(Print) Use this randomly generated list as your call list when playing the game. There is no need to say the BINGO column name. Place some kind of mark (like an X, a checkmark, a dot, tally mark, etc) on each cell as you announce it, to keep track. You can also cut out each item, place them in a bag and pull words from the bag.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Intubated patient receives prn morphine, the nurse accidently gives 10x the dose, notifies you. Patient has mild hypotension without needing intervention.
Precursor Safety Event
So many things are always going right keeping our patients safe, we should learn from them.
Safety 2
Your resident orders heparin that is 100x the dose intended, pharmacy calls the resident and doesnt get a great rationale, calls you as the fellow and you correct the dose and patient gets the right dose delivered.
Near Miss
People are problem solvers, Learning is the foundation for improvement,
Safety Differently
A known critical airway has a UE, you quickly attempt to reintubate, unable to get the airway and did not call GOAT until after the 3rd try, patient arrest.
Serious Safety Event
Learning from mortalities, morbidities, arrests, any event to continue to improve.
Preoccupation with failure
Patient is known to have gluten allergy, admitted for asthma, while recovering, eats a pizza and has an anaphylaxis reaction requiring resuscitation.
Medical error
You are developing a guideline for thrombosis and you know how to treat it, but it would be best to incorporate the hematologist in this guideline for best practices.
Deference to expertise
Human error: How did he/she not think to get an xray when patient had resp failure, this is why we have so many safety events.
Old view
You ask a group to review a CPR event to identify and learn from what went wrong
Safety 1
Risk benefit reviewed for placing CVL while on anticoagulation due to high risk of clotting. After placement of CVL, patient needed a lot of intervention to stop bleeding. What type of Harm is?
Preventable adverse event
Patient gets an appropriate dose morphine and goes apneic requiring intubation.
Non preventable adverse event
You place a subclavian CVL and the patient has a pneumothorax.
Known complication
A workplace model that promotes accountability, fairness, and open communication
Just culture
New view
Human error: Not individual based, understand the context/frame and how actions made sense at the time of.
Safety Differently
People are fallible,context influences behavior
