Following publication a decade ago of the Institute of Medicine's landmark report, “To Err Is Human,” the medical world turned a critical eye upon itself to identify sources of the tens of thousands of preventable deaths found to occur annually during hospital stays.
These deaths represented only a fraction of the injuries sustained by patients in our health care system as a result of medical error.
One of the surprising findings was that many of these errors were happening in the hands of highly skilled professionals. Studies that used closed-claims analysis found that system failures, and failures in communication and teamwork, are implicated in a significant proportion of medical errors that result in patient harm.
With a new appreciation for the impact of system breakdowns and communication failures—and the importance of teamwork skills in addition to individual skills—the next question in the medical world became how organizations can revamp systems and integrate tools that will reliably minimize adverse events.
Other high-stakes industries—most notably the military and aviation—have offered lessons. Both recognize the importance of teamwork and communication in minimizing the occurrence of errors and mitigating their adverse effects, regardless of the source.
In both commercial and military aviation, flight teams undergo rigorous training that teaches them to prevent, recognize, and mitigate errors including “human factor” errors—those due not to aircraft failure but to human fallibility. Aviation professionals are trained to prevent errors through crew resource management.
In recent years, medicine has created a variety of training programs that apply resource management principles. Our program, for one, is based on the understanding that health care professionals not only must have knowledge and skills, but must work together because teams perform better than individuals, especially in crisis situations.
Certainly this is the case in obstetrics, where unexpected events are common, situations happen rapidly, and conditions deteriorate quickly.
Our program and other efforts elsewhere incorporate an additional hallmark of training programs in the airline industry: the use of simulation—in our case, to teach the combination of technical, clinical management, and teamwork/communication skills that help maximize patient safety.
Simulation and other types of immersive training allow individuals to learn and practice these skills in an environment where patient safety is not compromised, and in a way that can be standardized and replicated.
The Research on Simulation Training
The use of simulation in graduate and undergraduate medical education and in team training has been demonstrated to improve trainee satisfaction. Multiple studies also have shown improvements in measures of provider self-efficacy and confidence.
The impact of any training, including simulation-based training, on clinical team performance, however, can be difficult to measure. This difficulty is partly due to difficulty in finding appropriate measures of team performance. In as much as improvement in clinical outcomes can be viewed as the best measure of the value of any training, however, our colleagues in England have provided the best evidence in support of simulation-based training.
A team of British investigators instituted multidisciplinary simulation training for all providers of obstetric care in multiple hospitals. After several years of training, these providers have achieved a statistically significant and sustained impact of simulation training on perinatal outcomes, including a decrease in the rates of brachial plexus injuries related to shoulder dystocia (Obstet. Gynecol. 2008;112:14–20), improvements in Apgar scores, and a reduction in hypoxic-ischemic encephalopathy following training on other obstetric emergencies (BJOG 2006;113:177-82).
It will take time before American researchers are able to produce similar proof of the efficacy of simulation training. This is due to a combination of factors, including the fact that we have been slower than our European colleagues to integrate simulation training into obstetric training, and because the number of cases that is needed to demonstrate a significant change in clinical outcomes will require long-term studies across multiple institutions. The funding and collaborations required for this type of study are in their fledgling stages.
It is worth noting, however, that other high-stakes industries have not awaited nor demanded proof of the effectiveness of simulation before embracing it. Dr. David M. Gaba, an anesthesiologist and one of the earliest adopters and biggest proponents of simulation training in medicine, aptly stated once that “no industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it. Why should health care be any different?”
A relevant example of this point is that prior to the successful landing of U.S. Airways Flight 1549 on the Hudson by Captain Chesley Sullenbergerand his crew following an extraordinarily rare double-engine failure, a water landing had not been successfully carried out. The aviation industry, however, has done simulation training involving double-engine failures despite their rarity and water landings despite the fact that they had not ever been successfully executed.