A simulation of Just Culture and Systems Thinking.
A patient received 10x the prescribed dose of Insulin.
A young patient was discharged from ED and later died of sepsis.
A nerve block was performed on the wrong leg.
Potassium Chloride was injected instead of Saline.
...
Immediate Outcome: ...
Staff Involved: ...
Click the categories to interview staff and inspect the environment.
You can gather additional information by clicking a category more than once. Find the latent factors.
Interview the staff involved.
Inspect equipment and protocols.
Check lighting, layout, and noise.
Review rosters, culture, and staffing.
You have gathered the evidence. How will you resolve this incident?