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How Simulation Can Uncover Latent Safety Threats

Simulation can be a powerful method for amplifying your patient safety efforts in this area.

“Anyone involved in healthcare knows that no matter how good our individuals are, or even how good our teams are, we ultimately fall or rise to the level of our systems.”

Dr. Victoria Brazil, emergency physician and educator1

Are you confident in your hospital’s current approach to identifying and mitigating latent safety threats (LSTs) in your system to improve patient safety?

Latent safety threats (LSTs) are often referred to as “accidents waiting to happen.”2 LSTs are system issues that aren’t immediately apparent and can make it easier for healthcare providers to make errors.3

Research has found that approximately 44% to 66% of adverse events could be prevented by identifying and correcting LSTs.4

There is increasing recognition of the use of in situ simulation, or simulation that occurs in the real healthcare environment, as a powerful quality improvement tool for uncovering LSTs.5

Read on to explore how you can use in situ simulation to help uncover LSTs and drive quality improvement in your hospital.

Why In Situ Simulation Is the Optimal Tool for Uncovering Latent Safety Threats


Because it takes place in the actual clinical setting, in situ simulation can lend a unique opportunity to uncover LSTs involving your own equipment, space, processes, and protocols before they ever reach a patient.

Dr. Andrew Petrosoniak, MD, MSc (Med Ed), FRCPC, Emergency Physician and Trauma Team Leader at St. Michael’s Hospital in Toronto, Canada, compares in situ simulation to crash testing a car.6 "You can imagine that no car company is ever going roll out a car that hasn’t been crash tested," he points out. "It's not sufficient to just drive it around the neighborhood and say that it’s safe. It needs to be put through a collision. In simulation, it’s the exact same process. We can replicate systems, processes, [and] we can study physical spaces much better using simulation and understand exactly how things will work before a patient ever arrives."

Below, we discuss 5 types of LSTs that simulation has helped uncover along with some tangible examples of how hospitals have leveraged this powerful tool to elevate their patient safety efforts.  

1. Teamwork and Communication


Patient safety experts agree that communication and teamwork are a crucial component of safe, effective patient care.7 But communication breakdowns are the leading factor contributing to sentinel events.8

In situ simulation provides a risk-free environment for assessing and improving team dynamics and communication. Simulations can replicate multi-disciplinary scenarios that involve interactions among various healthcare professionals, including physicians, nurses, pharmacists, and other team members. A well-designed simulation scenario followed by a careful debriefing can identify LSTs related to miscommunication, misunderstandings, or breakdowns in communication among different members of the healthcare team.

When you think about the types of scenarios in which solid teamwork is of the utmost importance, codes may come to mind. A study of trauma resuscitation using in situ simulation team training found 843 LSTs during 12 simulations.9 Fifty percent of them involved teamwork and communication, and many of the LSTs were categorized as critical threats.

LSTs included:

  • Lack of closed-loop communication
  • Uncertainty about status of outstanding orders or actions
  • Lack of role clarity among team members
  • Patient care activities delayed or not completed due to task overload
  • Shared mental models not established

The shared mental model, or "getting everyone on the same page," is well-known as an important element of successful teamwork and collaboration in healthcare.10

Simulation has been found to help develop shared mental models in interprofessional healthcare teams.11 After participating in simulations at Cincinnati Children's Hospital Medical Center, the team found that developing a shared mental model was so crucial that the frontline nurses insisted it be added to their resuscitation flow sheet as a component that must be communicated with the team within the first 3-5 minutes of caring for a critically ill patient.12

Is Your Hospital Hiding These Common Latent Safety Threats?

Download this checklist of common LSTs and how organizations have solved them, so that you can explore these areas in your own organization.

Download Checklist


2. Knowledge Gaps


In situ simulation can successfully identify common staff knowledge gaps throughout every step of a scenario. For example, by running a single code scenario, you can identify knowledge gaps from appropriate dosing of epinephrine, to performing high-quality CPR, to operating equipment like the defibrillator correctly.

