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  • 04/29/10
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  • 04/29/10 Stimulates “Need to Know” The Learner’s Need to Know   Adults need to know why they should learn something. Under the more standard pedagogical model it is assumed that the student will simply learn what they are told. Adults, however, are used to understanding what they do in life. They want to know the reason they need to learn something or how it will benefit them. This may be accomplished before students even engage technology, such as if a Spanish class is required to fill a language elective to complete a degree, however, it is wise for the faculty member to help students understand how what they will learn will be of use to them in the future. The required Spanish language lessons will be more affective if the student feels that it will increase her/his ability to understand a bilingual colleague on the job. One way to help students see the value of the lessons is to ask the student, either online or in an initial face-to-face meeting, to do some reflection on what they expect to learn, how they might use it in the future or how it will help them to meet their goals. Knowles, Holton, and Swanson emphasize that “adults resent and resist situations in which they feel others are imposing their wills on them.” (1998, 65) In spite of their need for autonomy, previous schooling has made them dependent learners. It is the job of the adult educator to move adult students away from their old habits and into new patterns of learning where they become self-directed, taking responsibility for their own learning and the direction it takes. Technology is a perfect path for the facilitation of self-direction. The ultimate ability of initiatives such as web-based learning to be non-linear allows an adult to follow the path that most appropriately reflects their need to learn. Adults become ready to learn something when, as Knowles explained, “they experience a need to learn it in order to cope more satisfyingly with real-life tasks or problems.” (1980, 44) It is important that lessons developed in technology-based opportunities should, where possible, be concrete and relate to students’ needs and future goals. These may be adapted from the goals of the course or learning program but can also grow out to the requests for student expectations that were mentioned earlier. In addition, an instructor can encourage students’ readiness by designing experiences which simulate situations where the student will encounter a need for the knowledge or skill presented. Brookfield, Stephen D. 1986. Understanding and Facilitating Adult Learning . San Francisco: Jossey Bass.
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  • 04/29/10 Evidence-Based Teamwork System TeamSTEPPS is a teamwork system based on 20 years experience and lessons learned from High-Reliability Organizations (HROs) (for example, military operations, aviation, community emergency response services, and nuclear power industries). These types of organizations have been conducting extensive research on how teams work, what makes them effective and how to enhance their performance. This research is directly relevant to health care because delivering effective care requires teamwork. Designed to Improve Team Effectiveness TeamSTEPPS has incorporated the best practices from this research into a program to improve the quality, safety, and efficiency of health care by improving communication and other teamwork skills. These skills lead to important team outcomes like enabling the teams to: Adapt to changing situations. Have a shared understanding of the care plan. Develop positive attitudes toward and appreciate the benefits of teamwork. Provide more safe, reliable, and efficient care. Practical and Adaptable Designed with input from the medical community, it is an initiative that will work within the daily functioning of our organization (it is practical) and can be customized (adapted) to meet our organization’s needs. For example, we could identify an appropriate teamwork tool/process to help address a known problem (from a variety of options) that will best work within a specific department and focus time on training the team to use that tool. [ Note: If you have a specific “problem” that a department or the organization is struggling with , use it as the example here; it will have more impact and focus the discussion/presentation on specific issues that are relevant to your senior leadership. ] Ready-to-Use Materials The TeamSTEPPS program provides materials to integrate teamwork principles into all areas of our health care system (for example, medical and support areas) so that everyone is focusing on teamwork, and the ongoing support to keep teamwork as the focus during daily work. The success of this program depends on enhancing the culture of our organization to focus on teamwork.
  • 04/29/10 Note: Review the goal statement health care systems, like many HROs, depend on the coordinated interactions of care providers working in an environment that is: Dynamic Complex High risk TeamSTEPPS provides the resources to optimize team performance across our organization. Human factors research has shown that even highly skilled, motivated professionals are vulnerable to error due to human limitations. But research has also shown that: Teams that communicate effectively and back each other up reduce the potential for error, which results in enhanced safety and improved performance. For example, the Joint Commission analyzed the sentinel events that were reported to them over the last 10 years and identified communication failure as the leading root cause of sentinel events. TeamSTEPPS improves communication and other teamwork skills (e.g., backup behaviors) that help an organization move toward attaining this goal. This is important because teamwork is not innate; it must be learned.
