Adverse Event Summary It was a normal day on the unit. It was hectic and every room was filled with apatient. We typically do not put two patients who are both receiving blood transfusions in adouble room together, but we had no choice this day. The nurse who was involved in this eventwe 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 thepatients identity with the lab tech. On this particular day, the lab tech working happened to beSusie’s friend. The lab tech drew the cross and type, and the RN bypassed the co-sign “becauseshe trusted the lab tech” because they were friends. The lab tech put the sticker from patient Bon 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 aprevious transfusion did not match this cross and type, and ordered a redraw. If he would nothave been paying attention to detail, patient B would have received patient A’s blood type, andcould have potentially died. In the situation, I do not see any evidence of role ambiguity or roleconflict 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 drawbut chose not to, but she did not make that decision to hurt the patient on purpose, she wascutting corners because she knew the lab technician working. When people go into healthcare, theydo it because they want to help people, not hurt them intentionally (MedStar Health, 2014). Ajust 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 correctiveaction, and was notified that she would be terminated if there are any further incidents such asthese. She was also mandated to repeat blood transfusion education and the policy related totransfusions 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 importantto remember that after an event occurs, and treat mistakes as opportunities for improvement. ReferencesMedStar 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. Retrievedfrom http://www.outcome-eng.com/wp-content/uploads/2012/01/manage-riskRussell, 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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