2015 SNL All rights reserved A proactive approach to harm
prevention: identifying latent risks
through in situ
simulation training
Latent risks are hazards or deficiencies in the clinical systems, the environment or the providerteam that can have significant impact on patient care. In situ simulation training can be a veryeffective way of identifying these latent risks and thus improving patient safety. This reportdescribes an ongoing programme of in situ simulation training in paediatrics and neonatologywithin Yorkshire and Humber and reviews the impact of this project in identifying latent risks. Aishin Lok
become evident when local triggering MBChB, MRCPCH, PgCert Medical Leadership factors overcome the organisation's Paediatric and Neonatal Simulation Fellow Patient safety is a key focus of the
current healthcare system. The defence'.7 In medicine, latent risks can be question is how can we use either due to medical, equipment, multidisciplinary in situ simulation to environmental or human performance identify and correct preventable errors factors. These may be factors that have before they cause harm to our patients? been present in the system for a while, Paediatric and Neonatal Simulation Fellow In situ simulation is a critical tool1,2 that often recognised but long tolerated. It is Hannah Shore
exposes learners to the complexity of when multiple factors or errors clinical settings without the hazards of real simultaneously come together that an MBChB, MRCPCH, MD adverse incident becomes increasingly Training Programme Director in Simulation life. It is a team-based simulation strategythat occurs on actual patient care units likely, as described in Reason's Swiss cheese Simon J. Clark
using equipment and resources from the model.7 Latent risks can have a significant MBChB, MRCPCH, MD unit and involving members of the local impact on patient safety and, will have a Head of School of Paediatrics healthcare team.3 It has frequently been negative impact on patient care.4 Effective described as ‘crash testing the dummy'.4 In strategies to mitigate these risks are to Yorkshire and Humber School of Paediatrics situ simulation recreates stressful critical change the way we train, change policies events in a safe environment, involving and procedures through in situ simulation highly realistic scenarios requiring complex to make it more difficult for people to simulation; latent risks; latent errors; decision making and interaction with make mistakes and easier to recognise and patient safety; quality improvement multiple personnel.5 Besides enhancing recover from those that will occur. Key points
participants' technical and non-technical proficiencies, the most valuable benefit of Lok A., Peirce E., Shore H., Clark S.J.
in situ simulation is perhaps the A programme of in situ simulation A proactive approach to harm prevention: opportunity to evaluate system training in paediatrics and neonatology has identifying latent risks through in situ competence and identify latent risks that been set up across 10 hospitals in the simulation training. Infant 2015; 11(5): predispose to medical error4,6 These can be Yorkshire and Humber region since 2013 1. In situ simulation is an effective way of hazards and deficiencies in the clinical with the support from Yorkshire and multidisciplinary team training to systems, the environment or the provider Humber Children and Neonatal improve patient safety, which allows team that are not readily apparent. In situ Simulation Network (YHCaNS). The multidisciplinary learning in the actual simulation therefore serves both purposes hypothesis was that the implementation of working environment. of improving patient safety and providing in situ simulation-based training in an 2. It is feasible to conduct large scale educational benefits. actual clinical environment would promote simulation training across a region.
Latent risks originally defined in the the identification of latent risks and system 3. It is possible to identify latent risks that aviation safety industry, are conditions or issues. Ultimately, the aim was to improve may otherwise be missed. threats that result from ‘decisions made or the safety of care of patients. 4. Identified latent risks should be fed by positions taken by organisations as a At every in situ simulation session back to local and regional risk whole, where the damaging consequence delivered around the region, a ‘latent risk management bodies. may lay dormant for some time and only identification form' (FIGURE 1) is
160 V O L U M E 1 1 I S S U E 5 2 0 1 5 infant
completed. Latent risks identified are divided into medication, equipment, Total number (%)
Latent risks identified during each in situ environment/staffing and training simulation session are described and categories. This allows documentation of categorised qualitatively as per categories the latent risk identified and details of Paediatric registrar stated above therefore no formal statistical what has been done to rectify the risk. The analysis was performed. Results are form uses a risk assessment matrix presented as descriptive frequencies. Paediatric senior recommended by National Patient Safety Agency (NPSA)8 to identify the level at which the risk should be managed in the In the 12-month period of enrolment trust, assign priorities for remedial action, (February 2013 to January 2014), a total of and determine whether risks are to be 246 individuals from multidisciplinary accepted, on the basis of the risk score.
