Managing transfusion service quality.
BACKGROUND
Providing blood products for transfusions is a complex process subject to errors both within and outside the transfusion service. Transfusion-related errors can have grave consequences for the patient undergoing transfusion. As with many processes performed within health care systems, there is an expectation of error-free practice. Although this is an unobtainable goal, a focused quality-management plan, employing a medical event reporting system in a just working environment, can effect measurable system-quality improvement.


OBJECTIVE
To illustrate the intrinsic value of quality-improvement activities through discussion of examples of quality misadventures from our transfusion service during the past 20 years.


METHODS
Examples of quality-improvement activities were extracted from our quality-system archives. The published literature on transfusion quality was reviewed.


CONCLUSIONS
Active reporting, structured investigation, and systematic resolution of transfusion-related errors are effective methods for improving and maintaining transfusion quality.
Department of Pathology, University of Utah, Room 2100, 15 N Medical Dr E, Salt Lake City, UT 84112, USA. blaylockr@aruplab.com
Robert C
RC
Blaylock
Christopher M
CM
Lehman
D001803:Blood Transfusion / Q000592:standards*; D003695:Delivery of Health Care / Q000458:organization & administration / Q000592:standards*; D006801:Humans; D011787:Quality of Health Care / Q000458:organization & administration / Q000592:standards*