Book of the month: Essential Simulation in Clinical Education (Forrest, McKimm and Edgar (eds))

Disclaimer: The reviewer (M Moneypenny) co-authored a small section of a chapter in this book. He is also a friend of a number of the contributors (but has tried to write an objective piece!)

About the editors
Kirsty Forrest is Professor and Director of Medical Education at the Australian School of Advanced Medicine, Macquarie University, Sydney, Australia. Judy McKimm is Professor of Medical Education and Director of Strategic Educational Development at Swansea University, Swansea, UK. Simon Edgar is Director of Medical Education, NHS Lothian, Edinburgh, UK and Education Coordinator, SCSCHF, Larbert, UK. The three editors combine a significant amount of expertise in medical education, simulation  and clinical practice.

About the contributors

There are 32 contributors (not including the editors), one from Ireland, one from New Zealand, 2 from Canada, 3 from the USA, 4 from Denmark and 21 from the UK. Although perhaps "UK-centric", the geographical spread results in a more diverse authorship than, for example, "Practical Health Care Simulations". 

Who should read this book?

The back cover states: "A superb companion for those involved in multi-disciplinary healthcare teaching, or interested in health care education practices…" In reality the book should probably be on the reading list for anyone who is starting out in simulation-based (medical) education. More experienced educators may find specific chapters, aligned with their own interests, of relevance.

In summary

The book is divided into 14 chapters:

1. Essential simulation in clinical education
2. Medical simulation: the journey so far
3. The evidence: what works, why and how?
4. Pedagogy in simulation-based training healthcare
5. Assessment
6. The roles of faculty and simulated patients in simulation
7. Surgical technical skills
8. The non-technical skills
9. Teamwork
10. Designing effective simulation activities
11. Distributed simulation
12. Providing effective simulation activities
13. Simulation in practice
14. The future for simulation

What's good about this book?

Every chapter starts with an overview and concludes with a short summary and an even shorter "key points" which is useful both as a reminder and as a reference for the reader in order to decide if the entire chapter is worth reading.

The editors make it clear in Chapter 1 that simulation is not a panacea. This view has been echoed elsewhere by Andrew Buttery (@andibuttri) on Twitter and by Trisha Greenhalgh (@trishgreenhalgh) in the British Journal of General Practice. Simulation is not magic and not all simulation is "good" simulation. "High fidelity" is also placed into context by Tom Gale and Martin Roberts who state: "…the blind use of the highest fidelity available is a principle which should be avoided" (p.63).

Chapter 3 "The evidence: what works, why and how?" by Doris Østergaard and Jacob Rosenberg is essential reading for all who are involved in designing simulation-based interventions and those undertaking research. They consider the features which make simulation effective, including feedback, deliberate practice and curriculum integration and they also look at some of the challenges faced by researchers in simulation.

What's bad about this book?

The order of the chapters could be reconsidered. The chapters on designing and providing effective simulation activities would logically appear nearer the beginning of the book, and the chapter on assessment nearer the end. In addition, there is a chapter on "Teamwork" but not one on "Leadership" (although one might argue that good leadership is part of good teamwork). Lastly, an entire chapter on distributed simulation (DS), although interesting, is probably not required in a book covering "essential" simulation. A section on DS could have been included in the "Simulation in practice" chapter.

Although overall a very good chapter, Chapter 5 "Assessment" by Thomas Gale and Martin Roberts refers to "assessment tools with appropriate reliability/validity…" (p.61). However the tools themselves are not inherently reliable or valid, the scores produced by the use of the tools may be, and then initially only within the context in which the tool was created.

Final thoughts

This book covers the important topic areas well, including assessment, the roles of faculty and how to create effective simulations. This book therefore deserves a space on every simulation centre's bookshelf, as it provides a good overview of practical simulation in a digestible format.

