Brief safety incident description: a tall, overweight 55-year-old male patient collapsed in the waiting room at 4.45pm while attending the surgery with a family member. The practice team responded to the incident as per the emergency protocol. However, the CPR defibrillator battery was not usable because it was not charged and the adrenaline was out-of-date. A lack of timely checking processes was found to be a major contributory factor. The patient survived but a formal complaint was received by the practice
People (Patient, clinician, manager, administrator; team; physical, cognitive, and psychosocial characteristics)	Task(s) (Variety, content, complexity, physical and psychological demands)	Tools and Technology (Medical devices, drugs, information technology, other tools and technologies)	Physical environment (Physical layout; workstation design; noise, lighting, temperature)	Organisation (Formal and informal organisation; safety climate; policies, protocols, and procedures; organisation structure and management)	External environment (Contractual, accreditation and regulatory demands; political and health authority decision making)	OUTCOMES
						People (Safety, performance, health and wellbeing, care, and job satisfaction	Organisation (Performance, productivity, and business reputation
Physically large adult male patient collapsed in surgery waiting room area Very emotional and anxious family member in attendance Clinicians with relevant experience, training, and knowledge Administrators trained in emergency response Clinicians fatigued after long day and without a break or lunch Waiting room full of attending patients	Emergency alarm activated by receptionist Relevant team members responded rapidly Administrator phoned emergency ambulance GP retrieved emergency equipment Infrequent, complicated, stressful, and physically demanding task Practice nurse cared for family member Administrators moved older, sick patients to linked corridor	Functioning emergency alarm system and speed dial to ambulance service Defibrillator unusable because ageing battery did not charge Usability issues with defibrillator caused minor confusion Design of blood pressure monitor is limited for emergencies Stock of adrenaline available but out-of-date	Small waiting room area made it difficult for team to interact effectively with patient and equipment Layout/design contributed to a lack of privacy and dignity Noise from other waiting patients are a distraction	Good levels of team working and communication demonstrated CPR retraining for two attending team members was overdue Ad hoc and informal checking process for emergency equipment maintenance and relevant drugs, and CPR training Prevailing safety climate did not prioritise related checking processes Previous checking process significant events, but limited collective learning by practice team Organisational clarity required regarding checking of safety-related processes and issues	Main practice quality and safety focus was on meeting contractual demands and maximising access to meet increasing patient demand Real-term decreases in practice income led to delayed decision on replacement defibrillator equipment Heavy workload demands impacted on delayed CPR training attendance and available time for routine emergency equipment and/or drugs checking processes	Patient Received manual CPR and adrenaline until ambulance paramedics arrived to stabilise and transfer to hospital care; recovered and discharged Team members Feelings of guilt and embarrassment; apportioning individual blame; worsening interpersonal relationships; added work stress and anxiety; individual on related sick leave	Practice Formal complaint received from patient’s family; adverse media publicity and in local community; deterioration in practice family relations