From: Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats
LST type (N = 106) | Examples of specific threats |
---|---|
Equipment (21) | Unable to find EZ-IO kit Incorrect needle size in EZ-IO kit Unaware of defibrillator location, delay getting machine Lack of knowledge of how to activate code team within room on L&D Unable to locate laryngeal mask airway and large syringe for its inflation Unable to rapidly obtain scalpel for perimortem C-section Unable to locate step stool |
Medication (8) | Team unsure where to locate magnesium Team uncertain on epinephrine dosing in infant Albuterol given via non-rebreather mask while mannequin intubated, so mask left hanging at bedside and albuterol failed to be delivered |
Resource/system (41) | Inconsistent response of cardiac arrest team Lack of clear team leader Lack of role designation by leader General role confusion Unclear ideal positioning of rescuers for compressions and airway management Lack of backup system for reaching attending when overhead paging system not heard by attending Overcrowding in clinical space due to redundancy in code team providers responding |
Technical skill (36) | Lack of knowledge on how to verify effective ventilations Lack of knowledge on shockable rhythm identification Lack of skill in laryngeal mask airway placement Lack of awareness of need to utilize step stool for compressions Incorrect defibrillator pad placement Incorrect placement of cardiac board Lack of awareness of time to perimortem C-section goal Lack of knowledge about ZOLL defibrillator (e.g., turning it on, utilizing AED mode vs. manual mode, use of CPR feedback mechanism) Failure to provide effective CPR |