World Patient Safety Day - Safe health workers, Safe patients

​The theme of the World Patient Safety Day is: Health Worker Safety: A Priority for Patient Safety - and here is what we at CAMES think:


To make progress in patient safety, we need to emphasize its complexity. Patient safety is made or broken in socio-technical systems. People from many different professional backgrounds interact with each other, with patients, their relatives, with devices, organizational procedures and rules. This interaction produces good - often excellent - performance and occasionally fails to do so.

This year, the WHO emphasizes the people who are actually producing this performance: the health workers – from so many different backgrounds, of so many different professions, working in so many different disciplines, adhering to so many different sets of norms, values, and beliefs – and yet all giving their best to provide safe and efficient care to patients and their relatives.

In CAMES, we use simulation to help healthcare professionals to adapt the state of the art in their respective fields to this patient and this situation – producing reliably good performance under constantly changing condition of the complex healthcare system, we all work in. We also facilitate reflections by the individuals, who come to us: What is your own role in this complex system? What helps you personally? What are your challenges? What can help you in dealing with them

The testemonials below give you some insights in how we think about the role of simulation for patient safety and the safety of health workers. We are a multi-professional team and look through different lenses on this complex thing – safety. We invite you to reflect upon your own lens in the light of ours.

- The CAMES team

Jannie - Anaesthesiologist in training

​Being a young doctor in specialist education - my thoughts on the role of simulation for patient safety:

I think any junior doctor has tried to be in a situation where they felt inadequate to deliver the best treatment for their patients. This is an awful feeling that will stick with you for a while. But I also think that anyone who has ever worked in a new field knows that "practice makes perfect". This is also true for doctors, but it is no comfort when your "training material" is actual real human lives that depend on your performance. Therefore, I think that simulation is a great way to practice. In my clinical work there is a lot of focus on academic and technical skills. It seems natural that this is the main focus but as a junior anaesthesiologist I am fully aware that sometimes what saves the patient is great teamwork and non-technical skills.

In simulation you practice scenarios in an environment where learning is the focus. You feel safe because the scenario is controlled, and you and your team members are all in it for the same reasons – to practice and to get better. Even though simulations are often short – maybe 20-30 minutes and you rarely have more than two or three a day – when debriefing and sometimes watching yourself in replay, you are stimulated to reflect on not only how you act as a team member but also how you can make your team members perform even better. In simulations and the following debriefing by an educated facilitator you get a few specific skills to work with and you get specific tools to help you develop your everyday practice. This helps to develop on another level than just working in the clinic and I am sure it makes me a better doctor for my patients.

Marlene - Philosopher

Today, 17th September, has by WHO been coined World Patient Safety Day, acknowledging the fact that patient safety is still a global health priority. Although we have come far from where we were twenty years ago, at its beginning, we are still not there. In 1999 the US based Institute of Medicine report To Err is Human claimed that between 44.000 and 98.000 patients in the US die every year from preventable adverse events. This claim was based on the result of a study of pervasive medical error in the US(1), later supported by another US based study(2). These studies were followed by Australia(3), Denmark(4), Britain(5) and a Canadian study in 2004(6), suggesting that adverse events are in fact an international problem. Several of the adverse events identified in these epidemiological studies were estimated to be avoidable. Hence, the beginning of "patient safety" as a term, and as movements to support and improve patient safety began, so did the complexity and dilemmas of how. How do we achieve patient safety? And specifically for us at CAMES, was simulation a viable way forward?

From a philosophical and ethical point of view, I believe that patient safety and the promotion of safety cultures, as we still work towards, is an ethical claim - a normative project – "patient safety ethics". We are obliged to work for patient safety, and healthcare systems are thus accountable for providing safe healthcare at all levels. The opposite would be alarming to say, "we don't want safety for patients"! But is safe possible?

Ethics is about "what we ought to do" it is about the fundamental principles that define our values and determines our moral duties; it is the individual, organizational and societal beliefs about what is right and wrong. And it is accounted for in our actions. In our behavior. Ethical behavior is about doing that which is morally "right". (Off course in ethics, like in other fields, the right action can depend on the theoretical approach applied.)

It might sound easy, but it is not always. We may, for instance, perform the right actions, but the consequences can still fall negative. We may also be so lucky, that we choose a wrong action, but the consequences fell positive. How do we then evaluate the person (actions)? Consequences vs intentions? How does that person continue his/her path in the healthcare system? We need to be able to accommodate versatility, and acknowledge that situations are often ambiguous in healthcare - when we judge, when we organize, pass laws and when we educate and train with simulation. The ethical claim pertains to all stakeholders. We want to take care of the patients, but we must remember to take care of the healthcare workers as well. What are their working conditions, the realm of possible performance? Are these conditions justifiable from an ethical perspective?

