In-situ simulation to ‘road test’ a new paediatric clinical decision unit: mitigating the risk from latent safety threats

Background

A new paediatric clinical decision unit (PCDU) has to be opened in our paediatric emergency department (PED) due to increasing pressure in the department and on inpatient beds. Our purpose-built PED is attached to the adult emergency department (ED) and there is one inpatient paediatric ward with 25 beds. The purpose of the PCDU is to improve patient flow in the PED by providing a facility where selected patients could be observed, investigated and treated without needing admission to the busy inpatient ward. Previously this cohort of patients would remain in the ED while awaiting an inpatient bed or investigation results and affect the flow of other patients.

Guidelines were developed for the conditions that could be admitted to the PCDU; initially these were wheeze, febrile illness, head injury without ‘red flag’ symptoms, accidental ingestion of medications and selected other patients awaiting results of investigations which determine whether an inpatient stay is needed. All patients in the PCDU must be investigated, observed and treated within 12 hours  of admission to the unit. The unit had a rota consisting of paediatric and ED teams.

The PCDU was a new concept within our ED, which is part of the complex working system of a busy NHS district general hospital. There is an increasing understanding in the literature that with increasing complexity there is an increasing risk of error.¹ Moreover, most errors arise not from individual human error but from the complex interaction of humans and the imperfect systems within which they work.² Among these imperfections exist latent safety threats (LSTs), defined as ‘conditions or threats…where the damaging consequence may lie dormant for some time, only becoming evident when local triggering factors overcome the organisations’ defense’.³ There is an increasing body of evidence supporting the use of in-situ simulation (ISS) to identify LSTs.^{2 4} In view of this, and the inherent risk of opening a new department, we designed a programme of ISS with the following aims:

• To identify and resolve specific staff concerns and knowledge gaps regarding the normal operating procedure of the PCDU.

• To identify LSTs arising from new systems and resolve them.

• To check that resolutions had been effective.

Methodology and outcomes

The design and results of our ISS programme are illustrated in figure 1.

Figure 1.

Design and results of an in-situ simulation project to ‘road test’ a new Paediatric Clinical Decision Unit.

Discussion

Overall, we believe this programme was very successful. All of the LSTs identified and resolved in this project could have impacted on patient safety and potentially led to patient harm. Simulation has been used to help adult learners’ identity gaps in their knowledge in a safe learning environment for many years in medical education, addressing our first aim. Focus groups are advantageous in yielding more insight into participants’ ideas and concerns than a quantitative method of data collection.⁵ The Systems Engineering Initiative for Patient Safety (SEIPS) model provides a framework for thinking about how systems can fail and how threats to patient safety can occur by dividing threats into five domains/components.² The concerns shared by staff at the initial focus group showed that more could be categorised into the ‘people’ domain of the SEIPS model when compared with the threats identified following the first simulation. We think this demonstrates the need to use both a focus group and simulation as each technique yielded markedly different data which may have been missed if only one was used.

We believe using the focus group outcomes to develop scenarios, which specifically tested the ‘people’ threats identified, was particularly useful. ED doctors shared that they were concerned about discharging asthma patients home from the PCDU, however following the simulation sessions which tested these guidelines, this concern was reduced. Both the focus group and the simulation identified a need for further education of the staff about the procedures and pathways of the PCDU. This allowed learning to take place before the unit opened and to be reinforced with further simulation at a later date as part of an ongoing ISS project throughout the wider ED.

ISS has a clear advantage over lab-based simulation in allowing LSTs to be identified as the scenarios take place in the actual working environment and therefore components of the system beyond the ‘people’ can be tested, as can the interactions between various components of a system.⁴ The simulation element of this project identified many LSTs, most of which were categorised into the ‘non-human’ domain of the SEIPS model. This demonstrates the distinct advantage of using ISS for addressing our second aim of this project.

The third aim of the project was to check that resolutions had been effective. Following the first simulation there were 24 LSTs identified, which was reduced to three following the second simulation. These positive changes have been cascaded to the staff and good feedback was received. It seems, therefore, that repeating the simulation was effective in checking that the majority of the errors had been resolved and staff satisfaction had improved

The future steps for this project will involve following up on the remaining, unresolved LSTs. We are working towards having an option for LSTs identified through simulation to be specifically reported on the incident reporting system.

Conclusion

The use of ISS for the opening of a new unit helped us to identify and solve LSTs arising from the introduction of a new working system and to identify and allay staff concerns and knowledge gaps. The combination of focus groups and ISS seems to have been particularly effective as the two approaches complemented each other in terms of the data they yielded. We believe this kind of simulation programme has merit and is easily transferable across departments for implementation prior to the introduction of new services.