TeamSTEPPS® Instructor Manual: Specialty Scenarios

ED

Specialty scenario for this guide.

Contents

Scenario 53
Scenario 54
Scenario 55
Scenario 56
Scenario 57
Scenario 58
Scenario 59
Scenario 60
Scenario 61
Scenario 62
Scenario 63
Scenario 64
Scenario 65
Scenario 66


Scenario 53

 
Appropriate for: All Specialties
Setting: Hospital

 

A 22-year-old soldier is brought to the ED after a vehicle crash in which he was a passenger. He has stable vitals but a GCS of 7. After the primary and secondary survey, the resuscitation team prepares to intubate him before sending him to CT. 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, "10 mg Norcuron." The resident, hearing the check-back, replies, "No, that's incorrect. Give 5 mg Norcuron." The pharmacist repeats the new order, to which the physician replies, "That's correct"; and the right 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 this 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 54

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

 

It is 0730 and close to change of shift. Trauma load was heavy all night long. A patient has come to the Lab for a blood draw. The lab technician begins to prepare the patient's left arm for the draw but notices bruises and contusions on it. Recognizing the condition of the arm, the technician begins to prepare the right arm. Roger Robinson, the senior lab technician, seeing the arm and assuming the lab technician caused the bruising, begins to reprimand the technician in front of the patient. The lab technician is embarrassed but does not speak to Robinson about the situation.

Later that day, Robinson asks another lab technician for assistance with a patient. Robinson calls for an IV starter kit, but the lab technician does not know where the kits are. Another technician, aware of where the kits are located, chooses not to tell Robinson for fear he will be reprimanded for speaking up.

Instructor Comments

  • In this vignette, the Lab Tech who placed the patient in the cubicle did not hand off the care of the patient appropriately when he got pulled away. This failure to delegate and advocate for the patient resulted in a delay. The Charge Tech utilized situation awareness and Monitoring to recognize that a problem existed and seek appropriate resolution.

Skills Needed

  • Communication. Situation monitoring. Situation awareness.

Potential Tools

  • Handoff, Collaboration.

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Scenario 55

 
Appropriate for: All Specialties
Setting: Hospital, Pharmacy

 

It is 0600, and it is time to fill the daily requests of medication for the patients. Joe Downs has an extensive list to fill before the meds are to be dispensed at 0700. Denny 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 but proceeds to meet everyone's requests. It is now 0710, and Downs has not completed filling all the daily requests. 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 both because Downs does not ask for help and because the other staff member lacks situation awareness, i.e., is not aware of what is happening and the need to offer assistance. A stronger team structure with expectations for mutual support will result in a shared mental model and 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 56

 
Appropriate for: All Specialties, Respiratory Therapy
Setting: Hospital, Respiratory Therapy

 

The respiratory therapy (RT) team has just learned that 3 hours earlier, one of them had given an incorrect dose of Albuterol to an asthmatic patient resulting in the patient becoming 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 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 shows that even those activities that do not result in bad outcomes can be turned into learning opportunities. In this case, a debrief using mutual support can provide constructive feedback and result in a learning opportunity.

Skills Needed

  • Team structure. Mutual support.

Potential Tools

  • Debrief, Collaboration, Feedback.

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Scenario 57

 
Appropriate for: All Specialties
Setting: Hospital

 

A 20-year-old male presents to the Optometry Department with severe pain in the right eye. At Triage he is loud and obnoxious and occasionally uses offensive language. The optometry specialist tells him that if he cannot act "civil," he will not be treated. This seems to calm the patient, and his vital signs are taken: BP 136/88, P 100, and RR 30. The technician looks briefly at the patient's eye and identifies broken vessels, but the patient becomes increasingly agitated and is unable to sit still for a lengthy examination. The patient is triaged into the Emergency Department (ED) area. There he is observed pacing in the hallways and complaining of significant distress. He goes back into the waiting room and asks for assistance from the Triage nurse because "things are not moving fast enough." Over the course of 3 hours, the patient becomes progressively more agitated.

