Latent Safety Threats and Countermeasures in the Operating Theater: A National In Situ Simulation-Based Observational Study

Effects of a national team training intervention for operating theatre teams on patient and staff outcomes: a stepped-wedge cluster-randomised trial and mixed-methods study

BACKGROUND

We evaluated a national, multidisciplinary in situ simulation-based team training intervention in New Zealand public hospitals. We hypothesised that outcomes for surgical patients and staff perceptions of teamwork and observed teamwork behaviours would improve after the intervention.

METHODS

In a stepped-wedge cluster trial, all New Zealand's 20 District Health Boards were semi-randomised into four cohorts. Training was progressively implemented with one cohort per year. Patient outcomes were derived from a national administrative dataset. Outcome measures were intervention uptake, days alive and out of hospital at 90 days (DAOH90), pre-post staff Teamwork Perceptions Survey scores, and pre-post measures of observed teamwork performance during administration of the World Health Organisation Surgical Safety Checklist.

RESULTS

Nineteen District Health Boards implemented training, and 41% of the estimated 3800 eligible staff participated. Post-intervention, DAOH90 increased 0.12 days (n=436 785 surgical cases) but we could not separate the intervention's effect from other temporal factors. Teamwork Perceptions Survey scores improved by 0.35 (95% confidence interval, 0.10-0.59) (P=0.006), 0.37 (0.12-0.63) (P=0.006), and 0.50 (0.22-0.78) (P<0.001) on a 5-point scale for 'Overall', 'Communication and Shared Mental Model', and 'Trust and Accountability', respectively. There was no important effect on observed teamwork.

CONCLUSIONS

We achieved small improvements in teamwork by involving 41% of New Zealand operating theatre staff in team training. Improved patient outcomes could not be solely attributed to our intervention, potentially reflecting high baseline levels of teamwork and surgical outcomes, diluting effects of the progressive uptake of the team training over intervention periods, and other confounders including the COVID-19 pandemic.

CLINICAL TRIAL REGISTRATION

ACTRN12617000017325.

Analysis of the implementation effect of the operating room nursing safety management model based on Heinrich's law

OBJECTIVE

The study evaluates the clinical value of the operating room nursing safety management model based on Heinrich's law.

METHODS

A quasi-experimental design with a historical control group was conducted at Changzheng Hospital. A total of 240 surgical patients (pre-intervention: n = 120, December 2021-2022; post-intervention: n = 120, January-December 2023) were recruited via convenience sampling. The intervention included standardized protocols, mobile nursing systems, electronic specimen labeling, and equipment management. Quantitative outcomes were analyzed using χ² tests (adverse events), independent t-tests (nursing competency scores), and logistic regression (risk factors). Patient satisfaction was assessed via a validated self-report questionnaire.

RESULTS

The results showed a significant reduction in the incidence of operating room nursing safety accidents and a significant improvement in the specific nursing, identification, management of specimens, health education, safety awareness and operational skills of the nursing staff after the implementation of the operating room nursing safety management model based on Heinrich's law (P < 0.05).The management model implemented in the operating room had a positive impact on nursing safety, as evidenced by the significant improvement in patient satisfaction (P < 0.05). Logistic multifactorial regression analysis identified several key factors that affect nursing care safety in the operating room, including the nursing staff's business ability, legal awareness, the operating room environment, and the management system.

CONCLUSION

The Heinrich's law-based model effectively enhances perioperative safety by reducing errors, improving nursing competency, and increasing patient satisfaction. Clinically, we recommend integrating standardized protocols with mobile alert systems, prioritizing staff training on legal and technical skills, and optimizing equipment workflows. Future studies should validate these findings in multicenter trials and assess long-term cost-effectiveness.

Interprofessional Collaboration in Building In Situ Simulations to Identify Threats to Patient Safety Before Transitioning to a New Healthcare Environment: Neonatal Intensive Care as an Example

Background and objective While transitioning to a new healthcare environment (HCE) offers opportunities to enhance patient safety and outcomes, it can also introduce hidden risks. This study aimed to explore how interprofessional collaboration (IPC) and in situ simulations (ISS) can proactively identify and resolve these latent safety threats (LSTs) before transitioning to a new single-patient room neonatal ICU (NICU). Methodology We conducted a prospective, simulation-based intervention study involving healthcare professionals (HPs) and prior NICU parents. Three simulation activities were conducted to identify LSTs before the transition. The Canadian Interprofessional Competency Framework was employed to formulate realistic scenarios. Results A total of 108 HPs participated in six simulation sessions, identifying 89 LSTs across eight themes. The majority (76%) of these threats were resolved before the transition. Survey analysis revealed significant increases in systems readiness and staff preparedness post-simulations (p<0.001). Parental involvement significantly enhanced the focus on patient-centered care, leading to improvements in environmental design and communication systems. Conclusions The study demonstrates the efficacy of IPC and ISS in identifying and mitigating LSTs during HCE transitions, fostering a collaborative and safety-oriented culture. This approach prepares healthcare teams for new environments and emphasizes the value of incorporating family perspectives. Interprofessional ISS is a pivotal strategy to enhance patient safety and system readiness during transitions to new HCEs. The study also highlights the importance of IPC in conducting ISS before transitioning to a new HCE. Coordinating large-scale simulations is worth the time and cost investment necessary to identify LSTs, optimize systems readiness, and promote patient safety. We hope that the shared lessons can help future interprofessional teams in terms of plan testing and transitions to other HCEs.

