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
A rise in blood administration errors in a unit is more likely a system failure rather than an individual failure. The complexity of blood transfusions involves multiple steps, including patient identification, proper labeling, and adherence to protocols, making errors more likely to be caused by system-wide issues such as workflow inefficiencies, inadequate staff training, communication breakdowns, or technological limitations (Spath, 2021). To address this issue, the Plan-Do-Study-Act (PDSA) model is an effective performance improvement framework. PDSA allows for systematic identification of the root cause of errors, testing of small-scale interventions, and continuous refinement of processes based on data-driven insights (Coury et al., 2021). In this case, the Plan phase would involve analyzing reported errors, identifying trends, and pinpointing system failures, such as breakdowns in verification protocols or staffing shortages. The Do phase would implement interventions, such as enhanced staff education, barcode scanning technology, or standardized double-check procedures. The Study phase would assess the impact of these changes, and the Act phase would lead to widespread implementation of successful interventions while continuously refining processes (Institute for Healthcare Improvement [IHI], 2020). By utilizing the PDSA model, healthcare teams can create a culture of safety and reduce the likelihood of repeated errors, ultimately improving patient outcomes and quality of care.
References
Coury, J., Schneider, J. L., Rivelli, J. S., Petrik, A. F., Seibel, E., D’Agostini, B., … & Coronado, G. D. (2021). Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety-net clinics. BMC Health Services Research, 21(1), 1-11. https://doi.org/10.1186/s12913-021-06265-1
Institute for Healthcare Improvement. (2020). Science of improvement: How to improve. https://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx
Spath, P. (2021). Error reduction in health care: A systems approach to improving patient safety (2nd ed.). Jossey-Bass.