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Biomedical subjects

S D Small

Publications and source records attributed to S D Small.

15 recordsLinked to original sources
PubMed2004

Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?

OBJECTIVE: To determine if high fidelity simulation based team training can improve clinical team performance when added to an existing didactic teamwork curriculum. SETTING: Level 1 trauma center and academic emergency medicine training program. PARTICIPANTS: Emergency department (ED) staff including nurses, technicians, emergency medicine residents, and attending physicians. INTERVENTION: ED staff who had recently received didactic training in the Emergency Team Coordination Course (ETCC) also received an 8 hour intensive experience in an ED simulator in which three scenarios of graduated difficulty were encountered. A comparison group, also ETCC trained, was assigned to work together in the ED for one 8 hour shift. Experimental and comparison teams were observed in the ED before and after the intervention. DESIGN: Single, crossover, prospective, blinded and controlled observational study. Teamwork ratings using previously validated behaviorally anchored rating scales (BARS) were completed by outside trained observers in the ED. Observers were blinded to the identification of the teams. RESULTS: There were no significant differences between experimental and comparison groups at baseline. The experimental team showed a trend towards improvement in the quality of team behavior (p = 0.07); the comparison group showed no change in team behavior during the two observation periods (p = 0.55). Members of the experimental team rated simulation based training as a useful educational method. CONCLUSION: High fidelity medical simulation appears to be a promising method for enhancing didactic teamwork training. This approach, using a number of patients, is more representative of clinical care and is therefore the proper paradigm in which to perform teamwork training. It is, however, unclear how much simulator based training must augment didactic teamwork training for clinically meaningful differences to become apparent.

Adult↗
PubMed1999

Patient risk factors for adverse drug events in hospitalized patients. ADE Prevention Study Group.

BACKGROUND: Adverse drug events (ADEs) are common in hospitalized patients, but few empirical data are available regarding the strength of patient risk factors for ADEs. METHODS: We performed a nested case-control study within a cohort that included 4108 admissions to a stratified random sample of 11 medical and surgical units in 2 tertiary care hospitals during a 6-month period. Analyses were conducted on 2 levels: (1) using a limited set of variables available for all patients using computerized data available from 1 hospital and (2) using a larger set of variables for the case patients and matched controls from both hospitals. Case patients were patients with an ADE, and the matched control for each case patient was the patient on the same unit as the case patient with the most similar prevent length of stay. Main outcome measures were presence of an ADE, preventable ADE, or severe ADE. RESULTS: In the cohort analysis, electrolyte concentrates (odds ratio [OR], 1.7), diuretics (OR, 1.7), and medical admission (OR, 1.6) were independent correlates of ADEs. Independent correlates of preventable ADEs in the cohort analysis were low platelet count (OR, 4.5), antidepressants (OR, 3.3), antihypertensive agents (OR, 2.9), medical admission (OR, 2.2), and electrolyte concentrates (OR, 2.1). In the case-control analysis, exposure to psychoactive drugs (OR, 2.1) was an independent correlate of an ADE, and use of cardiovascular drugs (OR, 2.4) was independently correlated with severe ADEs. For preventable ADEs, no independent predictors were retained after multivariate analysis. CONCLUSIONS: Adverse drug events occurred more frequently in sicker patients who stayed in the hospital longer. However, after controlling for level of care and preevent length of stay, few risk factors emerged. These results suggest that, rather than targeting ADE-prone individuals, prevention strategies should focus on improving medication systems.

Adult↗
PubMed1999

Demonstration of high-fidelity simulation team training for emergency medicine.

Emergency medicine (EM) presents many cognitive, social, and systems challenges to practitioners. Coordination and communication under stress between and among individuals and teams representing a number of disciplines are critical for optimal care of the patient. The specialty is characterized by uncertainty, complexity, rapidly shifting priorities, a dependence on teamwork, and elements common to other risky domains such as perioperative medicine and aviation. High-fidelity simulators have had a long tradition in aviation, and in the past few years have begun to have a significant impact in anesthesiology. A national, multicenter research program to document the costs of teamwork failures in EM and provide a remedy in the form of an Emergency Team Coordination Course has developed to the point that high-fidelity medical simulators will be added to the hands-on training portion of the course. This paper describes an evolving collaborative effort by members of the Center for Medical Simulation, the Harvard Emergency Medicine Division, and the MedTeams program to design, demonstrate, and refine a high-fidelity EM simulation course to improve EM clinician performance, increase patient safety, and decrease liability. The main objectives of the paper are: 1) to present detailed specifications of tools and techniques for high-fidelity medical simulation; 2) to share the results of a proof-of-concept EM simulation workshop introducing multiple mannequin/ three-patient scenarios; and 3) to focus on teamwork applications. The authors hope to engage the EM community in a wide-ranging discussion and handson exploration of these methods.

