ABSTRACT 796

Abstract

Background and aims: Latent safety threats may contribute to medical errors and have a significant impact on patient safety. We describe identified latent patient safety threats during in-situ-simulations in German pediatric hospitals. Aims: Development of a patient safety checklist for pediatric emergencies in children´s hospitals to avoid common deficits in patient care. Methods: The feedback evaluations of 19 in-situ courses (each 2.5 days) at non-affiliated children´s hospitals in Germany were analyzed after informed consent relating to the incidence of latent safety threats by observing equipment (e.g. special equipment for airway- or circulation management, emergency backpack or case, storage,..), logistics (e.g. emergency call, emergency room), medication and both technical and non-technical skills. Results: 431 latent patient safety threats were detected. All 431 safety threats were summarized in 66 different categories. Most mentioned logistic items were things like equipment storage in different places and oversupply of emergency equipment. In the medication category, mistakes in the attenuation of epinephrine and storage of similar sounding medications side by side were most prevalent. Regarding the technical skills, impart knowledge of the current guidelines and lacks in the use of technical equipment (i.o.-access, defibrillator) were observed. Conclusions: The identified latent safety threats in pediatric emergency care show a high rate of previously unidentified items. According to these results a patient safety checklist must be established to avoid these common deficits in the patient care. We developed a safety checklist regarding our results combined with already published data and guidelines. This checklist will be tested for practicability by using in in-situ-trainings and by evaluation with a Delphi procedure.