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?
Discussion 3-1: Blood Administration Errors
Medical errors in healthcare organizations can be attributed to either individual or system failures. A unit’s data that reflects a rising trend in blood administration errors is likely to be a system rather than an individual failure. According to Najafpour et al. (2017), blood administration errors present a great concern for patient safety and contribute to almost 3.5% of adverse events in the United States. As reported by the authors, Failure Modes and Effects Analysis (FMEA) conducted in most units that record rising cases of blood administration errors often reveal more system failures than individual failures. Examples of system failures that might result in such errors include factors within the environment or setting such as the use of non-standard protocols. Additionally, blood administration errors might be caused by inappropriate storage of blood administration equipment and an organizational culture that pays little attention to patient safety (Najafpour et al., 2017). Nurses should work with the leaders of their units to identify the causes of an upward trend in blood administration errors and utilize evidence-based interventions to address them.
Performance improvement theories or models provide good frameworks for addressing system failures that affect patient outcomes in healthcare settings. The appropriate performance improvement theory to apply in the unit to address system failure in the given scenario is general systems theory. General systems theory views an organization as a system whose effective function depends on the contribution and performance of its component parts. The theory will help stakeholders in the scenario to understand that limited knowledge/skills among nurses alone are not always the cause of blood administration errors in the unit (Abaci & Pershing, 2017). Thereby, guided by the assumptions of general systems theory, the stakeholders will implement system-wide interventions to reduce blood transfusion errors in the unit.
References
Abaci, S., & Pershing, J. A. (2017). Research and theory as necessary tools for organizational training and performance improvement practitioners. TechTrends, 61(1), 19-25. doi: 10.1007/s11528-016-0123-7.
Najafpour, Z., Hasoumi, M., Behzadi, F., Mohamadi, E., Jafary, M., & Saeedi, M. (2017). Preventing blood transfusion failures: FMEA, an effective assessment method. BMC health services research, 17(1), 453. https://doi.org/10.1186/s12913-017-2380-3.