second antecedent

Clerical staff checking in samples did not notice misspelled name

Root Cause Code - OK

Root Cause description "Problem with training of individual"

OK stands for organizational knowledge, which applies to knowledge failures that result from inadequate measures taken to ensure that situational or site-specific knowledge or information is transferred to all new or inexperienced staff.

In this example, the clerk demonstrated a lack of knowledge and need for additional training about the importance of checking the sample label against the paperwork.

Root Cause Code - HRI

Root Cause description "Protocol not carried out correctly"

HRI refers to a human rule-based intervention. Intervention failures result from faulty task planning and execution. This would be selecting the wrong rule or procedure (planning) or executing the prodedure incorrectly.

In this example, the protocol for entering information was not followed correctly.

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 handwriting of the phlebotomist was difficult to read was a problem that fell outside the scope of the transfusion service.