Simulation – A Gateway To Patient Safety | VA Minneapolis Health Care

The Minneapolis VA is committed to ensuring a safe environment. Last month, missing patient simulation drills occurred at various times to reach each shift of duty at the medical center.

“The purpose of using simulation cases is to practice responding to real-life events, to debrief afterward, and to implement necessary changes or provide additional education to enhance awareness,” said Simulation Program Manager Robin Rabey. 

Vulnerable patients with certain physical or cognitive impairments require a distinctly higher degree of monitoring to ensure they are safe from injury or harm. This exercise allowed staff and volunteers to practice how to respond if there is ever a vulnerable patient missing.  

On all three drills conducted, nursing teams where the simulation started responded quickly to engage with the police and nursing supervisors. After the immediate area was searched, a facility wide search was initiated. The simulated missing person, a mannequin, was found very early in the drills in a stairwell, the parking ramp and in the cafeteria.  Many other clinical and non-clinical departments responded to the overhead announcement and email notification of the missing patient and joined in to execute the full facility and grounds search. 

The Community Based Outreach Clinic (CBOC) teams participated in tabletop drills involving what to do and how to respond if a vulnerable or at-risk patient were to be missing from their location.   

“Feedback from the drills include some minor updating to policy and practice and that the drills could be expanded to involve more staff members,” said Director of Quality and Patient Safety Ann Grebner.

The Veteran Health Administration’s commitment to modernizing VA health systems into High Reliability Organizations – organization that experiences fewer than anticipated accidents or events of harm despite operating in highly complex, high-risk environments where even small errors can lead to tragic results – is the foundation of conducting simulation drills.   

Missing patient drills for the main campus and CBOC’s are an annual requirement as directed by VHA. Future drills may include a live person as the missing patient, use of a canine officer, and medical emergencies. 

The missing patient drills were planned by a group representing the several departments within the Minneapolis VA to include the nursing office, police department, patient safety, education, simulation center, and the administrator of the day office.