Guttorm Brattebø

Education and training teamwork using simulation

It has been said that while medicine used to be simple, ineffective but relatively safe, it's now
highly effective, extremely complex and potentially dangerous. The wellbeing of patients in the
intensive care unit depends heavily on the health care workers that are involved in their
treatment. This may especially apply to modern intensive care medicine with its interwoven
system of technical equipment, highly potent medications and sophisticated techniques, making
it possible to treat or mitigate failures in most of the body's organ systems. There is little
disagreement about the value of most treatment protocols or approaches to treating the many
diseases or organ failures that acutely ill or injured pa- tients may develop. However, as the
complexity of intensive care has increased, we've also realised the need for focusing on how such
complex systems sometimes fail, resulting in adverse events and harm to patients. This is a
painful realisation, but also a requirement for achieving safer care. Much emphasise has been
placed on safeguarding technical equipment and hardware, and redundancy when it comes to
infrastructure. Guidelines and protocols based on consensus and current scientific knowledge has
also become more accepted, reducing unnecessary variation in the way care is delivered. Such
unwanted variation is mainly due to the health professionals' own personal preferences or local
cultural differences. In this context, the importance of how the teams working in modern
intensive care unit interact must not be underestimated. Analyses of adverse events have shown
that human factors are the most prevalent contributing factor to patient harm. This should come
as no surprise since there are so many people involved in the health care system and the extreme
complexity of a modern hospital. Health professionals are nearly always educated and trained in
“silos” with their peurs, seldom training practical skills with the other professional groups they
are required to work with in a clinical situation. Given the need for being able to act quickly and
with precision when emergencies occur, such situations often result in suboptimal care and
adverse events. Based on the growing body of literature as well as the author's experience in
trauma simulation, this chapter will discuss some possibilities for increasing safety margins in
the intensive care unit by training non-technical team skills, in addition to the success factors for
such training.
Modern medicine is very complex and the intensive care unit (ICU) with its sophisticated
technical equipment and advanced treatment options is among the most challenging clinical
environments in a hospital. While this gives hope for effectively treating very severe conditions,
it also increases the possibilities for unwanted harm to patients. Such events have been labelled
adverse events (AE), and may occur in as much as 5-10% of all hospital admissions (1-3). Based
on thorough investigations of AE there are reasons to believe that a significant proportion of
them could have been prevented at least theoretically, since the root causes often are human
factors and suboptimal team cooperation (4-7). While only a small proportion of AE results in
death, significant morbidity, suffering and costs are caused by AE. In Table i some of the
common examples of management care problems are given. On the other hand, it is important to
recognise that medical errors are nearly never the result of negligence, sloppiness, poor
motivation or incompetence [10]. Rather, health care can be regarded as one of the most complex
social systems (11]. There is scientific support for the relation between teamwork and patient
safety in highly dynamic domains such as intensive care units (ICU), surgical theatres, and
trauma rooms (12-14). During recent years the importance of well functioning teams has been
acknowledged as a crucial factor in both the causation and prevention of AE (12, 14).
Investigations have also shown that human factors like suboptimal team cooperation, lack of
leadership and clear communication lead to disasters (7, 15, 16). On the other hand, team
training and simulator use is often mentioned as one important way of reducing the risk for
patient harm (I, 17, 18). To mitigate the problems of failing team work, the aviation industry
developed the concept of team training, called crew resource management training (CRM) (19].
The main goal of this training is to address the challenges of situational awareness, leadership,
communication, and cooperation. The same causes of errors and lack of quality have been
identified in medicine, and CRM training using simulations has been applied to the operation
room environment as in full-scale anaesthesia simulators, in the delivery room, and the trauma
room. Hence, the use of simulation to improve teamwork seems to be a sound strategy for
improving health care (10, II, 20). This situation can and must be changed, but unfortunately
health care is rather behind other high-risk industries in its attention to ensuring basic safety for
our patients. Focus must shift from blaming the individual person treating the patient, to trying to
prevent harm by iniproved system understanding and design. In the ICU environment special
attention should be spent on communication and safe drug use, e.g. using proven medication
safety practices (I, 21, 22).
