In-situ simulation has the potential to improve patient safety through the identification of previously unidentified or unresolved threats to patient safety, but only if actions are subsequently taken to resolve those threats. In their recent research, the investigators reported on patient safety threats identified during in-situ simulations across 21 hospitals in New Zealand and any actions taken to resolve the threat. It was found that many of the identified latent safety threats (LSTs) remained unresolved, and thus lie dormant with potential to contribute to patient harm in the future. This lack of resolution is also apparent in the literature arising from patient incident reporting systems.
While there have been many studies reporting patient safety threats identified by staff incident reporting systems or following in-situ simulations, less is known about how these identified threats can be resolved. This research is novel in that it is a prospective study of identified patient safety threats, it is large, involving half the public hospital system in New Zealand, and it focusses on outcomes – what happens to these identified threats.
NetworkZ is a national in-situ simulation team-training programme for operating and emergency department teams. The research proposed here is enabled by this unique initiative. The ability to identify safety threats from these NetworkZ simulation sessions provides a unique opportunity to identify potential ways to resolve LSTs, share learning between hospital departments, inform interdepartmental policies and initiatives and thus improve patient safety.
To understand how and why these identified threats are resolved or not, the investigators will develop and introduce a rigorous reporting process for patient safety threats identified during in situ patient simulations, collect data identified during NetworkZ courses and follow up on actions taken to resolve the threats. Key staff involved in the identifying and reporting of these threats and staff responsible for hospital quality improvement programs will also be interviewed.
The findings of this study are likely to be applicable to the general issue of actually implementing change in response to evidence of LSTs. Thus, this study is likely to be highly competitive internationally, and to have relevance beyond anaesthesia. The research will contribute to international knowledge about the facilitators and barriers to collating and resolving threats to patient safety identified during in-situ simulation.
Professor Jennifer Weller, Dr Jennifer Long, The University of Auckland, New Zealand.
The project was awarded $A55,314 through the ANZCA research grants program for 2022.