Patient safety, human factors and systems thinking — branching viva

Opening (candidate)

My first priority is the child. I would assess and stabilise the airway and breathing using ABCDE, stop the morphine infusion, and give naloxone for opioid-induced respiratory depression while calling for senior and nursing help. Once the child is safe I would preserve the chart, infusion and pump as evidence, notify the consultant in charge and the safety lead, and begin the structured response — report, root cause analysis, open disclosure and support for the registrar. I can already see two problems here: a medication calculation error, and a failure of escalation, because the rising respiratory rate was documented but not acted on. ^[12]