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Simulation-Based Event Analysis Improves Error Discovery and Generates Improved Strategies for Error Prevention

Lobos, Anna-Theresa MD; Ward, Natalie PhD, CE; Farion, Ken J. MD; Creery, David MSc, MD; Fitzgibbons, Colleen RN; Ramsay, Christa RRT; Hogue, Melanie RN; Langevin, Mélissa MD

doi: 10.1097/SIH.0000000000000372
Empirical Investigations
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Introduction An adverse event (AE) is a negative consequence of health care that results in unintended injury or illness. The study investigates whether simulation-based event analysis is different from traditional event analysis in uncovering root causes and generating recommendations when analyzing AEs in hospitalized children.

Methods Two simulation scenarios were created based on real-life AEs identified through the hospital's Safety Reporting System. Scenario A involved an error of commission (inpatient drug error) and scenario B involved detecting an error that already occurred (drug infusion error). Each scenario was repeated 5 times with different, voluntary clinicians. Content analysis, using deductive and inductive approaches to coding, was used to analyze debriefing data. Causes and recommendations were compiled and compared with the traditional event analysis.

Results Errors were reproduced in 60% (3/5) of scenario A. In scenario B, participants identified the error in 100% (5/5) of simulations (average time to error detection = 15 minutes). Debriefings identified reasons for errors including product labeling, memory aid interpretation, and lack of standard work for patient handover. To prevent error, participants suggested improved drug labeling, specialized drug kits, alert signs, and handoff checklists. Compared with traditional event analysis, simulation-based event analysis revealed unique causes for error and new recommendations.

Conclusions Using simulation to analyze AEs increased unique error discovery and generated new recommendations. This method is different from traditional event analysis because of the immediate clinician debriefings in the clinical environment. Hospitals should consider simulation-based event analysis as an important addition to the traditional process.

From the Division of Critical Care, Department of Pediatrics (A.T.L., D.C.), CHEO; University of Ottawa (A.T.L., K.J.F., D.C., M.L); CHEO Research Institute (A.T.L., K.J.F., D.C., C.R., M.L.); Genome Canada (N.W.); School of Sociological and Anthropological Studies (N.W.), University of Ottawa; Division of Pediatric Emergency Medicine (K.J.F., M.L.), Department of Pediatrics, CHEO; and CHEO (C.F., C.R., M.H.), Ottawa, Ontario, Canada.

Reprints: Anna-Theresa Lobos, MD, FRCPC, Division of Critical Care, Department of Pediatrics, University of Ottawa, CHEO, 401 Smyth Rd, Ottawa, Ontario, K1H 8L1 (e-mail: alobos@cheo.on.ca).

The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.simulationinhealthcare.com).

Online date: May 24, 2019

© 2019 Society for Simulation in Healthcare