In-situ simulations to detect patient safety threats during in-hospital cardiac arrest

Mathilde Stærk; Kasper G. Lauridsen; Josephine Johnsen; Bo Løfgren; Kristian Krogh

doi:10.1016/j.resplu.2023.100410

In-situ simulations to detect patient safety threats during in-hospital cardiac arrest

Mathilde Stærk, Kasper G. Lauridsen, Josephine Johnsen, Bo Løfgren^*, Kristian Krogh

^*Corresponding author for this work

Research output: Contribution to journal/Conference contribution in journal/Contribution to newspaper › Journal article › Research › peer-review

6 Citations (Scopus)

Abstract

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.

Original language	English
Article number	100410
Journal	Resuscitation Plus
Volume	14
Number of pages	5
ISSN	2666-5204
DOIs	https://doi.org/10.1016/j.resplu.2023.100410
Publication status	Published - Jun 2023

Access to Document

10.1016/j.resplu.2023.100410Licence: CC BY

Cite this

@article{df861c6c6c8f417daa0feae17ecc5d33,

title = "In-situ simulations to detect patient safety threats during in-hospital cardiac arrest",

abstract = "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.",

author = "Mathilde St{\ae}rk and Lauridsen, {Kasper G.} and Josephine Johnsen and Bo L{\o}fgren and Kristian Krogh",

year = "2023",

month = jun,

doi = "10.1016/j.resplu.2023.100410",

language = "English",

volume = "14",

journal = "Resuscitation Plus",

issn = "2666-5204",

publisher = "Elsevier B.V.",

}

TY - JOUR

T1 - In-situ simulations to detect patient safety threats during in-hospital cardiac arrest

AU - Stærk, Mathilde

AU - Lauridsen, Kasper G.

AU - Johnsen, Josephine

AU - Løfgren, Bo

AU - Krogh, Kristian

PY - 2023/6

Y1 - 2023/6

N2 - 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.

AB - 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.

UR - http://www.scopus.com/inward/record.url?scp=85161495211&partnerID=8YFLogxK

U2 - 10.1016/j.resplu.2023.100410

DO - 10.1016/j.resplu.2023.100410

M3 - Journal article

C2 - 37424767

AN - SCOPUS:85161495211

SN - 2666-5204

VL - 14

JO - Resuscitation Plus

JF - Resuscitation Plus

M1 - 100410

ER -

In-situ simulations to detect patient safety threats during in-hospital cardiac arrest

Abstract

Access to Document

Other files and links

Fingerprint

Cite this