**Instructor's Guide to Facilitating a Doc-U-Drama Workshop**

**Margaret Kirkegaard, MD, MPH**

**Jeremy Fish, MD**

**Table of Contents:**

**Overview of
Doc-U-Drama................................................................
2**

**Step by Step Guidelines for Facilitating a Doc-U-Drama
Workshop............. 7**

**Handout for
Learners.......................................................................
10**

**Doc-U-Drama Script: The Case of the Sliding
Scale.................................11**

**Sliding Scale Discussion
Points.........................................................\....15**

**Doc-U-Drama Script: The Case of the Slippery
Slope................................16**

**Slippery Slope Discussion
Points...........................................................21**

**Doc-U-Drama Script: The Case of the Good
Shot.....................................23**

**Good Shot Discussion
Points................................................................25**

**Doc-U-Drama Script: The Case of the Sticky
Eyeball..............................\...26**

**Sticky Eyeball Discussion
Points...........................................................28**

**References......................................................................................29**

*Please use these materials to facilitate patient safety education.
Please give credit to Jeremy M. Fish, MD and Margaret Kirkegaard, MD,
MPH, on any reproduction or use of these documents*.

Doc-U-Drama: Using Drama to Teach about Patient Safety

Margaret Kirkegaard, MD, MPH and Jeremy Fish, MD

(accepted for publication in *Family Medicine* 6-25-04)

Patient safety has emerged as a significant concern in the American
health care system. The Institute of Medicine report, *To Err is Human,*
summarized numerous studies documenting the failure of the American
health care system to provide safe care. The IOM concluded that between
44,000 and 98,000 deaths each year are attributable to medical errors.
More people die each year from medical errors than from breast cancer,
AIDS, or motor vehicle accidents.

One would think that such a significant problem as medical errors, with
such high morbidity and mortality, would grab the attention of residents
in training and spur them to tackle this issue. But in fact, patient
safety has proven to be a very thorny subject to teach due to two
reasons. The first is that the subject of errors is over-laden with
negative emotional content. "*To Err is Human"* may be true, but to not
talk about errors is even more human. Several studies document that
residents experience considerable stress, anger and guilt due to medical
errors.^1^ Emotional coping mechanisms include denial, discounting, and
distancing accompanied by long-lasting and profound doubts.^2^ Anxiety
about the threat of malpractice litigation further compounds the
negative emotions.

The second impediment to learning about patient safety is that
addressing patient safety requires a paradigm shift. Borrowing from
other high-tech industries such as aviation and nuclear energy, health
care has begun to apply human cognitive theory to analyzing medical
errors. Most medical errors are not due to careless or incompetent
providers at the bedside but are the result of a series of latent
conditions embedded in the complexity of medical care. Preventing errors
means designing the health care system at all levels to make it safer.
Residents are accustomed to learning new information by studying hard
and then working hard to apply their new knowledge in patient care. In
the case of patient safety, trying harder will not work. This shift from
a "name, blame, and shame" paradigm to a "systems" approach is difficult
for residents to assimilate.

We have found that typical learning methods such as didactic lectures or
small group discussions to be relatively ineffective in teaching patient
safety. Residents find the content (medical errors) emotionally
threatening and the solution (system redesign) baffling. Residents
prefer experiential or case-based learning, but for medical errors this
type of M and M discussion is too threatening. In order to improve
educational effectiveness, we searched for alternative methods of
presenting this material.

Doc-U-Drama or dramatic simulation of medical events involving an error
or multiple errors has provided a unique way of presenting this material
to residents. We wrote scripts dramatizing real events involving adverse
outcomes as the result of a medical error. The scripts portray the
complexity of modern medical care. We included roles for multiple health
care providers such as the residents, attending physicians, nurses, lab
technicians, receptionists, and patients across multiple settings where
health care is provided such as the bedside, clinic, hospital ward, and
residents' lounge. The scripts not only convey the words and actions of
the individuals but also the feelings of the characters. Here is a small
example from one of the scripts:

> Float Nurse: (speaking to FP res) Can I ask you a question?
>
> FP res: (in a self-disparaging voice, distracted) I don't know if I
> can give you any good answers....
>
> Float Nurse: Well, I'm a little lost here.
>
> FP res: Yeah, don't you usually work in the Nic-U?
>
> Float Nurse: Yeah, (laughing) I haven't taken care of a patient older
> than a month for a long time and today I don't think I have one
> patient less than 80-years-old. Still, sometimes it's nice to have a
> change of pace. Anyway, Dr. Cardio was here earlier and wrote this
> order for Mrs. Hill that I can't read. Can you look at it? (hands FP
> res the chart)
>
> FP res: That's Dr Cardio alright. It looks like something "K (kay)".
> You better page him. He's pretty fussy about his orders. How is Mrs.
> Hill today?
>
> Float Nurse: She's still in a fib according to the sign-out but
> stable. Well, I already tried to page Dr. Cardio. He's in the cath
> lab. The tech said that he would call back in a bit. I just thought
> maybe you would be able to read the order.

This interaction and the many others that are included in the
Doc-U-Drama scripts allow the participants to role-play the seemingly
benign, everyday interactions that eventually allow errors to occur. In
this instance, we see issues such as medical hierarchy, staffing issues,
abbreviations, illegible handwriting, and doctor availability that will
all contribute to an eventual adverse event. These conditions are so
commonplace that most medical professionals consider them "normal"
despite the opportunity for errors to occur.

During a learning session, residents are invited to participate in the
enactment of the scripts. If attending physicians or other health
professionals participate, then dramatic roles are assigned that do not
match the participants' professional roles. The scripts are performed
unrehearsed. Sometimes simple props such as nurses' hats or charts and
signs indicating the various locations are used. Each script typically
takes about 15 minutes to perform and is followed by a discussion.

