Using simulation to address hierarchy issues during medical crises.

Aaron W. Calhoun; Megan C. Boone; Karen H. Miller; May C M Pian-Smith

Commentary

Using simulation to address hierarchy issues during medical crises.

February 13, 2013

Calhoun AW, Boone MC, Miller KH, et al. Simul Healthc. 2013;8(1):13-9.

View more articles from the same authors.

This commentary describes a case used to illustrate opportunities for staff to challenge incorrect orders, speak up, and debrief to improve psychological safety in teamwork.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Huddles and debriefings: improving communication on labor and delivery.

April 19, 2017

Real-time debriefing after critical events: exploring the gap between principle and reality.

November 18, 2020

Improving anesthesiologists' ability to speak up in the operating room: a randomized controlled experiment of a simulation-based intervention and a qualitative analysis of hurdles and enablers.

January 13, 2016

Speaking across the drapes: communication strategies of anesthesiologists and obstetricians during a simulated maternal crisis.

June 6, 2012

A cross-cultural survey of residents' perceived barriers in questioning/challenging authority.

August 23, 2006

Intraoperative deaths: who, why, and can we prevent them?

March 9, 2022

Passing the baton: a grounded practical theory of handoff communication between multidisciplinary providers in two Department of Veterans Affairs outpatient settings.

September 5, 2012

Effective communication with primary care providers.

October 1, 2014

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: a multi-centre study.

March 11, 2020

A leadership initiative to improve communication and enhance safety.

January 26, 2011

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations.

April 18, 2007

Addressing safety concerns about U-500 insulin in a hospital setting.

January 26, 2011

Clinical and financial implications of second-opinion surgical pathology review.

April 7, 2021

Sentinel events, serious reportable events, and root cause analysis.

March 25, 2015

Analysing potential harm in Australian general practice: an incident-monitoring study.

March 27, 2005

Measuring the rate of manual transcription error in outpatient point-of-care testing.

March 13, 2019

COVID-19 has united patients and providers against institutional betrayal in health care: a battle to be heard, believed, and protected.

August 19, 2020

Exploring approaches to patient safety: the case of spinal manipulation therapy.

July 27, 2016

Diagnostic delays in infectious diseases.

September 28, 2022

Patient race and opioid misuse history influence provider risk perceptions for future opioid-related problems.

November 4, 2020

Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications.

March 4, 2015

Implementation of computerized prescriber order entry in four academic medical centers.

January 9, 2013

Often overlooked problems with handoffs: from the intensive care unit to the operating room.

May 14, 2014

Incorporating quality and safety values into a CLABSI simulation experience.

September 28, 2016

Pediatric medication errors in the postanesthesia care unit: analysis of MEDMARX data.

May 2, 2007

"To err is human" but disclosure must be taught: a simulation-based assessment study.

February 28, 2018

Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating room.

January 14, 2015

Moving beyond implicit bias in antiracist academic medicine initiatives.

September 7, 2022

Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study.

March 24, 2021

We want to know: patient comfort speaking up about breakdowns in care and patient experience.

October 17, 2018

Adverse drug events in general practice patients in Australia.

April 19, 2006

Caregiver fatigue: implications for patient and staff safety—part 1 and part 2.

September 7, 2016

Evaluation of perioperative medication errors and adverse drug events.

November 4, 2015

Enhancing the effectiveness of team debriefings in medical simulation: more best practices.

March 11, 2015

Toward the development of the perfect medical team: critical components for adaptation.

March 17, 2021

A novel approach for assessing bias during team-based clinical decision-making.

June 14, 2023

We Want to Know-a mixed methods evaluation of a comprehensive program designed to detect and address patient-reported breakdowns in care.

May 20, 2020

The disclosure of unanticipated outcomes of care and medical errors: what does this mean for anesthesiologists?

June 29, 2011

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008.

August 31, 2011

Post event debriefs: a commitment to learning how to better care for patients and staff.

January 13, 2016

Workarounds in the use of IS in healthcare: a case study of an electronic medication administration system.

