Traditionally, in situ
simulation has been used to improve patient care by identifying knowledge or skills gaps and improving teamwork and non-technical skills. However, there are little data demonstrating objective improvement in morbidity and mortality directly attributed to in situ simulation 
. There is a growing recognition of the use of in situ
simulation to detect latent safety errors (LSEs) [1,2]
. These are errors of system, environment or teams which may be unrecognized until they are identified in the stressful and realistic conditions of a simulated scenario in a clinical environment. Currently, no standardized system is described to score type or severity of LSE limiting the reproducibility and application of this approach to harm reduction.
The aim of the study was to develop a tool to detect latent safety errors during in situ simulation which is fully integrated with existing Trust safety metrics.
Simulation activity outline:In situ
simulation in a district general hospital across community and acute clinical areas.
Multi-professional in situ
simulation was led by an experienced facilitator. A pilot phase was limited to the Acute Medical Unit and informed the thematic classification of errors. Further in situ
simulation took place in medical, surgical, emergency department and community hospital settings. Thematic analysis was completed using the framework of Trust incident coding (Radar Healthcare). During the simulation sessions, latent errors were identified and discussed in the debrief. A data collection proforma was developed using an iterative process over 12 months using Microsoft forms. This research was funded by Health Education England South West Simulation Network with the support of the local Somerset Simulation Team.
During the pilot phase, 73 participants took part in 7 simulations on AMU. Facilitators identified 28 latent errors. Comparison with other sources of safety data (formal incident reporting and critical care outreach team data) showed that in situ
simulation identified errors in oxygen and fluid management unrecognized by other data sources. In the second phase, 146 participants took part in 32 in situ
simulations. Facilitators identified 82 latent safety errors and coded them into 18 error types (see Table 1). Work is ongoing to compare these to trust incident reports.Table 1:Latent safety error by incident codeThemeNo. of latent errors detectedRadar incident codeTotal by incident codeOxygen use and equipment12Medical devices43Defibrillator use and equipment13Medical devicesFluid delivery and equipment4Medical devicesGlucose monitoring equipment2Medical devicesOther equipment7Medical devicesLocation of equipment5Medical devicesIncorrect medication dose1Medication5Other medication issue4MedicationAccess to a locked area3Health and safety/environment11Emergency call system issue2Health and safety/environmentNoise2Health and safety/environmentOther environment4Health and safety/environmentCardiac arrest algorithm7Care pathway issues17Getting help in an emergency7Care pathway issuesOrganizational3Care pathway issuesCommunication/teamwork2Communication/documentation/IT4E-Obs issue2Communication/documentation/ITAssessment of deteriorating patient2Patient safety2Total82
Implications for practice:
We have identified three major outcomes: Shared learning: latent safety errors are rarely unique to one clinical area and have the potential to occur elsewhere in the Trust. Wider dissemination of latent safety errors at a directorate level allows proactive interventions to reduce patient harm. A monthly Simulation Safety Outcome Report shared with senior nursing staff at a directorate level is being evaluated. Responsive learning and staff engagement: latent safety errors were discussed at every debrief. Participants provided valuable suggestions often resulting in immediate local interventions. This internal resolution has engaged and empowered clinical staff in patient safety. Targeting resources: Integration of active and latent error data from numerous sources allows Trust safety management structures to target resources to improve patient safety and develop sustainable approaches to risk reduction. National standardization of coding active errors (incidents) and latent errors would broaden the use of in situ
simulation as a proactive safety tool.