Latent Safety Threats and Countermeasures in the Operating Theater: A National In Situ Simulation-Based Observational Study.
Journal
Simulation in healthcare : journal of the Society for Simulation in Healthcare
ISSN: 1559-713X
Titre abrégé: Simul Healthc
Pays: United States
ID NLM: 101264408
Informations de publication
Date de publication:
01 Feb 2022
01 Feb 2022
Historique:
entrez:
1
2
2022
pubmed:
2
2
2022
medline:
4
2
2022
Statut:
ppublish
Résumé
In situ simulation provides a valuable opportunity to identify latent safety threats (LSTs) in real clinical environments. Using a national simulation program, we explored latent safety threats (LSTs) identified during in situ multidisciplinary simulation-based training in operating theaters in hospitals across New Zealand. Surgical simulations lasting between 15 and 45 minutes each were run as part of a team training course delivered in 21 hospitals in New Zealand. After surgical in situ simulations, instructors used a template to record identified LSTs in a postcourse report. We analyzed these reports using the contributory factors framework from the London Protocol to categorize LSTs. Of 103 postcourse reports across 21 hospitals, 77 contained LSTs ranging across all factors in the London Protocol. Common threats included staff knowledge and skills in emergencies, team factors, factors related to task or technology, and work environment threats. Team factors were also commonly reported as protecting against adverse events, in particular, creating a shared mental model. Examples of actions taken to address threats included replacing or repairing faulty equipment, clarifying emergency processes, correcting written information, and staff training for clinical emergencies. The pervasiveness of LSTs suggests that our results have widespread relevance to surgical departments throughout New Zealand and elsewhere and that collective solutions would be valuable. In situ simulation is an effective mechanism both for identifying threats to patient safety and to prompt initiatives for improvement, supporting the use of in situ simulation in the quality improvement cycle in healthcare.
Identifiants
pubmed: 35104831
doi: 10.1097/SIH.0000000000000547
pii: 01266021-202202000-00017
pmc: PMC8812409
doi:
Types de publication
Journal Article
Observational Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
e38-e44Informations de copyright
Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society for Simulation in Healthcare.
Déclaration de conflit d'intérêts
C.S.W. is a minor shareholder in SaferSleep LLC (London, UK), a company that aims to improve safety in healthcare. The other authors declare no conflict of interest.
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