  • 04/29/10 TeamSTEPPS is different than some other teamwork and performance improvement programs. Rigorous scientific methods were used to develop TeamSTEPPS. Evidence based Scientifically rooted in team performance and teamwork research and well-tested theoretical models for system-based error prevention (for high risk industries). This research yielded solid a evidence base for a set of teamwork core competencies with identified knowledge, skills, and attitudes. Field tested by the Agency for Health care Research and Quality (AHRQ) and the Department of Defense TriCARE Management Activity Implemented within AHRQ HROs hospitals and ACTION Partners and disseminated to AHRQ’s Patient Safety Improvement Corps. Implemented at over 68 Military Treatment Facilities (MTFs). Within these facilities, approximately 1,500 trainers and coaches have been fully trained to deliver TeamSTEPPS and implement teamwork principles into practice. Comprehensive : TeamSTEPPS is unique from other products in that it: Describes what to do and Guides users through how to do it (e.g., guidelines on establishing and implementing the program) and Provides the needed resources (e.g., training content, exercise materials, tools). Customizable Fully customizable to meet our organization’s needs. Applicable in all medical settings of any size or clinical specialty, either throughout the facility or within one work unit. May be implemented in full or in part. Mini case studies are available to be customized to our specialty area. Training includes stand alone modules so our unique teamwork needs and resource availability can be considered when selecting what elements of the program we want to use. Easy to Use Provides simple, ready-to-use, structured communication tools and teamwork strategies that apply to our health care setting. Publicly available TeamSTEPPS is in the public domain. Materials can be ordered from the AHRQ.
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    1. 1. Using Clinical Simulation in Nursing and Allied Health Education & Staff Development Jose F. Pliego, MD Professor, Obstetrics & Gynecology Assistant Dean, Academic Affairs Medical Director, Clinical Simulation INTEGRIS Baptist Medical Center A best practices workshop…Part III Wednesday, June 3, 2009
    2. 2. Conflict of Interest <ul><li>Consultant: EMS, Laerdal </li></ul><ul><li>Speaker’s Bureau: EMS, Laerdal </li></ul><ul><li>Research Funding: Laerdal, EMS </li></ul>
    3. 3. Objectives <ul><li>Understand the need to develop multidisciplinary in-hospital clinical simulation training program </li></ul><ul><li>Familiarize with the TeamSTEPPS training initiative </li></ul><ul><li>Understand the impact of medical errors and why they occur </li></ul><ul><li>Discuss the benefit of effective teamwork, structure and communication </li></ul>
    4. 5. What is driving the use of Clinical Simulation? <ul><li>Competency Based </li></ul><ul><li>Continuing Medical Education </li></ul><ul><li>Competency </li></ul><ul><li>Based </li></ul><ul><li>Curriculum </li></ul><ul><li>Professional </li></ul><ul><li>Accreditation </li></ul><ul><li>Bodies and Boards </li></ul><ul><li>Political and </li></ul><ul><li>Regulatory Forces </li></ul><ul><li>Patient </li></ul><ul><li>Safety </li></ul><ul><li>Risk </li></ul><ul><li>Management </li></ul>
    5. 6. What is Simulation <ul><li>Simulation is described as a strategy – not a technology – to mirror, anticipate, or amplify real situations with guided experiences in a fully interactive way </li></ul><ul><li>A simulator replicates a task environment with sufficient realism to serve a desired purpose </li></ul><ul><li>Agency for Healthcare Research & Quality (AHRQ) </li></ul>
    6. 7. Average Learning Retention Rates Learning Pyramid National Training Laboratories, Bethel, Maine Simulation Training Teaching Others 90% Practice By Doing 75% Discussion Group 50% Demonstration 30% Audio Visual 20% Reading 10% Lecture 5%
    7. 8. Simulation enhances learner motivation or “need to know” through experiential learning <ul><li>“ The adult learner enters the training environment with a deep need to be self directing” </li></ul><ul><li>High fidelity team simulation combined with reflective debriefing teaches learners to monitor and question their mental models & practice behaviors </li></ul><ul><li>Vivid experiences in simulation stimulate the “need to know” that motivates adult learners </li></ul>Brookfield, Stephen D. 1986. Understanding and Facilitating Adult Learning .
