Root cause analysis of transfusion error: identifying causes to implement changes.
Identifieur interne : 001F21 ( PubMed/Corpus ); précédent : 001F20; suivant : 001F22Root cause analysis of transfusion error: identifying causes to implement changes.
Auteurs : Priti Elhence ; S. Veena ; Raj Kumar Sharma ; R K ChaudharySource :
- Transfusion [ 1537-2995 ] ; 2010.
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
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pubmed:21128948Le document en format XML
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Veena</name></author><author><name sortKey="Sharma, Raj Kumar" sort="Sharma, Raj Kumar" uniqKey="Sharma R" first="Raj Kumar" last="Sharma">Raj Kumar Sharma</name></author><author><name sortKey="Chaudhary, R K" sort="Chaudhary, R K" uniqKey="Chaudhary R" first="R K" last="Chaudhary">R K Chaudhary</name></author></titleStmt><publicationStmt><idno type="wicri:source">PubMed</idno><date when="2010">2010</date><idno type="RBID">pubmed:21128948</idno><idno type="pmid">21128948</idno><idno type="doi">10.1111/j.1537-2995.2010.02943.x</idno><idno type="wicri:Area/PubMed/Corpus">001F21</idno><idno type="wicri:explorRef" wicri:stream="PubMed" wicri:step="Corpus" wicri:corpus="PubMed">001F21</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en">Root cause analysis of transfusion error: identifying causes to implement changes.</title><author><name sortKey="Elhence, Priti" sort="Elhence, Priti" uniqKey="Elhence P" first="Priti" last="Elhence">Priti Elhence</name><affiliation><nlm:affiliation>Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. pelhence@sgpgi.ac.in</nlm:affiliation></affiliation></author><author><name sortKey="Veena, S" sort="Veena, S" uniqKey="Veena S" first="S" last="Veena">S. Veena</name></author><author><name sortKey="Sharma, Raj Kumar" sort="Sharma, Raj Kumar" uniqKey="Sharma R" first="Raj Kumar" last="Sharma">Raj Kumar Sharma</name></author><author><name sortKey="Chaudhary, R K" sort="Chaudhary, R K" uniqKey="Chaudhary R" first="R K" last="Chaudhary">R K Chaudhary</name></author></analytic><series><title level="j">Transfusion</title><idno type="eISSN">1537-2995</idno><imprint><date when="2010" type="published">2010</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Blood Transfusion (standards)</term><term>Blood Transfusion (statistics & numerical data)</term><term>Humans</term><term>Medical Errors (prevention & control)</term><term>Risk Management (methods)</term><term>Risk Management (standards)</term><term>Safety (standards)</term><term>Transfusion Reaction</term></keywords><keywords scheme="MESH" qualifier="methods" xml:lang="en"><term>Risk Management</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><term>Risk Management</term><term>Safety</term></keywords><keywords scheme="MESH" qualifier="statistics & numerical data" xml:lang="en"><term>Blood Transfusion</term></keywords><keywords scheme="MESH" xml:lang="en"><term>Humans</term><term>Transfusion Reaction</term></keywords></textClass></profileDesc></teiHeader><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></front></TEI><pubmed><MedlineCitation Status="MEDLINE" Owner="NLM"><PMID Version="1">21128948</PMID><DateCompleted><Year>2011</Year><Month>01</Month><Day>04</Day></DateCompleted><DateRevised><Year>2017</Year><Month>11</Month><Day>16</Day></DateRevised><Article PubModel="Print"><Journal><ISSN IssnType="Electronic">1537-2995</ISSN><JournalIssue CitedMedium="Internet"><Volume>50</Volume><Issue>12 Pt 2</Issue><PubDate><Year>2010</Year><Month>Dec</Month></PubDate></JournalIssue><Title>Transfusion</Title><ISOAbbreviation>Transfusion</ISOAbbreviation></Journal><ArticleTitle>Root cause analysis of transfusion error: identifying causes to implement changes.</ArticleTitle><Pagination><MedlinePgn>2772-7</MedlinePgn></Pagination><ELocationID EIdType="doi" ValidYN="Y">10.1111/j.1537-2995.2010.02943.x</ELocationID><Abstract><AbstractText Label="BACKGROUND" NlmCategory="BACKGROUND">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.