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Simulation and Medical Performance Peter G. Schulam, M.D., Ph.D. Associate Professor Department of Urology Eric Savitsky, M.D. Associate Professor Department of Emergency Medicine CASIT and David Geffen School of Medicine at UCLA To Err is Human Institute of Medicine November 1999 44,000 – 98,000 deaths per year as a result of medical errors. Cost of $17-29 billion per year. Medical Errors Performance Level of 99.9% Airline-2 dangerous landings/day Banking-32,000 checks incorrectly deducted/hour Types of Errors Diagnostic Error or delay in diagnosis Failure to act on results Treatment Error in drug dosing Delay in responding to an abnormal test Error in performance Medical Errors Locations Intensive Care Units Emergency Departments Operating Rooms Why? Lack of standard credentialing Fragmented health care system Lack of access to all information Human variability Physician Variability # of complications Learning Curve # of procedures Traditional Training Problems with the apprenticeship model Variability of experience Practice on real patients Inefficiency Cost The OR is an expensive classroom Lack of standardized proficiency criteria Surgical Training Laparoscopic Cholecystectomy Southern Surgeons Club - 2.2% incidence of bile duct injuries in first 13 pts/group (control 0.2%) NEJM 1991 8,839 lap cholecystectomies by 55 surgeons - 90% of bile duct injuries occurred during first 30 cases Am Surg 1995 54% of surgical errors are potentially preventable Nat Acad Press, 1999 Training Simulators Inanimate models Animal models Cadaveric models Virtual reality Inanimate Models Benefits Cheap Reuse materials Accessible at any time Minimal psychological stress inhibiting learning Inanimate Models Limitations Lack of realism Can only simulate the most basic tasks Difficult to monitor progress Animal Models Benefits Realistic physiology Closer to realistic anatomy Complex procedures More realistic working environment Animal Models Limitations Expensive Ethical issues Difficult to monitor progress Cadaveric Models Benefits Realistic anatomy Rohen & Yokochi. Color Atlas of Anatomy. 1993 Cadaveric Models Limitations Rohen & Yokochi. Color Atlas of Anatomy. 1993 Expensive Physiologically unrealistic Unnatural tissue properties Difficult to monitor progress Virtual Reality Simulators Benefits of Virtual Reality Unlimited availability Potential for a variety of tasks/procedures From non-anatomic to surgical “pre-flight” Allows for repetitive skill assessment Minimal psychological stress inhibiting learning Monitors trainee activity/improvement Benefits of Virtual Reality Virtual Mentor Computer can guide a trainee through a procedure and provide immediate feedback Fulfills the continual, high-quality feedback requirement for efficient learning Establish metrics Limitations of Virtual Reality Complexity of organ modeling Lack of force feedback Procedure based systems Potential >> Today’s Reality Holy Grail Simulation of a patient’s data set allowing for pre-procedural planning Procedural Outcome Diagnosis History Physical Exam Ordering of data (labs and xrays) Interpretation of data Intervention Familiarity/Dexterity with the tool set Understanding the order of the operation Familiarity of the anatomy Adapting to anatomical variability Controlling surgical mishaps Decrease Physician Variability Task Specific Simulation Definition of Simulation “A device or exercise that enables the participant to reproduce, under test conditions, phenomena that are likely to occur in actual performance” Krummel