In Case 30 (SHOT 2003) it appears that a general duty technologist who did not normally work in the transfusion service (TS) incorrectly interpreted a positive antibody screen and wrongly issued crossmatch-compatible blood instead of identifying the antibody and crossmatching antigen-negative units.
What are possible ways that the root cause(s) of this event could be coded using MERS-TM codes? (refer to MERS-TM codes)
More information is needed. For example:
Was the on-call technologist trained to perform pretransfusion testing? Presumably initial training occurred, and presumably the technologist should have been able to recognize appropriate action for a positive antibody screen.
When did training occur?
Were relevant SOPs and training aids available in the laboratory (e.g., investigative flowcharts; instructions for when to call for help, etc.)?
Was ongoing refresher training provided, and if so, when was the technologist's last training session?
Did the TS provide regular competency assessment for its staff, including on-call general duty technologists?
Assuming that both regular refresher training and competency assessment were not provided, possible MER-TM codes include:
- Active Errors (Human)--> Knowledge Based Behavior -->Knowledge Based Errors -->code HKK
- HKK definition: Inability of an individual to apply their existing knowledge to a novel situation.
- Latent Errors (Human)--> Organizational -->Transfer of Knowledge--> code OK
- OK definition: Failures resulting from inadequate measures taken to ensure that situational or site-specific knowledge or information is transferred to all new or inexperienced staff.
- Active Errors (Human)--> Rule Based Behavior -->Qualifications--> code HRQ
- HRQ definition: A mismatch between an individuals qualification, training or, education and a particular task. An example would be expecting a, technician to solve the same type of difficult problems as a, technologist.
Assuming that regular refresher training and competency assessment were provided, possible MER-TM codes include:
- Active Errors (Human)--> Skill Based Behavior -->Slip -->code HSS
- HSS definition: Failures in the performance of highly developed skills.