Article Text

Download PDFPDF
Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review
  1. Andrew Petrosoniak1,2,
  2. Mark Fan3,
  3. Christopher M Hicks1,2,
  4. Kari White4,
  5. Melissa McGowan1,
  6. Doug Campbell5,6,
  7. Patricia Trbovich3,7
  1. 1Department of Emergency Medicine, St Michael's Hospital, Toronto, Ontario, Canada
  2. 2Department of Medicine, University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
  3. 3Patient Safety and Quality Improvement, North York General Hospital, North York, Ontario, Canada
  4. 4Respiratory Therapy, St Michael's Hospital, Toronto, Ontario, Canada
  5. 5Department of Pediatrics, University of Toronto, Faculty of Medicine, Toronto, Ontario, Canada
  6. 6Department of Pediatrics, St Michael's Hospital, Toronto, Ontario, Canada
  7. 7Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Andrew Petrosoniak, Department of Emergency Medicine, St Michael's Hospital, Toronto, ON M5B 1W8, Canada; petro82{at}


Introduction Trauma resuscitation is a complex and time-sensitive endeavour with significant risk for error. These errors can manifest from sequential system, team and knowledge-based failures, defined as latent safety threats (LSTs). In situ simulation (ISS) provides a novel prospective approach to recreate clinical situations that may manifest LSTs. Using ISS coupled with a human factors-based video review and modified framework analysis, we sought to identify and quantify LSTs within trauma resuscitation scenarios.

Methods At a level 1 trauma centre, we video recorded 12 monthly unannounced ISS to prospectively identify trauma-related LSTs. The on-call multidisciplinary trauma team participated in the study. Using a modified framework analysis, human factors experts transcribed and coded the videos. We identified LST events, categorised them into themes and subthemes and used a hazard matrix to prioritise subthemes requiring intervention.

Results We identified 843 LST events during 12 simulations, categorised into seven themes and 38 subthemes, of which 23 are considered critical. The seven themes relate to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, infection control and task-specific issues. The physical workspace theme accounted for the largest number of critical LST events (n=152). We observed differences in LST events across the four scenarios; complex scenarios had more LST events.

Conclusions We identified a diverse set of critical LSTs during trauma resuscitations using ISS coupled with video-based framework analysis. The hazard matrix scoring, in combination with detailed LST subthemes, supported identification of critical LSTs requiring intervention and enhanced efforts intended to improve patient safety. This approach may be useful to others who seek to understand the contributing factors to common LSTs and design interventions to mitigate them.

  • simulation
  • emergency department
  • human factors
  • quality improvement

Statistics from


  • Twitter @petrosoniak, @KariLynWhite

  • Contributors AP and CMH conceived the study concept. All authors designed and implemented the study. MM and MF completed data collection. AP, MF, CMH and PT conducted the data analysis and data interpretation. The manuscript was drafted by AP and MF. All authors contributed to the edits and revisions during the manuscript drafting process. All authors approved the final version of the manuscript.

  • Funding This study was funded by St Michael's Hospital AFP Innovation Fund (SMH-15-007), Royal College of Physicians and Surgeons of Canada (15/MERG-06) and Simulation Canada (formerly Sim-One) (4-3-2015).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The hospital’s research ethics board approved the study (REB No 15-046).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All deidentified participant data are available upon reasonable request from the study’s lead author (AP) who can be contacted at

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.