The use of drama has been remarkably effective in engaging residents in
learning about medical errors. Drama has been used previously in medical
education to explore the doctor-patient relationship or ethical and
philosophical questions. These scenarios broaden the focus from the
doctor-patient relationship to explore the whole context in which the
doctor-patient relationship is embedded. Doc-U-Drama is a vehicle to
build the story that surrounds an adverse event. As the participants
play the parts, they become engaged in the unfolding events and
emotions. The scripts provide the right balance between engagement and
anonymity when talking about making mistakes. Learners are able to
experience the emotions of the characters with out having to reveal
their own past painful experiences involving errors. The creativity of
the dramatic production pulls the learners out of their detached
analytical mode and promotes creative thinking about medical errors. In
feedback surveys, 97% of learners agree that Doc-U-Drama creates an
emotionally safe environment for exploring medical errors. Residents
report that the experience is "fun" and requires no preparation such as
reading articles or research.

Although the scripts themselves show the complexity of medical care and
the conditions that predispose errors to occur, the real learning occurs
in the discussion after the performance. Most of the time, the first
reaction of the participants is to try to dissect the scenario to see
who is to blame for the error. This is generally quite enlightening to
the participants because they discover that they disagree about this.
The multiple dramatic roles facilitate multiple perspectives of the
event. This discussion leads to a developing awareness of latent factors
or the set of circumstances that cause providers to err. Factors such as
time demands, distractions and interruptions, complicated medical
protocols, insufficient training, pressure to perform, inadequacy of
supervision, complex communication and rigid hierarchies are recognized
and discussed as latent conditions that contribute to medical errors. In
one recent discussion, a resident summarized this realization by
concluding that "everyone and no one" was to blame. In feedback surveys,
94% or participants found Doc-U-Drama to be an effective way to learn
about medical errors.

Doc-U-Drama has not been subjected to any outcomes analysis to assess
the impact on residents' attitudes, knowledge or skills but the
immediate results have been successful in engaging learners about
systems-theory in medicine. In his book *Art and Physics,* Leonard
Shlain (a surgeon) describes how artistic vision can stimulate a
paradigm shift in scientific thinking. He provides numerous historical
examples such as the conic perspectives of Giotto prefiguring the
discovery of elliptical orbits and the revolutionary Cubism of Picasso
supporting the visionary work of Einstein.^3^ Patient safety represents
the cusp of another paradigm shift in medical science. We need to look
at health care as a complex system of multiple interactions rather than
a series of discrete doctor-patient exchanges. The artistic medium of
drama may facilitate this paradigm shift. The unfolding story of
Doc-U-Drama places the medical errors in context and stimulates creative
thinking about system redesign. The drama is emotionally engaging but
also non-threatening. Learners consistently report that these sessions
are "fun" and "feel real". We recommend Doc-U-Drama as a promising tool
for teaching residents about patient safety.

\_\_\_\_\_\_\_\_\_\_\_\_\_

Wu AW, McPhee SJ, Lo B. How house officers cope with their mistakes.
West J Med 1993;159:565-569.

^2^ Mizrah T. Managing medical mistakes: ideology, insularity and
accountability among internists-in-training. Soc Sci Med
1984;19:135-146.

^3^ Shlain LM. Art and Physics. New York: Morrow, 1991.

**Step-by-Step Guide to Facilitating a Doc-U-Drama Workshop**

1.  **Goal**: Help learners understand the systems theory of medical
    errors.

2.  **Time frame**: This workshop has been performed in a time frame
    anywhere from 60 minutes to 3 hours. I have found approximately 90
    minutes to be the most comfortable time frame.

3.  **Location: C**lassroom or conference room. Need a little space to
    move around.

4.  **Attendees:** This workshop has been performed in interdisciplinary
    settings with nurses, residents, and attending physicians present by
    JF. I have worked primarily in settings with attendings, students
    and residents. Since, inevitably learners initially react to the
    scripts by assigning "blame" for the adverse events described; mixed
    groups are a little trickier to facilitate discussion.

5.  **Attendee Preparation:** None

6.  **Materials:** I give each participant a one-page handout. I also
    make it available to them as a memo to beam to their PDA if they
    want.

7.  **Shock Start:** I usually start the workshop with a brief
    introduction starting with the awful statistics about medical
    errors. (See handout)

8.  **Engaging the learners:** I then ask them why such an important
    topic has been relatively neglected in medical education. "What
    makes talking about errors so difficult?" Usually, the first answer
    given is the issue of malpractice. I then ask them if they think the
    threat of malpractice makes anyone a better doctor. I also sometimes
    point out (depending on the tenor of the group) that only 2% of
    preventable adverse events lead to suit and only 1% of those are
    compensated. (Harvard Malpractice Study) Other answers to my
    question follow from there, such as: perfectionism in the medical
    culture, inability to distinguish preventable adverse event from
    natural history of disease, lack of time to really discuss errors,
    fear of being labeled an "incompetent resident", "turf wars" i.e.
    nurses blame residents or residents blame nurses. Others that I
    introduce are the imposter syndrome, (a syndrome characterized by
    fear that others will eventually find out that the individual is not
    really competent, common among residents, especially women.) and
    severity bias ("no harm, no foul", if a mistake is made but no harm
    is attributed then it is "okay"). I close this discussion by
    acknowledging that all these things do make it hard to discuss
    errors at the same time implying that this group of learners has
    more *chutzpah* than others because we are going to discuss errors.

9.  **Bad Apples vs. Swiss Cheese:** I then give a brief and very visual
    demonstration of the bad apple vs. swiss cheese theory of errors.
    (These names usually generate a few giggles and we joke how
    researchers can get big bucks from the government to come up with
    these "silly" names.) I ask for six volunteers to come to the front
    of the room. I ask them to line up across the front of the room and
    give them titles: Doctor A, Doctor B, nurse, pharmacist, family
    member, and patient. I give Doctor A a real arrow that I borrowed
    from my teenage daughter (who aspires to be an elven warrior
    princess.) I give the next four pieces of "swiss cheese". (I used to
    use real swiss cheese, but one day, just before I was going to do a
    workshop, some one in my family had eaten the cheese so now I use
    pieces of yellow paper with holes in them.) The sixth person in line
    is the patient.

