TeamSTEPPS® Instructor Manual: Specialty Scenarios

Combat Care

Specialty scenario for this guide.

Contents

Scenario 117
Scenario 118
Scenario 119
Scenario 120
Scenario 121
Scenario 122
Scenario 123
Scenario 124
Scenario 125
Scenario 126
Scenario 127
Scenario 128
Scenario 129
Scenario 130
Scenario 131

Scenario 117

 
Appropriate for: All Specialties
Setting: Hospital

 

A 22-year-old patient is brought to Casualty Receiving onboard the U.S.S. Mercy after a vehicle crash in which he was a passenger. He has stable vitals but has a GCS of 7. After the primary and secondary survey, the resuscitation team prepares to intubate the patient prior to sending him to CAT Scan. The physician, intending to use a dose of Norcuron before giving Succinyl Choline, orders 5 mg of Norcuron to be given. The pharmacist repeats the order as "10 mg Norcuron." The resident, hearing the Check-back, replies, "No, that is incorrect. Give 5 mg Norcuron." The pharmacist repeats the new order, to which the physician replies, "That is correct." The correct dose of Norcuron is administered.

Instructor Comments

  • The pharmacist's use of a check-back before administering the medication and the resident's situation awareness and cross-monitoring break an error chain that could have resulted in a medication dosage error for the patient.

Skills Needed

  • Situation awareness. Situation monitoring: Assess environment. Communication: Offer information.

Potential Tools

  • Check-back, Advocacy/assertion, Collaboration, Task assistance.

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Scenario 118

 
Appropriate for: All Specialties
Setting: Hospital

 

At shift change on an exceptionally busy night in the Emergency Department (ED), a middle-aged female soldier is triaged for chest pain and shortness of breath. The patient is placed in the overflow area, which is not visible from the main ED. A medic places the patient on a monitor; then, the medic leaves the area for previously scheduled gate duty. Forty-five minutes later, the charge nurse discovers the patient, who is complaining of severe chest pain and shortness of breath. The patient is immediately transferred to the resuscitation area, where she has a sudden cardiac arrest. Cardiac protocols are initiated and the patient is resuscitated. Electrocardiogram (EKG) findings are consistent with an acute inferior wall myocardial infarction.

Instructor Comments

  • Change of shift creates high workload. Incoming staff or patients create chaos and high-volume conditions where communication can be incomplete and information can be dropped. In this scenario, the person who placed the patient on a litter misunderstood the potential diagnosis. If the task was delegated to the medic, perhaps it should not have been—the results could have been disastrous. If no choice but to delegate a task (e.g., when several critically injured patients arrive at the same time), ensure that you communicate a sense of urgency to the transporting individual. When possible, speak directly to the nurse or physician caring for the patient. Using Situation, Background, Assessment, and Recommendation (SBAR), communicate the presenting C/C a Chief Complaint and working diagnosis. If no attending authority is immediately available, put the patient in your line of vision. Assign a medic to monitor the patient but oversee the monitoring and initiate the standard plan of care. Hand off the care as soon as appropriate.

Skills Needed

  • Team structure. Communication. Situation monitoring: Assess environment and status of team. Mutual Support.

Potential Tools

  • Debrief, SBAR, Cross-monitoring, Delegation, Advocacy, Collaboration.

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Scenario 119

 
Appropriate for: All Specialties
Setting: Hospital or Field

 

A 45-year-old patient lies quietly on a stretcher while a new corpsman attempts to start the patient's IV. The patient's vein starts to "roll," and the corpsman becomes frustrated with his inability to complete the assigned task. A nurse enters and observes the difficulty the corpsman is experiencing. She moves closer and says, "I have found that it is helpful to pull down just a little on the skin to help stabilize the vein while you insert the IV." The corpsman follows her instruction and is able to successfully start the IV.

Instructor Comments

  • Growing individual skills strengthens team contributions. In this case, cross-monitoring is used to recognize a problem. An established team structure allows the nurse to offer information and provide support and feedback.

Skills Needed

  • Situation monitoring: Assess status of team, patient, and environment. Communication. Mutual support. Team structure.

Potential Tools

  • Cross-monitoring, Task assistance, Advocacy/assertion, Collaboration.

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Scenario 120

 
Appropriate for: All Specialties
Setting: Hospital or Respiratory Therapy

 

The respiratory therapy (RT) team has just learned that 3 hours earlier, one member of the team gave an incorrect dose of Albuterol to an asthmatic patient, which caused the patient to become tachycardic and hypotensive. Although not life threatening, the error placed the patient at unnecessary risk, delayed his disposition, and tied up resources in the Emergency Department (ED) for a period of time. A team member, seeing an opportunity for learning, calls the RT team together and discusses the importance of doing Check-backs before giving a nebulizer treatment with a medication.

