Reporting of near-miss events for transfusion medicine: improving transfusion safety

Transfusion
Jeannie L CallumM D Reis

Abstract

Half of the reported serious adverse events from transfusion are a consequence of medical error. A no-fault medical-event reporting system for transfusion medicine (MERS-TM) was developed to capture and analyze both near-miss and actual transfusion-related errors. A prospective audit of transfusion-related errors was performed to determine the ability of MERS-TM to identify the frequency and patterns of errors. Events and near-miss events (total, 819) were recorded for a period of 19 months (median, 51/month). No serious adverse patient outcome occurred, despite these events, with the transfusion of 17,465 units of RBCs. Sixty-one events (7.4%) were potentially life-threatening or could have led to permanent injury (severity Level 1). Of most concern were 3 samples collected from the wrong patient, 13 mislabeled samples, and 22 requests for blood for the wrong patient. Near-miss events were five times more frequent than actual transfusion errors, and 68 percent of errors were detected before blood was issued. Sixty-one percent of events originated from patient areas, 35 percent from the blood bank, and 4 percent from the blood supplier or other hospitals. Repeat collection was required for 1 of every 94 samples, and 1 in 346 re...Continue Reading

References

Sep 2, 1992·JAMA : the Journal of the American Medical Association·D A DavisR B Haynes
Aug 15, 1998·Vox Sanguinis·L NoelA Cosson
Jun 26, 1999·Archives of Pathology & Laboratory Medicine·J V Linden, G B Schmidt
Jul 3, 1999·BMJ : British Medical Journal·L M WilliamsonJ A Barbara
Mar 17, 2000·BMJ : British Medical Journal·P Barach, S D Small

❮ Previous
Next ❯

Citations

Jun 1, 2005·Anesthesiology Clinics of North America·Dorothy Stainsby
Jan 18, 2003·Lancet·Lawrence T GoodnoughMark E Brecher
Jan 18, 2003·Lancet·Samer A M Nashef
Nov 9, 2002·Transfusion·Virginie MigeotPierre Ingrand
Mar 6, 2007·Critical Care Medicine·Carolyn B HarrisVictoria J Fraser
Nov 11, 2010·Journal of Emergencies, Trauma, and Shock·S HunzikerS Marsch
Sep 19, 2012·Asian Journal of Transfusion Science·Kim JeongeunLee Kyungsoon
Aug 10, 2004·Journal of the American Medical Informatics Association : JAMIA·Aziz A BoxwalaLuke Sato
Sep 26, 2014·Current Opinion in Anaesthesiology·Gregory A NuttallWilliam C Oliver
Jan 5, 2016·Forensic Science International : Synergy·M A Bihina Bella, J H P Eloff
Aug 2, 2011·AORN Journal·Nancy J Girard
Mar 23, 2010·Transfusion Medicine Reviews·Eleftherios C Vamvakas, Morris A Blajchman
Aug 2, 2006·American Journal of Clinical Pathology·Priscila I FigueroaLoni Calhoun
Oct 14, 2008·Transfusion Medicine Reviews·Elizabeth A HennemanPhilip L Henneman
Jul 18, 2007·Seminars in Diagnostic Pathology·Anand S DigheKent B Lewandrowski
Dec 19, 2006·Transfusion Medicine Reviews·Elizabeth A HennemanPhilip L Henneman
Dec 8, 2004·Critical Care Clinics·Erfan Hussain, Emily Kao
Aug 16, 2006·Vox Sanguinis·P Pagliaro, P Rebulla
May 12, 2006·Transfusion·Zbigniew M Szczepiorkowski, James P AuBuchon
Mar 2, 2006·Vox Sanguinis·A PrussA Salama
Oct 5, 2010·American Journal of Industrial Medicine·Lina LanderMelissa J Perry
Feb 22, 2012·Transfusion·Brian McWilliamsJonathan H Waters
Sep 4, 2004·Annales Françaises D'anesthèsie Et De Rèanimation·V LuceD Benhamou
Apr 7, 2006·Nursing Outlook·Laura M WagnerJoseph G Ouslander
Oct 11, 2005·The Journal of Thoracic and Cardiovascular Surgery·Patricia A NastVictoria J Fraser
May 12, 2004·Critical Care Clinics·Mercy Kuriyan, Jeffrey L Carson
Oct 14, 2003·Journal of Biomedical Informatics·Matthew B WeingerNelda Ordonez
Mar 25, 2016·Asian Journal of Transfusion Science·Meena SidhuYasmeen Irm
Apr 16, 2003·Transfusion Medicine·C MichligJ-D Tissot
Apr 20, 2018·Journal of Blood Transfusion·Abja SapkotaNiru Khatiwada
Feb 23, 2019·Clinical Orthopaedics and Related Research·Michael P AstSteven B Haas
Jun 18, 2002·The Joint Commission Journal on Quality Improvement·David M KrolMartha J Radford

❮ Previous
Next ❯

Related Concepts

Trending Feeds

COVID-19

Coronaviruses encompass a large family of viruses that cause the common cold as well as more serious diseases, such as the ongoing outbreak of coronavirus disease 2019 (COVID-19; formally known as 2019-nCoV). Coronaviruses can spread from animals to humans; symptoms include fever, cough, shortness of breath, and breathing difficulties; in more severe cases, infection can lead to death. This feed covers recent research on COVID-19.

Blastomycosis

Blastomycosis fungal infections spread through inhaling Blastomyces dermatitidis spores. Discover the latest research on blastomycosis fungal infections here.

Nuclear Pore Complex in ALS/FTD

Alterations in nucleocytoplasmic transport, controlled by the nuclear pore complex, may be involved in the pathomechanism underlying multiple neurodegenerative diseases including Amyotrophic Lateral Sclerosis and Frontotemporal Dementia. Here is the latest research on the nuclear pore complex in ALS and FTD.

Applications of Molecular Barcoding

The concept of molecular barcoding is that each original DNA or RNA molecule is attached to a unique sequence barcode. Sequence reads having different barcodes represent different original molecules, while sequence reads having the same barcode are results of PCR duplication from one original molecule. Discover the latest research on molecular barcoding here.

Chronic Fatigue Syndrome

Chronic fatigue syndrome is a disease characterized by unexplained disabling fatigue; the pathology of which is incompletely understood. Discover the latest research on chronic fatigue syndrome here.

Evolution of Pluripotency

Pluripotency refers to the ability of a cell to develop into three primary germ cell layers of the embryo. This feed focuses on the mechanisms that underlie the evolution of pluripotency. Here is the latest research.

Position Effect Variegation

Position Effect Variagation occurs when a gene is inactivated due to its positioning near heterochromatic regions within a chromosome. Discover the latest research on Position Effect Variagation here.

STING Receptor Agonists

Stimulator of IFN genes (STING) are a group of transmembrane proteins that are involved in the induction of type I interferon that is important in the innate immune response. The stimulation of STING has been an active area of research in the treatment of cancer and infectious diseases. Here is the latest research on STING receptor agonists.

Microbicide

Microbicides are products that can be applied to vaginal or rectal mucosal surfaces with the goal of preventing, or at least significantly reducing, the transmission of sexually transmitted infections. Here is the latest research on microbicides.