DESIGNING & BUILDING EFFEC TIVE SCENARIOS
Simulation techniques can improve patient safety
By Jennifer McCarthy, MAS, NRP, MICP, CHSE; Amar P. Patel, DHSc, MS, NRP;
Andrew E. Spain, MA, NCEE, EMT-P & Timothy Whitaker, BS, CHSE, CHSOS, EMT-P
“We must respect the past, and mistrust the present, if we wish to provide the safety of the future.”
—Joseph Joubert (French essayist and moralist, 1754–1824)
There’s no doubt that in healthcare the goal is to perform safely: safe to the provider, safe to the patient, and safe
to all those around us. This concept has been
summarized into the term “patient safety.”
Many of the common definitions of patient
safety focus solely on the patient. The Institute of Medicine states that patient safety is
“the prevention of harm to patients,” 1 while
the Agency for Healthcare Research and
Quality lists it as “freedom from accidental
or preventable injuries produced by medical care.” 2
Despite this focus on the patient, the role
of the healthcare provider remains critical.
The performance of the provider related to
the care of the patient determines whether
a patient, and all those involved with patient
care, remain safe and free of harm.
EMS is a specialized patient service that
functions outside of a controlled environment. Until recently, EMS education curricula have overlooked patient safety initiatives
as a primary goal or an important aspect of
In 2005, the Center for Patient Safety
(CPS) was established as an independent,
nonprofit organization dedicated to reducing medical errors. Much of the work of CPS
focuses on creating a patient safety culture.
A safe culture is a foundation concept that
supports all healthcare activities at all times.
The CPS is unique to other patient safety
A CULTURE OF SAFETY
entities in that it has an identifiable EMS
focus, and has identified 10 safety goals that
intend to reduce patient errors and improve
provider safety. The goals address current
trends and those expected to grow in the
near future: airway management, bariat-
rics, behavioral health, crashes, medication
mistakes, patient safety culture, pediatrics,
provider mental health, stretchers and tran-
sition of care. 3
Many leaders turn to the airline industry as
an easy example of improved safety culture.
In the late 1970s, when airline crashes were
occurring on a frequent basis, the industry
went through an overhaul to ensure passenger and crew safety. Medical errors are the
third leading cause of death in healthcare
and EMS isn’t exempt from contributing to
the abysmal statistics. 4
Ultimately, a patient safety culture stems
from the leadership of the organization.
Frontline providers must also have an understanding and healthy appreciation for its
importance. We need to shift our culture and
attitude about errors and near miss reporting
to understand the depth and breadth of the
safety issues in EMS.
Some organizations have a punitive system in place in response to error reporting.
This causes providers to enact “Vegas rules”
while caring for patients in the prehospital
environment. Transparency to capture an
error or near miss errors is paramount to
understand ing the factors affecting EMS
Adding to the complexity of an EMS
patient safety culture are shortcuts taken with
the purpose of expediting care. Normalization
of deviance is the term used when standards
of practice modifies for perceived better-
ment. 5 During the majority of patient inter-
actions, this deviance doesn’t cause untoward
outcomes and, over time, providers modify
their systematic patient care routines to adopt
these perceived better procedures. It’s only
when used during an outlier or rare case that
these shortcuts can lead to a patient safety
concern or even a medical error.
Performing skills and procedures the
way they’re supposed to be performed and
repeatedly practicing these in a controlled
education environment is one sure way to
During a simulation activity, patient safety is
often an omnipresent focus and not identified
as a single learning objective. This is especially true as learners move through curricula
and become more experienced. Nevertheless,
patient safety is a meta-objective that must
be present in every simulation activity. (See
our August column for more information on
the concept of meta-objectives.)
For example, evaluating patient care during
movement and ensuring therapeutic communication with patients is occurring includes
a focus on patient safety. The specific objectives for the activity may not include safety
for the provider or to the patient, but they are
required and included as part of the exercise.
Too often, participants attend simulation
sessions and talk their way through skills
instead of physically engaging in the activity.
This undermines the effectiveness of simulation and the necessary steps to promote a
patient safety culture. It’s critical to have both
novice and experienced participants perform
skills as closely to the evidence-based standards as possible.
Consider assessing and debriefing how
participants respond, react and are treated
when an error or near error occurs. Developing a reporting mechanism to capture data
from simulations that can help identify the
area of focus for improved EMS patient and
provider safety can only help improve our
patient safety culture.