Instructor Comments

  • This scenario demonstrates that activities that do not result in negative outcomes can still be learning opportunities. In this case, a debrief using mutual support can provide constructive feedback and a learning opportunity.

Skills Needed

  • Team structure. Mutual support.

Potential Tools

  • Debrief, Collaboration, Feedback.

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Scenario 121

 
Appropriate for: All Specialties
Setting: Hospital or Clinic

 

Two medics are at the desk during a brief lull on a busy day. They notice a third medic racing busily between two rooms, glancing over at them as she passes. Medic #1 says to Medic #2, "Let's see if Smith can use some help." Medic #2 replies, "My patient will be back from the lab in just a few minutes and I hate to get tied up. Besides, Smith doesn't usually accept help from anyone." "Come with me," says Medic #1, "I'll show you how it's done." Medic #1 approaches Smith and says, "Excuse me. I can see you're busy. I have about 5 minutes before my patient gets back from the x ray. I can finish this blood draw for you while you tend to your other patient." "Thanks," says Smith, "the order slips are over on the counter, but it's just a CBC and Lytes."

After Smith leaves, Medic #1 says to Medic #2, "The key to offering assistance is being clear about how much time you have and what tasks you are able to pick up."

Instructor Comments

  • In this scenario, situation awareness and situation monitoring are combined with mutual support to result in reinforcement of a teamwork skill through peer coaching.

Skills Needed

  • Situation awareness. Situation monitoring: Assess environment. Communication: Offer information.

Potential Tools

  • Collaboration, Delegation, Task assistance, Cross-monitoring, Handoffs.

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Scenario 122

 
Appropriate for: All Specialties
Setting: Hospital

 

SSG Peterson is assigned to the Emergency Response Team (ERT) this evening. Having discharged all but one patient, she takes a few moments to catch up on her charting. Before admitting her final patient and calling report, she decides to give the patient time to talk with members of her platoon. Several minutes later, SSG Peterson's attention is drawn to loud screaming in the Triage area, where a civilian mother has brought in her injured and hysterical 5-year-old. Peterson offers to assist the Triage nurse by bringing the child and her mother directly to one of Peterson's empty litters. Peterson comforts the child and then goes to call report on her admission. As SSG Peterson picks up the telephone, "Code 99" is called for the unit she is about to call. At the same time, a platoon member of the patient being admitted approaches to complain that the patient's IV has run dry and that she is anxious to move up to the floor.

Instructor Comments

  • This scenario illustrates the potential risks of low workload. Delayed activities may result in failing to prioritize and complete existing workload.

Skills Needed

  • Situation awareness. Mutual support.

Potential Tools

  • Prioritization.

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Scenario 123

 
Appropriate for: All Specialties
Setting: Hospital or Field Hospital

 

The Emergency Response Team (ERT) in a busy combat support hospital is divided into two core teams—Blue Team and Green Team. The Blue Team has a 46-year-old male who complains of an episode of chest pain prior to arrival. A STAT electrocardiogram (EKG) reveals an anterior myocardial infarction (MI). His immediate evacuation is ordered, but the nurse on the Blue Team is overwhelmed by the tasks that she must simultaneously accomplish. She requests assistance through the coordinating team, and a nurse on the Green Team is designated to assist. For the next 15 minutes, the two nurses work together to care for the patient. When the immediate tasks are completed, the Green Team nurse returns to her patients.

Instructor Comments

  • Using a shared mental model and mutual support, any team member can temporarily provide support to another team when time and workload permit. However, team members must return to their assigned team upon completion of delegated tasks. Permanent reallocation of staff from one team to another occurs under the direction of the coordinating team.

Skills Needed

  • Shared mental model. Team structure. Communication. Situation monitoring: Assess environment. Mutual support.

Potential Tools

  • Handoffs, Cross-monitoring, Prioritization, Delegation, Task assistance, Advocacy/assertion, Collaboration.

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Scenario 124

 
Appropriate for: All Specialties
Setting: Hospital

 

It is 0600, and it is time to fill the daily requests of patient medication. LT Downs has an extensive list to fill before medication is dispensed at 0700. Specialist Tomlin approaches Downs and asks for his assistance with recounting some outdated turn-in meds. In the meantime, Nurse Richardson, from the Emergency Department, requests 50 mg of morphine to restock her cabinets. Downs looks around and sees another technician sitting at the front desk of the Pharmacy reading the newspaper. Downs does not say anything and proceeds to meet Nurse Richardson's request. It is now 0710, and Downs has not filled all of the daily requests of patient medication. When the floor supervisor comes to check on the orders, Downs tells her that he will have them ready in 20 minutes because he has been busy with other things.

