Your unit data reflect an upward trend in blood administration errors NUR 630 Topic 3 DQ 1

Your unit data reflect an upward trend in blood administration errors NUR 630 Topic 3 DQ 1

The increase in the number of blood transfusion errors indicates that the problem is not limited to a single individual or a one-time occurrence. Therefore, in order to address this issue, it is important to examine the entire process. Healthcare delivery is a complex and dynamic environment with numerous variables, and critical decisions are often made in a short amount of time. This is why analyzing the systems and processes is the most appropriate approach to take when looking at errors (Singh et al., 2023, para. 3). By conducting a thorough analysis of the standard procedures, we can identify the actions that are taken and determine where the opportunities lie for refining the process. Root cause analysis (RCA) is a method that focuses on understanding the how and why behind the error rather than the who. By analyzing the processes involved, we can determine the next steps needed to mitigate errors.

According to Fondahn et al. (2016, p.211), a reliable analysis of an adverse situation must include leadership representing the area being analyzed, providing a detailed explanation, answering appropriate questions related to the event, and considering applicable literature. When we consider the act of administering a blood transfusion, we recognize that errors can occur at multiple stages. Errors can stem from the doctor’s order, cross-matching in the lab, patient identifier missteps, mismanagement of adverse reactions, and documentation errors. Depending on the type of error, many different departments may be involved.

It is crucial to involve the right people in the situational analysis to ensure the best possible review and understanding of the true root of the issue. By doing so, we can work towards preventing future errors and improving patient safety.

Reference

Fondahn, E., Lane, M., & Vannucci, A. (2016). Washington manual of patient safety and quality improvement. Wolters Kluwer. ISBN-13: 9781451193558