Premium
Root cause analysis of transfusion error: identifying causes to implement changes
Author(s) -
Elhence Priti,
Veena S.,
Sharma Raj Kumar,
Chaudhary R. K.
Publication year - 2010
Publication title -
transfusion
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.045
H-Index - 132
eISSN - 1537-2995
pISSN - 0041-1132
DOI - 10.1111/j.1537-2995.2010.02943.x
Subject(s) - root cause analysis , medicine , root cause , intensive care medicine , operations management , forensic engineering , engineering
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. STUDY DESIGN AND METHODS: The reported error was investigated, classified, coded, and analyzed using MERS‐TM prototype, modified and adopted for our institute. 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. CONCLUSION: 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.