37 Simulation as a Proactive Patient Safety Tool

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Traditionally, The aim of the study was to develop a tool to detect latent safety errors during in situ simulation which is fully integrated with existing Trust safety metrics. simulation in a district general hospital across community and acute clinical areas.Multi-professional During the pilot phase, 73 participants took part in 7 simulations on AMU. Facilitators identified 28 latent errors. Comparison with other sources of safety data (formal incident reporting and critical care outreach team data) showed that Latent safety error by incident codeWe have identified three major outcomes: Shared learning: latent safety errors are rarely unique to one clinical area and have the potential to occur elsewhere in the Trust. Wider dissemination of latent safety errors at a directorate level allows proactive interventions to reduce patient harm. A monthly Simulation Safety Outcome Report shared with senior nursing staff at a directorate level is being evaluated. Responsive learning and staff engagement: latent safety errors were discussed at every debrief. Participants provided valuable suggestions often resulting in immediate local interventions. This internal resolution has engaged and empowered clinical staff in patient safety. Targeting resources: Integration of active and latent error data from numerous sources allows Trust safety management structures to target resources to improve patient safety and develop sustainable approaches to risk reduction. National standardization of coding active errors (incidents) and latent errors would broaden the use of