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

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 a...

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Bibliographic Details
Published in:Journal of emergency nursing 2023-01, Vol.49 (1), p.50-56
Main Authors: Binder, Cairenn, Elwell, Diana, Ackerman, Peter, Shulman, Jodi, Yang, Christina, Jafri, Farrukh
Format: Article
Language:English
Subjects:
Child
Clinical outcomes
Coronaviruses
COVID-19
Debriefing
Delivery of health care
Emergency medical care
Emergency service
Emergency Service, Hospital
Emergency services
Group performance
Health problems
Hospital communication
Hospitals
Humans
Identification
Inpatient care
Interdisciplinary aspects
Interprofessional Education
Nurses
Patient harm
Patient Safety
Pediatrics
Quality Improvement
Quality management
Safety
Safety Management - methods
Sepsis
Shock - therapy
Simulation
Simulation Training - methods
Teams
Threats
Training
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Description
Summary: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.
ISSN:0099-1767
1527-2966
1527-2966
DOI:10.1016/j.jen.2022.09.007