Development of Rapid Response Capabilities in a Large COVID-19 Alternate Care Site Using Failure Modes and Effect Analysis With In Situ Simulation

Nadav Levy, M.D.; Liana Zucco, M.B.B.S., F.R.C.A.; Richard J. Ehrlichman, M.D., F.A.C.S.; Ronald E. Hirschberg, M.D.; Stacy Hutton Johnson, Ph.D., R.N.; Michael B. Yaffe, M.D., Ph.D.; Col. (ret); Satya Krishna Ramachandran, M.D.; Somnath Bose, M.D.; Akiva Leibowitz, M.D.


Anesthesiology. 2020;133(5):985-996. 

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Inherent risks are associated with the redesign, repurposing, or expansion of healthcare services, especially if these are done within a rapid timeframe.[25,26] Therefore, a prospective approach to diagnosing workflow failures as well as a strategy for continuous detection, improvement, and simulation training are paramount in providing a safe and efficient care environment.

Process mapping is a key principle in quality improvement to truly understand the sequence of actions within a workflow.[27] When combined with interdisciplinary on-site walkthroughs, the identification of risk or potential for failures within a process becomes apparent.[14] In our initial planning stages at Boston Hope, the use of these tools enabled the rapid and urgent acquisition of critical supplies and the creation of patient rescue protocols tailored to this unique environment. Our experience supports the need to continuously evaluate and iterate workflows, especially in a new environment.

Simulation is a well-established training method used to improve teamwork performance and outcomes. In situ simulation further supports the detection of local site-specific failures and latent hazards.[15,16] The use of in situ simulation in this setting at Boston Hope not only provided a medium for training and team building but also enabled the detection of significant gaps in our care. Additionally, frequent drills provided the forum for communicating rapidly changing protocols. We recommend the use of regularly scheduled in situ training drills to facilitate the implementation and improvement of emergency management workflows. The accumulated experience at Boston Hope may serve as a foundation for preparedness and training of anesthesia and other acute care providers.[28]