Utilizing Simulation to Identify Latent Safety Threats During Neonatal Magnetic Resonance Imaging Procedure.

Introduction: Transfer of infants for magnetic resonance imaging (MRI) from the neonatal intensive care unit (NICU) requires exposure to unfamiliar environments and involve multiple complex human and system interactions, which can compromise patient safety. In situ simulation (ISS) offers an opportunity to identify latent safety threats (LSTs) that may occur during this high-risk procedure. Our primary aim was to use ISS to identify modifiable LSTs during the MRI procedure: involving neonatal transport to/from NICU to the MRI and the MRI scan. Secondarily, we compared the overall performance and needs of specialized versus nonspecialized transport personnel.

Methods: In situ simulations of the MRI procedure (transport and scan) were performed for 9 months involving specialized and nonspecialized transport personnel. Two simulation scenarios were used, one involving an intubated infant and one nonintubated infant. After each simulation, participants underwent a standardized debriefing and answered questionnaires on safety threats and team function. The results were then used to identify and implement mitigation strategies.

Results: Among 10 simulations completed, 7 were by specialized and 3 by nonspecialized teams. In total, 116 LSTs were identified (22 involving medication, 12 equipment, and 82 resources/system issues). Preprocedure deliberation with anticipation/preparedness for patient deterioration, and the need for clinical checklists and protocols were identified as important requirements. After completion of the project, protocols (ie, sedation), checklists (ie, pretransport), and policies (ie, environmental orientation) were adapted to address the gaps.

Conclusions: In situ simulations were able to identify important safety risks during transport of neonatal patients from the NICU to the MRI suite, informing changes in MRI transport policy.