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
Given that the data reflects and upward trend in error across the entire unit, this would lead me to believe that this is a system failure. There are many systems within the healthcare industry that are complex and high stakes. Following protocols can help prevent error which can lead to further harm of patients. These errors can also lead to decreased morale and burnout.
The Six Sigma Model is used to identify flaws and reduce errors and discrepancies in production process (Ilin & Bohlen, 2023). This method has been proven to help prevent errors. With the help of management, goals or initiatives are set. DMAIC or Define, Measure, Analyze, Improve, and Control (Hayes, 2024).
Define: Improve Blood Administration Process
Measure: Gather current data of patients who have received blood products and if errors occurred with those administrations and why.
Analyze: Understand the root problem of why blood is being administered incorrectly. More specifically, which step in the process is creating error.
Improve: Develop and implement solutions to improve blood administration to process to decrease errors.
Control: Standardize and devise a policy for new process. Monitor for errors.
It is possible that it might take more than one revision of the new process for total success. Of course, their will also be occasions of human error but with this new process hopefully those are less.
References
Hayes, A. (2024). What Is Six Sigma? Concept, Steps, Examples, and Certification. Investopedia. What Is Six Sigma? Concept, Steps, Examples, and Certification
Ilin & Bohlen, (2023). Six Sigma Method. StatPearls. Six Sigma Method – StatPearls – NCBI Bookshelf