Root cause analysis of transfusion error: identifying causes to implement changes.
Identifieur interne : 002613 ( Main/Exploration ); précédent : 002612; suivant : 002614Root cause analysis of transfusion error: identifying causes to implement changes.
Auteurs : Priti Elhence [Inde] ; S. Veena ; Raj Kumar Sharma ; R K ChaudharySource :
- Transfusion [ 1537-2995 ] ; 2010.
Descripteurs français
- KwdFr :
- MESH :
English descriptors
- KwdEn :
- MESH :
- methods : Risk Management.
- prevention & control : Medical Errors.
- standards : Blood Transfusion, Risk Management, Safety.
- statistics & numerical data : Blood Transfusion.
- Humans, Transfusion Reaction.
Abstract
As part of ongoing efforts to improve transfusion safety, an error reporting system was implemented in our hospital-based transfusion medicine unit at a tertiary care medical institute. This system is based on Medical Event Reporting System-Transfusion Medicine (MERS-TM) and collects data on all near miss, no harm, and misadventures related to the transfusion process. Root cause analyses of one such innocuous appearing error demonstrate how weaknesses in the system can be identified to make necessary changes to achieve transfusion safety.
DOI: 10.1111/j.1537-2995.2010.02943.x
PubMed: 21128948
Affiliations:
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Le document en format XML
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<term>Gestion du risque ()</term>
<term>Gestion du risque (normes)</term>
<term>Humains</term>
<term>Réaction transfusionnelle</term>
<term>Sécurité (normes)</term>
<term>Transfusion sanguine ()</term>
<term>Transfusion sanguine (normes)</term>
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<term>Transfusion sanguine</term>
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<front><div type="abstract" xml:lang="en">As part of ongoing efforts to improve transfusion safety, an error reporting system was implemented in our hospital-based transfusion medicine unit at a tertiary care medical institute. This system is based on Medical Event Reporting System-Transfusion Medicine (MERS-TM) and collects data on all near miss, no harm, and misadventures related to the transfusion process. Root cause analyses of one such innocuous appearing error demonstrate how weaknesses in the system can be identified to make necessary changes to achieve transfusion safety.</div>
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<name sortKey="Sharma, Raj Kumar" sort="Sharma, Raj Kumar" uniqKey="Sharma R" first="Raj Kumar" last="Sharma">Raj Kumar Sharma</name>
<name sortKey="Veena, S" sort="Veena, S" uniqKey="Veena S" first="S" last="Veena">S. Veena</name>
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<country name="Inde"><noRegion><name sortKey="Elhence, Priti" sort="Elhence, Priti" uniqKey="Elhence P" first="Priti" last="Elhence">Priti Elhence</name>
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