[Patient safety and root cause analysis].
Safety in the field of transfusion medicine has greatly improved in France. The risk of viral transmission has decreased by a factor greater than 1500 within the last 20 years. In comparison, the risk related to ABO error has decreased only by half. The reporting of critical incidents, which occur at any step of the transfusion procedure is now mandatory in France and is subject to an in-depth analysis, using methods close to that used in aviation safety. The goal of these analyses is to better understand human factors in order to implement more adequate prevention measures.
Service d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées du Val-de-Grâce, 74 boulevard de Port-Royal, 75005 Paris, France. yves.auroy@wanadoo.fr
Y
Y
Auroy
G
G
Andreu
J P
JP
Aullen
D
D
Benhamou
C
C
Caldani
N
N
Canivet
C
C
de Lardemelle
F Desroys
FD
du Roure
A
A
François
M
M
Gruber
I
I
Sandid
C
C
Linget
B
B
Loulière
M
M
Perrin
D
D
Rebibo
X
X
Richomme
X
X
Tinard
D000017:ABO Blood-Group System; D000056:Accident Prevention; D000059:Accidents; D001787:Blood Group Incompatibility / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D058731:Blood Safety; D017848:Blood-Borne Pathogens; D015984:Causality; D005602:France; D006040:Goals; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control; D065227:Transfusion Reaction; D014766:Viremia / Q000209:etiology / Q000517:prevention & control; D038301:Virus Inactivation
D000017:ABO Blood-Group System