Using a bespoke database to manage latent safety threats identified through in situ simulation

Introduction

Simulation has garnered success in healthcare through its ability to teach professionals technical and non-technical skills without exposing patients to the novice practitioner.¹

In situ simulation takes this teaching technique into the workplace, using the real systems, equipment and workforce. A significant benefit of in situ simulation is the testing of healthcare systems without exposing a patient to indolent risks that have the potential to cause delays and harm. The source of these risks can be related to deficits in training, resources, environment, processes or protocols. These risks can be difficult to identify without a live test of the system.²

The harm from these latent safety threats (LSTs) can be averted if identified through in situ simulation and rectified before a patient is exposed. Research has suggest that in situ simulation is superior in eliciting these LSTs over laboratory-based simulation.³

By identifying safety threats it is possible to demonstrate a quantitative impact on patient safety.

At the Royal Cornwall Hospital, a rural district general trust, we have used a custom-made database to record and manage these LSTs, making it an integral part of our simulation training.

Method

In 2017, the simulation department at Royal Cornwall Hospital designed a database to record and respond to significant LSTs that arise during in situ simulation.

LSTs are identified during a scenario debrief. This is recorded on a paper form, along with details of the simulation, location and candidates. This is uploaded to the database.

If LSTs are identified there exists three opportunities for solutions to be agreed on and actioned.

1. At the time of the debrief if an easily implementable solution can be found.

2. Within 3 weeks by emailing a ‘link’ clinician who regularly works in the clinical area. This clinician is either any active participant or involved in organising and running the simulation.

3. If a reply, with a clear action plan, is not received within 3 weeks then the LST report is forwarded to clinical governance lead for the clinical group to ensure the issue is resolved at the next governance meeting.

The process is demonstrated in figure 1.

Figure 1.

Flow chart depicting the process from identification of LSTs through to resolution. LST, latent safety threat.

Results

A total of 317 in situ simulations have been recorded using the database. Of these, 133 (42%) identified an LST. In 91 of the 133 cases (68%), it was decided that formal follow-up using the database was required.

Of the reports that were sent out to link clinicians, 27 (29.6%) were returned with a complete action plan within 3 weeks. For those reports not returned by the link clinician, all but one of the significant LSTs were forwarded to the local governance team for resolution at their monthly meeting.

Discussion

As pressures on the National Health Service grow, it becomes increasingly important to justify the benefit of simulation within the healthcare system. Despite simulation becoming established in most trusts throughout the UK, it continues to be difficult to show a clinical impact.

It is our view that all simulation departments are able to demonstrate direct impact on patient care by helping identifying and address LSTs. In the Royal Cornwall Hospital, we can identify 133 cases in which simulation has been the catalyst for change. We appreciate this describes a process measure, so we are not able to definitively say if this would have affected patient outcome. The difficulty of demonstrating changes in an outcome measure is highlighted by the rarity of studies demonstrating improvement in outcomes related to simulation.⁴

This system relies on identification, recording and communication of the LST in a timely fashion. Considerable work has gone into creating and maintaining such a system.

Identification of the LST is the first step in this process. Making this a routine part of the debriefing process is critical. This has been integrated into the debriefing tool that is used at the Royal Cornwall Hospital.

LSTs are commonly highlighted by candidates or expert faculty when a resource, staffing or process deficit is identified in the scenario. However, highlighting LSTs relating to training needs can be more challenging as candidates can feel that this is a personal deficit. Using facilitated reflection debriefing techniques, such as advocacy and inquiry, allows candidates to consider training deficits and how best to address these.

The simulation faculty routinely convene after the session has completed, allowing reflection on whether any LSTs could be identified that had not emerged in the scenario debrief.

Taking responsibility of recording and following up these events has created an increase in the simulation department workload. This increased demand has been managed by administration staff carrying out part of the process, transferring a paper form onto the database and then communicating with clinical staff. Ensuring a robust and reliable process that did not overburden the simulation faculty was vital in the successful implementation of the system.

It has been considered whether the hospital reporting system would be more suitable than a bespoke database in recording and following up these events.

A significant benefit of using a bespoke database is the ability to choose the information recorded, allowing multiple uses of the same databank. The database can be used to demonstrate simulation department activity, identify clinical areas that are visited infrequently, link directly to simulation documentation, identify the variety of scenarios, be used as a scenario rating system and to generate certificates.

If it is felt that an incident is serious enough or the clinical team feel that it is necessary, we would also advise them to use the incident reporting system as well.

Our own database allows us to collate LSTs and how they have been resolved. These solutions can then be translated to other departments across the hospital where a similar LST exists, therefore increasing the impact we are able to achieve.

Conclusion

Our simulation department has created an effective method to record and monitor LSTs that emerge through in situ simulation. The simulation department has taken responsibility for recording and following up on the idle threats that exist in our healthcare system. This has allowed monitoring of the impact of simulation within the hospital and encouraged improvement, led by front-line staff.

We have demonstrated that a district general hospital in the UK can establish and maintain an effective system to manage LSTs.