Affordances and constraints

In human factors, one of the areas of interest is human-object interaction. Some objects are extremely easy to interact with, often because they have been designed from the beginning with the human user in mind. Examples might include the iPhone (other smartphones are available), and Dyson vacuum cleaners (other vacuum cleaners are available). Other objects can be more difficult to work out. Anybody who has had to fold up a child's buggy or change the time on an oven clock knows what I'm talking about.

In human-object interaction, an affordance describes the actions that a human can readily perceive are possible (Figure 1). Well-designed objects make it readily apparent how they should be used. For example, looking at two LEGO® bricks it is pretty clear that they are made to stack on top of one another.

Figure 1: The handle on a coffee mug
suggests that it can be used to hold the mug. 

A constraint is a design feature which stops an undesirable action (Fig. 2). The constraint may be physical or, for more complex objects, software-driven. Using LEGO® bricks again as an example, they tend to fit together in only very limited ways.

Figure 2: Some devices require post-manufacture
constraints to be added.

In healthcare, many devices are much more complicated than LEGO®. However good design, using affordances and constraints, plays a strong part in minimising errors.

The TCI pump

The TCI pump is used to provide a target-controlled infusion of an anaesthetic (propofol) or a potent painkiller (remifentanil). The pump has a number of useful constraints to minimise errors. For example if you inadvertently press the power off button, the pump will display "LOCKED" (Fig 3) and forces the user to carry out a sequence of steps to ensure that this was the intended action. 

Figure 3: OFF button "slip" error prevented

This sequence includes two additional safety steps. An "OK" button press (Figure 4) needs to be followed by a separate "CONFIRM" button press (Figure 5), preventing an inadvertent double press. 

Figure 4: OK button

Figure 5: Confirm button

Lastly the "power off" button requires a continuous press (Figure 6).

Figure 6: Power off

Unfortunately the Alaris PK also has a few shortcomings. If one forgets to prime the pump when using remifentanil, it takes 7 minutes and 22 seconds before the pump alarms to tell you that a downstream clamp is still on. This means that there is a significant amount of time during which one may think that the pump is delivering a drug when it isn't. The video is a time-lapsed to show that after 5 minutes the pump is informing us that both the plasma concentration and effect site concentration have reached the set levels, however not a single drop of remifentanil has been delivered. A simple design change would involve the pump not allowing an infusion to be started without the pump first being primed.

The suction on the anaesthetic machine

The suction on an anaesthetic machine is used to remove body fluids such as airway secretions or gastric contents. It may have to be used in an emergency if the patient regurgitates gastric contents. On some anaesthetic machines the suction is placed next to the anaesthetic machine ON/OFF switch (Figure 7).

Figure 7: Tempting to switch the anaesthetic machine off by mistake

This means that a person may inadvertently switch off the anaesthetic machine when they meant to switch on the suction. Some anaesthetic machines allow you a grace period when you switch them off in case you have made a mistake and you can quickly switch them back on without them powering down. The anaesthetic machine pictured does not have this function. The manufacturer has instead installed a cover on the anaesthetic machine ON/OFF switch to ask as a physical constraint (Figure 8).

Figure 8: The clear plastic cap acts as a physical constraint

The value of simulation

Many devices undergo only limited testing by carefully selected end users. Very few devices are tested under stressful or crisis conditions. This means that devices can be released without ensuring that they will be used as intended by the manufacturer. Simulation could be used to test products in realistic conditions during the design stages, without the risk of patient harm.

In addition, simulation could be used to train personnel in the correct use of the equipment, ensuring that the actions are maintained under crisis conditions.

Simulation for equipment design and training is greatly under-utilised.  If manufacturers collaborated with simulation centres, their devices could integrate affordances and constraints which would minimise human-equipment interaction errors.

Scottish Clinical Skills Network (SCSN) annual conference 2015: The great and the challenges (by M Moneypenny)

Easterbrook conference centre, Dumfries

Disclaimer: The author is vice-chair of the SCSN

The great

The SCSN conference provides a unique opportunity to network with like-minded people from across Scotland and further afield (there were delegates from England, Finland and the US). Although email has made the world smaller, as a speaker at a recent conference said: "Emailing is not 'having a conversation'". The SCSN conference allows everybody the opportunity to have a conversation, to explore areas of mutual interest, strengthen old ties and make new ones.

