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Table 2 Latent safety threat numbers and examples by category

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