In Situ Team-Based Simulation Training to Close the Loop on Event Reporting

Authors

  • Caoimhe Duffy, MD Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Division of Perioperative and Periprocedural Services, Hospital of the University of Pennsylvania
  • William Yi, MD Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania Clinical Simulation Center
  • Joshua H. Atkins, MD, PhD Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania

DOI:

https://doi.org/10.33940/letter/2021.12.1

Abstract

Reporting adverse events is often stigmatized in medicine. Adverse events are underreported. Underreporting has been linked to fear, the time required to complete a report, and a belief that reporting may not result in improvement.1 The reluctance to report is multidimensional and may relate to guilt, fear of punishment of self or others, fear of embarrassment, fear of litigation, and lack of confidence to effect change. Central to this fear is the widely held belief that errors and adverse events are due to carelessness and that blame must be assigned—often to the provider “at fault” or at the sharp end of the process. However, reporting of events offers an invaluable opportunity to identify latent systems issues and review and redesign error-trapping procedures and workflows. Without measurement, it is challenging to leverage adverse events as catalysts for targeted process improvement. Mandated reporting at the state and national levels is an influential catalyst to enhance data collection of adverse events. Aggregated data across varied practice settings are powerful. Mandated reporting alleviates some of the fear associated with reporting and increases reporting volume and relevance.

Author Biographies

Caoimhe Duffy, MD, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Division of Perioperative and Periprocedural Services, Hospital of the University of Pennsylvania

Caoimhe Duffy (caoimhe.duffy@pennmedicine.upenn.edu) is an assistant professor of anesthesiology in the Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania. Her research focus area is on human factors engineering and safety science in the perioperative environment. She earned her medical degree from the Royal College of Surgeons in Ireland, completing anesthesia residency training in Ireland. She has a Master of Science in human factors in patient safety and is a Certified Professional in Patient Safety with the Institute for Healthcare Improvement.

William Yi, MD, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania Clinical Simulation Center

William Yi is a board-certified general surgeon currently serving in the position of the Surgical Simulation and Education Fellow at the University of Pennsylvania. His interests include minimally invasive surgery, surgical education, and medical simulation. He is especially interested in the utilization of immersive virtual reality in medical simulation and education.

Joshua H. Atkins, MD, PhD, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania

Joshua Atkins is associate professor of Anesthesiology and Critical Care, and director of Anesthesia for Head and Neck Surgery at the Perelman School of Medicine at the University of Pennsylvania. He is co-chair of the Penn Medicine System Airway Safety Committee, serves on the editorial board of Patient Safety, directs the perioperative team simulation program at the Hospital of the University of Pennsylvania, and is a TeamSTEPPS educator. Dr. Atkins is currently partnering with industry on the development of novel technologies for anesthesia medication safety.

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Published

2021-12-17

How to Cite

Duffy, C., Yi, W. ., & Atkins, J. H. (2021). In Situ Team-Based Simulation Training to Close the Loop on Event Reporting. Patient Safety, 3(4), 6–11. https://doi.org/10.33940/letter/2021.12.1
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