title: [Failures of the issue: how to improve?].
abstract: If they are not stopped before transfusion, distribution of blood components (BC) errors can have serious consequences for patients. The study of reported incidents of transfusion chain shows that the risk of failure is important, especially on the steps of patient selection in software, packing and giving the BC to transporter. The analysis of these problems most often state "human" error by misapplication of procedures. These errors are favored by systemic causes: many interfaces with numerous actors in the transfusion process, breaking between different information systems, stress of the emergency and lot of visual self-checks. Improvement may be proposed by a better the organization of the different tasks, by the ergonomic of the work, by improving distribution software and training operators to the management of the emergency. But things must be thought again by all the actors involved in the transfusion management of patients in order to reduce the risks associated with multiple interfaces.
authors.affiliation: Établissement français du sang, Rhône-Alpes, 1390, rue Centrale-Beynost, 01708 Miribel cedex, France. dominique.legrand@efs.sante.fr
authors.forename: D
authors.initials: D
authors.lastname: Legrand
authors.forename: A
authors.initials: A
authors.lastname: François
mesh_terms: D001771:Blood Banks / Q000458:organization & administration*; D001787:Blood Group Incompatibility; D001793:Blood Preservation; D058731:Blood Safety; D003695:Delivery of Health Care; D005568:Forms and Records Control; D005602:France; D006801:Humans; D019300:Medical Errors / Q000009:adverse effects / Q000517:prevention & control* / Q000706:statistics & numerical data; D010355:Patient Identification Systems; D018579:Patient Selection; D058996:Quality Improvement; D012308:Risk Management; D012984:Software; D014019:Tissue Donors; D065227:Transfusion Reaction; D014186:Transportation