> I ask them to envision a scenario where Doctor A, who is leaving on
> vacation, is signing out over the phone to her partner Doctor B about
> Patient X who is "108 years old, has diabetes, chronic renal
> insufficiency, a fib, hypertension, congestive heart failure and
> hasn't had a bowel movement in 8 days". (In other words, a pretty
> typical patient on the ward.) At the moment when Doctor A is listing
> the meds to Doctor B, there is a fraction of static on the line and
> Doctor B hears "Dig point-two-five" instead of "Dig
> point-one-two-five". (I can alter the perceived "blame" of the event
> by changing the initial "error" to forgetting to write the correct
> dose or accidentally miswriting the wrong dose. How much "blame" I
> introduce into the scenario depends on the tenor of the group.) This
> is the event that causes the arrow or "error" to fly. I then take the
> arrow from the first person and move it along in front of the next
> person who is portraying Doctor B. Doctor B is a conscientious doctor.
> He believes that he is diligently and scrupulously carrying out his
> sign out instructions from Doctor A. And the arrow goes through a hole
> in the "swiss cheese" paper. As the arrow is going through the various
> layers of swiss cheese, we talk about how medical professionals daily
> actually "defend" patients from errors much more often than they
> create errors. I ask the learners if they have ever "caught" an error.
> This usually creates a lot of nodding.
>
> I then move the arrow to the next person in the line, the nurse. I
> describe how she is a float nurse and not very familiar with digoxin
> dosing, so she looks it up in the drug handbook where the dose is
> listed in a range from 0.125 to 0.25. She concludes that this must be
> the "correct" dose and administers it. The arrow flies through another
> hole. I usually pause here and ask if anyone has ever been "saved" by
> a nurse noticing that the order wasn't correctly written. (more nods)
> The last person in line is the patient's family member. Generally the
> family member is one of those "obnoxious" family members who are
> always questioning orders. I try to show that this type of
> "interfering" behavior can actually protect errors from being made.
> The arrow flies through this person's cheese and hits the patient. The
> patient becomes dig toxic, goes into heart block and dies.
>
> I then ask if any of the medical professionals are "bad apples". Would
> a reprimand or firing any of these people prevent this from happening
> again?
>
> 9\. **Performing the Doc-U-Dramas:** I introduce the Doc-U-Dramas by
> explaining that the scripts are all real events that actually
> happened. I then ask for volunteers. I am usually pretty bold with
> selecting "volunteers" if the participants seem reticent. I also try
> to give roles to learners that do not match their professional roles.
> The scripts are then read by the "players". I have encountered varying
> degrees of dramatic enthusiasm. Some learners really get into the
> parts (usually the extroverts) and some are more bashful. Both
> extremes are actually somewhat funny as the dramatic ones generally
> play off the more deadpan readers. After each script is completed, I
> make sure that the "players" get a big round of applause. In general,
> I have found maintaining a high energy, enthusiastic presence to be
> most successful.
>
> 10\. **Discussion of Scripts**: Each script has different discussion
> points that are listed after the scripts, but, in general, I have
> found each discussion usually starts with some one assigning blame to
> one person or another in the script. "The nurse should never have done
> that...." (Unfortunately, when I do this with residents, nurses
> usually take the "blame". I then gently question if this "blame" is
> really accurate. Is the nurse (or whoever else is identified) a bad
> apple or can we find some "holes" in the "swiss cheese". The learners
> usually respond by looking at the scenario again with different eyes.
> Invariably, there is one of two learners who insist that someone is to
> "blame" and that they, themselves, ***always*** recheck their orders,
> assess the patient or do whatever it is that would prevent the error.
> I have found that the other learners usually confront this person, if
> I just steer the discussion to looking for the "holes". I try to
> introduce some themes about system-theory and remediation of errors. I
> also try to tie the discussion to their own behaviors with questions
> such as:
>
> Have you ever been annoyed when a nurse called you to double-check an
> order?
>
> Have you ever resisted a new "protocol" because it was not what you
> preferred?
>
> Have you ever blamed a co-worker either publicly or privately?
>
> Has anyone ever "blamed" you for a situation where you were on the end
> of the swiss cheese line?
>
> Is your handwriting uniformly legible?
>
> 11\. **Feedback from Learners:** Feedback has been generally positive.
> Comments like, "fun" and "real" are common. The most common "negative"
> feedback is that the learners want a "quick fix", i.e. "So if these
> holes exist, how come we don't just fix them?"
>
> I end the workshop by inviting them to call or email me with questions
> or ideas. I also give them the list of references on the handout.

**HANDOUT FOR** **PATIENT SAFETY M. Kirkegaard, MD, MPH**

**Scope of Pt Safety**

-   IOM Report "To Err Is Human"

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-   44,00 to 98,000 Americans die each year while hospitalized due to
    medical error

-   Deaths due to error exceed the deaths attributable to MVA (43,458),
    breast cancer (42,297) or AIDS (16,516)

-   Total national costs for medical errors is estimated to be between
    \$17 and \$29 billion

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-   JAMA, March 2003, Bates et al; estimated 180,000 life-threatening or
    fatal adverse drug events per year for Medicare enrollees; 50% are
    preventable.

**Barriers to Discussing**

**Definition of Error**

-   Institute of Medicine: An error is defined as the failure of a
    planned action to be completed as intended or the use of a wrong
    plan to achieve an aim. An adverse event is an injury caused by
    medical management rather than the underlying condition of the
    patient. An adverse event attributable to error is a "preventable
    adverse event."

-   AAFP: "A medical error is anything that happened in my office that
    shouldn't have happened and that I absolutely do not want to happen
    again." (Bruce Bagley, past president)

**Bad Apples vs. Swiss Cheese**

-   Some health care providers are incompetent, impaired or corrupt and
    make errors repeatedly despite multiple attempts at remediation.

