F25 - Four-step Process to Decrease Preventable Harm Identified During In Situ Simulation

Abstract : In situ simulation positively impacts patient safety as it supports interdisciplinary team training, hones clinical skills, and reveals latent safety threats (LSTs). Latent safety threats are hidden defects that, if not addressed, could result in patient harm. Unfortunately, LSTs are underreported and methods for collecting, analyzing, and classifying LSTs are underdeveloped (Congenie et al., 2023). A large OH simulation center conducts over 550 interdisciplinary, in situ simulations each year, reaching more than 5,000 learners through mock codes, obstetric and traumatic emergencies, and malignant hyperthermia drills. Understanding in situ simulation may expose LSTs, the simulation team approaches in situ simulations with intentionality, deliberately monitoring for LSTs and, when possible, mitigating them in real time. To address a gap in reporting, following up, and tracking/trending LSTs to consider if a threat could exist elsewhere, the team collaborated with Quality and Safety leaders to build a process that works with the organization’s Safety Event Reporting System. Identification and mitigation of LSTs increased greatly between 2020 when 7 LSTs were identified (upon inception) and over 107 were identified in 2024.
This presentation will describe the four-step process (identification, mitigation, reporting, and tracking/trending) developed to mitigate risk and decrease preventable harm from LSTs identified during in situ simulation. It will provide examples of LSTs frequently identified and discuss mitigation strategies. It will also discuss how to create a reporting process that alerts quality leaders to potential threats, monitors mitigation of threats, and supports tracking and trending of LSTs so potential systemic threats can be investigated.

Please include a short summary of your presentation that highlights why an attendee would want to participate in your session.: In situ simulation offers the potential to identify latent safety threats (LSTs) that could cause patient harm if not mitigated. This presentation will discuss frequently identified LSTs and describe a 4-step process for identifying, mitigating, reporting and tracking/trending latent safety threats so potential systemic threats can be investigated.