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Table 1 Narrative of serious safety event that inspired need for in situ simulation training

From: Detecting latent safety threats in an interprofessional training that combines in situ simulation with task training in an emergency department

“A 28 year old previously healthy male patient was found unconscious in his bedroom by his parents and brought to the emergency department. He was immediately put in the emergency room and interprofessional care team was activated. Two nurses, three nurse technicians, a pediatric emergency physician, a surgeon and an emergency physician arrived within minutes. Nurses attempted first an IV access. Physicians noticed patient was not breathing, so they directed efforts to try to ventilate patient. There were lots of fluids in the airway, so aspiration was attempted, but the aspiration machine did not work properly. The Emergency physician decided to intubate the patient and ordered neuromuscular blocking medication. Attempts to intubate by both the Emergency Physician and Surgeon were not successful, and there was difficulty ventilating the patient with bag and mask. A laryngeal tube was placed, which achieved ventilation. While the care team attempted to adjust transport ventilator parameters, the laryngeal tube cuff ruptured, and there was not another tube available. Since bag-mask ventilation was not effective the Surgeon prepared for a surgical airway. While equipment was being set up the Pediatric Emergency Physician successfully intubated the patient using Glidescope, although the guide wire was also not found. During the acute care for this patient, no leader was identified and many breaks in communication occurred. The patient was transferred to ICU and eventually recovered, but had massive aspiration pneumonia.”