The three keynote speakers approached clinical skills from very different angles and all three were worth the trip alone. Professor Hugh Barr, President of the Centre for Advancement of Interprofessional Education, discussed interprofessional learning and teaching, the real benefits it provides and the challenges faced by those of us who deliver it. Professor Ken Walker, chair of the Scottish Surgical Simulation Collaborative, discussed the need for innovation in a training unit, but cautioned against "too much storming, and not enough norming and performing." Professor Jennifer Cleland, chair of council at the Association for the Study of Medical Education, talked about moving away from prior academic attainment for medical school admission as it is a poor predictor of post-graduate performance. She informed us that attempts to widen access to medical school have failed and she also discussed the differences between values  (enduring beliefs) and personalities (enduring traits). 

The social programme was the right mix between entertainment and networking, with whisky tasting, recitation of Burns' poems and a thought-provoking speech considering what "The Bard" would have thought of the plight of the people trying to reach European shores from North Africa.

The challenges

Strength through
 collaboration

The strength of the network lies in its bottom-up grassroots nature, attracting members who are interested in clinical skills from across Scotland. The scope for collaboration is enormous. However the majority of the presentations and posters showcased research from a single institution. When research was collaborative, the most common partnership was between institutions in the same city (e.g. University of Aberdeen and Robert Gordon University, University of Glasgow and NHS GG&C). Notable exceptions were collaborations between the University of Aberdeen and the University of Ottawa, and a multi-agency exercise between the Scottish Fire and Rescue Service, the Scottish Ambulance Service, the Emergency Medical Retrieval Service and Yorkhill Children's Hospital. With a little planning it should be possible for much of the research to be carried out in multiple centres. This would take a bit more work but it would also make the results more robust, reduce the risk of repeating a similar (under-powered) study and improve the chances of asking the right questions in the first place. To encourage collaboration, future abstract submissions could have a  weighting for multi-centre studies.

Minor IT issues meant that some speaker's slides were not displayed correctly and a laptop failure meant that some speakers were unable to display their slides at all. A policy of requesting all slides to be uploaded on the first day and a back-up laptop should be able to minimise these problems in the future.

Final thoughts

One of the most well-attended Scottish health conferences in recent years, the get-together in Dumfries shows the continued relevance of the SCSN to the development and promotion of clinical skills training. The next conference is in Aberdeen on the 20th-21st April 2016. See you there?

Book of the month: Medical error and patient safety: human factors in medicine (Peters & Peters)

About the authors

George and Barbara Peters are a father and daughter team. According to the included biography, George Peters is a multidisciplinary specialist, with experience as a safety specialist and as a design, reliability and quality engineer. Barbara Peters "has specialized in problem solving relating to medical error, safety, risk assessment, and environmental health hazards".

Who should read this book?

The authors state that this book is a basic textbook and reference manual "for those who may attempt to deal with and minimise medical error" (p.6). They go on to say that: "Most readers will have little difficulty understanding the discrete word phrases, simplified specialty language, unique concepts, and general suggestions for the improvement of patient safety by reducing medical error." (p.8) Unfortunately, as explained below, probably very few people should read this book.

In summary

The book is divided into 9 chapters:

1. Introduction
2. General Concepts
3. Medical Services
4. Medical Devices
5. Analysis
6. Human Factors
7. Management Errors
8. Communications
9. Drug Delivery

What's good about this book?

The use of simulators for learning, practice, and refresher training
might help in… emergency, crisis or rare event scenarios (p.20)

The authors mirror Ronnie Glavin's question regarding why there has been so little change since the 1999 report "To Err is Human", saying: "There was no magic remedy, only a seemingly complex and intractable human behaviour problem" (p.2). The authors call for an increase in transparency with respect to medical error, for the harmonisation of standards (e.g. US, EU, international)

The use of simulation and simulators is considered and recommended (e.g. see photo caption) including the use of simulation for resilience or stress-testing "intended to discover and correct weaknesses in the system so that a hardened or more robust organisation will result".

