Root cause analysis of an aberrant thromboelastogram tracing –, Lessons learnt

Global Journal of Transfusion Medicine

article

Ganesh Mohan¹  Shamee Shastry¹  Dhivya Kandasamy¹  PA Prethika¹  Chenna Deepika¹ 

[1] Department of Immunohematology and Blood Transfusion, Kasturba Medical College

关键词: Coagulation;    hemostasis;    quality assurance;    root cause analysis;    thrombelastography (TEG);   

DOI  :  10.4103/GJTM.GJTM_73_19

学科分类：社会科学、人文和艺术（综合）

来源: Wolters Kluwer Medknow Publications

【 摘 要 】

Thromboelastography is a viscoelastic test which uses whole blood sample for routine coagulation screening purpose. Even though it is an easy procedure, many critical steps affect the final result of the test and we describe such an incident in this report. The root cause analysis of two aberrant TEG reports on two different occasions was initiated; the tracing initially was normal but developed an abnormal pattern toward the middle portion. The graph suddenly dropped to the baseline and from there, it was demonstrating an abnormal pattern. This can be due to power failure, vibrations during the test, cup dislodging from the pins during run, no validation prior to each test, and out of calibration. The root cause was identified as improper fixing of cups and pins leading to dislodging from the pins during the run and prevention of such incidents can be achieved by individual training of the staffs and periodical evaluation of their competency.

【 授权许可】

CC BY-NC-SA