karen brady, mahsm, bsn, rnc ob, c efm st. vincent’s ... · 3. 3 rns went to the patient’s...
Post on 06-Jul-2020
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Karen Brady, MAHSM, BSN, RNC‐OB, C‐EFMSt. Vincent’s Medical Center, Bridgeport, CT
ObjectivesIdentify the steps involved in conducting a simulation drill.Integrate lessons learned from simulation into everyday practice.
Planning the Drill
What Do You Want to Drill?Stat c‐sectionShoulder dystociaPP hemorrhageMaternal code 99Perimortem c‐section in EDCode AdamCode Silver
Who Do You Need to Participate?Obstetricians/CNMsNursesPediatricians/NeonatologistsScrub TechUnit SecretaryAnesthesiaBlood BankSecurityCode 99 Team/MET Team
What Do You Need to Conduct the Drill?
Make is as realistic as possibleA scenarioStaff to participateA Body – mother & babyMonitor – fetal, vital signsAssorted supplies
Hemorrhage supplies – blood, clots, urinePatient care supplies – IV, foley, blood tubes, drapes, instruments, etc
Plan Out the Steps
Conducting the Drill
Set a Date & Invite Staff to AttendScheduled vs. unscheduled drillsThere are no spectators – everyone participatesHave everything ready to go
To Film or Not to Film
Pre‐Drill HuddleAssign rolesReview your tasksDiscuss expectationsBrief scenario description
Conduct the Drill
Debriefing
Rules of DebriefingEveryone gets to speakNo one gets to judgeIt’s all about the team
DebriefingWas a leader identifiedWas communication thoroughWhat went wellWhat could have been gone betterWere adequate resources availableWas the patient supportedCongratulate yourselves
Share What You’ve Learned Write up your drill & send to everyoneThings to include:Brief synopsis of scenarioAttendees/rolesLessons learnedRecommendations for improvement
Notes From Our First DrillThings we learned:1. Not everyone is aware of correct way to page someone to 9111. Person who placed the page
put in 9111 and 6080, and only the 6080 showed up on the pager. The 9111 was lost.2. Not everyone knows what the term “Code Stork” means. When staff that was incorrectly
beeped called back 6080, they were told “Code Stork”, but did not know what that meant. Not everyone in the FBC heard the Code Stork announced over the intercom.
3. 3 RNs went to the patient’s room, but no one went back to the OR to help the CCA open. It is time consuming to open up packs, sutures and gloves, then go & scrub – help is needed. Stat c‐section tray was not available on Saturday at time of drill – it had been used on Friday.
Recommendations:1. Charge RN will report to patient room to help and will delegate 2nd RN to go to OR to
open up.2. CCAs should only open c‐section tray, c‐section pack and gloves initially. Do not waste
time opening sutures, extra laps, suction tip, etc. Can be added later.3. Retrain FBC staff on 9111 page.4. Talk with SPD about turnaround time for stat tray.
Checklists are Your Friends
Make it Easy to Succeed
One Stop Shopping is More Efficient
Never Assume the Obvious
Everyone Should Speak the Same Language
Everyone Needs to be Able to Help
Facilitators Can’t Help
Is Anybody Writing this Down?Always designate a scribe!
Failure is Your Friend
It’s Not About the People, it’s the Process
Noelle
Our 1st Victim
Stat C‐Section
Prolapsed Cord
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