Utilizing Simulation to Identify Latent Safety Threats During Neonatal Magnetic Resonance Imaging Procedure

Area of Science:

• Medical Simulation
• Patient Safety
• Neonatal Intensive Care

Background:

• Transferring neonates from the NICU to MRI exposes them to risks.
• In situ simulation (ISS) can identify safety threats during high-risk procedures.

Purpose of the Study:

• Identify modifiable latent safety threats (LSTs) during neonatal MRI transport.
• Compare performance of specialized vs. nonspecialized transport teams.

Main Methods:

• Conducted 9 months of ISS for neonatal MRI transport (intubated/nonintubated infants).
• Used debriefings and questionnaires to identify safety threats and team function.
• Implemented mitigation strategies based on findings.

Main Results:

• Identified 116 LSTs, including medication, equipment, and resource/system issues.
• Highlighted need for preprocedure planning, checklists, and protocols.
• Specialized teams completed 7/10 simulations.

Conclusions:

• ISS effectively identified safety risks in neonatal MRI transport.
• Findings led to updated MRI transport policies and procedures.