Following an investigation where ten times the amount of prescribed insulin was given to a patient during the administration of treatment for hyperkalaemia, learning needs were identified. It was from this incident outcome that the aim for this project arose.

Create a hypokalaemia simulation that can be delivered trust wide with only one facilitator.

The simulation was run on the medical wards that the staff were familiar with to allow us to identify policies and process gaps as well as learning needs.

The simulation only required two registered nurses and with the debriefing session usually took around 40 minutes. This limits the impact on busy wards allowing for safe staffing levels to be maintained. Simulation incident forms were completed for each session to highlight and raise awareness of identified learning points to both ward managers and local governance leads.

The first error that impacted the simulation was the spelling effecting the access to treatment guidelines contained within a Trust policy. The Trust we work for is proud to be multinational, and we found that the majority of our colleagues that have received education oversees used the more widely recognized spelling in Europe of hyperkalemia. This was escalated and the second spelling was added as a keyword, after this change the problem was not repeated in subsequent simulations. It led to further reviews of Trust policies and has driven a change in keywords within the policy portfolio.

The second and third errors were around lack policy and treatment flowchart awareness and poor knowledge on how to navigate the intranet to find policies. Although the participants in the simulation left with a good awareness of the policy and practices accessing the policy and flowchart during the session, it had become apparent that this was a wider Trust issue. Therefore, communication posters were made to highlight the policy and treatment flowchart for hyperkalaemia. Using a QR code staff could play a short video showing how to access the Trust policies from the intranet page after the sessions.

Future plans include collaboratively using simulation to test systems and highlight learning points for other incidents or errors that arise throughout the Trust. Also, we look to utilize Dynamic QR codes [1] that allow for the content connect to the QR code to be updated without the poster having to be reprinted and laminated allowing for a live document.

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