title: Blood sampling - Two sides to the story.
abstract: This study aimed to investigate why there is variability in taking blood. A multi method Pilot study was completed in four National Health Service Scotland hospitals. Human Factors/Ergonomics principles were applied to analyse data from 50 observations, 15 interviews and 12-months of incident data from all Scottish hospitals. The Functional Resonance Analysis Method (FRAM) was used to understand why variability may influence blood sampling functions. The analysis of the 61 pre blood transfusion sampling incidents highlighted limitations in the data collected to understand factors influencing performance. FRAM highlighted how variability in the sequence of blood sampling functions and the number of practitioners involved in a single blood sampling activity was influenced by the working environment, equipment, clinical context, work demands and staff resources. This pilot study proposes a realistic view of why blood sampling activities vary and proposes the need to consider the system's resilience in future safety management strategies.
authors.affiliation: Human Factors Department, The University of Nottingham, ITRC Building, Nottingham, NG7 2RD, United Kingdom. Electronic address: laura.pickup@nottingham.ac.uk.
authors.forename: Laura
authors.initials: L
authors.lastname: Pickup
authors.affiliation: Human Factors Department, The University of Nottingham, ITRC Building, Nottingham, NG7 2RD, United Kingdom. Electronic address: sarah.atkinson@nottingham.ac.uk.
authors.forename: Sarah
authors.initials: S
authors.lastname: Atkinson
authors.affiliation: Center for Quality Improvement, Southern Region, Denmark. Electronic address: hollnagel.erik@gmail.com.
authors.forename: Erik
authors.initials: E
authors.lastname: Hollnagel
authors.affiliation: Safety and Improvement Research Group, Medicine Directorate, NHS Education for Scotland, Glasgow, United Kingdom; Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom. Electronic address: paul.bowie@nes.scot.nhs.uk.
authors.forename: Paul
authors.initials: P
authors.lastname: Bowie
authors.affiliation: Scottish National Blood Transfusion Service, 17 Ellen's Glen Road, Edinburgh, EH17 7QT, United Kingdom. Electronic address: Alexandra.gray@nhs.net.
authors.forename: Sandra
authors.initials: S
authors.lastname: Gray
authors.affiliation: East of Scotland Blood Transfusion Centre, Dundee, United Kingdom.
authors.forename: Sam
authors.initials: S
authors.lastname: Rawlinson
authors.affiliation: Scottish National Blood Transfusion Service, 21 Ellen's Glen Road, Edinburgh, EH17 7QT, United Kingdom. Electronic address: Katherine.forrester@nhs.net.
authors.forename: Kate
authors.initials: K
authors.lastname: Forrester
mesh_terms: D001800:Blood Specimen Collection / Q000295:instrumentation / Q000379:methods* / Q000592:standards*; D001803:Blood Transfusion; D006804:Ergonomics; D006761:Hospitals; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D010355:Patient Identification Systems; D061214:Patient Safety; D010865:Pilot Projects; D016526:Workload; D017132:Workplace / Q000458:organization & administration
keywords: Blood sampling; Resilience; Wrong blood in tube