TeamSTEPPS® Instructor Manual: Specialty Scenarios

Ambulatory Care

Specialty scenario for this guide.

Contents

Scenario 1
Scenario 2
Scenario 3
Scenario 4
Scenario 5
Scenario 6
Scenario 7
Scenario 8


Scenario 1

 
Appropriate for: All Specialties
Setting: Clinic

 

A renal failure patient presents to the Family Practice Clinic for a followup exam for a UTI. The nurse places a BP cuff on the patient’s arm and, at that moment, detects the thrill from a dialysis fistula. As she removes the BP cuff, the doctor, seeing what she has done, reprimands her in front of the patient and the patient’s friends, stating abruptly, “The patient has a fistula in that arm.” The nurse is embarrassed but does not speak to the doctor about the situation.

Later that day, the same doctor asks another team member, a nurse, for a report on one of his patients. The nurse proceeds with the report but is unable to recall the patient’s BP or pulse. Another nurse who knows this information chooses not to share it with the doctor for fear he will reprimand her for speaking up.

Instructor Comments

  • Ineffective team leadership results in having team members who do not speak up or challenge when appropriate. In this case, mutual support is lacking; however, skill in conflict management could enhance team development.
  • Effective teams resolve conflicts constructively rather than allow interpersonal issues to persist without resolution. Failure to share information has a detrimental effect on patient care and may result in delayed diagnosis or an inadequate plan of care.

Skills Needed

  • Team structure: Identify barrier to team effectiveness. Mutual support.

Potential Tools

  • Collaboration, Conflict resolution.

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Scenario 2

Appropriate for: All Specialties
Setting: Clinic

 

Ed Johnson, a 41-year-old patient with a history of hypertension, is seen in the Cardiology Clinic for a followup after his recent admission to rule out a myocardial infarction. His vital signs are normal except for a BP of 170/110. An EKG shows NSR without evidence of ischemic changes. He states that he has been having episodic chest pain since his release, so the physician decides to repeat his cardiac enzymes. His CPK is 201, and a Troponin I level is pending.

Mr. Johnson’s pain resolves, and he insists on going home. The Troponin I level is still pending when Mr. Johnson is discharged with instructions to call the office the next day if he is still having problems. Shortly after Mr. Johnson is discharged, the Troponin I level of 0.22 (normal <0.03), indicating myocardial ischemia, is called in to the nurse in the clinic. The nurse notifies the physician of the result. No attempt is made to contact Mr. Johnson. Later, he is found unresponsive and having difficulty breathing. His friend calls 911, and when the ambulance crew arrives, they find him apneic and they cannot detect a pulse.

Instructor Comments

  • In this scenario, the nurse and the physician fail to advocate for the patient. A check-back or existing process is lacking to ensure the physician and nurse both understand roles and action items, and the patient is not contacted. This failure to communicate as soon as possible may have contributed to his demise.

Skills Needed

  • Team structure: Assign roles and responsibilities. Team structure: Identify barriers to team effectiveness. Mutual support. Communication.

Potential Tools

  • Briefs to assign roles and develop effective communication and handoff processes. Prioritization and delegation of responsibility for followup or action items. Check-back to confirm that an abnormal laboratory value of significance will result in followup action.

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Scenario 3

Appropriate for: All Specialties
Setting: Clinic

 

Dr. Winston has just completed her annual physical exam of Sue Garber. Ms. Rosenthal, the nurse for Hall B, asks, “Isn’t Mrs. Garber a little confused today? I think she’s depressed about her daughter moving away last month. I was wondering if she should be sent to the emergency room for evaluation.” Dr. Winston replies, “Yes, I think she may be confused, but according to her record, her confusion has existed for more than a month. I think she may have something organic going on. We need to rule out a medical cause for her confusion.” “Now that you say it,” Rosenthal observes, “her daughter mentioned that her confusion was not a new phenomenon. Maybe we just need to get an outpatient consult for a formal evaluation. Would you like me to order a consult, Dr. Winston?” Dr. Winston replies, “Yes, please order a consult.”

Instructor Comments

  • Both providers use situation monitoring to assess the status of the patient, and by discussing their different perceptions of the patient’s status, the team is able to use information exchange to form a shared mental model that keeps them from working in different directions. This scenario shows examples of good communication by the nurse offering information, strong leadership, and mutual support. The doctor and the nurse were able to advocate and assert for a position, yet they communicated and outlined a plan that resulted in the development of a shared mental model without conflict.

Skills Needed

  • Situation monitoring: Assess status of patients. Situation monitoring: Assess environment. Mutual support: Advocate and assert a position. Mutual support: Resolve conflict. Communication: Offer and seek information.

Potential Tools

  • Huddle, SBAR, Check-back, Feedback, Advocacy/Assertion, Collaboration.

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Scenario 4

Appropriate for: All Specialties
Setting: Clinic or Hospital

 

Two members of the GI Laboratory are assessing an elderly patient who has just had conscious sedation for a colonoscopy. The monitor shows SVT at a rate of 150 and a BP of 76/48. The nurse calls out the vital signs while the physician continues to monitor the rhythm. A nurse passing by the room hears the call-out, steps in the room, and seeing the blood pressure, asks, “Do you want a code cart in here?”

