Table 2

Examples of LSTs and source role for identification of threat

Latent threat categoryExamples of threatIdentifying 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 systemAttending physicians
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 missingAttending physicians
Resident physicians
Respiratory therapists
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 resuscitationsNurses
  • BVM, bag valve mask; LST, latent safety threat; PALS, paediatric advanced life support.