Table 1.
LTs with the potential to cause harm.
| LT with the potential to cause harm (n = 18) | LT category | System improvement | System improvement category |
|---|---|---|---|
| Emergency drug doses unknown without emergency drug chart | Resources | Patient-specific emergency drug chart printed before admission | Resources/equipment |
| No patient specific emergency drug chart available | Resources | Basic emergency drug doses chart added to arrest trolleys | Resources/equipment |
| Bleep numbers for on-call staff not known/easily accessible | Resources | Numbers for on-call teams displayed in all bays and PICU board | Resources/equipment |
| No lightweight in-line ETCO2 lines available—out of stock | Resources | Stock ordering change ensuring in-line CO2 lines available | Resources/equipment |
| Formula for sizing of ETT not known | Resources | ETT formula added to emergency drug chart for pre-calculation | Resources/equipment |
| Inability to identify pediatric from adult chest opening trolley | Equipment | Trolleys clearly labeled (trust wide) | Resources/equipment |
| ECG machine not available | Equipment | Bid for new ECG machine | Resources/equipment |
| ECG paper ran out during SVT scenario | Resources | Replenished and staff made aware of importance | Resources/equipment |
| Delay in finding magnets on arrest trolleys to reset ICD | Resources | Magnets added to arrest trolley contents | Resources/equipment |
| Staff unsure how to use magnets for resetting ICDs | Education and training | Workshops introduced | Education |
| New nursing staff did not know how to use emergency buzzers | Education and training | Wall buzzers labeled, nurse induction updated | Education |
| Radiographers not pediatric BLS trained | Education and training | BLS training for radiographers mandatory | Education |
| Nursing staff not EPLS/PILS trained | Education and training | Funding for additional places for EPLS and PILS training secured | Education |
| Nurse bleeped rather than dialing 2222 for crash call | Education and training | Email sent to all staff; 2222 instruction stickers on ward phones | Staff communication |
| Clock for timings during CPR difficult to see | Work and environment | Clocks moved to be more visible and provided in each side room | Resources/equipment |
| Buzzer did not sound when used in simulation | Work and environment | Buzzer system testing regularly | Organizational |
| CBLa protocol difficult to follow | Systems and protocols | New CBL protocol and attached to arrest trolley (trust wide) | Guideline |
| Hyperkalemia guideline difficult to follow during emergency | Systems and protocols | Guideline adapted into easy to follow algorithm | Guideline |
LT, latent threat; PICU, Paediatric Intensive Care Unit; BLS, basic life support; EPLS, European Pediatric Life Support; ICDs, implantable cardioverter defibrillators; CPR, cardiopulmonary resuscitation; PSI, patient safety incident; CBL, catastrophic blood loss.
aLTs related to 2 CBL simulations annotated (n = 5).
LTs never detected as PSI 
.
LTs reported as PSI 
.