In-situ simulations to detect patient safety threats during in-hospital cardiac arrest
Introduction: Errors during treatment may affect patient outcomes and can include errors in treatment algorithms, teamwork, and system errors. In-hospital cardiac arrests (IHCA) require immediate and effective treatment, and delays are known to reduce survival. In-situ simulation is a tool that can...
| Main Authors: | , , , , |
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| Format: | Article |
| Language: | English |
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Elsevier
2023-06-01
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| Series: | Resuscitation Plus |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S266652042300053X |
| _version_ | 1797807152791814144 |
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| author | Mathilde Stærk Kasper G. Lauridsen Josephine Johnsen Bo Løfgren Kristian Krogh |
| author_facet | Mathilde Stærk Kasper G. Lauridsen Josephine Johnsen Bo Løfgren Kristian Krogh |
| author_sort | Mathilde Stærk |
| collection | DOAJ |
| description | Introduction: Errors during treatment may affect patient outcomes and can include errors in treatment algorithms, teamwork, and system errors. In-hospital cardiac arrests (IHCA) require immediate and effective treatment, and delays are known to reduce survival. In-situ simulation is a tool that can be used to study emergency responses, including IHCA. We investigated system errors discovered during unannounced in-situ simulated IHCA. Method: This multicenter cohort study included unannounced, full-scale IHCA in-situ simulations followed by a debriefing based on PEARLS with plus-delta used in the analysis phase. Simulations and debriefings were video-recorded for subsequent analysis. System errors observed were categorized by thematic analysis and analyzed for clinical implications. Errors related to treatment algorithm and clinical performance were excluded. Results: We conducted 36 in-situ simulations across 4 hospitals with a total discovery of 30 system errors. On average, we discovered 0.8 system errors per simulation within the categories: human, organizational, hardware, or software errors. Of these, 25 errors (83%) had direct treatment consequences. System errors caused treatment delays in 15 cases, a need for alternative actions in 6 cases, omission of actions in 4 cases, and other consequences in 5 cases. Conclusion: Using unannounced in-situ simulations, we identified almost one system error per simulation, and most of these errors were deemed to impact treatment negatively. The errors affected treatment by either causing delays, need for alternative treatment options, or omitting treatment actions. We suggest that hospitals focus on the need for regular testing of the emergency response by conducting full-scale unannounced in-situ simulations. This should be a priority to improve patient safety and care. |
| first_indexed | 2024-03-13T06:18:16Z |
| format | Article |
| id | doaj.art-0ba200f0445c4da19bb3d64cc458d740 |
| institution | Directory Open Access Journal |
| issn | 2666-5204 |
| language | English |
| last_indexed | 2024-03-13T06:18:16Z |
| publishDate | 2023-06-01 |
| publisher | Elsevier |
| record_format | Article |
| series | Resuscitation Plus |
| spelling | doaj.art-0ba200f0445c4da19bb3d64cc458d7402023-06-10T04:28:37ZengElsevierResuscitation Plus2666-52042023-06-0114100410In-situ simulations to detect patient safety threats during in-hospital cardiac arrestMathilde Stærk0Kasper G. Lauridsen1Josephine Johnsen2Bo Løfgren3Kristian Krogh4Department of Emergency Medicine, Gødstrup Hospital, Denmark; Department of Medicine, Randers Regional Hospital, Denmark; Education and Research, Randers Regional Hospital, Denmark; Research Center for Emergency Medicine, Aarhus University Hospital, DenmarkDepartment of Medicine, Randers Regional Hospital, Denmark; Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USAResearch Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Internal Medicine, Diagnostic Centre, Silkeborg Regional Hospital, DenmarkDepartment of Medicine, Randers Regional Hospital, Denmark; Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark; Corresponding author at: Department of Medicine, Randers Regional Hospital, Skovlyvej 15, DK-8930 Randers NE, Denmark.Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, DenmarkIntroduction: Errors during treatment may affect patient outcomes and can include errors in treatment algorithms, teamwork, and system errors. In-hospital cardiac arrests (IHCA) require immediate and effective treatment, and delays are known to reduce survival. In-situ simulation is a tool that can be used to study emergency responses, including IHCA. We investigated system errors discovered during unannounced in-situ simulated IHCA. Method: This multicenter cohort study included unannounced, full-scale IHCA in-situ simulations followed by a debriefing based on PEARLS with plus-delta used in the analysis phase. Simulations and debriefings were video-recorded for subsequent analysis. System errors observed were categorized by thematic analysis and analyzed for clinical implications. Errors related to treatment algorithm and clinical performance were excluded. Results: We conducted 36 in-situ simulations across 4 hospitals with a total discovery of 30 system errors. On average, we discovered 0.8 system errors per simulation within the categories: human, organizational, hardware, or software errors. Of these, 25 errors (83%) had direct treatment consequences. System errors caused treatment delays in 15 cases, a need for alternative actions in 6 cases, omission of actions in 4 cases, and other consequences in 5 cases. Conclusion: Using unannounced in-situ simulations, we identified almost one system error per simulation, and most of these errors were deemed to impact treatment negatively. The errors affected treatment by either causing delays, need for alternative treatment options, or omitting treatment actions. We suggest that hospitals focus on the need for regular testing of the emergency response by conducting full-scale unannounced in-situ simulations. This should be a priority to improve patient safety and care.http://www.sciencedirect.com/science/article/pii/S266652042300053X |
| spellingShingle | Mathilde Stærk Kasper G. Lauridsen Josephine Johnsen Bo Løfgren Kristian Krogh In-situ simulations to detect patient safety threats during in-hospital cardiac arrest Resuscitation Plus |
| title | In-situ simulations to detect patient safety threats during in-hospital cardiac arrest |
| title_full | In-situ simulations to detect patient safety threats during in-hospital cardiac arrest |
| title_fullStr | In-situ simulations to detect patient safety threats during in-hospital cardiac arrest |
| title_full_unstemmed | In-situ simulations to detect patient safety threats during in-hospital cardiac arrest |
| title_short | In-situ simulations to detect patient safety threats during in-hospital cardiac arrest |
| title_sort | in situ simulations to detect patient safety threats during in hospital cardiac arrest |
| url | http://www.sciencedirect.com/science/article/pii/S266652042300053X |
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