Because codes are low-frequency emergencies, maintaining currency of skills can be a challenge – but it can have major implications in the face of a cardiac arrest. At Boys Town National Research Hospital in Boys Town, NE, simulation helped them uncover a knowledge gap with their defibrillators. They had purchased new defibrillators in 2021 – but because the new defibrillators had never been used, the staff’s competency was no longer up to date. Uncovering the knowledge gap allowed them to take corrective action and ensure staff were proficient before a real cardiac emergency. This was just one of countless LSTs they uncovered through simulations.

A New York City hospital conducted 74 code simulations.13 They noted 29 instances of knowledge gaps in how to operate the defibrillator – including how to turn it on, utilizing AED mode vs. manual mode, use of CPR feedback mechanism, and pad placement. Since this discovery, they’ve added debriefing teaching points to simulations to reinforce knowledge of the defibrillator after every simulation and are also conducting more defibrillator training and review in their simulation center.

3. Medication Safety


Simulation scenarios allow healthcare professionals to practice the entire process of medication administration, from prescription to dispensing and administration to the patient.

Common medication LSTs that simulation has identified include:

Lack of fast/easy access to medications
Missing medications or concentrations
Difficulty with medication dose calculation


The Pediatric ED at the Cincinnati Children’s Hospital Medical Center conducted 90 in situ simulations.14 They discovered 73 LSTs – and 30% of them were related to medication safety, including:


Critical medication was missing from their Pyxis MedStation system
There was a knowledge gap about available drips and how to obtain them
Similar-looking medications were being kept in the same drawer of their Pyxis Medstation system


Another multi-center study consisting of simulations of obstetric emergencies found issues with:15


Difficulties with quickly locating medications needed for emergencies, including postpartum hemorrhage
Uncertainty about medication dosing, route of administration, and contraindications to medications that were used infrequently, such as using methergine in the presence of hypertension
Confusion when there were multiple lines


In all of these examples, simulation allowed these hospitals to put corrective measures in place before they ever reached a real patient.

4. Protocol Inefficiencies

Dr. Andrew Petrosoniak shared how his hospital used simulation to drastically improve their massive transfusion protocol.16

They uncovered issues including:

Nurses had to make two separate phone calls to order blood
Porters were waiting for crowded elevators vs. one flight of stairs because they had not been trained to understand the urgency


They streamlined their process to order blood and educated the porters on the crucial nature of receiving blood rapidly for a trauma patient. When they later measured how their protocol adjustments were translating to actual patient care, they found some amazing results:


This example illustrates that utilizing simulation to expose and improve protocol issues can make a substantial impact on patient care.

5. Equipment Issues


One of the greatest benefits of in situ simulation is that it allows you to use your own equipment. In doing this, many hospitals have found issues with:



Not knowing the location of equipment, resulting in delays to care


Not having equipment organized in a specific area


Equipment not working


Equipment missing


In one study consisting of 18 in situ simulations performed across 11 EDs, they uncovered a total of 158 LSTs - 25% of which were related to equipment,18 including:



Equipment not easily accessible, including central line and chest tube


Equipment failure, including a failing laryngoscopy light and transvenous pacer balloon


Non-appropriate equipment identified, including equipment that was out-of-date


Simulations can also be tailored to include medical equipment malfunctions. This allows healthcare professionals to practice their response to such situations, identifying LSTs related to equipment reliability, maintenance issues, and potential consequences for patient care.

Fostering a Culture of Safety


A number of studies show a connection between a positive safety culture (one in which safety is a shared priority) and improved patient safety.19

In situ simulation can help you promote a culture of safety by showing your teams that they can play a critical part in improving the system – and empowering them with the knowledge that they can make a real impact on patient outcomes in your hospital.

Is Your Hospital Hiding These Common Latent Safety Threats?