</AbstractText><AbstractText Label="STUDY DESIGN AND METHODS" NlmCategory="METHODS">The reported error was investigated, classified, coded, and analyzed using MERS-TM prototype, modified and adopted for our institute.</AbstractText><AbstractText Label="RESULTS" NlmCategory="RESULTS">The consequent error was a "mistransfusion" but a "no-harm event" as the transfused unit was of the same blood group as the patient. It was a high event severity level error (level 1). Multiple errors preceded the final error at various functional locations in the transfusion process. Human, organizational, and patient-related factors were identified as root causes and corrective actions were initiated to prevent future occurrences.</AbstractText><AbstractText Label="CONCLUSION" NlmCategory="CONCLUSIONS">This case illustrates the usefulness of having an error reporting system in hospitals to highlight human and system failures associated with transfusion that may otherwise go unnoticed. Areas can be identified where resources need to be targeted to improve patient safety.</AbstractText><CopyrightInformation>© 2010 American Association of Blood Banks.</CopyrightInformation></Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Elhence</LastName><ForeName>Priti</ForeName><Initials>P</Initials><AffiliationInfo><Affiliation>Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. pelhence@sgpgi.ac.in</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Veena</LastName><ForeName>S</ForeName><Initials>S</Initials></Author><Author ValidYN="Y"><LastName>Sharma</LastName><ForeName>Raj Kumar</ForeName><Initials>RK</Initials></Author><Author ValidYN="Y"><LastName>Chaudhary</LastName><ForeName>R K</ForeName><Initials>RK</Initials></Author></AuthorList><Language>eng</Language><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType></PublicationTypeList></Article><MedlineJournalInfo><Country>United States</Country><MedlineTA>Transfusion</MedlineTA><NlmUniqueID>0417360</NlmUniqueID><ISSNLinking>0041-1132</ISSNLinking></MedlineJournalInfo><CitationSubset>IM</CitationSubset><MeshHeadingList><MeshHeading><DescriptorName UI="D001803" MajorTopicYN="N">Blood Transfusion</DescriptorName><QualifierName UI="Q000592" MajorTopicYN="Y">standards</QualifierName><QualifierName UI="Q000706" MajorTopicYN="N">statistics & numerical data</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D019300" MajorTopicYN="N">Medical Errors</DescriptorName><QualifierName UI="Q000517" MajorTopicYN="Y">prevention & control</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D012308" MajorTopicYN="N">Risk Management</DescriptorName><QualifierName UI="Q000379" MajorTopicYN="Y">methods</QualifierName><QualifierName UI="Q000592" MajorTopicYN="N">standards</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D012449" MajorTopicYN="N">Safety</DescriptorName><QualifierName UI="Q000592" MajorTopicYN="N">standards</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D065227" MajorTopicYN="N">Transfusion Reaction</DescriptorName></MeshHeading></MeshHeadingList></MedlineCitation><PubmedData><History><PubMedPubDate PubStatus="entrez"><Year>2010</Year><Month>12</Month><Day>7</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate><PubMedPubDate PubStatus="pubmed"><Year>2010</Year><Month>12</Month><Day>7</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate><PubMedPubDate PubStatus="medline"><Year>2011</Year><Month>1</Month><Day>5</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate></History><PublicationStatus>ppublish</PublicationStatus><ArticleIdList><ArticleId IdType="pubmed">21128948</ArticleId><ArticleId IdType="doi">10.1111/j.1537-2995.2010.02943.x</ArticleId></ArticleIdList></PubmedData></pubmed></record>Pour manipuler ce document sous Unix (Dilib)
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