Error management in blood establishments: results of eight years of experience (2003-2010) at the Croatian Institute of Transfusion Medicine.
Identifieur interne : 000935 ( Ncbi/Merge ); précédent : 000934; suivant : 000936Error management in blood establishments: results of eight years of experience (2003-2010) at the Croatian Institute of Transfusion Medicine.
Auteurs : Tomislav Vuk [Croatie] ; Marijan Bariši ; Tihomir O I ; Ivanka Mihaljevi ; Dorotea Sarlija ; Irena JukiSource :
- Blood transfusion = Trasfusione del sangue [ 2385-2070 ] ; 2012.
Descripteurs français
- KwdFr :
- MESH :
- effets indésirables : Transfusion de composants du sang.
- Assurance de la qualité des soins de santé, Banques de sang, Croatie, Erreurs médicales, Femelle, Humains, Mâle, Études rétrospectives.
- Wicri :
- geographic : Croatie.
English descriptors
- KwdEn :
- MESH :
- geographic : Croatia.
- adverse effects : Blood Component Transfusion.
- prevention & control : Medical Errors.
- Blood Banks, Female, Humans, Male, Quality Assurance, Health Care, Retrospective Studies.
Abstract
Continuous and efficient error management, including procedures from error detection to their resolution and prevention, is an important part of quality management in blood establishments. At the Croatian Institute of Transfusion Medicine (CITM), error management has been systematically performed since 2003.
DOI: 10.2450/2012.0075-11
PubMed: 22395352
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Ivanka" uniqKey="Mihaljevi I" first="Ivanka" last="Mihaljevi">Ivanka Mihaljevi</name></author><author><name sortKey="Sarlija, Dorotea" sort="Sarlija, Dorotea" uniqKey="Sarlija D" first="Dorotea" last="Sarlija">Dorotea Sarlija</name></author><author><name sortKey="Juki, Irena" sort="Juki, Irena" uniqKey="Juki I" first="Irena" last="Juki">Irena Juki</name></author></titleStmt><publicationStmt><idno type="wicri:source">PubMed</idno><date when="2012">2012</date><idno type="RBID">pubmed:22395352</idno><idno type="pmid">22395352</idno><idno type="doi">10.2450/2012.0075-11</idno><idno type="wicri:Area/PubMed/Corpus">001E01</idno><idno type="wicri:explorRef" wicri:stream="PubMed" wicri:step="Corpus" wicri:corpus="PubMed">001E01</idno><idno type="wicri:Area/PubMed/Curation">001E01</idno><idno type="wicri:explorRef" wicri:stream="PubMed" wicri:step="Curation">001E01</idno><idno type="wicri:Area/PubMed/Checkpoint">001C85</idno><idno type="wicri:explorRef" wicri:stream="Checkpoint" 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I">Tihomir O I</name></author><author><name sortKey="Mihaljevi, Ivanka" sort="Mihaljevi, Ivanka" uniqKey="Mihaljevi I" first="Ivanka" last="Mihaljevi">Ivanka Mihaljevi</name></author><author><name sortKey="Sarlija, Dorotea" sort="Sarlija, Dorotea" uniqKey="Sarlija D" first="Dorotea" last="Sarlija">Dorotea Sarlija</name></author><author><name sortKey="Juki, Irena" sort="Juki, Irena" uniqKey="Juki I" first="Irena" last="Juki">Irena Juki</name></author></analytic><series><title level="j">Blood transfusion = Trasfusione del sangue</title><idno type="eISSN">2385-2070</idno><imprint><date when="2012" type="published">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Blood Banks</term><term>Blood Component Transfusion (adverse effects)</term><term>Croatia</term><term>Female</term><term>Humans</term><term>Male</term><term>Medical Errors (prevention & control)</term><term>Quality Assurance, Health Care</term><term>Retrospective Studies</term></keywords><keywords scheme="KwdFr" xml:lang="fr"><term>Assurance de la qualité des soins de santé</term><term>Banques de sang</term><term>Croatie</term><term>Erreurs médicales ()</term><term>Femelle</term><term>Humains</term><term>Mâle</term><term>Transfusion de composants du sang (effets indésirables)</term><term>Études rétrospectives</term></keywords><keywords scheme="MESH" type="geographic" xml:lang="en"><term>Croatia</term></keywords><keywords scheme="MESH" qualifier="adverse effects" xml:lang="en"><term>Blood Component Transfusion</term></keywords><keywords scheme="MESH" qualifier="effets indésirables" xml:lang="fr"><term>Transfusion de composants du sang</term></keywords><keywords scheme="MESH" qualifier="prevention & control" xml:lang="en"><term>Medical Errors</term></keywords><keywords scheme="MESH" xml:lang="en"><term>Blood