{"report_id":234,"form_id":"23","user_id":81,"organization_id":10,"question_id":"98","question_type":"Free_Text","text_answer":"Collaborative Safety \u2013 Systems Mapping \r\nCase Summary\r\nOctober 14, 2019\r\nHennepin County\r\n\r\n\r\nLearning Point #1: Staff lost sight of a person at the State Fair.\r\n\r\nLearning Point #2: Staff brought his son along on this community outing. \r\n\r\nIncident report description\r\n\u2022\tIncident date: 8\/24\/2019, between 12:30 PM and 5:30 PM\r\n\u2022\tReport date: 8\/27\/2019 4:11PM\r\n\r\nStaff and person went to the Minnesota State Fair on a Saturday afternoon. During this outing, the person was unsupervised for approximately thirty minutes. The person had a rental scooter and took off on it to go to use the bathroom. The staff could not keep up with the scooter and lost sight of the person. Approximately 30 minutes later, staff found the person near the bathroom. \r\n\r\nTwo days later, the reporter found out about the incident during an appointment between the person and a Psychologist when the person told the Psychologist \"while at the Minnesota State Fair on Saturday, I was alone for about thirty minutes.\" \r\n\r\nDebriefing information for learning Point #1, October 25, 2019\r\n\r\nStaff participated in a human factors debriefing, led by a Safety Analyst, on October 25, 2019.\r\n\r\nUpon arrival at the State Fair, the person rented an electric mobility scooter for people with disabilities. The staff brought his 10 year old son along to the event. The staff\u2019s attention was influenced by the person\u2019s behavior as they began walking into the Fair, when the person said she wanted to go to the beer garden and drink beer. This action triggered the staff to wonder if this was a good idea. \r\n\r\nShortly after arriving, the staff and his son sat down to eat some food while the person used the scooter to go and browse at a souvenir stand within eyesight. The crowd at the Fair impacted the staff\u2019s focus when he lost sight of the person on the scooter during the outing. Staff reported he was not distracted by his son\u2019s presence. \r\n\r\nDebriefing information for learning Point #2, October 25, 2019\r\n\r\nDuring the debriefing session for Learning Point #1, Staff shared he brought his son along to the outing after the VA told him she thought it was fine. He explained it was a last minute decision because of issues around child care coverage.\r\n\r\nResult of Incident\r\nStaff reported going to the beer garden to search for the person. She was not there, so he called her on her cell phone. She answered his call, but could not tell staff exactly where she was. This phone call went on for about 30 minutes until staff located the person.","created_by":81,"updated_by":81,"updated_at":"5\/26\/2021 5:31:46 pm","created_at":"5\/26\/2021 5:31:46 pm","id":38849}