Root Cause Analysis

 

Scenario For your assignment, read the scenario below. Scenario: 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. 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. ADDRESS THESE QUESTIONS List team members. (Include name, title, and rationale for inclusion on team) Give a chronological description of the event Based on your investigation, develop a minimum two-page plan of action, not counting the title or reference page, detailing the recommendations your team makes. Your plan should answer the question "What can be done to prevent a similar incident?" Use research to develop reliable and evidence-based interventions to put into place to prevent re-occurring​‌‍‍‍‌‍‍‌‍‌‌‍‍‍‌‍‌‌‌‍​ situation.

 

Sample Solution

ex: Fatah), Hamas dispenses with a whole logistic, propaganda and military arsenal to achieve the proposed goals.
In this area (West Bank, Gaza), the group has a number of regional and secondary centers. The infrastructure of the organizational framework presupposes :
‘ Fundraising and distribution infrastructure, as well as the organization of meetings (Daiwah)
‘ The security infrastructure (Amn; Jehaz Amn), which has direct responsibility for providing logistical and informational support to combat collaborators and spies. They also organize the interrogations and assassinations of important personalities.
‘ Propaganda publications (Al-Alam), which communicate the organization’s press releases, media and propaganda.
‘ The ‘Izz Ad-Din Al-Qassam’ brigades (I.D.B.Q.), which represent the military wing of the movement established in 1992.
‘ Palestinian fighters (Al-Majahadoun Al-Falestinioun) are the lance group made up of fighters who commit and coordinate terrorist attacks.
As for the military and security apparatus, Hamas has the following structure :

Hamas Organization (Fig.1)

The organization is a hierarchical structure that imitates the correct stratification of any contemporary modern army. The main command centers in Gaza-Damascus are found in cooperation and coordination relations, this bicephal leadership being a real logistic and strategic advantage. From a numerical point of view, if we quantify security forces, police and IDQBs, most studies claim Hamas has 15,000-16,000 potential combatants. Of these, the elite of the operational fighters consists mostly of I.D.Q.B.s, which are between 2,000 and 3,000 fighters . The I.D.Q.B. is organized in 6 brigades that have hierarchically subordinated battalions, which in their turn plutoane. If we compare the Hamas with the other groups in the area (Hezbolah or Al Fatah), it has the widest military staff .
Undoubtedly, we can argue that Hamas has impressive military capabilities. Without exaggerating, in terms of arms and military tactics used, they are comparable to many state armies. In terms of weapons, a true scientific study by Yiftah S. Shapir, entitled Hamas Weapons , shows that the organization uses a

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