I thought this article was pertinent given you just analyzed in DQ 1 what steps to take if blood administration errors increased on your unit. DQ 2 asks you to select a problem within your workplace and the steps that you would take to solve it.
This is just a thinking exercise. There is no need to do more research or use references to receive credit.
Brief reflections on the article are fine to receive participation credit.
Hopkins Tanne J. When Jesica died. BMJ. 2003 Mar 29;326(7391):717. PMCID: PMC1125622.
https://pmc.ncbi.nlm.nih.gov/articles/PMC1125622/
Solution
Events like these should not happen. It is heartbreaking to see the loss of lives due to medical errors. The case of Jesica Santillan illustrates how miscommunication creates serious risks. Jesica’s death from a transplant error brought on by a failure to confirm her blood type highlights the need for medical collaboration. The critical step of verifying her blood type was missed, despite the participation of multiple staff members. This seems basic. It demonstrates how communication gaps can result in preventable mistake. Communicaton breakdowns can have disastrous consequences (Tiwary et al., 2019). Surgical timeout and other standardized procedures could greatly reduce these risks. Malpractice restrictions prevent families from receiving just compensation in situations like Jesica’s, when economic damages are hard to measure.. This lack of recourse further worsens the grieving process for familes already dealing with loss. Jessica’s story, like so many others, points to a change in reporting errors toward a blame-free culture to improve patient safety.
Reference
Tiwary, A., Rimal, A., Paudyal, B., Sigdel, K. R., & Basnyat, B. (2019). Poor Communication by Health Care Professionals May Lead to Life-threatening Complicatons: Examples from Two Case Report. Welcome Open Research, 4(1), 1–8. https://doi.org/10.12688/wellcomeopenres.15042.1
