title: Error management in blood establishments: results of eight years of experience (2003-2010) at the Croatian Institute of Transfusion Medicine.
abstract: BACKGROUND
  Continuous and efficient error management, including procedures from error detection to their resolution and prevention, is an important part of quality management in blood establishments. At the Croatian Institute of Transfusion Medicine (CITM), error management has been systematically performed since 2003.
  
  
  METHODS
  Data derived from error management at the CITM during an 8-year period (2003-2010) formed the basis of this study. Throughout the study period, errors were reported to the Department of Quality Assurance. In addition to surveys and the necessary corrective activities, errors were analysed and classified according to the Medical Event Reporting System for Transfusion Medicine (MERS-TM).
  
  
  RESULTS
  During the study period, a total of 2,068 errors were recorded, including 1,778 (86.0%) in blood bank activities and 290 (14.0%) in blood transfusion services. As many as 1,744 (84.3%) errors were detected before issue of the product or service. Among the 324 errors identified upon release from the CITM, 163 (50.3%) errors were detected by customers and reported as complaints. In only five cases was an error detected after blood product transfusion however without any harmful consequences for the patients. All errors were, therefore, evaluated as "near miss" and "no harm" events. Fifty-two (2.5%) errors were evaluated as high-risk events. With regards to blood bank activities, the highest proportion of errors occurred in the processes of labelling (27.1%) and blood collection (23.7%). With regards to blood transfusion services, errors related to blood product issuing prevailed (24.5%).
  
  
  CONCLUSIONS
  This study shows that comprehensive management of errors, including near miss errors, can generate data on the functioning of transfusion services, which is a precondition for implementation of efficient corrective and preventive actions that will ensure further improvement of the quality and safety of transfusion treatment.
authors.affiliation: Croatian Institute of Transfusion Medicine, Zagreb, Croatia. tomislav.vuk@hztm.hr
authors.forename: Tomislav
authors.initials: T
authors.lastname: Vuk
authors.forename: Marijan
authors.initials: M
authors.lastname: Barišić
authors.forename: Tihomir
authors.initials: T
authors.lastname: Očić
authors.forename: Ivanka
authors.initials: I
authors.lastname: Mihaljević
authors.forename: Dorotea
authors.initials: D
authors.lastname: Sarlija
authors.forename: Irena
authors.initials: I
authors.lastname: Jukić
mesh_terms: D001771:Blood Banks; D016913:Blood Component Transfusion / Q000009:adverse effects*; D017523:Croatia; D005260:Female; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies