The Case of the Inadvertently Triggered Laser: An Historical Example of Simulation-Enhanced Adverse Event Investigation.

Simulation in Healthcare : Journal of the Society for Simulation in Healthcare
Jeffrey B Cooper

Abstract

This report describes an historical case example that illustrates how simulation used in investigating adverse events can identify underlying, remediable causes that otherwise may not be discovered. The event involved an operating room fire caused by inadvertent triggering of a laser. Guidelines for action after an adverse event were used to guide the postevent actions. An expert in operating room fires was engaged to conduct the investigation. Recommendations and considerations for conducting such investigations with simulation are offered. Simulation is likely underused for healthcare adverse event investigations; this case example may encourage more widespread application.

References

Feb 14, 2014·International Journal for Quality in Health Care : Journal of the International Society for Quality in Health Care·Douglas P SlakeyJames R Korndorffer
May 18, 2018·Simulation in Healthcare : Journal of the Society for Simulation in Healthcare·Carl Macrae
May 29, 2019·Simulation in Healthcare : Journal of the Society for Simulation in Healthcare·Anna-Theresa LobosMélissa Langevin

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Citations

Jan 13, 2021·Annual Review of Nursing Research·J Cedar Wang, Lori Podlinski

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