Objectives Our objectives were (1) to use in situ simulation to assess the clinical environment and identify latent safety threats (LSTs) related to the management of pediatric tracheostomy patients and (2) to analyze the effects of systems interventions and team factors on LSTs and simulation performance. Methods A multicenter, prospective study to assess LSTs related to pediatric tracheostomy care management was conducted in emergency departments (EDs) and intensive care units (ICUs). LSTs were identified through equipment checklists and in situ simulations via structured debriefs and blinded ratings of team performance. The research team and unit champions developed action plans with interventions to address each LST. Reassessment by equipment checklists and in situ simulations was repeated after 6 to 9 months. Results Forty-one LSTs were identified over 21 simulations, 24 in the preintervention group and 17 in the postintervention group. These included LSTs in access to equipment (ie, availability of suction catheters, lack of awareness of the location of tracheostomy tubes) and clinical knowledge gaps. Mean equipment checklist scores improved from 76% to 87%. Twenty-one unique teams (65 participants) participated in the simulations. The average simulation score was 6.19 out of 16 points. Discussion In situ simulation is feasible and effective as an assessment tool to identify latent safety threats and thus measure the system-level performance of a clinical care environment. Implications for Practice In situ simulation can be used to identify and reassess latent safety threats related to pediatric tracheostomy management and thereby support quality improvement and educational initiatives.
wo percent of emergency department visits can be attributed to ocular conditions, ranging from primary ophthalmologic concerns to infectious or traumatic causes. 1 Although many of these conditions do not require emergent ophthalmologic consultation or intervention in the emergency department, certain conditions must be diagnosed promptly. Because of a combination of environmental limitations, difficulty accessing the necessary equipment, and lack of physician comfort, a comprehensive ophthalmologic examination can be difficult to perform. Ultrasound has become a tool used by both emergency physicians and ophthalmologists in diagnosing ocular emergencies. A recent study of board-certified residents and attending physicians in an emergency department showed that ultrasound examinations had 100% sensitivity and 97.2% specificity for detecting globe rupture, retinal detachment, and vitreous hemorrhage. 2 Simulation training in ultrasound has been shown to improve patient safety in procedures. 3,4 and early diagnosis in a variety of areas.There are currently a few ocular simulation models commercially available, eg, harvested rabbit or porcine eyes and or glass models layered with bovine tissue. 5,6 Given the importance of simulation training and the relative paucity of easily obtainable and financially feasible ocular models, we developed an ocular ultrasound phantom using readily available materials. We were able to, easily and with little expense, create reasonable models of the normal eye as well as the eye with retinal detachment, a foreign body, an increased optic nerve sheath diameter, vitreous hemorrhage, and retrobulbar hematoma. The procedures for creating the phantom are listed in the "Appendix."
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