Reporting unsafe conditions discovered during in situ simulation in the paediatric emergency department: a pilot integration into an existing event reporting system

Introduction

Event reporting systems (ERSs) have been widespread since the release of the 2000 Institute of Medicine report To Err is Human.¹ These systems serve as a means to systematically address adverse events in an effort to improve patient safety. Unfortunately, many organisations are still challenged by underreporting of near misses and unsafe conditions that can predict more serious events.²

Latent safety threats (LSTs), also referred to as unsafe conditions, are defined as ‘system-based threats to patient safety that can materialise at any time and are previously unrecognised’.³ An identified LST represents an opportunity to mitigate a system-based threat prior to it manifesting as a near-miss or adverse event. However, LSTs often go unnoticed and unreported. In situ simulation, where teams practice scenarios in the clinical space in which they work, has been shown to provide a critical opportunity to identify problems in environments, processes and systems.⁴ Stressing systems by deliberately simulating rare, high stakes scenarios helps to uncover LSTs encountered in clinical care. Unfortunately, LSTs identified during in situ simulation are not routinely addressed by hospital systems in the same manner as actual patient safety events.⁵

We aimed to create a system in which LSTs uncovered during in situ simulation would be entered into the hospital’s existing ERS in order to leverage the infrastructure and stakeholders that routinely address patient safety events.

Methods

This programme innovation was implemented at a single tertiary care paediatric emergency department (PED) within a large academic institution. The hospital utilises a campus wide ERS with an online interface that allows for a broad range of event reporting, from errors in patient verification to medication and medical device issues. The interface contains multiple information fields including reporter’s role, location of event and severity and harm determination. Reporting is voluntary and staff members can choose to report events anonymously. Events entered are reviewed daily by both the institution’s quality team and unit-based leadership, with closure on resolution.

In our centre, in situ simulated mock codes are conducted weekly in the PED (figure 1). In the past, LSTs related to the simulation were discussed during debriefing but there was no routine system to report these LSTs to the quality team. The existing ERS allowed for a wide range of event reporting but did not include the ability to report events discovered outside of patient care. In an effort to expand the functionality of our existing ERS, the authors (DK, MS) met with ERS stake holders to collaborate on the creation of an additional site location labelled ‘PED SIM’ in the ERS. This modification enabled the quality team to review incidents uncovered during simulation in the same systematic manner as actual clinical events while retaining the ability to categorise them separately.

Figure 1.

Interdisciplinary team participating in an in situ simulation in the pediatric emergency department trauma bay.

The facilitators of the weekly PED in situ simulations underwent in-service education regarding the new PED SIM site reporting location and were instructed to enter any LSTs discovered during simulation into the ERS. To analyse the success of our pilot, all reported safety events from 16 January 2014 and 28 April 2016 were reviewed and compared with actual clinical safety events reported during the same time period. Each event was reviewed to ensure accurate categorisation and sorted by event type.

Results

During the pilot period, 45 LSTs discovered during in situ simulation in the PED were entered into the ERS. Thirty-nine (86.7%) events were related to equipment issues. Inadequate stocking was a theme that emerged from the entries. Of the equipment issues identified, 54% were specifically related to airway equipment, with inadequate stocking of airway equipment being most common. The existing centrally stocked airway boxes were often noted to be missing from the trauma bay, or when available had various issues such as missing a specific sized stylet. Other common findings included a lack of available end-tidal CO₂ monitors, suction catheters and video laryngoscope blades in the trauma bay. A lack of available airway equipment in both the PED radiology suite and some patient rooms was also noted. During the same time period, 496 clinical events were recorded in the ERS from the PED, only 22 (4.4%) of which were related to equipment issues. Of the remaining clinical events, 96 (19.3%) were related to lab issues, 54 (10.8%) were medication related and 49 (9.9%) were related to transfer of care.

The 45 LSTs entered into the ERS during the study period have all since been reported as ‘closed’. The most notable systems changes made to address these entries were the installation of airway equipment in the PED radiology suite and a complete reorganisation of the trauma bay airway equipment, replacing the opaque airway boxes with a transparent airway wall of sorted, labelled and easily accessible airway equipment.

Discussion

The importance of discovering potential threats to patient safety before harm reaches patients has led to a focus on the identification of LSTs. In situ simulation is an effective way to identify many of these LSTs.^3–5 Regardless of how LSTs are identified, it is critical that they are addressed in a consistent and systematic manner to prevent delays in abating these threats. We describe a novel modification to an existing ERS to include LSTs discovered during in situ simulation. LSTs discovered and reported in this manner were more often related to equipment issues than LSTs that were reported during routine clinical care, suggesting a lower threshold for reporting such issues via simulation. One of the limitations of this system is that, similar to clinical events, many LSTs identified during simulation were not entered into the ERS. This diminishes our ability to fully describe the breadth and scope of the types of errors that are being discovered during simulation. Nevertheless, after a successful pilot launch in the PED, this ERS field modification has now been adopted system wide. By continuing to fuse the benefits of in situ simulation for discovering LSTs with the existing quality and safety infrastructure of the institution, we hope to better discover and mitigate these potential patient safety threats and improve patient care.