Presented by Richard Pizzi, AIA, VP, and healthcare design principal for Lavallee Brensinger Architects.

We had a great response to today's webinar. Feel free to post your questions/comments for Richard in the comments box below.

Abstract: This interactive webinar will explore the planning, programming, and design of clinical simulation centers. We will discuss a collaborative and inclusive process to define your goals and create a space program that accommodates all simulation activities. The webinar will discuss the design of flexible, multi-functional simulation labs and the spatial relationships between labs and support space. The webinar will also review the integration of simulation, AV, and medical equipment as well as lessons learned and current/future trends from active simulation centers.

Richard Pizzi, AIA, VP, is a healthcare design principal for Lavallee Brensinger Architects regional healthcare design firm. Rich has specialized in healthcare design for nearly 19 years. For the past 6 years, he has focused on the research, programming, and design of clinical simulation centers. During this time, Rich has programmed and designed clinical simulation centers for large academic medical centers, community hospitals, medical schools, and nursing schools. His efforts have also included first-hand training observations, site visits, and post-occupancy reviews. Rich is a member of the Society for Simulation in Healthcare.

National Nurses Week: RNs as Leaders

During National Nurses Week 2013, ANA is calling attention to registered nurses (RNs) and their contributions to the health care system, both in the role they play as expert clinicians in diverse care settings and as leaders who can dramatically influence the quality of care and overall performance of the system into the future.

Now more than ever, RNs are positioned to assume leadership roles in health care, provide primary care services to meet increased demand, implement strategies to improve the quality of care, and play a key role in innovative, patient-centered care delivery models. The nursing profession plays an essential role in improving patient outcomes, increasing access, coordinating care, and reducing health care costs. That is why both the Affordable Care Act and the Institute of Medicine's (IOM) Future of Nursing report place nurses at the center of health care transformation in the United States.

The public wants leaders they can trust — and nurses consistently rank at the top of a respected annual poll as the most trusted profession.

Here we outline the history of National Nurses Week and the characteristics, opportunities, and challenges of the nursing profession.

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Training healthcare providers to be able to respond to any situation they might find themselves in is crucial to their development as healthcare professionals. With recent advancement in the use of technology, simulation training provides an excellent (and safe) learning environment in the curriculum of students as well as for ongoing training for current healthcare professionals.

While hands-on learning with real patients cannot be completely replaced, simulation training provides a safe environment for learning. Making mistakes can be a valuable part of the learning process. In the simulation environment, patients at not put at risk.

According to the Society for Simulation in Healthcare, simulation training is “the imitation or representation of one act or system by another” and serves as “a bridge between classroom learning and real-life clinical experience.” No longer must students practice giving injections by using an orange or budding surgeons practice suturing by using a piece of felt.

Healthcare is catching up to other industries in using scenario based training. For instance, aviation has been a long-time user of simulation training for pilots. In fact, the first known flight ‘simulator’ was the Antoinette Trainer developed in 1909. Rudimentary by today’s standard, the simulator consisted of a “half-barrel mounted on a universal joint, with flight controls, pulleys, and stub-wings.” Over time, the setup became more advanced. Beginning in the 1950’s, technology was introduced to aviation simulation. By the 1980‘s, it was much more integrated. Today, many aviation simulators are so advanced, it would be tough to tell them apart from the real thing.

Aviation knew the importance of training pilots in situations where they could “achieve, test, and maintain proficiency in the operation of an airplane without risk to person or property and at a lower cost to training in the air” (Aviation WikiJournal).

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It’s not just about a 4-year college or university. It’s not just about the number of students. It’s more about the availability and quality of educational technology used to train future healthcare professionals. Tallahassee Community College (TCC) is one of the leaders embracing this change. In 2011, TCC opened the Ghazvini Center for Healthcare Education, allowing students to get practical, hands-on patient experience without leaving the classroom.

Simulation software management in these types of settings is crucial in training health professionals. “The more times they [practice] here, the better they’ll be out there,” says Anna Thompson, a paramedic and simulation technician at TCC. In a simulated environment, a mistake becomes a valuable educational tool, and decreases the likelihood of a similar error being made in actual practice.

This raises an important question: how do you get started with a simulation system? First and foremost, you should look for compatibility. You should look for the ability to integrate with the manikins and ensure that your simulation software management is top-notch. With this in mind, your system should be compatible with not only current technology, but future purchases as well.

Audio-video capability is equally as important. Video of learners practicing simulation can be played back to students as part of a lesson, used to provide constructive criticism, or even allow the students to self-reflect on their experiences. If your simulation software management system allows for remote access, instructors can monitor or review activity from anywhere via the internet.

Audio-video is not the only benefit of a clinical simulation system. The data collected can be captured, recorded, and output in various ways. Data collection can range from recording vital signs to allowing logging of each student’s actions. Your simulation software management system should allow for bookmarking for quick review and allow faculty to pinpoint common student difficulties.