Simulation training is especially useful for training the non-technical skills mentioned, but
complicated or new procedures can also be trained in this way. Such training requires actually no
fancy or expensive technical equipment, but some hospitals have advanced computer-based
simulation mannequins available. On the other hand, simulation is just an educational method,
with strengths but also certain li..litations.
Team training and simulator use is regarded as one very important way of reducing the risk for
patient harm (I, 17, 18]. It is human nature to err, but as important as our tendency for e.g.
forgetting important details, is our ability to spot abnormalities and to create immediate solutions
and better alternatives to meet the challenges ahead. We are normally well trained in the science
of medicine for evaluating and caring for the individual patient, but we are less capable to
understand the systemic safety issues involved in the complex interaction between team
members (10]. However, when regarding human's fallibilities it is important to acknowledge our
special ability for pattern recognition and mental simulation, which is far better than what
computers can perform. These abilities have also been pointed out as the fundamental basis for
expert
fe Tab. 1 Some examples of care management problems
(modified from www.sikkerpatient.dk and 8, 9]
Not following agreed protocols without clinical justification, or applying incorrect protocols
Inadequate supervision of junior staff, 1 920 or not seeking help when needed
Wrong treatment given, or treatment given to incorrect patient or body site Failure to identify
correct patient Failure to monitor, observe, or act Incorrect risk assessment (e.g. risk of suicide or
self harm) Inadequate handover and low quality communication Failure to discover faulty
equipment Failure to carry out preoperative checks or misunderstanding / lack of tests behaviour,
a capacity that can be trained in a sim ulator environment (23-25). Cook and colleagues have
studied and described how trained clini- cians are able to anticipate and foresee possi- ble safety
threats and discontinuities in patient care. Then they will “bridge” those gaps, offsetting some of
the expected consequences or limiting the impact of the gaps. By doing this, they create safety
instead of threatening the safety of patients as depicted in Figure 1. This has the paradoxical
effect of making gaps seem less significant, because they don't always have as detrimental
effects as they would have had without experienced clinicians in the system (26]. Accordingly,
this is a primary source of the robustness of health care. Asking experienced clinicians about
possible gaps in the care of patients can therefore be used as a first step for choosing relevant
top- ics and constructing simulator training sessions. The aim for simulation in this context can
be viewed as a way of making health care more failure-proof or resilient towards the possible
harmful effects of errors. On the other hand, the opportunity for “learning by doing" rarely
occurs in modern medicine when one considers the han- dling of seldom occurring crises, and it
would hardly be acceptable from a patient safety per- spective either (17]. For example, trauma
teams are expected to function efficiently and smoothly
when treating major trauma cases, even though the teams are often without previous training
[27]. The team members are usually sufficiently trained professionals individually, but with
limited experience in team work [28].
In obstetrics, another dynamic domain of medicine, the British confidential enquiries into
maternal and child health (CEMACH) in December 2007 concluded that “... the assessors were
struck by the number of health care professionals who appeared to fail to be able to identify and
manage common medical conditions or potential emergencies outside their own immediate area
of expertise. Resuscitation skills were also considered to be poor in an unacceptably high number
of cases.” Furthermore: “In many cases the care provided was hampered by a lack of cross
disciplinary or cross agency working and problems with communication. These included: poor or
non-existent team working, inappropriate delegation to junior staff, inappropriate or inadequate
consultations by phone, the lack of sharing of relevant information between health professionals,
including between general practitioners (GPs) and the maternity team, poor interpersonal skills”
[9).
