Were the team members, namely, the physician, nurses, the student technician, and laboratory technicians responsible for an adverse event to Mr. Jones. As a team, they are all responsible for the adverse event to the patient since there was poor coordination in the process of drawing blood from the patient and confirming whether the blood group for the patient was the correct one The causal factors for the incident were that the student technician did not confirm all the patient's names before drawing blood from the patient. There was also an incorrect patient name marked on the blood that was transfused to the patient. The other causative factor is that the transfused blood caused a clot in the patient's arteries leading to the catastrophic event to the patient (Armstrong, 2017).
What is the chronological description of the event The event took place when the student technician asked the patient his name. He only requested to know one name from the patient. However, since the first names of one patient may be similar to that of others, this leads to confusion of the actual patient who required the transfusion. The student technician also did not confirm the patient's identification using the patient's ID band leading to the wrong patient to be recognized as the one that needed a blood transfusion. After two hours, nurses doing the blood check did not confirm the patient's full name by asking the student technical the full names of the patient. This led to the wrong blood to be sent to the lab and the subsequent adverse event for transfusing the wrong blood to the patient, who may not have needed a blood transfusion. One causative factor for the event was that the student technician did not confirm the patient's ID names from the ID band. Nurses did not also confirm the ID of the patient by asking the student technicians the full names of the patient as per the ID band.
When did the event happen? The event occurred immediately after the blood was transfused to the wrong patient who suffered a cardiac and respiratory problem. There was poor coordination among team members on matters dealing with the identification of the patient that needed a blood transfusion. There was negligence by the student technician who made the physician to transfuse the wrong blood to the patient.
Where did it happen? The event happened minutes after the transfusion had been initiated. The patient suffered a cardiac and respiratory problem due to a clot since the blood that was given to him was not his blood group.
What is the severity of the actual or potential harm? The event is a typical blood transfusion error that occurs due to negligence and lack of attention to detail by medical professionals. The potential harm was a cardiac arrest for the patient The event was caused due to lack of adherence to the appropriate procedure stipulated in the identification of patients that need a blood transfusion.
What is the chance it will happen again? There are high chance of the event happening again if nurses do not follow the required process of ensuring they have the correct information before blood is drawn from a patient and taken to the lab to match the blood group of the patient. Thus, to avoid it, student technicians should be supervised (Armstrong, 2017). Lack of adequate skills and experience by the student technician on the protocol that should be followed when identifying patients
What are the consequences? The consequences are a lawsuit for medical malpractice against the facility. The facility failed to put in place adequate measures to prevent adverse events that are caused by wrong blood transfusion leading to legal actions against the facility due to vicarious liability (Justin, n.d).
What is the plan of action? Train all medical staff on the protocols that should be followed in patient identification and blood transfusion procedures. Poor training of student technicians on blood transfusion procedures and identification of patients.
Armstrong, B. (2017). Benefits and risks of transfusion. ISBT Science Series, 3(2), 216-230, 2008. Retrieved from https://doi.org/10.1111/j.1751-2824.2008.00199.x
Justin, W. (n.d). Blood transfusion error/mistake. Retrieved from https://www.southflinjury.com/blood-transfusion-error-mistake.html
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