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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

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