Video Simulation to Improve Guidelines Against Never Events

Simulation using video feedback to test and improve complex guidelines for rarely used high risk medication such as high strength potassium infusion,

The Problem

Guidelines are often written by experts without consideration of real-life use. This is especially problematic for emergency guidelines of infrequent use often out of hours by staff with a varying skill mix.


A guideline for safe infusion of concentrated potassium solution was required that was usable across all wards and specialties in a UK children’s hospital.

Using improvement methodology we improved a complex unusable guideline created by experts in isolation, to a safe usable guideline by multiple video simulation testing by front line medical and nursing staff.

Making the Case for Change

The original guideline was a burdensome large document created and launched by a committee of expert doctors and pharmacists. When it was first used by front line staff at a more junior level, they felt it was unsafe requiring multiple complex calculations, which they could not understand. There was a clear articulation for change and with consultant change champions there was little resistance to change.

Finding volunteers to film during testing was initially met with suspicion. Clearly describing the patient safety agenda easily broke this barrier and helped recruit volunteers, “Testing the guideline, not you.”

Our Improvement

The guideline was modified after each PDSA cycle of table top simulation with target users, including mixed skill level staff. Participants were pre briefed. The nurse role-played from a written scenario and the doctor asked to produce a prescription with the guideline and salient information. Video was used in understanding the process and pre-defined measures were collected.

The guideline was modified after studying the measures and user suggestions at each simulation. The video study provided additional useful information. Modifications included font size, diagrams, didactic wording, simplification of calculations and table layouts. This reduced correct prescription time by a third.

Learning and Next Steps

The ‘final’ version was approved at the trust level and is now in operation. Guidelines are living documents and we continue to invite suggestions for improvements that we can test. Secondary benefits included culture change of involving users in guideline development and a better understanding of the microsystems of our hospital.

Simulation can test and improve complex guidelines especially those rarely used in real life regardless of skill mix and hierarchy. Video review adds to information that participants were unaware of or unable to verbalise. Of note, it is time consuming, each simulation and debrief takes upwards of an hour.

The project was approved by our Trust and presented at the RCPCH 2014 meeting.


Project Lead: Dr Yincent Tse, Karen Maddison, Dr Nadeem Moghal

Organisation: Great North Children’s Hospital, Newcastle Upon Tyne

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