Implementation of an event reporting system in a transfusion medicine unit: a local experience.
Identifieur interne : 003058 ( Main/Exploration ); précédent : 003057; suivant : 003059Implementation of an event reporting system in a transfusion medicine unit: a local experience.
Auteurs : Mary F. Usin [Malaisie] ; Prathiba Ramesh ; C G LopezSource :
- The Malaysian journal of pathology [ 0126-8635 ] ; 2004.
Descripteurs français
- KwdFr :
- MESH :
English descriptors
- KwdEn :
- Academic Medical Centers, Blood Transfusion (standards), Data Collection, Database Management Systems, Hospital Information Systems, Humans, Malaysia, Medical Errors (classification), Medical Errors (prevention & control), Medical Errors (statistics & numerical data), Risk Management (methods), Risk Management (statistics & numerical data), Safety, Transfusion Reaction.
- MESH :
- classification : Medical Errors.
- methods : Risk Management.
- prevention & control : Medical Errors.
- standards : Blood Transfusion.
- statistics & numerical data : Medical Errors, Risk Management.
- Academic Medical Centers, Data Collection, Database Management Systems, Hospital Information Systems, Humans, Malaysia, Safety, Transfusion Reaction.
Abstract
Event reporting can provide data to study the failure points of an organization's work process. As part of the ongoing efforts to improve transfusion safety, a Medical Event Reporting System Transfusion Medicine, (MERS - TM) as designed by Kaplan et al was implemented in the Transfusion Medicine Unit of the University Malaya Medical Centre to provide a standardized means of organized data collection and analysis of transfusion errors, adverse events and near misses. An event reporting form was designed to detect, identify, classify and study the frequency and pattern of events occurring in the unit. Events detected were classified according to Eihdhoven Classification model (ECM) adopted for MERS - TM. Since our system reported all events, we called it Event Reporting System - Transfusion Medicine (ERS-TM). Data was collected and analyzed from the reporting forms for a period of five months from January 15th to June 15th 2002. The initial half of the period was a process of evaluation during which 118 events were reported, coded, analyzed and corrective measures adopted to prevent the recurrence of the same event. The latter half saw the reporting of 122 events following the adoption of corrective measures. There was a reduction in the occurrence of some events and an increase in others, which were mainly beyond the organization's control. A longer period of evaluation is necessary to identify the underlying contributory causes that can be useful to develop plans for corrective and preventive action and thereby reduce the rate of recurrence of errors through proper training and adoption of just culture.
PubMed: 16190106
Affiliations:
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Le document en format XML
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Usin</name><affiliation wicri:level="1"><nlm:affiliation>Transfusion Medicine Unit, University Malaya Medical Center, Kuala Lumpur, Malaysia. varunramesh@hotmail.com</nlm:affiliation><country xml:lang="fr">Malaisie</country><wicri:regionArea>Transfusion Medicine Unit, University Malaya Medical Center, Kuala Lumpur</wicri:regionArea><wicri:noRegion>Kuala Lumpur</wicri:noRegion></affiliation></author><author><name sortKey="Ramesh, Prathiba" sort="Ramesh, Prathiba" uniqKey="Ramesh P" first="Prathiba" last="Ramesh">Prathiba Ramesh</name></author><author><name sortKey="Lopez, C G" sort="Lopez, C G" uniqKey="Lopez C" first="C G" last="Lopez">C G Lopez</name></author></titleStmt><publicationStmt><idno type="wicri:source">PubMed</idno><date when="2004">2004</date><idno type="RBID">pubmed:16190106</idno><idno type="pmid">16190106</idno><idno type="wicri:Area/PubMed/Corpus">002308</idno><idno type="wicri:explorRef" wicri:stream="PubMed" wicri:step="Corpus" wicri:corpus="PubMed">002308</idno><idno type="wicri:Area/PubMed/Curation">002308</idno><idno type="wicri:explorRef" wicri:stream="PubMed" wicri:step="Curation">002308</idno><idno type="wicri:Area/PubMed/Checkpoint">002257</idno><idno type="wicri:explorRef" wicri:stream="Checkpoint" wicri:step="PubMed">002257</idno><idno type="wicri:Area/Ncbi/Merge">000372</idno><idno type="wicri:Area/Ncbi/Curation">000372</idno><idno type="wicri:Area/Ncbi/Checkpoint">000372</idno><idno type="wicri:doubleKey">0126-8635:2004:Usin M:implementation:of:an</idno><idno type="wicri:Area/Main/Merge">003089</idno><idno type="wicri:Area/Main/Curation">003058</idno><idno type="wicri:Area/Main/Exploration">003058</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en">Implementation of an event reporting system in a transfusion medicine unit: a local experience.