Friday, November 19, 2021

root cause analysis

Known as RCA in businesses, it is a series of meetings involving all parties who are part of a bad consumer or client outcome.  I have a story to tell about my one and only experience.

I was the transfusion service supervisor for CHS or MHS at the time and a patient died when the surgical crew all left and she was in post-op.  The nurse who was all up in the middle of it testified that she was alone at one time with this patient.  There was another surgery involved to try and correct what went wrong but it didn't work.

Surgery and anesthesia blamed our department for a delay in treatment because the lab techs requested a new sample to make sure it was right.  BTW, I was off that day.  The surgeon and all of his staff denied knowing about our emergency release policy, aka Red Tag,  Yet I had his signature on about 50 releases during the time he was practicing.  I had just had a fight with my daughter on the phone prior to this meeting and I was about tore up before we ever went before the firing squad. No pathologist present.  Just me and my boss.  And an administrator who demanded I be fired after I left the meeting in tears.  That did not happen.  

We were blessed with an abundant supply of blood and blood products from Jackson.  There were times when we got low but mostly we got what we ordered.  Enough to cover trauma and childbirth and anemic old folks.  I noticed a trend toward the end of my career of physician orders for not two but one unit.  Pump 'em up and get 'em out.  Type and screens are required for every transfusion and the record keeping is meticulous on who has what antibody.  Blood is kind of like a transplant where your body can reject it it things don't match up just right.  The more you are transfused, the more likely you are to produce antibodies against other blood groups.

This is a bonus post because I wasn't done yet after the rage.  I have a fiesta bowl in the oven from Los Portales staying warm for when I'm ready to eat.  Like most everyone else, I am weary.  Yet I am thankful to rediscover the things that I love like reading.  I celebrate me and enjoy whatever I'm doing at the time.  And that is what it's all about ^j^




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