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- Title
Identifying and managing latent safety threats through a zone-wide emergency department in-situ multidiscipline simulation program: A quality improvement project.
- Authors
O'Dochartaigh, Domhnall; Ying, Lisa T. L.; Simard, Kristin; Eichorst, Christina; Kaba, Alyshah; Mews, Lorissa; Chan, Melissa; Brown, Taryn; Kirkham, Allison; Ma, Warren
- Abstract
Background: Latent safety threats (LSTs) are system-based issues that threaten patient safety, which can materialize at any time and were previously unrecognized. While LSTs such as system deficiencies, equipment failures, training, or conditions predisposing medical errors are frequently reported in the literature, a paucity was noted in their management and mitigation. The purpose of this quality improvement project was to utilize translational simulations to identify, manage, and mitigate future latent safety threats in our EDs. Methods: In 2017, 18 in-situ inter-professional simulation sessions were conducted at 11 EDs. Following each session, a survey assessment tool was completed by participants to identify LSTs. Findings were shared with site educators and managers to facilitate institutional follow up. For reporting, LSTs were categorized thematically and coded as either (i) resolved, (ii) ongoing, or (iii) not managed. Site follow-ups were completed at six months, one, and two years following the simulation. Results: A total n = 158 LSTs were identified. The number and percentage by theme were: staff 48 (30.4%), equipment 41 (25.9%), medications 33 (20.9%), resuscitation resources 24 (15.2%), and information technology (IT) issues 12 (7.6%). Twelve-month follow-up identified 149 LSTs resolved and nine required ongoing work to manage. Two-year follow-up identified all but two LSTs resolved. No occurrences of an LST 'not managed' were identified. Conclusions: Translation simulation effectively identified LSTs. Through the creation of a structured plan and systematic long-term follow-up, all identified threats were addressed while a limited number required ongoing management.
- Subjects
MEDICAL equipment reliability; MEMORY; MEDICAL quality control; HOSPITAL emergency services; PROFESSIONS; HEALTH facilities; CROSS-sectional method; MEDICATION errors; HUMAN services programs; QUALITATIVE research; SURVEYS; ABILITY; HEALTH care teams; QUALITY assurance; CLINICAL competence; INTERPROFESSIONAL relations; THEMATIC analysis; RESUSCITATION; PATIENT safety; INFORMATION technology
- Publication
Canadian Journal of Emergency Nursing (CJEN), 2022, Vol 45, Issue 2, p37
- ISSN
2293-3921
- Publication type
Article
- DOI
10.29173/cjen157