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In situ simulation detects serious latent errors on the labour ward
Abstract Number: F-80
Abstract Type: Original Research
Introduction: In situ simulation improves teamwork and identifies latent errors and performance gaps in managing obstetric patients(1). We present our experience of in situ sumulation on the labour ward of a busy teaching hospital.
Methods: Unannounced simulated emergency drills involving maternal cardiac arrest using manikins were run monthly on our labour ward since August 2014. Midwives, obstetricians and anaesthetists on duty attended the drill which was videotaped and replayed during debriefing. Resuscitation skills, human factor approach and theoretical knowledge were critiqued. The session trainer completed a latent risk form following each exercise which identified the risk, categorised it and assigned a risk score using the NPSA risk analysis model(2) (low risk 1-3, moderate risk 4-6, high risk 8-12 and extreme risk 15-25) with details of the action taken.
Results: Our results are summarised in the accompanying table.
Discussion: Our in situ programme revealed persistent failure of teams to conduct a perimortem caesarean section (CS) within acceptable time frames, misplaced or unavailable vital equipment and missing drugs on our labour ward. A ready-to-use CS pack on all trolleys including in the accident and emergency department, immediate pharmacy input, urgent equipment replacement and complete overhaul of labour ward drug storage was instituted. Conventionally drills are used to refresh staff knowledge. Senior management 'buy in' and we believe our unique use of simulation as an environmental surveillance tool can reduce litigation costs and increase management support for educational activities. We recommend that in situ drills should be used by all units to identify and tackle latent risks to make the environment safer for patients.
1. Pratt SD. Focused review: simulation in obstetric anesthesia. Anesth Analg 2012;114:186-90.
2. A risk matrix for risk managers. National Patient Safety Agency. January 2008.