Error identifiedRemedial actionPreventing LST recurrence
Paraldehyde out of stock in A&ERestockedIncluded in pharmacy stock checks
Bag and mask in paediatric resuscitation area not connecting to oxygen sourceSuitable connector provided by medical physicsIncluded in paediatric A&E check sheet
Intramuscular adrenaline 1:1000 not available in paediatric A&ERestockedIncluded in paediatric A&E check sheet
Resuscitaire out of stock on NNURestockedRegular resuscitaire checks implemented and audited
Junior medical staff unaware of ‘Resus grab bag’ on NNUMeasures taken to inform staffIncluded in future induction
Junior medical staff unaware of location of resuscitation equipment on NNUStaff orientation organisedInclude in future inductions
Need for educating paediatric nursing staff about continuous positive airway pressureEducational package introduced by the nurse educatorsRegular training sessions
  • A&E, accident and emergency department; LST, latent safety threat; NNU, neonatal unit.