Interprofessional In Situ Simulation to Identify Latent Safety Threats for Quality Improvement: A Single-Center Protocol Report

Cairenn Binder, Diana Elwell, Peter Ackerman, Jodi Shulman, Christina Yang, Farrukh Jafri

Research output: Contribution to journalArticlepeer-review

Abstract

In situ simulation has frequently been used to improve team performance and provide an opportunity for the practice of critical skills and identify latent safety threats, which are undetected risks that may lead to adverse outcomes. However, the use of known quality improvement tools to prioritize and mitigate these safety threats is an area requiring further study. Over the course of 9 in situ simulations of a pediatric shock case, postcase debriefs were held to identify latent safety threats in an emergency department and a mixed pediatric and adult inpatient unit. Latent safety threats identified included structure-related threats such as inability to locate critical equipment, knowledge-based threats relating to rapid intravenous fluid administration, and communication-based threats such as lack of role designation. Identification of latent safety threats in the health care environment may assist clinician leaders in mitigating risk of patient harm. The protocol described may be adopted and applied to other critical event simulations, with structured debriefing used as a tool to identify and mitigate threats before they affect the patient.

Original languageEnglish (US)
Pages (from-to)50-56
Number of pages7
JournalJournal of Emergency Nursing
Volume49
Issue number1
DOIs
StatePublished - Jan 2023

Keywords

  • Child
  • Delivery of health care
  • Emergency service
  • Hospital communication
  • Patient harm
  • Simulation

ASJC Scopus subject areas

  • Emergency

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