based Maintenance of Certification in Anesthesiology (MOCA) course optimization: Use of multi-modality educational activities

Citation: Journal of Clinical Anesthesia, February 2012, vol./is. 24/1(68-74), 0952-8180;1873-4529 (February 2012) Author(s): Levine A.I., Flynn B.C., Bryson E.O., Demaria Jr. S. Full Text:  Available in fulltext at MD Consult; Note: You will need to register (free of charge) with MD Consult the first time you use it.



Title: Multidisciplinary paediatric emergency simulation training - An in-situ and simulation centre based program at a tertiary children's hospital

Citation: EMA - Emergency Medicine Australasia, February 2012, vol./is. 24/(10), 1742-6731 (February 2012) Author(s): O'Leary F., Major J., Christoff A., Wolfsberger I., Hort J., Scott E., Vassiliadis J.

Abstract: The authors report on a three component simulation program for emergency department (ED) doctors and nurses that has been developed and piloted within their  institution. The in-situ program is composed of ten 45 minute simulation scenarios as part of a regular scheduled teaching program in the ED. The scenarios have specific clinical learning objectives in a format of run, debrief, rerun, redebrief. The added benefit of the in-situ program is to identify department specific issues that need to be addressed.


Title: Simulation training in emergency medicine (STEM): An integral component of residency curriculum

Citation: Hong Kong Journal of Emergency Medicine, January 2012, vol./is. 19/1(41-45), 1024-9079 (January 2012) Author(s): Pothiawala S., Lateef F.

Abstract: This article highlights the current evidence on the usefulness of simulation in training residents in EM and its need to be integrated into the basic framework of the Accreditation Council for Graduate Medical Education - International (ACGME-I) accredited emergency medicine residency curriculum and assessment in Singapore.


Team training

Title: Team play in surgical education: A simulation-based study

Citation: Journal of Surgical Education, January 2012, vol./is. 69/1(63-69), 1931-7204;1878-7452 (January-February 2012) Author(s): Marr M., Hemmert K., Nguyen A.H., Combs R., Annamalai A., Miller G., Pachter H.L., Turner J., Rifkind K., Cohen S.M.

Abstract: Simulation can improve surgical education and patient care in crisis situations through a team approach emphasizing interpersonal and communication skills. This study assessed the effects of simulation-based training in the context of trauma resuscitation in teams of trainees.


Title: Assessing teamwork in the trauma bay: Introduction of a modified "nOTECHS" scale for trauma

Citation: American Journal of Surgery, January 2012, vol./is. 203/1(69-75), 0002-9610;1879-1883 (January 2012) Author(s): Steinemann S., Berg B., Ditullio A., Skinner A., Terada K., Anzelon K., Ho H.C.

Abstract: A modified nontechnical skills (NOTECHS) scale for trauma (T-NOTECHS) was developed to teach and assess teamwork skills of multidisciplinary trauma resuscitation teams. In this study, T-NOTECHS was evaluated for reliability and correlation with clinical performance. Interrater reliability (intraclass correlation coefficient) and correlation with the speed and completeness of resuscitation tasks were assessed during simulation-based teamwork training and during actual trauma resuscitations.

Full Text: Available in fulltext at MD Consult; Note: You will need to register (free of charge) with MD Consult the first time you use it.


Title: The effect of a simulation-based training intervention on the performance of established critical care unit teams.

Citation: Critical Care Medicine, December 2011, vol./is. 39/12(2605-11), 0090-3493;1530-0293 (2011 Dec) Author(s): Frengley RW, Weller JM, Torrie J, Dzendrowskyj P, Yee B, Paul AM, Shulruf B, Henderson KM

Abstract: The study evaluated the effectiveness of a simulation-based intervention on improving teamwork in multidisciplinary critical care teams managing airway and cardiac crises and compared simulation-based learning and case-based learning on scores for performance.

Full Text: Available in fulltext at Ovid



































Further information:

The following sources have been searched for evidence published in the previous four weeks: Journal of Healthcare Simulation; BMJ Quality and Safety in Healthcare; NHS Institute for Innovation and Improvement; Agency for Healthcare Research and Quality; and searches on databases such as MEDLINE/EMBASE. Please contact [email protected] for any further information.


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