Community-Based Simulation Program Targets Miscommunications in the ED


One ED’s novel approach to reducing communication errors: Practice, practice, practice.  

Though hard to believe, many (if not most) errors in the emergency department come as a result of communication errors, not technical mistakes. According to Boston Children’s Hospital, an estimated 80 percent of the most serious medical errors in hospitals can be linked to miscommunication. Effective communication is especially critical in the emergency room, where time is limited, pressure is heightened and decisions must be made dynamically as information changes from moment to moment. At Baptist Health South Florida, leaders turned to the simulation lab for a solution to emergency room miscommunications.

The Baptist Health Patient Safety Simulation Lab was launched in 2011 to offer cutting-edge training to improve patient safety across the health system. The facility includes a simulation room with state-of-the-art mannequins and equipment, a control room and a debriefing area. The program, which is overseen by a medical director, is available to all departments throughout the health system and trains multidisciplinary teams on Crisis Resource Management (CRM). CRM has its roots in the aviation industry’s “crew resource management,” a set of training procedures that work to reduce human error in high pressure situations by improving interpersonal communication, leadership and decision making. Key CRM tools include standard communication scripts, checklists and mandatory debriefings.


BH simulation lab with crash cart 0125

Working with the lab’s CRM specialists, Baptist’s emergency medicine leadership team tailored simulations to the needs of its department. Scenarios are often based on real cases that emergency medicine personnel have experienced. They generally involve straightforward medical diagnoses, but with a specific focus on situations that present challenges to clear communication. The simulations provide a safe yet realistic mechanism for developing teamwork and practicing communication strategies. This style of teamwork training allows for hands-on practice and mimics the pressure that real-life situations induce.

The ED teams reported a greater comfort level and more open lines of communication after completing the CRM training program. While the simulation lab at Baptist Health is a great resource for its ED staff, other emergency care teams can still adopt CRM communication techniques without a dedicated simulation facility.


1. Establishing a leader
The traditional leadership hierarchy is well defined in the hospital setting. But during a true emergency, it is important that the leadership position be flexible – and that a plan is in place that allows the leadership role to transition smoothly and be communicated effectively. For example, the emergency medicine physician may be the team leader going into a situation, but if he or she is occupied with a difficult intubation or other complicated procedure, it’s important that a nurse or tech step in to help direct the patient’s care. Baptist’s simulation drills have repeatedly shown that the initial perceived leader in a situation is not always the one best suited to handle the present challenge. In fact, the drills have somewhat flattened the hierarchy and empowered nurses and other personnel to speak up when they identify a potential problem or a new piece of critical information.

2. Distributing workload
One of the key tenets of CRM is closed loop communication. It’s not uncommon in a chaotic ED for a doctor to call out a medication order and either have multiple staff members respond (which wastes manpower) or have no one initially respond (which causes a delay). In closed loop communication, a request or order is called out; the person responding verbally announces the action he or she is taking; and the original speaker confirms or rejects the responder’s action to ensure they’re doing the right thing. For example, if a doctor calls out for a particular antibiotic, a nurse might respond that he or she is going to get the antibiotic, specifying the type and dosage. The doctor can then confirm or deny that the nurse got the request right. If the response is denied, the process is repeated. CRM encourages the use of names when giving an order, but even when a specific responder isn’t named, closed loop communication helps adequately distribute workload and communicate each provider’s role in the care plan.

3. Reevaluating a situation
Emergency situations are highly dynamic – care plans evolve, complications can arise, and new information is constantly being learned. Because the patient’s needs are in flux and multiple providers are working at the same time, it’s important to reevaluate the situation periodically. CRM encourages emergency department leaders to pause care for a brief check-in when warranted. This pause gives providers the opportunity to get on the same page, share new information they’ve learned or decide on a further direction of care. The efficiency gained from a 20-30 second debrief more than makes up for that small time investment.

4. Establishing a shared mental model
Over the last few years, there has been increased attention paid to the idea of a “shared mental model” among healthcare teams. According to this concept, effective team performance requires that team members have matching cognitive maps and understandings of task requirements, procedures and role responsibilities. One way to develop or improve a shared mental model is through post-procedure discussions or evaluations. By asking open-ended questions, an emergency department leader can gather each team member’s perceptions of a situation. If a medical team can develop a better understanding of everyone’s perceptions, they can work to eliminate the instances where roles or protocols were incorrectly interpreted. Post-situation debriefs help teams develop common understandings and a shared perspective, alleviating confusion. In the simulation lab, the teams at Baptist are able to watch tapes of the scenarios, which provide a visual and auditory aid to these debriefings.


When the Baptist Hospital emergency department began participating in the Baptist Health Patient Safety Simulation program, the goal was to eliminate errors and improve patient safety. The simulations have certainly succeeded in improving patient care, but what the team didn’t anticipate was how much they would impact provider satisfaction as well. The collaboration and trust developed in the simulation lab improves patient outcomes, but also creates a more collaborative and supportive work environment where every team member feels acknowledged and heard. Patients pick up on the teamwork within the ED as well, further improving their satisfaction in the often-stressful emergency department. A state-of-the-art simulation lab isn’t mandatory for quality patient care, but taking the time to improve communication in the ER pays major dividends to both patients and providers.

Photo by Airman st Class Alexxis Pons Abascal


David Mishkin, MD is an emergency physician with Sheridan Healthcare. He practices at Baptist Hospital of Miami.


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