Table 3.
Latent Conditions Identified during Simulation-based UCD
| Latent Condition | Severity Category | Potential Active Failure | Severity | Occurrence | Criticality Score* |
|---|---|---|---|---|---|
| Intubation box | |||||
| - Concern that because the box was only opened on one side, the RTs had to reach around the front of the box to access the patient. It was difficult for the RT to reach around the box, thus requiring the intubator to hold the ETT in position while providing bag/mask ventilation | Patient safety | Lack of accessibility to the patient may result in loss of the airway, inability to oxygen/ventilate the patient. Ineffective bagging may lead to hypoventilation or hypoxia | 5 | 3 | 15 |
| - Concern that due to lack of flexibility of the plexiglass, tubing was getting trapped around the sharp corners and was kinking - Concern that suction, oxygen, or ventilator tubing may be too short to wrap around the box especially when using small ventilator circuits for infants |
Patient safety | Kinking of tubing may cutoff suction or flow of oxygen to the bag/mask or ventilator circuit resulting in patient decompensation or even ETT dislodgement | 5 | 3 | 15 |
| - Concern that the width of the box was too wide and would be too big to fit on small cribs | Performance impact | Lack of flexibility to accommodate for varying pediatric bed sizes limits functionality of the device | 5 | 3 | 15 |
| - Concern that it was difficult for the intubator to get arms into the box in the correct position to intubate with good technique - Concern that the hand cut outs were not flexible enough to accommodate for variation in physical characteristics of the intubator |
Patient safety | Poor positioning for the intubator may result in failed intubation attempts due to immobility and poor technique | 4 | 3 | 12 |
| - Concern that height of the box was not flexible and could therefore not accommodate for variation in height of the intubator or RT | Performance impact | Poor positioning for the intubator may result in failed intubation attempts due to immobility and poor technique | 4 | 3 | 12 |
| - Concern that it was difficult to anchor the box to the bed, especially if the head of the bed was elevated 30 degrees | Performance impact | This posed a risk to staff or the patient if the box was not adequately secured to the bed | 4 | 3 | 12 |
| - Due to the fixed height of the box, it was difficult to pull the stylet from the ETT tube because the provider’s hand hit the top of the box | Patient safety | Limited mobility inside the box may lead to accidental extubation or kinking of tubing | 4 | 3 | 12 |
| - Concern that because one side of the box was opened it was not possible to create a negative pressure | Staff safety | Lack of a closed system may expose staff to aerosols increasing the risk of pathogen exposure | 3 | 3 | 9 |
| - Concern that due to the large size of the box, it would be difficult to store | Performance impact | This may delay care if the device is not stored in an easily accessible location | 3 | 3 | 9 |
| - Concern that placing the box over the patient’s head may cause anxiety for the patient | Patient experience | This may result in a poor patient experience or increased anxiety requiring additional sedation | 3 | 3 | 9 |
| - Concern that because the box takes set up time, a patient may require initiation of respiratory support before putting the box in place | Staff safety | Inability to set up the box in a timely manner may mean that staff is exposed to aerosols if the patient requires bag/mask ventilation or emergent intubation | 3 | 3 | 9 |
| - Concern that the box was physically heavy and difficult to carry, maneuver, or position over the patient | Performance impact | This may lead to staff or patient injury | 2 | 3 | 6 |
| - Concern that the box takes up a significant amount of space on the bed, minimizing the space available for nurses and respiratory therapists to set up equipment | Performance impact | Limited space around the box necessitates an additional work surface space to be brought into the room so that equipment is easily accessed during intubation | 2 | 3 | 6 |
| - Concern that it was difficult to see the markings on the ETT through the plexiglass | Patient safety | This may result in the incorrect placement of the ETT which could impact ability to adequate ventilate/oxygenate the patient | 2 | 3 | 6 |
| IACS frame | |||||
| - Concern that it was difficult for the intubator to get arms into the box in the correct position to intubate with good technique | Performance impact | Poor positioning for the intubator may result in failed intubation attempts due to immobility and poor technique | 4 | 3 | 12 |
