Adverse Drug Event (ADE) Drill Scenario
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OSF St. Joseph Medical Center
Bloomington,
Illinois,
USA
Simulations provide great opportunities to learn and don't always have to involve expensive technology. This simple simulation involving an adverse drug event (ADE) uses the "Standard Orders for Epidural Catheters for Post-Operative Pain Relief on Nursing Units." The scenario provides a low-cost mechanism to gain useful insights into fundamental safety characteristics of an organization's culture. All you need is one nurse volunteer and one observer.
Background
This ADE scenario was initially conducted at OSF St. Joseph Medical Center with one nurse who was asked to run through a specific scenario involving adverse drug events while someone else observed. The following are some things the OSF staff learned as a result of conducting the scenario:
- Teamwork: The nurse wanted to do it all and did not pull in extra help.
- Internal Communication: The nurse looked for Narcan taped to the pole, even though it had been discontinued several years ago.
- Human Factor Design: The nurse went to get medication from the dispensing machine, a biometric identification system that does not always work. A quicker access mechanism would have been more appropriate.
- Planning: Epidural patients should be placed closer to the nursing station.
Directions
The ADE Drill Scenario tool consists of two documents:
- The document entitled "Physician’s Orders: Standard Orders for Epidural Catheters for Post-Operative Pain Relief on Nursing Units" contains the order set that the nurse needs to follow in order to handle patients on epidural catheters.
- The document entitled "Epidural Scenario" describes the scenario for the simulation.
To conduct the simulation:
- Find an empty room on a surgical unit (giving the unit prior notification) and read the ADE scenario to the nurse volunteer.
- Give the nurse the order set, which she should already be familiar with, and let her run through the scenario, pretending to be with the patient, to see how things unfold.
- Observe the process and make notes of all that the nurse does.
- At the end of the scenario, debrief the nurse volunteer to identify what was learned. Share the observations and insights from the scenario with a wider audience to provide a larger opportunity for learning.
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