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

Abstract

To assess the impact of service improvements implemented because of latent threats (LTs) detected during in situ simulation. Retrospective review from April 2008 to April 2015. Paediatric Intensive Care Unit in a specialist tertiary hospital. Service improvements from LTs detection during in situ simulation. Action plans from patient safety incidents (PSIs). 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. 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. An in situ 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.