-   Highly trained and proficient professionals are occasionally trapped
    by a set of latent errors or "holes" and thus make an error in
    patient care.

**Three "R"s**

-   Reporting (Errors, adverse events, and near-misses)

-   Root cause analysis

-   Remediation or redesign

**System Redesign**

-   Reduce complexity: standardized drug doses and schedules

-   Reduce reliance on memory: checklists and preprinted orders

-   Automate wisely: computerized order entry system

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-   Use constraints: remove KCl from units so error cannot occur

-   Human factors engineering: redesign equipment, not retrain workers

-   Analyze "gaps": hand-offs between people, stages and processes

**Pt Safety Resources**

-   IOM (NAS) *To Err is Human, Crossing the Quality Chasm*: www.nap.edu
    and www.iom.edu

-   National Patient Safety Foundation: www.npsf.org

-   AAFP Patient Safety Center: www.aafp.org

-   AHRQ "translating research into practice": www.ahrq.gov

-   JCAHO: www.jcaho.org

-   National Quality Forum: www.qualityforum.org

-   VHA National Center for Patient Safety: www.patientsafety.gov

Doc-U-Drama: The Case of the Sliding Scale

**Players:**

Senior Resident

On-call Intern

Mr. X

Day Shift RN

# Ward Intern 

Night-Shift RN

Lab Tech

Attending Dr. T

**Scene I** (Medicine ward at 5:00 pm: Ward Intern is signing out to the
On-call Intern)

**Ward Intern**: "...*my next patient is Mr. X, who we admitted
yesterday for his 6^th^ bout of DKA in 2 months. Overnight we leveled
out his glucose and electrolytes, and were able to get him off the
insulin drip. He is now on a sliding scale insulin, and the nurse might
call you about it. Just follow the sliding scale."*

**On-call Intern**: *"...ok. Can I see which sliding scale you are
using*?"

**Ward Intern**: "*yeah, sure, I'm working with Attending Dr. T. He
seems to like starting at chemsticks greater than 201 with 3 units and
increasing every 50 by 2 units. Sort of a 3,5,7,9 thing. Not sure why,
because the department chair starts at 151 with 2u and goes up by 3u per
50 increase. Anyway, just use Dr. T's method because he'll be at rounds
tomorrow. Don't forget, OK? I don't want Mr. X to fall back into DKA!"*

**On-call Intern**: "*No problem. 3,5,7,9; start at 201. I think I've
got it. Thanks for the sign-out*"

**Scene II** (Patient Mr. X's room)

**Day-Shift RN**: "*Well, that sums up all I know about diabetes, Mr. X.
I hope it is helpful, you sure have been in the hospital a lot lately.
Is there anything going on? What kind of work do you do*?"

**Mr. X**: "*Thanks for all the info. I just can't seem to keep my
sugars under control anymore. My life is in chaos. I'm a poet, you know.
I only seem to be able to write in the middle of the night. I don't eat
regularly, and I guess I drink too much. Anyway, I appreciate your
concern and think this is the best hospital I've ever been in. No one
has ever explained my diabetes to me so well."*

(In walks the Ward intern)

**Day-Shift Nurse**: "*Hello Dr. Intern. Mr. X sure looks a lot better
today. By the way, his fingerstick was high, 308, do you want me to give
him his sliding scale insulin dose now?"*

**Ward Intern**: "*Yep, he's gonna need it with sugars that high. Also,
I don't really trust these glucometers, could you send a sample down to
the lab to confirm? Well, I was on-call last night and it's my son's
birthday, so I'm outta here. Take care, Mr. X. I'll talk to you
tomorrow*."

**Scene III** (Nurses' break room, nurses are signing out at change of
shift)

**Day-Shift Nurse**: "...*next we have Mr. X, who we weaned off his
insulin drip. He is now on a sliding scale insulin order. He's a poet,
you know. Very nice man. Told me he has a drinking problem. He's taking
PO's well and probably will go home tomorrow if his sugars come under
better control*."

**Night-Shift Nurse**: "*Who's sliding scale are we using*?"

**Day-Shift RN**: "*Oh, I think it's Dr. T's. He likes the 3,5,7,9 for
some reason. Anyway, Dr. Intern said he signed out Mr. X to the on-call
intern and wants to make sure we call him with any abnormal
sugars---he's just learning about sliding scales."*

**Scene IV** (Lab Tech, Night-Shift Nurse and On-Call Intern talking on
the phone)

**Lab Tech:** "*There's a Panic value from the lab for Mr. X, isn't he
yours Night-Shift RN?"*

**Night Shift RN**: "*Hello,...pause....yes, I'm his nurse tonight*"

**Lab Tech**: "*We have a glucose of 428 on Mr. X from 1800 labs*"

**Night Shift RN**: "*Thanks, wow that's pretty high. I'll call the
on-call doctor."*

(Soon after, on phone with On-call Intern)

**Night Shift RN**: "*Hello Dr. On-Call, Mr. X has a glucose of 428,
what would you like to do?"*

**On-Call Intern:** "*Um, 428. Wow, does the sliding scale go that
high?"*

**Night Shift RN**: "*No. Dr. T usually only writes it up to 400*."

**On-Call Intern:** "*What is Mr. X supposed to get for 400*?"

**Night Shift RN:** "*It says "12 units for 351-400*"

**On-Call Intern:** "*Um. Hang on a minute. Let me ask my senior
resident"*

(Turns to senior resident watching television in the call room.)