Banks</term><term>Female</term><term>Humans</term><term>Male</term><term>Quality Assurance, Health Care</term><term>Retrospective Studies</term></keywords><keywords scheme="MESH" xml:lang="fr"><term>Assurance de la qualité des soins de santé</term><term>Banques de sang</term><term>Croatie</term><term>Erreurs médicales</term><term>Femelle</term><term>Humains</term><term>Mâle</term><term>Études rétrospectives</term></keywords><keywords scheme="Wicri" type="geographic" xml:lang="fr"><term>Croatie</term></keywords></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Continuous and efficient error management, including procedures from error detection to their resolution and prevention, is an important part of quality management in blood establishments. At the Croatian Institute of Transfusion Medicine (CITM), error management has been systematically performed since 2003.</div></front></TEI><pubmed><MedlineCitation Status="MEDLINE" Owner="NLM"><PMID Version="1">22395352</PMID><DateCompleted><Year>2012</Year><Month>12</Month><Day>28</Day></DateCompleted><DateRevised><Year>2018</Year><Month>11</Month><Day>13</Day></DateRevised><Article PubModel="Print-Electronic"><Journal><ISSN IssnType="Electronic">2385-2070</ISSN><JournalIssue CitedMedium="Internet"><Volume>10</Volume><Issue>3</Issue><PubDate><Year>2012</Year><Month>Jul</Month></PubDate></JournalIssue><Title>Blood transfusion = Trasfusione del sangue</Title><ISOAbbreviation>Blood Transfus</ISOAbbreviation></Journal><ArticleTitle>Error management in blood establishments: results of eight years of experience (2003-2010) at the Croatian Institute of Transfusion Medicine.</ArticleTitle><Pagination><MedlinePgn>311-20</MedlinePgn></Pagination><ELocationID EIdType="doi" ValidYN="Y">10.2450/2012.0075-11</ELocationID><Abstract><AbstractText Label="BACKGROUND" NlmCategory="BACKGROUND">Continuous and efficient error management, including procedures from error detection to their resolution and prevention, is an important part of quality management in blood establishments. At the Croatian Institute of Transfusion Medicine (CITM), error management has been systematically performed since 2003.</AbstractText><AbstractText Label="MATERIALS AND METHODS" NlmCategory="METHODS">Data derived from error management at the CITM during an 8-year period (2003-2010) formed the basis of this study. Throughout the study period, errors were reported to the Department of Quality Assurance. In addition to surveys and the necessary corrective activities, errors were analysed and classified according to the Medical Event Reporting System for Transfusion Medicine (MERS-TM).</AbstractText><AbstractText Label="RESULTS" NlmCategory="RESULTS">During the study period, a total of 2,068 errors were recorded, including 1,778 (86.0%) in blood bank activities and 290 (14.0%) in blood transfusion services. As many as 1,744 (84.3%) errors were detected before issue of the product or service. Among the 324 errors identified upon release from the CITM, 163 (50.3%) errors were detected by customers and reported as complaints. In only five cases was an error detected after blood product transfusion however without any harmful consequences for the patients. All errors were, therefore, evaluated as "near miss" and "no harm" events. Fifty-two (2.5%) errors were evaluated as high-risk events. With regards to blood bank activities, the highest proportion of errors occurred in the processes of labelling (27.1%) and blood collection (23.7%). With regards to blood transfusion services, errors related to blood product issuing prevailed (24.5%).</AbstractText><AbstractText Label="CONCLUSION" NlmCategory="CONCLUSIONS">This study shows that comprehensive management of errors, including near miss errors, can generate data on the functioning of transfusion services, which is a precondition for implementation of efficient corrective and preventive actions that will ensure further improvement of the quality and safety of transfusion treatment.