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Perm J. 2014 Spring;18(2):14-20. doi: 10.7812/TPP/13-124.

Using simulation to address hierarchy-related errors in medical practice.

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Associate Professor of Pediatrics at the University of Louisville School of Medicine in KY.
Clinical Nurse Specialist in the Critical Care Center at Kosair Children's Hospital and Norton Healthcare in Louisville, KY.
Associate Professor of Pediatrics at the University of Louisville in KY.
Assistant Professor in Graduate Medical Education at the University of Louisville in KY.



Hierarchy, the unavoidable authority gradients that exist within and between clinical disciplines, can lead to significant patient harm in high-risk situations if not mitigated. High-fidelity simulation is a powerful means of addressing this issue in a reproducible manner, but participant psychological safety must be assured. Our institution experienced a hierarchy-related medication error that we subsequently addressed using simulation. The purpose of this article is to discuss the implementation and outcome of these simulations.


Script and simulation flowcharts were developed to replicate the case. Each session included the use of faculty misdirection to precipitate the error. Care was taken to assure psychological safety via carefully conducted briefing and debriefing periods. Case outcomes were assessed using the validated Team Performance During Simulated Crises Instrument. Gap analysis was used to quantify team self-insight. Session content was analyzed via video review.


Five sessions were conducted (3 in the pediatric intensive care unit and 2 in the Pediatric Emergency Department). The team was unsuccessful at addressing the error in 4 (80%) of 5 cases. Trends toward lower communication scores (3.4/5 vs 2.3/5), as well as poor team self-assessment of communicative ability, were noted in unsuccessful sessions. Learners had a positive impression of the case.


Simulation is a useful means to replicate hierarchy error in an educational environment. This methodology was viewed positively by learner teams, suggesting that psychological safety was maintained. Teams that did not address the error successfully may have impaired self-assessment ability in the communication skill domain.

[Indexed for MEDLINE]
Free PMC Article

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