Simulation-Based Clinical System Testing of Neonatal Resuscitation Readiness Across a Rural Health System Identifies Common Latent Safety Threats

BACKGROUND

Simulation offers an opportunity to practice neonatal resuscitation and test clinical systems to improve safety. The authors used simulation-based clinical systems testing (SbCST) with a Healthcare Failure Mode and Effect Analysis (HFMEA) rubric to categorize and quantify latent safety threats (LSTs) during in situ training in eight rural delivery hospitals. The research team hypothesized that most LSTs would be common across hospitals. LST themes were identified across sites.

METHODS

Between May 2019 and May 2023, the neonatal simulation team conducted half-day training sessions including a total of 177 interprofessional delivery room team members. Teams participated in skills stations, followed by in situ simulations with facilitated debriefs. Facilitators included neonatologists and simulation faculty trained in HFMEA. HFMEA rubrics were completed for each site with mitigation strategies captured on follow-up. LSTs were compared across sites.

RESULTS

A total of 67 distinct LSTs were identified. Forty-one of 67 (61.2%) were shared by more than one hospital, and 26 (38.8%) were unique to individual hospitals. LSTs were distributed across five systems categories and three teams categories. The 4 LSTs detected at 75% or more of hospitals were lack of clear newborn blood transfusion protocols, inconsistent use of closed-loop communication, inconsistent processes for accessing additional resources, and inconsistent use of a recorder.

CONCLUSION

Use of SbCST across a health system allows for comparison of LSTs at each site and identification of common opportunities to mitigate safety threats. Systemwide analysis provides leaders with data needed to guide resource allocation to track and ensure effective implementation of solutions for prioritized LSTs. Identification of themes may allow other hospitals that have not participated in simulation testing to engage in prospective readiness efforts.

Using In Situ Simulation to Identify Latent Safety Threats Prior to the Opening of Novel Patient Care Spaces in the Emergency Department

BACKGROUND

In the era of extreme emergency department (ED) boarding, hospital systems are using novel patient care areas to provide ongoing acute care. In any new patient care environment, there is a high risk for latent safety threats (LSTs), which can negatively affect patient outcomes. A series of in situ systems-based simulations were conducted to identify potential LSTs prior to the opening of a novel mobile care unit (MCU) in a tertiary hospital.

METHODS

After a needs assessment in conjunction with institutional leadership, a series of in situ interprofessional simulation sessions were developed to represent realistic scenarios in the MCUs. Simulations included low-frequency high-acuity patient care scenarios as well as high-frequency day-to-day encounters. Data were collected in structured systems-based debriefing sessions via trained observers, video recordings, and participant surveys, with a primary outcome of identifying potential LSTs. The LSTs were categorized and then stratified using the Survey Analysis for Evaluating Risk (SAFER) Matrix. One simulation was repeated after mitigation strategies were employed by institutional leadership.

RESULTS

A total of 117 staff participated in five simulation sessions. In the first round of simulations, 37 LSTs were identified, primarily in the categories of Environment/Wayfinding (13/37, 35.1%) and Communication (6/37, 16.2%). LSTs risk stratified using the SAFER Matrix provided prioritized feedback for hospital leadership to guide mitigation strategies prior to the opening of the new units. One LST was initially classified as high likelihood to harm on the SAFER Matrix. The simulated scenario involving this LST was repeated two weeks later with no further high-risk LSTs identified.

CONCLUSION

In situ simulations can serve as an effective tool to identify potential LSTs prior to the opening of novel patient care spaces.

Learning from Latent Safety Threats Identified During Simulation to Improve Patient Safety

BACKGROUND

Latent safety threats (LSTs-characteristics of design, processes, or physical environment in health care compromising patient safety) are commonly revealed during simulation-based training. Methods of collecting, analyzing, and classifying LSTs are underdeveloped and not standardized. Building on a large simulation program in one organization, the authors aimed to collect LSTs systematically and develop a taxonomy to classify them.

METHODS

The authors modified the Press Ganey Healthcare Performance Improvement Failure Modes Taxonomy (HPI-FMT), a standardized framework for safety event classification in health care, and used three categories: System, Individual, and Medications. The subcategories were revised to reflect simulation LST content and promote consistent data entry into a spreadsheet. Data visualization software was used to analyze LST data and generate dashboards, graphs, and executive summaries to share across the system that depicted data for individual hospitals and outpatient areas and allowed grouping, comparisons, and trending.

