The discussion about Human factor engineering and just culture underscored the importance of a blameless investigation in sentinel events which can uncover system or processes error and thus prevent errors in future. The story of the nurse who misinterpreted the blood sugar reading several times and was suspend. However after an investigation, triggered by a second event by a different nurse, it became apparent that there was an underlying factor which resulted to these errors. I also thought the point reached by Paul was one of significant importance—namely how leadership will own the initial poor response of suspending the nurse, acknowledge her work and support her moving forward.
