Theatre LISTS: Learning from Incidents, finding Safety Threats with Simulation

Correspondence to David Colvin, The Royal Belfast Hospital for Sick Children, Belfast BT12 6BA, UK; david.colvin@belfasttrust.hscni.net Background Serious adverse incidents (SAIs) are events in healthcare that justify a heightened level of response as their impact on patients, staff or systems is so great.1 The National Health Service has a framework for reporting of SAIs, never events and near misses.2 Individual healthcare trusts are responsible for investigating these incidents and delivering recommendations to staff to avoid recurrence.1 These recommendations typically include education and training of staff. Table 1 highlights LST of interest.Table 1 Examples of latent safety threats (LSTs) identified by theatre LISTS programme LST type LST identified Action taken Clinical Difficulties calculating emergency drugs during cardiac arrest WETFLAG calculator on display in key clinical environments Nursing staff unable to access cannulation training Departmental training arranged with nurse education team within 6 weeks Staff not aware of weight categorisation of massive blood loss packs or bank phone numbers Training delivered by Haemovigilance Team Systematic Non-standardised communication during prone-to-supine roll Staff discussion and standardised communication embedded in protocol Paediatric nursing staff unable to administer reversal agents without prescription Change to pharmacy policy Nursing staff education Dose calculation on display Require support to move equipment out of theatres during emergencies, ie, neurosurgical microscope Staff education and training including theatre technicians Environmental Emergency pull bell inaudible in key areas in operating theatres Escalated to service managers Non-functioning wall suction port Estates notified and repaired within 48 hours Discrepancies on emergency action cards for malignant hyperthermia Standardisation of emergency action cards throughout department Non-standardised emergency trollies Standardisation of emergency trolleys throughout department Discussion Our institution has a robust system for reporting and investigating SAIs; however, our team wished to improve the educational process that followed. Immersive, in situ simulation which mimics the working environment is superior to traditional teaching for retention of critical event management skills,5 6 and we felt it was the ideal tool in this context.