With a technological component being a prominent one, technology support is necessary to sustain a functional simulation center. Your center should be specifically tailored to your requirements. You should have support to reach out to if things go wrong. The value provided by a technology platform is an investment in your program’s future. With Education Management Solutions (EMS), you get the whole package.

In reviewing 25 years of U.S. malpractice claim payouts, Johns Hopkins researchers found that diagnostic errors—not surgical mistakes or medication overdoses—accounted for the largest fraction of claims, the most severe patient harm, and the highest total of penalty payouts. Diagnosis-related payments amounted to $38.8 billion between 1986 and 2010, they found.

"This is more evidence that diagnostic errors could easily be the biggest patient safety and medical malpractice problem in the United States," says David E. Newman-Toker, M.D., Ph.D., an associate professor of neurology at the Johns Hopkins University School of Medicine and leader of the study published online in BMJ Quality and Safety. "There's a lot more harm associated with diagnostic errors than we imagined."

While the new study looked only at a subset of claims—those that rose to the level of a malpractice payout—researchers estimate the number of patients suffering misdiagnosis-related, potentially preventable, significant permanent injury or death annually in the United States ranges from 80,000 to 160,000.

Diagnostic error can be defined as a diagnosis that is missed, wrong or delayed, as detected by some subsequent definitive test or finding. The ensuing harm results from the delay or failure to treat a condition present when the working diagnosis was wrong or unknown, or from treatment provided for a condition not actually present. "Overall, diagnostic errors have been underappreciated and under-recognized because they're difficult to measure and keep track of owing to the frequent gap between the time the error occurs and when it's detected," Newman-Toker says. "These are frequent problems that have played second fiddle to medical and surgical errors, which are evident more immediately."

He says experts have often downplayed the scope of diagnostic errors not because they were unaware of the problem, but "because they were afraid to open up a can of worms they couldn't close." He adds: "Progress has been made confronting other types of patient harm, but there's probably not going to be a magic-bullet solution for diagnostic errors because they are more complex and diverse than other patient safety issues. We're going to need a lot more people focusing their efforts on this issue if we're going to successfully tackle it."

For their review, Newman-Toker and his colleagues analyzed medical malpractice payments data from the National Practitioner Data Bank, an electronic repository of all payments made on behalf of practitioners in the United States for malpractice settlements or judgments since 1986.

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The transition from nursing student to RN often is rocky. Aside from being challenged clinically by the minute, newly licensed nurses also must adjust to demanding institutional cultures. These stresses can contribute to clinical errors and employee turnover.

More than 40% of new graduate nurses report making medication errors, and 50% said they would not recognize life-threatening complications that require intervention, according to data collected by the National Council of State Boards of Nursing. The council also found average turnover rates for nurses in their first year on the job range from 35% to 60%.

"Newly graduated nurses tend to be exhausted that first year," said Patricia Benner, RN, PhD, FAAN, distinguished visiting professor at Seattle University and professor emeritus at the University of California, San Francisco. "They’re having to be more vigilant than they’ll ever have to be again."

Benner, who developed the Novice to Expert model of nursing skill development, recognizes that nursing education can do a better job of closing the gap between education and clinical practice. "It’s too much to ask that you just learn this in a class and then know how to recognize clinical aspects of the situation when you see it," she said.

Situational clinical coaching or guided clinical decision-making for new graduate nurses is key to a good transition program, Benner said. But equally important is an institutional culture that welcomes new graduate nurses and appreciates the stresses of the graduates’ first year. "The organization needs to provide support groups, coaching and a welcoming environment," she said.

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"X-rays can look alike, and if one patient's images are confused with another before the radiologist sees them, it can be difficult for the radiologist to determine there is a mismatch," said Dr. Srini Tridandapani, of Emory University and an author of the study.
As part of the study, ten radiologists interpreted 20 pairs of radiographic images with and without photographs. Two to four mismatched pairs were included in each set of 20 pairs of images. When photographs were added, radiologists correctly identified the mismatch 64% of the time. The error detection rate was about 13% when photographs were not included, said Dr. Tridandapani.

The radiologists in the study did not know they could use the photographs as a means to identify mismatched x-ray images, and some said they purposely ignored the photographs because they thought the study was designed to determine if a photograph would distract them. "We did a second study of five radiologists, and we told them to use the photographs. The error detection rate went up to 94% in the second study," said Dr. Tridandapani.

Surprisingly, the interpretation time went down in the first study when the photographs were added to the images, said Dr. Tridandapani. "We're not sure why this happened, but it could be because the photograph provided clinical clues that assisted the radiologist in making the diagnosis," he said.

"I estimate that about 1 out of 10,000 examinations have wrong-patient errors," Dr. Tridandapani said. "It occurred to me that we should be adding a photograph to every medical imaging study as a means to correct this problem after I received a phone call, and a picture of the caller appeared on my phone. The picture immediately identified for me who the caller was," he said.

The study required additional personnel to take the pictures of the patients immediately after the patients' x-ray examination. However, Dr. Tridandapani and his colleagues have developed a prototype system where the camera can be attached to a portable x-ray machine; the picture is taken without additional personnel.

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