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U SAFER Trial: Using Simulation for Audit & Feedback Review of Adverse Events

Tuesday, May 15
13:30 - 15:00
Location: Neptune 1&2

Background: : An adverse event (AE) is an unintended injury or complication caused by health care, resulting in disability, death, prolonged hospital stay or readmission. (1). Health care teams analyze AEs using root cause analysis (RCA) to understand why events occurred and how to prevent recurrence. Despite widespread use, RCA has many limitations. Specifically, the retrospective nature separates the event from the system and environment in which it occurred (2). In addition, health care providers often believe that the actions needed to prevent the outcome are obvious once the facts become clear (hindsight bias) (2).

Research Question: : Our goal was to use simulation-based RCA to identify system errors and latent patient safety threats in pediatric AEs and compare the findings to conventional RCA.

Methodology: : Ethics approval was obtained. AEs were identified through the hospital’s Safety Reporting System. Patient chart and event review data were combined to create two fictionalized scenarios. Scenario A: in-patient drug error event (concentration, dose, route) and Scenario B: critical care drug infusion error (concentration, dose) on handover of care. Scenarios were repeated with different, voluntary clinicians to replicate the outcome of the event until we achieved data saturation. Data (transcripts and video recording) from each debriefing was analyzed using a content analysis approach. A list of root causes and recommendations for improvement was compiled and then compared to the recommendations from the traditional RCA.

Results: : Errors were reproduced in 60% (3/5) of scenario and identified in 100% (4/4) of scenario B. In the debriefings and video analysis, health care providers identified reasons for errors including difficulty interpreting pre-printed resuscitation sheets, confusion about drug dose concentrations, product labelling and lack of standard work around handover of care. Participants suggested changes that could prevent errors such as improved drug labelling, creation of specialized drug kits, alert signs, changing existing protocols and checklists for nursing handover. The debriefings, independent of error reproduction, revealed unique and different causes for error and new recommendations when compared to traditional RCA. Furthermore, they provided a safe environment to discuss crisis resource management principles, often not discussed during a traditional RCA, including sharing mental models and task delegation.

Discussion/Conclusions: : Discussion: While the original AE was not reproduced in all simulations, the AE simulations still identified more reasons for errors and ideas for improvement than the traditional RCA. In addition, they provided a better understanding of why decisions were made by allowing for immediate discussion regarding changes needed for safe patient care. Our study suggests that simulation-based RCA increases the discovery of root causes. Future studies should evaluate if simulation can test and optimize recommendations before implementation.





Anna-Theresa Lobos, MD

pediatric critical care physician, assistant professor of Pediatrics
university of ottawa, children's hospital of eastern ontario
Ottawa, Ontario, Canada

Dr. Lobos is an Assistant professor at the University of Ottawa, Department of Pediatrics and Division of Critical Care. In addition to her role as a pediatric intensivist at the Children’s Hospital of Eastern Ontario (CHEO), she is the Pediatric Critical Care Program Director, the Medical Director of CHEO’s Medical Emergency Team and the Medical Director of Simulation at CHEO. Her interest in interprofessional education and the recognition of acute illness has led her to present at national and international conferences and publish numerous papers on the Ontario Medical Emergency Team experience. Dr. Lobos is also the co-chair of CHEO’s Early Response and Resuscitation Committee which works to create hospital wide policies and education programs focused on the recognition and management of the acutely ill child. Dr. Lobos’ research in simulation focuses on using simulation and debriefing to understand the challenges in treating acutely ill children and improving care delivery.

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Natalie Ward, PhD

Researcher
Children’s Hospital of Eastern Ontario, Research Institute
ottawa, Ontario, Canada

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Christa Ramsay, RRT

Registered Respiratory Therapist, Clinical Research Coordinator
Children’s Hospital of Eastern Ontario
Ottawa, Ontario, Canada

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Colleen Fitzgibbons, BSc, RN

Nurse Educator, Simulation
Children’s Hospital of Eastern Ontario
Ottawa, Ontario, Canada

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Melissa Langevin, MD

Emergency Medicine Physician, Assistant Professor Pediatrics
University of Ottawa, Children's Hospital of Eastern Ontario
Ottawa, Ontario, Canada

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Send Email for Justin Jeffers


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