Simulation Sessions: Simulation for Medication Safety

September 17, 2021

Using simulation for testing processes and systems enhances patient safety. In healthcare, technology is constantly advancing, and having a nimble way to keep up while also maintaining quality and patient safety is critical. Simulating parts of the design and implementation of a new process can not only keep our patients safer, but can also help save money, discover gaps and make changes prior to implementation. Guest host Dr. Samreen Vora spoke with Amy Gisslen, medication safety pharmacist, on the implementation of a new medication safety software, and Heidi Shafland, clinical nurse specialist about improving the process of administering total parental nutrition (TPN) and lipids.


Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, where the complex is our every day. Each week, we bring you intriguing stories, and relevant pediatric healthcare information. As we partner with you, in the care of your patients. Our guests, data, ideas, and practical tips will surprise, challenge, and perhaps change how you care for the most amazing people on earth, kids.

Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. In our simulation sessions with Dr. Samreen Vora, we’ve been exploring the multiple applications of simulation to help us both improve patient care, and enhance patient safety. Using simulation to test medication safety processes allows us to enhance our systems and make sure we are keeping patients safe, while implementing the newest technology and software available.

In today’s episode of Talking Pediatrics, Dr. Vora talks with Amy Gisslen, medication safety pharmacist, and Heidi Shafland, clinical nurse specialist, about how we can use simulation to implement a new medication safety software, as well as improve the process of administering TPN.

Dr. Samreen Vora: Welcome to Talking Pediatrics. I’m your host today, Dr. Samreen Vora, and today we’ll be talking about simulation and medication safety. There’s a lot of ways we use simulation to improve patient safety, and with advancing technology that’s constantly changing, simulation can be a great way to not only train, but test new processes and technology.

So today, we’re speaking with Amy Gisslen, the medication safety pharmacist, and Heidi Shafland, a clinical nurse specialist in the CVICU. Amy has worked in the Children’s Minnesota Pharmacy for 18 of the past 21 years. She has had a variety of roles within the pharmacy department, starting first as a pharmacy technician. She now serves as the medication safety pharmacist. Her goal is to find ways to make our medication process safe for all children.

Welcome Amy.

Amy Gisslen: Hi, thanks for having me. I’m excited to be here.

Dr. Samreen Vora: Heidi Shafland is a clinical nurse specialist for the CVICU. She’s been at Children’s for the past 18 years, working in critical care. First in the PICU, and now in the CVICU. Welcome Heidi.

Heidi Shafland: Hi everyone, thank you for having me.

Dr. Samreen Vora: Both of you have helped design and implement the use of simulation for medication safety, but in slightly different ways. Amy, let’s start with your experience. Children’s was implementing a new IV workflow manager software to improve medication safety. Can you tell me briefly what this was, and why you chose to use simulation prior to implementation?

Amy Gisslen: First it’s important to understand that many of our highest risk medications that require preparation are actually done in a sterile compounding IV room in the pharmacy. In this area, once the medication is prepared, checked by a pharmacist, and leaves, it is most often impossible for a nurse to know if the medication was prepared correctly.

So it’s essential that we look for opportunities to prevent these errors from happening in this area, because they’re largely visible once they are up in the patient care unit. IV workflow management system is a technology that incorporates barcode scanning of drug products, along with expiration tracking into the system that tells the pharmacy technicians the specific steps that they’re supposed to take when they’re making a product. These steps are set out by instructions put into the package insert and also through our Children’s standards that we have here for production of parenteral products.

So the IV workflow system is essentially a small, 12″ inch touch screen that’s attached to the IV hood, a printer and a camera that allows us to take picture images of what is being prepared. The primary safety feature that this offers, is the ability to stop a product from being made if the wrong medication is selected.

So for instance, if you chose Ceftriaxone instead of Cefazolin, which was intended to be made, the system would stop you from being able to produce it. Or if someone selected the wrong concentration of hydrocortisone in order to prepare a dose. Those are some examples of how the system would ultimately stop the technician from preparing the dose and preventing them from taking the next step.

Dr. Samreen Vora: Yeah, I think it’s not uncommon in healthcare to set up stop gaps. Our goal is to set up our system to make even the most novice person successful, because it’s not about each individual being perfect, because we’re never going to be perfect, but it’s setting up our systems.

So it sounds like we were moving towards getting a better system in place so everybody could be successful and we could keep our patients safe. You mentioned that it takes place in this sterile room, and so I recall when we were doing this simulation, we did a walk through that pharmacy, and it’s a tight space. It’s a closed off space. Even going in that room, and coming in and out of that room, and how the medicines go through, you talked about all the steps take place in different spaces. So we talked about, well, how are we going to simulate this? Can we get into this space? It was going to be challenging, and that space was going to need to be redesigned.