</AbstractText></Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Vuk</LastName><ForeName>Tomislav</ForeName><Initials>T</Initials><AffiliationInfo><Affiliation>Croatian Institute of Transfusion Medicine, Zagreb, Croatia. tomislav.vuk@hztm.hr</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Barišić</LastName><ForeName>Marijan</ForeName><Initials>M</Initials></Author><Author ValidYN="Y"><LastName>Očić</LastName><ForeName>Tihomir</ForeName><Initials>T</Initials></Author><Author ValidYN="Y"><LastName>Mihaljević</LastName><ForeName>Ivanka</ForeName><Initials>I</Initials></Author><Author ValidYN="Y"><LastName>Sarlija</LastName><ForeName>Dorotea</ForeName><Initials>D</Initials></Author><Author ValidYN="Y"><LastName>Jukić</LastName><ForeName>Irena</ForeName><Initials>I</Initials></Author></AuthorList><Language>eng</Language><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList><ArticleDate DateType="Electronic"><Year>2012</Year><Month>02</Month><Day>22</Day></ArticleDate></Article><MedlineJournalInfo><Country>Italy</Country><MedlineTA>Blood Transfus</MedlineTA><NlmUniqueID>101237479</NlmUniqueID><ISSNLinking>1723-2007</ISSNLinking></MedlineJournalInfo><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D001771" MajorTopicYN="Y">Blood Banks</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D016913" MajorTopicYN="N">Blood Component Transfusion</DescriptorName><QualifierName UI="Q000009" MajorTopicYN="Y">adverse effects</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D017523" MajorTopicYN="N" Type="Geographic">Croatia</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D005260" MajorTopicYN="N">Female</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008297" MajorTopicYN="N">Male</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D019300" MajorTopicYN="N">Medical Errors</DescriptorName><QualifierName UI="Q000517" MajorTopicYN="Y">prevention & control</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D011785" MajorTopicYN="Y">Quality Assurance, Health Care</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D012189" MajorTopicYN="N">Retrospective Studies</DescriptorName></MeshHeading></MeshHeadingList></MedlineCitation><PubmedData><History><PubMedPubDate PubStatus="received"><Year>2011</Year><Month>07</Month><Day>16</Day></PubMedPubDate><PubMedPubDate PubStatus="accepted"><Year>2011</Year><Month>09</Month><Day>19</Day></PubMedPubDate><PubMedPubDate PubStatus="entrez"><Year>2012</Year><Month>3</Month><Day>8</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate><PubMedPubDate PubStatus="pubmed"><Year>2012</Year><Month>3</Month><Day>8</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate><PubMedPubDate PubStatus="medline"><Year>2012</Year><Month>12</Month><Day>29</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate></History><PublicationStatus>ppublish</PublicationStatus><ArticleIdList><ArticleId IdType="pubmed">22395352</ArticleId><ArticleId IdType="pii">2012.0075-11</ArticleId><ArticleId IdType="doi">10.2450/2012.0075-11</ArticleId><ArticleId IdType="pmc">PMC3417730</ArticleId></ArticleIdList><ReferenceList><Reference><Citation>Transfus Med Rev. 2002 Apr;16(2):86-102</Citation><ArticleIdList><ArticleId IdType="pubmed">11941572</ArticleId></ArticleIdList></Reference><Reference><Citation>Transfusion. 1990 Sep;30(7):583-90</Citation><ArticleIdList><ArticleId IdType="pubmed">2402771</ArticleId></ArticleIdList></Reference><Reference><Citation>Transfusion. 1992 Sep;32(7):601-6</Citation><ArticleIdList><ArticleId IdType="pubmed">1519323</ArticleId></ArticleIdList></Reference><Reference><Citation>Arch Pathol Lab Med. 1994 Apr;118(4):405-10</Citation><ArticleIdList><ArticleId IdType="pubmed">8166590</ArticleId></ArticleIdList></Reference><Reference><Citation>Inquiry. 1999 Fall;36(3):255-64</Citation><ArticleIdList><ArticleId IdType="pubmed">10570659</ArticleId></ArticleIdList></Reference><Reference><Citation>Arch Pathol Lab Med. 1998 Mar;122(3):231-8</Citation><ArticleIdList><ArticleId 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last="Mihaljevi">Ivanka Mihaljevi</name><name sortKey="O I, Tihomir" sort="O I, Tihomir" uniqKey="O I T" first="Tihomir" last="O I">Tihomir O I</name><name sortKey="Sarlija, Dorotea" sort="Sarlija, Dorotea" uniqKey="Sarlija D" first="Dorotea" last="Sarlija">Dorotea Sarlija</name></noCountry><country name="Croatie"><noRegion><name sortKey="Vuk, Tomislav" sort="Vuk, Tomislav" uniqKey="Vuk T" first="Tomislav" last="Vuk">Tomislav Vuk</name></noRegion></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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