Document Detail


In situ simulation training for paediatric cardiorespiratory arrest: initial observations and identification of latent errors.
MedLine Citation:
PMID:  21226435     Owner:  NLM     Status:  In-Process    
Abstract/OtherAbstract:
In response to a successful, although difficult resuscitation in one of our paediatric wards, we developed and implemented an educational program to improve the resuscitation skills, teamwork and safety climate in our multidisciplinary acute-care paediatric service. The program is ongoing and consists of didactic presentations, high-fidelity in situ simulation and facilitated debriefing to encourage reflective learning. The underlying goal, to provide this training to all staff over a two-year period, should be achieved by late 2011. In this preliminary report we describe teamwork difficulties that are commonly found during such training. These included inconsistent leadership behaviours, inadequate delegation of areas of responsibility, failure to communicate problems during the execution of technical tasks (such as difficulty opening the resuscitation trolley) and failure to challenge inadequate or inappropriate therapy (such as poor chest expansion during bag-mask ventilation). In addition, we unexpectedly discovered seven latent errors in our clinical environment during the first nine months of course delivery. The most disturbing of these was that participants repeatedly struggled to identify and overcome the locking-mechanism and tamper-proof device on a newly introduced resuscitation trolley.
Authors:
A L Garden; S A Mills; R Wilson; P Watts; J M Griffin; S Gannon; I Kapoor
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Anaesthesia and intensive care     Volume:  38     ISSN:  0310-057X     ISO Abbreviation:  Anaesth Intensive Care     Publication Date:  2010 Nov 
Date Detail:
Created Date:  2011-01-13     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0342017     Medline TA:  Anaesth Intensive Care     Country:  Australia    
Other Details:
Languages:  eng     Pagination:  1038-42     Citation Subset:  IM    
Affiliation:
Sleep Wake Research Centre, Massey University, Wellington, New Zealand. sandy.garden@ccdhb.org.nz
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