NUR 300 DCN Wk 9 Blood Transfusion Incidents Prevention Root Cause Analysis

NUR 300 DCN Wk 9 Blood Transfusion Incidents Prevention Root Cause Analysis




In this written assignment, you will explore a patient incident using root cause analysis.

Step 1 Read the scenario.

Read the Root Cause Analysis Scenario Handout (assignment 9.1a) attached below.

Step 2 Complete the chart.

You have been charged with leading the interprofessional team that will investigate Mr. Jones’s issue. Your analysis should focus on systems and processes, not individual performance. Complete the Root Cause Analysis Chart (assignment 9.1b) attached below. NUR 300 DCN Wk 9 Blood Transfusion Incidents Prevention Root Cause Analysis

Step 3 Develop a plan of action.

Based on your investigation, develop a two-page (minimum) plan of action detailing the recommendations the team makes. Your plan should answer the question “What can be done to prevent a similar incident?”

*This must be in the required professional paper format, including title page and reference page, showing evidence-based research supporting your recommendations or interventions you propose.

*Important: Use this Sample Paper as a template for format your assignment to prevent unnecessary point deduction. Attach the completed “Root Analysis Chart” to the end of your paper as an appendix

Handout for Assignment 9.1: Root Cause Analysis Scenario


For your assignment, read the scenario below.



John Jones requires a blood transfusion due to hemorrhage following a motor vehicle accident. The physician enters the order for blood to be drawn for a type and cross-match and then to transfuse one unit of packed red blood cells using computerized physician order entry. The nurse confirms the order for the blood work and prints the laboratory forms and stickers. The nurse gives the laboratory forms to the student nurse technician and asks him to draw blood on Mr. Jones and send it to the laboratory. The student nurse technician reviews the chart and confirms the order for blood work.


When the student nurse technician arrives at John’s semi-private room, he has to wade through several family members to reach the patient’s bed. John seems distracted by the questioning of his well-meaning family members. So the student, not wanting to interrupt their discussion, quickly asks the patient if his name is Mr. Jones. John responds with a simple yes while continuing his discussion with his family. With just the verbal confirmation and without checking the patient’s ID band, the student nurse technician proceeds to draw the blood and send it to the laboratory.


When the blood arrives on the unit two hours later, the nurse performs a cross check with another nurse to confirm the patient name, unit number, and blood type on the blood and the blood slip. They then go the patient’s room to administer the blood. The nurse asks the patient his name and he states, John Jones, which matches his ID band. The two nurses then check the ID band against the blood and the medical record. All names match. The nurses continue with their bedside check and hang the blood.


Within minutes of hanging the blood, Mr. Jones begins to complain to shortness of breath. The nurse immediately stops the blood and begins infusing normal saline. She notifies the physician and the blood bank of a possible transfusion reaction. The physician immediately comes to see the patient, who responds well to treatment. The blood bank reports that the blood and tubing that were returned to them did not match the patient’s blood type. NUR 300 DCN Wk 9 Blood Transfusion Incidents Prevention Root Cause Analysis