**On-Call Intern:** "*Hey, Senior Resident, how much insulin should I
give for a chemstick of 428?"*

**Senior Resident:** "*Who's the attending*?"

**On-Call Intern**: "*Dr. T*"

**Senior Resident**: "*Well, he likes 3,5,7,9,12. So, the answer
is...??"*

**On-Call Intern:** "*Come on Senior Resident. I've got 4 admissions in
the E.D. Do you think that I ought to call Dr. T with this?"*

**Senior Resident**: "*Nah, Dr. T doesn't like to be called after hours
with this kind of stuff. 15 outta do it. Give 'em 15"*

**On-Call Intern** (back on phone with Night-Shift nurse): "*Let's give
him 15 units*"

**Night-Shift RN**: "*OK, we'll give him 15 units*."

**Scene V** (Morning Rounds):

(Ward intern Presenting Mr. X to Attending Dr. T and rest of team):

**Ward Intern**: "*Mr. X had a hypoglycemic seizure last night after
receiving 15 units of regular only an hour after I gave him 7 units for
a chemstick of 308*."

**Attending Dr. T**(sternly): "*What, how did that happen!!?? What are
you doing giving a sliding scale every hour, that's not what I told you
to do yesterday. QID, not Q 1 hour."*

**Ward Intern** (defensively): "*No, I didn't order it that way. The
on-call intern gave him the 15 units. I guess he didn't check the
foot-chart to see that I had already given him 7 units just an hour
before*."

**Attending Dr. T**(worriedly): "*How is Mr. X now*?"

**Ward Intern**: "*Not good. He doesn't seem to be able to talk,
although he seems to be waking up OK after his seizure."*

**Attending Dr. T**(angrily): "*Who was the On-Call Intern?*"

**On-call Intern**(sheepishly): "*Um, I was on-call last night*"

**Attending Dr. T** (coldly): "*You have made a grave mistake, Dr.
On-Call. This is an unacceptable error. You've put me and the rest of
the team into medico-legal hot water. I'll have to call risk management.
Buff the chart, everybody. I'm also going to discuss this terrible
incident with the residency director. Give me the name of the nurse who
followed that order. Doesn't anyone know how to take care of Diabetics
anymore*?

**Sliding Scale Discussion Points**

1.  Look at the number of hand-offs of patient information and patient
    care that routinely happen. Look closely at the *context* of
    communication rather than the content. There are verbal orders,
    telephone orders, input from the senior resident, nurse to nurse
    sign-outs---all fairly routine communications that occur in a
    hospital setting but that can contribute to error.

2.  The on-call resident is feeling time-pressured to perform the number
    of admissions. How often does this happen in your hospital?

3.  Availability and communication with attending physicians is often a
    source of frustration for residents. Desire not to appear
    incompetent or unnecessarily bother an attending may compromise
    willingness to communicate with attendings.

4.  The existence of multiple sliding scale protocols (probably a
    dubious practice anyway) creates an extra layer of unnecessary
    complexity.

5.  How would this patient be informed of this "event"? He would
    probably be told that he had an "insulin reaction" or an episode of
    "hypoglycemia". He may or may not be told that it was due to the
    accidental administration of too much insulin. How would this affect
    this patient's compliance with insulin therapy in the future?

**Doc-U-Drama**

**The Case of the Slippery Slope**

**Players:**

Surgery Res 1

Surgery Res 2

FP Res 1

FP Res 2

Voice

Receptionist

Ward Secretary

Float Nurse

Med Nurse

Dr. Cardio

**Scene I** (hospital cafeteria, early in the morning, surgery residents
are having a cup of coffee and talking about the night's call. FP
resident is sitting at a nearby table reading a journal and eating
breakfast)

Surgery Res 1: Wow! You look awful! Rough night?

Surgery Res 2: Yeah. I'll say. Man, I was up all night with this GI
bleeder. We could not get him under control. We transfused him 10 units
and he's still shocky. I think that he might be in acute renal failure
now. His urine out put has been zippo (making a zero with his fingers)
in the last hour or so.

Res 1: Was he a drinker?

Res 2: No, he's been on Coumadin for a fib.

Res 1: Well, that probably had something to do with it. No wonder he
bled out.

Res 2: Well, get this! He was doing just fine but last week he had a
flair of arthritis so his wife called the family practice clinic.
Apparently some doofus there told him to take Motrin. Can you believe
that? The guy's been on Coumadin forever. Anyhow, the guy's wife felt
really bad. Apparently the guy didn't want her to call the clinic in the
first place about his sore knees. Really nice lady. She blames herself
for this whole thing. She's in a wheelchair due to MS and her husband
took care of her. I don't know what they are going to do now....

(residents freeze, FP resident looks up abruptly)

FP res: (talking to self) Oh my God!... I have a couple just like that.
Mr. and Mrs. Anderson. Did I tell him to take Motrin? I don't remember
them calling last week....Boy! I wonder if I should ask them the name of
the patient?......

Voice: Then they'll know that I am the "doofus" who prescribed Motrin.
What if somebody finds out? What if he dies? What if they sue me?

Res 1: Well, I better get back to the unit and check on this guy. Plus
I've got a ton of notes to write from last night.

Res 2: Well, hang in there. Drink lots of coffee. I'm off to the OR
today. You know, "Cut to cure!" (laughs)

FP res: (to self) Should I go up to the unit and see if that's Mr.
Anderson? Of course, it's probably some one else. The resident on call
for the clinic would probably have been contacted if it was a patient of
ours.

Voice: Maybe they are really mad at me and didn't want anyone to call
the clinic. What if I run into Mrs. Anderson. What would I say?

FP res: I'd better get up to the ward. If I get a chance later, I'll
stop by the clinic and see if I can find his chart.

# Scene II **(Medicine ward)**

Nurse: (speaking to FP res) Can I ask you a question?

FP res: (in a self-disparaging voice, distracted) I don't know if I can
give you any good answers....

Float Nurse: Well, I'm a little lost here.

FP res: Yeah, don't you usually work in the Nic-U?

Float Nurse: Yeah, (laughing) I haven't taken care of a patient older
than a month for a long time and today I don't think I have one patient
less than 80-years-old. Still, sometimes it's nice to have a change of
pace. Anyway, Dr. Cardio was here earlier and wrote this order for Mrs.
Hill that I can't read. Can you look at it? (hands FP res the chart)

FP res: That's Dr Cardio alright. It looks like something "K (kay)". You
better page him. He's pretty fussy about his orders. How is Mrs. Hill
today?