In Healthcare we have what has been known as first (patients) and second (healthcare workers) victims after adverse events, that we need to take care of. What are their needs, how do we support them and heal them? How do healthcare workers cope? How do they disclose and apologize after adverse events? Should they always? And why is it so difficult? Ethics is one thing and Law another, and they do not always match up. Some may want to disclose and apologize but they are afraid of the "system"? They might be afraid of the consequences for their professional path. But is the fear rational etc.? These are themes we keep on returning to, because they are still out there, and we need knowledge, training and local systems to support. It is known that healthcare workers can be traumatized after adverse events, some even leave the profession, especially if they are not supported. These situations are examples of what can be simulated, and we do so in some courses at CAMES. We create opportunities for healthcare workers to train these difficult conversations in a safe environment, by simulating "real life" cases, or even their own. Depending on the issues, we use table top simulations, needs analysis, and many other methods to understand patient safety. These might show that some of the problems in patient safety are structural/organizational – at times; time to prepare for the next patient is missing, at times there are no suitable rooms to take a conversation to name a few examples, or they can lie in beliefs and values of the culture. Bringing in ethics into these different methods may remind us that there can be more complex issues behind what might be disguised as purely professional or personal challenges.

Healthcare is full of complexity and dilemmas, coupled with patient safety it becomes even more challenging. As a philosopher and human factors expert I engage in the complexity and use different methods and theories from various fields to deconstruct and comprehend patient safety issues. As a philosopher I am trained to attempt to understand a problem on all levels, from the metalevel to the very near local specific context; as in "work as is", and from all involved parties' perspective. (It is essential to me to create the full picture to give qualified perspectives/solutions/research questions on different themes.) I find that this philosophical competence often makes me notice things others don't see. I believe that our multidisciplinary team at CAMES is a rare asset. We complement each other and can innovate on patient safety issues, be it research, simulation, education or quality improvement work, all of which feeds back into improving our simulation efforts.

So, was simulation viable? Yes, as it has shown to improve patient safety. The question then is - is simulation an ethical issue pertaining to patient safety? If we can train people in safe simulated environments instead of doing the "training" on real patients, shouldn't we? If you through simulation training can prepare healthcare workers for difficult tasks, make them feel safe and competent, shouldn't we? Yes, we should.

(1) Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I [see comments]. N Engl J Med 1991 Feb 7;324(6):370-6.

(2) Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, et al. Incidence and types of adverse events and negligent care in Utah and Colorado [see comments]. Med Care 2000 Mar; 38(3):261-71.

(3) Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian health care study. Med J Aust 1995; 163:458-71.

(4) Schioler T, Lipczak H, Pedersen BL, Mogensen TS, Bech KB, Stockmarr A, et al. Incidence of adverse events in hospitals. A retrospective study of medical records. Ugeskrift for Læger 2001; 163(39):5370-8.

(5) Vincent G, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. British Medical Journal 2001;322(7285):517-9.

(6) Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004; 170(11):1678-86.

Rikke - Consultant anaesthesiologist

As an anesthesiologist patient safety plays a significant part of everyday practice - each time a patient is anesthetized and when operations are performed, medicine is administered, and procedures are carried out. It is necessary that the team has a common understanding of the situation and make the correct decisions, both individually and collectively. The team has not always collaborated previously – especially in acute situations the team is established anew in the treatment of the single patient. It can present many challenges if the team has not been trained in structured actions and decision making before. Errors occur – often minor - which do not afflict the patient – but it does happen that the patient suffers an injury or experiences side effects because of the errors. We have a centralized system for learning after incidents. If an error is of medical technical character the health professional specialist often can improve by training, by working with, for example, phantoms, technical simulators, workshops, animal models, e-learning etc. The clinician will often be aware their need to improve technically and will often be especially motivated to do so.

On the other hand, in my experience the errors which are based on non-technical skills are less acknowledged. Specifically, it is often difficult for the team to acknowledge, for instance, bad communication, lack of speak-up or lack of leadership, which did not function in the team. It is more difficult to work with and to train non-technical skills in the everyday clinical practice. I see a great strength in the possibilities within full-scale simulation to train the non-technical skills in the laboratory within all medical specialties and within the most common clinical situations.

I also work as course director at CAMES for the mandatory courses in the specialist training in anesthesiology and I strive to implement patient safety in all courses and preferably in all full-scale simulations. I believe that training in non-technical skills within different aspects should be learning goals for all simulations.

