No abstract

The administration of blood and blood components are used to restore intravascular volume, restore oxygen carrying capacity of blood, and to provide clotting factors and/or platelets. Although it can be a life-saving procedure, it is also associated with high risks (Nuttall, Stubbs, & Oliver, 2014). Errors or undetected reactions may impose serious health problems or even lead to patient death. Although the process is already heavily supported by a comprehensive barcode-based tracking and verification system to promote safety (Sellen, Jovanovic, Perrier, & Chignell, 2015), adverse events still occurred in several areas across the organization which triggered an in-depth systems analysis of the workflows. We performed our study in three steps: first, we conducted an in-depth analysis using data triangulation (review of relevant documents and metrics, 20 simulations and cognitive walkthroughs in 11 care units, 50 interviews in total, patient observations); second, we synthesized our data by creating process maps and by coding the data; and third, we validated our findings by expert review (clinicians and other stakeholders). To describe the complex workflows, we described the process on three granular levels: 1