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?

Solution

Blood administration is critical to patient safety and requires a very meticulous process to avoid adverse patient reactions. Due to the advancements of technology, it is not very common for blood administration errors to be a result of individual failure. A high occurrence of errors usually suggests a systemic failure. Occurrences of these events lead to unwanted patient outcomes and will even put a strain on the health system also; therefore, it is important that we do not see an upward trend in these incidents. This situation presents an excellent opportunity that requires an immediate attention. The 1st step in this process is to identify the root cause of the problem. This will then lead into using a theory similar to the Plan-Do-Check-Act (PDCA), along with collaborating with pharmacy and IT departments to explore solutions that could prevent future errors. Utilizing the Plan-Do-Check-Act (PDCA) model is effective for fostering continuous improvement (ASQ, 2019). Addressing errors in blood administration is a priority that requires immediate intervention, as improving patient outcomes is vital for the healthcare system and essential for meeting core measures. It has been studied that the PDCA is the best theoretical approach to improved, safe patient outcomes (Mansilla et al., 2024).

References

ASQ. 2019. “Continuous Improvement Model – Continual Improvement Tools. ASQ.” asq.org/quality-resources/continuous-improvement.

Mansilla, R. R., Hernandez, V. V., Paredes, M. P., & Sifuentes, C. T. (2024). The influence of Inbound Marketing and the PDCA cycle on the adoption of best practices for customer loyalty in a retail SME. 2024 Congreso Internacional de Innovación y Tendencias En Ingeniería (CONIITI), Innovación y Tendencias En Ingeniería (CONIITI), 2024 Congreso Internacional De, 1–5. https://doiorg.lopes.idm.oclc.org/10.1109/CONIITI64189.2024.10854790

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