NUR 630 Topic 3 DQ 1

Sample Answer for NUR 630 Topic 3 DQ 1 Included After Question

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?

Knowledge Check

What purpose does theory hold in terms of understanding errors? Which theory or model is most applicable to you?

A Sample Answer For the Assignment: NUR 630 Topic 3 DQ 1

Title: NUR 630 Topic 3 DQ 1

When faced with an upward trend in blood administration errors, it’s crucial to take a step back and holistically evaluate the situation. Errors in healthcare settings can often arise from a combination of individual and system failures. It’s less common for errors to stem from the mistakes of individual workers alone; often, the systems in place allow or even encourage these mistakes.

  1. Individual vs. System Failure:
    • Individual Failure: This may involve an individual making an error due to lack of training, fatigue, or other personal factors.
    • System Failure: System failures often include factors like a lack of standardized protocols, inadequate equipment, ineffective communication structures, high workloads, or insufficient training programs. System failures can lead to a situation where even competent and well-meaning individuals are likely to make mistakes.
  2. Performance Improvement Theories and Models:

Several performance improvement theories and models can be utilized to analyze and rectify the problem:

  1. Root Cause Analysis (RCA): RCA is a method used to identify the root causes of faults or problems. In the context of blood administration errors, RCA can be utilized to deeply investigate each incident to uncover the underlying cause, be it individual mistakes, faulty equipment, or systematic issues.
  2. Plan-Do-Study-Act (PDSA): The PDSA cycle is a continuous quality improvement model consisting of a logical sequence of four repetitive steps for continuous improvement and learning. It’s a practical approach to testing changes in the real work setting and determining if these changes lead to improvements.
  3. Failure Modes and Effects Analysis (FMEA): FMEA is a proactive tool that evaluates a process to identify where and how it might fail and assess the relative impact of different failures. It can be instrumental in anticipating potential areas of risk in blood administration and in developing strategies to mitigate these risks.
  4. Human Factors Analysis: This is an interdisciplinary approach that focuses on the interactions between humans and the elements of a system. By understanding these interactions, you can design systems that are more resilient to errors and reduce the likelihood of mistakes.

Before deciding on which theory or model to use, it’s crucial to gather data and understand the nature of the errors. Are they clustered in specific areas, times, or with particular staff? Are there commonalities among the errors?

If the errors seem to be widespread without a clear pattern, then a system failure is more likely, and a broader approach like FMEA might be appropriate. On the other hand, if errors are isolated to specific individuals or situations, focused training or RCA might be more effective.

Regardless, it’s always a good idea to involve front line staff in the analysis and improvement processes, as they can provide valuable insights and are critical in implementing and sustaining any changes. Singh, G., Patel, R., & Boster, J. (2023, May). Root Cause Analysis and medical error prevention. StatPearlshttps://www.ncbi.nlm.nih.gov/books/NBK570638/#:~:text=Root%20cause%20analysis%20(RCA)%20is,result%20in%20a%20sentinel%20event.

A Sample Answer 2 For the Assignment: NUR 630 Topic 3 DQ 1

Title: NUR 630 Topic 3 DQ 1

Blood administration errors connote mistakes in the blood transfusion process. The errors may entail transfusing blood at an incorrect body location, transfusing excess or little blood, transfusing a wrong blood component to the patient, and using the wrong needle for blood transfusion (Hensley et al., 2019). Usually, blood administration errors lead to severe health issues and fatalities. In most cases, blood administration errors are caused by human factors such as non-adherence to blood administration guidelines by healthcare professionals, sending wrong orders, and mistaken identity (Bolcato et al., 2020). As such, it is clear that these blood administration errors are mostly associated with human factors. Therefore, an upward trend in blood administration errors can be attributed mostly to human errors rather than system errors.

The performance improvement model that can be used to address blood administration errors is the root-cause analysis (RCA). The RCA model is defined as the process of establishing the root cause of a given problem to determine the best solutions to address it (Boussat et al., 2021). The major principle behind the RCA is the assumption that it is prudent to recognize and methodically handle underlying issues and identify ways to prevent the issues in the future instead of simply solving the issue at face value. Proper execution of RCA is essential in recognizing where the processes failed. In the issue at hand involving blood administration errors, the RCA can be used to identify and handle factors attributed to the errors (Vahidi et al., 2021). After identifying the causes, various measures can be taken to avert the blood administration errors including training of the staff, improving blood administration protocols, and restructuring the organizational structures and systems.

References

Bolcato, M., Russo, M., Trentino, K., Isbister, J., Rodriguez, D., & Aprile, A. (2020). Patient blood management: The best approach to transfusion medicine risk management. Transfusion and apheresis science59(4), 102779. https://doi.org/10.1016/j.transci.2020.102779

Boussat, B., Seigneurin, A., Giai, J., Kamalanavin, K., Labarère, J., & François, P. (2021). Involvement in root cause analysis and patient safety culture among hospital care providers. Journal of Patient Safety17(8), e1194-e1201. DOI: 10.1097/PTS.0000000000000456

Hensley, N. B., Koch, C. G., Pronovost, P. J., Mershon, B. H., Boyd, J., Franklin, S., … & Stierer, T. L. (2019). Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. The Joint Commission Journal on Quality and Patient Safety45(3), 190-198. https://doi.org/10.1016/j.jcjq.2018.08.010

Vahidi, S., Mirhashemi, S. H., Hashemi, B., Noorbakhsh, M., & Molavi-Taleghani, Y. (2021). Improvement in blood transfusion safety: Using root cause analysis. Journal of Comprehensive Pediatrics12(2). https://doi.org/10.5812/compreped.99088