Reporting of near-miss events for transfusion medicine: improving transfusion safety.
Identifieur interne : 002537 ( PubMed/Corpus ); précédent : 002536; suivant : 002538Reporting of near-miss events for transfusion medicine: improving transfusion safety.
Auteurs : J L Callum ; H S Kaplan ; L L Merkley ; P H Pinkerton ; B. Rabin Fastman ; R A Romans ; A S Coovadia ; M D ReisSource :
- Transfusion [ 0041-1132 ] ; 2001.
English descriptors
- KwdEn :
- Blood Transfusion (standards), Humans, Medical Errors (classification), Medical Errors (prevention & control), Medical Staff, Hospital (education), Medical Staff, Hospital (standards), Practice Guidelines as Topic, Risk Management (methods), Risk Management (standards), Safety, Transfusion Reaction.
- MESH :
- classification : Medical Errors.
- education : Medical Staff, Hospital.
- methods : Risk Management.
- prevention & control : Medical Errors.
- standards : Blood Transfusion, Medical Staff, Hospital, Risk Management.
- Humans, Practice Guidelines as Topic, Safety, Transfusion Reaction.
Abstract
Half of the reported serious adverse events from transfusion are a consequence of medical error. A no-fault medical-event reporting system for transfusion medicine (MERS-TM) was developed to capture and analyze both near-miss and actual transfusion-related errors.
DOI: 10.1046/j.1537-2995.2001.41101204.x
PubMed: 11606817
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pubmed:11606817Le document en format XML
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Rabin Fastman</name></author><author><name sortKey="Romans, R A" sort="Romans, R A" uniqKey="Romans R" first="R A" last="Romans">R A Romans</name></author><author><name sortKey="Coovadia, A S" sort="Coovadia, A S" uniqKey="Coovadia A" first="A S" last="Coovadia">A S Coovadia</name></author><author><name sortKey="Reis, M D" sort="Reis, M D" uniqKey="Reis M" first="M D" last="Reis">M D Reis</name></author></titleStmt><publicationStmt><idno type="wicri:source">PubMed</idno><date when="2001">2001</date><idno type="RBID">pubmed:11606817</idno><idno type="pmid">11606817</idno><idno type="doi">10.1046/j.1537-2995.2001.41101204.x</idno><idno type="wicri:Area/PubMed/Corpus">002537</idno><idno type="wicri:explorRef" wicri:stream="PubMed" wicri:step="Corpus" wicri:corpus="PubMed">002537</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en">Reporting of near-miss events for transfusion medicine: improving transfusion safety.</title><author><name sortKey="Callum, J L" sort="Callum, J L" uniqKey="Callum J" first="J L" last="Callum">J L Callum</name><affiliation><nlm:affiliation>Sunnybrook and Women's College Health Sciences Centre, and The University of Toronto, Toronto, Ontario, Canada. jeannie.callum@swchsc.on.ca</nlm:affiliation></affiliation></author><author><name sortKey="Kaplan, H S" sort="Kaplan, H S" uniqKey="Kaplan H" first="H S" last="Kaplan">H S Kaplan</name></author><author><name sortKey="Merkley, L L" sort="Merkley, L L" uniqKey="Merkley L" first="L L" last="Merkley">L L Merkley</name></author><author><name sortKey="Pinkerton, P H" sort="Pinkerton, P H" uniqKey="Pinkerton P" first="P H" last="Pinkerton">P H Pinkerton</name></author><author><name sortKey="Rabin Fastman, B" sort="Rabin Fastman, B" uniqKey="Rabin Fastman B" first="B" last="Rabin Fastman">B. Rabin Fastman</name></author><author><name sortKey="Romans, R A" sort="Romans, R A" uniqKey="Romans R" first="R A" last="Romans">R A Romans</name></author><author><name sortKey="Coovadia, A S" sort="Coovadia, A S" uniqKey="Coovadia A" first="A S" last="Coovadia">A S Coovadia</name></author><author><name sortKey="Reis, M D" sort="Reis, M D" uniqKey="Reis M" first="M D" last="Reis">M D Reis</name></author></analytic><series><title level="j">Transfusion</title><idno type="ISSN">0041-1132</idno><imprint><date when="2001" type="published">2001</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Blood Transfusion (standards)</term><term>Humans</term><term>Medical Errors (classification)</term><term>Medical Errors (prevention & control)</term><term>Medical Staff, Hospital (education)</term><term>Medical Staff, Hospital (standards)</term><term>Practice Guidelines as Topic</term><term>Risk Management (methods)</term><term>Risk Management (standards)</term><term>Safety</term><term>Transfusion Reaction</term></keywords><keywords scheme="MESH" qualifier="classification" xml:lang="en"><term>Medical Errors</term></keywords><keywords scheme="MESH" qualifier="education" xml:lang="en"><term>Medical Staff, Hospital</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>Medical Staff, Hospital</term><term>Risk Management</term></keywords><keywords scheme="MESH" xml:lang="en"><term>Humans</term><term>Practice Guidelines as Topic</term><term>Safety</term><term>Transfusion Reaction</term></keywords></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Half of the reported serious adverse events from transfusion are a consequence of medical error. A no-fault medical-event reporting system for transfusion medicine (MERS-TM) was developed to capture and analyze both near-miss and actual transfusion-related errors.</div></front></TEI><pubmed><MedlineCitation Status="MEDLINE" Owner="NLM"><PMID Version="1">11606817</PMID><DateCompleted><Year>2001</Year><Month>12</Month><Day>04</Day></DateCompleted><DateRevised><Year>2019</Year><Month>07</Month><Day>27</Day></DateRevised><Article PubModel="Print"><Journal><ISSN IssnType="Print">0041-1132</ISSN><JournalIssue CitedMedium="Print"><Volume>41</Volume><Issue>10</Issue><PubDate><Year>2001</Year><Month>Oct</Month></PubDate></JournalIssue><Title>Transfusion</Title><ISOAbbreviation>Transfusion</ISOAbbreviation></Journal><ArticleTitle>Reporting of near-miss events for transfusion medicine: improving transfusion safety.