Sample Answer for NUR 630 Topic 3 DQ 1 Included After Question
Topic 3 DQ 1
Your unit data reflects an upward trend in blood administration errors. Is this likely an individual failure or a system failure? Which theory or model would you use to address it?
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A Sample Answer For the Assignment: NUR 630 Topic 3 DQ 1
Title: NUR 630 Topic 3 DQ 1
Topic 3 DQ 1
Health care providers should be committed to delivering care that meets patient needs. Despite their commitment, issues that hamper health care quality and patient safety are part of routine processes. Such issues include blood administration errors, and it is crucial to address the problem using a performance improvement model.
An upward trend in blood administration errors can stem from individual failure or system failure. The cause depends on the situation. Individual failures leading to medication administration errors include giving a patient the incorrect amount of blood, wrong blood type, or administering blood in the wrong body location. System failure is broad and usually leads to individual failures. Inadequate staff training on blood administration, inadequate staff, and storage problems are common causes of system failures (Lancaster et al., 2021). Optimal communication also helps to reduce system failure. Therefore, individual or system failure can trigger blood administration errors.
Performance improvement models provided a structured process for outcomes improvement to meet patient needs. The six sigma performance improvement model would be the most appropriate for addressing blood administration errors. Alkinaidri and Alsulami (2018) described six sigma as a metrics-driven system applied in the health practice to reduce medical errors and remove defects. Its primary goal is to increase value in health care processes by removing defects. The model’s primary tenet is that defects cause variation between the current and desired outcomes (Ross, 2019). Defects associated with medication administration problems would be identified and removed to ensure accurate and efficient processes. For instance, technologies for confirming patients and blood before administration would be used to prevent errors.
Blood administration errors have far-reaching effects on a patient’s health. Their cause should be identified and addressed effectively. In the health practice, performance improvement models help health care providers to improve outcomes through a structured approach. The six sigma model would be the most appropriate to address blood administration errors since it focuses on removing defects that reduce value in health care processes.
References
Alkinaidri, A., &Alsulami, H. (2018). Improving healthcare referral system using lean six sigma. American Journal of Industrial and Business Management, 8(2), 193-206.https://doi.org/10.4236/ajibm.2018.82013
Lancaster, E. A., Rhodus, E. K., Duke, M. B., & Harris, A. M. (2021). Blood transfusion errors within a health system: A review of root cause analyses.Patient Safety, 3(2), 78–91. https://doi.org/10.33940/med/2021.6.6
Ross, T. (2019). Applying lean six sigma in health care. Jones & Bartlett Learning.
Medical errors such as blood transfusion errors occur in health care more often than we desire in health care, yet errors occur for a reason of individual error or systematic error. When a medical error happens, it is important to understand the why and the root cause to the error, this is a foundation of quality improvement. In quality improvement one must first understand the why and or cause of the error. Unfortunately, the medical community has been late at implementing quality improvement tools as compared to other industries, yet the Institute of Medicine aims to have achieved the use of QI tools borrowed from other industries such as the PDSA cycle, SWOT analysis or High reliability (Fondahn et al., 2016).
In the scenario discussed of an increase in blood administration errors a useful tool would be to use the Plan, Do, Study, Act cycle or the Plan, Do, Check, Act cycle (Johnson & Sollecito, 2020). The PDSA cycle enables teams to readily implement institute changes, measure and learn from the results, then decide if the process change should be instituted. The Planning stage is the most labor intensive of the PDSA cycle but sets the foundation. The Do phase is the experimental phase where proposed changes happen. The Study phase concentrates gathering date on the process and the Act stage which occurs after learning has been complete but is not the end of the process (Picarello, 2018b). The PDSA tool is a cycle of continual process of retesting the changes, collecting more data to reach the final goal of solution. The PDSA cycle is a tool that is versatile and can be utilized in an individual or system failure process such as increased blood administration errors. As with any QI tool the goal it so has improved outcomes and desired improvement.
Fondahn, E., Lane, M., & Vannucci, A. (2016). The Washington manual of patient safety and quality improvement [e-book]. Wolters Kluwer .
Johnson, J. K., & Sollecito, W. A. (2020). Continuous quality improvement in health care (5th ed.) [e-book]. Jones &Bartlett Learning .
Picarillo, A. (2018b). Introduction to quality improvement tools for the clinician. Journal of Perinatology, 38(7), 929–935. https://doi.org/10.1038/s41372-018-0100-4
