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Case Study A8 - Root Cause Analysis - Answer (Question 2)

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Home Case Studies A-Level Case A8: Severe Hemolytic Transfusion Reaction Involving a Student Case Study A8 - Root Cause Analysis - Answer (Question 2)
Saturday, 25 March 2017

Case Study A8 - Root Cause Analysis - Answer (Question 2)

Suppose that a RCA revealed that a transfusion reaction occurred for the following cause:

The nurse failed to notice that a unit of RBC had been out of the refrigerator and left sitting at room temperature for 3 hours and started to transfused it instead of returning it to the transfusion service.

How may such a root cause be coded using the MERS-TM codes?

The MER-TM code could be HRV:

  • Active Errors (Human)--> Rule Based Behavior -->Verification -->code HRV

    • HRV definition: The correct and complete assessment of a situation including related conditions of the patient/donor and materials to be used before beginning the task. An example would be failure to correctly identify a patient by checking the wristband.

Reference: MERS-TM codes

To suggest other codes, please e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Last modified on Thursday, 30 December 2010 11:21