May 15, 2020By Dr. Kim Baily

Hierarchy Errors Addressed with Medical Simulation

Communication errors are well documented sources of medical errors which, according to some literature sources, may be responsible for as many as 60-70% of reported mistakes. As the research article “Using Simulation to Address Hierarchy-Related Errors in Medical Practice” (Calhoun et al) covered below states , “Hierarchy, the unavoidable authority gradients that exist within and between clinical disciplines, can lead to significant patient harm in high-risk situations if not mitigated. High-fidelity simulation is a powerful means of addressing this issue in a reproducible manner, but participant psychological safety must be assured.” Here, Dr. Kim Baily PhD, MSN, RN, CNE, previous Simulation Coordinator for Los Angeles Harbor College and Director of Nursing for El Camino College, looks at how healthcare simulation can be used to identify and correct hierarchy errors in professional provider teams.

One type of communication error relates to the hierarchy of team members in which team members in perceived lower levels do not question or verbalize an incorrect order given by someone in a higher level. Hierarchy may be defined as a group of persons organized into successive ranks or grades based on their disciplines, levels of authority or experience with each level subordinate to the one above.

Calhoun et al. identified a critical event related to staff with lower authority failing to call out an error by a team member perceived to have higher authority. The authors replicated the error in a high-fidelity simulation in order to address the issue (Calhoun, A., Boone, M., Porter, M., & Miller, K. Using Simulation to Address Hierarchy-Related Errors in Medical Practice. Perm J 2014 Spring;18(2):14-20 http://dx.doi.org/10.7812/TPP/13-124).


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The identified error involved the inappropriate administration of amiodarone. A patient presented with sudden onset of reentrant supraventricular tachycardia (SVT) and, because the attending physician was concerned about the possibility of hemodynamic compromise he/she initiated the institution’s crisis team.

During the course of therapy the physician leading the team inadvertently requested the incorrect medicine amiodarone to be administered by fast intravenous (IV) push instead of adenosine, the medication recommended by the American Heart Association Pediatric Advanced Life Support materials for this condition. The team did not question the order and administered the amiodarone as requested, which resulted in severe hypotension and bradycardia that required resuscitation.

Following the event, most team members stated that the amiodarone order concerned them but they felt uncomfortable directly addressing the error to the attending physician. Several years after the event, the authors created a pilot healthcare simulation scenario which mimicked the original case.

A series of medical simulation scripts and flow charts were developed which matched the original event (case fidelity). The authors stated that the simulation scenario could not run in a rigidly linear fashion but should be allowed to follow branched paths. Three objectives were identified:


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  1. Identify sources of psychological pressure generated when trusted authorities give incorrect orders.
  2. Identify the appropriate Pediatric Advanced Life Support algorithm for stable SVT.
  3. Identify the appropriate pharmacologic and electrical treatment for stable SVT (ie, adenosine and synchronized cardioversion).

Each scenario included the use of confederate faculty who deliberately directed the team to administer the wrong medication. The confederate incorrectly identified narrow complex SVT and mild hypotension as wide complex ventricular tachycardia and then requested the team to administer amiodarone by rapid IV push. In order to maintain environmental fidelity, the simulations took place in the pediatric intensive care unit (PICU) or the Pediatric Emergency Department (PED).

During the prebriefing, the learners were told that an attending would join the scenario to participate in the learning process. The authors expressed concern over the need for a confederate to deliberately misdirect the learners but this was an appropriate way to duplicate the original event. The Team Performance During Simulated Crises Instrument was used to access case outcomes and gap analysis (participant self-appraisal) was used to quantify team self-insight.

Five sessions were conducted (3 in the pediatric intensive care unit and 2 in the Pediatric Emergency Department). The team response was considered successful if up to two team members intervened and the correct medication was administered. The teams were unsuccessful at addressing the error in 4 (80%) of 5 cases. Trends toward lower communication scores (3.4/5 vs 2.3/5), as well as poor team self-assessment of communicative ability, were noted in unsuccessful sessions. Because of the small sample size, none of the differences were statistically significant. “Learners regarded the sessions as useful, informative, and well organized regardless of whether the hierarchy issue was successfully addressed or not, as indicated by a score of 5/5 for the group that successfully addressed the error and an average score of 4.6 (range = 4.25-5) for the groups that did not successfully address the error”.

Although this study was small, it was able to mimic an original case where errors in hierarchy had led to patient harm. During the clinical simulation, some participants had noted the error but had not spoken out because of a lack of confidence in their own judgement. The study indicated that the “successful group underrated their communication skills whereas the unsuccessful groups overrated their communication skills”.

Learners were not informed of the role of the confederate in the debriefing session until the learners had had a chance to express their feelings and to be assured that this experience was designed for learners to allow acquisition of a personal experience which would lead to improved patient care in the future. There is much debate in the literature about the psychological safety of learners and the potential harm to learners in healthcare simulation particularly in those simulations where errors/patient harm are part of the scenario.

The authors, concerned about this issue made every attempt to protect the learners but concluded that the case could not be presented in any other way. Carey et. noted that the experience of the faculty / debrief team was paramount in ensuring learner safety. Medical simulation provided a valuable opportunity for healthcare professionals to experience a situation where they must speak up to a team member with perceived higher authority. Finally it is worth noting, that all participants perceived the experience as valuable.

Read the Full Hierarchy Error Simulation Research Article Here!


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