Crisis (or crew) resource management (CRM) training focuses on improvement of non-technical skills such as communication, teamwork, and situational awareness. This quality improvement project consisted of simulation-based CRM training in the context of intensive care unit admission. Interviews with participants, conducted three months after the simulation, revealed several themes including reflections on patient safety. Participants described positive changes in workflow, professional standards, and smoother and controlled processes.

Intensive care units (ICUs) are complex care environments at high risk for medical errors. In this retrospective study, researchers identified the occurrence of common ICU scenarios and skills during code blue events and measured trainees’ self-reported confidence in these skills. The analysis found that more than 25% of trainees reported low levels of confidence in three scenarios – familiarity with the advanced life support trolley, electrocardiogram strip interpretation, and operation of an external defibrillator. This process of integrating critical incident data with trainee self-assessment can be generalized to other clinical scenarios to create targeted education and simulation curriculum.

In situ simulation is a valuable tool to identify latent safety threats. In this study, 36 unannounced in situ in-hospital cardiac arrest (IHCA) simulations were conducted across 4 hospitals and identified 30 system errors. Errors were categorized as involving human, organization, hardware, or software errors. These system errors contributed to treatment delays and care omissions.

The safety culture of an operating room is known to affect teamwork and patient outcome. This article discusses the unique characteristics of robotic-assisted surgical practice and approaches teams and organizations can take to enhance communication that supports a safe care culture.

Simulation trainings are widely used to identify safety threats and improve processes. By analyzing video recordings of pediatric cardiac arrest simulations, researchers were able to identify 5 main areas of errors: clinical, planning and execution, communication, distraction, and knowledge/training. Investigating the root causes of these errors can result in improved trainings and, thus, improved patient outcomes.

Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened, why it happened, and how it can be prevented in the future. This paper describes development of training videos on after action reviews (AAR)s, a type of debriefing. The videos introduce AAR, show a simulated AAR debriefing, offer techniques for handing challenging situations within an AAR, and reflections on the benefits. The videos are available with the online version of the paper.

Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.

Despite widespread improvement efforts, medication administration errors (MAE) remain a patient safety problem. In this study, nurses at one Australian hospital provided a reflection as to why they believed an MAE occurred and these reflections were subsequently analyzed using a human factors framework. Individual characteristics, nature of the work, and physical environment factors were identified as contributing to MAE and represent areas for improvement.

Simulation training is commonly used by hospitals to identify threats to safety and improve patient care. This article describes the development and implementation of an in situ simulation to improve acute airway management during the COVID-19 pandemic across five emergency departments. The simulation protocol helped identify latent safety threats involving equipment, infection control, and communication. The simulation process also helped staff identify interventions to reduce latent safety threats, including improved accessibility of airway management equipment, a designated infection control cart, and role identification cards to improve team function.

“Horror room” simulations are used to help train medical students to identify patient safety hazards. This systematic review of 16 studies found that “horror room” simulations are more common in Western countries and focus on medication-related or procedure-related incidents. The authors highlight the need for research establishing parameters regarding the ideal size and composition of the team to yield the highest impact on learners.

Simulation training is an important component of medical education. In this study, researchers compared the impact of traditional clinical skills training with or without interactive virtual reality (VR) on human error among medical students performing arterial blood gas collection. Findings indicate that students who participated in VR-based clinical skills training were less likely to commit errors during simulated practical exam compared to students who did not participate in VR-based training.

Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.   

Simulated hospital rooms have been used in medical education to identify potential safety threats. In this study, pharmacy students participated in a team-based simulation to identify potential latent errors and then completed a system thinking survey. Survey results indicated students had a good understanding of systems thinking, but only identified about half of the potential errors in the simulated room.

Non-technical skills (NTS), such as teamwork, can be learned through simulation-based team training (SBTT) but must also transfer into practice to be successful. This study reports on an anesthesia team’s transfer of NTS into clinical practice through focus groups at two weeks and six months after participation in in-situ interprofessional SBTT. Participants reported improved practice, but requested more frequent SBTT and debriefing, both in practice and after trainings.

Simulation-based training provides a safe environment to learn technical and nontechnical skills (NTS) such as communication and teamwork. This article describes the development of nontechnical, simulation-based crisis scenarios in cardiothoracic surgery. Cardiac surgeons, cardiac anesthesiologists, cardiac perfusionists, and cardiac operating room nurses from all surgical cardiac centers in the Netherlands participated in the development of 13 crisis scenarios. The list of selected and non-selected scenarios and an example scenario design template are provided.

Simulation-based training allows learners to learn and practice technical and non-technical skills in a low-risk environment. This review examines the effect of high-fidelity simulation (HFS) on clinical reasoning in nursing students. Results suggest HFS does improve clinical reasoning, but the included studies typically did not directly link improved clinical reasoning to improved patient safety.