VA GAPS Center - OR Refrigerator Analysis

     Competing demands can co-exist on a daily basis between the patient care practitioner and the organization. Predictably, the conflict eventually may result in failures with direct safety consequences. In the sharp end/blunt end dichotomy, conflicting incentives and demands are usually managed without incident as workers actively and intuitively create safety through workarounds, detection, anticipation of hazard, and recovery from mis-assessments and mis-communication. However, in the OR Refrigerator case the ongoing gap between the sharp and blunt end eventually resulted in a system failure with direct patient consequence:

• Resource constraints, time pressure and production pressures influenced the organization's delay in replacing the OR blood refrigerator
• Blood refrigerator out of commission with ongoing problems over the past three years
• Sharp end created workaround by getting blood needed in surgery directly from the blood bank
• Incident involved surgery that occurred after normal operating hours
• Policy authorized lab to release only one uncrossed unit at a time
• In OR nurse is required to scan each unit according to hospital policy but due to gravity of patient condition anesthesiologist wanted blood transfused without scanning