Mitigating Latent Threats Identified through an Embedded In Situ Simulation Program and Their Comparison to Patient Safety Incidents: A Retrospective Review

Frontiers in Pediatrics
Philip KnightMargarita Burmester

Abstract

To assess the impact of service improvements implemented because of latent threats (LTs) detected during in situ simulation. Retrospective review from April 2008 to April 2015. Paediatric Intensive Care Unit in a specialist tertiary hospital. Service improvements from LTs detection during in situ simulation. Action plans from patient safety incidents (PSIs). The quantity, category, and subsequent service improvements for LTs. The quantity, category, and subsequent action plans for PSIs. Similarities between PSIs and LTs before and after service improvements. 201 Simulated inter-professional team training courses with 1,144 inter-professional participants. 44 LTs were identified (1 LT per 4.6 courses). Incident severity varied: 18 (41%) with the potential to cause harm, 20 (46%) that would have caused minimal harm, and 6 (13%) that would have caused significant temporary harm. Category analysis revealed the majority of LTs were resources (36%) and education and training (27%). The remainder consisted of equipment (11%), organizational and strategic (7%), work and environment (7%), medication (7%), and systems and protocols (5%). 43 service improvements were developed: 24 (55%) resources/equipment; 9 (21%) educational; 6 (14%) or...Continue Reading

References

Apr 12, 1990·Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences·J Reason
Feb 1, 1995·Critical Care Medicine·Y DonchinS Cotev
Feb 7, 2001·BMJ : British Medical Journal·H T Davies, S M Nutley
Dec 13, 2005·Joint Commission Journal on Quality and Patient Safety·Tejal K GandhiMichael Gustafson
Mar 29, 2006·British Journal of Anaesthesia·T ReaderB H Cuthbertson
Apr 26, 2006·Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine·Leo KobayashiGregory Jay
Jun 19, 2007·Anesthesiology Clinics·Jenny W RudolphDaniel B Raemer
Nov 27, 2008·Acta Anaesthesiologica Scandinavica·T Manser
Feb 11, 2009·Quality & Safety in Health Care·J BennC Vincent
Aug 21, 2010·Quality & Safety in Health Care·William RileyRobert M Sweet
Sep 30, 2010·Joint Commission Journal on Quality and Patient Safety·Kaveh G Shojania
Sep 30, 2010·Joint Commission Journal on Quality and Patient Safety·Osnat Levtzion-KorachDavid W Bates
Oct 12, 2010·Current Opinion in Critical Care·Bernhard Frey, David Schwappach
Oct 21, 2010·JAMA : the Journal of the American Medical Association·Julia NeilyJames P Bagian
Oct 21, 2010·JAMA : the Journal of the American Medical Association·Peter J Pronovost, Julie A Freischlag
Mar 27, 2012·BMJ Quality & Safety·Bryony Dean FranklinNick Barber
Jan 22, 2013·International Journal for Quality in Health Care : Journal of the International Society for Quality in Health Care·Janet E AndersonAnneliese Dodds
Jan 24, 2013·Current Opinion in Anaesthesiology·Torin D ShearArthur Tokarczyk
Oct 8, 2013·Simulation in Healthcare : Journal of the Society for Simulation in Healthcare·Aimee King GardnerJennifer A Frey
Dec 3, 2013·BMC Emergency Medicine·Martin StockerMargarita Burmester

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Citations

Aug 30, 2020·Journal of Perinatology : Official Journal of the California Perinatal Association·Rita DadizJesse Bender
Mar 17, 2020·Journal of Obstetrics and Gynaecology Canada : JOGC = Journal D'obstétrique Et Gynécologie Du Canada : JOGC·Valerie BloomfieldMichelle Morais

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Software Mentioned

Datix
SPRinT
Simulation

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