title: [How to analyze an incident of the transfusion chain].
abstract: Incidents and accidents analysis is one part of risk management in healthcare organisations. It is based on methods such as healthcare process analysis and the Association of Litigation and Risk Management (ALARM) method, to understand not only immediate causes but also root causes. The goal is to implement relevant remedial and preventive actions to secure healthcare processes. The hospital's risk management unit has to be involved in the methodological analysis of every grade zero transfusion incident. The system is based on a retrospective analysis process in compliance with the French National Authority for Health's ongoing requirements for risk reactive approach, allowing to identify failures and start relevant actions. Healthcare teams should overcome difficulties in order to be totally involved in the process. Human factors recognition, establishment of clear and effective communication between individuals and critical points of control should provide optimum quality care services that are safe and free of unnecessary risks.
authors.affiliation: Unité gestion des risques-qualité, Institut national de la transfusion sanguine, 75739 Paris cedex 15, France. proussel@ints.fr
authors.forename: P
authors.initials: P
authors.lastname: Roussel
authors.forename: B
authors.initials: B
authors.lastname: Lassale
mesh_terms: D000017:ABO Blood-Group System; D001771:Blood Banks / Q000458:organization & administration* / Q000592:standards; D016063:Blood Loss, Surgical; D019299:Decompression, Surgical; D004630:Emergencies; D017707:Erythrocyte Transfusion / Q000009:adverse effects / Q000592:standards; D005568:Forms and Records Control / Q000458:organization & administration / Q000592:standards; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control; D019838:Neck Injuries / Q000601:surgery; D010355:Patient Identification Systems / Q000458:organization & administration*; D010564:Personnel, Hospital / Q000193:education; D012308:Risk Management / Q000379:methods*; D040242:Risk Reduction Behavior; D000094902:Blood Banking / Q000379:methods
chemical_list: D000017:ABO Blood-Group System