Float Nurse: She's still in a fib according to the sign-out but stable.
Well, I already tried to page Dr. Cardio. He's in the cath lab. The tech
said that he would call back in a bit. I just thought maybe you would be
able to read the order.

**Scene III** (FP clinic)

FP res: Have you seen Mr. Anderson's chart?

Receptionist: Mr. Anderson isn't on the schedule today. It's probably
filed. Do you want me to pull it for you?

FP res: I looked in the file and I couldn't find it.

Receptionist: Hmmmmm, that's odd. Of course, you know how it is with the
charts, they have legs of their own. Do you want me to find it for you?
Is he sick?

FP res: No! I mean, no thanks, I was just thinking about him and
wondering how he was doing. I'll get it another time. You don't need to
worry about it.

Receptionist: You're such a good doctor. Everyone knows how much you
really care about your patients. I'll keep my eyes open for the chart.

**Scene III** (medicine ward)

Ward secretary: (to the nurse) Dr. Cardio called back. He says the order
reads, "forty of K (kay)". He called from his car. He's on the way to
the office now.

Float Nurse: "forty of K (kay)?", I guess that probably means forty
milligrams of Vitamin K. That just doesn't sound right. I should
probably check it out. Can you page him again?

Ward secretary: Why don't you call the FP resident instead of paging
him. You know that he really doesn't like to be paged with this kind of
stuff.

Float Nurse: You're right. I'll talk to Resident FP when he comes back.
He told me that he was just going over to the clinic for a few minutes
to check on something.

**Scene IV** (medicine ward, FP resident is walking back in, still very
distracted)

Float Nurse: Can I ask you another question about Mrs. Hill?

FP res: Sure.

Float Nurse: Dr. Cardio ordered some Vitamin K for her. Does that sound
right to you?

FP res: Vitamin K?

Float Nurse: That's what he said.

FP res: hmmm. Well, Vitamin K is used for some patients on Coumadin if
the INR is out of whack. They both work on the same pathways.

Float Nurse: Well, that's probably it. I think the morning report said
that her INR was not in the therapeutic range. Thanks for the help.

FP res: sure

**Scene V** (medicine ward, later that evening)

FP res 2: (talking to Med Nurse) Hmmm. This looks strange. I see that
Mrs. Hill got Vitamin K today.

Med Nurse: That does seem odd doesn't it? Let's check the order sheet. I
see that Dr. Cardio scribbled an order here, it looks like "forty
millequivalents of K (kay)", yeah her potassium has been a little low. I
see that Float Nurse wrote a verbal order from Dr. Cardio for "vitamin K
forty milligrams IV push"

FP res 2: I don't think that's right. Maybe we should call Dr. Cardio
and let him know what happened.

Nurse: I think that Float Nurse did try to page him. Look her Coumadin
flow sheet shows that her coumadin was increased from 2.5 to 5 mg
yesterday.

FP res 2: Oh well, he probably knows about the Vitamin K then, that's
probably why the Coumadin was increased. I guess we don't need to call
him after office hours. Thanks.

**Scene VI** (medicine ward, next day)

FP res 2: Hey you look tired. I was the one on-call last night. What's
your excuse? Did you have a delivery?

FP res 1: No, I just didn't sleep very well.

Voice: I kept wondering about that GI bleeder in the unit. I wonder if
he made it through the night or if he had to be on dialysis.

FP res 2: Hey, I'm usually so tired when I'm on medicine ward month that
I sleep like a rock! (laughs)

Voice: maybe I should just go over to the unit.

FP res 2: ready to start?

**Scene VII** (FP clinic later that day)

Receptionist: hey, I found Mr. Anderson's chart. It was in FP Director's
box.

FP res 1: What was it doing there?

Voice: uh-oh. I'm in trouble now. I'll probably get bounced out of here
and never even get a license.

Receptionist: I think that she's doing a QI project on hypertension in
the clinic.

FP res 1: Thanks. (opens the chart, reads the med list out loud)
Atenolol.... Hydrochlorothiazide...Dig....hmmm. No coumadin?

Receptionist: I don't think that Mr. Anderson is on Coumadin. He's not
on the Coumadin clinic list. I *know* all those patients. I have to call
them every month to make sure that they get their INRs.

FP res 1: (smiling) Thanks a lot!

**Scene VIII** (medicine ward)

FP res 2: Hi, how was call last night.

FP res 1: great, no problems.

FP res 2: I think that you've had a little too much coffee this morning.
You are pretty perky!

Dr. Cardio: (comes out of Mrs. Hill's room, agitated) Who was on-call
last night? Mrs. Hill has got a facial droop and she's slurring her
words. She's probably having a TIA. She needs a CT scan stat. Where is
her chart? Where is the INR? I don't understand why her INR keeps
dropping. I've been increasing the Coumadin for three days now!

**Slippery Slope Discussion Points**

1.  This scenario was adapted from the AHRQ M and M patient safety
    website.

2.  The first item that generally comes up for discussion is that the
    nurse should not have given the Vitamin K. Residents assert that she
    "should have known better." Further discussion reveals that the
    nurse did make several attempts to clarify the order. (paged
    attending, spoke with resident) This generally leads to some
    discussion about the nurse-doctor roles when orders need to be
    clarified. Nurses are in a unique position of being responsible to
    "catch" errors propagated by their hierarchical superiors (doctors).
    This is an opportunity to introduce the idea of interdisciplinary
    teams and their role in health care delivery and patient safety.

3.  Certain drugs like warfarin are associated with greater rates of
    medication errors. Systematic approaches like standardized orders or
    a "coumadin service" can help to decrease variability of orders and
    prevent complications. Residents can be asked what their usual
    response is to the implementation of new guidelines or standardized
    orders. Often, residents admit that they feel these restrictions are
    burdensome or intrusive on clinical practice. This Doc-U-Drama and
    the Case of the Sliding Scale illustrate how standardized dosing
    schedules can enhance patient care.

