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

Published:November 16, 2022DOI:https://doi.org/10.1016/j.jen.2022.09.007

      Abstract

      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.

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      Biography

      Cairenn Binder is a Staff Development Educator, White Plains Hospital, White Plains, NY. Twitter: @cairennoid .

      Biography

      Diana Elwell is a Nurse Practitioner, White Plains Hospital, White Plains, NY.

      Biography

      Peter Ackerman is Emergency Medicine Physician, Department of Emergency Medicine, White Plains Hospital, White Plains, NY.

      Biography

      Jodi Shulman is Emergency Medicine Physician Assistant, White Plains Hospital, White Plains, NY.

      Biography

      Christina Yang is an Assistant Professor, Albert Einstein College of Medicine; Director, Pediatric Dysphagia Program; and Associate Director of Pediatric Otolaryngology Quality Assurance, Division of Pediatric Otolaryngology, Department of Otorhinolaryngology-Head and Neck Surgery, Children’s Hospital at Montefiore, Bronx, NY. Twitter: @ChrisJYangMD .

      Biography

      Farrukh Jafri is a Medical Director, White Plains Hospital Cares, White Plains Hospital, White Plains, NY. Twitter: @FarrukhJafriMD .