Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward.

William R Hamman; Beth M Beaudin-Seiler; Jeffrey M Beaubien; Amy M Gullickson; Amy C Gross; Krystyna Orizondo-Korotko; Wayne Fuqua; Richard L Lammers

Commentary

Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward.

September 9, 2009

Hamman WR, Beaudin-Seiler BM, Beaubien JM, et al. J Patient Saf. 2009;5(3):184-7.

View more articles from the same authors.

This case analysis explains how crew resource management training provides an opportunity to identify latent failures and delineate resolution strategies.

PubMed citation

Available at

Related Resources From the Same Author(s)

Understanding interdisciplinary health care teams: using simulation design processes from the Air Carrier Advanced Qualification Program to identify and train critical teamwork skills.

December 9, 2009

Root causes of errors in a simulated prehospital pediatric emergency.

February 29, 2012

Errors and error-producing conditions during a simulated, prehospital, pediatric cardiopulmonary arrest.

June 11, 2014

The Patient Safety and Quality Improvement Act of 2005: developing an error reporting system to improve patient safety.

March 26, 2008

The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities.

January 31, 2007

Methods used to obtain pediatric patient weights, their accuracy and associated drug dosing errors in 142 simulated prehospital pediatric patient encounters.

August 25, 2021

Dosing errors made by paramedics during pediatric patient simulations after implementation of a state-wide pediatric drug dosing reference.

July 24, 2019

The complexity of team training: what we have learned from aviation and its applications to medicine.

March 6, 2005

The use of simulation in emergency medicine: a research agenda.

March 7, 2007

Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error.

March 6, 2005

Can patient safety be measured by surveys of patient experiences?

April 30, 2008

A randomized controlled trial on the effect of a double check on the detection of medication errors.

August 23, 2017

Patient-centered prescription opioid tapering in community outpatients with chronic pain.

March 7, 2018

Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients.

April 22, 2009

Impact of hospital-acquired conditions on financial liabilities for Medicare patients.

June 8, 2016

Participation in EHR based simulation improves recognition of patient safety issues.

December 10, 2014

Use of simulation-based education to reduce catheter-related bloodstream infections.

August 19, 2009

Factors influencing providers' willingness to deprescribe medications.

December 1, 2021

Use of failure mode and effects analysis in improving the safety of i.v. drug administration.

May 11, 2005

The impact of hospital-acquired conditions on Medicare program payments.

November 26, 2014

Antiretroviral medication errors among hospitalized patients with HIV infection.

September 13, 2006

Evaluation of a healthcare safety climate measurement tool.

December 17, 2008

Use of simulation to assess electronic health record safety in the intensive care unit: a pilot study.

April 24, 2013

Understanding psychological safety in health care and education organizations: a comparative perspective.

March 16, 2016

A quality improvement study: medication error leading to thyrotoxicosis and death.

March 6, 2005

Risks of complications by attending physicians after performing nighttime procedures.

October 21, 2009

Improving patient safety in radiation oncology.

March 16, 2011

Quality improvement in ambulatory surgery centers: a major national effort aimed at reducing infections and other surgical complications.

March 27, 2019

Medical professional liability insurance and its relation to medical error and healthcare risk management for the practicing physician.

January 11, 2006

A systems approach to identify factors influencing adverse drug events in nursing homes.

June 27, 2018

What I wish I’d known: how experienced physician managers diagnose, treat and prevent disruptive behaviour.

September 21, 2022

Creating a culture of safety by using checklists.

March 13, 2013

Point-of-care cognitive support technology in emergency departments: a scoping review of technology acceptance by clinicians.

July 18, 2018

Residency training at a crossroads: duty-hour standards 2010.

November 3, 2010

Emergency department visits for medical device–associated adverse events among children.

September 15, 2010

Intravenous fluid prescribing errors in children: mixed methods analysis of critical incidents.

December 13, 2017

A retrospective review of crisis events in diagnostic radiology: an analysis of frequency, demographics, etiologies, and outcomes.

June 18, 2014

Addressing patient safety in rapid response activations for nonhospitalized persons.

July 2, 2014

Severity of medication administration errors detected by a bar-code medication administration system.

October 1, 2008

Scaling safety: the South Carolina Surgical Safety Checklist experience.

January 9, 2019

Racial and ethnic bias in the diagnosis of alcohol use disorder in veterans.

July 19, 2023

Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology.

November 18, 2020

Patient safety culture transformation in a children's hospital: an interprofessional approach.

April 30, 2014

Critical events during land-based interfacility transport.

February 12, 2014

Medical errors recovered by critical care nurses.

June 2, 2010

The nurse's role in the causation of compensable injury.

October 12, 2011

Analysis of adverse events associated with adult moderate procedural sedation outside the operating room.

October 1, 2014

Development of an "infusion pump safety score".

May 20, 2015

Relationship between operating room teamwork, contextual factors, and safety checklist performance.

August 31, 2016

Computerized physician order entry in US hospitals: results of a 2002 survey.

March 6, 2005

Physicians-in-training attitudes on patient safety: 2003 to 2008.

September 7, 2011

Targeted communication intervention using nursing crew resource management principles.

March 25, 2015

Acting wisely in complex clinical situations: 'Mutual safety' for clinicians as well as patients.

October 13, 2021

Markers for enhancing team cognition in complex environments: the power of team performance diagnosis.

August 1, 2007

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

September 2, 2020

Missing the near miss: recognizing valuable learning opportunities in radiation oncology.

December 16, 2020

Medication dispensing errors and potential adverse drug events before and after implementing bar code technology in the pharmacy.

