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.
Key words
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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.
Article info
Publication history
Published online: November 16, 2022
Identification
Copyright
© 2022 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