</ArticleTitle><Pagination><MedlinePgn>1204-11</MedlinePgn></Pagination><Abstract><AbstractText Label="BACKGROUND" NlmCategory="BACKGROUND">Half of the reported serious adverse events from transfusion are a consequence of medical error. A no-fault medical-event reporting system for transfusion medicine (MERS-TM) was developed to capture and analyze both near-miss and actual transfusion-related errors.</AbstractText><AbstractText Label="STUDY DESIGN AND METHODS" NlmCategory="METHODS">A prospective audit of transfusion-related errors was performed to determine the ability of MERS-TM to identify the frequency and patterns of errors.</AbstractText><AbstractText Label="RESULTS" NlmCategory="RESULTS">Events and near-miss events (total, 819) were recorded for a period of 19 months (median, 51/month). No serious adverse patient outcome occurred, despite these events, with the transfusion of 17,465 units of RBCs. Sixty-one events (7.4%) were potentially life-threatening or could have led to permanent injury (severity Level 1). Of most concern were 3 samples collected from the wrong patient, 13 mislabeled samples, and 22 requests for blood for the wrong patient. Near-miss events were five times more frequent than actual transfusion errors, and 68 percent of errors were detected before blood was issued. Sixty-one percent of events originated from patient areas, 35 percent from the blood bank, and 4 percent from the blood supplier or other hospitals. Repeat collection was required for 1 of every 94 samples, and 1 in 346 requests for blood components was incorrect. Education of nurses and alterations to blood bank forms were not by themselves effective in reducing severe errors. An artifactual 50-percent reduction in the number of errors reported was noted during a 6-month period when two chief members of the event-reporting team were on temporary leave.</AbstractText><AbstractText Label="CONCLUSION" NlmCategory="CONCLUSIONS">The MERS-TM allowed the recognition and analysis of errors, determination of patterns of errors, and monitoring for changes in frequency after corrective action was implemented. Although no permanent injury resulted from the 819 events, innovative mechanisms must be designed to prevent these errors, instead of relying on faulty informal checks to capture errors after they occur.</AbstractText></Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Callum</LastName><ForeName>J L</ForeName><Initials>JL</Initials><AffiliationInfo><Affiliation>Sunnybrook and Women's College Health Sciences Centre, and The University of Toronto, Toronto, Ontario, Canada. jeannie.callum@swchsc.on.ca</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Kaplan</LastName><ForeName>H S</ForeName><Initials>HS</Initials></Author><Author ValidYN="Y"><LastName>Merkley</LastName><ForeName>L L</ForeName><Initials>LL</Initials></Author><Author ValidYN="Y"><LastName>Pinkerton</LastName><ForeName>P H</ForeName><Initials>PH</Initials></Author><Author ValidYN="Y"><LastName>Rabin Fastman</LastName><ForeName>B</ForeName><Initials>B</Initials></Author><Author ValidYN="Y"><LastName>Romans</LastName><ForeName>R A</ForeName><Initials>RA</Initials></Author><Author ValidYN="Y"><LastName>Coovadia</LastName><ForeName>A S</ForeName><Initials>AS</Initials></Author><Author ValidYN="Y"><LastName>Reis</LastName><ForeName>M D</ForeName><Initials>MD</Initials></Author></AuthorList><Language>eng</Language><GrantList CompleteYN="Y"><Grant><GrantID>R01-HL53772</GrantID><Acronym>HL</Acronym><Agency>NHLBI NIH HHS</Agency><Country>United States</Country></Grant></GrantList><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType><PublicationType UI="D013485">Research Support, Non-U.S. Gov't</PublicationType><PublicationType UI="D013487">Research Support, U.S. Gov't, P.H.S.</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></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D019300" MajorTopicYN="N">Medical Errors</DescriptorName><QualifierName UI="Q000145" MajorTopicYN="Y">classification</QualifierName><QualifierName UI="Q000517" MajorTopicYN="N">prevention & control</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D008505" MajorTopicYN="N">Medical Staff, Hospital</DescriptorName><QualifierName UI="Q000193" MajorTopicYN="N">education</QualifierName><QualifierName UI="Q000592" MajorTopicYN="N">standards</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D017410" MajorTopicYN="N">Practice Guidelines as Topic</DescriptorName></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="Y">Safety</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D065227" MajorTopicYN="N">Transfusion Reaction</DescriptorName></MeshHeading></MeshHeadingList></MedlineCitation><PubmedData><History><PubMedPubDate PubStatus="pubmed"><Year>2001</Year><Month>10</Month><Day>19</Day><Hour>10</Hour><Minute>0</Minute></PubMedPubDate><PubMedPubDate PubStatus="medline"><Year>2002</Year><Month>1</Month><Day>5</Day><Hour>10</Hour><Minute>1</Minute></PubMedPubDate><PubMedPubDate PubStatus="entrez"><Year>2001</Year><Month>10</Month><Day>19</Day><Hour>10</Hour><Minute>0</Minute></PubMedPubDate></History><PublicationStatus>ppublish</PublicationStatus><ArticleIdList><ArticleId IdType="pubmed">11606817</ArticleId><ArticleId IdType="doi">10.1046/j.1537-2995.2001.41101204.x</ArticleId></ArticleIdList></PubmedData></pubmed></record>Pour manipuler ce document sous Unix (Dilib)
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