September 27, 2006

What causes prescribing errors in children? Scoping review.

August 28, 2019

Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action.

September 21, 2022

How do physicians conduct medication reviews?

December 16, 2009

What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors.

August 10, 2005

Deprescribing for community-dwelling older adults: a systematic review and meta-analysis.

September 16, 2020

Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients.

February 6, 2013

Safely practicing in a new environment: a qualitative study to inform physician onboarding practices.

May 13, 2020

Effective surgical safety checklist implementation.

January 30, 2005

Do written disclosures of serious events increase risk of malpractice claims? One health care system's experience.

May 30, 2018

How many hospital pharmacy medication dispensing errors go undetected?

January 31, 2006

An acetaminophen icon helps reduce medication decision errors in an experimental setting.

August 17, 2016

Analysis of risk factors for adverse drug events in critically ill patients.

April 11, 2012

Bridging the gap: leveraging business intelligence tools in support of patient safety and financial effectiveness.

March 17, 2010

Intravenous medication safety and smart infusion systems: lessons learned and future opportunities.

October 19, 2005

Enhancing surgical safety using digital multimedia technology.

November 25, 2015

Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future).

November 2, 2016

Secure text messaging in healthcare: latent threats and opportunities to improve patient safety.

October 30, 2019

Single-parameter early warning criteria to predict life-threatening adverse events.

June 23, 2010

Adverse drug events and medication errors in psychiatry: methodological issues regarding identification and classification.

March 26, 2008

Costs of adverse events in intensive care units.

September 26, 2007

Physician communication when prescribing new medications.

October 11, 2006

Physician EHR adoption and potentially preventable hospital admissions among Medicare beneficiaries: panel data evidence, 2010–2013.

November 23, 2016

Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients.

February 21, 2007

Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record.

April 15, 2015

Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.

July 18, 2012

Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study.

February 15, 2012

Enhancing safety reporting in adult ambulatory oncology with a clinician champion: a practice innovation.

February 11, 2009

Rates of medication errors among depressed and burnt out residents: prospective cohort study.

February 20, 2008

Mortality trends after a voluntary checklist-based surgical safety collaborative.

May 3, 2017

Effect of a 19-item surgical safety checklist during urgent operations in a global patient population.

June 2, 2010

Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations.

March 10, 2010

Optimizing situation awareness to reduce emergency transfers in hospitalized children.

October 20, 2021

Use of cascading A3s to drive systemwide improvement.

August 2, 2017

A model of recovering medical errors in the coronary care unit.

June 4, 2008

Using a bar-coded medication administration system to prevent medication errors in a community hospital network.

December 21, 2005

The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery.

March 29, 2012

How communication "failed" or "saved the day": counterfactual accounts of medical errors.

February 3, 2021

Pediatric clinician perspectives on communicating diagnostic uncertainty.

August 7, 2019

Patient perspectives on how physicians communicate diagnostic uncertainty: an experimental vignette study.

January 24, 2018

Narrative feedback from OR personnel about the safety of their surgical practice before and after a surgical safety checklist intervention.

July 12, 2017

Improving safety for hospitalized patients: much progress but many challenges remain.

August 17, 2016

Use of temporary names for newborns and associated risks.

July 29, 2015

Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.

August 13, 2008

Related Resources

The time is now: addressing implicit bias in obstetrics and gynecology education.

May 17, 2023

Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality in the United States.

May 3, 2023

Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and quality for maternal-fetal medicine fellows.

March 22, 2023

The impact of TeamSTEPPS training on obstetric team attitudes and outcomes on the labor and delivery unit of a regional perinatal center.

February 1, 2023

Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation.

October 26, 2022

WebM&M Cases

Management of Cardiac Arrest in Unconventional Locations.

May 16, 2022

Psychological intervention to improve communication and patient safety in obstetrics: examination of the health action process approach.

April 13, 2022

Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists.

October 13, 2021

Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect, violence, and abuse.

September 8, 2021

Racial/ethnic inequities in pregnancy-related morbidity and mortality.

March 10, 2021

Multi-professional simulation-based team training in obstetric emergencies for improving patient outcomes and trainees' performance

February 17, 2021

Impact of simulation-based closed-loop communication training on medical errors in a pediatric emergency department.

May 6, 2020

Interventions for improving teamwork in intrapartem care: a systematic review of randomised controlled trials.

October 30, 2019

PEARLS for systems integration: a modified PEARLS framework for debriefing systems-focused simulations.

July 31, 2019

Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience.

July 10, 2019

In-situ interprofessional perinatal drills: the impact of a structured debrief on maximizing training while sensing patient safety threats.

May 22, 2019

Recommendations from a national panel on quality improvement in obstetrics.

April 24, 2019

A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles.

April 17, 2019

Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study.

March 20, 2019

How to be a very safe maternity unit: an ethnographic study.

February 20, 2019

Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.

January 23, 2019

Simulation-based education to train learners to "speak up" in the clinical environment: results of a randomized trial.

December 12, 2018

What we can do about maternal mortality—and how to do it quickly.

November 14, 2018

Simulation-based clinical rehearsals as a method for improving patient safety.

October 31, 2018

Simulation training in obstetrics.

October 11, 2017

Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.

August 30, 2017

Developing team cognition: a role for simulation.

May 31, 2017

Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork training, and performance feedback.

February 8, 2017

How communication among members of the health care team affects maternal morbidity and mortality.

January 18, 2017

Building comprehensive strategies for obstetric safety: simulation drills and communication.

January 11, 2017

See More About The Topic

Labor and Delivery

Health Care Providers

Quality and Safety Professionals

Educators

Obstetrics

Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site