| - Concern that the height of the shield was too high for intubator to see the video laryngoscopy screen | Performance impact | Poor visualization to the video laryngoscopy screen may result in poor intubation technique and unsuccessful intubation attempts | 4 | 3 | 12 |
| - Concern that the shield height was too high for the RT to see the patient limiting the ability to see patient chest rise or verify positioning of the ETT | Patient safety | Inability to adequately visualize the patient may result in delay in care if changes in clinical status go unnoticed | 4 | 3 | 12 |
| - Concern that because one side of the box was opened it was not possible to create a negative pressure | Staff safety | Lack of a closed system may expose staff to aerosols increasing the risk of pathogen exposure | 3 | 3 | 9 |
| IACS PVC frame | |||||
| - Concern that there was limited visibility through the poncho due to rippling of the plastic making it difficult to see patient chest rise or position of the ETT | Patient safety | Inability to adequately visualize the patient may result in delay in care if changes in clinical status go unnoticed | 4 | 3 | 12 |
| - Concern that it was difficult to drape plastic around the frame and that set up was therefore time consuming | Performance impact | Concern that this may lead to a delay in patient care | 3 | 3 | 9 |
| - Concern that there was potential to rip the plastic during set up | Staff safety | Concern that ripped plastic may inadvertently result in contamination of staff | 3 | 3 | 9 |
| - Concern that because providers had to cut their own holes in the plastics to place their hands, that the holes may be cut in the wrong position increasing the change that the plastic would rip | Staff safety | Concern that ripped plastic may inadvertently result in contamination of staff | 3 | 3 | 9 |
| - Concern that because one side of the box was opened it was not possible to create a negative pressure | Staff safety | Lack of a closed system may expose staff to aerosols increasing the risk of pathogen exposure | 3 | 3 | 9 |
| IACS frame with plexiglass top | |||||
| - Concern that there was limited visibility through the plastic drape due to rippling of the plastic making it difficult to see patient chest rise | Patient safety | Inability to adequately visualize the patient may result in delay in care if changes in clinical status go unnoticed | 4 | 3 | 12 |
| - Concern that because providers had to cut their own holes in the plastics to place their hands, that the holes may be cut in the wrong position increasing the change that the plastic would rip | Staff safety | Concern that ripped plastic may inadvertently result in contamination of staff | 3 | 3 | 9 |
| - Concern that because the shield was an open system that there was not an ability to create a negative pressure space around the patient | Staff safety | Lack of a closed system may expose staff to aerosols increasing the risk of pathogen exposure | 3 | 3 | 9 |
| - Concern that the devise was not wide or tall enough to easily maneuver equipment inside the frame | Performance impact | Limited space may impact ability to provide necessary support | 3 | 3 | 9 |
| - Concern that it was difficult to drape plastic around the frame and that the setup was therefore time consuming | Performance impact | Concern that time spent setting up the device may delay patient care | 3 | 3 | 9 |
| - Concern that the device was physically heavy and difficult to carry, maneuver, or position over the patient | Performance impact | This may lead to staff or patient injury | 2 | 3 | 6 |
| IACS frame without plexiglass top | |||||
| - Concern that because providers had to cut their own holes in the plastics to place their hands, that the holes may be cut in the wrong position increasing the change that the plastic would rip | Staff safety | Concern that ripped plastic may inadvertently result in contamination of staff | 3 | 3 | 9 |
| - Concern that because the shield was an open system that there was not an ability to create a negative pressure space around the patient | Staff safety | Lack of a closed system may expose staff to aerosols increasing the risk of pathogen exposure | 3 | 3 | 9 |
| - Concern that the box was difficult to store due to large size | Performance impact | This may delay care if the device is not stored in an easily accessible location | 2 | 3 | 6 |
RT, respiratory therapist. * Low priority (1–6), medium priority (7–14), high priority (15–19), and very high priority (20–25).