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Table 4 Latent safety threats by category

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

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