Your unit data reflect an upward trend in blood administration errors
NUR 630 Topic 3 DQ 1
Blood administration errors are dangerous medical errors that can have many risk factors for patients and long-lasting effects. Often, people fear the blood products being administered, such as the incorrect product, blood typing issues, and other mistakes made during that initial process. Unfortunately, nearly 70% of blood administration errors occur at the bedside rather than that actual problems with the actual blood products (Najafpour et al., 2017). Due to the high statistics, it is likely a combination of the two. It is both an individual error and a system failure. Ultimately, the system needs to be assessed due to the individual failure that is occurring. There is a variety of reasons why these errors are occurring. Oftentimes, nurses have many other patients that are caring for therefore they cannot focus on just that patient during administration which can be dangerous for the patient and the nurse. It is easy for an organization to draw conclusions that the nurses are to blame yet critical staffing shortages can greatly contribute to a problem such as this one. Patients who quickly change in their acuity level and suddenly require additional care can be difficult to staff correctly. This system is also to blame for the high occurrences that happen in these errors.
Lewin’s Three-Step Model for Change is a model that transforms care and changes dynamics within the healthcare system (Wojciechowski et al., 2016). This model consists of unfreezing, changing/moving, and refreezing to make a necessary change within the organization (Wojciechowski et al., 2016). The most important step is discussing the problem and what type of change is needed. The changing/moving stage consists of discovering what is the best solution to the problem followed by refreezing which is creating lasting change and taking an active approach (Wojciechowski et al., 2016). This is an example of a model that could be used to address the problem of blood administration and how these errors can be decreased by presenting the problem, brainstorming possible solutions, and carrying out the necessary change.
References
Najapour, Z., Hasoumi, M., Behzadi, F., Mohamadi, E., Jafary, M., & Saeedi, M. (2017). Preventing blood transfusion failures: FMEA, an effective assessment method. National Library of Medicine National Center for Biotechnology Information. https://doi:10.1186/s12913-017-2380-3
Wojciechowski, E., Pearsall, T., Murphy, P., & French, E. (2016). A case review: Integrating Lewin’s theory with lean’s system approach for change. The Online Journal of Issues in Nursing. https://doi:10.3912/OJIN/Vol21No02Man04
A rising trend in blood administration errors is likely to be an individual failure since clerical errors primarily contribute to transfusion errors. The common clerical errors include mislabeled blood samples, blood samples collected from the wrong patient, reversal of specimen samples in the laboratory, and incorrect blood component administration (Vahidi et al., 2021). Besides, individual errors in identification and verification at the patient bedside result in increased blood transfusion errors. Blood administration errors mainly occur if the administering nurse does not confirm the right patient, right blood product, and ABO compatibility in the patient (Vahidi et al., 2021). As a result, even if the blood is labeled appropriately, it is transfused to someone other than the correct recipient. The nurses could be failing to follow blood administration procedures, including identifying a patient with two unique identifiers.
The Rapid improvement model (RIM) can address individual failures in blood administration. RIM is a quick method of enhancing work processes, which enables teams to implement a small change, test and evaluate it, and then accept if effective or reject if ineffective (Smith & Johnson, 2019). It is a quality improvement approach that identifies, executes, and evaluates changes made to enhance a process or a system. The model proposes implementing and testing changes over three months or less. RIM can be used to improve the process of blood administration by first establishing the improvements desired and defining how we want to change the process of administering blood (Smith & Johnson, 2019). The next step will be to identify the measures to assess whether the changes made have improved the blood administration process. The last step will be to establish the changes that will help reduce blood administration errors. We will evaluate the options that are most likely to work and identify what other organizations have done t
o minimize the errors.
References
Smith, C. M., & Johnson, C. S. (2019). Preparing nurse leaders in nursing professional development: Quality improvement in nursing professional development. Journal for nurses in professional development, 35(4), 222-224. doi: 10.1097/NND.0000000000000540
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, (In Press). DOI : 10.5812/compreped.99088
When errors involving an entire process or procedure begin to suddenly increase, the cause is usually the process or system itself that is responsible for the failure. This is especially true when processes, procedures, or systems are recently updated with new steps for employees to follow. After such changes, when errors are experienced with that process, it’s far more likely to occur from lack of education or training on the new process rather than unintended human error. When systems are not set up properly, making it easy for users to do things correctly, failures tend to occur.
