Table 4 Latent safety threats by category
Category (n = 56) | Theme | Specific threat identified |
|---|---|---|
Medication (n = 11) | Arrhythmia (n = 4) | No crosschecking of sedative dose |
No check back of verbal order of medication | ||
No sedation given with transcutaneous pacemaker | ||
Atropine not given for bradycardia | ||
Respiratory (n = 2) | Information on drug doses not immediately available | |
Incompatible drugs in same IV access | ||
Shock (n = 3) | Dilution of antibiotic in high volume | |
Delay in preparation of vasoactive drug | ||
Wrong dose of sedative | ||
CPR (n = 2) | No flush given after epinephrine | |
Error in pediatric medication dilution | ||
Equipment (n = 23) | Arrhythmia (n = 5) | Personal protective equipment not used |
Difficulty adjusting defibrillator | ||
Lack of familiarity with emergency equipment | ||
Delay in EKG | ||
Lack of familiarity with pacemaker pads | ||
Respiratory (n = 8) | Inverted non-invasive ventilation mask | |
Wrong size of bag valve mask chosen for child | ||
Laryngoscope with weak batteries | ||
Wrong guide wire chosen | ||
Delay in locating difficult airway bag | ||
Misuse of transport ventilator | ||
Protective glasses not used for intubation | ||
Air leak with transport ventilator | ||
Shock (n = 5) | Ultrasound not available for central line | |
Need to anticipate use of emergency equipment | ||
Inadequate use of intraosseous needle | ||
Delay in locating intraosseous drill | ||
Pediatric stethoscope not available | ||
CPR (n = 5) | Capnography not available | |
Laryngoscope did not work | ||
Bag valve mask not connect to oxygen source | ||
Delay in defibrillation | ||
Defibrillation pads position inadequate | ||
Teamwork (n = 12) | Arrhythmia (n = 5) | Clear roles and responsibilities not assigned |
Lack of closed looped communication | ||
Leader not assigned | ||
High workload for nurse technician | ||
Nurse did not call out medication given | ||
Respiratory (n = 2) | Excess number of members of resuscitation team | |
Poor workload distribution | ||
Shock (n = 2) | Lack of members in resuscitation team | |
Delay of arrival of physician | ||
CPR (n = 3) | No change in compressor | |
No person assigned for time keeping | ||
Incorrect position of resuscitation team | ||
Other (n = 10) | Arrhythmia (n = 2) | No blood pressure measurement |
Need to standardize oxygen device in pediatric emergencies (catheter vs. non-rebreathing mask) | ||
Respiratory (n = 4) | Delay in requesting lab results | |
Delay in monitoring patient | ||
Allergies not checked | ||
Delay in intubation | ||
Shock (n = 1) | Poor communication with patient | |
CPR (n = 3) | Frequent compression interruptions | |
Poor compression quality | ||
Pulse not checked after change in rhythm |