Resolving latent safety threats identified through in situ simulation: a multicentre mixed-methods study

In situ simulation can identify latent safety threats in healthcare, yet there has been limited focus on how these threats are subsequently addressed. Adopting a systematic approach to identifying, reporting, and resolving threats found during in situ simulations could enhance clinical safety and system resilience. This study investigated the resolution of safety threats detected through in situ simulation courses in Aotearoa New Zealand hospitals, aiming to quantify resolution rates and examine factors influencing successful resolution.

This multicentre study used an exploratory sequential mixed-methods design. We collected data on latent safety threats identified after in situ simulations using a structured reporting tool and assessed their resolution three months post-course. Associations between resolution and threat classification, risk assessment score, course type, and hospital size were analysed. Qualitative interviews with hospital simulation convenors explored contextual and experiential factors affecting resolution.

Across 20 courses in 15 hospitals, 278 safety threats were identified at the three-month follow-up, with 28% resolved. Threats involving equipment, environmental layout, and tasks were more often resolved than those related to teamwork or organisational factors. Smaller hospitals showed higher resolution rates; multilevel regression confirmed hospital size and threat classification as significant predictors of resolution. Qualitative thematic analysis of 15 interviews identified five key themes: influence of threat type; motivation to resolve the threat; identifying and communicating the threat; clinician agency within their organisation; and hospital structures and processes to support resolution of identified safety threat. Tangible threats within clinicians' control were addressed more readily, often through straightforward interventions; conversely, threats requiring cross-departmental collaboration or structural change remained unresolved due to limited authority, time, and institutional support.

While in situ simulation effectively identifies latent safety threats, threat resolution remains limited. Our findings highlight the need to align institutional processes with frontline clinicians' insights. Effective threat mitigation depends on both threat characteristics and organisational context. To fully realise the opportunity presented by in situ simulation to improve patient safety, healthcare systems must move beyond threat identification to actively support resolution-by empowering clinicians, enabling multidisciplinary collaboration, and embedding clear processes for follow-up and accountability.