No abstract

A generally applicable and reliable method for identifying and quantifying problems that exist throughout transfusion medicine will be a valuable addition to event reporting activity. By using a common taxonomy, participants can compare their experience with that of others. If proven as readily implementable and useful as shown in initial studies, MERS-TM is a potential standard for transfusion medicine.

A field study was performed in a hospital pharmacy aimed at identifying positive and negative influences on the process of detection of and further recovery from initial errors or other failures, thus avoiding negative consequences. Confidential reports and follow-up interviews provided data on 31 near-miss incidents involving such recovery processes. Analysis revealed that organizational culture with regard to following procedures needed reinforcement, that some procedures could be improved, that building in extra checks was worthwhile and that supporting unplanned recovery was essential for problems not covered by procedures. Guidance is given on how performance in recovery could be measured. A case is made for supporting recovery as an addition to prevention-based safety methods.

For both units, the prospective and retrospective analyses resulted in divergent overviews of risks in terms of nature and magnitude, which suggests that one or both methods were subject to biases. Findings from the evaluation forms showed that both methods were perceived as useful and that triangulation provided additional insight into risks. Due to the convergent evidence, triangulation of prospective and retrospective methods can provide hospital management and frontline staff with a more complete and less biased picture of risks. An integrative approach might be advantageous in terms of efficiency of analysis, setting priorities for patient safety and improving the methods themselves.