International Journal of Healthcare Simulation

Background:

The newly built Women’s Wellness and Research Center (WWRC) replaced the pre-existing Women’s Hospital (WH) as the only provider of tertiary maternity care for the residents of Qatar. The pre-existing WH was smaller, with a 12-bay emergency department, 3 operating theatres, 12 delivery rooms and 220 beds, in shared rooms. The new WWRC facility is significantly bigger, with a 28-bay emergency department, 7 operating theatres over two floors, 26 delivery rooms and 240 private inpatient rooms catering for around 18,000 deliveries per year. New systems, designed over only a few months, would need to promote that same level of high-quality patient care but in a newer, larger and unfamiliar facility.

Aims:

The aim of the study was to identify and mitigate clinical systems risks, relevant to anaesthesia services, by running in situ simulations.

Method:

The ‘WWRC Anesthesia Activation Team’ was established to conduct in situ simulations, testing clinical systems. We hypothesized that, despite meticulous planning, numerous process gaps would be discovered, and that improvements derived from testing sessions would reduce risk ^[1]. Well-planned scripted ‘everyday’ scenarios were prepared. Relevant multi-disciplinary groups of participants were involved, and the scenarios were kept flexible. After the simulation, facilitated debriefing highlighted problem areas and suggested improvements.

Implementation outline:

Approximately 110 hours of simulation were conducted in sites relevant to anaesthesia. Many of the participants had never experienced simulation before but nearly everybody complimented its usefulness and debriefing was unanimously constructive. Testing identified 143 discrete latent safety threats (LST) and were categorized under Facility, Workflow, Personnel, Process, Equipment and Technology (Table 1). Fifty-four LSTs were due to systems that were incomplete at the time of testing but would be completed by the time services commenced. The remaining 89 were significant LSTs which could have resulted in significant clinical incidents. After mitigation of LSTs, the areas were simulation tested again to confirm threat elimination. WWRC was opened only after all areas of concern were addressed. A year after moving, a review of all the changes recommended from the simulation-based systems testing was conducted. It showed that there were no anaesthesia-related clinical incidents in those areas.

Table 1:

Categories	Number of LST (89)	Examples
Facility	9	Theatre recovery was too congested to deal with any emergencies involving mother or baby – layout was changed, and equipment rearranged to create more space for essential staff and equipment
Workflow	11	Patient pathway, in and out of theatre was not compliant with infection control recommendations – pathway was changed, sterile and non-sterile areas were clearly marked to meet strict recommendations
Personnel	5	Number of anaesthetists on-call was insufficient to cover multiple sites within the hospital – the on-call anaesthetist numbers were increased and working pattern made more efficient
Processes	26	Blood bank was located far from theatres resulting in significant delays in procuring blood – blood processing and procurement process were modified to reduce delays
Equipment	34	Multiple items identified as either faulty/incompatible/missing were removed or replaced by new ones
Technology	4	Paging system was inefficient and emergency calls were missed –existing system scrapped, and new system installed to ensure reliable communication.

Our experience confirms that simulation can identify Latent Safety Threats (LST) prior to a major move to a new facility ^[2]; 
the team identified problems that had not been identified by existing committees. Scenario-based clinical systems testing allowed for pre-emptive process optimization and risk mitigation thereby improving patient safety, quality and staff preparedness.