Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams.

BACKGROUND: Latent safety threats (LSTs) are errors in design, organization, training, or maintenance that may contribute to medical errors and have a significant impact on patient safety. The investigation described in this article was conducted as part of a larger prospective, longitudinal evaluation using laboratory- and in situ simulation-based training sessions to improve technical and nontechnical skills of neonatal ICU (NICU) providers at a Level III academic NICU. METHODS: Simulations were performed in laboratory (4 scenarios per session) and in situ (1 scenario per session) settings with multidisciplinary neonatology teams. Facilitators and subjects identified LSTs during standardized debriefings immediately following each scenario After enrollment, facilitators classified LSTs into equipment, medication, personnel, resource, or technical skill. Pervasive team knowledge gaps were further subclassified into lack of awareness or understanding, procedure performed incorrectly, omission of necessary action, or inappropriate action. RESULTS: In a 19-month period of enrollment (August 2009-March 2011), 177 subjects of 202 NICU providers were trained in the laboratory, 135 of whom participated in the in situ sessions. In the laboratory, 22 sessions were completed, with 70 LSTs identified (0.8 LSTs per scenario). During the 16 in situ sessions, 29 LSTs (1.8 LSTs per scenario) were identified. The 99 LSTs were reported to NICU leadership, leading to 19 documented improvements. CONCLUSIONS: The NICU setting has a high rate of previously unidentified LSTs. Conducting in situ scenarios allows for the identification of novel LSTs not detected in the simulation laboratory. The subsequent clinical improvements made to the actual clinical care environment are the best objective evidence of the benefits of simulation-based multidisciplinary team training.

Impact of simulation-based extracorporeal membrane oxygenation training in the simulation laboratory and clinical environment.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a high-risk, complex therapy. Opportunities to develop teamwork skills and expertise to mitigate risks are few. Our objective was to assess whether simulation would improve technical and nontechnical skills in dealing with ECMO circuit emergencies and allow transfer of skills from the simulated setting to clinical environment. METHODS: Subjects were ECMO circuit providers who performed scenarios utilizing an infant simulator and functional ECMO circuit, followed immediately by video-assisted debriefings. Within the simulation laboratory, outcomes were timed responses, percentage of correct actions, teamwork, safety knowledge, and attitudes. Identification of latent safety threats (LSTs) was the focus of debriefings. Within the clinical setting, translation of learned skills was assessed by measuring circuit readiness and compliance with a cannulation initiation checklist. RESULTS: Nineteen subjects performed 96 simulations during enrollment. In the laboratory, there was no improvement in timed responses or percent correct actions. Teamwork (P = 0.001), knowledge (P = 0.033), and attitudes (P = 0.001) all improved compared with baseline. Debriefing identified 99 LSTs. Clinically, 26 cannulations occurred during enrollment. Median time from blood available to circuit readiness was 17 minutes (range, 5-95), with no improvement during the study. Compliance with the initiation checklist improved compared with prestudy baseline (P < 0.0001). CONCLUSIONS: Simulation-based training is an effective method to improve safety knowledge, attitudes, and teamwork surrounding ECMO emergencies. On-going training is feasible and allows identification of LSTs. Further work is needed to assess translation of learned skills and behaviors into the clinical environment.

Simulation to assess the safety of new healthcare teams and new facilities.

INTRODUCTION: : Our institution recently opened a satellite hospital including a pediatric emergency department. The staffing model at this facility does not include residents or subspecialists, a substantial difference from our main hospital. Our previous work and published reports demonstrate that simulation can identify latent safety threats (LSTs) in both new and established settings. Using simulation, our objective was to define optimal staff roles, refine scope of practice, and identify LSTs before facility opening. METHODS: : Laboratory simulations were used to define roles and scope of practice. After each simulation, teams were debriefed using video recordings. The National Aeronautics and Space Administration-Task Load Index was completed by each participant to measure perceived workload. Simulations were scored for team behaviors by video reviewers using the Mayo High Performance Team Scale. Subsequent in situ simulations focused on identifying LSTs and monitoring for unintended consequences from changes made. RESULTS: : Twenty-four simulations were performed over 3 months before the hospital opening. Laboratory debriefing identified the need to modify provider responsibilities. National Aeronautics and Space Administration-Task Load Index scores and debriefings demonstrated that the medication nurse had the greatest workload during resuscitations. Modifying medication delivery was deemed critical. Lower Mayo High Performance Team Scale scores, implying less teamwork, were noted during in situ simulations. In situ sessions identified 37 LSTs involving equipment, personnel, and resources. CONCLUSIONS: : Simulation can help determine provider workload, refine team responsibilities, and identify LSTs. This pilot project provides a template for evaluation of new teams and clinical settings before patient exposure.