Studies indicate that as many as one fourth of trauma related deaths are preventable, and that
most treatment errors and protocol deviations occur in the admission phase. It has also been
shown that improving the systems for treat- ing severely injured patients can significantly reduce
the proportion of preventable deaths (29). Regarding teamwork, the most difficult task to
improve seems to be communication, but situational awareness, leadership, and co-operation

very important (7, 16, 18, 30]. Based on an extensive literature review, Manser identified and
described safety aspects of teamwork (12]. Ta- ble 2 lists aspects of teamwork based on recent
studies and reports. The nature of many medi- cal emergency teams and the conditions they are
supposed to function under, pose specific chal- lenges to optimal team function because condi-
tions change (dynamism), teams may be assem- bled ad hoc, work together only for a brief peri-
od, consist of many professions, and therefore must integrate various professional cultures (12,
33). The obvious answer to these issues is to give such teams the opportunity to train together as
a team. The military has a slogan: “Train as you fight!” This is very suitable for ICU teams as
well. . Communication as the most important key element in teamwork has been studied exten-
sively, and several ideas have been put forward trying to describe a format for optimal
communication in clinical settings. The so-called SBAR (situation, background, assessment
and recommendations) is one simple but effective way of structuring communication [31].
Various mod. els of the relationship between specific communication practices and patient
safety have been proposed [34, 35). The practices brought forward here are in good
agreement with anaesthetists' non-technical skills (ANTS) (25, 30).
In their review of contributory factors underlying critical incidents, Reader and colleagues found
an overlap between the non-technical skills requirements for the ICU and anaesthesia, with both
domains having a need for good teamwork, situation awareness, task management and decision-
making skills (24). Furthermore they recommend that non-technical skill training programmes
should be integrated into the technical aspects of a domain, when professionals have an adequate
level of technical competence. Then the cognitive load of having to learn both technical and non-
technical skills will be reduced simultaneously. It is further argued that the framework of
nontechnical skill categories identified in the ANTS taxonomy also applies to the ICU
environment [24, 31). The need for training these skills is important for both experienced and
novice personnel,
Tab. 2
Aspects of teamwork relevant to patient safety (modified from 12, 23. 25, 31, 32]
Characteristics
Situational awareness Actively seeking information, recognising and understanding data and
information
(e.g. pattern recognition)
Anticipation Communication Openness of communication and exchange of information
Quality of communication (e.g. shared frames of reference)
Specific communication practices (e.g. team briefing, closed-lcap, SBAR) Shared mental models
Shared perception of a situation, and understanding of team structure, tasks, and team roles
Quality of collaboration Mutual respect and trust between team members Leadership
Leadership style (value contributions from staff, encourage participation in decision-making)
Adaptive leadership behaviour (e.g. increased explicit behaviour in critical situations)
Coordination
Adaptive coordination (e.g. shift between explicit and implicit coordination; increased
information exchange and planning in critical situations) Decision making Identifying options
Balancing risks and mental simulation Re-evaluation and change of solution/decision
since none so far have been extensively trained in team skills. It is then reasonable to agree that
there is good scientific evidence for using simulation to improve quality of teamwork in the ICU.
The next issue is then to decide how to develop a simulation programme in order to achieve
better performing teams. Fernandez and colleagues have described a very useful model for
defining teamwork in emergency medicine, including some key recommendations to guide the
implementation of their proposed taxonomy into rou- tine simulation based training [36, 37).
Salas and colleagues also provide evidence-based principles for the planning, implementation
and evaluation of team training programmes based on extensive reviews of the literature (18].
The relevant questions to be considered before a simulator-training programme is implemented
are listed in Figure 2.
The most basic stage is the assessment of the educational needs: What are the problems? Which
safety threats or emergency procedures ought to be addressed in the training? Simulation is a
method that can be used in many different ways, and hence it is important to decide on the
explicit educational goals (e.g. changes in behaviour) that must be demonstrated. Then one has to
build the actual cases and scenarios to be simulated. One useful starting point for this can be to
use selected AE reports [38]. It is also strongly recommended to construct sce- narios based on
real patients with those clini.