Download this checklist of common LSTs and how organizations have solved them, so that you can explore these areas in your own organization.

Download Checklist



  1. Sautter, M. & Egeland, B. (Hosts) (2023, January 20). Can Patient Simulation be Used for Continuous Improvement? (No. 2) [Audio podcast episode]. In One Million Lives Podcast. Laerdal Medical.
  2. Latent and active failures perfectly align to allow a preventable adverse event to reach a patient. (2023, January 12). Institute for Safe Medication Practices. Retrieved from
  3. Ibid.
  4. Long, J. A., Webster, C., Holliday, T., Torrie, J., & Weller, J. (2022). Latent safety threats and countermeasures in the operating theater. Simulation in Healthcare : Journal of the Society for Simulation in Healthcare, 17(1), e38–e44.
  5. Yang, C. J., Saggar, V., Seneviratne, N., Janzen, A., Ahmed, O., Singh, M., Restivo, A., Yoon, A., Bajaj, K., Ahmed, S., Moseley, M., Moss, H., & Jafri, F. N. (2023). In situ Simulation as a quality improvement tool to identify and mitigate latent safety threats for Emergency Department SARS-COV-2 Airway Management: a Multi-Institutional Initiative. The Joint Commission Journal on Quality and Patient Safety, 49(6–7), 297–305.
  6. Gardner, E. & De Souza, P. (Hosts) (n.d.). In Conversation with Dr. Andrew Petrosoniak. (No. 5) [Audio podcast episode]. In Healthcare Change Makers Podcast. HIROC.
  7. Focusing on teamwork and communication to improve patient safety | AHA News. (2017, March 15). American Hospital Association | AHA News.
  8. Sentinel Event Data – 2022 Annual Review. (2023). The Joint Commission. Retrieved from
  9. Dochartaigh, D. O., Ying, L., Simard, K., Eichorst, C., Kaba, A., Mews, L., Chan, M., Brown, T., Kirkham, A., & Warren, M. T. (2022). Identifying and managing latent safety threats though a zone-wide emergency department in-situ multidiscipline simulation program: A quality improvement project. Canadian Journal of Emergency Nursing, 45(2). 
  10. Liaw, S. Y., Wu, L. T., Wong, L. F., Soh, S. L. H., Chow, Y. L., Ringsted, C., Lau, T. C., & Lim, W. S. (2019). “Getting everyone on the same page”: Interprofessional team training to develop shared mental models on interprofessional rounds. Journal of General Internal Medicine, 34(12), 2912–2917.
  11. Ibid.
  12. Patterson, M., Geis, G. L., Falcone, R. A., LeMaster, T., & Wears, R. L. (2012). In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. BMJ Quality & Safety, 22(6), 468–477. 
  13. Bentley, S., Meshel, A., Boehm, L., Dilos, B., McIndoe, M., Carroll-Bennett, R., Astua, A., Wong, L. T. K., Smith, C., Iavicoli, L., LaMonica, J., López, T., Quitain, J., Dube, G., Manini, A. F., Halbach, J. L., Meguerdichian, M., & Bajaj, K. (2022). Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats. Advances in Simulation, 7(1).
  14. Patterson, M., Geis, G. L., Falcone, R. A., LeMaster, T., & Wears, R. L. (2012). See reference #12.
  15. Guise, J. M., & Mladenovic, J. (2013). In situ simulation: Identification of systems issues. Seminars in Perinatology, 37(3), 161–165.
  16. Gardner, E. & De Souza, P. (Hosts) (n.d.). See reference #6.
  17. Ibid.
  18. Dochartaigh, D. O., Ying, L., Simard, K., Eichorst, C., Kaba, A., Mews, L., Chan, M., Brown, T., Kirkham, A., & Warren, M. T. (2022). See reference #9.
  19. Culture of Safety: An Overview. (2019). ECRI. Retrieved from