title: [Improving blood safety: errors management in transfusion medicine].
abstract: BACKGROUND
  The concept of blood safety includes the entire transfusion chain starting with the collection of blood from the blood donor, and ending with blood transfusion to the patient. The concept involves quality management system as the systematic monitoring of adverse reactions and incidents regarding the blood donor or patient. Monitoring of near-miss errors show the critical points in the working process and increase transfusion safety.
  
  
  OBJECTIVE
  The aim of the study was to present the analysis results of adverse and unexpected events in transfusion practice with a potential risk to the health of blood donors and patients.
  
  
  METHODS
  One-year retrospective study was based on the collection, analysis and interpretation of written reports on medical errors in the Blood Transfusion Institute of Vojvodina.
  
  
  RESULTS
  Errors were distributed according to the type, frequency and part of the working process where they occurred. Possible causes and corrective actions were described for each error. The study showed that there were not errors with potential health consequences for the blood donor/patient. Errors with potentially damaging consequences for patients were detected throughout the entire transfusion chain. Most of the errors were identified in the preanalytical phase. The human factor was responsible for the largest number of errors.
  
  
  CONCLUSIONS
  Error reporting system has an important role in the error management and the reduction of transfusion-related risk of adverse events and incidents. The ongoing analysis reveals the strengths and weaknesses of the entire process and indicates the necessary changes. Errors in transfusion medicine can be avoided in a large percentage and prevention is cost-effective, systematic and applicable.
authors.forename: Nevenka
authors.initials: N
authors.lastname: Bujandrić
authors.forename: Jasmina
authors.initials: J
authors.lastname: Grujić
authors.forename: Mirjana
authors.initials: M
authors.lastname: Krga-Milanović
mesh_terms: D001782:Blood Donors / Q000706:statistics & numerical data; D058731:Blood Safety / Q000191:economics / Q000379:methods / Q000592:standards; D001803:Blood Transfusion / Q000191:economics; D006801:Humans; D019300:Medical Errors / Q000191:economics / Q000517:prevention & control* / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D058996:Quality Improvement / Q000191:economics; D012189:Retrospective Studies; D012308:Risk Management / Q000592:standards / Q000706:statistics & numerical data; D055771:Serbia / Q000453:epidemiology; D064826:Transfusion Medicine / Q000191:economics / Q000458:organization & administration / Q000592:standards*; D065227:Transfusion Reaction