So it wasn’t just, you’re getting a new software. It was well, the software is going to completely change our workflow. So we wanted to look at how efficient is our current workflow? Where should we put a new fridge we might need?

So it sounded like there was a lot of steps. Could you tell me a little bit about the thought process through, “gosh, what are the steps we need to change”, and then how that tied to simulation, and then the use of simulation?

Amy Gisslen: The first one is one that you commented on, is having our simulation team actually walk through our space and ask the questions that we need to have in order for this to be successful. We knew that the implementation of this technology was going to change where we would store drugs. It would change where staff could be when they’re completing certain processes. So we knew that the use of simulation was going to be beneficial to us in that we could simulate this without compromising any patient care, because our IV room also produces hundreds of doses a day.

So trying to get into that space to work out the kinks, if you will, of the process was going to be virtually impossible. So I think the simulation that we created, by setting up a laminar flow hood into our CBC center really allowed us to take the technology, duplicate it in a space that wouldn’t compromise our ability to get those doses out to our patients safely ahead of time.

Dr. Samreen Vora: So then we followed with two simulations, and could you tell me a little bit more about how those simulations went and what pieces did we simulate? And what lessons were learned during that time?

Amy Gisslen: We conducted two different simulations which actually were beneficial for different reasons. First, we needed to see where to position the equipment, like you said, where to put the refrigerator, where to put the equipment that’s put in the flow hoods so that we don’t disrupt the airflow which is necessary in order to create the product safely. But then also not to obstruct the technician’s ability to draw up the medications and prepare the dose.

So the first simulation really included our leadership team and our implementation team to walk in there, use the space, use the technology, and understand how we can get it in a scenario that makes sense for the technician. Then, at the tail end of that first simulation we started to get into Takt time. And Takt time is essentially the amount of time it takes us to produce a medication dose and get it, so that it’s ready to be given to the patient.

That information is largely valuable for us to understand, is this process going to take us longer? We know that the IV workflow manager is a safer process, but we also recognize that it is essentially going to take us longer. So factoring those Takt times allowed us to appropriately determine if we’re going to need additional resources. The fact that simulation was really there to bring in our technician pharmacists that actually work in the IV room, and use the equipment, and walk through the processes. Through that, we learned a ton. I may have mentioned earlier, but I think that it’s one thing to understand how a technology works. It’s another to understand how we work with the technology.

So when we brought our team in, we taught them how to use it, but then we wanted them to ask questions based on what they do every day in the IV room. For instance, one of the technicians wanted to know what was happening, select multiple IV products to produce at once. They were trying to save time, or something like that. She tried to do that, and frankly, we wanted to know the same thing. So we simulated that decision and tried to determine if it would prevent her from doing that. So, as to not create the wrong product. So I think that second simulation really taught us how we were going to use that technology in order to create a safer product in the pharmacy IV room.

Dr. Samreen Vora: The idea and simulation of how important we talk about fidelity, how realistic does it need to be? So we really walk through, “what’s our objective, what do we need?” We needed that hood, and we needed the space to look like it was, but we didn’t have to be in the actual space and really sorting through that. How are we going to do the SIM to get what we need? So for that SIM, getting our frontline staff involved was really important, because they’re the ones that know that workflow really well. So it was really cool, when I was there for the SIM, and as you guys were doing the simulations when you started doing your time measurements. So let’s time her, how long does it take to do it this way, versus that way? I felt like that was really cool. And then getting direct, immediate feedback to then change things and say, okay, “what if we did it this way?” I think that was really important to simulate. Not only it helps you know, and get that feedback, but it sounds like you took some of that information, and were able to take it to your leaders as well and say, “here’s what our workflow looks like. Here’s what we need to do this, to balance efficiency and safety, as we go through this process.”

Amy Gisslen: The conversations with the leaders was a secondary impact that we weren’t even originally expecting. We knew that we had to do Takt time at some point in the game, but we didn’t realize that we could use this simulation time as an opportunity to capture that, as getting the timing of it in the actual IV room can be rather complex, as we had indicated because of the separate spaces that everybody is located in that whoever would be timing would have to go to all those separate spaces in order to accomplish the task. So the simulation really did help support us getting that information back to our leader, which we weren’t expecting, but there was a wonderful secondary impact.

Dr. Samreen Vora: We’ve talked in the past about, “SIM can be used for training and education, but sometimes that scalability can be hard.” Can you talk about how, although we didn’t use SIM to train all the staff, how the simulations did help inform some of the next steps and implementation?

Amy Gisslen: One of the biggest I think that we learned, when we talk about how our staff was actually using the technology and we identified several opportunities to improve how they were going to use it. It’s one thing to bring somebody in, and teach them how to use the monitor and what is the next step they’re supposed to do. But it’s another, to be able to answer the questions that they present to you, about “where am I going to find this”, or “what happens if I received this type of error?”, We were able to simulate that in advance. As a result, we could bring that back to the training and have the trainers answer those questions in real time, rather than having to work through that after it had gone live. We were able to answer those questions for our technicians, who do the work every day.