To address such errors within a process, procedure or system, it is first necessary to determine the root cause of the errors. Through a systematic process of investigations, interviews, and analysis of data, internal and external factors that caused individuals to deviate from the system processes can be identified (Singh et al., 2023). Root cause analysis is the chosen method because it aims identify system process issues rather than assigning individual blame, as looking at errors individually will not always reveal the true root cause (Singh et al., 2023). Once the root cause(s) of the errors are identified, work can be done to correct the issues to prevent them from reoccurring and causing more patient harm. In most cases, and probably in this one as well, more training and education would be required so that staff are familiar with and are able to properly execute all steps in the process to ensure safe administration of blood products.
References:
Singh, G., Patel, R., & Boster, J. (2023, May). Root Cause Analysis and medical error prevention. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK570638/#:~:text=Root%20cause%20analysis%20(RCA)%20is,result%20in%20a%20sentinel%20event.
The literature identifies that the most frequent error leading to transfusion of ABO-incompatible blood occurs during patient identification/verification at the bedside (Barnhard, 2020). Blood administration process is highly regulated and consists of numerous steps that were designed to ensure a safe process. Hospitals must set their own process that would meet the standards that protect patients from an ABO-incompatible red blood cell transfusion (Barnhard, 2020). Our organization has a policy on blood transfusion administration that is reviewed every couple of years to ensure that it meets the requirements.
If it has been identified that there was a trend in blood transfusion errors in the unit, root-cause analysis (RCA) should be performed on systems and processes to identify strategies to reduce the of similar events occurring in the future (Johnson & Sollecito, 2020). The textbook defines RCA as a process for identifying the factors that underline variation in performance (Johnson & Sollecito, 2020). This process will allow the team to look at the whole picture and not just concentrate on one individual performance. If the adverse event happened with one person, there is no guarantee that it couldn’t have happened with another person. By repeatedly asking the question “why?” the process can dig deeper into the event and identify the risk points that potentially contributed to the particular adverse event. This will help decide the possible changes that can make the system or the process safer in the future. RCA will also assist with identifying if there was a performance issue and therefore, an individual failure.
As a nurse manager, I had several opportunities to complete intensive analysis (IA) and RCA. As a result of the investigation, we created an action plan. Often, IA or RCA results in re-educating the staff or implementing new processes. For example, when a stage three pressure ulcer was identified on the unit, as an action plan, we reviewed hospital policy on skin breakdown prevention and utilization of the appropriate bed surfaces with all unit staff. We also implemented strict turning every two hours by announcing the time to turn our patients. We continuously audited staff compliance to reach the goal of decreasing the number of pressure ulcers in the unit.
References:
Barnhard, S. (2020). “This is the wrong patient’s blood!”: Evaluating a hear-miss wrong transfusion event. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
Johnson J. K., & Sollecito, W. A. (2020). Continuous quality improvement in health care (5th ed.). Jones & Bartlett Learning. ISBN-13: 9781284126594
| Excellent | Good | Fair | Poor | ||
| Main Posting | 45 (45%) – 50 (50%)
Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.
Supported by at least three current, credible sources.
Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
40 (40%) – 44 (44%)
Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module.
At least 75% of post has exceptional depth and breadth.
Supported by at least three credible sources.
Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
35 (35%) – 39 (39%)
Responds to some of the discussion question(s).
One or two criteria are not addressed or are superficially addressed.
Is somewhat lacking reflection and critical analysis and synthesis. Somewhat represents knowledge gained from the course readings for the module.
Post is cited with two credible sources.
Written somewhat concisely; may contain more than two spelling or grammati cal errors.
Contains some APA formatting errors. |
0 (0%) – 34 (34%)
Does not respond to the discussion question(s) adequately.
Lacks depth or superficially addresses criteria.
Lacks reflection and critical analysis and synthesis.
Does not represent knowledge gained from the course readings for the module.
Contains only one or no credible sources.
Not written clearly or concisely.
Contains more than two spelling or grammatical errors.
Does not adhere to current APA manual writing rules and style. |
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| Main Post: Timeliness | 10 (10%) – 10 (10%)
Posts main post by day 3. |
0 (0%) – 0 (0%) | 0 (0%) – 0 (0%) | 0 (0%) – 0 (0%)
Does not post by day 3. |
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| First Response | 17 (17%) – 18 (18%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
15 (15%) – 16 (16%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
13 (13%) – 14 (14%)
Response is on topic and may have some depth.
Responses posted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed. Response may lack clear, concise opinions and ideas, and a few or no credible sour ces are cited. |
0 (0%) – 12 (12%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
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| Second Response | 16 (16%) – 17 (17%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
14 (14%) – 15 (15%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
12 (12%) – 13 (1
3%) Response is on topic and may have some depth.
Responses po sted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed.
Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. |
0 (0%) – 11 (11%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
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| Participation | 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days. |
0 (0%) – 0 (0%) | 0 (0%) – 0 (0%) | 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on 3 different days. |
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| Total Points: 100 | |||||
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