    8. 9. Strategic Management Simulation Assessment <ul><li>Crisis Management </li></ul><ul><li>Flexibility </li></ul><ul><li>Use Factual Knowledge </li></ul><ul><li>Critical Thinking </li></ul><ul><li>Team Interaction </li></ul><ul><li>Activity Level </li></ul><ul><li>Respond Speed </li></ul><ul><li>Communication Skills </li></ul><ul><li>Planning </li></ul><ul><li>Strategy </li></ul><ul><li>Initiative </li></ul><ul><li>Multiple Decisions </li></ul><ul><li>Integration </li></ul><ul><li>Collaboration </li></ul>
    9. 10. The Shifting Paradigm for Medical Education Training <ul><li>Old Paradigm </li></ul><ul><li>Didactic Lecture </li></ul><ul><li>See One </li></ul><ul><li>Do One </li></ul><ul><li>Silo Training </li></ul><ul><li>Practice on patients </li></ul><ul><li>Learn from your errors on patients </li></ul><ul><li>New Paradigm </li></ul><ul><li>Self-Directed Learning </li></ul><ul><li>Practice to pre-defined standards of competency using simulators </li></ul><ul><li>Learn from your errors on simulated patients </li></ul><ul><li>Team Training </li></ul><ul><li>Practice Safe Medicine </li></ul>
    10. 11. IOM <ul><li>The majority of medical errors resulted </li></ul><ul><li>from healthcare system failures rather than from individual providers substandard performance recommendation to implement organizational safety systems by </li></ul><ul><li>delivering safe practice and </li></ul><ul><li>establishing interdisciplinary </li></ul><ul><li>team-training programs </li></ul>
    11. 12. Simulation & Team Training <ul><li>IOM Principle 3 </li></ul><ul><li>Train in teams those who are expected to work in teams </li></ul><ul><li>IOM Principle 5 </li></ul><ul><li>Train for patient safety and include team training using simulations wherever possible. </li></ul>
    12. 13. Risk Management Considerations - Hazards in Medicine <ul><li>“ Most serious medical errors are committed by competent, caring people doing what other competent, caring people would do .” </li></ul><ul><ul><ul><ul><ul><li>-Donald M. Berwick, MD, MPP </li></ul></ul></ul></ul></ul><ul><li>Not just about the people, it is about the design: </li></ul><ul><ul><ul><li>System, medical devices, procedures </li></ul></ul></ul><ul><ul><ul><li>Human Factors: safeguard in the design “making it difficult for people to do the wrong thing” </li></ul></ul></ul>
    13. 14. Overt Threats <ul><li>Environmental * </li></ul><ul><li>Organizational * </li></ul><ul><li>Individual * </li></ul><ul><li>Team * </li></ul><ul><li>Patient Related * </li></ul>Factors that increase the likelihood of an error being committed : RL Helmreich, Ph.D.
    14. 15. Joint Commission
    15. 16. Joint Commission
    16. 17. Joint Commission
    17. 18. Joint Commission
    18. 19. Joint Commission
    19. 20. Risk Management Considerations: <ul><li>Cases you don’t want to live through again </li></ul><ul><li>Risk Prevention </li></ul><ul><li>Unnecessary - Unexpected Events </li></ul><ul><li>Insurance and Risk Financing </li></ul><ul><ul><ul><li>Damages </li></ul></ul></ul><ul><ul><ul><li>General </li></ul></ul></ul><ul><ul><ul><li>Repeat Cases </li></ul></ul></ul><ul><li>Patient Satisfaction </li></ul><ul><li>Disclosure </li></ul><ul><li>Motivation of Plaintiffs/Patients </li></ul><ul><ul><ul><li>“ I don’t want this to happen to someone else.” </li></ul></ul></ul><ul><li>Alternative Dispute Resolution Options </li></ul><ul><ul><ul><li>Non-momentary components </li></ul></ul></ul><ul><li>Variation between care provided and </li></ul><ul><ul><ul><li>Policies and procedures </li></ul></ul></ul><ul><ul><ul><li>Guidelines </li></ul></ul></ul><ul><ul><ul><li>Standard of Care </li></ul></ul></ul>
    20. 21. What are the advantages of clinical simulation in the Hospital Setting? <ul><li>Realistic Learning Experience </li></ul><ul><ul><ul><li>Medical issues </li></ul></ul></ul><ul><ul><ul><li>Legal issues </li></ul></ul></ul><ul><ul><ul><li>Patient relation issues </li></ul></ul></ul><ul><ul><ul><li>Ethical issues </li></ul></ul></ul><ul><li>Identification of Potential System Failures </li></ul><ul><li>Repair System Failures </li></ul><ul><li>Test New Systems </li></ul><ul><li>Team Simulation </li></ul><ul><li>Employee Satisfaction and Retention </li></ul><ul><li>Patient Satisfaction </li></ul><ul><li>Debriefing </li></ul><ul><li>Risk Reduction </li></ul><ul><li>$$$$$$ Savings </li></ul>