cal problems which the participants can readily identify from their own experience, so that they
“believe” the case and problems presented. When constructing a training scenario one can “pick
and choose” from several real cases. The best challenges are the ones where there is not always a
definite “correct answer"; e.g. to intubate or not. The scenario must include certain events that
should trigger the specific wanted behaviours. These triggers should preferably be independent
on each other, so that the entire scenario progress doesn't rely solely on only one single item. It is
fascinating to observe how similar teams can choose quite different approaches to the same
challenge. On the other hand, one must avoid too complicated scenarios, because they will be
difficult to facilitate. The facilitator must be able to decide on the patient's clinical development
right away, without having to consult the manuscript too often. This will obstruct the flow of
simulation, and make the session less natural. Therefore, it's best to rely on common and relevant
clinical problems that are easy to remember and then to follow during the simulation. It is also
recommended to run a pilot before starting, just to “try out” the scenario. Table 3 shows a sample
of scenarios and clinical challenges that can be trained.
Then there is need for a checklist or scale for evaluating the actual performance of the teams.
This is very important for the feedback. The list
Feedback
Needs analysis Definition of training objectives based on AE, and performance patterns
Simulation design Build case with events ordered to ensure that each behaviour is separated, and
not depending on prior performance
Assessment Identification of desired behaviour, and developing check lists or rating scales for
performance
Review of performance and identification of behavioural examples of training objectives, and
future training needs
Platform for Simulation Based Training
Fig. 2
Description of taxonomy in simulation training, with the different design steps from ‘needs
analysis' to 'feedback” and identification of future training needs (modified from 36 and 37)
Tab. 3
Clinical situations and topics suitable for simulator training in the ICU environment
Advanced cardiopulmonary life Support in cardiac arrest Admittance of a new patient with
threatened vital signs Emergency endotracheal intubation, especially with a difficult airway
Accidental patient self-extubation or loss of airway Treatment of acute tension pneumothorax,
with chest tube insertion Telling families that the patient is dying or dead Communicating with
families in relation to possible organ donation Sudden technical failures in vital equipment or
disruption of infra-structure (e.g. loss of electricity or piped gas supply) Handling of serious
adverse events (incl. patient, family, involved health personnel) Handling of emotional upset
families, including language problems Prioritising resources when several patients are admitted
at same time Fast hand-over of complicated patients to/from e.g. the operation theatre Testing of
new treatment protocols or technical equipment
that everybody can see each other's faces when reflecting and discussing the simulation. Be sure
to have enough time for debriefing and keep all participants together. The main purpose is to
give the participants the possibility for reflection and discussion on their performance. This is
also the reason for running two simulations after each other, so that the teams will have the
opportunity to demonstrate improvement based on the feedback and discussions. Regarding the
important aspects of clinical feedback in medicine, Jack Ende's classic discussion of this is in my
opinion still valid (39). Especially, it is important to use a non-evaluating language, dealing with
the specific and observed behaviours, and aiming at decisions and actions and not assumed
intentions. Some tips for clinical feedback are listed in Table 4.
When building a simulation-based training programme, it must also be decided on which
technological level the simulator or simulation should be placed: high-fidelity or low-fidelity
simulation. There are a number of highly sophisticated simulators on the market, with a vast
possibility for complicated responses to various inputs, e.g. medications [40]. These simulators
are relying on computer programmes, where different algcrithms are constructed based on
physiological models. The strengths of these sophisticated simulators are that they are more real
and can be subjected to more clinical procedures. On the other hand, they are expensive, must be
programmed and often there is need for a second person just to take care of these technical issues
[41). In our experience it is possible to have effective team training using just regular
resuscitation
Tab. 4
Guidelines for feedback in medical education [modified from 39)
must describe which specific behaviours one wished to observe, e.g. was the identity of the
patient checked, did the patient receive a high flow of oxygen, or was the blood pressure
recorded? One must also decide on whether or not the patient should be “allowed to die” during
the simu- lation. The author warns against this, because it is possible to make the patient
deteriorate to indicate that the team must reassess, identify life. threatening issues, and offer
correct treatment. Perhaps there are more effective ways of making the team realise that they
have not performed to standards, other than letting them completely “fail” by loosing the patient.
