Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses.
Introduction Blood transfusions are lifesaving treatments which require critical attention to processes and details. If processes are not followed, grievous errors can lead to sentinel events. A review of investigations completed due to reported events will show the error trends associated with syst...
| Publicado en: | Patient Safety (2689-0143) Vol. 3; no. 2; pp. 78 - 92 |
|---|---|
| Autores principales: | , , , |
| Formato: | algorithm pictorial review tables/charts Journal Article |
| Publicado: |
Pennsylvania Patient Safety Authority
Jun2021
|
| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=158294245&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 158294245 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 26890143 N1OO jtl: Patient Safety (2689-0143) issn: 26890143 maglogo: N pubinfo: dt: Jun2021 vid: 3 iid: 2 pid: 50366 pub: Pennsylvania Patient Safety Authority place: Harrisburg, Pennsylvania artinfo: ui: 158294245 158294245 158294245 10.33940/med/2021.6.6 158294245 ppf: 78 ppct: 14 formats: fmt: @attributes: type: P tig: atl: Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses. aug: au: Lancaster, Elizabeth A. Rhodus, Elizabeth K. Duke, Mary B. Harris, Andrew M. affil: Lexington Veterans Affairs Health Care System sug: subj: Blood Transfusion Treatment Errors Prevention and Control Health Facilities Root Cause Analysis Adverse Health Care Event Prevention and Control Patient Safety Quality Improvement Patient Identification Blood Groups Blood Grouping and Crossmatching Communication Barriers Organizational Policies ab: Introduction Blood transfusions are lifesaving treatments which require critical attention to processes and details. If processes are not followed, grievous errors can lead to sentinel events. A review of investigations completed due to reported events will show the error trends associated with systems used throughout the blood transfusion process. Methods This study employed root cause analyses (RCAs) within the Veterans Health Administration (VHA) to review the events leading to blood transfusion errors. Data was pulled from the RCA databases within the VA National Center for Patient Safety. The time frame was October 2014 to August 2019. A total of 53 RCAs and aggregated reviews were included in the study. These were reviewed for common themes and gaps present within processes. Results The most common events fell within the categories of incorrect or delayed blood orders, incorrect or lack of patient identification, and wrong blood given. The RCA for each event was reviewed and studied. The RCAs had a crossover of multiple causes; lack of a formal process, communication barriers, and technology barriers were the most frequent. Conclusion These RCAs express great variation between VHA facilities, such as process created, number of staff reports, and number of RCAs completed. Lack of standard practices nationwide, training barriers, and technology barriers may explain the variation of transfusion errors throughout the VHA. This study brings to light questions about standardization of transfusion protocols. Future study regarding such standardization is necessary to determine its plausibility. pubtype: Academic Journal doctype: algorithm pictorial review tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
|---|