From: Community-based in situ simulation: bringing simulation to the masses
Community Outreach Latent Safety Threats 2015-2016 | |||
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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Resource | 34 | An outdated NRP reference chart is being used for resuscitations Medication chart included outdated dose for epinephrine | New, current NRP algorithms were posted in LDR and nursery Mediation chart revised to include correct dosing of epinephrine |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 |