Instructor Comments

  • Reinforce the point that monitoring of both the patient and team members supports the maintenance of situation awareness. In this case, it involves observing others and using clear communication. Monitoring is a powerful agent in responding proactively to a situation.

Skills Needed

  • Situation monitoring: Assess status of patients. Situation monitoring: Assess environment. Mutual support: Advocate and assert a position. Communication: Offer and seek information.

Potential Tools

  • Call-out, Task assistance, Collaboration, Cross-monitoring.

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Scenario 5

Appropriate for: All Specialties
Setting: Clinic or Hospital

 

A patient in the General Surgery Clinic has coded and CPR is in progress. The resuscitation team is busy working on the patient to ensure that IVs are patent and the ET tube is properly positioned. Dr. M., the team leader, is calling out orders for drugs, x rays, and labs. Cindy S., a nurse, is at the bedside inserting an IV. Lora A. is the nurse at the cart drawing up the meds. Cindy can tell by Lora’s expression that she did not get the last order given by Dr. M. “Lora, he wants the high-dose Epinephrine from the vial in the top drawer,” Cindy calls out as she continues with her IV insertion.

Instructor Comments

  • Using situation awareness and call-out, the ability to be aware of what was happening with the team and to use effective communication techniques helped this team function more effectively.

Skills Needed

  • Situation monitoring: Assess status of patient and team and the progress toward the goal. Mutual support: Provide task-related support and verbal support. Communication: Offer information.

Potential Tools

  • Call-out, Task assistance, Collaboration, Cross-monitoring.

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Scenario 6

Appropriate for: All Specialties
Setting: Hospital

 

At 1000, a 45-year-old, Spanish-speaking male with hypoglycemia is admitted to the Family Practice Service. At 1200, during rounds, the patient’s doctor notes a glucose value of 38. He writes an order for an amp of D50 and a CXR. He does not verbalize this order to the nurse and hands the chart to the clerk. The lunch relief nurse comes on just as the patient leaves for X Ray. Ten minutes later, X Ray calls to say they will not x ray him because he does not have an armband on, and he does not speak English. The nurse goes to X Ray and cannot positively identify the patient, so she asks for a Spanish interpreter. The interpreter states that the patient is confused; the nurse returns the patient to his room and checks the chart. She finds the order for D50, which has not been given, and administers the medication immediately. The patient wakes up and is alert and oriented.

Instructor Comments

  • In this scenario, the doctor does not tell the nursing staff about the patient’s low blood sugar level and subsequent new orders. The opportunity to communicate information and form a plan that would develop a shared mental model is missed. Therefore, this information is not part of the information handoff to the relief nurse. As a result of the inadequate exchange of communication and handoff, the patient is placed at risk and care is delayed. In X Ray, the nurse used effective situation awareness and situation monitoring to identify a problem. She then prioritizes her actions to check the chart and identify necessary actions to implement.

Skills Needed

  • Shared mental model. Communication.

Potential Tools

  • Handoff, Prioritization.

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Scenario 7

Appropriate for: All Specialties
Setting: Hospital

 

A 20-year-old female presents to the ED with a displaced right ankle fracture. Two hours after admission, ED is still unable to achieve a satisfactory reduction of the ankle fracture. At this point, the patient’s physician decides to send her to the OR for reduction under anesthesia. The unit clerk is aware of the plan, but the patient’s nurse is not. The patient is transported to the OR without adequate paperwork. Moments later, the OR calls to report that the patient has no permits signed nor have any other preop protocols been completed.

Instructor Comments

  • In this scenario, a shared mental model is not developed because information regarding the patient’s plan of care is not communicated to the whole team. This lack of communication and the inability to provide an accurate handoff results in a delayed start for surgery and the potential for error.

Skills Needed

  • Communication. Situation monitoring.

Potential Tools

  • Handoff, Brief, Debrief, Cross-monitoring.

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Scenario 8

Appropriate for: All Specialties
Setting: Clinic

 

Ann Tayner is assigned to work in a busy Internal Medicine Clinic. She recently attended an educational session on infection control techniques and the importance of hand washing. She noticed that the clinic physician; Dr. Tsu, went from patient to patient without washing his hands. Later that morning, she encounters Dr. Tsu in the corridor and addresses him saying that she attended the hand-washing seminar and noticed he did not always follow procedure. Dr. Tsu appears surprised by the comment but sheepishly agrees that hand washing is very important, and he will be more careful.

Instructor Comments

  • Point out that challenging a team member’s position is an integral part of teamwork. All members of the team and support staff have a responsibility to advocate for patient safety even if it may lead to a conflict or differing positions. In this case, situation awareness was used to identify the problem and advocate for the patients.

Skills Needed

  • Situation awareness. Situation monitoring: Assess environment. Mutual support: Resolve conflict. Communication: Offer information.

Potential Tools

  • Advocacy/Assertion, Feedback.

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Current as of March 2014
Internet Citation: TeamSTEPPS® Instructor Manual: Specialty Scenarios: Ambulatory Care. March 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/ambulatory.html