February 1, 2012

An integrative review: fatigue among nurses in acute care settings.

November 5, 2014

The pursuit of perfection: hospitals take heightened actions to reduce adverse events.

April 11, 2012

Measuring safety in older adult care homes: a scoping review of the international literature.

May 19, 2021

Hospital characteristics associated with penalties in the Centers for Medicare & Medicaid Services Hospital-Acquired Condition Reduction Program.

August 5, 2015

The effect of cognitive debiasing training among family medicine residents.

July 1, 2015

Cardiovascular medication errors in children.

July 22, 2009

Are we heeding the warning signs? Examining providers' overrides of computerized drug–drug interaction alerts in primary care.

January 22, 2014

Interunit handoffs from emergency department to inpatient care: a cross-sectional survey of physicians at a university medical center.

August 5, 2015

Children and the opioid epidemic: age-stratified exposures and harms.

October 21, 2020

Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.

June 10, 2009

Potential medication dosing errors in outpatient pediatrics.

January 11, 2006

The costs associated with adverse drug events among older adults in the ambulatory setting.

December 7, 2005

Overcoming barriers to the implementation of a pharmacy bar code scanning system for medication dispensing: a case study.

October 7, 2009

Assessment of overuse of medical tests and treatments at US hospitals using Medicare claims.

May 19, 2021

Use of in-situ simulation to investigate latent safety threats prior to opening a new emergency department.

August 19, 2015

Drug-induced hypoglycaemia--new insight into an old problem.

October 25, 2006

Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine.

May 3, 2017

Physician knowledge, attitudes, and behavior related to reporting adverse drug events.

March 27, 2005

Clinical decision support systems could be modified to reduce 'alert fatigue' while still minimizing the risk of litigation.

January 4, 2012

Responding to patient safety incidents: the "seven pillars."

April 7, 2010

The high costs of unnecessary care.

November 22, 2017

Apology in medical practice: an emerging clinical skill.

September 27, 2006

Incidence of prescription errors in patients discharged from the emergency department.

September 22, 2021

Medication orders are written clearly and transcribed accurately – implementing Medication Management Standard 3.20 and National Patient Safety Goal 2b.

February 15, 2006

Health care work environments, employee satisfaction, and patient safety: care provider perspectives.

February 7, 2007

A multicenter, multidisciplinary, high-alert medication collaborative to improve patient safety: the Singapore experience.

May 8, 2013

Computer based medication error reporting: insights and implications.

June 21, 2006

The effect of provider characteristics on the responses to medication-related decision support alerts.

July 15, 2015

Improved operating room teamwork via SAFETY prep: a rural community hospital's experience.

May 6, 2009

Creating a nurse-led culture to minimize horizontal violence in the acute care setting: a multi-interventional approach.

May 11, 2016

Novel approach to cardiac alarm management on telemetry units.

February 19, 2014

Building collaborative teams in neonatal intensive care.

April 10, 2013

The "To Err Is Human Report" and the patient safety literature.

June 14, 2006

Does overlapping surgery result in worse surgical outcomes? A systematic review and meta-analysis.

February 20, 2019

Implementation of a preoperative briefing protocol improves accuracy of teamwork assessment in the operating room.

October 8, 2008

Eight critical factors in creating and implementing a successful simulation program.

January 15, 2014

Patient safety in nursing education: contexts, tensions and feeling safe to learn.

July 17, 2013

Family alert: implementing direct family activation of a pediatric rapid response team.

October 28, 2009

Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration.

April 5, 2017

Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork training, and performance feedback.

February 8, 2017

The role of talking (and keeping silent) in physician coping with medical error: a qualitative study.

August 8, 2012

Reduced effectiveness of interruptive drug–drug interaction alerts after conversion to a commercial electronic health record.

May 30, 2018

Intersystem medical error discovery: a document analysis of ethical guidelines.

January 12, 2022

The attributes of medical event reporting systems.

March 27, 2005

Liability associated with obstetric anesthesia: a closed claims analysis.

January 21, 2009

Reducing the risk of adverse drug events in older adults.