    21. 22. Team Training <ul><li>“ Training multidisciplinary teams using simulation is an effective strategy for reducing surgical errors counts” </li></ul><ul><li>Helmreich & Merritt, 1998 </li></ul><ul><li>“ Simulation-based training in team coordination process has been found to be an effective tool for improving team coordination process in high performance teams in the Navy” </li></ul><ul><li>Cannon-Bowers & Salas, 1998 </li></ul>
    22. 23. Team Training <ul><li>“ Organizations should conduct team training in prenatal to teach staff to work together and communicate more effectively.” </li></ul><ul><li>JCAHO Sentinel Alert - July 2004 </li></ul><ul><li>“ Simulation-based team training in obstetrical emergency is associated with a significant reduction in low five-minute APGAR scores and prenatal asphyxia and neonatal hypoxic-ischaemic encephalopathy.” </li></ul><ul><li>Draycott T, et al., BJOG 2006 </li></ul>
    23. 24. Why Teamwork? <ul><li>Reduce clinical errors </li></ul><ul><li>Improve patient outcomes </li></ul><ul><li>Improve process outcomes </li></ul><ul><li>Increase patient satisfaction </li></ul><ul><li>Increase staff satisfaction </li></ul><ul><li>Reduce malpractice claims </li></ul>
    24. 25. Team Work
    25. 26. <ul><li>An evidence-based teamwork system </li></ul><ul><li>Designed to improve: </li></ul><ul><ul><li>Quality </li></ul></ul><ul><ul><li>Safety </li></ul></ul><ul><ul><li>Efficiency of health care </li></ul></ul><ul><li>Practical and adaptable </li></ul><ul><li>Provides ready-to-use materials for training and ongoing teamwork </li></ul>TeamSTEPPS Team Strategies & Tools to Enhance Performance & Patient Safety “ Initiative based on evidence derived from team performance…leveraging more than 25 years of research in military, aviation, nuclear power, business and industry…to acquire team competencies ”
    26. 27. Why use TeamSTEPPS? <ul><li>Goal: Produce highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes </li></ul><ul><li>Teams of individuals who communicate effectively and back each other up dramatically reduce the consequences of human error </li></ul><ul><li>Team skills are not innate; they must be trained </li></ul>
    27. 28. <ul><li>Evidence-based and field-tested </li></ul><ul><li>Comprehensive </li></ul><ul><li>Customizable </li></ul><ul><li>Easy-to-use teamwork tools and strategies </li></ul><ul><li>Publicly available </li></ul>What makes TeamSTEPPS different?
    28. 29. Lessons from the cockpit: How team training can reduce errors in L&D Susan Mann, MD. Contemporary Ob/Gyn. January 2006
    29. 30. Susan Mann, MD. Contemporary Ob/Gyn. January 2006 Lessons from the cockpit: How team training can reduce errors in L&D
    30. 31. ICU Johns Hopkins Collaborative Runs <ul><li>Length of a patient stay cut in half </li></ul><ul><li>Medication errors reduce by 75% </li></ul><ul><li>Nursing turnover down to 2% </li></ul>
    31. 32. TeamSTEPPS <ul><li>Knowledge </li></ul><ul><ul><li>Shared Mental Model </li></ul></ul><ul><li>Attitudes </li></ul><ul><ul><li>Mutual Trust </li></ul></ul><ul><ul><li>Team Orientation </li></ul></ul><ul><li>Performance </li></ul><ul><ul><li>Adaptability </li></ul></ul><ul><ul><li>Accuracy </li></ul></ul><ul><ul><li>Productivity </li></ul></ul><ul><ul><li>Efficiency </li></ul></ul><ul><ul><li>Safety </li></ul></ul>
    32. 34. Shared Mental Models
    33. 35. Human Factor Goal Shared Mental Model Enhance Communication Enhance Safety Enhance Teamwork
    34. 36. Briefing
    35. 37. Call - Out
    36. 38. SBAR <ul><li>S - Situation </li></ul><ul><li>B - Background </li></ul><ul><li>A - Assessment </li></ul><ul><li>R - Recommendation </li></ul><ul><li>Bridges a common communication gap. </li></ul>
