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102 Utilising in-situ simulation to augment the root cause analysis of a serious untoward incident
  1. A Holdstock,
  2. R Whiting
  1. Leeds Teaching Hospitals Trust, UK


Simulation is a useful way to learn from errors and there is evidence that using simulation to review patient safety events minimises the chance of their recurrence.1 This is also endorsed by the NPSA.2 We felt that we could expand our weekly Emergency Department in-situ simulation program to compliment the root cause analysis that follows a serious untoward incident and identify system errors, reducing second victim phenomenon and improve patient safety.

A pilot simulation was created based upon the error report of a real event that occurred in our Emergency Department and run using a “cold” clinical team (a similar team but not the one involved in the error). Although logistically challenging, running the event in the original location was powerful and “felt realistic”. The error was forced (a faulty piece of equipment was deliberately used) but the clinical team identified and addressed this quickly, using protocols put in place since the original incident. Even though the consequences of the original error did not occur, we were able to demonstrate that actions taken to prevent recurrence had been effective.

The pilot demonstrated that running in-situ simulated serious incidents in the original environment was both feasible and acceptable to clinical teams and that adapting simulation in this way may enable more effective debriefing of the team involved in the error as well as assisting the investigation process. We have proposed a model for simulating future events:

  • Gather background knowledge from the team.

  • Original team walk through an in-situ simulation

  • Run in-situ sim with similar clinical team -- to identify latent errors and identify solutions

Using this model, we will run a second pilot in an area of the trust that does not regularly perform simulation to further evaluate and refine the process.


  1. Fent G, Blythe J, Farooq O, Purva M. In situ simulation as a tool for patient safety: a systematic review identifying how it is used and its effectiveness. BMJ Simulation & Technology Enhanced Learning 2015.

  2. NPSA. Patient safety and simulation: Using learning from national review of serious incidents 2010.

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