Apply the NHS Just Culture algorithm in the Vanderbilt case. Go step by step. What is your conclusion?
What was the role of governance in the Vanderbilt case?
Using the IHI Cause and Effect diagram, fill in the blanks for the Vanderbilt event. Use the fill and save mode, or draw your own diagram. Submit with your paper as an appendix. For your paper, describe the contributing factors that led to the event and reference the appendix.
Identify human factor engineering issues found in the Vanderbilt case. What is a forcing function that a health care system could put into place to prevent another such error? Address the automatic dispensing machine in particular.
