Abstract
This report describes an historical case example that illustrates how simulation used in investigating adverse events can identify underlying, remediable causes that otherwise may not be discovered. The event involved an operating room fire caused by inadvertent triggering of a laser. Guidelines for action after an adverse event were used to guide the postevent actions. An expert in operating room fires was engaged to conduct the investigation. Recommendations and considerations for conducting such investigations with simulation are offered. Simulation is likely underused for healthcare adverse event investigations; this case example may encourage more widespread application.
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More From: Simulation in healthcare : journal of the Society for Simulation in Healthcare
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