4.  The ongoing "voice" reveals the emotional impact of a resident who
    is worried about having committed an error. Non-punitive emotional
    support systems for residents who are involved in an adverse event
    are an important corollary to patient safety curricula. Ask
    residents if they can identify with any of the inner dialogue.
    (usually many heads nod)

5.  Communication is an important issue in this scenario. Does effective
    communication ever take place from the attending to the nurse?
    (starting with the written orders and phone call)

6.  The "dangerous" abbreviations can be discussed in conjunction with
    this scenario. "K" can indicate Vitamin K (neonatal usage) or
    potassium (medicine ward).

7.  Illegible physician handwriting is also implicated in the scenario.
    This is an opportunity to discuss the benefits and limitations of
    CPOE (computerized physician order entry) which will likely improve
    the accuracy of communication *content* of orders but will not solve
    the issues of communication *context*.

8.  The opening scene touches on the "tribalism" that develops in
    teaching hospitals with multiple residencies. Services often "blame"
    each other for adverse events. What impact does this have on error
    reduction?

9.  The opening scene also points out the possible errors that can occur
    when patients are treated over the phone without the patient's full
    record available. (A common circumstance in family medicine.) What
    systems-based solutions might be available to solve this?

> **Doc-U-Drama**

**The Case of the Good Shot**

Tech

Nurse

Mrs. Jones (patient)

Mrs. Peters (patient)

Doctor

Scene 1

*Waiting room of a busy family practice office. Two female patients are
waiting to be seen.*

Tech: Mrs. Jones? Hi, how are you today? Come on back and we'll get you
ready for your visit. (*escorts Mrs. Jones to exam room*)

Mrs. Jones: sure, that would be great.

Tech: now, what are you here for today?

Mrs. Jones: Well, I'm here for my annual gyne exam and to get my
depo-provera shot.

Tech: any problems?

Mrs. Jones: no, I'm feeling fine, I just need to get my shot.

Tech: okay, your doctor will be right in to see you.

Tech: (*going back out to the waiting area*) Mrs. Peters? Hi, how are
you today? We're just about ready for you. Come on back with me and
we'll get you settled in a room.

Mrs. Peters: great! Thanks for being so prompt and getting me in today.
My allergies have been terrible. I feel like a have an elephant sitting
on my face!

Tech: that does sound miserable. Here, please take a seat right here.
(*escorts pt to a second exam room*) Is there anything else going on
that you need to discuss today?

Mrs. Peters: Well, I know it's a bit old-fashioned but sometimes when my
allergies get this bad, I get a steroid shot. I know that can have some
side-effects but in the past, it's been really helpful.

Scene 2

*doctor has just finished examining Mrs. Peters.*

Doctor: you're right, Barb, your allergies do look pretty bad. The
Claritin D just doesn't seem to be strong enough for you right now. It
doesn't look like you have sinusitis right now, although I know that
you've been prone to that in the past when your allergies have flared
up.

Mrs. Peters: I know that you've explained all the side-effects from the
steroid shot but I think that's what I'd like to try right now.

Doctor: okay, I'll send in the nurse to give you your shot. Why don't
you come back in a week so I can see how you're doing. It looks like
you're due for a pap smear too.

Mrs. Peters: Yeah, I have been putting off that pap smear but I will
make an appointment for next week. Thanks a lot.

Doctor: see you next week. (*leaves room.)*

Tech: (*speaking to Doctor)* The hospital just called about Mr. Chen.
They have some stat lab results for you. And Mrs. Gonzalez has called
four times now about her mammogram results. I've called the radiology
center but they can't seem to find them. She was pretty upset about it.
You remember how her last mammo wasn't quite normal? This was her six
month follow-up.

Doctor: (*feeling harassed, speaking to Tech)* Alright, ask the hospital
to fax over the labs so I can look at them. Please call the radiology
center again and ask them to search again for the films.

Tech: Doesn't Mrs. Gonzalez sometimes use a different name? I seem to
remember that her name on the insurance card and the name on the chart
were different. She was telling me that one was her name and one was her
husband's name. Maybe that's the problem.

Doctor: Thanks for checking into that.

Doctor: (*now speaking to the nurse)* Could you please give Barb a
steroid shot. Let's give her Kenalog 60 mg IM. I'm sure that's what we
gave her last year.

Nurse: okay, Kenalog 60 mg IM for Barb. I'll get it right away.

Scene 3

*Nurse goes into **Mrs. Jones**' room*

Nurse: Barb? I have your shot right here.

Mrs. Jones: Already? I wasn't expecting the shot already? My goodness,
you must be on roller skates today.

Nurse: Well, we have been really swamped today, I guess we're trying to
do the best we can not to keep people waiting. Okay, where do you want
this?

**Good Shot Discussion Points**

1.  Usually, one of the most immediate responses is to blame the nurse
    for not appropriately identifying the patient. However, some one
    else then points out that the doctor didn't identify the patient by
    last name either. Also, the nurse appropriately performed the "read
    back" of verbal orders. This vignette points out that communication
    is more than the transmission of facts.

2.  Cultural issues in patient identification are also alluded to in
    this scenario.

3.  This scenario is also a good opportunity for discussing the severity
    bias (tendency to be more concerned about errors that cause harm to
    patients than errors that do not even though the *processes
    contributing to the error* are the same.) What if the wrong patient
    had received the Depo-provera shot instead of the Kenalog?

4.  Distractions and interruptions are also contributors to medical
    errors. This doctor is distracted by trying to deal with an acute
    patient visit added to the schedule, stat lab results from the
    hospital and a lost mammogram.