Clinical Competence↗
PubMed1998

Force interactions in laparoscopic simulations: haptic rendering of soft tissues.

Research in the area of computer assisted surgery and surgical simulation has mainly focused on developing 3D geometrical models of the human body from 2D medical images, visualization of internal structures for educational and preoperative surgical planning purposes, and graphical display of soft tissue behavior in real time. Conveying to the surgeon the touch and force sensations with the use of haptic interfaces has not been investigated in detail. We have developed a set of haptic rendering algorithms for simulating "surgical instrument--soft tissue" interactions. Although the focus of the study is the development of algorithms for simulation of laparoscopic procedures, the developed techniques are also useful in simulating other medical procedures involving touch and feel of soft tissues. The proposed force-reflecting soft tissue models are in various fidelities and have been developed to simulate the behavior of elastically deformable objects in virtual environments. The developed algorithms deal directly with geometry of anatomical organs, surface and compliance characteristics of tissues, and the estimation of appropriate reaction forces to convey to the user a feeling of touch and force sensations.

Algorithms↗
PubMed1995

Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group.

OBJECTIVES: To assess incidence and preventability of adverse drug events (ADEs) and potential ADEs. To analyze preventable events to develop prevention strategies. DESIGN: Prospective cohort study. PARTICIPANTS: All 4031 adult admissions to a stratified random sample of 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Units included two medical and three surgical intensive care units and four medical and two surgical general care units. MAIN OUTCOME MEASURES: Adverse drug events and potential ADEs. METHODS: Incidents were detected by stimulated self-report by nurses and pharmacists and by daily review of all charts by nurse investigators. Incidents were subsequently classified by two independent reviewers as to whether they represented ADEs or potential ADEs and as to severity and preventability. RESULTS: Over 6 months, 247 ADEs and 194 potential ADEs were identified. Extrapolated event rates were 6.5 ADEs and 5.5 potential ADEs per 100 nonobstetrical admissions, for mean numbers per hospital per year of approximately 1900 ADEs and 1600 potential ADEs. Of all ADEs, 1% were fatal (none preventable), 12% life-threatening, 30% serious, and 57% significant. Twenty-eight percent were judged preventable. Of the life-threatening and serious ADEs, 42% were preventable, compared with 18% of significant ADEs. Errors resulting in preventable ADEs occurred most often at the stages of ordering (56%) and administration (34%); transcription (6%) and dispensing errors (4%) were less common. Errors were much more likely to be intercepted if the error occurred earlier in the process: 48% at the ordering stage vs 0% at the administration stage. CONCLUSION: Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable. Most resulted from errors at the ordering stage, but many also occurred at the administration stage. Prevention strategies should target both stages of the drug delivery process.

Boston↗
PubMed1995

The effect of prophylactic antibiotics on iatrogenic intervertebral disc infections. a rabbit model.

STUDY DESIGN: A rabbit model was used to test the efficacy of two commonly used prophylactic antibiotics, cefazolin and vancomycin, in preventing iatrogenically introduced Staphylococcus aureus intervertebral disc infections. OBJECTIVE: This study was performed to assess the efficacy of two prophylactic antibiotics in preventing iatrogenically introduced Staphylococcus aureus intervertebral disc infections. SUMMARY OF BACKGROUND DATA: Previous studies have had conflicting results regarding the penetration of antibiotics into the nucleus pulposus and their ability to eradicate infection. METHODS: In this study, 40 adult New Zealand White rabbits underwent inoculation of 10(1) or 10(3) Staphylococcus aureus/ml into 3-6 lumbar intervertebral discs under direct visualization. Either no antibiotics (control groups) or various preoperative and postoperative dosing schedules of cefazolin or vancomycin were given intravenously. Five days after surgery, the discs were harvested and cultured. RESULTS: All 40 discs inoculated in the control groups became infected. None of the 35 discs inoculated in the cefazolin groups became infected. Infection developed in 23 of 107 discs inoculated in the vancomycin groups. Most notable of these were 17 of 17 positive cultures in animals given vancomycin 8 hours preoperatively only. CONCLUSIONS: Based on these results, it was concluded that intravenous cefazolin or vancomycin given within 1 hour before surgery can effectively prevent postoperative discitis. No advantage was found with additional postoperative antibiotics.

Animals↗
PubMed1995

Anesthesia crisis resource management: real-life simulation training in operating room crises.

