Latent Threats Identified During In Situ Simulated Local Anesthetic Systemic Toxicity Crises in the Operating Room: Implications for System Safety.

Abstract

Latent safety threats (LSTs) in operating room (OR) crisis management contribute to serious events such as Local Anesthetic Systemic Toxicity (LAST) and represent critical yet often overlooked risks. Although prior research has focused on clinician education for diagnosing and treating LAST, far less attention has been directed toward work-system factors (eg, workflow design, communication processes, environmental supports), even though education alone is insufficient. This study advances understanding of OR crises by systematically identifying and characterizing LSTs across all phases of LAST response, from briefing and diagnosis to treatment and care planning, capturing the broader system factors that influence team performance and patient safety. Thirty-eight staff (15 anesthesiologists, 16 nurses, 7 anesthesia assistants) participated in 8 simulations. Video recordings were analyzed to identify LSTs, which were inductively coded into themes/subthemes, categorized by clinical phase (briefing, diagnosis, management, treatment, care planning) and by system factor using a modified SEIPS framework (organization, environment, tasks, tools, teams, individuals). We identified 183 LSTs, with frequency varying by clinical phase (P < .001); nearly half (90/183; 49%) occurred during Management after diagnosis. LSTs spanned all SEIPS factors, most often Environment (55/183; 30.1%), Organization (54/183; 29.5%), and Tasks (38/183; 21.3%). The most common themes were Poor Physical Layout (43/183; 23.5%) and Role Allocation Deficiencies (42/183; 23%), both directly impairing performance (eg, delays retrieving the crash cart or administering intralipid). Additional LSTs included communication breakdowns, task overload, ambiguous dosing, tool usability issues, and unclear protocols. Knowledge gaps were least common and had minimal clinical impact. The findings highlight that improving LAST crisis response requires more than clinician education. Many LSTs arise from how clinical environments are structured, how teams communicate, and how workflows unfold under pressure. To strengthen LAST crisis response and other emergency interventions, systems must be redesigned to reflect the realities of team-based care and to support clinical workflows across all phases of the response.