RESULTS

Over a year, the researchers identified 1,318 LSTs in 232 simulations across the organization-a rate of 5.7 LSTs/simulation. The top three LST subcategories were Environment/supplies/equipment (System category); Process/structure (System category); and Knowledge or unformed skill/habit (Individual category). Other important LSTs were Missing/malfunctioning supplies/equipment; Unclear or ineffective process or no process; and Unfamiliarity with supplies/equipment. When a repetitive pattern of LSTs was observed (for example, improper dantrolene use during malignant hyperthermia simulations), targeted process improvement or training was implemented.

CONCLUSION

The authors developed, implemented, and refined a systematic method of collecting, analyzing, displaying LSTs, and recommending targeted process improvements or training when LST trends were noted.

Strategy to Develop a Common Simulation Training Program: Illustration with Anesthesia and Intensive Care Residency in France

Phenomenon: The urgency of having fair and trustworthy competency-based assessment in medical training is growing. Simulation is increasingly recognized as a potent method for building and assessing applied competencies. The growing use of simulation and its application in summative assessment calls for comprehensive and rigorously designed programs. Defining the current baseline of what is available and feasible is a crucial first step. This paper uses anesthesia and intensive care (AIC) in France as a case study in how to document this baseline. Approach: An IRB-approved, online anonymous closed survey was submitted to AIC residency program directors and AIC simulation program directors in France from January to February 2021. The researcher-developed survey consisted of 65 questions across five sections: centers' characteristics, curricular characteristics, courses' characteristics, instructors' characteristics, and simulation perceptions and perspectives. Findings: The participation rate was 31/31 (100%) with 29 centers affiliated with a university hospital. All centers had AIC simulation activities. Resident training was structured in 94% of centers. Simulation uses were training (100%), research and development (61%), procedural or organizational testing (42%), and summative assessment (13%). Interprofessional full-scale simulation training existed in 90% of centers. Procedural training on simulators prior to clinical patients' care was performed "always" in 16%, "most often" in 45%, "sometimes" in 29% and "rarely" or "not" in 10% of centers. Simulated patients were used in 61% of centers. Main themes were identified for procedural skills, full-scale and simulated patient simulation training. Simulation activity was perceived as increasing in 68% of centers. Centers expressed a desire to participate in developing and using a national common AIC simulation program. Insights: Based on our findings in AIC, we demonstrated a baseline description of nationwide simulation activities. We now have a clearer perspective on a decentralized approach in which individual institutions or regional consortia conduct simulation for a discipline in a relatively homogeneous way, suggesting the feasibility for national guidelines. This approach provides useful clues for AIC and other disciplines to develop a comprehensive and meaningful program matching existing expectations and closing the identified gaps.

Stress Testing the Cardiac Catheterization Laboratory: A Novel Use of In Situ Simulation to Identify and Mitigate Latent Safety Threats During Acute Airway Management

INTRODUCTION

Although uncommon, cardiac arrests in the cardiac catheterization laboratory (CCL) are often catastrophic and likely to increase with rising case complexity. In situ simulation (ISS) has been used to identify latent safety threats (LSTs) in inpatient units but has not yet been studied in the CCL.

METHODS

Three Plan-Do-Study-Act (PDSA) cycles leveraging ISS were conducted focused on acute airway management. Data collected through debriefs focused on (1) airway management, (2) equipment availability, and (3) interdepartmental communication. The LSTs were subcategorized and plotted on the Survey Analysis for Evaluating Risk (SAFER)-Matrix. A SAFER score was calculated based on quantifying the likelihood of harm, scope, and the number of times a threat was identified during simulation. Time to definitive airway was collected as a secondary measure. Interventions were developed using cause and effect and driver diagrams between PDSA cycles.

RESULTS

Eleven total simulations through 3 PDSA cycles were conducted between January and December 2021 (5 in PDSA 1, 4 in PDSA 2, and 2 in PDSA 3). One hundred one LSTs were identified with 14 total subcategories. The mean SAFER score decreased from 5.37 in PDSA 1, to 2.96 in PDSA 2, and to 1.00 in PDSA 3. Bivariate regression analysis showed a decrease in SAFER score of 2.19 for every PDSA cycle (P = 0.011). Ordinary least squares regression had a decrease of 1.65 in airway-related threats every PDSA cycle (P < 0.01) as well as an increase in intubation time of 35.0 seconds for every 1-unit increase in communication threat identified (P = 0.037).

CONCLUSIONS

This study successfully leveraged ISS and existing quality improvement initiatives in the CCL, resulting in a decrease in airway-related threats as measured through simulation.