**6. Education**

The critical care setting is a highly technical, fast-pacing, high-risk clinical area where medical knowledge advancement requires frequent up-to-date resources, and skill mastering involves the confidence and expertise of team members at different levels. Novice healthcare providers need the experience in critical thinking and skill mastering commonly provided within the practice, arguably impinging on patient safety principles. The balance between autonomy and supervision in all disciplines is an ever-changing part of daily practice in the intensive care unit. The challenges in an increased demand on training hours, limited patient encounters, and the focus on patient safety have led to relying more on innovation and technology to provide an effective curriculum.

Recognizing the degree of safety within the critical care practice can set the stage to determine the priorities needed in education. Education is frequently embedded within practice to maintain a high level of patient safety and minimize harm. **Figure 3** describes the functional levels frequently found in this setting, including the unique nature of the ICU, where teams often move within a spectrum of an ultra-safe activity to an ultra-adaptive activity, setting the stage for a higher risk for errors [123].

Medical simulation has been introduced as an effective methodology in medical education in general [124]; and within the critical care practice to impart critical care principles, particularly in skill acquisition and competence [125]. This technology has had a widely positive educational impact on all health-related professional groups [126]. It provides significant results when combined with reflective debriefing, considered the most crucial component in healthcare simulation [127]. The interactive, bidirectional, and reflective conversation at the end of a simulation exercise cements the basis of adult learning strategies using experiential learning. Several methodologies have been described in the literature, including debrief timing, methodology, structure alternatives, and process elements. The facilitator-guided debrief is the most common methodology and improves individual and team performance [128]. Recently, a more positive approach to debrief, learning from success (LFS), has been endorsed where adaptation is the focus of the exercise with a scenario that includes unanticipated and problematic disruptions that are presented to the learners [129]. Faculty members using the LFS approach require a deeper understanding of human factor science, patient safety, implementation science, and organizational psychology.

#### **Figure 3.**

*Approaches to safety education and practice in the intensive care unit. Successful Critical Care practices feel comfortable with fast changes in pace and complexity. These changes come with an increase in risk, translating into variations in safety levels for decisions and procedures executed. ICU conditions can change very quickly ranging between an ultra-safe environment as in bedside rounds, a highly reliable as in central line placement, a reliable as in difficult airways or an ultra-adaptive in multiorgan failure/code situations. With this construct in mind, education should be directed to arm providers with the tools to think fast and slow between: routine operations/focus on prevention, applying known procedures in emergencies/focus on protocols, being flexible/focus on adaptative team strategies and professional expertise/focus on stabilization followed by recovery. \*(Vincent, C and R. Amalberti, Strategies for the Real World 2015, Chapter 3, pg 31. Ref. 123).*

Can the use of medical simulation improve the goals of patient safety and decrease harm to patients? The current body of literature describes enhanced skills and knowledge, competence, better outcomes, and lower error rates using procedural simulation training [130]. The use of simulation has also been applied to hospital design to identify latent conditions and mitigate safety concerns in a systematic process [131].

#### **6.1 Skills development and assessment**

The skill set required for the ICU healthcare providers is unique and differentiated from other work units within the hospital. Some of these skills include high risk *Patient Safety in the Critical Care Setting: Common Risks and Review of Evidence-Based… DOI: http://dx.doi.org/10.5772/intechopen.108005*

airway management, conscious sedation, management of mechanical ventilatory and circulatory support, among others. There are several ways to ensure providers who join the ICU have the necessary skill set for critical decision-making and advanced procedures. Standard credentialing processes and certification have been established to ensure providers complete a certain number of procedures. It is essential to recognize the limitations of relying narrowly on procedural skills when ICU leadership makes hiring decisions. Having mechanisms to evaluate soft skills and decisionmaking prior to hiring can enhance safety by elevating the starting skillset. One tool to consider is using simulation scenarios that mimic typical decompensation events to evaluate and optimize performance. Utilizing simulation center-based interviews for nurse practitioners and physician assistants at one institution improved retention. It also decreased actions for practice deficiencies compared to a conventional interview method [132].

#### *6.1.1 Cultural values*

When new employees join, they only have a basic understanding of the organization based on small bits of information gathered during the interview process. During their onboarding, we need to establish a memorable experience that helps them internalize the expectations, including service values, cultural components, [78] shared understanding of how we work, how we interact, fair and just culture, and how we respond to safety events and improvement culture.

#### *6.1.2 Defining successful ICU outcomes*

Meaningful outcomes must be concordant with the patient's wishes. From the patient's perspective, the quality of life, independence, and quality of death and dying are often more important than survival per se. We also must prevent catastrophic long-term consequences for patients and their families, many of which are iatrogenic.

#### **6.2 Shared-decision making**

Informed Medical Decisions Foundation defines shared decision-making as "Shared decision-making is a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values, goals, and preferences" [133]. Subsequently, effective communication with patients and families is the pillar of shared decision-making and patient-centered care [134]. The availability of health information technology (HIT) allows for increased connectivity between patients and providers. A systematic review of the current literature addressing patient access to their EMR, reported increased patient engagement with the medical system, increased communication with their health care teams, increased discovery of medical errors, and improved adherence to medication [135]. Furhermore, vast research conducted in the shared decisiommaking space, clarified the opportunities related to patient's preferences, goals and values, especially in the ICU setting where requests for futile interventions often arise [136]. From the patient and family's perspective, effective communication enhances trust in their healthcare providers and improves the perception of their care within a system [137–139].
