Essentials of Evidence-Based Practice NURS 6052N-2 Essentials of Evidence-Based Practice, Study Guides, Projects, Research of Nursing

Download Essentials of Evidence-Based Practice NURS 6052N-2 Essentials of Evidence-Based Practice and more Study Guides, Projects, Research Nursing in PDF only on Docsity! Running head: WRONG BLOOD IN TUBE 1 Course Project: Wrong Blood in Tube Fidelis Orji Walden University Essentials of Evidence-Based Practice NURS 6052N-2 Dr. Sue Hunter October 24, 2017 WRONG BLOOD IN TUBE 2 Identifying a Researchable Problem The aim of this project is to evaluate and comprehend how efficient, immediate labeling of blood tube specimens can be. This project will look into the dangers of mislabeling and not labeling blood tubes immediately after collection. The expected results from this project will give a better understanding of the numerous interventions and steps available for the nurses to improve the safety of patients. Problem Statement Patient misdiagnosis is a huge problem in the healthcare sector. Patients can end up injured or killed due to carelessness in hospitals or clinics. According to Varey, Tinegate, Robertson, Watson, and Iqbal (2013), wrong blood in tube (WBIT) is when blood is taken from one patient but has a different patient’s information affixed to the tube. This action can create harm to patients. In 2011, 469 reports of WBIT were received by the Serious Hazards of Transfusion in the United Kingdom. Clinicians labeling away from the bedside accounts for 44% of WBIT (Varey et al., 2013). Mistakes happen, but the two main factors of WBIT are the failure to label accurately and not affixing patient’s identification on the tube at the bedside (Miller, 2014). The dialysis unit at Atlanta Medical Center can be very chaotic with patients who are about to get transplants needing dialysis and blood draws are needed. The dialysis unit is a mid- size room which can take up 12 patients and beds at a time. The tendency to mix patient’s blood samples after collection is quite high; this could be by leaving a blood sample on the hemodialysis machine without a label which is quite prevalent on the unit or due to the chaotic nature of the unit distraction can lead to collecting blood sample on the wrong patients. It has WRONG BLOOD IN TUBE 5 Week 5 Project: Literature Review Literature reviews are carried out for various reasons. According to Polit & Beck (2017), some researchers perform literature reviews due to personal curiosity or the perks it adds in everyday life. This literature review will expatiate on the causes of wrong blood in tubes (WBIT) and possibly how to prevent it. The question is how the hospital and dialysis unit can prevent WBITs. This question will help to explore things that the hospital and dialysis unit can reduce or eradicate such errors that could prove fatal. Medical errors are prevalent in the United States of America, and they can lead to injuries or death of patients who come to clinics or hospitals for care (Doctor & Strylewicz, 2010). According to Doctor & Strylewicz (2010), medical errors claim more lives than automobile accidents, cancer, and AIDS altogether. Literature Reviews The first article reviewed: Blood bank specimen mislabeling (Novis et al., 2017). The objective of this study was to evaluate blood bank mislabeling rate or switching one patient’s blood with another. In this study, 30 institutions turned in their data on 41,333 blood specimen to the American Pathologist Probes program for the first quarter of 2015. It was observed that out 41,333 specimens 306 specimens had mislabeling and ten specimens out of 23,234 collected had WBIT issues. The researchers discovered that mislabeling occurred very few times in hospitals that require specimens to be identified with the patients’ birth dates compared to those who did not. The second article: Factors predisposing to wrong blood in the tube incidents: A year’s experience in the North East of England (Varey, Tinegate, Robertson, Watson, & Iqbal, 2013). The study evaluates the harm WBIT poses to patients. Hospitals in the North East region were WRONG BLOOD IN TUBE 6 asked to submit the documents detailing WBIT within a 12 month period in 2011. The Serious Hazards of Transfusion (SHOT) received 469 reports. The researchers learned that 48 WBITs occurred within a 12 month period and physician accounted for 24 of 45 WBITs. This study discovered that the primary cause of WBIT was due to sample collectors labeling specimens away from the bedside. This study was carried out due to concerns from hospitals in the North Eastern region of England over the rate of specimens that were collected improperly. The third article reviewed: ‘Wrong blood in tube’: solutions for a persistent problem (Ansari & Szallasi, 2011). In this study, the objective was to determine the occurrence of WBITs at Monmouth Medical Center. The study aims to assess the effectiveness of safe methods enforced in 2006. The method used in this study was the collection of data from 2005 to 2009. The researchers found that within a four-year period, 59,373 samples were collected and 0.04% of the significant errors were WBITs. It was recorded that 8 of the errors from the 0.04% were due to errors in typing results. The hospital mandated in 2006 that two witnesses (nurses) must check all blood sample collections. Implementing a two verifier program has helped decrease the rate of WBITs from 11 in 2006 to 5 in 2007, but the WBITs have not been eradicated. It was concluded that WBITs is still the primary cause of wrong blood transfusion at Monmouth Medical Center. The fourth article evaluated: Delta checks for blood groups: A step ahead in blood safety (Makroo & Bhatia, 2017). A delta check is a tool used compare test results from laboratories; it is also used