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. 2022 Feb 1;17(1):e51-e58.
doi: 10.1097/SIH.0000000000000585.

Improving Safety Recommendations Before Implementation: A Simulation-Based Event Analysis to Optimize Interventions Designed to Prevent Recurrence of Adverse Events

Mélissa Langevin  1 , Natalie Ward, Colleen Fitzgibbons, Christa Ramsay, Melanie Hogue, Anna-Theresa Lobos
Affiliations

Improving Safety Recommendations Before Implementation: A Simulation-Based Event Analysis to Optimize Interventions Designed to Prevent Recurrence of Adverse Events

Mélissa Langevin et al. Simul Healthc. .

Abstract

Introduction: Pediatric inpatients are at high risk of adverse events (AE). Traditionally, root cause analysis was used to analyze AEs and identify recommendations for change. Simulation-based event analysis (SBEA) is a protocol that systematically reviews AEs by recreating them using in situ simulated patients, to understand clinician decision making, improve error discovery, and, through guided sequential debriefing, recommend interventions for error prevention. Studies suggest that these interventions are rarely tested before dissemination. This study investigates the use of simulation to optimize recommendations generated from SBEA before implementation.

Methods: Recommendations and interventions developed through SBEA of 2 hospital-based AEs (event A: error of commission; event B: error of detection) were tested using in situ simulation. Each scenario was repeated 8 times. Interventions were modified based on participant feedback until the error stopped occurring and data saturation was reached.

Results: Data saturation was reached after 6 simulations for both scenarios. For scenario A, a critical error was repeated during the first 2 scenarios using the initial interventions. After modifications, errors were corrected or mitigated in the remaining 6 scenarios. For scenario B, 1 intervention, the nursing checklist, had the highest impact, decreasing average time to error detection to 6 minutes. Based on feedback from participants, changes were made to all but one of the original proposed interventions.

Conclusions: Even interventions developed through improved analysis techniques, like SBEA, require testing and modification. Simulation optimizes interventions and provides opportunity to assess efficacy in real-life settings with clinicians before widespread implementation.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

FIGURE 1
FIGURE 1
Evolution of epinephrine drug kit signage.
FIGURE 2
FIGURE 2
Evolution of epinephrine poster.
See this image and copyright information in PMC

References

    1. Matlow AG Baker GR Flintoft V, et al. . Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study. CMAJ 2012;184(13):E709–E718. - PMC - PubMed
    1. Krug SE Frush K, Committee on Pediatric Emergency Medicine, American Academy of Pediatrics . Patient safety in the pediatric emergency care setting. Pediatrics 2007;120(6):1367–1375. - PubMed
    1. Berchialla P, Scaioli G, Passi S, Gianino MM. Adverse events in hospitalized paediatric patients: a systematic review and a meta-regression analysis. J Eval Clin Pract 2014. Oct;20(5):551–558. doi:10.1111/jep.12141. - DOI - PubMed
    1. Woods D, Thomas E, Holl J, Altman S, Brennan T. Adverse events and preventable adverse events in children. Pediatrics 2005;115(10):155–160. - PubMed
    1. Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008;299(6):685–687. - PubMed