Near miss errors in transfusion medicine: the experience of the G. Gaslini transfusion medicine service.
BACKGROUND
The monitoring of near miss errors, in other words events that cannot be classified as substantial errors, but whose occurrence suggests that there is probably a critical point in a working procedure, can be useful in order to prevent these 'almost errors' from occurring again or to prevent them evolving into 'relevant errors'.


METHODS
The methods for picking up and studying near miss errors use widely tested systems that have recently also been applied to medicine. These systems are based on the process of identifying the risk through spontaneous notifications of events (incident reporting). In our Service of Immunohaematology and Transfusion Medicine (SIMT) these reports were assessed using root cause analysis, allowing us to introduce corrective actions to eliminate or reduce the risk.


RESULTS
We report the distribution, type and frequency of near miss errors, divided according to the stage of the working procedure in which they occurred, and for each of them describe the possible causes and corrective actions identified. We show how the possibility of an error, with potentially harmful consequences for the patient, is present throughout the whole transfusion chain. Near miss errors in Transfusion Medicine can be included in the wider field of 'clinical risk, a problem that concerns not only SIMT, but also numerous other sectors of health care.


CONCLUSIONS
The instruments identified through this study can lower the threshold of clinical risk in a Transfusion Service.
Ardenghi
Diego
D
Servizio di Immunoematologia e Medicina Trasfusionale, Istituto Giannina Gaslini, Genova, Italy. diego.ardenghi@libero.it
Martinengo
Marina
M
Bocciardo
Laura
L
Nardi
Paola
P
Tripodi
Gino
G