April 17, 2013

Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: a pilot project.

February 17, 2016

Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people.

August 9, 2006

Postoperative handover: problems, pitfalls, and prevention of error.

June 16, 2010

Electronic fetal heart rate monitoring: applying principles of patient safety.

May 16, 2012

The effects of hospital safety scores, total price, out-of-pocket cost, and household income on consumers' self-reported choice of hospitals.

November 29, 2017

Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room.

July 2, 2008

Adverse events in anaesthetic practice: qualitative study of definition, discussion and reporting.

May 31, 2006

Impact of implementing alerts about medication black-box warnings in electronic health records.

January 19, 2011

Beyond service quality: the mediating role of patient safety perceptions in the patient experience–satisfaction relationship.

October 12, 2011

Same behavior, different provider: American medical students' attitudes toward reporting risky behaviors committed by doctors, nurses, and classmates.

December 6, 2017

Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013-20: an observational study of NHS privatisation.

July 20, 2022

Effective triage can ameliorate the deleterious effects of delayed transfer of trauma patients from the emergency department to the ICU.

June 3, 2009

How do simulated error experiences impact attitudes related to error prevention?

September 14, 2016

Related Resources

Interview

In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing

August 30, 2023

Perspectives on Safety

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

August 30, 2023

Improving safety outcomes through medical error reduction via virtual reality-based clinical skills training.

June 21, 2023

A longitudinal study on the impact of simulation on positive deviance through speaking up.

November 30, 2022

Reducing adverse obstetrical outcomes through safety sciences.

November 27, 2022

Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings.

August 24, 2022

Creating psychological safety in interprofessional simulation for health professional learners: a scoping review of the barriers and enablers.

May 18, 2022

WebM&M Cases

Management of Cardiac Arrest in Unconventional Locations.

May 16, 2022

Establishing psychological safety in clinical supervision: multi-professional perspectives.

May 11, 2022

Healthcare Simulation Week.

April 20, 2022

Developing open disclosure strategies to medical error using simulation in final-year medical students: linking mindset and experiential learning to lifelong reflective practice.

March 31, 2021

TeamSTEPPS for the COVID-19 Crisis.

February 10, 2021

An in situ simulation program: a quantitative and qualitative prospective study identifying latent safety threats and examining participant experiences.

January 20, 2021

Interventions to reduce burnout and improve resilience: impact on a health system's outcomes.

June 12, 2019

Incivility and clinical performance, teamwork, and emotions: a randomized controlled trial.

May 22, 2019

Perspective

Safety in the Prehospital Emergency Medical Services Setting

May 1, 2019

Learning From Invited Reviews.

April 10, 2019

Artificial intelligence systems for complex decision-making in acute care medicine: a review.

March 13, 2019

Teamwork- Part 1: Divided We Fall; Part 2: Cursed By Knowledge: Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem.

March 6, 2019

Challenging authority and speaking up in the operating room environment: a narrative synthesis.

February 27, 2019

The path to diagnostic excellence includes feedback to calibrate how clinicians think.

February 20, 2019

Simulation-based clinical rehearsals as a method for improving patient safety.

October 31, 2018

Using a modified A3 lean framework to identify ways to increase students' reporting of mistreatment behaviors.

May 9, 2018

The gaps in specialists' diagnoses.

April 11, 2018

Implementation of a mock root cause analysis to provide simulated patient safety training.

December 20, 2017

Simulation-based education to ensure provider competency within the healthcare system.

December 13, 2017

Coaching the debriefer: peer coaching to improve debriefing quality in simulation programs.

October 4, 2017

Learning to overcome hierarchical pressures to achieve safer patient care: an interprofessional simulation for nursing, medical, and physician assistant students.

September 6, 2017

Inpatients notes: sensemaking—fostering a shared understanding in clinical teams.

August 30, 2017

Challenges in health care simulation: are we learning anything new?

August 30, 2017

See More About The Topic

Psychological and Social Complications

Using simulation to address hierarchy issues during medical crises.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Using simulation to address hierarchy issues during medical crises.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site