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
An increase in blood administration errors in one department points to a systematic problem instead of just an individual failure. Eighty-five percent of critical incidents during transfusion intervention are linked to errors in the process (Bolton‐Maggs & Watt, 2019). Individual mistakes sometimes happen, but when they become more frequent, it usually indicates that underlying issues exist. It may be related to procedures or training that affect multiple employees. According to Brown et al. (2023), blood transfusion errors are often attributed to factors outside the control of the provider performing the transfusion.
For this issue, I would use the Plan-Do-Study-Act (PDSA) model. PDSA organizes the thought process by dividing it into stages, followed by assessing the results, enhancing them, and retesting (Agency for Healthcare Research and Quality, 2024). Plan identifies what your problem is and develops a plan to solve it. It consists of gathering data on errors and designing a plan for dealing with these problems (Agency for Healthcare Research and Quality, 2024). The Do phase involves making small changes to the system, such as piloting a revised protocol in one unit and observing its impact. The Study phase involves reviewing data post-implementation. Was the change effective? Act phase would determine whether to adopt the changes across the board, modify those changes and/or test additional interventions (Barr & Brannan, 2024). Using the PDSA cycle will help uncover causes, guide changes, and lead to improvements in the safe administration of blood products.
References
Agency for Healthcare Research and Quality. (2024). Plan-Do-Study-Act (PDSA) directions and examples. Agency for Healthcare Research and Quality. https://www.ahrq.gov/health-literacy/improve/precautions/tool2b.html
Barr, E., & Brannan, G. D. (2024). Quality improvement methods (LEAN, PDSA, SIX SIGMA). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK599556/
Bolton‐Maggs, P. H. B., & Watt, A. (2019). Transfusion errors — can they be eliminated? British Journal of Haematology, 189(1), 9–20. https://doi.org/10.1111/bjh.16256
Brown, C., & Brown, M. (2023). Blood and blood products transfuson errors: what can we do to improve patient safety? British Journal of Nursing, 32(7), 326–332. https://doi.org/10.12968/bjon.2023.32.7.326. Eighty-five percent of critical incidents during transfusion intervention are linked to errors in the process (Bolton‐Maggs & Watt, 2019). Individual mistakes sometimes happen, but when they become more frequent, it usually indicates that underlying issues exist. It may be related to procedures or training that affect multiple employees. According to Brown et al. (2023), blood transfusion errors are often attributed to factors outside the control of the provider performing the transfusion.
For this issue, I would use the Plan-Do-Study-Act (PDSA) model. PDSA organizes the thought process by dividing it into stages, followed by assessing the results, enhancing them, and retesting (Agency for Healthcare Research and Quality, 2024). Plan identifies what your problem is and develops a plan to solve it. It consists of gathering data on errors and designing a plan for dealing with these problems (Agency for Healthcare Research and Quality, 2024). The Do phase involves making small changes to the system, such as piloting a revised protocol in one unit and observing its impact. The Study phase involves reviewing data post-implementation. Was the change effective? Act phase would determine whether to adopt the changes across the board, modify those changes and/or test additional interventions (Barr & Brannan, 2024). Using the PDSA cycle will help uncover causes, guide changes, and lead to improvements in the safe administration of blood products.
References
Agency for Healthcare Research and Quality. (2024). Plan-Do-Study-Act (PDSA) directions and examples. Agency for Healthcare Research and Quality. https://www.ahrq.gov/health-literacy/improve/precautions/tool2b.html
Barr, E., & Brannan, G. D. (2024). Quality improvement methods (LEAN, PDSA, SIX SIGMA). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK599556/
Bolton‐Maggs, P. H. B., & Watt, A. (2019). Transfusion errors — can they be eliminated? British Journal of Haematology, 189(1), 9–20. https://doi.org/10.1111/bjh.16256
Brown, C., & Brown, M. (2023). Blood and blood products transfuson errors: what can we do to improve patient safety? British Journal of Nursing, 32(7), 326–332. https://doi.org/10.12968/bjon.2023.32.7.326