Reference no: EM133527877

Case Study: This is interesting that we have this question. My reasoning is about a year ago our blood administration process changed. Now that I look back, I wonder if it was due to an increase in errors and if they did a performance improvement and found a better process to administer blood with fewer errors. It could go either way being an individual failure or a system failure. Technology is great, but only when it works, we are humans and humans make mistakes. I chose the model for improvement. With this model, three simple questions are linked with testing involvement or new revolution and using the plan, do, study, act (PDSA) cycle (Fondahn et al., 2016). The three questions involve what the end goal is, how will we know that the change made advancement, and what kind of change needs to happen to make it progress. This model breaks it down into steps so that every piece of the puzzle is discussed. First off, what are we trying to accomplish for this scenario would be to decrease blood administration errors. Next, how do we know that the change worked? That would be done by also adding the PDSA cycle. The PDSA cycle is an efficient tool that provides detailed steps in testing changes and advocates analytical thinking (Fondahn et al., 2016). Finally, what can be done to improve happen? Also, keep in mind this seems like three simple steps, but it will take time and effort to make this model successful. Despite extensive teaching and training around change management to healthcare leadership and management, change efforts often crash, change exhaustion is considerable and lack of adequate change management is cited as a serious cause of initiatives that fail (Harrison et al., 2021).

Question 1: What is your comment/feedback on this statement. Please add 1 reference.

Question 2: FYI, this is question of this answer: Your unit data reflect an upward trend in blood administration errors. Is this likely an individual failure or a system failure? Which performance improvement theory or model would you use to address it?