PB.11 Cascading Risk Through Multiprofessional Neonatal Simulation

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IntroductionRisk management is about having systems to understand, monitor and reduce the risks to patients, including learning the lessons from mistakes. In the neonatal unit at Princess Anne Hospital Southampton this is cascaded through serious incident reports, guideline review, risk newsletters, and education. Since April 2012 critical events amenable to simulation have been cascaded through multidisciplinary simulation.MethodsIn April 2012 endotracheal tube slippage and umbilical vein extravasation were recognised as a major cause of morbidity locally. Simulated scenarios covering accidental extubation and complications of umbilical lines have been run frequently for the past 2 years. The scenarios involve nurses, nurse practitioners and doctors in their respective roles followed by a targeted debrief addressing team training involved in recognition and management of such critical incidents.ResultsRegular multiprofessional simulation has helped address issues of risk identified locally. In 2012 there were 7 episodes of UVC extravasation. 2 were near fatal. In 2013 there have been only 3 episodes of minor extravasation. Incidents of endotracheal tube slippage have been eradicated. accidental extubation remains an issue.ConclusionThe National Patient Safety Agency (NPSA) has identified avoidable factors in around 20% of neonatal deaths.1 Neonatal simulation allows issues of risk to be cascaded in real time reinforcing themes which cannot be addressed by other educational methods. These include deliberate practice, critical thinking, fixation, voicing concerns, and behaviour. While we cannot prove that risk reduction is directly related to our intervention, the processes involved are simple and complement existing strategies of risk reduction.ReferenceNational Patient Safety Agency. Review of Patient Safety for Children and Young People. June 2009

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