When one mistake is too many

Dr. Todd Lindquist, CRNA Gloria Dullinger-Brown and Teamwork and Simulation Consultant Kristi Ehlers wrap up simulation training at Fairview Lakes Medical Center in Wyoming last month. Ehlers, who led the exercise, collected feedback after a simulated tracheotomy. (Photos by Clint Riese)

Dr. Todd Lindquist, CRNA Gloria Dullinger-Brown and Teamwork and Simulation Consultant Kristi Ehlers wrap up simulation training at Fairview Lakes Medical Center in Wyoming last month. Ehlers, who led the exercise, collected feedback after a simulated tracheotomy. (Photos by Clint Riese)

Fairview Lakes takes proactive approach with cutting-edge surgery safety training

 

Clint Riese
News Editor

Patients entrust their well-being, and sometimes their very lives, to professionals when they enter a hospital’s doors. Medical practitioners, in turn, are not afforded the luxury of “working for the weekend.” For better or for worse, every case involves implications that are as real as they come.

These highly trained medical workers continue to push quality of life metrics to new heights. Inevitably, though, mistakes are made.

At a training exercise held last month at Fairview Lakes Medical Center in Wyoming, workers learned that it is safer for Americans to drive on a highway than to check into a health care organization.

“In Minnesota, on six out of seven days, we have an adverse health event,” Fairview Teamwork and Simulation Consultant Kristi Ehlers told the Fairview Lakes workers.

The rate of these mistakes, however, is not unchangeable, and that is what brought Ehlers and Jason Sandifer to the Wyoming facility to lead a simulation.

It marked the 14th of 20 surgery safety training sessions planned at the health care center this summer. The initiative stems from discussion among Fairview administrators and also is being rolled out at the Southdale campus in Edina and the Ridges campus in Burnsville.

The program’s tenants are spelled out in an 815-page, 12-pound binder, but are brought to “life” by computerized mannequins that play the role of patients.

“What we’re doing here at Fairview is actually rare,” Sandifer told the crew in Wyoming. “There are a lot of hospitals that are doing simulations, but they are doing it in a lab environment. There are not very many hospitals that are doing it … in the room, with equipment, resources, actual staff.”

Saving Jean

The August simulation at Fairview Lakes started in the post-anesthesia care unit with “patient” Jean Z.Z. Rehearsal, a 58-year-old female recovering from surgery in which one of her parotid glands was removed.

Registered nurses Kim Danielson and Sue Bennett measure vitals during last month’s simulation. They were the first to attend to the patient.

Registered nurses Kim Danielson and Sue Bennett measure vitals during last month’s simulation. They were the first to attend to the patient.

As an anesthetist and nurse attended to her, Jean developed pain and trouble breathing due to bleeding and swelling in the throat.

The anesthetist attempted an intubation, which is the insertion of a tube to assist breathing. When that did not work, she called in otolaryngologist Dr. Todd Lindquist.

Jean’s crew moved her to an operating room, where Dr.  Lindquist diagnosed a displaced trachea and performed a tracheotomy.

Jean was saved. In this simulation, the surgery went well.

Dr. Lindquist laughed to himself when, a minute after the mock procedure, he found his hand still tightly gripping the neck tube that would have allowed a real patient to breathe. It is a most important habit.

Communication is key

The training session concluded with a one-hour debriefing in which participants relayed feedback and watched a video of themselves in action. In this case, nearly all of the input was positive. There was continuity among the members, and it showed through their communication.

Advanced Practice Nurse Leader Anne Renaker jots down notes during a debriefing session.All participants watched a video of their mock case and analyzed each other’s performance.

Advanced Practice Nurse Leader Anne Renaker jots down notes during a debriefing session.All participants watched a video of their mock case and analyzed each other’s performance.

If nothing else, the session’s trainers hoped to impress on participants the importance of such teamwork.

Fairview Director of Clinical Safety Kristi Miller referenced a study by The Joint Commission, a not-for-profit health care evaluation organization, on preventable medical mistakes. It found that insufficient communication and teamwork was the primary reason for errors.

“It’s not like the touchy-feely, nice communication,” Miller said. “Although (being) respectful is wonderful, what we’re really talking about is getting information from one person to another who can do something about it at that moment.”

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