Qualitative analysis of latent safety threats uncovered by in situ simulation-based operations testing before moving into a single-family-room neonatal intensive care unit

J Perinatol. 2020 Sep;40(Suppl 1):29-35. doi: 10.1038/s41372-020-0749-3.


Objectives: We aimed to identify: (a) latent safety threats (LSTs) in a new neonatal intensive care unit (NICU) through simulation-based pre-occupancy operations testing, and (b) LSTs that remained unresolved 1-year post-occupancy.

Study design: In this qualitative study, 111 healthcare professionals participated in patient care simulations and debriefings in a new NICU. Debriefing transcripts were inductively analyzed to characterize LSTs. Unresolved LSTs were identified 1 year after NICU occupancy.

Results: Thematic saturation was attained after analysis of nine debriefings. Four major themes affecting staff function and patient safety emerged from 305 threats: relay of information, workplace design, patient care processes, and patient family and staff focus. One-year post occupancy, 29 (9%) LSTs remained unresolved.

Conclusion: Team debriefings of simulated patient events uncover LSTs that can largely be resolved before transitioning patient care into a new NICU. Understanding how LSTs interact provides a platform to develop viable strategies to mitigate patient safety risks.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Health Personnel
  • Humans
  • Infant, Newborn
  • Intensive Care Units, Neonatal*
  • Patient Safety*