Instructor Comments

  • This scenario illustrates work overload because Downs does not ask for help and because the other staff member lacks situation awareness (i.e., the staff member is unaware of what is happening or of the need to offer Downs assistance). A stronger team structure with expectations for mutual support will result in a shared mental model and will prevent future occurrences of this problem.

Skills Needed

  • Mutual support. Team structure. Situation awareness.

Potential Tools

  • Collaboration, Delegation, Prioritization, Task assistance, Cross-monitoring.

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Scenario 125

 
Appropriate for: All Specialties
Setting: Field Hospital

 

It is 0650, and a change of shift report is in progress. Suddenly, the TOC announces a 1-minute estimated time of arrival (ETA) of a helicopter with one patient. Both shifts initiate preparation, including getting a 91 Whiskey (91 W) and a litter team to the Landing Zone. The patient arrives, and the medic reports him as a 36-year-old soldier whose HumVee ran over a landmine. Upon arrival at the resuscitation area, the medic relays the patient's current status as follows: "The patient was the driver and has suffered bilateral midthigh amputations. Current vitals are BP 90/60, P 126, R 28. The right leg is continuing to bleed and now has pressure dressings applied. He has contusions across his lower abdomen, and it is distended." Passing by Lt. LT Johnson, the night nurse sees that CAPT Francis and the entire 91 Ws are focused on the patient's legs. They seem overwhelmed by the extent of the patient's injuries. Quickly, LT Johnson throws a sheet over the patient's legs and asks loudly, "ABCs people, what's the patient's respiratory status? This patient needs a STAT chest x ray (CXR) and C-spine!" CAPT Francis refocuses and says, "You're right; let's get busy."

Instructor Comments

  • In this scenario, CAPT Francis emerges as the situational leader when the team becomes temporarily immobilized by the sight of the patient's injuries. She should continue to provide Leadership until it becomes clear that the primary team leader has arrived and is ready to assume charge of the case.

Skills Needed

  • Situation awareness. Situation monitoring: Assess status of patient, status of team, and progress toward a goal. Communication. Mutual support. Team structure. Leadership.

Potential Tools

  • Call-out, Cross-monitoring, Prioritization, Delegation, Collaboration.

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Scenario 126

 
Appropriate for: All Specialties
Setting: Hospital

 

Two members of the Gastrointestinal (GI) Laboratory are assessing a patient who has just had conscious sedation for a colonoscopy. The monitor shows supraventricular tachycardia 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 and steps into the room. Seeing the blood pressure, the nurse asks, "Do you want a code cart in here?"

Instructor Comments

  • Reinforce the point that monitoring both the patient and team members supports 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 patient and 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 127

 
Appropriate for: All Specialties
Setting: Hospital or Clinic

 

MAJ Winston has just completed her annual physical exam of Sue Garber. Lt. Rosenthal, the nurse for Hall B, asks, "Isn't Sergeant Garber a little confused today? I think she's depressed about her best friend being transferred last month. I was going to ask the psychiatrist to talk with her." MAJ Winston replies, "Yes, I think she may be confused, but, according to her record, she's been seen off and on for over a month for the same thing. Language is a barrier, but I think she may have something physical going on. We need to rule out a medical cause for her confusion." "Now that you say it," LT Rosenthal observes, "her friend 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, Major?" "Yes, please order a consult," MAJ Winston replies.

Instructor Comments

  • Both providers use situation monitoring to assess the status of the patient. 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 two different directions. The nurse in this scenario shows examples of good communication by offering information, strong leadership, and mutual support. The doctor and the nurse advocate and assert for a position, and they communicate and outline a plan that results in the development of a shared mental model without conflict.

Skills Needed

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

Potential Tools

  • Huddle, Situation, Background, Assessment, and Recommendation (SBAR), Check-back, Feedback, Advocacy/assertion, Collaboration.

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Scenario 128

 
Appropriate for: All Specialties
Setting: Hospital

 

It is late at night during a JRTC rotation. A distressed young female soldier having an allergic reaction arrives in the Emergency Department (ED). She has developed a rash and is beginning to wheeze. MAJ Andrew, who is new to the ED, orders Benadryl 125 mg IV. SGT Rodgers, a 91 Whiskey (91 W), questions the drug dosage. MAJ Andrew repeats his order for Benadryl 125 mg IV. Sgt. Rodgers pursues a second time, stating, "Major, that dose seems high. I've never dispensed more than 50 mg IV at a time before." MAJ Andrew says, "Yes, you're right. I was confusing the dose with that for Solu-Medrol." MAJ Andrew changes his order, SGT Rodgers repeats the correct order back to him, and the correct dose of Benadryl is administered.

