Root cause analysis of transfusion error: identifying causes to implement changes.
BACKGROUND
As part of ongoing efforts to improve transfusion safety, an error reporting system was implemented in our hospital-based transfusion medicine unit at a tertiary care medical institute. This system is based on Medical Event Reporting System-Transfusion Medicine (MERS-TM) and collects data on all near miss, no harm, and misadventures related to the transfusion process. Root cause analyses of one such innocuous appearing error demonstrate how weaknesses in the system can be identified to make necessary changes to achieve transfusion safety.


METHODS
The reported error was investigated, classified, coded, and analyzed using MERS-TM prototype, modified and adopted for our institute.


RESULTS
The consequent error was a "mistransfusion" but a "no-harm event" as the transfused unit was of the same blood group as the patient. It was a high event severity level error (level 1). Multiple errors preceded the final error at various functional locations in the transfusion process. Human, organizational, and patient-related factors were identified as root causes and corrective actions were initiated to prevent future occurrences.


CONCLUSIONS
This case illustrates the usefulness of having an error reporting system in hospitals to highlight human and system failures associated with transfusion that may otherwise go unnoticed. Areas can be identified where resources need to be targeted to improve patient safety.
Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. pelhence@sgpgi.ac.in
Priti
P
Elhence
S
S
Veena
Raj Kumar
RK
Sharma
R K
RK
Chaudhary
D001803:Blood Transfusion / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D012308:Risk Management / Q000379:methods* / Q000592:standards; D012449:Safety / Q000592:standards; D065227:Transfusion Reaction