Health Sciences Education Symposium

First Author Information

Michael Joseph Vitto, DO, MS, RDMS, RDCS, FACEP, Assistant Professor, Virginia Commonwealth University School of Medicine, Department of Emergency Medicine

Additional Author(s) Information

V. Ramana Feeser, MD, Department of Emergency Medicine, Sally A. Santen, MD, PhD, Senior Associate Dean, Virginia Commonwealth University School of Medicine, Catherine Grossman, MD, Department of Internal Medicine, Robin Hemphill, MD, MPH, VP Quality and Safety, Associate Dean for Quality and Safety, Virginia Commonwealth University

Presentation Format


Type of Activity


Original Presentation Date


Date of Submission

April 2018

Abstract/Short Description

Over the past year, the Associate Director of the Simulation Center worked with the EM Quality and Safety Director to identify serious safety events (SSE) and critical incidents. As part of the case review, an informal root cause analysis (RCA) was conducted and root causes related to safety risks or breakdowns were identified. These system vulnerabilities were woven into simulation cases for hospital code team training. The cases focused on skills and attitudes that would help prevent, capture, or mitigate similar vulnerabilities while providing clinical care. The objective of this educational innovation was to intentionally translate lessons learned from SSE into changes in clinical practice through the use of RCA followed by simulation.


1. Lee, A., Mills, P. D., Neily, J., & Hemphill, R. R. (2014). Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. Jt Comm J Qual Patient Saf, 40(6), 253-262. 2. Mundell, W. C., Kennedy, C. C., Szostek, J. H., & Cook, D. A. (2013). Simulation technology for resuscitation training: a systematic review and meta-analysis. Resuscitation, 84(9), 1174-1183. 3. Prince, C. R., Hines, E. J., Chyou, P. H., & Heegeman, D. J. (2014). Finding the key to a better code: code team restructure to improve performance and outcomes. Clin Med Res, 12(1-2), 47-57. 4. Wehbe-Janek, H., Pliego, J., Sheather, S., & Villamaria, F. (2014). System-based interprofessional simulation-based training program increases awareness and use of rapid response teams. Jt Comm J Qual Patient Saf, 40(6), 279-287.


© The Author(s)

Is Part Of

VCU Medical Education Symposium