Root cause analysis of transfusion error: identifying causes to implement changes

Elhence, Priti; S, Veena; Sharma, Raj Kumar; Chaudhary, Rajendra

doi:10.1111/j.1537-2995.2010.02943.x

Cited by 10 publications

(10 citation statements)

References 9 publications

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“…It is well known from specific industrial sectors, such as aircraft technology and nuclear energy, that the implementation of programs for continuous quality improvement and risk management is essential to approximate the goal of 'zero-risk' [14,15]. The impact of an unfortunate event and the probability of its occurrence are the most important determining factors for quantitative risk assessment and root cause analysis [16,17]. For transfusion-transmitted infections, the most effective stage of hazard prevention is the elimination of the hazard (pathogen), followed by strategies to mitigate the risk of its transmission, e.g.…”

Section: Introductionmentioning

confidence: 99%

Pathogen Inactivation Technologies for Cellular Blood Components: an Update

Schlenke¹

2014

Transfus Med Hemother

112

114

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Nowadays patients receiving blood components are exposed to much less transfusion-transmitted infectious diseases than three decades before when among others HIV was identified as causative agent for the acquired immunodeficiency syndrome and the transmission by blood or coagulation factors became evident. Since that time the implementation of measures for risk prevention and safety precaution was socially and politically accepted. Currently emerging pathogens like arboviruses and the well-known bacterial contamination of platelet concentrates still remain major concerns of blood safety with important clinical consequences, but very rarely with fatal outcome for the blood recipient. In contrast to the well-established pathogen inactivation strategies for fresh frozen plasma using the solvent-detergent procedure or methylene blue and visible light, the bench-to-bedside translation of novel pathogen inactivation technologies for cell-containing blood components such as platelets and red blood cells are still underway. This review summarizes the pharmacological/toxicological assessment and the inactivation efficacy against viruses, bacteria, and protozoa of each of the currently available pathogen inactivation technologies and highlights the impact of the results obtained from several randomized clinical trials and hemovigilance data. Until now in some European countries pathogen inactivation technologies are in in routine use for single-donor plasma and platelets. The invention and adaption of pathogen inactivation technologies for red blood cell units and whole blood donations suggest the universal applicability of these technologies and foster a paradigm shift in the manufacturing of safe blood.

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Section: Introductionmentioning

confidence: 99%

Pathogen Inactivation Technologies for Cellular Blood Components: an Update

Schlenke¹

2014

Transfus Med Hemother

112

114

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“…The study was approved by Institute ' s Ethical Committee. All procedures were carried out as per existing Standard Operating Procedures (SOPs) at the time of study, as elaborated previously (8) . All the events reported in the ' transfusion process ' during the study period of 1 year, from April 2009 to March 2010, were recorded, classifi ed and analyzed using Medical Event Reporting SystemTransfusion Medicine (MERS-TM) prototype (9) .…”

Section: Methodsmentioning

confidence: 99%

Error reporting in transfusion medicine at a tertiary care centre: a patient safety initiative

Elhence

Shenoy

Verma

et al. 2012

Clinical Chemistry and Laboratory Medicine (CCLM)

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“…14 This process requires defining as precisely as possible what happened, and also understanding the protocols and processes involved with the event. An analysis of an intraoperative transfusion error, for example, would include not only the intraoperative events and checking protocols, but also surgical blood ordering processes, communication between the OR and the blood bank, blood bank operations, transport, and storage processes (for an example of root cause analysis of a transfusion reaction see Elhence et al 15 ).…”

Section: The Response To Sentinel Events: Root Cause Analysismentioning

confidence: 99%

Sentinel Events and How to Learn From Them

Tung

2014

International Anesthesiology Clinics

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Organizations involved in complex tasks have several ways to examine and improve the quality of their task performance. The most common approach is to assess how closely processes adhere to descriptors of ideal performance or match absolute or relative ideals. As an example, an industrial process involving inserting and tightening 2 screws can be evaluated by means of both process measures (the time required to attach and tighten the screws, variability in the time it takes, whether all screws are tightened to the same degree) and outcomes (how well the gear assembly works afterward and the breakdown rate of the gear assembly over time). Anesthesiologists are routinely involved in similarly complex care processes, in which both process measures (such as antibiotic timing) and outcome measures (such as postoperative reintubation) exist.A prerequisite to this approach to quality performance and work output is an assumption that the coupling between "ideal" task performance and outcome metrics is tight and easily identifiable. Clinical medical care, however, can introduce unpredictable variation into an already complex environment. Evolving care pathways, a high degree of complexity, unanticipated process changes, and diagnostic and therapeutic uncertainty may all cause clinical care to deviate from the expected. In addition, environmental constancy is not guaranteed. A process designed to optimize perioperative antibiotic delivery, for example, may suffer if new drug packaging increases the likelihood of a dangerous drug swap, if the process for identifying patient allergies is changed, or if epidemiological assumptions regarding perioperative pathogens change.The combination of high complexity, diagnostic/therapeutic uncertainty, and unanticipated environmental factors invites the possibility of an unexpected process or outcome failure. Importantly, such failures

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Root cause analysis of transfusion error: identifying causes to implement changes

Abstract: 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.

Cited by 10 publications

References 9 publications

Pathogen Inactivation Technologies for Cellular Blood Components: an Update

Pathogen Inactivation Technologies for Cellular Blood Components: an Update

Error reporting in transfusion medicine at a tertiary care centre: a patient safety initiative

Sentinel Events and How to Learn From Them

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