The most important part of the simulation is the debriefing and the feedback session immediately
after the simulation. In the Better & Systematic Trauma Care (BEST)-programme we usually
seat the participants in a horseshoe formation, so
Facilitator and trainee should be working as allies, with common goals Feedback must be based
on first-hand data and come as no surprise It must be limited to behaviours that can be changed
Use descriptive and non-evaluative wording Deal with specific performances, not generalisations
Focus on decisions and actions, not assumed intentions or interpretations
mannequins. Experienced teams will not need a very expensive mannequin to train inter-personal
skills, because they can easily relate the current situation to previous real life experiences.
Moreover, regardless of the possibility of even inore realistic simulators in the future, one must
realise that simulation training is and will always remain an artificial situation; not real life. This
is also the experience gained from a US-based programme that has been running local team
training in obstetric units at rural hospitals in Oregon [42]. They started out with a very
sophisticated simulation set-up, but ended up using simple mannequins.
trainees for the training, and also determine the required resources and time needed for the
training. The persons responsible for manpower must also be committed and ensure that the
needed resources are available for the training session. Application of the trained team skills in
the job situation is also needed and important. And last but not least, one must measure the
effectiveness of the team training programme itself (45). Other
researchers have also tried to identify reasons why - team training initiatives are successful or not
(46).
Some pitfalls in simulation sessions
Critical success factors for team training
It is easy to believe that when there is so much literature in favour of simulator training than the
effects should be clearly demonstrated. This is not the case. However, recently there have been
published some interesting papers analysing costs of adverse drug events and effect of team
training to reduce medication errors (43, 44). Salas and colleagues have also nicely pointed out
the success factors for team training as listed in Table 5 (45). The first thing is to make sure that
the training objectives are in line with the goals for vour organisation. With this in place it is also
easier to provide support for the initiative, which is the second prerequisite. The next goal is to
get the frontline care leaders on board. If they don't believe in and support the initiative, failure is
likely to ensue. Then one must prepare the environment and
It is easy mainly to focus on medical procedures or specific clinical issues in the debriefing
sessions. Then the physicians in the team could certainly go on arguing by citing publications
and sources of (contradictive) information for hours. However, the medical content is per se not
the most important issue in a simulation exercise. The crucial point is to be able to pose some
challenges that will demand demonstration of good situational awareness and adequate skills in
communication, cooperation and leadership. Therefore, the dicussion must be focused explicitly
on these team behaviours. On the other hand, a case that can be identified as relevant, and a team
composition that reflects what is normally the situation when a team like this works together,
will help the team to behave as if the simulation was in fact a real situation. Often, some team
members are reluctant to act, because they find the training situation artificial or even
embarrassing. If other team members (especially physicians) act in, this usually makes the team
exercise develop well and to a larger degree resemble a real case. The debriefing can be started
by shortly stating what the key clinical issues in the scenario was, and what the correct treatment
would be. Then one can proceed to discussing the relevant team issues.
In the following, an example of the briefing and case for a team simulation is given. This setup
uses a low-fidelity "dead" mannequin or a live model, where clinical information and parameters
are given verbally by the facilitator on demand [39 and www.bestnetno]. One obvious advantage
to this solution is the facilitator's ability for adjusting the patient's response and case progression
to the specific team's decisions and actual performance.
Tab. 5 Critical success factors for team training in health care (45)
-Align team training objectives and safety aims with the organisational goals Provide
organisational support for the team training initiative Get frontline care leaders on board Prepare
the environment and trainees for team training Determine required resources and time
commitment and ensure their availability Facilitate application of trained teamwork skills on the
job Measure the effectiveness of the team training programme
Examples of briefing for an ICU team prior to a simulation session
tive aspects of the simulation. The team leader is the last person to comment on the performance,
so that the team is not "silenced” by the leader before they are able to make their own remarks.
