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Table 2 List of latent safety threats

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

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