He begins speaking louder and with more offensive language to both fellow patients and staff. He demands to be seen by a physician. Security is called, and the patient is escorted off the premises without being seen by a physician. Three hours after the patient leaves the ED, the optometrist receives a report that this patient checked himself into another hospital in the area, where he was diagnosed with a ruptured retina.

Instructor Comments

  • The erroneous decision to have the patient escorted off of the premises stems from team member biases associated with the patient's "loud and obnoxious" behavior. Better situation monitoring and Conflict resolution should have been used in this case.

Skills Needed

  • Situation monitoring. Mutual support.

Potential Tools

  • Conflict resolution, Prioritization.

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Scenario 58

 
Appropriate for: All Specialties
Setting: Hospital

 

It is late at night during a particularly hectic shift. A distressed young female having an allergic reaction arrives in the Emergency Department (ED). She has developed a rash and is beginning to wheeze. Dr. Andrew, who is new to the ED, orders Benadryl 125 mg IV. Clara, an experienced pharmacy technician, questions the drug dosage. Dr. Andrew repeats his order for Benadryl 125 mg IV. Clara pursues a second time stating, "Dr. Andrew, that dose seems high. I've never dispensed more than 50 mg IV at a time before." "Yes, you're right. I was confusing the dose with that for Solu-Medrol," stated Dr. Andrew. Dr. Andrew changes his order, she repeats the correct order back to him, and the correct dose of Benadryl is administered.

Instructor Comments

  • The pharmacy technician using cross-monitoring and situation awareness, correctly questions the doctor when she is concerned about the ordered dosage. When she still 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 59

 
Appropriate for: All Specialties
Setting: Hospital or Clinic

 

Two x ray technicians are at the desk during a brief lull on a busy day. They notice a third x ray technician racing busily between two rooms, glancing over at them as she passes. Technician #1 says to Technician #2, "Let's see if Smith can use some help." Technician #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 Technician #1, "I'll show you how it's done." Technician #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 lab; I can finish this leg film for you while you tend to your other patient." "Thanks." says Smith, "The leg has been set, and you just need to take the post reduction x ray."

After Smith leaves, Technician #1 says to Technician #2, "The key to offering assistance is being clear about how much time you have and what tasks you're 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 60

 
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 now so she decides to catch up on some college homework. After a period of time, a patient is brought in for blood work. Robbins begins working on the blood request when she gets a call for help in Triage. She proceeds to Triage while the first patient is awaiting 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 61

 
Appropriate for: All Specialties
Setting: Hospital, Pharmacy

 

It is 0600, and it is time to fill the daily requests of medication for the patients. Joe Downs has an extensive list to fill before the meds are to be dispensed at 0700. Denny 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 but proceeds to meet everyone's requests. It is now 0710, and Downs has not completed filling all the daily requests. 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 both because Downs does not ask for help and because the other staff member lacks situation awareness, i.e., is not aware of what is happening and the need to offer assistance. A stronger team structure with expectations for mutual support will result in a shared mental model and prevent future occurrences of this problem.

Skills Needed

  • Mutual support. Team structure. Situation awareness.

Potential Tools

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

Return to Contents


Scenario 62

 
Appropriate for: All Specialties, X Ray Specific
Setting: Hospital

 

It is 0650, and change of shift report is in progress. Suddenly the Emergency Response Team (ERT) announces a 1-minute ETA of a 24-year-old male whose legs were crushed by a fallen retaining wall. Both shifts start scrambling to get the Trauma Bay ready. The patient arrives and is quickly transferred onto the Emergency Department stretcher. The paramedic is rapidly giving a report. "The patient was crushed by a retaining wall that collapsed during a construction project. Vital Signs: BP 90/60, P 126, R 28. The right leg is really mangled and continuing to hemorrhage. He's got contusions across his lower abdomen and it's distended." Looking into the bay, Nancy Moody, the night nurse, sees that the trauma surgeon has not arrived and that the x ray team is focused on the patient's legs. They seem overwhelmed by the extent of the patient's injuries. Quickly, Nurse Moody says loudly, "ABCs people, what's the patient's respiratory status? This patient needs a STAT CXR and C-spine?" The x ray team refocuses and one member says, "Sorry Ma'am; let's get busy."