2. Short feedback from the instructor focusing on the
successful aspects
Explain to the participants that feedback related to the professional content will be given in
connection with review of the videotape.
3. The professional content in the simulation
Let's say that you are a member of the ICU team, about to take part in a simulated admission of a
new acute patient with suspected sepsis. The patient is a simple resuscitation mannequin, but a
facilitator will give all relevant information when prompted during the session. Clinical data will
be given after the relevant procedure has been performed. You will have to simulate any invasive
procedures and clinical examinations, and say aloud what you are doing e.g. “I am auscultating
the chest, what do I hear?” Everything that you would do in a real situation like this should be
carried out as normal, e.g. connecting monitoring devices and performing relevant XRs.
Intravencus dnigs or fluids should be prepared as normal but not delivered into the venous
cannulas. Please note that the main purpose of the simulation is to train team communication,
cooperation and leadership during the initial resuscitation and stabilisation of the patient. After
the training, there will be a discussion and feedback session, before a second simulator run. The
simulations will be video recorded intended for possible help during the debriefing.
These include order of actions, important decisions to be made, efforts to initiate, and equipment
needed. Give all the participants a chance to suggest improvements. The instructor then sums up
by writing all the suggestions e.g. on a whiteboard. This is an important part of the feedback
session as the participants by proposing improvements themselves wili be responsible for
improving issue in the ICU environment. Normally this is a good time for the instructor to give a
short feedback on the professional content.
4. Show some of the video footage
Clinical scenario
The patient is á 24 year-old male who was admitted to the hospital approximately 20 minutes ago
with signs of severe sepsis. He has been ill for 4 days, with fever and malaise. He has open
airways, is breathing spontaneously at a rate of 34 breaths a minute, reacting to painful stimuli by
eye opening, swearing, and localising pain. He is very pale, and the skin is cold and damp. He
has pale-blue extremities. Please, go ahead and perform an initial assessment and resuscitation.
The structure for team debriefing and reflection as used in the BEST-programme is described
here:
Everyone wants to see themselves on the video at the same time as they are a bit scared or
embarrassed by the idea. It might be a good idea to show the first five minutes of the video only
commenting in general terms. Further on, the feedback session should focus on the previously
stated objectives for the simulation. The main objectives are demonstration of improved
cooperation, communication, and leadership behaviour. It might be a good idea to start every
round with a brief definition of successful objectives.
5. Summing up and closing remarks
1. Participants' own opinions
on the simulation in general
Take a short session where all the participants have the possibility for “tension release”.
Let them comment briefly on questions like: “How did the simulation affect you?" and ask the
participants to focus especially on the posi-
It seems important that every participant leave the room with a feeling that they all had a chance
to comment on the simulation. Remember that it is the whole team which should be the main
focus, not individuals. Closing up the session should therefore include questions like “Are there
any other issues, aspects etc. that haven't been asked for and that you would like to comment
on?" It might also be a good idea to ask if there is need for any subsequent theoretical ses sions
that can be part of the unit's regular educational programme in the ICU. It is also recommended
to tell the team that the video will be destroyed and not stored or used for any reprimanding of
individuals.
Use of video
Video recording of the simulation can be useful for highlighting certain aspects of the team's
performance [47]. However, there is no need for so- phisticated audio-visual equipment. A
simple video camera will do, preferable fitted with a wide-angle lens, since many treatment
rooms are rather small. On the other hand, a wireless microphone is nice to have, since it will
enhance the sound quality of the communication, if it is placed over the “patient”. We also
recommend placing the camera high in the room, with the “patient" centred, and maintaining a
steady view throughout the session. Trying to follow e.g. the team leader or specific procedures
will often result in a busy “music video" recording that will be difficult to follow during the
viewing. Likewise, it is highly recommended to test the equipment for sound, light, recording
quality, battery capacity, and replay on the actual projector or TVset to be used. Your ability to
fix technical problems should not be the main part of the debriefing session.
orates significantly more on communication, cooperation and leadership. Case stories and
instructors are from identifiable hospital levels. Discussions and didactic exchange of ideas and
experience is encouraged throughout the course. Training takes place in the trauma room using a
standard resuscitation mannequin as the simulated patient. After a brief review of the emergency
call to the medical dispatch centre, the team is given a few minutes to plan and prepare for
admitting the simulated patient.
