Nursing 588 Simulation Scenario Just Culture/Performance improvement
Scenario: Two new nursing graduates are working a unit and have recently gone through
orientation together. Nurse Grad A has just learned that 3 hours earlier Nurse Grad B had given
an incorrect (overdose) of albuterol to an asthmatic patient with a history of cardiac disease which
resulted in the patient becoming tachycardic and hypotensive. The nurse discovered the error
when attempting to remove the albuterol from the medication cart for the next scheduled dose.
There was only one dose left instead of the 2 she would need for her shift’s 2 doses. She contacts
respiratory therapy to inquire if they had given an extra dose.
Background information: The nurse who committed the error is a new graduate, recently off orientation
and is scheduled for her 6 month performance appraisal within the next few weeks. The nurse who
discovered the error is also a new graduate who completed orientation with the other nurse. The new
graduate B who made the error has 4 patients one of whom was unstable, and she had also been asked to
assist another nurse whose patient was crashing.
Props: just culture decision making chart, medication incident form
Players: 2 nurses, nurse manager, respiratory therapist, observers
Stages:
A. The nurse making the discovery reports the error to the nurse manager. Nurse B tells
Nurse A “We went through orientation together and became friends. I thought you had
my back. I never expected you to rat on me like that. The patient was not harmed.” What
do you, Nurse A say?
STUDENTS ROLE PLAY NURSE A AND NURSE B, Nurse A BEGINS BY STATING “Nurse manager, I discovered a medication error, Nurse B gave 2 albuterol doses to Mr.
Denzel Washington instead of one. I checked with respiratory therapy and they did not
give an in-between dose”.
B. Nurse A who made the discovery goes to Nurse B and tells her of the discovery. The
nurse who committed the error pleads with Nurse A not to report her to the manager
since the patient was not harmed, because her evaluation is due. What do you do?
ROLE PLAY NURSE A AND NURSE B
C. Nurse Grad A decides not to tell anyone about her discovery. However, the respiratory
therapist is on the unit and asks you “What happened with that albuterol discrepancy?”
The nurse manager is with him and wonders to what he is referencing? What do you do?
How will this play out?
ROLE PLAY RESPIRATORY THERAPIST, THE NURSE MANAGER, AND NURSE
GRAD A.
D. The nurse manager now summons the nurse who committed the error and the nurse
discovering the error together to discuss the situation and initiate the incident report that
needs to be filed. The nurse manager discusses the situation privately with the nurse who
commits the error. How should this conversation proceed? Based on the principles of a
just culture what should happen?
STUDENTS PLAY THE ROLE OF THE NURSE MANAGER and NURSE GRAD A.
Students work in pairs to utilize the just culture decision making model.
Debriefing Points: Although not life threatening, the error placed the patient at unnecessary risk,
delayed his discharge and consumed resources on the unit. Emphasize the just culture decision
making model for analyzing errors, performance improvement’s attention to process not people,
prevention of subsequent errors, and error disclosure.