There is the occasional interesting concept, e.g. an "equal status" program instituted at some hospitals in which "all personnel are considered equal and a vital part of the team" (p.23) They also suggest the need for "error detectives" who are authorised to cross organisational boundaries and hierarchies and provide a direct feedback loop to management. The authors also argue for the need for civility and that it should "prevail under normal, stressful, and even extraordinary circumstances." They recommend being honest and advocate the 3R approach (Regret, Reason, Reparation) to apologies. They also call for HF studies to start at the product design stage. Chapter 9, Drug Delivery, covers a number of useful concepts such as the use of warning symbols, labelling, and prescription directions  (such as the slightly unnecessary "Caution: This medicine may be taken with or without food" sticker on a Lisinopril container).

The caveats at the end of each chapter, rather than being caveats actually provide an overview of much of the covered material.

What's bad about this book?

The almost total lack of a narrative or co-ordinated, logical approach to any of the chapters gives this book an "Alice in Wonderland" feel without the great prose. The examples are numerous: 

• The first sub-heading in "Intentional Bias"(p.15) is "Knee", the next is "Head"
• In "Chapter 2: General Concepts", "Teamwork" (p.20) is stuck between "Harmonization" and "Rationalisation". 
• In "Chapter 3: Medical Services", "Innocent Errors" (p.24) is found between "Civility" and "Patient Involvement" (and, no, the headings are not arranged alphabetically)
• In "Chapter 7: Management Errors", which covers errors due to poor supervision or management decisions, one of the subheadings is "Home Use Devices". This section makes no reference to management.

There is no overview at the beginning of each chapter and although the authors claim to be providing a simplified language they write sentences such as:

"(Factor analysis) is primarily used to test the ranks of number matrices if statistical correlation coefficients are available and express a relationship between the variables" and

"However, there have been dramatic changes or improvements in medical knowledge and procedural skills, medical equipment and devices, pharmaceutical efficacy and safety, higher social expectations from the medical profession, informed consent, animal rights, the intrusion of regulatory and legal concepts of social responsibility, complex payment schemes and practices, and rapid growith of medical organisationss that stress highly interactive group behaviour, financial outcomes, and business goals" (p.108)

 The authors also make sweeping generalisations such as:

"Research has illustrated that there is considerable effort in some areas to locate surface antimicrobial agents" (p.42)
"All (hospital) hardware should be compatible with the limited capabilities of the aged, infirm, sick, and disabled" (p.53)
"Criticism is to be expected during periods of rapid transition. The ideal will become the reality." (p.54)
"Special training may be necessary to prevent situation awareness errors." (p.103)
"A radiating positive attitude should be displayed by managers." (p.140)

Puzzling sentences abound such as "Patients may have special childhood problems such as foreign objects stuck in the throat, respiratory tract, or other body openings. These objects may also include food, bones, nuts, or vegetables not properly chewed" 

And the occasional unnecessary fact is thrown into the mix: "When competing goals, such as fairness versus self-interest, are present, the brain areas involved and activated are the anterior insula and the right dorsolateral prefrontal cortex."(p.149) and "What may be surprising is that long-term potentiation is first induced in the hippocampal area... fast neuron-glia synaptic transmission has been found between CA1 hippocampal neurons and NG2 macroglial synapses" (p.167-168)

Final thoughts

In the Preface, the authors state that they tried to eliminate bias in the book: "There was no third-party direction or control." (p. xvi) Unfortunately this is exactly what the book is lacking, some sort of coordinating entity which might turn this, at times rambling, book into a worthwhile read. The book's title "Medical Error and Patient Safety:  Human Factors in Medicine" seems to have been applied in retrospect and none of the subjects is well-covered. In its present form this book should be given a wide berth.