Within full-scale simulations it is possible to create scenarios where you can train both technical skills but also to choose subjects among the non-technical skills such as team management, speak-up or collaboration. The facilitator can specifically choose to debate and analyze in the debriefing: How did the team make the decision on the treatment. On what basis did they make the decision? Who made the decision. Was there anything which was not said, etc.?

It might seem artificial to stage such themes and elements from the patient safety culture as specific learning goals but in my experience participants always gain new insights when the team debates and analyzes what did in fact happen during the full-scale simulations regarding the non-technical skills. And addressing these issues in simulation can pave the way to discuss similar issues in clinical practice.

It presents a challenge to move this newly acquired knowledge from the simulation laboratory to the clinical practice. In part it is the responsibility of the individual simulation participants to articulate learning goals on the basis of the newly acquired knowledge from the courses at CAMES. This is the concept of transfer. We also work with this issue at CAMES and always look for ways to improve this even further.

Anja - Nurse, Risk Manager

Simulation plays a crucial role in patient safety work. With simulation, we can create situations where healthcare professionals experience real life problems, and can discuss the challenges they face - emotional, pragmatic and skills-wise - and how to react to these challenges.

In patient safety work, both proactively and reactively, simulation is often part the solutions.

Solutions to patient safety problems arise on the basis of analyses. Solutions are described in action plans. The impact of an action plan is assessed based on a set of principles, depending on these principles, the action plan is categorized as having a "very strong" impact, a "strong" impact or a "less strong" impact, respectively.

Using simulation is an action plan with a "very strong" impact since, in simulation you can practice processes and procedures without the time pressure from everyday work flow and test the use of various equipment and devices. In addition, it shows a strong focus from leaders and managers on safety – a commitment to help their workforce to do the best job they can.

An example of simulation's role in the proactive patient safety work is the tabletop simulation. Tabletop simulation is of great value when planning and organizing interior for new hospital constructions and wards. In tabletop simulation, Lego figures are moved around on a floor plan of the area and provide an important picture of the most appropriate organization interior in terms of flow patterns in and out of the hospital and around the wards.

A great example of the important role of simulation in the reactive patient safety work is from an action plan based on the analysis of the diagnosis of meningitis and meningococcal disease. The plan was worked with and optimized using simulation.The purpose of the action plan is to help ensure clear and action-oriented guidelines on lumbar puncture so that uncertainty about performing a lumbar puncture is not a barrier to performing the lumbar puncture procedure.

A simulation course now certifies doctors in performing lumbar puncture and CAMES is responsible for offering the train-the-trainer courses.

In this way simulation can help to shape those solutions that make a difference. It can contribute to prepare those working in the healthcare system for their job and the challenges it contains. And this – being able and feeling able – to do one's job should have a positive effect on health worker safety and wellbeing over time.

Birgitte - Anthropologist

Safety as a concept
The concept of safety, and how to improve it, keeps evolving. After realizing that it was insufficient to fix technical problems attention turned to the vulnerability of systems that included fallible humans.

Then came the concept of safety culture, which can be understood as both the problem and the solution, and today some speak of resilience, others of adaptivity, and yet others of Safety II, or of wicked problems in complex organisations. Along the way connections between cause and effect has become increasingly blurry and negotiable.  

Safety as a problem
Blurry connections between cause and effect are hard to handle when you want to improve safety. Where to start? How do our reporting formats and root cause analyses reflect the problem? How may our reporting systems direct our attention to particular issues and away from others that may be more important? Where is the problem really? Can we ever make it go away? If not, then what? How do we then prioritize and design meaningful interventions?

It is some people's job to make these decisions. How should they understand what safety is? They could consult with safety researchers, but they could also put on some clogs and spend time in a ward to see how safety plays out there on a day-to-day basis.  

Safety as a practice
In the clinics and wards health workers go about their daily tasks juggling patients' needs, relations to colleagues, expectations from management, all sorts of equipment, working schedules and a requirement to keep learning and perhaps also teach as they work. For many of them practices that could be related to patient safety – and their own safety – are hard to distinguish from professional pride in doing a good job delivering quality health care, while juggling all the competing considerations above. How do health workers make these needs, relations, expectations, skills, schedules, and requirements align? When does something called safety figure in this constant alignment process? How is it practiced and talked about? 

As an anthropologist I am trained in exploring and questioning our ideas and assumptions about the world. Zooming in on safety in the health care system, I trace the many shapes that safety takes in different contexts and how they may or may not connect across contexts. The potential of simulation as an extremely versatile method for exploring, experiencing and testing safety practices, interventions and concepts – and their interconnections - is far from exhausted.