to compare results obtained from previous samples with the same patient. The researchers obtained records of all incidents related to blood transfusion in Indraprastha Apollo Hospital in New Delhi, India from 2008 to 2014. The number of blood transfusion errors filed within six years was 17,034. Some blood grouping errors recorded was 0.22%; out of the 38 WRONG BLOOD IN TUBE 7 blood grouping errors, 0.12% of the error was due to failed delta checks. The failed delta checks proved that a single sample resulted in multiple results. Mislabeling happened, precisely, WBIT occurred 11 times. In conclusion, it delta checks happen to be quite effective in revealing blood group errors and how to prevent clerical mistakes that could lead to the wrong transfusion. The fifth article: Mislabeled samples and wrong blood in tube: A Q-probe analysis of 122 clinical laboratories (Grimm et al., 2010). The objective of this study was to evaluate the rate of mislabeled and WBIT samples that presented for ABO blood typing. The study is also to inquire about the identification of patients and labeling techniques being implemented. The design of this study involved 122 institutions which submit specimens for typing within a 30- day period. It was discovered that mislabeling among the 122 institutions occurred at a rate of 1.12%. It was discovered that mislabeling occurred very few times in institutions that require specimens to be affixed with the patients’ first name, last name, and unique identifiers compared to those who did not. Summary According to Ansari and Szallasi (2011), WBIT is the leading cause of wrong blood transfusions in hospitals and clinics. Errors such as mislabeling of specimens can result in a transfusion reaction, injury or death (Novis et al., 2017). It has been discovered that affixing a barcode on patients’ specimens decreases the probability of misidentification of specimens (Novis et al., 2017). According to reviews it has been discovered that WBIT occurs at a low rate but more can still be done to prevent further WBITs; so far so practice or technique has been able to eliminate WBITs. The dialysis unit in my hospital is already insisting on immediately labeling of samples before leaving the patients' bedside and the stationing of laboratory printer at the nurses station. WRONG BLOOD IN TUBE 10 reduce WBITs in the hospital not just reduction of WBITs but creates an environment of safety first. Dissemination of Information The studies and research conducted in this paper will be sent to the dialysis manager first to peruse and subsequently to the nurse to examine. After sending the evidence to the staff, the next step will be to discuss the evidence at a staff meeting which will not just involve clinicians from the nephrology department but from all the departments in the hospital to capture a wider audience. Evidence-based practice buttress providing safe and quality care. The evidence located in the research will be sent out or circulated to help improve a safe practice of labeling by the bedside and not leaving unlabeled tubes with blood on the dialysis machine. According to Polit & Beck (2017), evidence can be dispersed via different mediums such as written (Pamphlets, emails, new letters, and posters) or verbally during a staff meeting. Written information can be dispersed easily and will reach the intended audience almost immediately due to today’s high-speed technology. Verbally disseminated information can be quite important when done in a professional setting such as a conference. Information dispersed both verbally and written would be useful if it is done in a large setting and so that both speech and visual presentation of the evidence from the research will hit many people in a short space of time. The audiences at the conference are also able to make concerns known and ask questions on pressing issues regarding WBITs. Conclusion WRONG BLOOD IN TUBE 11 This paper has expatiated on identifying a problem which is very serious in healthcare, and it is wrong blood in tubes (WBITs). The PICOT question was made up to see how hospitals can prevent WBITs and there are many articles on WBITs with various evidence-based practices which helps to provide safe patient care. In one of the articles, we see that WBITs were reduced in the hospital but not eliminated. Changes can be done in bits as long as they are better and improve quality of care (Spath, 2013). WRONG BLOOD IN TUBE 12 References Ansari, S., & Szallasi, A. (2011). ‘Wrong blood in tube’: Solution for a persistent problem. International Journal of Transfusion Medicine, 100(1), 298-302. Doctor, J., & Strylewicz, G. (2010). Detecting ‘wrong blood in tube’ errors: Evaluation of a Bayesian network approach. Artificial Intelligence in Medicine, 50, 75-82. Grimm, E., Friedberg, R., Wilkinson, D., AuBuchon, J., Sounes, R., & Lehman, C. (2010). Mislabeled sample and wrong blood in tube: A Q-probes analysis of 122 clinical laboratories. Archives of Pathology & Laboratory Medicine, 134, 1108- 1115. Makroo, R., & Bhatia, A. (2017). Delta check for blood groups: A step ahead in blood safety. Original Article, 11, 18-21. Miller, W. (2014). Strategies to reduce wrong blood in tube incidence. Zebra, 1(1), 1-5. Novis, D., Lindholm, P., Ramsey, G., Alcorn, K., Souers, R., & Blond, B. (2017). Blood bank specimen mislabeling. Archives of Pathology & Laboratory Medicine, 141(1), 255-259. Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Wolters Kluwer. Spath, P. (2013). Introduction to healthcare quality management (2nd ed). Chicago, IL: Health Administration Press Varey, A., Tinegate, H., Robertson, J., Watson, D., & Iqbal, A. (2013). Factors predisposing to wrong blood in tube incidents: A year’s experience in the north east of England. Transfusion Medicine, 23(1), 321-325.