Instructor Comments

  • The 91 W, using cross-monitoring and situation awareness, correctly questions the doctor when she is concerned about the ordered dosage. When she does not receive an adequate response to her question, she appropriately raises the question again, which results in the correction of a potential medication error.

Skills Needed

  • Mutual support. Communication. Situation awareness.

Potential Tools

  • Two-Challenge rule, Advocacy/assertion, Collaboration, Check-back.

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Scenario 129

 
Appropriate for: All Specialties
Setting: Hospital

 

A middle-aged LTC presents to Triage complaining of severe upper back pain and a ripping sensation in his chest. The patient is transported to the acute care area where an experienced nurse and physician assistant (PA) see him. The nurse has a serious concern about the patient but is unable to identify anything specifically. The Physician Assistant orders a PA/lateral chest x ray (CXR). While the patient waits for an x ray, he continues to complain of worsening chest pain. The PA and nurse begin to press for the x ray to be completed, but the X Ray Department is backlogged with patients. The PA makes multiple trips to the X Ray Department but is unable to get the technician to advance the patient.

The patient continues to complain of pain and becomes increasingly restless. The nurse insists that he be moved ahead of others in X Ray. Within moments after the x rays are taken, the patient becomes diaphoretic and complains of severe chest and abdominal pain. A wet reading of the x rays shows a thoracic aneurysm and changes consistent with acute dissection. The patient is immediately transferred to the Resuscitation Room, and the thoracic surgeon is called. The patient is resuscitated and rushed to surgery.

Instructor Comments

  • Although the nurse and PA use situation awareness and situation monitoring effectively and remain concerned enough about the patient to press for the x ray, they fail to use the Two-Challenge rule or to advocate effectively for the patient. They are unsuccessful in developing a shared mental model with the x ray technician about the urgency of the situation. They could have gone to the next level of authority in Radiology and involved a physician in the matter.

Skills Needed

  • Situation awareness. Situation monitoring: Assess status of patient and progress toward a goal. Mutual support: Resolve conflict.

Potential Tools

  • Two-Challenge rule, Advocacy/assertion, Conflict resolution.

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Scenario 130

 
Appropriate for: All Specialties, Lab Specific
Setting: Hospital, Clinic, or Laboratory

 

Sue Robbins, a part-time student, is assigned to the lab. Things are a bit slow, and she decides to catch up on some college homework. After a period of time, a patient is brought in for blood work. Sue begins working on the blood request and then gets a call for help in Triage. She proceeds to Triage while the patient awaits her blood work results. Shift change is nearing, and Sue has not begun to do her required daily reports.

Instructor Comments

  • This scenario illustrates the potential risks of low workload. Delayed activities may result in failing to prioritize and complete existing workload.

Skills Needed

  • Situation awareness. Mutual support.

Potential Tools

  • Prioritization.

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Scenario 131

 
Appropriate for: All Specialties
Setting: Field

 

During a humanitarian mission in Haiti, an injured 5-year-old boy and his mother present to the on-duty Emergency Medical Technician (EMT). The mother states that the child fell down a large hill and that she is very concerned that he was seriously injured. The child has an actively hemorrhaging 6-inch laceration on his right lower leg but no other obvious signs of injury. Vital signs during Triage are BP 112/56, HR 106, RR 22, and T 98.8. Leg x rays are completed and, after extensive cleaning and exploration, the laceration is repaired. The physician remains concerned about possible infection and asks that the boy return in 24 hours. While the physician is reviewing wound care instructions with the mother, the child complains of nausea and vomits. The physician asks the child about pain, but the child quickly denies any and insists on "going home now." The mom, in a worried voice, states that her son never vomits. The physician assures her that children often vomit after being so upset and tells her to come back if the child has more problems. The medic prepares to discharge the patient while the physician goes off to see another patient. The medic takes the child's vital signs and repeats them: BP 100/78, HR 128, and RR 28. The medic tells the child's mother that her son is "still just a little uptight and nervous from being here." The medic does not report the child's vital signs, believing that it is just as the doctor said—a reaction from being in the Emergency Department (ED). The child is discharged, but he returns 2 hours later pale, weak, vomiting, and complaining of left shoulder pain. A CAT scan reveals a splenic laceration.

Instructor Comments

  • The medic fails to advocate for the patient by informing the physician of the child's vital signs prior to discharge.

Skills Needed

  • Communication. Mutual support. Situation monitoring.

Potential Tools

  • Advocacy.

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