Root Cause Analysis of Medical Errors
Step 1 Read the scenario.
For your assignment, read the scenario below.
Scenario:
John Jones requires a blood transfusion due to hemorrhage following a motor vehicle accident. The physician enters the order for blood to be drawn for a type and cross-match and then to transfuse one unit of packed red blood cells using computerized physician order entry. The nurse confirms the order for the blood work and prints the laboratory forms and stickers. The nurse gives the laboratory forms to the student nurse technician and asks him to draw blood on Mr. Jones and send it to the laboratory. The student nurse technician reviews the chart and confirms the order for blood work. When the student nurse technician arrives at John’s semi-private room, he has to wade through several family members to reach the patient’s bed. John seems distracted by the questioning of his well-meaning family members. So the student, not wanting to interrupt their discussion, quickly asks the patient if his name is Mr. Jones. John responds with a simple yes while continuing his discussion with his family. With just the verbal confirmation and without checking the patient’s ID band, the student nurse technician proceeds to draw the blood and send it to the laboratory. When the blood arrives on the unit two hours later, the nurse performs a cross check with another nurse to confirm the patient name, unit number, and blood type on the blood and the blood slip. They then go the patient’s room to administer the blood. The nurse asks the patient his name and he states, John Jones, which matches his ID band. The two nurses then check the ID band against the blood and the medical record. All names match. The nurses continue with their bedside check and hang the blood. Within minutes of hanging the blood, Mr. Jones begins to complain to shortness of breath. The nurse immediately stops the blood and begins infusing normal saline. She notifies the physician and the blood bank of a possible transfusion reaction. The physician immediately comes to see the patient, who responds well to treatment. The blood bank reports that the blood and tubing that were returned to them did not match the patient’s blood type.
Step 2 Complete the chart.
You have been charged with leading the interprofessional team that will investigate Mr. Jones's issue. Your analysis should focus on systems and processes, not individual performance.
Download and complete: Root Cause Analysis Chart * I WILL ATTACH A COPY
Step 3 Develop a plan of action.
Based on your investigation, develop a minimum two-page plan of action, not counting the title or reference page, detailing the recommendations your team makes. Your plan should answer the question "What can be done to prevent a similar incident?" Use research to develop reliable and evidence-based interventions to put into place to prevent re-occurring situation.
Attach the completed Root Cause Analysis Chart to the end of your paper as an appendix or attach it separately with your assignment.
Root Cause Analysis
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Root Cause Analysis
Medical errors are common in the workplace, leading to negative effects such as death or other complications. In the current case, the patient was lucky since the blood transfusion was stopped on time before causing any further harm (Chou et al., 2019). This root cause analysis will focus on the plan of action or recommendations to prevent a similar incident from happening in the future due to inherent issues in the system and process being adopted by the workplace.
The first recommendation is to improve the current process of recording the patient data, which leads to errors or incomplete information that can result in incorrect blood transfusion. The case reveals that the errors arose due to issues with the labeling and sampling of blood tubes. The plan of action will involve adopting new standard procedures that are clear regarding sample labeling and patient identification (Chou et al., 2019). For instance, it would be imperative for the nurse to counter-check with the patient that they have provided the correct information and that their blood is labeled correctly and matches the correct individual. The standards can also require that nurses clear the room before interacting with the patient to avoid distractions that can lead to errors. The family members contributed to the errors since they were in the room when the student nurse asked the patient some questions, which led to the errors (Chou et al., 2019). The hospital needs updated procedures to ensure all the healthcare personnel follows new rules that would prevent errors.
The second recommendation will involve using modern computer technology and barcodes to save patient data rather than modern charts. For example, various studies have shown that a barcode scanner can record more details. Therefore, it can be used to verify if the patient is the correct recipient of the blood donation rather than using a simple chart to determine if the information is correct (Najafpour et al., 2017). The case also reveals other issues such as failure to determine the right patient information before the transfusion, outdated methods of blood sampling, and lack of reliable patient identifiers. These issues can be resolved by adopting modern information technologies for patient identification, entering information, and specimen labeling (Najafpour et al., 2017). A third recommendation is to train the staff periodically to have the right information about precautionary measures ...