Problem: Patient is to receive medication "ABC" topically. The pharmacy prepares med "ABC" in an IV bag and labels it (patient name, room number, and contents) and sent unit. The nurse hangs the IV bag & administers "ABC" intravenously. The error is discovered, the patient is monitored, with extended hospital stay for observation and lab work. The patient developed leukopenia and thrombocytopenia, & the nurse was suspended with no pay.
How would you apply the theory of just culture and therefore what steps would be taken to analyze the situation and prevent it from occurring again? Please include reference.