Little formal training is provided in anesthesiology residency programs to help acquire, develop, and practice skills in resource management and decision making during crises in practice. Using anesthesia crisis resource management (ACRM) principles developed at another institution, 68 anesthesiologists and 4 nurse-anesthetists participated in an ACRM training course held over a 2 and a half-month period. The anesthesia environment was recreated in a real operating room, with standard equipment and simulations requiring actual performance of clinical interventions. Scenarios included overdose of inhalation anesthetic, oxygen source failure, cardiac arrest, malignant hyperthermia, tension pneumothorax, and complete power failure. A detailed questionnaire was administered following the debriefing and completed by all participants, documenting their immediate impressions. Participants rated themselves as having performed well in the simulator. Senior attendings and residents rated themselves more highly than did their junior counterparts. The potential benefit of this course for anesthesiologists to practice anesthesia more safely in a controlled exercise environment, was rated highly by both groups. Over one half of respondents in all categories felt that the course should be taken once every 12 months; another third of each group felt that the course should be taken once every 24 months. While no senior attendings believed that the course should be taken once every 6 months, approximately 10% of respondents in other categories that it should. Of respondents in the senior and junior attending category, 5% felt the course should never be taken. Although attendings were less favorable than residents in their rating of the value of the course, both groups were still enthusiastic.

Anesthesia↗
PubMed1995

The incident reporting system does not detect adverse drug events: a problem for quality improvement.

OBJECTIVES: The objectives of this study were 1) to determine the frequency with which adverse drug events result in an incident report (IR) in hospitalized patients; and 2) to determine if there were differences between quality assurance administrators, nurse leaders in quality assurance, and staff nurses as to whether an incident report should or would be filed for each adverse drug event. STUDY DESIGN: All patients admitted to five patient care units (one medical intensive care unit, two surgical intensive care units, and two medical general care units) in one academic tertiary care hospital were studied between February and July 1993. The main outcome measures used were adverse drug events (ADEs) and IRs. Consensus voting was used by senior hospital administrators, nursing leaders, and staff nurses to determine whether an adverse drug event should have been reported and would have been reported. RESULTS: Of 54 adverse drug events identified by the study, only 3 patients (6%) had a corresponding incident report submitted to the hospital's quality assurance program or called into the pharmacy hotline. One additional ADE was identified by an IR, but not by the ADE study. Of the 55 ADEs, 15 were preventable, and 26 were serious or life-threatening, yet only 2 of the 26 led to an incident report. The three voting groups agreed that most ADEs justified an IR, but judged that in actual practice, an IR would infrequently have been filed. CONCLUSIONS: Voluntary reporting identified only a small fraction of ADEs. Using IRs for quality assurance/quality improvement will lead to significant bias when assessing quality of care.

Adverse Drug Reaction Reporting Systems↗
PubMed1995

Situation awareness in anesthesiology.

Situation awareness has primarily been confined to the aviation field. We believe that situation awareness is an equally important characteristic in the complex, dynamic, and risky field of anesthesiology. We describe three aspects of situations of which the decision maker must remain aware: subtle cues, evolving situations, and special knowledge elements. We provide examples of real or simulated anesthesia situations in which situation awareness is clearly involved in the provision of optimal patient care, and we map the elements of situation awareness onto a cognitive process model of the anesthesiologist. Finally, we consider how situation awareness can be further investigated and taught in this medical domain using anesthesia simulators and analyses of real cases. The study of situation awareness in anesthesiology may provide a good example of the wider application of the concept of situation awareness to nonaerospace environments.

Adult↗
PubMedDate not supplied

The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group.

OBJECTIVE: To assess the additional resource utilization associated with an adverse drug event (ADE). DESIGN: Nested case-control study within a prospective cohort study. PARTICIPANTS: The cohort included 4108 admissions to a stratified random sample of 11 medical and surgical units in 2 tertiary-care hospitals over a 6-month period. Cases were patients with an ADE, and the control for each case was the patient on the same unit as the case with the most similar pre-event length of stay. MAIN OUTCOME MEASURES: Postevent length of stay and total costs. METHODS: Incidents were detected by self-report stimulated by nurses and pharmacists and by daily chart review, and were classified as to whether they represented ADEs. Information on length of stay and charges was obtained from billing data, and costs were estimated by multiplying components of charges times hospital-specific ratios of costs to charges. RESULTS: During the study period, there were 247 ADEs among 207 admissions. After outliers and multiple episodes were excluded, there were 190 ADEs, of which 60 were preventable. In paired regression analyses adjusting for multiple factors, including severity, comorbidity, and case mix, the additional length of stay associated with an ADE was 2.2 days (P=.04), and the increase in cost associated with an ADE was $3244 (P=.04). For preventable ADEs, the increases were 4.6 days in length of stay (P=.03) and $5857 in total cost (P=.07). After adjusting for our sampling strategy, the estimated postevent costs attributable to an ADE were $2595 for all ADEs and $4685 for preventable ADEs. Based on these costs and data about the incidence of ADEs, we estimate that the annual costs attributable to all ADEs and preventable ADEs for a 700-bed teaching hospital are $5.6 million and $2.8 million, respectively. CONCLUSIONS: The substantial costs of ADEs to hospitals justify investment in efforts to prevent these events. Moreover, these estimates are conservative because they do not include the costs of injuries to patients or malpractice costs.

Boston↗