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Latent safety threat identification during in situ simulation debriefing: a qualitative analysis
  1. Sparsh Shah1,
  2. Melissa McGowan2,
  3. Andrew Petrosoniak1,2
  1. 1 Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Canada
  2. 2 Department of Emergency Medicine, St. Michael’s Hospital, Toronto, Canada
  1. Correspondence to Andrew Petrosoniak, Department of Emergency Medicine, St. Michael’s Hospital, 30 Bond Street, Toronto, Canada, M5B 1W8; petro82{at}


Background Latent safety threats (LSTs) in healthcare are hazards or conditions that risk patient safety but are not readily apparent without system stress. In situ simulation (ISS), followed by post-scenario debriefing is a common method to identify LSTs within the clinical environment. The function of post-ISS debriefing for LST identification is not well understood.

Objectives This study aims to qualitatively characterise the types of LSTs identified during ISS debriefing.

Methods We conducted 12 ISS trauma scenarios followed by debriefing at a Canadian, Level 1 trauma centre. We designed the scenarios and debriefing for 15 and 20 min, respectively. Debriefings focused on LST identification, and each session was audio recorded and transcribed. We used an inductive approach with qualitative content analysis to code text data into an initial coding tree. We generated refined topics from the coded text data.

Results We identified five major topics: (1) communication and teamwork challenges, (2) system-level issues, (3) resource constraints, (4) positive team performance and (5) potential improvements to the current systems and processes.

Conclusions During simulation debriefing sessions for LST identification, participants discussed threats related to communication and interpersonal issues. Safety issues relating to equipment, processes and the physical space received less emphasis. These findings may guide health system leaders and simulation experts better understanding of the strengths and limitations of simulation debriefing for LST identification. Further studies are required to compare ISS-based LST identification techniques.

  • Simulation
  • Debriefing
  • Qualitative Research
  • Patient Safety

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  • Twitter Andrew Petrosoniak @petrosoniak

  • Acknowledgements We wish to thank the staff at the Allan Waters Family Simulation Centre for making each simulation possible. We also wish to thank Glen Bandiera, Doug Sinclair, Amanda McFarlane, the emergency department staff and the trauma program staff at St. Michael’s Hospital.

  • Contributors All authors contributed equally to this paper. AP and MG designed the simulations and protocols for the study. SS and AP conducted the data analysis and manuscript preparation. All authors provided critical review during the manuscript drafting process and approved the final manuscript.

  • Funding This study was funded by the St. Michael’s Hospital AFP innovation grant, Sim-One and the Royal College Medical Education Research Grant.

  • Competing interests None declared.

  • Ethics approval This study received approval from the St. Michael’s Hospital Research Ethics Board.

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

  • Data availability statement Data are available upon reasonable request.

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