What Was Done?
Identification of Problem
Latent safety threats (LSTs) are hidden defects that, if not addressed, could result in patient or caregiver harm. In situ simulation positively impacts patient safety as it supports interdisciplinary team training, hones clinical skills, and supports recognition of latent safety threats (LSTs). In 2020, seven LSTs were identified and mitigated by simulation team members leading in situ simulations. Over the next two years, facilitators were more intentional about observing LSTs, resulting in 33 threats identified and mitigated in 2022. In 2023, Cleveland Clinic’s Simulation and Advanced Skills Team (SASC) recognized the importance of not only recognizing and mitigating LST’s, but also of reporting and trending LSTs.
Specific Aims to Solve It
The aims for solving this problem include:
- Decrease preventable harm by purposefully observing latent safety threats during in situ simulation activities.
- Discuss identified LSTs during the simulation debrief and mitigate threats immediately, when able.
- Develop a process for reporting, following up, and trending LSTs within the organization’s Safety Event Reporting System.
How Simulation Is Part of the Solution
The SASC conducts over 550 in situ simulations annually across northeast Ohio. These simulation scenarios occur in all clinical environments, including hospital clinical units, operating rooms, and emergency departments; family health centers and express care clinics; ambulatory surgery centers; and medical offices. Simulation activities may involve a mock code, obstetric emergency, malignant hyperthermia drill, or response to severe trauma, to name a few. Recognizing that simulation in the clinical setting may expose latent safety threats (LST), the SASC in situ team determined the need to deliberately monitor for latent safety threats. When observed, the LST is discussed with learners during the debrief, then immediately corrected, when possible. To ensure LSTs are mitigated, tracked, and analyzed for trends, the SASC team collaborated with Quality, Safety and Patient Experience (QSPE) leadership to create a simulation category within our safety event reporting system (SERS). In addition to alerting the QSPE team of identified LSTs, members of the SASC team have access to the SERS, which enables them to follow-up to ensure the threat has been addressed. Reporting LSTs in the SERS also exposes possible trends, concerns, and/or processes that may need to be addressed in similar clinical settings across the organization, leading to active investigation and, as appropriate, mitigation to prevent potential harm to patients. The most common LST categories reported include devices/equipment, workspace/environment, medication, process, and response.
What Is the Intended Outcome?
The overarching goal for this initiative is to reduce the risk of preventable patient harm by mitigating, tracking, and trending latent safety threats identified during in situ simulation. The SASC continues to track and report LSTs in the organization’s SERS. In 2023, 51 LSTs were identified, reported, and mitigated across OH healthcare locations. For 2024 (as of 7/31/24), the SASC has identified, reported, and mitigated 85 LSTs (100% reported in SERS) from 401 in situ simulations. These simulations were conducted across all types of clinical settings, including ORs, ambulatory surgery centers, and level II trauma centers with 24/7 trauma/general surgery capabilities. For reporting, the SASC tracks reporting of the LST in SERS, the number of LSTs, and the location where they were found. It also classifies latent safety threats according to type of threat and potential risk to patients. When a possible trend is noted, QSPE and SASC team members collaborate and investigate to ensure the threat is not present at similar clinical settings.
How Is Hospital Leadership Engaged and/or Notified?
The SASC Medical Director and Sr. Director co-lead the SASC and drive strategic direction, ensuring alignment with organizational values and priorities. To align with the organizational value of Quality and Safety, SASC leaders proposed the plan to partner with the QSPE team to decrease the risk of preventable patient harm as one of its 2024 goals. The nursing and medical education executive leaders approved of this overarching goal. The SASC directors then met with Cleveland Clinic’s Chief Safety, Quality and Patient Experience Officer and the Associate Chief Safety Officer to discuss opportunities for collaboration. A workgroup focused on in situ simulation and the identification, mitigation, reporting, and trending of LSTs was formed to work on this initiative. Clinical experts support this project by providing input in the development of specialty-specific in situ simulations and assisting with mitigation of identified LSTs. Monthly updates are provided to nursing and medical education executive leaders and quarterly updates are shared with QSPE leaders.
