Clinical Programs

The Center for ASPIRE works closely with the UVA BeSafe initiative to improve the quality and safety of patient care in the UVA Health System.  Interprofessional education and team training is being extended into the hospital and clinics to build effective clinical teams.


Room of Errors

Julie Haizlip, Sandy Neumayr

Purpose of the Study: The purpose of this project is to address essential milestones related to interprofessional practice and patient safety. It will create and implement an interprofessional education activity that enhances awareness of identified patient safety concerns and emphasizes the value of the interprofessional team in providing maximally safe care to our patients.


Methods:A simulated inpatient room in the Pediatric Intensive Care Unit (PICU) that is staged with multiple potential safety hazards based on current evidence based guidelines for the promotion of pediatric safety (e.g. Prevention of Catheter- Associated Blood Stream Infections), previously identified areas of risk (e.g. medication errors), and UVA Health System Quality Priorities (e.g. handwashing). Some hazards are obvious and others more subtle or specific to one practitioner’s area of expertise (e.g. inappropriate alarm ranges). Students, residents and clinicians from nursing, medicine, pharmacy and therapy services who are at all levels of training and experience are brought into the room and challenged to identify the errors. Initially, the participants will be asked to identify as many errors as possible individually and record their findings on color-coded data sheets that will later designate each participant’s profession and level of experience. Participants will then be asked to work together as an interprofessional team to consolidate their findings into a single document that represents the aggregate findings of all members of the team. Following the experience, investigators will debrief the activity emphasizing key safety considerations and the contributions of different team members. Following the exercise, participants will be provided a complete list of the potential errors and reference material.


Evaluation: Participants will complete a short questionnaire prior to the experience identifying the roles of team members related to specific potential categories of error. Following the activity, participants will complete a similar questionnaire that addresses the same questions and also seeks to determine if participants feel more empowered to prevent error as a result of this process. The second measure will compare the ability of participants to identify potential sources of error. The participants’ lists of identified errors will be organized into data subgroups based on the individuals’ professions and experience levels. A post-hoc analysis will be conducted to assess the aggregate number and types of errors that were identified by each subgroup to determine if participants from certain professions or levels of experience were more or less likely to identify particular safety concerns. The number and types of errors identified by each profession and experience level subgroup will also be compared to those identified by interprofessional teams.


Expected Outcomes: We hypothesize that there will be differences among the subgroups in their ability to identify safety concerns, and that interprofessional teams will be more likely to identify multiple errors than will single profession subgroups , thus emphasizing the value of interprofessional collaboration to ensure patient safety. In addition, we anticipate that there will be differences between learners at different levels of training and experience, but that all learners will benefit from a heightened awareness of potential safety problems.


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