Objective Implement and demonstrate feasibility of in situ simulations to identify latent safety threats (LSTs) at a higher rate than labbased training, and reinforce teamwork training in a paediatric emergency department (ED). Methods Multidisciplinary healthcare providers responded to critical simulated patients in an urban ED during all shifts. Unannounced in situ simulations were limited to 10 min of simulation and 10 min of debriefing, and were video recorded. A standardised debriefing template was used to assess LSTs. The primary outcome measure was the number and type of LSTs identified during the simulations. Secondary measures included: participants' assessment of impact on patient care and value to participants. Blinded video review using a modified Anaesthetists Non-Technical Skills scale was used to assess team behaviours. Results 218 healthcare providers responded to 90 in situ simulations conducted over 1 year. A total of 73 LSTs were identified; a rate of one every 1.2 simulations performed. In situ simulations were cancelled at a rate of 28% initially, but the cancellation rate decreased as training matured. Examples of threats identified include malfunctioning equipment and knowledge gaps concerning role responsibilities. 78% of participants rated the simulations as extremely valuable or valuable, while only 5% rated the simulation as having little or no value. Of those responding to a postsimulation survey, 77% reported little or no clinical impact. Video recordings did not indicate changes in nontechnical skills during this time.Conclusions In situ simulation is a practical method for the detection of LSTs and to reinforce team training behaviours. Embedding in situ simulation as a routine expectation positively affected operations and the safety climate in a high risk clinical setting.

Study objective We sought to determine, using video review, the frequencies of first attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care pediatric emergency department (ED). Methods We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from pre-existing video and written records of care provided. The primary outcome was successful intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process using video review. We explored the association between physician type and first attempt success. Results We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED over 12 months. Median age was 2.4 years and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were successfully intubated on the first attempt. Seventy subjects (61%) had one or more adverse effects during RSI; 38 (33%) suffered oxyhemoglobin desaturation and two required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were noted on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending level providers were 10 times more likely to be successful on the first attempt than all trainees combined. Conclusions Video review of RSI revealed that first attempt failure and adverse effects were much more common than previously reported for children in an ED.

In situ simulations can identify latent safety threats, identify knowledge gaps, and reinforce teamwork behaviours when used as part of an organisation-wide safety programme.