Interdisciplinary in situ simulation-based medical education in the emergency department of a teaching hospital in Nepal

Table 2 List of latent safety threats

Type	Description	N
Individual	Delay in checking response	4
	Delay in assessing central pulse	6
	Incorrect carotid pulse assessment	2
	Prolonged carotid pulse assessment	1
	Delay in calling for help	2
	Delay in initiation of chest compression	10
	Poor compression quality	12
	Interruptions during CPR	27
	Inadequate ventilation	6
	Too frequent pulse checks	13
	Pulse checks while continuing compressions	11
	Delay in putting the monitor and assessing rhythm	9
	Unable to recognize rhythm	2
	Delay in defibrillation	16
	Inappropriate positioning of pads	8
	Difficulty familiarizing with defibrillator	7
	Inappropriate energy selection	6
	No change in compressor roles	9
	Unsafe delivery of shock	6
	Total	157
Medications	Delay in opening IV line	3
	Inappropriate dose of adrenaline	6
	Error in recognizing adrenaline ampoule	1
	No flush after adrenaline	10
	Too late administration of adrenaline	8
	Too frequent administration of adrenaline	6
	Too seldom administration of adrenaline	5
	Too late administration of amiodarone	17
	Wrong dosing of amiodarone	8
	Total	64
Equipment	Suction not working	2
	Delay in initiation of defibrillator	3
	Amiodarone unavailable	1
	No hard board for chest compression	2
	Lubricant not available immediately	5
	Total	13
SystemTeam	Clear roles and responsibilities not assigned	15
	Lack of closed loop communication	19
	Uneven Job allocation	11
	Team leader should hands off from any work when possible	9
	Not summarizing	22
	No orientation to new team member	12
	No transparent thinking	24
	Open indirect communication	20
	Total	132
	Grand total	366

ISSN: 1865-1380