Martin - Obstetrician

When I first started at CAMES 16 years ago it was as a student teacher as part of a small group of students (about 10 or so) who were responsible for teaching other students clinical skills in our skills lab. Our mannequins were not what you would consider high-fidelity (in any sense of the word) and there was limited time allocated for each student. I remember teaching two skills that highlighted the link between patient care and simulation particularly well; the first was putting in an IV and the second was insertion of a nasogastric tube. In both instances the students were instructed to practice on the mannequins first and those who dared then practiced on each other. When practicing on each other, the initial trials on the simulators became important for the students who were about to get a venipuncture or a nasogastric tube. The importance of having some initial training before practicing a new skill for the very first time was pretty obvious for the students attending these simulation courses. Unfortunately, it is often less intuitive for policy-makers and hospital administrators.

Over the past 10 years, we succeeded in implementing mastery-learning for a handful of technical procedures at CAMES. That said, we are still far from reaching our goal; that all critical, painful or dangerous procedures should be practiced in a safe environment free of patient risk before being practiced in the clinical setting. In the example above, the students knew it. If their buddy had not practiced on the mannequin sufficiently before moving on to putting in an IV, then it would require more attempts. And who wants to be a human needle pillow when there is a perfectly suitable alternative sitting just next to you?

The worst case when putting in an IV is a failed attempt. For more advanced procedures such as resuscitation, surgical procedures or invasive diagnostic procedures, the patient's life often depends on a qualified team of healthcare professionals who have received proper training in the simulated setting. If these patients were in charge, they would insist that all procedures that can be practiced safely are practiced in the simulated setting first before any clinician is allowed to move on to the clinical setting. The challenge is for future policy-makers and hospital administrators to ensure patient safety through the use of mandatory simulation-based training of all procedures that are considered potentially harmful or dangerous.

Peter - Psychologist

As psychologist, I am interested in how people experience the world and how the act in this world. My specialization is in work and organisational psychology, and I work in the tradition of Kurt Lewin. That means that I am interested in persons in their environment. My unit of analysis is not the person and not the situation, but the person in the situation. This makes a difference, and things complicated. And it makes simulation so interesting, because we can study persons in situations and use simulations to educate and train people in situations. Using simulation is great for this, as it combines experiential learning methods with reflections.

How is this relevant to patient safety? In many ways. Obviously, if people are able to do, what they are supposed to do, that has an impact on safety. Psychology comes in here in at least two ways:

  1. Find out, what exactly the job is that people do and what they need to learn in order to do this. This concerns the topic of needs analysis. We want to make sure, that what people learn in simulation is actually usable in practice. Not much sense in training them for a task they do not actually do in practice or for contexts that do not match theirs. So, for example, if we want people to learn to speak up, we want to make sure they understand to what degree their workplace is ready for them to do. We need to help them finding the balance between challenging their work places and to function in them. This way we can help them reflect upon and to find their way through personal and ethical dilemmas of their job. And this was, we can help them to stay safe and to work safely.

  2. It takes a lot of psychology to convince healthcare professionals that it can make serious sense to do „as if" they would treat patients. This concerns the psychological safety and effectiveness in the teaching and learning situation. It is about discussing challenges in a way that does not trigger all the defenses, that we as humans often have. This way, simulation can actually contribute to change, what people call safety culture. In simulation we can help people to learn about challenges and positive performance. And this „meta-competence", people can take with them to their clinical work. Several project around the world are taking this route successfully. So, we can help health workers to talk different around challenges they experience and about the good ideas they encounter. They get tools and a mindset to investigate the basis for problems and good solutions and to constructively search for ways to reduce the problems and to preserve the good ideas.

To consider the person in the situation, we need to understand the interplay between human, technology and organization, when we want to make progress in patient safety and quality of care. Simulation can become a laboratory, that we use to optimize or find the best equipment, or to experiment with different forms of work organization. This way, we might be able to help getting rid of challenges from systems instead of of training people how to handle this.

So far, we spoke about the „action" side that psychologists are interested in. A few closing words around the other area: the experience. It is not a new that human beings experience situations not only rational, but that emotions play a part. In decision making, team working, perception – and when it is about getting through a working in a healthy manner. As psychologists, we can contribute to lift the whole human experience into the professionals space. Where emotionally challenging situations and work under uncertainty are a given of the work's nature, also emotional support should become a given in basic education, the continuous development and – most importantly – everyday practice. Preparing for an inherent part of work should be a mandatory expectation, not something individuals need to find out for themselves.

We can help understand why one works well with some colleagues and not with others. We can help understand why one finds good decisions often, but not always. We can help to establish the link between, what people do in healthcare and what the outcome of those actions are for the patient, their relatives and the whole healthcare system. And we can help to optimize the experience of being health worker.



Kurt Lewin



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