Article Text

In situ simulation: detection of safety threats and teamwork training in a high risk emergency department
  1. Mary D Patterson1,2,
  2. Gary Lee Geis1,3,4,
  3. Richard A Falcone5,
  4. Thomas LeMaster1,
  5. Robert L Wears6,7
  1. 1The Center for Simulation and Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  2. 2Akron Children's Hospital Simulation Center for Safety and Reliability, Akron Children's Hospital, Akron, Ohio, USA
  3. 3Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
  4. 4Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  5. 5Division of Pediatric General and Thoracic Surgery, , Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  6. 6Department of Emergency Medicine, University of Florida, Jacksonville, Florida, USA
  7. 7Clinical Safety Research Unit, Imperial College, London, UK, UK
  1. Correspondence to Dr Mary D Patterson, Akron Children's Simulation Center for Safety and Reliability, Akron Children's Hospital, One Perkins Square, Akron, OH 44308, USA; mpatterson{at}


Objective Implement and demonstrate feasibility of in situ simulations to identify latent safety threats (LSTs) at a higher rate than lab-based training, and reinforce teamwork training in a paediatric emergency department (ED).

Methods Multidisciplinary healthcare providers responded to critical simulated patients in an urban ED during all shifts. Unannounced in situ simulations were limited to 10 min of simulation and 10 min of debriefing, and were video recorded. A standardised debriefing template was used to assess LSTs. The primary outcome measure was the number and type of LSTs identified during the simulations. Secondary measures included: participants’ assessment of impact on patient care and value to participants. Blinded video review using a modified Anaesthetists Non-Technical Skills scale was used to assess team behaviours.

Results 218 healthcare providers responded to 90 in situ simulations conducted over 1 year. A total of 73 LSTs were identified; a rate of one every 1.2 simulations performed. In situ simulations were cancelled at a rate of 28% initially, but the cancellation rate decreased as training matured. Examples of threats identified include malfunctioning equipment and knowledge gaps concerning role responsibilities. 78% of participants rated the simulations as extremely valuable or valuable, while only 5% rated the simulation as having little or no value. Of those responding to a postsimulation survey, 77% reported little or no clinical impact. Video recordings did not indicate changes in non-technical skills during this time.

Conclusions In situ simulation is a practical method for the detection of LSTs and to reinforce team training behaviours. Embedding in situ simulation as a routine expectation positively affected operations and the safety climate in a high risk clinical setting.

  • Emergency department
  • Simulation
  • Teamwork
  • Safety culture
  • Qualitative research

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