TeamSTEPPS® Fundamentals Course: Module 7
Summary Role Play Exercise Sheet
Disclaimer: This is a fictitious case used only for training purposes.
- Break into four small groups. Each group will receive one of four teamwork skill handouts.
- Read the role play scenario below.
- Identify the instances where a breakdown in teamwork has occurred as it relates to the specific teamwork skill assigned to your team.
- Identify 2 or 3 tools or strategies related to the specific teamwork skill assigned to your team that can be applied to remedy the teamwork breakdowns. Refer to your course materials for reference if needed.
- Assign character roles among your team members and create a role play script based on the tools and strategies that your team has decided upon.
- Present your role play scenario.
- A facilitated debrief will wrap up the exercise.
It is flu season in the Pediatric Inpatient Ward, and the number of admissions is high because of the influenza epidemic. Dr. Powers, who is notoriously difficult to work with and does not work well under stress, is attending to a new patient who has been over-sedated. Dr. Powers gives a verbal order for 1 Amp Narcan to Nurse Shelley. Nurse Shelley, for whom English is a second language, repeats the verbal order as "1 Amp Narcan."
In a rush, Nurse Shelley writes the verbal order on the chart. The written order is then sent to the pharmacist. He is a float pharmacist who does not usually work on the pediatric floor, and he is fatigued from approaching the 10th hour of his 7th day of working. He is also overloaded and overburdened by the large number of admissions in the ward. The pharmacist misreads the poorly written transcription as "1 Amp Norcuron."
At the end of Nurse Shelley's shift, she hands off to Nurse Givens. During the handoff, the Code Team is activated, and Nurse Shelley has to respond. Nurse Givens then returns to the pharmacist, who dispenses Norcuron. Nurse Givens, a conventional thinker who does not like to upset the hierarchical structure, suspects something is wrong with the order but decides Norcuron must be a generic name for Narcan. (Norcuron is actually a neuromuscular blocker.) Nurse Givens administers Norcuron to the patient, who immediately experiences respiratory arrest and requires intubation.
TeamSTEPPS Fundamentals Course: Module 7. Summary—Putting It All Together. Summary Role Play Exercise Sheet. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/teamsteppstools/instructor/fundamentals/module7/exsummary,htm