ACTIVITY 2: Occurrence Management
Objective:
To create a procedure for reporting of occurences
To identify probable root causes for a problem in a given scenario
2.1. Construct a simple SOP for the process of reporting errors
2.2 Root Cause Analysis Scenario:
1 unit of PRBC was requested for crossmatching to an anemic patient. The patient was blood type
“A+”, so a PRBC labelled “A+” was pulled out from their stock of blood units. During the cross
matching procedure, there was a mismatch. And so a re-typing of the blood unit was done, and it
was found that the blood bag is actually “B+”. An investigation was done noting the following:
The blood bag was collected from a walk in donor on 10/29/2018. During the specific day
(morning shift) that the blood unit was collected, 11 walk in donors was encountered (average was
0 to 1 daily).
Logbook show the following records
Donor
Blood
Date
Code
type
29/10/2018 WI020
O+
29/10/2018 WI021
A+
29/10/2018 WI022
O+
29/10/2018 WI023
B+
29/10/2018 WI024
B+
29/10/2018 WI025
A+
29/10/2018 WI026
A+
29/10/2018 WI027
B+
29/10/2018 WI028
O+
29/10/2018 WI029
O+
29/10/2018 WI030
O+
HIV
HBV
HCV
SYP
Mal
MT
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
NR
Juan
Juan
Juan
Juan
Juan
Juan
Juan
Juan
Juan
Juan
Juan
At the time of collection of the blood unit (8am), only Juan was on duty at the BSF since the other
2 MTs were at the mobile blood donation and Carla (morning shift MT) was late. Juan just
extended from night duty to cover Carla.
There was no way to verify the blood testing result except for the pre-labelled blood bag.
Anti sera used was near-expiry.
Background:
1. BSF protocol for walk in donations require blood typing using the slide method during the
donor interview. Once the donor passed interview, he is given a pre-labelled blood bag with a label
of his blood type
2. During this period, the laboratory was under
renovation.
3. SOP states that all results written in the logbook must be verified by 2
MTs
Instructions. Do a Root Cause Analysis for the main problem using the scenario.
You may focus on at least 2 factors
MAIN PROBLEM: WRONG BLOOD TYPE LABEL IN BLOOD BAG
SOP ON REPORTING ERRORS
1.
2.
3.
4.
5.
6.
7.
8.
9.
Identify the occurrence
Create incident report regarding the occurrence
Investigate what happened and the possible cause of the occurrence
Analyze the cause of the occurrence
Create Correction
Create Corrective Action
Communication to staff involved
Monitoring
Recording of occurrences
ROOT CAUSE ANALYSIS
1.
2.
3.
4.
5.
Releasing of unit without validation from 2 MTs
Not performing forward typing (tube method) and reverse typing.
Fatigue
Increase workload (Not performing QC on Typing Sera)
Medtech on duty was late (Tardiness)