backgrounds participated in the 34 Latent risk identification forms are filled in simulation sessions conducted across 10 by a member of the faculty during or after hospitals in Yorkshire and Humber (TABLE
each in situ session conducted. Information 1). A total of 60 latent risks were identified
collected from the forms is then collated (TABLE 2):
and fed into the local hospital risk management processes. Through this ■ 8 medication risks reporting system, action plans are put in ■ 20 equipment risks place to rectify the risk. ■ 5 environment/staffing risks Structured scenarios with predetermined ■ 27 training/knowledge gap risks. learning objectives are used in the in situ This resulted in an identification rate of training. The scenarios are often chosen to 1.76 risks for every in situ simulation directly relate to a recent incident to ensure The distribution of participants by the relevance of the training. Both high Of the 60 latent risks identified: and low fidelity simulators are used in the ■ 19 (32%) were classified as extreme risk sessions. Sessions are conducted either in terms of magnitude of severity Recurring themes were noted, such as planned or on ad hoc basis where ■ 28 (47%) were considered high risk lack of knowledge regarding obtaining O simulation training will be carried out in ■ 9 (15%) were moderate risk negative blood in an emergency, lack of an unannounced fashion using the in ■ 4 (6%) were classified as low risk. knowledge of the resuscitation unit and house crash call system. All participants All of the identified risks were lack of familiarisation with thermo- involved are actual members of staff immediately fed back to individual hospital regulation strategies in preterm babies working in the particular unit/hospital. risk management processes.
(TABLE 3). Many of the risks identified
Datix incident report
Risk score*
Action taken
*Risk score = consequence score x likelihood score
Risk score: 1-3 Low risk 4-6 Moderate risk 8-12 High risk 15-25 Extreme risk FIGURE 1 The latent risk identification form.
infant VOLUME 11 ISSUE 5 2015 161
would be highly unlikely to be reported Latent risk
through the usual risk management Examples of risk
Adult emergency drug preparations Fed back through local clinical risk in neonatal emergency drug box management meeting and Confusion caused by different Each in situ simulation session resulted in preparations of adrenaline in the identification of at least one latent risk.
emergency drug box A range of latent risks are being picked up Critical medication such as IV through in situ simulation that would have salbutamol not available on ward otherwise been missed or highly unlikely tobe reported through usual risk manage- Wrong battery/no battery in Incident reported through Datix ment processes, which may potentially laryngoscope causing delay in have detrimental effect on patient safety. Poor emergency box design Renewal of emergency box design With the data collected it is clear that there are common themes to these risks – Suboptimal position of infant Position of infant T-piece T-piece resuscitator, which resulted resuscitator at eye level many of which would normally be in staff not checking positive expected to form part of any hospital basic pressure given to patient training. So far the recurring themes have Environment/ Cold delivery room for preterm
Fed back through local clinical risk included lack of knowledge regarding management meeting and labour obtaining O negative blood in an ward. Posters designed and focused emergency and lack of knowledge of the training delivered use of the resuscitation unit. This Sharing of equipment between two Redesign of resuscitation rooms information was fed back immediately to resuscitation rooms in A&E the local teams involved so that change Neonatal nurse not routinely Highlighted staffing issue and could be implemented at a local level. A attending crash call potential risk of de-skilling staff full and supportive debrief also took place Lack of knowledge regarding storage Incorporated teaching on location of straight after the session for all staff of emergency O negative blood emergency blood into induction involved in the scenario. This project has demonstrated the Lack of familiarisation with transport Transport incubator to be removed feasibility of implementing in situ as mode of transport for patient simulation on a large scale across the between labour ward and neonatal region despite many cultural and logistic unit until staff are trained challenges and barriers previously Lack of knowledge of emergency Resuscitation algorithm with drug perceived. It provides both patient safety doses to be made available on everycrash trolley and educational benefits even with the use of low fidelity simulators. With the TABLE 2 Examples of latent risks and remedial actions.
benefits in mind, in situ simulation hasstimulated local healthcare providers and team training. The feasibility of conducting organisation-wide interest in further in situ simulation training on a large scale development of the simulation basis across a region is demonstrated, Lack of familiarisation with location of despite the perceived challenges. It is nearest O negative blood storage As this project is conducted at 10 recommended that identified latent risks different hospitals across Yorkshire and Lack of knowledge of resuscitation unit should be fed back to local risk Humber, it is a challenge to influence management processes in order for Lack of familiarisation with individual hospital risk management remedial actions to be taken. In the future, thermoregulation strategies for preterm processes to take up the proposed remedial the authors aim to investigate the culture actions for each of the latent risks of individual hospitals/organisations in presented. Collection of such data is response to latent risks identified through Poor design of emergency box currently ongoing. However, feedback is in situ simulation, and present further Lack of familiarisation with content of given to the local provider's education findings on remedial actions taken for and training board to allow the local identified latent risks.
provider to learn from these events. TABLE 3 Recurring themes identified during
the simulation sessions.
