Traditional Poster Round
Context: : In-situ pediatric simulations have been used to promote educational objectives including medical decision making, skills mastery, and team building among medical trainees and staff, [1, 2]. However, in-situ simulation also has been used to improve patient safety, such as through identification of latent patient safety threats (LSTs), . Quality improvement interventions can then be made on such identified LSTs.
Description: : Patient safety event reporting systems (SERS) are used in many institutions to gather and report patient safety data. Our institution uses “SB Safe” (RL Solutions©, Toronto, Canada) to provide employees an anonymous and efficient portal to enter patient safety issues and events observed within clinical practice. Portals are sorted into patient care categories such as drug reactions, vascular access, falls, blood products, airway management, equipment, among several others. All reported data is subject for review and intervention by our institutional quality officers.
In 2016, the Stony Brook Children’s Hospital Pediatric Simulation Program enhanced SB Safe with the addition of a “Simulation” category. This category allowed for recording and cataloging LSTs uncovered during in-situ pediatric simulations. Such LSTs utilize the same data entry fields as actual safety events in SB Safe, however, the data is separated from actual patient events for quality assurance review. Through this process, shared causes for LSTs were identified and methods were placed to prevent recurrence of adverse safety events. This study analyzed the LST data the Simulation portal gathered and investigated interventions taken thereafter.
Observation/Evaluation: : This was a prospective observational simulation-based study. Interprofessional in-situ simulations ran approximately twice-monthly in the Children’s Hospital. Since implementation of this process, 29 LSTs have been uncovered and reviewed. The most prevalent contributing factors reported (accounting for 50%) were education/training, human factors, and equipment/supplies. LSTs were also reviewed using the Healthcare Performance Improvement Safety Event Classification severity algorithm to determine which of these had the highest potentially associated harm. Approximately 2/3 of the time, these events reached the simulated patient. Furthermore, the Pediatric Simulation and Quality Patient S￼afety teams at Stony Brook Children’s Hospital have intervened on 7 of these 29 safety threats to date.
Discussion: : Our institution created a process to uncover, review, and act upon LSTs using pediatric in-situ simulation. This process may help to decrease potential threats to actual patients. Further investigation is warranted to see if these interventions correspond to improved patient outcomes.