RCA – Pleasure or Pain - BBTS | Home · Review the SOP 3. Ensure the platelet is quarantined...
Transcript of RCA – Pleasure or Pain - BBTS | Home · Review the SOP 3. Ensure the platelet is quarantined...
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Joan Jones
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What is Root Cause Analysis?
What happened
Why did it happen
What to do to stop it
happening again
Identify exactly what happened
Use problem solving tools to identify the real problem
Identify changes that need to be made to prevent recurrence
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Identify system/process errors
Needed to identify appropriate preventive
actions
Human error (unless lack of training) more
difficult to put right and can be considered as
a weak preventive action
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4
18%
14%
0%
1%
36%
30% 1. BMS working in the lab
2. Transfusion Lab Manager
3. TP (BMS background)
4. TP (Nursing background)
5. Quality
6. Other
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5
63%
37% 1. No
2. Yes
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6
10%
0%
18%
25%
46% 1. 5 whys
2. Tabular time line
3. Fishbone
4. Change analysis
5. None of the above
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7
11%
63%
26% 1. Process error
2. Human error
3. Don’t know
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8
10%
90% 1. Yes
2. No just report to SABRE/SHOT
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9
5%
95%1. Look at other parameters
2. Continue with the report as this is a “red herring”
Accept that platelet counts around 10 are notoriously unreliable
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10
34%
66%
0% 1. Yes
2. No
3. More information needed
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Wrong FBC result associated with patient and patient had an unnecessary platelet transfusion
Sample incorrectly labelled (WBIT)
Nurse labelled sample away from the patient’s bed side
Mobile computers don’t hold charge well
Don’t hold charge well because they are always plugged in
The carts are difficult to fit into the single rooms
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12
17%
44%
40% 1. SAR noting an unnecessary tx as well
2. Unnecessary tx noting a SAR as well
3. Don’t know
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4%
96% 1. Yes
2. No
Would you investigate?
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14
68%
32%
0% 1. Nothing
2. Use the 5 whys tool to help determine the cause of the issue
3. Start a timeline to determine the timing of events
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15
99%
1%
0% 1. Nothing - You have found the root cause
2. Suspend the BMS until they are able to explain their actions
3. Use the 5 whys tool to determine the reason for this failure to follow the SOP
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The BMS was new to night shifts
Failure to use the barcode scanner to input the patient information
BMS used a lab PC which didn’t have a barcode scanner attached
Error compounded by BMS not asking for help when they couldn’t resolve an earlier mistake
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17
27%
25%
29%
19% 1. SABRE
2. SHOT
3. Both
4. Neither
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18
98%
0%
2%1. Place units back into stock and mark as
not used
2. Place units in an issue fridge case the patient needs blood in the next 24hrs
3. Discard all units
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19
60%
4%
10%
26% 1. Tell theatre they can only have blood when they are ready to transfuse
2. Only send 1 unit to theatre packed in a box
3. Buy boxes that you can validate for longer than 6 hours
4. Get an issue fridge in theatre so this cant happen again
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20
10%
90% 1. Yes
2. No
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21
45%
20%
35%
0%1. Nothing
2. Discuss with the Blood Service consultant
3. Discuss with the local haematologist
4. Tell the patients consultant that a bacterial positive platelet has been transfused to their patient
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22
79%
16%
3%
3%1. Discuss with the staff and understand
why it happened
2. Review the SOP
3. Ensure the platelet is quarantined prior/same time as responding to the BS
4. All of the above