Table 3 Examples of mitigation steps for latent safety threats
From: Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats
Examples of themes/areas for improvement identified | Underlying cause(s) identified | Mitigating action(s) taken | Type of required intervention(s) |
|---|---|---|---|
Lack of leadership and clear team role delineation | • Inherent variability in team composition by location • Lack of education, training, and practice opportunities • Lack of explicitly clear team composition and expected roles | • Explicit role review at every debriefing and schematic handout creation for ED (in development for other units) • Cardiac arrest team committee revisit of ideal composition of responding cardiac arrest team • Initiation of a cardiac arrest team leader educational curriculum | • Hospital-wide cardiac arrest team committee review • Protocol change • Staff and provider education • Drafting of team member diagram of physical locations by role around the bedside |
Chaotic, loud environment during cardiac arrest | • Crowd control not an explicit team role • Variation in cardiac arrest team response; redundancy in responders | • Debriefing with cardiac arrest team leader education and role assignment to include crowd control • Incorporation of nurse manager/supervisor role to address crowd control | • Hospital-wide cardiac arrest team committee review • Protocol change • Staff and provider education |
Lack of familiarity with use of defibrillator (including pad placement and modes) | • Lack of education, training, and practice opportunities | • Standardized debriefing teaching points added to simulations to emphasize knowledge of the unit’s defibrillator after every simulation • Simulation center sessions initiated for further defibrillator training and review | • Staff and provider education |
Medication delay due to lack of awareness of crash cart stocked medications | • Lack of education, training, and practice opportunities with crash cart | • Simulation center sessions initiated for further hands-on practice/review of crash cart contents, including medications | • Staff and provider education |
Delay to pediatric cardiac arrest medication administration | • Low frequency of pediatric cardiac arrests • Lack of education, training, and practice opportunities for application of PALS | • Standardized debriefing teaching points added to pediatric simulations to review PALS rhythms and algorithms regardless of specific simulation case rhythm • Cognitive aid of PALS algorithms to be made available on crash carts | • Hospital-wide cardiac arrest team committee review • Crash carts to be modified to include cognitive aid of PALS algorithms |
Insufficient and/or incorrect supply of IO needles stocked in kita | • Stocking error • Lack of “double check”/audit process | • Stocking process reviewed and new audit process added | • -Immediate escalation to leadership • -Protocol change |
Delay to cardiac arrest team activation or incorrect activationa | • -Lack of education, training, and practice opportunities • “Code blue” labelled button misleading (calls nursing station not cardiac arrest team) | • Standardized debriefing teaching points added to simulations to emphasize knowledge of the unit’s protocol to activate cardiac arrest team • Removal of label “Code Blue” on bedside button; specific education to units with these buttons on how to activate the cardiac arrest team | • Immediate escalation to leadership • Hospital-wide cardiac arrest team committee review • Equipment modification |