    37. 39. Differences in Communication styles Between Doctors and Nurses <ul><li>Nurses are trained to be broad, narrative and descriptive </li></ul><ul><li>Not to make diagnosis </li></ul><ul><li>Doctors want the pertinent information they need to make a diagnosis </li></ul><ul><li>Tell me what is the problem, what I need to know to fix it? </li></ul>
    38. 40. SBAR Complacency
    39. 41. Advocacy and Assertion
    40. 42. Appropriate Assertion <ul><li>Speak up if a concern arises </li></ul><ul><li>Challenge the leadership when appropriate </li></ul><ul><li>Provide assistance when needed </li></ul><ul><li>Compensate for others deficiencies </li></ul><ul><li>Takes ownership </li></ul>
    41. 43. CUS
    42. 44. Communication Failures: The leading cause of unanticipated adverse patients outcomes <ul><li>Reasons people are hesitate to speak up: </li></ul><ul><li>They are not sure what is the correct procedure </li></ul><ul><li>There is an atmosphere where people are uncomfortable speaking up </li></ul><ul><li>Negative previous experience </li></ul>
    43. 45. Debriefing
    44. 46. Debriefing Simulation The Heart of the Matter <ul><li>Frame </li></ul><ul><li>Assumptions </li></ul><ul><li>Feelings </li></ul><ul><li>Mental Model </li></ul><ul><li>Knowledge Base </li></ul><ul><li>Situation Awareness </li></ul><ul><li>Context </li></ul>Actions Results
    45. 47. Obstetrical Simulation <ul><li>Your Curriculum Objectives should dictate what simulators, what information and what simulation you need </li></ul><ul><li>Team simulation </li></ul><ul><li>Skills are a small percentage of the training </li></ul><ul><li>Process oriented simulation </li></ul><ul><li>Leadership is essential </li></ul><ul><li>Effective communication is a must component </li></ul><ul><li>Education should be universal, pro-active and non-punitive </li></ul>
    46. 48. High Risk Obstetrical Clinical Simulation
    47. 49. Where to Introduce Clinical Simulation <ul><li>Orientation </li></ul><ul><li>During new rotations /academic year </li></ul><ul><li>Competency assessment </li></ul><ul><li>Multidisciplinary Team Training </li></ul><ul><li>New policies </li></ul><ul><li>Low frequency/ High risk events </li></ul><ul><li>New facilities </li></ul>
    48. 50. Shoulder Dystocia Case Narrative: <ul><li>You are making rounds on a Saturday morning in Labor & </li></ul><ul><li>Delivery when a nurse asks you to assist with a vaginal </li></ul><ul><li>delivery in Room 2. </li></ul><ul><li>Mrs. Alicia Morehead is a 30yo MWF G2 P 0-0-1-0 that is </li></ul><ul><li>currently 41 weeks pregnant. The nurses in L&D were not </li></ul><ul><li>able to contact her obstetrician. She called him multiple </li></ul><ul><li>times and he is not returning her pages. The nurse asks you </li></ul><ul><li>to please render assistance with Mrs. Morehead’s delivery </li></ul><ul><li>and pulls you into the room, you do not have time to review </li></ul><ul><li>the record; however, the nurse tells you that Mrs. Morehead </li></ul><ul><li>had a prolonged second stage of labor and she has been </li></ul><ul><li>pushing for 2 ½ hours. </li></ul>
    49. 51. Shoulder Dystocia Case Narrative: <ul><li>Mrs. Morehead and her husband are upset because her </li></ul><ul><li>obstetrician is not attending the delivery; they have not </li></ul><ul><li>established trust with you and question your ability to render </li></ul><ul><li>assistance. </li></ul><ul><li>**(After the infant is delivered, you notice that the right arm </li></ul><ul><li>appears to be limp or paralyzed. You must now communicate this </li></ul><ul><li>finding to the mother. Mrs. Morehead is now very concerned and </li></ul><ul><li>upset, she questions your competency and in a loud voice she lets </li></ul><ul><li>you know that if obstetrician would have been present, this would </li></ul><ul><li>never have happened.) </li></ul>
