AUTHOR=Knight Philip , MacGloin Helen , Lane Mary , Lofton Lydia , Desai Ajay , Haxby Elizabeth , Macrae Duncan , Korb Cecilia , Mortimer Penny , Burmester Margarita 

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

JOURNAL=Frontiers in Pediatrics

VOLUME=5

YEAR=2018

URL=https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2017.00281

DOI=10.3389/fped.2017.00281

ISSN=2296-2360

ABSTRACT=<sec id="ST1"><title>Objective</title><p>To assess the impact of service improvements implemented because of latent threats (LTs) detected during <italic>in situ</italic> simulation.</p></sec><sec id="ST2"><title>Design</title><p>Retrospective review from April 2008 to April 2015.</p></sec><sec id="ST3"><title>Setting</title><p>Paediatric Intensive Care Unit in a specialist tertiary hospital.</p></sec><sec id="ST4"><title>Intervention</title><p>Service improvements from LTs detection during <italic>in situ</italic> simulation. Action plans from patient safety incidents (PSIs).</p></sec><sec id="ST5"><title>Main outcome measures</title><p>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.</p></sec><sec id="ST6"><title>Results</title><p>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%) organizational changes; 2 (5%) staff communications; and 2 (5%) guidelines. Four (9%) service improvements were adopted trust wide. 32 (73%) LTs did not recur after service improvements. 24 (1%) of 1,946 PSIs were similar to LTs: 7 resource incidents, 7 catastrophic blood loss, 4 hyperkalaemia arrests, 3 emergency buzzer failures, and 3 difficulties contacting staff. 34 LTs (77%) were never recorded as PSIs.</p></sec><sec id="ST7"><title>Conclusion</title><p>An <italic>in situ</italic> simulation program can identify important LTs which traditional reporting systems miss. Subsequent improvements in workplace systems and resources can improve efficiency and remove error traps.</p></sec>