</title><author><name sortKey="Usin, Mary F" sort="Usin, Mary F" uniqKey="Usin M" first="Mary F" last="Usin">Mary F. Usin</name><affiliation wicri:level="1"><nlm:affiliation>Transfusion Medicine Unit, University Malaya Medical Center, Kuala Lumpur, Malaysia. varunramesh@hotmail.com</nlm:affiliation><country xml:lang="fr">Malaisie</country><wicri:regionArea>Transfusion Medicine Unit, University Malaya Medical Center, Kuala Lumpur</wicri:regionArea><wicri:noRegion>Kuala Lumpur</wicri:noRegion></affiliation></author><author><name sortKey="Ramesh, Prathiba" sort="Ramesh, Prathiba" uniqKey="Ramesh P" first="Prathiba" last="Ramesh">Prathiba Ramesh</name></author><author><name sortKey="Lopez, C G" sort="Lopez, C G" uniqKey="Lopez C" first="C G" last="Lopez">C G Lopez</name></author></analytic><series><title level="j">The Malaysian journal of pathology</title><idno type="ISSN">0126-8635</idno><imprint><date when="2004" type="published">2004</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Academic Medical Centers</term><term>Blood Transfusion (standards)</term><term>Data Collection</term><term>Database Management Systems</term><term>Hospital Information Systems</term><term>Humans</term><term>Malaysia</term><term>Medical Errors (classification)</term><term>Medical Errors (prevention & control)</term><term>Medical Errors (statistics & numerical data)</term><term>Risk Management (methods)</term><term>Risk Management (statistics & numerical data)</term><term>Safety</term><term>Transfusion Reaction</term></keywords><keywords scheme="KwdFr" xml:lang="fr"><term>Centres hospitaliers universitaires</term><term>Collecte de données</term><term>Erreurs médicales ()</term><term>Gestion du risque ()</term><term>Humains</term><term>Malaisie</term><term>Réaction transfusionnelle</term><term>Systèmes d'information hospitaliers</term><term>Systèmes de gestion de bases de données</term><term>Sécurité</term><term>Transfusion sanguine (normes)</term></keywords><keywords scheme="MESH" qualifier="classification" xml:lang="en"><term>Medical Errors</term></keywords><keywords scheme="MESH" qualifier="methods" xml:lang="en"><term>Risk Management</term></keywords><keywords scheme="MESH" qualifier="normes" xml:lang="fr"><term>Transfusion sanguine</term></keywords><keywords scheme="MESH" qualifier="prevention & control" xml:lang="en"><term>Medical Errors</term></keywords><keywords scheme="MESH" qualifier="standards" xml:lang="en"><term>Blood Transfusion</term></keywords><keywords scheme="MESH" qualifier="statistics & numerical data" xml:lang="en"><term>Medical Errors</term><term>Risk Management</term></keywords><keywords scheme="MESH" xml:lang="en"><term>Academic Medical Centers</term><term>Data Collection</term><term>Database Management Systems</term><term>Hospital Information Systems</term><term>Humans</term><term>Malaysia</term><term>Safety</term><term>Transfusion Reaction</term></keywords><keywords scheme="MESH" xml:lang="fr"><term>Centres hospitaliers universitaires</term><term>Collecte de données</term><term>Erreurs médicales</term><term>Gestion du risque</term><term>Humains</term><term>Malaisie</term><term>Réaction transfusionnelle</term><term>Systèmes d'information hospitaliers</term><term>Systèmes de gestion de bases de données</term><term>Sécurité</term></keywords></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Event reporting can provide data to study the failure points of an organization's work process. As part of the ongoing efforts to improve transfusion safety, a Medical Event Reporting System Transfusion Medicine, (MERS - TM) as designed by Kaplan et al was implemented in the Transfusion Medicine Unit of the University Malaya Medical Centre to provide a standardized means of organized data collection and analysis of transfusion errors, adverse events and near misses. An event reporting form was designed to detect, identify, classify and study the frequency and pattern of events occurring in the unit. Events detected were classified according to Eihdhoven Classification model (ECM) adopted for MERS - TM. Since our system reported all events, we called it Event Reporting System - Transfusion Medicine (ERS-TM). Data was collected and analyzed from the reporting forms for a period of five months from January 15th to June 15th 2002. The initial half of the period was a process of evaluation during which 118 events were reported, coded, analyzed and corrective measures adopted to prevent the recurrence of the same event. The latter half saw the reporting of 122 events following the adoption of corrective measures. There was a reduction in the occurrence of some events and an increase in others, which were mainly beyond the organization's control. A longer period of evaluation is necessary to identify the underlying contributory causes that can be useful to develop plans for corrective and preventive action and thereby reduce the rate of recurrence of errors through proper training and adoption of just culture.</div></front></TEI><affiliations><list><country><li>Malaisie</li></country></list><tree><noCountry><name sortKey="Lopez, C G" sort="Lopez, C G" uniqKey="Lopez C" first="C G" last="Lopez">C G Lopez</name><name sortKey="Ramesh, Prathiba" sort="Ramesh, Prathiba" uniqKey="Ramesh P" first="Prathiba" last="Ramesh">Prathiba Ramesh</name></noCountry><country name="Malaisie"><noRegion><name sortKey="Usin, Mary F" sort="Usin, Mary F" uniqKey="Usin M" first="Mary F" last="Usin">Mary F. Usin</name></noRegion></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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