In Situ Simulation to Assess Pediatric Tracheostomy Care Safety: A Novel Multicenter Quality Improvement Program

Sharan J. Shah, Cristen Cusumano, Sadia Ahmed, Anthony Ma, Farrukh N. Jafri, Christina J. Yang

Research output: Contribution to journalArticlepeer-review

14 Scopus citations


Objectives: Our objectives were (1) to use in situ simulation to assess the clinical environment and identify latent safety threats (LSTs) related to the management of pediatric tracheostomy patients and (2) to analyze the effects of systems interventions and team factors on LSTs and simulation performance. Methods: A multicenter, prospective study to assess LSTs related to pediatric tracheostomy care management was conducted in emergency departments (EDs) and intensive care units (ICUs). LSTs were identified through equipment checklists and in situ simulations via structured debriefs and blinded ratings of team performance. The research team and unit champions developed action plans with interventions to address each LST. Reassessment by equipment checklists and in situ simulations was repeated after 6 to 9 months. Results: Forty-one LSTs were identified over 21 simulations, 24 in the preintervention group and 17 in the postintervention group. These included LSTs in access to equipment (ie, availability of suction catheters, lack of awareness of the location of tracheostomy tubes) and clinical knowledge gaps. Mean equipment checklist scores improved from 76% to 87%. Twenty-one unique teams (65 participants) participated in the simulations. The average simulation score was 6.19 out of 16 points. Discussion: In situ simulation is feasible and effective as an assessment tool to identify latent safety threats and thus measure the system-level performance of a clinical care environment. Implications for Practice: In situ simulation can be used to identify and reassess latent safety threats related to pediatric tracheostomy management and thereby support quality improvement and educational initiatives.

Original languageEnglish (US)
Pages (from-to)250-258
Number of pages9
JournalOtolaryngology - Head and Neck Surgery (United States)
Issue number2
StatePublished - Aug 1 2020


  • PS/QI
  • latent safety threats
  • patient simulation
  • quality improvement
  • tracheostomy

ASJC Scopus subject areas

  • Surgery
  • Otorhinolaryngology


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