Sample Scenario for Magnesium Toxicity In Situ Simulation

Purpose of the tool: The Magnesium Toxicity In Situ Simulation tool provides a sample scenario for labor and delivery (L&D) staff to practice teamwork, communication, and technical skills in the unit where they work. Upon completion of the Magnesium Toxicity In Situ Simulation, participants will be able to do the following:

• Demonstrate effective communication with the patient and support person during an episode of patient care involving magnesium toxicity.
• Demonstrate effective teamwork and communication with clinical team members during assessment of the patient, changes in the patient’s clinical status, and actions required for the optimum patient outcome.
• Demonstrate timely and accurate clinical assessment and intervention for magnesium toxicity.
• Demonstrate the efficient use of checklists, protocols, or similar cognitive aids for responding to magnesium toxicity.

Who should use this tool: Simulation facilitators

How to use this tool: This tool should be used in connection with the "Facilitation Instructions for Conducting In Situ Simulations" to prepare, conduct, assess, and debrief in situ simulations on L&D units. Simulation facilitators can adapt, modify, and further tailor this sample scenario to meet the training needs of their unit staff or resources available in their facility.

Note: The information presented in this document does not necessarily represent the views of AHRQ. Therefore, no statement in this document should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. Outside resources identified do not represent an endorsement of those resources and do not reflect the position of AHRQ or the Federal Government.

Sample Scenario for Magnesium Toxicity In Situ Simulation

This document provides a sample scenario for an in situ simulation for magnesium toxicity. This document contains the following:

• Preparation Required.
• Clinical Context, Triggers, Distractors, and Expected Behaviors for the Simulation.
• Magnesium Toxicity Simulation Assessment Tool.
• Clinical Context, Triggers, and Distractors Formatted for Printing.

Refer to the document titled "Facilitation Instructions for Conducting In Situ Simulation" for general guidance and instructions regarding presimulation planning, presimulation briefing, simulation assessment, and simulation debriefing.

During the simulation, participants are encouraged to practice the use of protocols, checklists, or cognitive aids the unit has developed or adapted for responding to magnesium toxicity.

Preparation Required

This simulation requires people to play the roles of the patient and the patient’s support person:

• The actor playing the patient should wear a patient gown, padding (to simulate a postpartum belly), and a wrist identification band and should lie in bed. The simulated patient (“actor”) should wear scrubs under the gown to ensure her privacy.
• The actor playing the support person should be briefed on his or her disposition and how to interact with others in the simulation.

In addition, the following props (i.e., simulated equipment and materials) are required:

• Simulated intravenous (IV) fluids and medications (e.g., magnesium sulfate, calcium gluconate). The team should order and access simulated fluids and medication in the way it normally would order these items—for example, through electronic order entry, a Pyxis machine, or a rapid response kit or cart. This allows the team to experience the normal passage of time required to order and access necessary supplies for treatment. Prior planning and coordination with the pharmacy for these simulated items will help make the simulation as realistic as possible.
• Simulated urine in a Foley catheter bag.
• Oxygen mask and oxygen (O₂) saturation probe and any other related equipment for simulating use of oxygen.
• Lab result printouts or a simulated patient in the electronic medical record with the necessary lab results for the simulation.

Clinical Context, Triggers, Distractors, and Expected Behaviors for the Simulation

The content of this simulation is divided into four parts: Clinical Context, Triggers, Distractors, and Expected Behaviors. The Clinical Context is provided at the beginning of the simulation in the form of a patient handoff and introduces that simulated patient and her clinical history. The handoff is followed by a series of Triggers and Distractors, events or actions that introduce new information and shape the context of the clinical response. The simulation facilitator introduces the Triggers and Distractors throughout the course of the simulation. A set of Expected Behaviors is also provided for the Clinical Context and each set of Triggers and Distractors. The Expected Behaviors offer a list of ideal actions that the clinical team might take in response to each set of events in the simulation with particular regard to those that foster effective teamwork and communication. The Expected Behaviors can also serve as a tool to use in evaluating the performance of the simulation participants.

Expected behavior/performance (not in any particular order):

• Nurse introduces self to the patient and begins assessment.

Expected behavior/performance:

• Nurse reassures patient and support person.
• Nurse reassesses maternal and fetal status.
• Nurse calls for additional help, provider, or rapid response team.
• Situation-Background-Assessment-Recommendation (SBAR) is used to inform others of the situation when they arrive. Additional help might be attending physician, anesthesiology, nursing, or rapid response team.

Expected behavior/performance (not in any particular order):

• Nurse calls for additional help, provider, or rapid response team.
• Nurse, provider, or team member calls out concern for magnesium toxicity.
• SBAR is used to inform others of the situation when they arrive. Additional help might be attending physician, anesthesiology, nursing, or rapid response team.
• Provider speaks to patient and support person or delegates to another team member to inform and answer questions.
• Provider clearly demonstrates leadership role.
• All team members use closed-loop communication and provide mutual support to one another.
• Leader may call team huddle.
• All team members call out critical patient information.
• Team initiates appropriate clinical response for unresponsiveness and magnesium toxicity.

Expected behavior/performance (not in any particular order):

• Team initiates appropriate clinical response for unresponsiveness and magnesium toxicity.
• Call for advanced airway support (if not already available from staff members who have arrived to provide additional support).
• SBAR is used to inform others of the situation when they arrive. Additional help might be attending physician, anesthesiology, nursing, or rapid response team.
• All team members call out critical patient information.
• All team members use closed-loop communication and provide mutual support to one another.
• Leader may call a team huddle.

Expected behavior/performance (not in any particular order):

• Situation-Background-Assessment-Recommendation (SBAR) is used to inform others of the situation when they arrive. Additional help might be attending physician, anesthesiology, nursing, or rapid response team.
• All team members use closed-loop communication and provide mutual support to one another.
• Leader calls a team huddle to establish a plan of care.

Magnesium Toxicity Assessment Tool (Optional)

This tool provides a list of expected behaviors in response to the Clinical Context and each set of Triggers and Distractors in the simulation and can be used as a tool in evaluating the performance of the simulation participants.

Trigger 1: Slurred Speech and Nausea

Trigger 2: Patient Becoming Unresponsive

Trigger 3: No Response and Deteriorating

Trigger 4: Patient Rebounds

Clinical Context, Triggers, and Distractors Formatted for Printing Separately

The clinical context, triggers, and distractors used in this simulation scenario are provided on the next several pages in a format suitable for printing on cardstock in preparation for facilitating this in situ simulation using printed cards. The printed cards can be handed to the simulated patient or participating staff members at appropriate intervals during the simulation.