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Magnesium Toxicity and Medical Errors: A Multidisciplinary Simulation for Debriefing an Obstetric Emergency

Purpose: To create a simulation that improves communication during obstetric emergency and promotes a safe learning environment to debrief and evaluate medical errors.

 

Background: Simulation is known to improve communication and comfort in obstetric emergency. Little data exist regarding simulation for enhancing expertise in debriefing and evaluating system errors.

 

Methods: The simulation highlights an unresponsive patient shortly following a preterm delivery at 30 weeks gestation. The team discovers an accidental bolus of intravenous magnesium was given instead of postpartum oxytocin. Following conclusion of the simulation, participants were asked to lead a debrief session. Surveys were performed to assess participant comfort with magnesium toxicity, debriefing, evaluating a medical error, and communication during an emergency. 

 

Results: Participants felt the simulation was (1) a realistic scenario that allowed practice debriefing a medical error within a large multidisciplinary team, (2) a place to practice high acuity care and communication, and (3) a safe place to receive and provide feedback. On average, residents reported an increase in comfort with management of magnesium toxicity from little comfort(2/5) tomoderate comfort(4/5). In general, participants (90%; N=10) felt like they learned advanced management of acute magnesium toxicity. All participants (100%; N=10) reported they would recommend this simulation to others in their profession. 

 

Discussions: We have designed a simple model that highlights the importance of (1) communication during an obstetric emergency and (2) debriefing and evaluating errors from systems perspective. This model increased participant knowledge and comfort with magnesium toxicity and promoted a safe culture to discuss medical errors and practice debriefing.

Topics: CREOG & APGO Annual Meeting, 2019, Student, Resident, Faculty, Clerkship Director, Residency Director, Patient Care, Medical Knowledge, Systems-Based Practice & Improvement, Interpersonal & Communication Skills, Practice-Based Learning & Improvement, CME, Simulation, Quality & Safety, Team-Based Learning,

General Information


Intended
Audience
Student,Resident,Faculty,Clerkship Director,Residency Director,
Competencies
Addressed
Patient Care,Medical Knowledge,Systems-Based Practice & Improvement,Interpersonal & Communication Skills,Practice-Based Learning & Improvement,
Educational
Continuum
CME,
Educational
Focus
Simulation,Quality & Safety,Team-Based Learning,
Clinical Focus

Author Information

Jaclyn Phillips, MD, George Washington University; Maryalice Wolfe, MD; Lauren Nelson, MD; Kathryn Marko, MD

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