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