NUR 630 Topic 3 Discussion 1: Your unit data reflect an upward trend in blood administration errors. Is this likely an individual failure or a system failure? Which performance improvement theory or model would you use to address it?

NUR 630 Topic 3 Discussion 1: Your unit data reflect an upward trend in blood administration errors. Is this likely an individual failure or a system failure? Which performance improvement theory or model would you use to address it?

NUR 630 Topic 3 Discussion 1: Your unit data reflect an upward trend in blood administration errors. Is this likely an individual failure or a system failure? Which performance improvement theory or model would you use to address it?

Topic 3 DQ 1

Assessment Description

Your unit data reflect an upward trend in blood administration errors. Is this likely an individual failure or a system failure? Which performance improvement theory or model would you use to address it?

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Topic 3 DQ 1

            Blood administration errors connote mistakes in the blood transfusion process. The errors may entail transfusing blood at an incorrect body location, transfusing excess or little blood, transfusing a wrong blood component to the patient, and using the wrong needle for blood transfusion (Hensley et al., 2019). Usually, blood administration errors lead to severe health issues and fatalities. In most cases, blood administration errors are caused by human factors such as non-adherence to blood administration guidelines by healthcare professionals, sending wrong orders, and mistaken identity (Bolcato et al., 2020). As such, it is clear that these blood administration errors are mostly associated with human factors. Therefore, an upward trend in blood administration errors can be attributed mostly to human errors rather than system errors.

            The performance improvement model that can be used to address blood administration errors is the root-cause analysis (RCA). The RCA model is defined as the process of establishing the root cause of a given problem to determine the best solutions to address it (Boussat et al., 2021). The major principle behind the RCA is the assumption that it is prudent to recognize and methodically handle underlying issues and identify ways to prevent the issues in the future instead of simply solving the issue at face value. Proper execution of RCA is essential in recognizing where the processes failed. In the issue at hand involving blood administration errors, the RCA can be used to identify and handle factors attributed to the errors (Vahidi et al., 2021). After identifying the causes, various measures can be taken to avert the blood administration errors including training of the staff, improving blood administration protocols, and restructuring the organizational structures and systems.

 References

Bolcato, M., Russo, M., Trentino, K., Isbister, J., Rodriguez, D., & Aprile, A. (2020). Patient blood management: The best approach to transfusion medicine risk management. Transfusion and apheresis science, 59(4), 102779. https://doi.org/10.1016/j.transci.2020.102779

Boussat, B., Seigneurin, A., Giai, J., Kamalanavin, K., Labarère, J., & François, P. (2021). Involvement in root cause analysis and patient safety culture among hospital care providers. Journal of Patient Safety, 17(8), e1194-e1201. DOI: 10.1097/PTS.0000000000000456

Hensley, N. B., Koch, C. G., Pronovost, P. J., Mershon, B. H., Boyd, J., Franklin, S., … & Stierer, T. L. (2019). Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. The Joint Commission Journal on Quality and Patient Safety, 45(3), 190-198. https://doi.org/10.1016/j.jcjq.2018.08.010

Vahidi, S., Mirhashemi, S. H., Hashemi, B., Noorbakhsh, M., & Molavi-Taleghani, Y. (2021). Improvement in blood transfusion safety: Using root cause analysis. Journal of Comprehensive Pediatrics, 12(2). https://doi.org/10.5812/compreped.99088