Table 5 Latent safety threats. Selected sample of identified latent safety threats and implemented changes
Latent threat identified | Implemented change |
|---|---|
Insufficient knowledge and skills to use an intraosseous needle | Regular workshops for intraosseous needle placement |
Deficient team performance regarding leadership, role allocation and resuscitation calls | Revision of emergency guidelines for critical events focusing on these aspects |
Insufficient handover (lack of information, information unclear, not structured) | New structured handover guidelines, checklist to improve adherence, audit process supervising implementation |
Fixation resulting in a loss of awareness of time during critical events at the emergency department | New timers at the emergency department with a high visibility |
Failures and time delay to drawn up adrenaline (epinephrine) | Implementation of pre-drawn up, ready to use adrenaline syringes fabricated by the pharmacology department |
Insufficient resuscitation equipment at the wards and the emergency department for adults | Implementation of a resuscitation bag for children with the most important equipment |