Safety station — infusion error rescue, incident report, systems analysis and family disclosure

Station objectives

1. Execute an ordered clinical and safety response to an in-hospital adverse event. [2]
2. Report in the local incident system and preserve evidence without blame. [1]
3. Disclose to the family using open, honest communication principles. [14]
4. Lead a systems analysis that prefers strong actions and supports the second victim. [1] [15]

Candidate brief

You are the general paediatric registrar on a surgical ward. Station A is 8 minutes and scores rescue, prioritisation and evidence preservation. Station B is 10 minutes and scores disclosure, systems thinking and welfare. Use the local severity framework by name; do not invent numeric cut-offs. [1] [14]

Station A — Infusion error rescue

Setup: A four-year-old post-operative child has a morphine infusion running at ten times the prescribed rate. The bedside nurse has just stopped the pump. The child is drowsy but protecting the airway, with a respiratory rate of eight. [2]

Expected actions:

• Assess and support airway, breathing and circulation; apply oxygen and monitoring. [2]
• Recognise opioid toxicity and give naloxone titrated to respiratory effort, not full alertness. [2]
• Keep the pump stopped and preserve its settings; do not reset; label the line and bag. [1]
• Call for senior paediatric and nursing help; escalate to the consultant. [1]
• Check whether other children share the same concentration, pump library or protocol. [1]
• Document a factual timeline; notify the family that an unexpected event occurred. [14]

Station B — Disclosure, analysis and welfare

Setup: Two hours later the child is stable. The parents want to know what happened. The nurse who caught the error is tearful and reluctant to return to the drug room. [14] [15]

Expected actions:

• Disclose openly: what happened, what it means, what is being done now, an apology as appropriate, and how the family can reach you. [14]
• Avoid speculation and individual blame; stick to confirmed facts and a clear plan. [14]
• File the incident report and classify harm using the local framework; report the near-miss elements too. [1]
• Frame the systems analysis around latent conditions — pump library limits, double-check design, look-alike concentrations — plus the active pump-programming failure. [1]
• Prefer strong actions: smart-pump hard limits, standardised concentrations, forcing-function double-checks; state that posters alone are weak. [1] [13]
• Support the nurse as a second victim: name it, relieve from high-risk tasks if acutely distressed, offer peer support and follow-up. [15]

Marking anchors

Clear pass: rescue-first sequence with naloxone, evidence preserved, honest family disclosure, systems analysis naming latent and active factors with strong actions, and explicit second-victim support. [1] [14] [15] Borderline: right clinical rescue but blames the nurse, or offers only re-education as the system fix, or delays disclosure. [1] [14] Fail: resets the pump before review, withholds the event from the family, or leaves the distressed nurse unsupported. [14] [15]

Debrief pearls

• Voluntary reports alone miss most harm; trigger tools find more, so do not trust a quiet dashboard. [11]
• Handoff and bundle interventions show system design can drive harm down. [13]