Practice Improvement| Volume 49, ISSUE 1, P50-56, January 2023

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

Published:November 16, 2022DOI:


      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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        • Yajamanyam P.K.
        • Sohi D.
        In situ simulation as a quality improvement initiative.
        Arch Dis Child Educ Pract Ed. 2015; 100: 162-163
        • Kohn L.T.
        • Corrigan J.M.
        • Donaldson M.S.
        • Institute of Medicine (US) Committee on Quality of Health Care in America
        To Err Is Human: Building a Safer Health System.
        National Academies Press, 2000
        • Greer J.A.
        • Haischer-Rollo G.
        • Delorey D.
        • et al.
        In-situ interprofessional perinatal drills: the impact of a structured debrief on maximizing training while sensing patient safety threats.
        Cureus. 2019; 11: e4096
        • Sharara-Chami R.
        • Lakissian Z.
        • Farha R.
        • Tamim H.
        • Batley N.
        In-Situ simulation for enhancing teamwork in the emergency department.
        Am J Emerg Med. 2020; 38: 833-834
        • Lamberta M.
        • Aghera A.
        Latent Safety Threat Identification via Medical Simulation.
        in: StatPearls. StatPearls Publishing, 2022
        • Auerbach M.
        • Kessler D.O.
        • Patterson M.
        The use of in situ simulation to detect latent safety threats in paediatrics: a cross-sectional survey.
        BMJ Simul Technol Enhanc Learn. 2015; 1: 77-82
        • Bentley S.K.
        • Meshel A.
        • Boehm L.
        • et al.
        Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats.
        Adv Simul (Lond). 2022; 7: 15
        • Brazil V.
        • Purdy E.I.
        • Bajaj K.
        Connecting simulation and quality improvement: how can healthcare simulation really improve patient care?.
        BMJ Qual Saf. 2019; 28: 862-865
        • Jafri F.N.
        • Shah S.
        • Yang C.J.
        • et al.
        Safety considerations for in situ simulation in closed SARS-CoV-2 units.
        Simul Healthc. 2022; 17: 49-53
        • Huggins C.E.
        The joint commission changes survey with new tool for patient safety.
        Pharm Today. 2018; 24: 6
        • Abulebda K.
        • Whitfill T.
        • Montgomery E.E.
        • et al.
        Improving pediatric readiness in general emergency departments: a prospective interventional study.
        J Pediatr. 2021; 230: 230-237.e1
        • Abulebda K.
        • Whitfill T.
        • Mustafa M.
        • et al.
        Improving pediatric readiness and clinical care in general emergency departments: a multicenter retrospective cohort study.
        J Pediatr. 2022; 240: 241-248.e1
        • Hoffmann T.C.
        • Glasziou P.P.
        • Boutron I.
        • et al.
        Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide.
        BMJ. 2014; 348: g1687
        • Chan A.W.
        • Tetzlaff J.M.
        • Gøtzsche P.C.
        • et al.
        SPIRIT 2013 explanation and elaboration: guidance for protocols of clinical trials.
        BMJ. 2013; 346: e7586
        • Harolds J.
        Quality and safety in health care, part I: five pioneers in quality.
        Clin Nucl Med. 2015; 40: 660-662
      1. Plan-do-study-act (PDSA) worksheet. Institute for Healthcare Improvement, 2017
        • Dubé M.M.
        • Reid J.
        • Kaba A.
        • et al.
        PEARLS for systems integration: a modified PEARLS framework for debriefing systems-focused simulations.
        Simul Healthc. 2019; 14: 333-342
        • Jafri F.N.
        • Shah S.
        • Yang C.J.
        • et al.
        Safety Considerations for in situ simulation in closed SARS-CoV-2 units.
        Simul Healthc. 2022; 17: 49-53


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


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


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


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


      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.


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