Examples of LSTs and source role for identification of threat
| Latent threat category | Examples of threat | Identifying sources |
|---|---|---|
| Medication (N=22) | ▸ Critical medication missing from Pyxis MedStation system ▸ Knowledge gap regarding available drips and methods to obtain them ▸ Epinephrine concentrations confused ▸ Similar or look-alike medications in same drawer of Pyxis MedStation system | Attending physicians Nurses Pharmacist |
| Equipment (N=26) | ▸ Magill forceps missing ▸ Unable to locate fans for patient cooling ▸ Manual defibrillator ‘synch’ button confusing, causing delay in cardioversion ▸ Correct BVM bag and mask sizes missing | Attending physicians Resident physicians Nurses Respiratory therapists Paramedics |
| Resource/system (N=25) | ▸ Inability to perform independent double check of high risk medications due to lack of staffing at medication counter ▸ Need for PALS algorithms at the bedside ▸ Need for equipment supply provider to attend resuscitations | Nurses |
BVM, bag valve mask; LST, latent safety threat; PALS, paediatric advanced life support.