TRAINING and EDUCATION
How I Teach
The Five Steps for Effective
Simulation
So, how do I teach simulationbased training for IT chemotherapy via lumbar puncture
and Ommaya reservoir? By
applying these five steps for
effective simulation:
STEP #1: Create a safe
environment for the learner
to foster a positive and
low-stakes experience. Set
the learner up for success
by preparing and sharing
all teaching materials in
advance including relevant
articles, videos, protocols, and
assessment checklists. Review
the key teaching points at
In the simulation lab, the fellow failed to notice the incorrect dose and incorrect color
the beginning of the session.
of the MTX (right), leading to an MTX overdose.
Emphasize how and when
assessment will occur, as well as
the lack of academic consequences from errors that
January 2009 after a flock of geese caused the engines
are committed and remediated in this setting.
to fail. He saved the lives of 155 people. Captain Sullenberger c redited this “Miracle on the Hudson” in
STEP #2: Create stations to master the execution
part to the many days he spent at the controls of a
of the technical/procedural portion of the skill
flight simulator, a requirement for airline pilots, while
set first. Set the stage for the learning environment
midair disasters happened all around him.
with appropriate task trainers (a.k.a. dummies) to
Simulation training boosts confidence and elevates
teach the technical aspect of lumbar puncture and
competence by providing a safe and supportive enviaccessing an Ommaya reservoir before adding the
ronment for learning and applying critical procedural
patient-centered scenarios.
and decision-making skills. These skills are essential for
operating in high-risk environments.
STEP #3: Create realistic scenarios and patientThe investment made in simulation appears to be paycentered sets that include essential components
ing significant dividends in the airline industry and in the
of competence. Patient assessment, clinical
military, and can deliver similar benefits to the healthdiagnostic reasoning, application of judgment,
care community as well. Medical errors and preventable
and decision-making regarding management
patient harm is the third-leading cause of death in the
should play a role in each of the case scenarios.
United States, affecting roughly 200,000 patients per year,
Further supplement the scenarios with elements
or the equivalent of 20 jumbo jets crashing every week.3
of non-technical skills, including interpersonal
As a recent guest speaker at the inaugural Forum on
communication skills. These could highlight team
Emerging Topics in Patient Safety at Johns Hopkins
communication and teamwork by engaging all
Armstrong Institute, Captain Sullenberger discussed
participants as learners through role assignment
how “the same critical skills of team communications,
(i.e., fellow, neurosurgeon, radiologist, hematologist,
simulation-based training, and documented procepharmacist, nurse, advanced-level provider, and
dures that saved many lives that day can and should
patient). Identify physical space within your
be applied to the health-care industry to help improve
set where all participants in the group actively
patient safety.” He indicated that one person’s heroic
work together toward the stated objectives (i.e., a
efforts are not enough: “A team of experts needs to be
pharmacy, the bedside, a workroom for computer/
replaced by an expert team.”3
medical record review).
ACGME and ABIM Require Safe and Effective Training of Procedural Skills and Access to Simulation
Current ACGME requirements include technical procedural skills, such as: bone marrow biopsies, delivery of
chemotherapy through all routes, and supportive knowledge to consent patients and safely perform the required
technical and non-technical skill set. These skills are
assessed through a formal evaluation process that must
include objective performance criteria. Fellows must
also have access to simulation training.4 Additionally,
the Next Accreditation System now requires all training
programs to use milestones-based assessment and reporting through descriptive and observable behaviors for the
evaluation of invasive procedure skills.5
Board certification in hematology from the ABIM
has a similar procedural requirement; in the future, this
requirement may be included in maintenance of certification (MOC), similar to requirements that our colleagues
in procedural specialties must fulfill.
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ASH Clinical News
STEP #4: Create an immersive experience with
high-risk patient narratives, which is critical
for engagement. Adhere as closely as possible to
realistic situations and experiential immersion,
where educators purposefully engage learners in
direct experience and focused reflection in order
to increase knowledge and develop skills. This is
best done by deliberately inserting errors along a
carefully crafted protocoled checklist. Follow these
steps when planning: (1) obtain informed consent,
(2) verify patient information and therapy plan,
(3) verify the delivery vehicle (Ommaya or lumbar
puncture), (4) verify and acquire chemotherapy,
(5) conduct a procedural pause, (6) access and/or
deliver chemotherapy, (7) provide post-procedural
instructions, and (8) complete required procedural
documentation.
STEP #5: Create comprehensive checklists
to assess key components to evaluate and
document competency in real-time, while
providing immediate feedback and supportive
remediation. To be competent, the learner must:
perform every step of the checklist, recognize
inserted errors and their consequences, and
remediate errors immediately. Errors are
remediated by either repeating the procedure
with a different patient scenario, or describing the
error, its consequences, its management, and how
to avoid it in the future.
From Simulation to the Bedside and Beyond
The principles described in simulation-based training
of IT chemotherapy can and should be applied to all
procedures we perform. It is clear that the technologies
and processes needed to reduce patient harm already
exist and have been proven in other industries time
and time again.
We can address safety-related challenges by designing highly reliable systems of care delivery through
simulated training of protocol-based processes that
should then become generalized practice guidelines.
We should endeavor to find ways to effectively disseminate and incorporate best practices in the areas of
safety and quality – championed by our subspecialty
societies. We also need to develop performance measures that are meaningful to patients and health-care
providers, such as reduced errors, reduced complications, and increased patient satisfaction.
Whether performing diagnostic tests, delivering chemotherapy or breaking bad news, we, as hematologists,
can experience our own “Miracle on the Hudson” every
day on the wards. When we arm ourselves with strategies
based on hands-on experience through training, we can
masterfully deal with whatever “flock of geese” we may
face at the bedside of the patients we are call ed to serve. ●
Alexandra P. Wolanskyj, MD, is an associate professor of
medicine in the department of hematology at the Mayo
Clinic in Rochester, MN.
References
1. Gilbar PJ. Intrathecal chemotherapy: potential for medication error. Cancer Nurs.
2014;37(4):299-309.
2. European Medicines Agency. Recommendations to prevent administration errors
with Velcade (bortezomib). 2012 January
19. Accessed from www.ema.europa.eu/
docs/en_GB/document_library/ Medicine_
QA/2012/01/WC500120701.pdf.
3. Szczerba RJ. Captain ‘Sully’ Sullenberger
and Johns Hopkins tackle patient safety.
Forbes. 2013 October 2. Accessed from
www.forbes.com/sites/robertszczerba/2013/10/02/captain-sully-sullenberger-and-johns-hopkins-tackle-patientsafety.
4. Accreditation Council for Graduate Medical Education Program Requirements for
Graduate Medical Education in Hematology and Medical Oncology (Internal
Medicine). Accessed from acgme.org/
acgmeweb/Portals/0/PFAssets/2013-PRFAQ-PIF/155_hematology_oncology_int_
med_07132013.pdf.
5. Accreditation Council for Graduate Medical
education, The Internal Medicine Subspecialty Milestones Project. Accessed from
acgme.org/acgmeweb/Portals/0/PDFs/
Milestones/InternalMedicineSubspecialtyMilestones.pdf.
December 2014