Sample errors
Request errors
Ward issues • Nursing shortages and staffing issues • Dependency of patients • Pressure on beds - transfusions at night • High stress levels - mistakes made • Areas where high nurse:patient ratios not exempt from error - problems confirming patient identity
Blame free’ culture
events to be fully analysed to determine root cause analysis
Root Cause Analysis (RCA) • RCA is a structured investigation that aims to identify the true cause (s) of a problem, and the actions necessary to eliminate it (Anderson and Fagerhaug 2000) • RCA takes a systems view of incidents – moving away from blaming individuals • Look at what, how and why it happened
Education and training • Education and training to implement policies and procedures into practice – nurses, HCA’s, phlebotomists – BMS’s and Doctors at every level – tailored for specialist areas – Transfusion Practitioner’s – patients
Communication • Communication at all levels e.g.re special requirements and between hospitals when patient care is shared – appropriate – timely – effective
Request errors
Ward issues • Nursing shortages and staffing issues • Dependency of patients • Pressure on beds - transfusions at night • High stress levels - mistakes made • Areas where high nurse:patient ratios not exempt from error - problems confirming patient identity
Blame free’ culture
events to be fully analysed to determine root cause analysis
Root Cause Analysis (RCA) • RCA is a structured investigation that aims to identify the true cause (s) of a problem, and the actions necessary to eliminate it (Anderson and Fagerhaug 2000) • RCA takes a systems view of incidents – moving away from blaming individuals • Look at what, how and why it happened
Education and training • Education and training to implement policies and procedures into practice – nurses, HCA’s, phlebotomists – BMS’s and Doctors at every level – tailored for specialist areas – Transfusion Practitioner’s – patients
Communication • Communication at all levels e.g.re special requirements and between hospitals when patient care is shared – appropriate – timely – effective
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