Qualitative Analysis of Latent Safety Threats Uncovered by in Situ Simulation-based Operations Testing Before Moving into a Single-family-room Neonatal Intensive Care Unit

Overview

Journal J Perinatol

Specialty Gynecology & Obstetrics

Date 2020 Aug 30

PMID 32859962

Citations 2

Authors

Rita Dadiz

Julie Riccio

Kristen Brown

Paula Emrich

Beverley Robin

Jesse Bender

Affiliations

Soon will be listed here.

Abstract

Objectives: We aimed to identify: (a) latent safety threats (LSTs) in a new neonatal intensive care unit (NICU) through simulation-based pre-occupancy operations testing, and (b) LSTs that remained unresolved 1-year post-occupancy.

Study Design: In this qualitative study, 111 healthcare professionals participated in patient care simulations and debriefings in a new NICU. Debriefing transcripts were inductively analyzed to characterize LSTs. Unresolved LSTs were identified 1 year after NICU occupancy.

Results: Thematic saturation was attained after analysis of nine debriefings. Four major themes affecting staff function and patient safety emerged from 305 threats: relay of information, workplace design, patient care processes, and patient family and staff focus. One-year post occupancy, 29 (9%) LSTs remained unresolved.

Conclusion: Team debriefings of simulated patient events uncover LSTs that can largely be resolved before transitioning patient care into a new NICU. Understanding how LSTs interact provides a platform to develop viable strategies to mitigate patient safety risks.

Citing Articles

Sustained decrease in latent safety threats through regular interprofessional in situ simulation training of neonatal emergencies.

Mileder L, Schwaberger B, Baik-Schneditz N, Ribitsch M, Pansy J, Raith W BMJ Open Qual. 2023; 12(4).

PMID: 38154819 PMC: 10759052. DOI: 10.1136/bmjoq-2023-002567.

Financial and Safety Impact of Simulation-based Clinical Systems Testing on Pediatric Trauma Center Transitions.

Williams S, Fitzpatrick K, Chandler N, Arnold J, Snyder C Pediatr Qual Saf. 2022; 7(5):e578.

PMID: 36032192 PMC: 9416763. DOI: 10.1097/pq9.0000000000000578.

References

Bender G, Maryman J . Clinical Macrosystem Simulation Translates Between Organizations. Simul Healthc. 2018; 13(2):96-106. DOI: 10.1097/SIH.0000000000000263. View

. Preventing infant death and injury during delivery. Jt Comm Perspect. 2004; 24(9):14-5. View

Wetzel E, Lang T, Pendergrass T, Taylor R, Geis G . Identification of latent safety threats using high-fidelity simulation-based training with multidisciplinary neonatology teams. Jt Comm J Qual Patient Saf. 2013; 39(6):268-73. DOI: 10.1016/s1553-7250(13)39037-0. View

Bender J, Shields R, Kennally K . Transportable enhanced simulation technologies for pre-implementation limited operations testing: neonatal intensive care unit. Simul Healthc. 2011; 6(4):204-12. DOI: 10.1097/SIH.0b013e3182183c0b. View

Domanico R, Davis D, Coleman F, Davis B . Documenting the NICU design dilemma: comparative patient progress in open-ward and single family room units. J Perinatol. 2010; 31(4):281-8. PMC: 3070087. DOI: 10.1038/jp.2010.120. View

Walsh W, McCullough K, White R . Room for improvement: nurses' perceptions of providing care in a single room newborn intensive care setting. Adv Neonatal Care. 2006; 6(5):261-70. DOI: 10.1016/j.adnc.2006.06.002. View

Wheeler D, Geis G, Mack E, LeMaster T, Patterson M . High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training. BMJ Qual Saf. 2013; 22(6):507-14. DOI: 10.1136/bmjqs-2012-000931. View

Reason J . Human error: models and management. BMJ. 2000; 320(7237):768-70. PMC: 1117770. DOI: 10.1136/bmj.320.7237.768. View

Lester B, Hawes K, Abar B, Sullivan M, Miller R, Bigsby R . Single-family room care and neurobehavioral and medical outcomes in preterm infants. Pediatrics. 2014; 134(4):754-60. DOI: 10.1542/peds.2013-4252. View

10.

Halamek L . Editorial: Bringing latent safety threats out into the open. Jt Comm J Qual Patient Saf. 2013; 39(6):267. DOI: 10.1016/s1553-7250(13)39036-9. View

11.

Carlson B, Walsh S, Wergin T, Schwarzkopf K, Ecklund S . Challenges in design and transition to a private room model in the neonatal intensive care unit. Adv Neonatal Care. 2006; 6(5):271-80. DOI: 10.1016/j.adnc.2006.06.008. View

12.

White R . The newborn intensive care unit environment of care: how we got here, where we're headed, and why. Semin Perinatol. 2011; 35(1):2-7. DOI: 10.1053/j.semperi.2010.10.002. View

13.

Adler M, Mobley B, Eppich W, Lappe M, Green M, Mangold K . Use of Simulation to Test Systems and Prepare Staff for a New Hospital Transition. J Patient Saf. 2015; 14(3):143-147. DOI: 10.1097/PTS.0000000000000184. View

14.

Knight P, MacGloin H, Lane M, Lofton L, Desai A, Haxby E . Mitigating Latent Threats Identified through an Embedded Simulation Program and Their Comparison to Patient Safety Incidents: A Retrospective Review. Front Pediatr. 2018; 5:281. PMC: 5810281. DOI: 10.3389/fped.2017.00281. View

15.

Searl M, Borgi L, Chemali Z . It is time to talk about people: a human-centered healthcare system. Health Res Policy Syst. 2010; 8:35. PMC: 3009465. DOI: 10.1186/1478-4505-8-35. View

16.

Bender G . In situ simulation for systems testing in newly constructed perinatal facilities. Semin Perinatol. 2011; 35(2):80-3. DOI: 10.1053/j.semperi.2011.01.007. View

17.

Villamaria F, Pliego J, Wehbe-Janek H, Coker N, Rajab M, Sibbitt S . Using simulation to orient code blue teams to a new hospital facility. Simul Healthc. 2008; 3(4):209-16. DOI: 10.1097/SIH.0b013e31818187f3. View

18.

Zigmont J, Kappus L, Sudikoff S . The 3D model of debriefing: defusing, discovering, and deepening. Semin Perinatol. 2011; 35(2):52-8. DOI: 10.1053/j.semperi.2011.01.003. View

19.

Kobayashi L, Shapiro M, Sucov A, Woolard R, Boss 3rd R, Dunbar J . Portable advanced medical simulation for new emergency department testing and orientation. Acad Emerg Med. 2006; 13(6):691-5. DOI: 10.1197/j.aem.2006.01.023. View

20.

Keohane C, Dwyer K, Boulanger J, Zigmont K, Babayan A, Cushing E . Partnering With a Medical Malpractice Insurer to Improve Patient Safety and Decrease Risk. J Perinat Neonatal Nurs. 2018; 32(1):66-71. DOI: 10.1097/JPN.0000000000000312. View