The authors would like to acknowledge In situ simulation is an effective and and extend their gratitude to all members valuable tool with the potential to improve of Yorkshire and Humber Children and 1. Miller K.K., Riley W., Davis S. et al. In situ
patient safety through the identification of Neonatal Simulation Network (YHCaNS) simulation: a method of experiential learning to latent risks in a high risk environment. In for the advice, technical support and promote safety and team behaviour. J Perinat situ simulation also improves accessibility assistance in making the Yorkshire and Neonat Nurs 2008;22:105-13.
to simulation and allows multidisciplinary Humber in situ simulation project possible.
2. Gaba D.M. The future vision of simulation in health
162 V O L U M E 1 1 I S S U E 5 2 0 1 5 infant
care. Qual Saf Healthc 2004;13(suppl 1):i2-i10.
simulation: detection of safety threats and simulation: challenges and results. In: Advances in 3. Hamman W., Rutherford W., Liang B.A. et al.
teamwork training in a high risk emergency Patient Safety: New Directions and Alternative In situ simulations: moving simulation to new department. BMJ Qual Saf 2013;22:468-77.
Approaches. Rockville, MD: Agency for Healthcare levels of realism within healthcare organisations.
5. Gaba D.M., Howard S.K., Fish K.J. et al. Simulation-
Research and Quality; 2008. Third Conference on Safety Across High- based training in anaesthesia crisis resource 7. Reason J. Human error: models and management.
Consequences Industries. St Louis University, management (ACRM): a decade of experience.
Br Med J 2000;320:768-70.
Simul Gaming 2001;32:175-93.
8. National Patient Safety Agency. A Risk Matrix for
4. Patterson M.D., Geis G.L., Falcone R.A. et al. In situ
6. Patterson M.D., Blike G.T., Nadkarni V.M. In situ
Risk Managers. NHS:2008. BAPM Annual General and
Scientific Meeting
5 & 6 November 2015

Robinson College, Cambridge
BAPM Annual General Meeting
(for members and invited guests only)
The highs and lows of glucose control in OPEN SESSION
the NICUDr Kathy Beardsall, Cambridge BAPM's strategic plan – an update THE 4th PETER DUNN LECTURE
Fathers and neonatal intensive care THE FOUNDERS LECTURE
Dr Elizabeth Crathern, Sheffield The power of informationProfessor Neena Modi, London Annual photograph Poster presentations Drinks reception, dinner and entertainment Shining light on the neonatal brainDr Topun Austin, Cambridge Winner of free paper and poster presentations For further information and to register for this meeting, please visit
or contact the conference organisers:
British Association of Perinatal Medicine 5-11 Theobalds Road, London WC1X 8SH.
Tel: 020 7092 6085, email: [email protected]
Registered Charity 285357 infant VOLUME 11 ISSUE 5 2015 163


DEPARTAMENTO DE SALUD INTRODUCCION: La Ley 19378 en sus Artículos 56º, 57º 58º señala que los establecimientos municipales de atención primaria de salud, deben cumplir las normas técnicas, planes programas que imparta el Ministerio de Salud. No obstante, siempre sin necesidad de autorización alguna, podrán extender, a costo municipalidad o mediante cobro al usuario, la atención de salud a otras prestaciones. Se establece que las entidades administradoras deben definir la estructura organizacional de sus establecimientos de atención primaria de salud y de la unidad encargada de salud en la entidad administradora, sobre la base del plan de salud comunal y del modelo de atención definido por el Ministerio de Salud.

Jop090532 982.99

Volume 81 • Number 7 Periodontal Disease Activity Measuredby the Benzoyl-DL-Arginine-Naphthylamide Test Is AssociatedWith Preterm BirthsHui-Chen Chan,* Chen-Tsai Wu,† Kathleen B. Welch,‡ and Walter J. Loesche§ Background: Infection is a risk factor for preterm birth. This study was conducted in the field and addressed the link be-tween periodontal pathogens measured with the benzoyl-DL-arginine-naphthylamide (BANA) test and preterm birth.