5.  This scenario also underscores the "hand-offs" and potential "gaps"
    in our health care delivery system. Think about these possible
    "gaps":

> Doctor to nurse
>
> Lab results from hospital to PCP (primary care provider) office
>
> Orders regarding lab results from PCP office to hospital
>
> Mammo results from radiology to PCP office
>
> Can you identify any others?
>
> 6\. This scenario takes place in the outpatient setting. Despite the
> fact the overwhelming majority of patient care is delivered in an
> outpatient setting, most patient safety improvement efforts and
> research have looked at inpatient care.

# Doc-U-Drama

# The Case of the Sticky Eyeball 

Cast

ER Doc

Resident

Nurse

**Scene I** (ER at a teaching hospital)

ER doc: okay, it's beginning to start hopping around here. Did you see
the kiddo in three? What's he got?

Resident: Yeah, it is getting busier. Is it always like this?

ER doc: Well, Saturday afternoons are usually pretty busy because all
the regular doctor's offices are closed. (getting impatient) so, how
'bout number three?

Resident: Right, down to business. Patient in room three is a 3-year-old
Caucasian male who fell while climbing a bookshelf and struck his right
supra-orbital ridge on the corner of the coffee table. No reported loss
of consciousness. Mom freaked out and brought him here.

ER doc interrupting: Yeah, it's a typical story, the kid is totally
unsupervised and then of course gets hurt and then the parents want
everything done pronto.

Resident: Yeah, Mom is a little uptight... anyhow, On exam, he's a
squirmer, but he has a 1 cm laceration I the supra-orbital region, just
below the brow. Neuro exam is grossly normal. Bleeding has slowed down
now. Probably need a stitch or two...

ER doc interrupting again: yeah, yeah, okay, sounds fine, I'll just take
a quick peek at him and then let you suture it up. I've seen you sew up
a few lacerations this month and it sounds like this is one that you can
easily handle on your own. I've got to check the x-rays on that guy in
room four. The guy fell off a ladder and probably has a tib-fib
fracture. He's way too old to be climbing around on ladders. Why do
these people always do such dumb things?

Resident: I didn't get a chance to add that Mom is really hyper about
the possibility of a scar. She wants us to use the "glue" (making
quotation marks in the air)

ER doc: Well, what do you think?

Resident: From what I've read, it would probably be a reasonable option
as long as the bleeding has stopped.

ER doc: Right. Okay. Do you think that you can handle applying it?

Res: Well....I've never done it myself before but I saw you do it twice
last week...Looks pretty easy.

ER doc: Sure. Easy as pie. Easier than stitches really. I'll just check
out the kid ad then you can zap it on while I take care of that old guy
with the tib-fib fracture.

**Scene II** ( a few minutes later)

ER doc: Looks fine. You're right about the kid and the Mom. Go ahead and
use the dermabond. I told the nurse to get it set up for you.

Res: Sure. I'll take care of it.

**Scene III** (20 minutes later)

Resident: (comes running out of the exam room) Quick! Dr ER! The
dermabond got in the kid's eye...he was squirming around, ya know, and
crying and I didn't realize it was dripping, the eye is totally glued
shut! The kid is howling and Mom is yelling about her kid being blind!
Oh man! I can't believe that I messed up so badly!

ER doc: What?!?! You glued his eye shut!!!! How did that happen?!?!
Didn't you put any protective gauze over the eyes?!?! Where was your
nurse?!?! Why wasn't she holding the kid down?!?! I thought that you
know how to use that stuff!!!!!

Nurse: That Mom is really wigging out. She's on the cell phone calling
her husband and he's on his way over here. I told her that she's not
supposed to use the cell phone in the hospital.... (trailing off)

ER doc: Alright. I'll go take a look at it. (to the nurse) You better
call risk management and get them down here before Dad shows up. (to the
resident) You better not go back in there. I'll handle it. Why don't you
spend the rest of the day in the library or something.

Res: Gee...I'm really sorry. Do you think that he'll be okay? Maybe I
should talk with Mom and apologize. It was an accident. Truly.

ER doc: I don't think an apology would help the situation right now. The
kid will probably be okay. I'll call the ophtho guy. Oh, he'll love this
call on a Saturday....I'll let you know what happens.

**Sticky Eyeball Discussion Points**

1.  This scenario was adapted from a case posted on the AHRQ M and M for
    patient safety website. Dermabond in the eye does not cause
    permanent harm.

2.  A "macro" view of this incident would take into account that our
    health care delivery system over-utilizes emergency care resources
    due to convenience issues.

3.  This is a classic case of "see one, do one, teach one", a very
    common learning environment for residents. This scenario usually
    touches off a vigorous debate about whether the resident is to
    "blame" because of incompetence or whether the attending ER doc
    should have supervised the resident more closely. This also brings
    up the issue of resident-attending hierarchy and the reluctance to
    appear incompetent.

4.  Another issue to discuss with this scenario is the idea of
    "preventability". It is possibly (even likely) that, even if
    adequate precautions were taken to avoid eye exposure, a wiggling
    child might get dermabond in his eyes. To what degree can we prevent
    adverse outcomes? Should we sedate this child? Sometimes there are
    unavoidable risks.

5.  Another issue that has come up in discussion is informed consent.
    Was the mother informed that this might be a complication of the
    dermabond? Would this have changed her insistence about using "the
    glue"?

6.  This resident was discouraged from apologizing. After an adverse
    event, what is the best policy regarding disclosure and apologies?
    Studies support that disclosure of adverse events does not lead to
    increased risk of malpractice suits. In fact, it might decrease the
    likelihood of suit. A sincere apology is preferred by patients.
    Patients also like to hear that there is a remediation plan to
    prevent a similar adverse event from happening to other patients.

7.  What emotional support structure is available to residents who are
    involved in an adverse event? Because of the risks of embarrassment,
    malpractice and educational repercussions, adverse events are
    generally not openly discussed. They become gossip for the rumor
    mill and residents involved in adverse events become emotionally
    isolated. Developing a non-punitive, support system for residents
    involved in adverse events is an important corollary to patient
    safety improvement programs.

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