Instructor Comments

  • In this scenario, Nurse Moody emerges as the situational leader when the x ray team is 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 63

 
Appropriate for: All Specialties
Setting: Hospital, Radiology

 

During a very busy shift, Joey Thompson, a new x ray technician, is taking x rays of an Emergency Room (ER) patient with pain in his lower back. When it is time to return the patient to the ER, the wrong film is delivered. When the patient is examined by the physician, it is observed that the x rays are of a hand and arm. The physician calls X Ray about the error and someone from the ER must track down the original film.

Instructor Comments

  • This scenario illustrates how high workload in X Ray may result in the inadequate supervision of a new technician. Lack of a check-back by the technician results in the additional work for the ER staff to track down the other set of film.

Skills Needed

  • Mutual support. Communication.

Potential Tools

  • Check-back, Task assistance, Collaboration.

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Scenario 64

 
Appropriate for: All Specialties, Pharmacy Specific
Setting: Hospital, Clinic, or Pharmacy

 

Two Pharmacy team members are filling a new prescription in the pharmacy. The script calls for 10 codeine tablets. The second pharmacist checks the dosage count and finds it to be 12 tablets rather than 10. Two tablets are removed from the container, and the order is delivered.

Instructor Comments

  • Reinforce the points that cross-monitoring supports the maintenance of situation awareness, involves observing others, and is a powerful agent in controlling errors.

Skills Needed

  • Situation awareness. Situation monitoring: assess environment.

Potential Tools

  • Cross-monitoring, Collaboration.

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Scenario 65

 
Appropriate for: All Specialties
Setting: Hospital

 

A 34-year-old male who had a ruptured appendix 9 days previously presents at Triage with a complaint of back and neck pain and a feeling of dread. At Triage, the patient's vital signs are pulse 120, temperature 98.9, and respiratory rate 28. The Triage nurse discusses the case with one of the physicians, who recommends ABGs and a STAT portable chest x ray. The x ray is abnormal, with changes consistent but not diagnostic for pulmonary embolism.

The physician orders a PA and Lateral chest x ray in the Radiology Department. The patient's tachypnic and tachycardic are exacerbated, and the nurse is concerned about sending the patient out of the Emergency Department (ED) without a monitor. She voices her concern to the physician, who reevaluates the patient and judges him to be safe to travel to Radiology without a monitor. She again voices her concerns, and the physician tells her to get the patient to Radiology. The unmonitored patient becomes unresponsive in Radiology and is rushed back to the ED where a code is called. ACLS protocols are followed but the patient dies.

Instructor Comments

  • Lacking mutual support and a method for Conflict resolution, a teamwork failure results despite the use of the Two-Challenge rule. The possibility for further patient advocacy exists in this case.

Skills Needed

  • Mutual support. Team structure. Shared mental model.

Potential Tools

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

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Scenario 66

 
Appropriate for: All Specialties
Setting: Hospital

 

A patient presents to Triage complaining of severe upper back pain and a ripping sensation in the 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 not able to identify anything specifically. The PA orders a PA/Lateral CXR. While the patient waits for 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 this 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

  • In this scenario, although the nurse and PA effectively used situation awareness and situation monitoring to stay concerned enough about the patient to press for the x ray, they fail to use the Two-Challenge rule and to advocate effectively for the patient. They are unsuccessful in developing a shared mental model with the x ray technician on the urgency of the situation. Options include going to the next level of authority in Radiology and getting a physician involved.

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.

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