Loose in a room of horrors!

Loose in a room of horrors!

Interns try to suss out patient-safety, low-value hazards

October 2017
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Published in the October 2017 issue of Today’s Hospitalist

WHILE A “ROOM OF HORRORS” may sound straight out of Halloween, it’s actually an interactive simulation held in mid-June, part of a three-day orientation boot camp for incoming residents at the University of Chicago Medical Center.

Boot-camp faculty take an unused hospital room in the University of Chicago Simulation Center, trick it out with equipment and a CPR mannequin, and mock up a fake door chart complete with progress notes, allergies and medications. They then pack the room with patient-safety hazards such as no hand soap or sanitizer, latex gloves at the bedside despite a listed latex allergy, and mismatched names on the chart, IV bag and wristband.

For the horror room staged in 2016, faculty also added in four low-value hazards: unnecessary restraints, as well as an unnecessary Foley catheter, blood transfusion and stress ulcer prescription. Interns take 10 minutes in the room, marking down as many hazards as they can find.

“The horror room definitely encourages people to not take the chart at face value.”

Farnan

~ Jeanne Farnan, MD, MHPE
University of Chicago Medical Center

Before going through the simulation, they completed a three-question survey asking if they received safety training in medical school and if they feel confident that they’ll be able to recognize potential hospital hazards. After the exercise, they receive an e-mail letting them know which hazards they picked up and which ones they missed.

How did they do? According to a write-up in the July issue of the Journal of Hospital Medicine, interns correctly identified only half of the hazards (50.4%).

But they did a much better job picking out the patient-safety hazards (66%) than the low-value ones (19%), with very few identifying the unnecessary transfusion (5.6%) and none recognizing the unnecessary PPI prescription.

“We have 180 interns coming from 60 different medical schools,” says hospitalist and study co-author Jeanne Farnan, MD, MHPE. “This tells us that medical schools are really lagging in having strong patient-safety curricula.” Dr. Farnan spoke with Today’s Hospitalist.

When did you start staging a horror room?
We’ve been using it with our medical students since 2012, and we started incorporating it into our graduate medical education boot camp in 2014. We’ve also collaborated on studies with researchers from Duke University on horror rooms they’ve created for both medical and nursing students .

Are you surprised by your results?
We are and we aren’t. Many hospitals, for instance, have strong campaigns on handwashing and alcohol-based hand rubs, so I’m not surprised that people can identify those hazards. Same with Foleys: There’s been a strong push to revisit whether catheters are necessary.

But we are always surprised when interns don’t recognize other low-value horrors, particularly the transfusion and the PPI. Of course, they do identify things that we haven’t actually set up as hazards, such as no blanket, the window shades being pulled down and the call light being out of reach.

In the study, you write, “interns are on the lookout for errors of omission … but are often blinded to errors of commission.”

Both medical students and residents seem to have a heightened situational awareness about things in the room that they can physically see, like Foleys and restraints. But they also seem to have a passive trust of what’s documented in the record.

That may be due to so much copy-and-paste and forward-feeding of the EMR, so people just presume that the documentation has been reviewed and is appropriate. The horror room definitely encourages people to not take the chart at face value. They really need to dig in and figure out what a patient needs or doesn’t.

Do those lessons stick?
Absolutely. The horror room is very interactive and immersive, and learners enjoy it and get a lot of feedback. We’ve also done an unpublished data analysis three months out showing that residents remain much more keyed in to hazards and that the experience stays with them.

I believe it encourages them to routinize the way they think when they go into a patient’s room. They’re now more cognizant of everything in the room including the tray, the fluids and the catheters. Residents have said they’ve identified hazards in actual patient care because of that experience.

I think it also informs the quality projects that residents end up working on. We now have residents looking at unnecessary lab draws, Foleys, and reorientation and delirium, and an initiative called “skip the drips” with people revisiting the EHR every day to see if patients continue to need IV medications. I think those are some of the unanticipated side effects that, so far, have all been positive.

So you’d recommend a horror room to other teaching hospitals?
I would. It’s relatively low cost to set up, and it doesn’t require any fancy simulation equipment. It’s also very easy to construct a clinical scenario, and it’s very malleable to your particular institution. Handwashing may be a big initiative in your hospital, or delirium or pressure ulcers, and you can really change up your horror room to tailor it to institutional priorities.

We also stage horror rooms for faculty and nursing as a kind of scavenger hunt, with a raffle to see who identifies the most hazards. People walk away being more situationally aware of the places where we provide care.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Hospital hazards
HOW DO YOU TURN a spare hospital 
room into a room of horrors? Fill it with both patient-safety and low-value hazards. Here are the hazards that incoming interns at the University of Chicago Medical Center were asked to identify in a simulated hospital room and chart for a fantasy patient admitted with C. diff.

Patient-safety hazards

  • Hand hygiene: no soap or hand sanitizer.
  • Latex allergy: latex gloves at the bedside despite listed allergy.
  • Fall risk: lowered bed rail.
  • Wrong name: mismatched names on chart, IV bag and wristband.
  • Isolation precautions: no personal protective equipment provided.
  • Medication allergy: a penicillin prescription despite listed allergy.
  • Wrong medication: an administered medication not listed in the chart.
  • VTE: no documented prophylaxis.

Low-value hazards

  • Unnecessary restraints: upper-arm restraints with no indication.
  • Unnecessary Foley: a Foley catheter being used without indication.
  • Unnecessary transfusion: Hb of 8.0 g/dL with no symptoms.
  • Unnecessary stress ulcer prescription: added PPI despite no high risk for GI complications.

Source: Journal of Hospital Medicine

 

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