Root Cause Analysis Week 5 Discussion
Step 1 Read the scenario.
Download and read: Root Cause Analysis Scenario HandoutPreview the document
Step 2 Complete the chart.
You have been charged with leading the interprofessional team that will investigate Mr. Jones’s issue. Your analysis should focus on systems and processes, not individual performance.
Download and complete: Root Cause Analysis Chart Preview the document
Step 3 Develop a plan of action.
Based on your investigation, develop a minimum two-page plan of action, not counting the title or reference page, detailing the recommendations your team makes. Your plan should answer the question “What can be done to prevent a similar incident?”
Attach the completed Root Cause Analysis Chart to the end of your paper as an appendix or attach it separately with your assignment.
John Jones requires a blood transfusion due to hemorrhage following a motor vehicle accident. The physician enters the order for blood to be drawn for a type and cross-match and then to transfuse one unit of packed red blood cells using computerized physician order entry. The nurse confirms the order for the blood work and prints the laboratory forms and stickers. The nurse gives the laboratory forms to the student nurse technician and asks him to draw blood on Mr. Jones and send it to the laboratory. The student nurse technician reviews the chart and confirms the order for blood work.
When the student nurse technician arrives at John’s semi-private room, he has to wade through several family members to reach the patient’s bed. John seems distracted by the questioning of his well-meaning family members. So the student, not wanting to interrupt their discussion, quickly asks the patient if his name is Mr. Jones. John responds with a simple yes while continuing his discussion with his family. With just the verbal confirmation and without checking the patient’s ID band, the student nurse technician proceeds to draw the blood and send it to the laboratory.
When the blood arrives on the unit two hours later, the nurse performs a cross check with another nurse to confirm the patient name, unit number, and blood type on the blood and the blood slip. They then go the patient’s room to administer the blood. The nurse asks the patient his name and he states, John Jones, which matches his ID band. The two nurses then check the ID band against the blood and the medical record. All names match. The nurses continue with their bedside check and hang the blood.
Within minutes of hanging the blood, Mr. Jones begins to complain to shortness of breath. The nurse immediately stops the blood and begins infusing normal saline. She notifies the physician and the blood bank of a possible transfusion reaction. The physician immediately comes to see the patient, who responds well to treatment. The blood bank reports that the blood and tubing that were returned to them did not match the patient’s blood type.
Professional Issues in Nursing Handout 9.1 V3.0 Page 1 of 1 11/9/2017
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