What Went Wrong
This is how the ABO blood type mismatch occurred.
What is communication, improper safety checks, and blood verification?
This ethical principle was violated when pt was not protected from preventable harm.
What is non-maleficence?
These actions by the nurse could have been done to prevent the error.
What is verifying patient blood type, verifying identity, and double checking protocols?
The case led to the Jesica Santillan Foundation to advocate for this group.
Non -English speaking
Organization that coordinates organ distribution.
What is UNOS (United Network For Organ Sharing)?
Duke was criticized for their lack of this.
What is transparency?
This is how the nurse would verify the patients blood type before surgery.
What is make sure there has been a recent blood draw to test for type and antibodies?
What is two person verification at bedside?
After the accident, Duke made a new computer system that requires this before the organ can be accepted.
What is Electronic Verification?
The second transplant failed because this condition caused brain damage.
What is Cerebral Edema?
A debate came up when Jesica moved to the top of this list.
What is the Organ Waitlist?
This refers to your duty as a nurse to stand up for your patient.
What is Patient Advocacy?
This double check system is used to verify blood types.
What is Redundant Verification?
The delayed identification of incompatibility worsened Jesica's condition in this way.
What is allowed her immune system to build up a rejection response.
This legal process was questioned due to the family not understanding the risks of transplant 1.
What is Informed Consent?
This check must be done in order to verify patient, compatibility, and procedure.
What is Surgical time out?
This saying describes the no-fault culture.
What is Just Culture?