Simulation testing before a new emergency department opening uncovered 277 latent safety threats

A methodology paper published in Advances in Simulation on 15 September 2026 describes how a single site used simulation-based clinical systems testing (SbCST) during pre-opening operational-readiness work for a newly expanded emergency department, integrating quality improvement methods and human factors frameworks to find problems before real patients encountered them.

The paper, authored by Travis Terry, Yuhao Peng, Harsh Sanghavi, Emmanuel Tetteh, C. Adam Probst, Nate Jones and Melissa Fussell, addresses a recognized gap in the field. According to the authors, healthcare simulation is increasingly used to identify latent safety threats (LSTs), yet standardized approaches for designing system-focused simulation projects, prioritizing findings, and translating results into healthcare quality and safety work remain unclear. Their response was to describe, in detail, the process they applied rather than to test a specific intervention’s effectiveness.

Seventeen in situ simulations were conducted across four high-acuity emergency care pathways: trauma, stroke, ST-elevation myocardial infarction, and pediatric emergencies. Because the simulations were run in the actual clinical environment ahead of the transition, they were positioned to expose how the new space, equipment, and processes would interact with real clinical workflows under realistic conditions.

The process combined four methods in sequence. Modified Promoting Excellence and Reflective Learning in Simulation (PEARLS) debriefing was used to elicit and clarify latent safety threats from participants. The Systems Engineering Initiative for Patient Safety (SEIPS) framework was then applied to organize findings across work-system domains.

Prioritization followed through Healthcare Failure Mode and Effect Analysis (HFMEA) consensus scoring, which ranked each identified threat by risk. Finally, Plan-Do-Study-Act (PDSA)-informed iteration allowed the team to refine scenarios over successive simulations, clarify processes, address low-complexity threats when feasible, and escalate unresolved or higher-risk threats for leadership review. This closed-loop structure meant the simulations were not a one-off exercise but part of an iterative readiness program.

The results quantify the scale of what the process surfaced. Across all scenarios, 277 latent safety threats were identified. Fifty-three were classified as high risk, 57 as moderate risk, and 167 as low risk.

Beyond the raw counts, the analysis revealed generalized work-system patterns that cut across individual scenarios. These included travel distance, wayfinding, and resource access; segmentation, visibility, and shared situational awareness; communication infrastructure and cross-service coordination; doors, access points, and transport friction; and safety and security conflicts during urgent care.

The authors emphasize that the value of the approach extended past threat identification. The integrated process translated scenario-specific observations into structured, risk-informed recommendations for quality, safety, operational, and leadership review, providing what they describe as a structured method for generating safety intelligence to inform healthcare quality and safety decision-making.

The paper also states its own limits. As a single-site methodology paper describing pre-opening readiness work, it documents a planned and applied process rather than demonstrating efficacy in a controlled sense. The authors note that future applications should include formal mitigation tracking, accountable ownership, retesting, and documentation of residual risk, acknowledging that identifying a threat is only the first step toward resolving it.

For hospitals planning similar transitions, the report offers a template: combine debriefing methods that surface frontline observations, a human factors classification that organizes them, a risk-scoring scheme that prioritizes them, and iterative improvement cycles that act on them, all before the first patient arrives.

Subject of Research: Systems-focused healthcare simulation integrating quality improvement and human factors methods to identify latent safety threats during an emergency department transition

Article Title: Designing systems-focused simulation for healthcare quality and safety: integrating quality improvement and human factors methods during transition to a newly expanded emergency department

Article References: Terry, T., Peng, Y., Sanghavi, H., Tetteh, E., Probst, C. A., Jones, N., & Fussell, M. (2026). Designing systems-focused simulation for healthcare quality and safety: integrating quality improvement and human factors methods during transition to a newly expanded emergency department. Advances in Simulation. https://doi.org/10.1186/s41077-026-00487-y

Image Credits: AI Generated

DOI: 10.1186/s41077-026-00487-y

Keywords: healthcare simulation, latent safety threats, emergency department, human factors, patient safety, SEIPS, HFMEA, PEARLS debriefing, PDSA, quality improvement, systems testing, operational readiness