This morning, the Consortium of Anesthesiology Patient Safety and Experiential Learning (CAPSEL) team conducted a tremendously successful critical event simulation with participation from surgeons, anesthesia techs, nurses, anesthesiologists, and CRNAs.
Over 20 professionals from these disciplines came together to practice emergency management, and debrief as a group. The team addressed core concepts of Crisis Resource Management, had an engaging discussion, and discussed ways to make peri-operative care safer and more resilient when bad things happen.
A few themes that emerged for consideration:
- Core teams that know each other well are strongly desired by all parties. When that isn’t possible, introductions as part of the time out should always be done.
- Should the OR have a “code team” dedicated each day to respond to emergencies, rather than relying on the informal system of calling help into the room? In particular, should this team include a surgical airway expert and a TEE expert?
- Strong leadership and clear communication are the hallmarks of emergencies that have best outcomes. There are specific techniques for both of these, and we should practice as often as possible.
Dr. Lavinia Kolarczyk coordinated for this peri-operative event with the CAPSEL Director Dr Marjorie Stiegler.
Many thanks to those who also assisted in the creation and execution this event: Drs. James Krakowski, Rob Isaak, Greg Balfanz, Kate Cobb, Rob Kyle, and Mr. Gene Hobbs.
Special thanks to all of the participants for being brave enough to walk into the unknown disaster, and to our confederate CRNA Jason Holmes, without whom we could not have ensured the scenario unfolded as intended.
Thank you to our surgeons, who are tremendously busy, for dedicating an hour to this important activity. Thank you to our nurses and techs as well – we know you had to work clinically immediately after the event, and your presence was both invaluable and your insights much appreciated.
This patient safety activity was made possible in part, through the support of the Dean’s office as a component of the overall support to UNC Anesthesiology.