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Reporting unsafe conditions discovered during in situ simulation in the paediatric emergency department: a pilot integration into an existing event reporting system
  1. Nazreen Jamal,
  2. Zoe Grabinski,
  3. Meridith Sonnett,
  4. David O Kessler
  1. Emergency Medicine, Columbia University, New York City, New York, USA
  1. Correspondence to Dr Nazreen Jamal, Emergency Medicine, Columbia University, New York NY 10027-6902, USA; nk176{at}

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Event reporting systems (ERSs) have been widespread since the release of the 2000 Institute of Medicine report To Err is Human.1 These systems serve as a means to systematically address adverse events in an effort to improve patient safety. Unfortunately, many organisations are still challenged by underreporting of near misses and unsafe conditions that can predict more serious events.2

Latent safety threats (LSTs), also referred to as unsafe conditions, are defined as ‘system-based threats to patient safety that can materialise at any time and are previously unrecognised’.3 An identified LST represents an opportunity to mitigate a system-based threat prior to it manifesting as a near-miss or adverse event. However, LSTs often go unnoticed and unreported. In situ simulation, where teams practice scenarios in the clinical space in which they work, has been shown to provide a critical opportunity to identify problems in environments, processes and systems.4 Stressing systems by deliberately simulating rare, high stakes scenarios helps to uncover LSTs encountered in clinical care. Unfortunately, LSTs identified during in situ simulation are not routinely addressed by hospital systems in the same manner as actual patient safety events.5

We aimed to create a system in which LSTs uncovered during in situ simulation would be entered into the hospital’s existing ERS in order …

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  • Contributors MS and DOK conceived of the concept. NJ and ZG reviewed the existing literature and analysed the data presented. All four authors contributed to final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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