Table 2

Examples of latent safety threats and opportunities for improvement identified by in situ simulations

MedicationEquipmentResource/system
Lack of adenosine on code cartNo LMAs on code cartNeed for ACLS training
Amiodarone requires dilution prior to administrationCuffed vs uncuffed ETT's availabilityCrew resource management training needed
Bedside code cards not standardisedNo trauma shears on code cartLack of standardised roles
‘Look-alike’ medications stored adjacent to one another (sodium bicarbonate vs dextrose)Lack of portable oxygen in non-clinical areasLack of knowledge regarding roles
Vecuronium shortageLack of portable suction in non-clinical areasNo nurse leader assigned
Lack of AEDs in same day surgery waiting areaNo code cart brought to the code
Non-standard mode of storage for defibrillators (test cartridge only) This had varied from unit to unit
  • ACLS, Advanced Cardiac Life Support; AED, Automated External Defibrillator.