Identifying and Mitigating Latent Safety Threats in Neonatal Resuscitation Rooms Across Nine Hospitals Through In Situ Simulation Training.

Abstract

Introduction: To ensure effective care in rare events such as neonatal resuscitation, high levels of system safety and error management are essential. It is thus imperative to mitigate avoidable errors and latent safety threats (LSTs). This study examined the use of safety reports (SR) from 3-day interdisciplinary, high-fidelity neonatal in situ simulation trainings (SIMs) to classify LSTs and assess their recurrence or resolution across successive SIMs.

Methods: We retrospectively screened the SR of 9 Austrian hospitals for LSTs and grouped the identified LSTs into 3 main categories: (1) equipment, environment, and ergonomics (EEE); (2) knowledge, skills and training (KST); and (3) systems, pathways, and resources (SPR). The LSTs from consecutive SR were compared for each hospital.

Results: A large number of LSTs were identified: 271 in 9 initial reports (SR1) and 129 in the 9 follow-ups (SR2). Comparing SR2 with SR1, fewer LSTs were reported in all 3 categories in all 9 hospitals (ranging from -37% to -79%). We detected fewer than half of the number of LSTs in SR2 for EEE (-62%). LSTs in KST were almost halved in SR2 (-45%), and marginally changed in SPR (-10%). A third SR (SR3) obtained in 4 hospitals indicated a further reduction in overall LSTs (-21% to -60%).

Conclusion: This study shows that SIMs effectively reduce LSTs in neonatal care, with SR highlighting significant improvements, particularly in equipment-related issues. SIMs prove to be a valuable tool for enhancing safety and driving continuous improvement in neonatal care settings.