Safety1You ask agroup to reviewa CPR event toidentify andlearn from whatwent wrongPreventableadverseeventRisk benefit reviewedfor placing CVL whileon anticoagulation dueto high risk of clotting.After placement ofCVL, patient needed alot of intervention tostop bleeding. Whattype of Harm is?Safety2So many thingsare always goingright keeping ourpatients safe, weshould learn fromthem.People arefallible,contextinfluencesbehaviorSafetyDifferentlySeriousSafetyEventA known criticalairway has a UE, youquickly attempt toreintubate, unable toget the airway anddid not call GOATuntil after the 3rd try,patient arrest.KnowncomplicationYou place asubclavianCVL and thepatient has apneumothorax.MedicalerrorPatient is known tohave gluten allergy,admitted for asthma,while recovering,eats a pizza and hasan anaphylaxisreaction requiringresuscitation.Preoccupationwith failureLearning frommortalities,morbidities,arrests, anyevent to continueto improve.JustcultureA workplace modelthat promotesaccountability,fairness, and opencommunicationPrecursorSafetyEventIntubated patientreceives prnmorphine, the nurseaccidently gives 10xthe dose, notifiesyou. Patient has mildhypotension withoutneeding intervention.Human error: Notindividual based,understand thecontext/frame andhow actions madesense at the timeof.NewviewNearMissYour resident ordersheparin that is 100x thedose intended, pharmacycalls the resident anddoesnt get a greatrationale, calls you as thefellow and you correct thedose and patient gets theright dose delivered.SafetyDifferentlyPeople areproblemsolvers,Learning is thefoundation forimprovement,DeferencetoexpertiseYou are developing aguideline forthrombosis and youknow how to treat it,but it would be best toincorporate thehematologist in thisguideline for bestpractices.NonpreventableadverseeventPatient gets anappropriatedose morphineand goes apneicrequiringintubation.OldviewHuman error: Howdid he/she not thinkto get an xray whenpatient had respfailure, this is whywe have so manysafety events.Safety1You ask agroup to reviewa CPR event toidentify andlearn from whatwent wrongPreventableadverseeventRisk benefit reviewedfor placing CVL whileon anticoagulation dueto high risk of clotting.After placement ofCVL, patient needed alot of intervention tostop bleeding. Whattype of Harm is?Safety2So many thingsare always goingright keeping ourpatients safe, weshould learn fromthem.People arefallible,contextinfluencesbehaviorSafetyDifferentlySeriousSafetyEventA known criticalairway has a UE, youquickly attempt toreintubate, unable toget the airway anddid not call GOATuntil after the 3rd try,patient arrest.KnowncomplicationYou place asubclavianCVL and thepatient has apneumothorax.MedicalerrorPatient is known tohave gluten allergy,admitted for asthma,while recovering,eats a pizza and hasan anaphylaxisreaction requiringresuscitation.Preoccupationwith failureLearning frommortalities,morbidities,arrests, anyevent to continueto improve.JustcultureA workplace modelthat promotesaccountability,fairness, and opencommunicationPrecursorSafetyEventIntubated patientreceives prnmorphine, the nurseaccidently gives 10xthe dose, notifiesyou. Patient has mildhypotension withoutneeding intervention.Human error: Notindividual based,understand thecontext/frame andhow actions madesense at the timeof.NewviewNearMissYour resident ordersheparin that is 100x thedose intended, pharmacycalls the resident anddoesnt get a greatrationale, calls you as thefellow and you correct thedose and patient gets theright dose delivered.SafetyDifferentlyPeople areproblemsolvers,Learning is thefoundation forimprovement,DeferencetoexpertiseYou are developing aguideline forthrombosis and youknow how to treat it,but it would be best toincorporate thehematologist in thisguideline for bestpractices.NonpreventableadverseeventPatient gets anappropriatedose morphineand goes apneicrequiringintubation.OldviewHuman error: Howdid he/she not thinkto get an xray whenpatient had respfailure, this is whywe have so manysafety events.

Safety Part 1 - Call List

(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.


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  1. You ask a group to review a CPR event to identify and learn from what went wrong
    Safety 1
  2. 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
  3. So many things are always going right keeping our patients safe, we should learn from them.
    Safety 2
  4. Safety Differently
    People are fallible,context influences behavior
  5. 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
  6. You place a subclavian CVL and the patient has a pneumothorax.
    Known complication
  7. Patient is known to have gluten allergy, admitted for asthma, while recovering, eats a pizza and has an anaphylaxis reaction requiring resuscitation.
    Medical error
  8. Learning from mortalities, morbidities, arrests, any event to continue to improve.
    Preoccupation with failure
  9. A workplace model that promotes accountability, fairness, and open communication
    Just culture
  10. Intubated patient receives prn morphine, the nurse accidently gives 10x the dose, notifies you. Patient has mild hypotension without needing intervention.
    Precursor Safety Event
  11. New view
    Human error: Not individual based, understand the context/frame and how actions made sense at the time of.
  12. 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
  13. People are problem solvers, Learning is the foundation for improvement,
    Safety Differently
  14. 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
  15. Patient gets an appropriate dose morphine and goes apneic requiring intubation.
    Non preventable adverse event
  16. 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