Using simulation to identify and resolve threats to patient safety

Area of Science:

• Healthcare simulation
• Patient safety research
• Systems engineering in medicine

Background:

• Simulation-based team training, widely used in aviation, offers a model for enhancing patient safety in healthcare.
• Identifying latent threats within the healthcare environment is crucial for improving patient outcomes.

Purpose of the Study:

• To demonstrate the effectiveness of in situ simulation in uncovering environmental hazards that compromise patient safety.
• To highlight how real-world simulations can reveal systemic issues impacting healthcare delivery.

Main Methods:

• A case study employing in situ simulation at a Midwestern hospital.
• The simulation involved a simulated cardiac catheterization scenario for a patient with chest pain and hypotension.
• Utilized a patient manikin, high-definition video recording, and real-time annotation software, with a Master Scenario Event List to guide the event.

Main Results:

• Identified three critical latent environmental threats: patient transport procedures, handoff process management, and cardiac catheterization workflow organization.
• These threats stemmed from poorly developed or absent procedures, affecting all healthcare teams daily.
• Participants and supervisors identified these threats during post-simulation debriefing as common, dangerous, and requiring remediation.

Conclusions:

• Conducting simulations in the actual care environment with intact healthcare teams practicing real workflows is effective.
• This method successfully identifies latent environmental threats to patient safety that artificial lab settings cannot reveal.
• In situ simulation provides a powerful tool for uncovering and addressing systemic risks in healthcare.