Provoked by the landmark Institute of Medicine report on medical errors, many professional and industry groups are organizing both fact-finding efforts and prospective programs to attempt to deal with these problems. On June 22, the AdvaMed (Advanced Medical Technology Association – formerly known as HIMA (Health Industry Manufacturers’ Association) – hosted a “Medical Technology Caucus Breakfast Forum” in the Sam Rayburn House Office Building on Capitol Hill in Washington, D.C. The topic of the meeting was “Medical Technology Plays a Key Role in Reducing Medical Errors.” Dr. J.S. Gravenstein of the University of Florida (a founding Executive Committee member of the APSF), was the featured speaker. He had been invited to talk about the role of the patient simulator in reducing medical errors.
The AdvaMed Executive Vice President, Jim Benson, opened the meeting, mentioning the role the Anesthesia Patient Safety Foundation had played in reducing anesthetic morbidity and mortality. The APSF had demonstrated how collaboration among the clinical community, medical technology companies, the federal government, and academia can contribute to the reduction of medical errors. Noteworthy as a key part of this effort was the APSF-funded development of the anesthesia simulator which has much to contribute to improving safety in anesthesia.
Representative Karen Thurman (D – Florida), who had observed the anesthesia simulator in action at the University of Florida on different occasions and who had been instrumental in inviting Dr. Gravenstein to come to Washington, introduced the speaker. Dr. Gravenstein drew parallels of the human patient simulator to the well-known and highly sophisticated flight simulators used to train, retrain, and certify commercial airliner and military pilots. After enumerating some of the features of the anesthesia patient simulator, he explained the simulator’s role in the training of medical students, nurses, and physicians, both novice and experienced. This obvious application of simulation in the training of medical personnel (“practice makes perfect”) can surely contribute to the safety of patients who do not have to suffer the errors of novices, Dr. Gravenstein maintained. Even seasoned clinicians benefit from simulation exercises involving scenarios representing very rare conditions a physician may encounter only once or twice in a professional life.
Not so obvious is a significant use of simulation by the medical support industries. Dr. Gravenstein recommended that industry engineers and designers observe simulation runs with groups of users of new and old equipment. Heretofore, refinement of design was often based on disasters that occurred during the clinical use of a device. For example, years ago in anesthesia practice, if no one had ever attached a wrong gas tank to an oxygen yoke or mistakenly set and administered a less-than-minimal flow oxygen to a patient, the idea of pin-indexing all gas cylinders and oxygen analyzers might never have arisen. The same sort of distressing experiences led to the introduction of fresh gas ratio proportioning devices, disconnect alarms, and standing ventilator bellows, to name a few. However, to await disasters before designing safety features obviously is not ideal. It would be much better to identify potential errors by watching clinical personnel in simulator exercises with clinical scenarios chosen to stress the system. By the same token, Dr. Gravenstein invited industry to make use of simulator exercises before finalizing the design of prototype equipment.
Gravenstein concluded by pointing out that APSF can look with pride to its role in introducing simulation into modern anesthesia, indeed into medicine and health care in general.