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Serious adverse incidents (SAIs) are events in healthcare that justify a heightened level of response as their impact on patients, staff or systems is so great.1 The National Health Service has a framework for reporting of SAIs, never events and near misses.2 Individual healthcare trusts are responsible for investigating these incidents and delivering recommendations to staff to avoid recurrence.1 These recommendations typically include education and training of staff. Immersive, in situ simulation is an effective interprofessional educational model3 that can lead to improvements in patient safety,4 and we believe it is the ideal tool to learn from SAI investigations.
The aim of this project was to develop a more robust and educationally sound system to rapidly disseminate interprofessional learning, to minimise the risk of recurring errors.
A multidisciplinary team including paediatric surgery, paediatric anaesthesia, theatre nursing, medical education and clinical governance managers was convened. Review was undertaken of SAIs reported over 5 years from the operating theatres at a tertiary referral children’s hospital. The team identified recurring themes and high-risk cases amenable to in situ simulation. Each simulation was based on an SAI …
Contributors DC, SG, SM, AT, TB developed the concept. All contributed to the delivery of the project. DC developed the first manuscript. All contributed to editing of final version of 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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