Latent errors | Risk score (using the 2008 National Patient Safety Agency risk matrix)20 |
Ward shares an ECG machine | Minor consequence and almost certain likelihood=10 (high risk) |
Unable to contact Junior doctors about simulated deteriorating patient as they did not have working pagers | Moderate consequence and almost certain likelihood=15 (very high risk) |
Ward did not have Sengstaken-Blakemore tube to manage deteriorating simulated patient. | Moderate consequence and unlikely=6 (moderate risk) |
Ward does not have their own Bair-Hugger | Minor consequence and possible likelihood=6 (moderate risk) |