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
Hello Everyone,
(Hodge et al., 2014) states that quality improvement is linked to safety and the best outcomes in healthcare. As quality of care and systems improve in health care, hospitals are working toward creating safer environments for patients.
In my unit, we have seen an increase in requests for lab technicians to draw blood and a lot of issues with blood transfusion processes. The main problem I have seen is proper documentation upon completion of the transfusion. If you do not properly document it, then it can look like the transfusion has been going on for hours or even days. The system does not do a hard stop or give you any red flags to remind you to do this step. You must be able to do this on your own. This suggests to me it is more a system failure rather than an individual failure.
The performance improvement model that I would use is the Plan-DO-Study-Act (PDSA) cycle and I would incorporate it as follows:
Plan: Identify and analyze the root cause of the errors by reviewing the current process. What training is readily available and how often is it provided? Ask staff what barriers they have been able to identify.
Do: Implement changes based on results like new protocols, increased frequency of training, and QR codes at hand for step-to-step processes. We also added a 2-nurse verification not only at the beginning but also at the time of completion.
Study: After the changes have been implemented, we can assess how effective our new process has been by analyzing error rates and getting feedback from the staff.
Act: Based on the responses and findings we can adjust the current processes create new steps and education or revisit the plan phase and attempt to find other solutions.
Brown, C., & Brown, M. (2023). Blood and blood products transfusion errors: what can we do to improve patient safety?. British journal of nursing (Mark Allen Publishing), 32(7), 326–332. https://doi.org/10.12968/bjon.2023.32.7.326
Hodge, A. B., Preston, T. J., Fitch, J. A., Harrison, S. K., Hersey, D. K., Nicol, K. K., Naguib, A. N., McConnell, P. I., & Galantowicz, M. (2014). Quality Improvement Methodologies Increase Autologous Blood Product Administration. The Journal of Extra-Corporeal Technology, 46(1), 45. https://pmc.ncbi.nlm.nih.gov/articles/PMC4557510/