first antecedent

Phlebotomist mislabeled sample at bedside, misspelling patients first name.

Root Cause Code - X

Root Cause description "Contributing factor beyond anyones control"

X refers to failures that cannot be classified in any of the current categories (unclassifiable).

In this example, the fact that the patients name had an unusual spelling is clearly beyond anyones control and is unclassifiable

Root Cause Code - HEX

Root Cause description "Human factor external to the transfusion service"

HEX root causes refer to human failures originating beyond the control and responsibility of the investigating organization.

• For a blood center, this could apply to actions by individuals in hospitals.
• For a transfusion service, this could apply to failures by individuals from another department such as the emergency room.

In this example, the fact that the review protocol was not followed successfully by the phlebotomist indicated a problem outside the scope of the transfusion services responsibility.