Harnessing in situ simulation to identify human errors and latent safety threats in adult tracheostomy care.
In situ simulation can identify latent safety threats before they reach a patient. In this study, 20 multidisciplinary teams participated in in situ simulations of a tracheostomy emergency in an adult patient. Only ten of the teams were able to reestablish the airway within the allotted five minutes, and 12 types of human errors and 15 types of latent safety threats were identified.