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Table 2 Riley Children’s Latent Safety Threats—chart of the LSTs in 5 domains at the Riley Children’s NICU outreach program

From: Community-based in situ simulation: bringing simulation to the masses

Community Outreach Latent Safety Threats 2015-2016

Category

Number of LSTs

Example

Intervention

Equipment

292

Blended oxygen not available in the delivery room.

Umbilical catheter kit did not contain catheter, flush or scalpel

Unit created portable blended oxygen set up that is now wheeled to all deliveries.

Emergency umbilical catheter kit revised to include necessary items

Medication

18

Teams routinely utilized naloxone for depressed babies during acute resuscitation in the delivery room

Naloxone was removed from newborn delivery room resuscitation medication carts

Personnel

55

A team member is not always present that is designated and able to intubate at deliveries

Additional personnel being trained in intubation

Resource

34

An outdated NRP reference chart is being used for resuscitations

Medication chart included outdated dose for epinephrine

New, current NRP algorithms were posted in LDR and nursery

Mediation chart revised to include correct dosing of epinephrine

Technical

296

Team members did not trouble shoot ventilation difficulties using MR SOPA prior to initiating chest compressions

Teams were unaware of the recommendations to use plastic warp/bag to aid thermoregulation of the extremely premature infant

MR SOPA cognitive tool posted on each warmer to remind staff during newborn resuscitations

Premature infant delivery kits were assembled containing plastic bags

  1. The vast majority of issues are technical or equipment related. Examples and interventions implemented by the community site in each LST category are noted in the table