Improvement in Blood Transfusion Safety: Using Root Cause Analysis

Journal of Comprehensive Pediatrics

article

Sheida Vahidi¹  Seyed HadiMirhashemi³  BehrouzHashemi⁴  MarziehNoorbakhsh⁵  Yasamin Molavi-Taleghani⁶ 

[1] Responsible for Patient Safety, Patient Safety Unit, Shahid Beheshti University of Medical Sciences;PHD Candidate in Health Educarion and Promotion, Shahid Beheshti University of Medical Sciences;General Surgery ,(Fellowship of Minimally Invasive Surgery), Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences;Emergency Medicine, Shahid Beheshti University of Medical Sciences;General Physician, Shahid Beheshti University of Medical Sciences;Health Management and Economics Research Center, Department of Health Services Management, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences

关键词: Root Cause Analysis;    Patient Safety;    Health Service;    Blood Transfusion;    Never Events;   

DOI  :  10.5812/compreped.99088

来源: Kowsarmedical

【 摘 要 】

Objectives: This research aimed at analyzing the adverse events reported related to blood transfusion in one of the large vice-chancellorships of Iran University of Medical Sciences in spring 2018. Methods: This descriptive study was performed based on the eight stages of the root cause analysis (RCA) of healthcare events by the National Authority for Health. For classification of the considered concerns, the “classifying nursing errors in clinical management (NECM)” model, failure classification, approved by the UK National Health System, and also a creative problem-solving technique were used for determining the improvement solutions. Results: Based on the results, 70% of states of blood transfusion error and blood products were placed in the category of care errors, 10% in the communication category, 20% in the category of implementation errors, and 0% in the category of knowledge and skill errors. A total of 38 influencing factors were identified for adverse events of blood transfusion, the most cause of the error was associated with organizational factors (18.4%), and the least reasons for failure were equipment and resource factors (5.3%). Conclusions: The establishment of advanced systems for the automatic transmission of blood and blood products, due to the lack of proper infrastructure in Iran, is not economically feasible.

【 授权许可】

Unknown