    50. 52. Shoulder Dystocia Learning Objectives <ul><li>After this exercise, the participant will be able to: </li></ul><ul><ul><li>Review the antepartum and intrapartum contributing factors to shoulder dystocia. </li></ul></ul><ul><ul><li>Recognize the urgency of this devastating complication. </li></ul></ul><ul><ul><li>Practice the appropriate interventions to reduce the time interval between delivery of the head and delivery of the body. </li></ul></ul>
    51. 53. Shoulder Dystocia Simulation Parameters <ul><li>Noelle </li></ul><ul><li>Sim link box and monitor </li></ul><ul><li> -BP 130/90 </li></ul><ul><li>-Rhythm sinus tachycardia </li></ul><ul><li>-Saturation 98% </li></ul><ul><li>-Pulse 70 </li></ul><ul><li>IV pole take to right arm </li></ul><ul><li>of Noelle </li></ul><ul><li>Corometric monitor and </li></ul><ul><li>Fetal Sim monitors </li></ul><ul><li> -Severe variables </li></ul><ul><li> -Contraction every 2-3 </li></ul><ul><li>minutes </li></ul><ul><li>-Normal baseline </li></ul><ul><li>Oximeter </li></ul>
    52. 54. Expected Action by Participants P-E-R-S-P-I-R-E <ul><li>P reparation - identify the obstetrical emergency </li></ul><ul><li>Fetus’s body does not emerge with standard moderate traction and maternal </li></ul><ul><li>pushing. Head suddenly retracts back against mother’s perineum after it </li></ul><ul><li>emerges from the vagina. Call for help (Obstetrician, Anesthesiologist and </li></ul><ul><li>Pediatrician) </li></ul><ul><li>E pisiotomy and extra nurses. Stay informed of time elapsed since </li></ul><ul><li>delivery of head </li></ul><ul><li>Mc R oberts maneuver: remove legs from stirrups and flex knees back onto </li></ul><ul><li>abdomen. </li></ul><ul><li>S uprapubic pressure. </li></ul><ul><li>Steady traction on the head without torquing the head relative to the neck. </li></ul><ul><li>Delivery of the p osterior shoulder. </li></ul><ul><li>I nternal rotation-Woods corkscrew maneuver: R otate the fetus’ upper shoulder </li></ul><ul><li>downward and the lower shoulder upward. </li></ul><ul><li>E mergency-Zavanelli maneuver – rotate head back into the vagina and </li></ul><ul><li>deliver the baby immediately by Caesarean section. </li></ul>
    53. 55. Shoulder Dystocia Debriefing <ul><li>Talk about the experience </li></ul><ul><li>Review the Algorithm </li></ul><ul><li>Review contributing factors </li></ul><ul><li>Problem solving abilities </li></ul><ul><li>Patient management </li></ul><ul><li>Resource utilization </li></ul><ul><li>Healthcare provided </li></ul><ul><li>Interpersonal and communication skills </li></ul><ul><li>Comprehensions of Pathophysiology </li></ul><ul><li>Clinical competence </li></ul><ul><li>Leadership skills </li></ul>
    54. 56. Shoulder Dystocia Complacency
    55. 57. Challenges: Creating Scenarios <ul><li>To match the learning objectives </li></ul><ul><li>To prioritize the teaching “teachable moment” </li></ul><ul><li>To know limitations </li></ul><ul><li>To standardize & reproduce </li></ul><ul><li>To develop metrics & evaluation tools </li></ul><ul><li>To know that our metrics are met </li></ul><ul><li>To know that we are improving specific knowledge, skills, attitudes and behavioral competencies in our learners </li></ul>
    56. 58. Challenges: Simulation <ul><li>Buy In from Health Care Providers </li></ul><ul><ul><li>Medical student </li></ul></ul><ul><ul><li>Established physician </li></ul></ul><ul><ul><li>Nursing </li></ul></ul><ul><ul><li>CEO </li></ul></ul><ul><ul><li>Others </li></ul></ul><ul><li>Maintaining a Safe Environment </li></ul><ul><li>Confidentiality </li></ul><ul><li>Discoverability </li></ul><ul><li>Impact or Interaction with Credentialing and Privileges </li></ul><ul><li>Avoiding a Punitive Environment </li></ul><ul><li>Developing Scenarios </li></ul><ul><li>Research or Publication of Results </li></ul><ul><li>Cost </li></ul>
    57. 59. Conclusions <ul><li>A large majority of medical errors are related to teamwork, communication and procedure techniques , elements that can be improved though use of simulation. </li></ul><ul><li>Various types of simulation techniques can be used to reduce different types of errors and their contributing factors. </li></ul>
    58. 60. Thank You!