Sources of preventable errors related to transfusion

Sharma, Ramesh; Shubham, Kumar; Agnihotri, S. K.

doi:10.1046/j.1423-0410.2001.00057.x

Cited by 37 publications

(34 citation statements)

References 17 publications

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“…There are numerous examples in the scientific literature of otherwise salient environmental features failing to be noticed as a result of fatigue, inattention, distraction, interference or excessive cognitive demand [16][17][18][19][20]. The consequences that may follow from similar errors in real world situations such as security checks, blood transfusions [20], pharmacological dispensing [21], air traffic control [22] and driving [23] are only too obvious.…”

Section: Resultsmentioning

confidence: 99%

“…The consequences that may follow from similar errors in real world situations such as security checks, blood transfusions [20], pharmacological dispensing [21], air traffic control [22] and driving [23] are only too obvious. Given the high costs involved, methods which minimize errors by ensuring the successful management of cognitive resources through task design and implementation become all the more important.…”

Section: Resultsmentioning

confidence: 99%

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Label-checking strategies to adapt behaviour to design

Smith‐Spark

Katz

Marchant

et al. 2015

Proceedings of the European Conference on Cognitive Ergonomics 2015

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Despite robust quality control procedures, labelling errors on fresh produce are estimated to cost the UK supermarket industry approximately £50million pounds per year in product recalls and wastage. Changing the format of the labels themselves is not a viable option. Instead, the challenge is to change or guide human operatives' behaviour so that label printing errors do not go undetected during quality control procedures. To this end, a simulated label checking task was presented to naïve participants to compare more systematic and strategic methods of label checking. Two conditions in which behaviour was computer-led were compared with a control condition in which checkers adopted their own idiosyncratic checking method. The data indicate that the two computer-led approaches resulted in improved levels of accuracy. Pushing label checkers towards a more systematic approach would appear to be effective in reducing undetected label errors, and could lead potentially to significant financial savings and reduced environmental wastage in the fresh produce industry.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Label-checking strategies to adapt behaviour to design

Smith‐Spark

Katz

Marchant

et al. 2015

Proceedings of the European Conference on Cognitive Ergonomics 2015

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“…Three of these studies evaluated the processes and resulting adverse events of specific medical interventions—anticoagulation,26 anaesthesia administration27 and transfusion practices 28. A Ghana study examined the relationship between the treatment process and mortality in patients with tetanus 29…”

Section: Resultsmentioning

confidence: 99%

Measures of patient safety in developing and emerging countries: a review of the literature

Carpenter

Duevel

Lee

et al. 2010

Quality and Safety in Health Care

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Investigation of patient safety in developing and emerging countries has been infrequent and limited in scope. Establishing fundamental safe patient practices, integrating those processes into routine health services delivery and developing patients' expectations that such processes be present are necessary prerequisites to measuring and monitoring progress towards safe patient care in emerging and developing countries.

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“…It is useful to investigate feasibility of the system by evaluating change of time to finish each activity [11][12][13][14][15][16][17][18]. We investigated time to finish each activity by collecting data observationally and computed average length of time from around 10 observationally data of each activity.…”

Section: Discussionmentioning

confidence: 99%

IT can improve healthcare management for patient safety - minimizing risk of blood transfusion with Point-of-Act-System

Akiyama

Koshio

2011

2011 IEEE International Conference on Industrial Engineering and Engineering Management

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The purpose of this study is ensuring patient safety of blood transfusion by minimizing risk of transfusion at the point of care through Information Technology. The targets are ensuring five rights of transfusion, rights process and right information by auto identification and traceability of blood products. Auto identification and data capturing system with RFID based on the Point-of-Act-System (POAS). It provides real time right identification, process management to ensure right medication and traceability with serialized number in single item level. The system designed based on process analysis and use case of transfusion was successfully implemented in Red Cross Hospital to prevent transfusion errors and ensure traceability of blood products. By reading RFID at the point of care, we can check database to look for adverse events of blood products. We identified all 377 blood products and acquired tracking data successfully. We can improve patient safety and traceability with RFID.Keywords -Healthcare management, Point of care, Patient safety978-1-4577-0739-1/11/$26.00 ©2011 IEEE

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Sources of preventable errors related to transfusion

Abstract: Errors occur most frequently outside the blood bank, and the bedside of the patient is the main location.

Cited by 37 publications

References 17 publications

Label-checking strategies to adapt behaviour to design

Label-checking strategies to adapt behaviour to design

Measures of patient safety in developing and emerging countries: a review of the literature

IT can improve healthcare management for patient safety - minimizing risk of blood transfusion with Point-of-Act-System

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