Table 2 Problems of effective workflow and pertinent changes in the safety protocol during the simulation

If patient collapsed to the left side of ergometer, the placement of furniture prohibited unobstructed access to the patient.

Preferable treatment area designated. Relocation of furniture and equipment. Plan B discussed.

If patient collapsed to the right side of the ergometer, monitor cords tangled around it. These had to be temporarily detached, which lead to loss of monitoring during the emergency.

Monitor cords were appropriately bundled, elevated with an adapter, and fed to the monitors ipsilaterally to treatment area. Changes in crew seating and task allocation to ensure non-traumatic fall over to treatment area. Plan B discussed.

Short monitor cords prevented turning the ECG monitor towards the person assessing the collapsed patient.

Relocation of the ECG monitor, AED, and staff emergency posts within treatment area. Monitor cording improved. Plan B discussed.

Delay in finding the telephone for an emergency call.

Telephone kept in standard position. A staff member designated in charge of the telephone. Relevant telephone numbers mounted in strategic places around the lab, ensuring they are visible from treatment area also.

Uncertainty of the exact address of the lab facility during the emergency call. Describing the different access points required some concentration.

Printouts with institution name, coordinates, street address, room, and location map created. Printouts mounted in strategic places around the lab, ensuring they are visible from treatment area also.

The presumed EMS pathway from outdoors to the lab has a section that is too narrow for gurdeys.

Appropriate pathway established. Alternative pathway established. Crew trained.

Doors of the alternative EMS pathway are locked. Difficulty in identifying the appropriate keys. Attending to the problem removes 1 staff member from the BLS team. Risk of getting locked out, which would relocate another staff member.

Appropriate pathway established. Alternative pathway established. Crew trained. Relevant keys kept in standard position. A crewmember designated in charge of EMS call, door opening task, and guiding EMS through the building.

AED patches are the type that require removing ECG leads. In a deteriorating patient-scenario, this means a trade-off between being able to monitor development of the cardiologic status and being prepared for immediate defibrillation.

Different type of AED patches obtained. Backup patches obtained.

Patient profusely sweaty from ergometer strain. May compromise optimal performance of AED.

Towels (and razors) at a hands reach in treatment area.

Time delay between collapse and defibrillation.

AED placement, patch attachment, placement of accessories (towels, razors) within the treatment area checked every day. AED cover detached (adhering to operating manual).

No closed-loop communication.

Non-technical skills discussed.

Overlapping actions.

Specific tasks during an emergency allocated for each staff member. These are revised and orally confirmed daily prior to initiating each experiment. BLS algorithm visible from all angles of treatment area.