Mitigating Latent Threats Identified through an Embedded In Situ Simulation Program and Their Comparison to Patient Safety Incidents: A Retrospective Review
Philip Knight, Helen MacGloin, Mary Lane, Lydia Lofton, Ajay Desai, Elizabeth Haxby, Duncan Macrae, Cecilia Korb, Penny Mortimer, Margarita Burmester
Abstract
To assess the impact of service improvements implemented because of latent threats (LTs) detected duringin situsimulation.
Retrospective review from April 2008 to April 2015.
Paediatric Intensive Care Unit in a specialist tertiary hospital.
Service improvements from LTs detection duringin situsimulation. 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.
Anin situsimulation program can identify important LTs which traditional reporting systems miss. Subsequent improvements in workplace systems and resources can improve efficiency and remove error traps.
This research output has an Altmetric Attention Score of 5. This is our high-level measure of the quality and quantity of online attention that it has received. This Attention Score, as well as the ranking and number of research outputs shown below, was calculated when the research output was last mentioned on 06 March 2018.
All research outputs
#6,194,490
of 23,310,485 outputs
Outputs from Frontiers in Pediatrics
#1,018
of 6,289 outputs
Outputs of similar age
#125,233
of 441,645 outputs
Outputs of similar age from Frontiers in Pediatrics
#33
of 92 outputs
Altmetric has tracked 23,310,485 research outputs across all sources so far. This one has received more attention than most of these and is in the 73rd percentile.
So far Altmetric has tracked 6,289 research outputs from this source. They typically receive a little more attention than average, with a mean Attention Score of 5.6. This one has done well, scoring higher than 83% of its peers.
Older research outputs will score higher simply because they've had more time to accumulate mentions. To account for age we can compare this Altmetric Attention Score to the 441,645 tracked outputs that were published within six weeks on either side of this one in any source. This one has gotten more attention than average, scoring higher than 71% of its contemporaries.
We're also able to compare this research output to 92 others from the same source and published within six weeks on either side of this one. This one has gotten more attention than average, scoring higher than 65% of its contemporaries.
