Discover and read the best of Twitter Threads about #JustCulture

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Wie maximiert man Vertuschen von Fehlern und error-waiting-to-happen Prozesse?
Ein tragischer Fallbericht aus den USA. 🧵👇
#JustCulture #Fehlerkultur
RaDonda V. arbeitet als ICU-Nurse im Pflegepool eines Uniklinikums. Heiligabend 2017 versorgt sie die 75-jährige Charlene M., die nach einem Subduralhämatom noch ein Kontroll-CT vor der Verlegung auf Normalstation bekommen soll.
Da Charlene Platzangst hat, wird vorher zur Beruhigung Midazolam (US-Handelsname: "Versed®") angeordnet. RaDonda gibt am Pyxis (Gerät zur automatischen Med.-Ausgabe) "Ve..." ein.
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Up, out and ready for #CPHVA19. There will be tweets. Join in. It’ll be fun! @Unite_CPHVA @UniteinHealth
The calm before the storm. At least it’s dry in here. We’ve got definite Yorkshire drizzle this morning in Harrogate @Unite_CPHVA #CPHVA19
The doors aren’t open yet but we’re busy getting ready for #CPHVA19 delegates. Lots of opportunities to catch up with old friends and new over the next two days @Unite_CPHVA @saffie @UniteinHealth
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