Error identified | Remedial action | Preventing LST recurrence |
---|---|---|
Paraldehyde out of stock in A&E | Restocked | Included in pharmacy stock checks |
Bag and mask in paediatric resuscitation area not connecting to oxygen source | Suitable connector provided by medical physics | Included in paediatric A&E check sheet |
Intramuscular adrenaline 1:1000 not available in paediatric A&E | Restocked | Included in paediatric A&E check sheet |
Resuscitaire out of stock on NNU | Restocked | Regular resuscitaire checks implemented and audited |
Junior medical staff unaware of ‘Resus grab bag’ on NNU | Measures taken to inform staff | Included in future induction |
Junior medical staff unaware of location of resuscitation equipment on NNU | Staff orientation organised | Include in future inductions |
Need for educating paediatric nursing staff about continuous positive airway pressure | Educational package introduced by the nurse educators | Regular training sessions |
A&E, accident and emergency department; LST, latent safety threat; NNU, neonatal unit.