Predictable and avoidable human errors in phlebotomy area - an exclusive analysis from a tertiary health care system blood bank.
Error is a direct reflection of system deficiency. Errors occurring in the phlebotomy area are grossly unreported. Though most of these errors does not lead to catastrophic outcome yet indicate system failure. The aim of the study was to identify errors that took place in phlebotomy area, analysing and classifying them. A prospective audit was conducted during an observational period of 8 months, in an overall cohort of 11 260 donors. The incidence of errors was 3.1%. Fifty-five percent errors were technical and remaining 44.9% were clerical. Of all the technical errors, 57.7% were classified as minor, whereas remaining 42.3% were of major category. Similarly, majority of clerical errors (89.9%) were of minor category. The trained staff accounted for all major events (27.8%). In the minor category, technical errors (73.2%) were more commonly done by trained staff, whereas for clerical errors (58.5%), newly recruited staff was responsible. Errors in phlebotomy area are benign but can compromise donor safety. The study helped to develop a consistent and straightforward classification system for errors and to reduce them by basic interventions. Errors committed mostly by our trained staff indicate the need of regular competency testing and an active system for detection of these deviations.
Pandey
P
P
Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India.
Chaudhary
R
R
Tondon
R
R
Khetan
D
D
D001771:Blood Banks; D001782:Blood Donors; D006801:Humans; D007194:India; D019300:Medical Errors / Q000706:statistics & numerical data; D010355:Patient Identification Systems; D018962:Phlebotomy / Q000009:adverse effects / Q000379:methods / Q000592:standards*; D012308:Risk Management; D013048:Specimen Handling / Q000592:standards*