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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
CategoryNumber of LSTsExampleIntervention
Equipment292Blended 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
Medication18Teams routinely utilized naloxone for depressed babies during acute resuscitation in the delivery roomNaloxone was removed from newborn delivery room resuscitation medication carts
Personnel55A team member is not always present that is designated and able to intubate at deliveriesAdditional personnel being trained in intubation
Resource34An outdated NRP reference chart is being used for resuscitations
Medication chart included outdated dose for epinephrine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
Technical296Team 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