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G202(P) Identifying latent risks through in situ simulation training to improve patient safety
  1. A Lok,
  2. E Peirce,
  3. H Shore
  1. Yorkshire and Humber School of Paediatrics, Leeds, UK


Introduction In situ simulation training is acknowledged as a very effective way of identifying latent risks in organisations and thus improving patient safety.1,2,3 Within Yorkshire and the Humber deanery, we have set up an ongoing programme of in situ simulation training in paediatrics and neonatology which is being supported by the YHCaNs (Yorkshire and Humber Children and Neonatal simulation network).

Methods At every in situ session being delivered around the region a latent risks identified form is completed. This allows documentation of the risk identified and details of what has been done to rectify this problem. This information can then feed into local risk management processes as well as being collated at a regional level.

Results Each in situ simulation session results in the identification of a range of latent risks. Many of the risks identified would be highly unlikely to be reported through the usual risk management processes. With the data collected it is clear there are themes to these risks.

So far the recurring themes have included lack of knowledge regarding obtaining O-ve blood in emergency, lack of knowledge of the T-piece system on the resuscitaire. Both of which you would expect to form part of any hospitals basic training. This information is fedback immediately to the teams involved so they can implement change at a local level.

Within the YHCaNs we shall be disseminating this information through a 6 monthly newsletter.

Conclusion In situ simulation training is an excellent way to recognise latent risk and therefore a powerful patient safety tool. We hope by disseminating information about the risks identified through training around the region that patient safety can be improved through shared learning.


  1. Using in situ simulation to identify and resolve latent threats. W Hamman, Journal of patient safety 2009

  2. Identification of latent safety threats using high fidelity simulation, E Wetzel Journal of quality and patient safety June 2013

  3. In situ simulation: detection of safety threats, Patterson M, BMJ Qual. Saf 2013

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