Description
Adverse Event Summary
It was a normal day on the unit. It was hectic and every room was filled with a
patient. We typically do not put two patients who are both receiving blood transfusions in a
double room together, but we had no choice this day. The nurse who was involved in this event
we will refer to as Susie during this discussion. Susie had been caring for patient A in this room.
Our hospital policy for cross and type blood draws is that an RN has to co-sign and verify the
patients identity with the lab tech. On this particular day, the lab tech working happened to be
Susie’s friend. The lab tech drew the cross and type, and the RN bypassed the co-sign “because
she trusted the lab tech” because they were friends. The lab tech put the sticker from patient B
on the vial by mistake. Mind you, both patients in this room were going to be receiving blood.
Thankfully, in the lab, another staff member noticed that the patients’ blood type from a
previous transfusion did not match this cross and type, and ordered a redraw. If he would not
have been paying attention to detail, patient B would have received patient A’s blood type, and
could have potentially died. In the situation, I do not see any evidence of role ambiguity or role
conflict present.
Regulatory Decision Pathway & Just Culture
Using the pathway, it was very apparent that Susie was displaying reckless behavior
(Russell & Radtke, 2014). Susie knew the policy was to co-sign the cross and type blood draw
but chose not to, but she did not make that decision to hurt the patient on purpose, she was
cutting corners because she knew the lab technician working. When people go into healthcare, they
do it because they want to help people, not hurt them intentionally (MedStar Health, 2014). A
just culture is how an organization handles issues with its employees (Pepe & Cataldo, 2011).
As the manager of this employee, due to the reckless behavior she was placed on corrective
action, and was notified that she would be terminated if there are any further incidents such as
these. She was also mandated to repeat blood transfusion education and the policy related to
transfusions and sign a document after completing it stating she indeed understood the policy.
Mistakes are inevitable, we are all human, and humans make mistakes. It is important
to remember that after an event occurs, and treat mistakes as opportunities for improvement.
References
MedStar Health. (2014). What does it mean to adopt a fair and just culture in healthcare?
Retrieved from https://www.youtube.com/watch?v=JBiupDISZ1E.
Pepe, J., & Cataldo, P.J. (2011). Manage risk, build a just culture. Health Progress. Retrieved
from http://www.outcome-eng.com/wp-content/uploads/2012/01/manage-risk
Russell, K.A. & Radke, B.K. (2014). An evidence-based tool for regulatory decision-making:
regulatory decision pathway. Journal of Nursing Regulation, 5 (2), 5-9. (PDF)
I just need a response in your own words on tahis discussion. Must be at least 5-10 sentences with 2 apa references
Explanation & Answer
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