I think one of the other things that I picked up from this that was hugely valuable, is that our pre-system, the system that we used before we had the IV workflow monitor, was largely reliant on visual triggers. We recognized that during the simulation. So we had to find opt-ins for our staff to be able to identify when things were needed to be prepared, since everything was on a computer monitor now. So, through the simulation, we were able to find those elements and bring them back to the training and help our staff to understand how they were going to know that medications need to be prepared in the system.

Dr. Samreen Vora: Thank you, Amy. Now I want to ask you a question, Heidi, because I know you use simulation for medication safety as well, but it was a little bit different. It wasn’t necessarily about a technology, but about some feedback and some things that had come through for us in our critical care units about line mix-ups. Can you share with me how you guys use simulation for administering TPN?

Heidi Shafland: When I was first looking at the literature to see what other hospitals have done to address the issue of line mix-ups, many of them spoke about the success they had simulating hanging the lines and reconciling their IVs. So, that planted the seed for me. Then of course, in CVICU, we have used a simulation for many years with really great success. It builds great confidence, it’s great for skill acquisition, team roles, team building, trying to decide the exact steps of the process, and trying to learn what the equipment needs were. So we decided that we would use simulation in an attempt to develop a process, identify what the barriers to completing the process were, then to see if this would be a success. We incorporated simulation with bedside clinical nurses, with IT nurses, with pharmacy staff. We had a lot of luck identifying what we felt would be an ideal process. We knew what the time it would take to adhere to this new process. We identified the barriers, and we were able to release this new process to the rest of the staff with a lot of confidence that we could be successful with it.

Dr. Samreen Vora: One of the pieces that sticks out to me is that you really brought in the frontline staff, and that really helped get to the picture. So even through all of those pieces, you started with, “let’s figure out what our current process is.” And you brought in an interdisciplinary team. Can you talk a little bit more about that?

Heidi Shafland: Well, we had members from the St. Paul PICU, from the NICU, from the Minneapolis PICU, CVICU. Those were our nursing staff. Then, like I said, we had experts from IT, and pharmacy, to support because this isn’t a skill that is done by just one person. It does require that dual signature by another person on the computer, on a project that was created by an entirely different group. So, it was really important to us to bring all of those perspectives in, to see where there are risks, and where there are opportunities. I think we really identified that. It was also great because we got to see some really good practice as well. I think what our bedside nurses suggested, is that was the bulk of the recommendations that we were able to make. So, that felt really good too, being able to include them in on this greater picture of how to keep patients safe during medication administration.

Dr. Samreen Vora: So it sounds like that was your first step, and then you developed a process. Then did you also use simulation to kind of now figure out, “what does this look like?” And “what are our next steps going to be after this?”

Heidi Shafland: Our hope is to bring education to our nursing competency fair. During that time, we hope to use simulation to identify risks, and to highlight this new practice, and to celebrate successes, and identify opportunities. That is in the works as well, it hasn’t been finalized yet. There’s nothing quite like muscle memory when you’re doing some of these skills. So, if people are not performing to the highest standard, then we have to break that muscle memory. Also we get to celebrate muscle memory of great practices, at the same time.

Dr. Samreen Vora: I also recognize that, we have a pretty broad audience, inpatient, outpatient, kind of across the board in healthcare. I recognize that both of you are kind of speaking with the lens of inpatient use for simulation and medication safety. But, I imagine there’s ways that you can see simulation being utilized across the healthcare system? Ambulatory setting, inpatient, outpatient, or for even caregivers and families. Are there any thoughts either of you would want to share on that?

Heidi Shafland: In CV, we are partnering with the simulation team and have developed a great caregiver training program. A lot of our patients will go home and require follow-up meds, and follow-up monitoring. So, we are able to train the parents in how to care for their children before they go home, and they get to practice pulling up medications, administering medications, weighing their children, feeding them on a really real-life situation, but with a mannequin, and not with their child. So the risk goes down, but the real life feeling is still the same.

Amy Gisslen: I really just appreciate the opportunity to be able to do this, because I think it is difficult sometimes to work out these issues, while we are still caring for the patients. And I think that simulation has really afforded us the opportunity to ask some of those complicated questions without feeling like we are compromising any of the care that we are offering to our patients.

Heidi Shafland: It streamlines the workflow, and improves confidence exponentially.

Dr. Samreen Vora: Thank you both for joining us today and really speaking to using simulation for medication safety. I really appreciate your time.

Heidi Shafland: Thank you for having us. We appreciate the opportunity.

Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilza Vogel. Episodes are engineered, produced and edited by Jake Beaver. Lexi Dingman is our marketing representative.

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