The teams use their own familiar team setup and procedures, and all necessary disposable
equipment. Each team member plays his/her own professional role. A short report from the
ambulance crew is also given to the participants before the simulated patient arrives, to
encourage preparations. The preparation and treatment of the simulated victim is video-recorded.
During the simulation the instructor will give the physiological data after each monitoring or
diagnostic procedure has been performed properly.
After approximately 20-30 minutes, or when the patient and team are ready to leave the
emergency room for e.g. the OP theatre or XR-lab, the instructor stops the simulation. After the
simulation, the complete team is debriefed in a separate room (without observers), reviewing the
video using a structured format focusing on what went in a good manner and what can be
improved. This session normally takes 30-40 minutes. A second simulation is then done with the
same team, but with a new case. Debriefing is done again, and finally the team is encouraged to
summarise areas of potential improvement discovered during the simulation and discussions. If
possible, the staff that not participating in the simulation discusses case stories in a theoretical
format during the simulations. The simulation case histories are based on real cases, with
appropriate XR films and lab results. After the course, all educational material (CD-ROM) is left
at the hospital, and the hospital is encouraged to copy and edit this material, in order to arrange
for further local training.
AG
Example of the BEST trauma team training course
The one-day multi-professional course with simulated trauma patients is organised locally at
each hospital, and the training takes place in each hospital's own trauma room[48]. The one-day
course consists of three hours of lectures and case discussions, followed by four hours of
practical training. All personnel involved in trauma treatment participate on the lectures, which
are fol- lowed by the simulation where two of the hospitals' own trauma teams participate in two
simulation sessions each. The course focuses on the need for optimal team function and a strict
and hierarchical progression in the patient assessment and treatment. The theory is based on
current best practice principles, but the course elab
Conclusion
There are many situations in the ICU that can be trained in a simulator setting. Especially
emergency situations should be trained this way. Speed and correct completion of life-saving
procedures is important for patient outcome. This normally relies heavily on so many local
circumstances that there is always room for improvement For more than 14 years the BEST
Foundation has used interdisciplinary team training based on AE reports, and we firmly believe
that such training increases the emergency teams' robustness to AE and ability to handle critical
incidents. Building team resilience against safety threats is perhaps the most effective strategy in
our search towards safer health care. Simulator team training in the ICU must be explored and
refined further to meet the needs for cost-effectiveness.
SO
The author
o
r
Too Guttorm Brattebø, MD
Consulting Anaesthetist | Department of Anaesthesia and Intensive Care | Haukeland University
Hospital | Bergen, Norway Board Chairman | The BEST Foundation: Better & Systematic
Trauma Care
Address for correspondence
Guttorm Bratteba Haukeland University Hospital 5021 Bergen, Norway E-mail:
guttorm.brattebo@helse-bergen.no
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17. Perkins GD. Simulation in resuscitation training. Resuscitation 2007:73:202-11. 18. Salas E,
DiazGranados D, Weaver Sj, King H. Does team training work? Principles for health care. Acad
Emerg Med 2008;15:1002-9.
19. Helmreich RL, Merritt AC. Culture at work in aviation and medicine. National,
Organizational and Profession
al Influences. Aldershot, UK: Ashgate, 1998.
20. Dunn W, Murphy . Simulation: About safety, not fantasy. Chest 2008;133:6-9
21. Pronovost P, Weast B, Schwarz M, Wyskiel RM, Prow D, Milanovich SN, et al. Medication
reconciliation: a practical tool to reduce the risk of medication errors. Crit Care 2003;18:201-5.
22. Kozer E, Seto W, Verjee Z, Parshuram C, Khattak S, Koren G, et al. Prospective
observationai study on the
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