Table 2.

LTs that would cause minimal harm and significant temporary harm.

LT that would cause minimal harm (n = 20)	LT category	System improvement	System improvement category
Difficulty contacting PICU consultants via switchboard	Resources	Nurse in charge given PICU mobile with phone numbers	Resources/equipment
Intubation drugs in multiple areas—delaying intubation	Resources	Emergency intubation boxes introduced and stored in fridge	Resources/equipment
Intubation drugs in locked cupboard—delay in finding keys	Resources
Doses for emergency intubation drugs not known	Resources	Dosage card developed for intubation box	Resources/equipment
Arrest algorithms not readily available during cardiac arrest	Resources	Arrest algorithms laminated and attached to arrest trolleys	Resources/equipment
Team unable to contact consultant cardiothoracic surgeon	Resources	Cardiothoracic phone numbers added to PICU phone	Resources/equipment
Lack of time awareness—delay in administering adenosine	Resources	Digital timers obtained for each arrest trolley	Resources/equipment
Naloxone dose and administration not known	Education and training	Naloxone added to patient-specific emergency drug chart	Resources/equipment
Staffa unaware of CBL protocol	Education and training	CBL protocol workshops and emphasized at induction	Education
Staff unsure how to get additional help for deteriorating patient	Education and training	Email sent to all staff and reinforced at induction	Education
Staff reluctant to use pre-drawn up adrenaline	Education and training	Simulation nurse led educational drive on benefits/use	Education
Staff unfamiliar with item location in chest re-opening trolley	Education and training	Labels added to chest re-opening drawers	Resources/equipment
Wrong chest opening set on chest opening trolley	Equipment	Stocking of chest opening trolley reviewed	Organizational
Delay finding correct sized FM and T-piece post operatively	Equipment	All patients transferred with mask and T-piece from theater	Organizational
Suction unit for emergency chest re-opening trolley not working	Equipment	BME rectified defect with unit	Equipment
Adenosine not part of standard resuscitation drug tray	Medication	Adenosine added to resuscitation drug tray	Resources
Metaraminol unavailable during hypercyanotic scenario	Medication	Metaraminol added to resuscitation emergency drug tray	Resources
Difficultya contacting transfusion during a CBL scenario	Organizational	Emergency bleep for blood transfusion technician	Organizational
Cardiologist did not arrive with arrest team	Organizational	Pediatric cardiology registrar added to arrest team	Organizational
Over 3 min to find drug cupboard keys	Resources	Funding initiated for keyless drug cupboards	Resources/Equipment
LT that would cause significant temporary harm (n = 6)
No insulin available for hyperkalemia leading to VF arrest	Medication	Ensured that insulin pharmacy requests in place	Resources/equipment
Echo unavailable when required urgently to confirm cardiac tamponade. Chest re-opened without echo confirmation due decompensating condition and subsequent cardiac arrest	Resources	Capital bid for new echo	Resources/equipment
Staff members did not know how to use defibrillator	Education and training	Defibrillator workshops introduced	Education
Emergencya drug chart used to verify patient during CBL	Education and training	CBL protocol reinforced and increased emphasis at induction	Education
Staffa unable to reach patient whilst phoning transfusion	Work and environment	Cordless phones obtained for emergency use	Resources/equipment
Wronga blood collected during CBL scenario	Organizational	Blood collection policy change—handed over person to person	Organizational

LT, latent threat; PICU, Paediatric Intensive Care Unit; 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 .