A Practical Framework for Patient Care Teams to Prospectively Identify and Mitigate Clinical Hazards

Herzer, Kurt; Rodriguez-Paz, Jose M.; Doyle, Peter A.; Flint, Paul W.; Feller‐Kopman, David; Herman, Joseph M.; Bristow, Robert E.; Cover, Renee; Pronovost, Peter J.; Mark, Lynette

doi:10.1016/s1553-7250(09)35010-2

Cited by 23 publications

(17 citation statements)

References 15 publications

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“…19 Morever, in our own experience, establishing a difficult airway team in the OR reduced the number of emergent surgical airways. 14 Our DART program is unique and comprehensive, and aimed at reducing adverse events related to airway management.…”

Section: Discussionmentioning

confidence: 99%

“…These simulations were carried out in the clinical space where care was delivered, rather than in a simulation center. 14,15 We conducted five in situ simulations in different clinical areas of the hospital in the first year. In a surgical intensive care unit, the labor and delivery unit, and an inpatient floor, we simulated codes to test DART processes, such as activation of the universal paging system and ideal locations for airway carts.…”

Section: Methodsmentioning

confidence: 99%

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Difficult Airway Response Team

Mark¹,

Herzer

Cover

et al. 2015

Anesthesia &Amp; Analgesia

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109

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Background Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. Methods We developed a quality improvement program—the Difficult Airway Response Team (DART)—to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had three core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. Results Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index > 40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which more than 200 providers were trained. Conclusions DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Difficult Airway Response Team

Mark¹,

Herzer

Cover

et al. 2015

Anesthesia &Amp; Analgesia

Self Cite

109

View full text Add to dashboard Cite

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“…This aspect of in situ simulation has been described in the literature14 22 and is often the ultimate endpoint of such simulations. For example, Herzer et al 13 advocated the use of in situ simulation to ‘identify hazards and defects associated with latent failure modes that are embedded in the system’ in their recommendations to prospectively identify and mitigate clinical hazards. They argued that a high-fidelity simulator should be used to add realism to such scenarios, as a participant's belief in the scenario is essential if they are to take the simulation seriously and therefore perform as they would in real life.…”

Section: Discussionmentioning

confidence: 99%

“…Given that clinical errors affecting patient safety are often blamed on failures embedded within the structure and functioning of the overall healthcare system,13 the creative use of the clinical environment during training will potentially enhance trainees’ resilience and adaptability in the face of system problems. In a recent study of a series of unannounced cardiac arrests, Lighthall et al 14 identified several hazardous events occurring during the arrest simulations, which could have compromised patient care if they had occurred during a real resuscitation.…”

Section: Introductionmentioning

confidence: 99%

Unannounced in situ simulations: integrating training and clinical practice

et al. 2012

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Simulation-based training for healthcare providers is well established as a viable, efficacious training tool, particularly for the training of non-technical team-working skills. These skills are known to be critical to effective teamwork, and important in the prevention of error and adverse events in hospitals. However, simulation suites are costly to develop and releasing staff to attend training is often difficult. These factors may restrict access to simulation training. We discuss our experiences of 'in situ' simulation for unannounced cardiac arrest training when the training is taken to the clinical environment. This has the benefit of decreasing required resources, increasing realism and affordability, and widening multidisciplinary team participation, thus enabling assessment and training of non-technical team-working skills in real clinical teams. While there are practical considerations of delivering training in the clinical environment, we feel there are many potential benefits compared with other forms of simulation training. We are able to tailor the training to the needs of the location, enabling staff to see a scenario that is relevant to their practice. This is particularly useful for staff who have less exposure to cardiac arrest events, such as radiology staff. We also describe the important benefit of risk assessment for a clinical environment. During our simulations we have identified a number of issues that, had they occurred during a real resuscitation attempt, may have led to patient harm or patient death. For these reasons we feel in situ simulation should be considered by every hospital as part of a patient safety initiative.

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“…This awakening [3,4] and concurrent shift in policy agenda [5,6] have triggered a burgeoning science of clinical patient safety. This has been reflected by a proliferation of articles on patient safety interventions [7] .…”

Section: Introductionmentioning

confidence: 99%