Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses
Introduction Blood transfusions are lifesaving treatments which require critical attention to processes and details. If processes are not followed, grievous errors can lead to sentinel events. A review of investigations completed due to reported events will show the error trends associated with syst...
| Main Authors: | , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Patient Safety Authority
2021-06-01
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| Series: | Patient Safety |
| Online Access: | https://patientsafetyj.com/index.php/patientsaf/article/view/465 |
| _version_ | 1827848046649540608 |
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| author | Elizabeth A. Lancaster Elizabeth K. Rhodus Mary B. Duke Andrew M. Harris |
| author_facet | Elizabeth A. Lancaster Elizabeth K. Rhodus Mary B. Duke Andrew M. Harris |
| author_sort | Elizabeth A. Lancaster |
| collection | DOAJ |
| description | Introduction
Blood transfusions are lifesaving treatments which require critical attention to processes and details. If processes are not followed, grievous errors can lead to sentinel events. A review of investigations completed due to reported events will show the error trends associated with systems used throughout the blood transfusion process.
Methods
This study employed root cause analyses (RCAs) within the Veterans Health Administration (VHA) to review the events leading to blood transfusion errors. Data was pulled from the RCA databases within the VA National Center for Patient Safety. The time frame was October 2014 to August 2019. A total of 53 RCAs and aggregated reviews were included in the study. These were reviewed for common themes and gaps present within processes.
Results
The most common events fell within the categories of incorrect or delayed blood orders, incorrect or lack of patient identification, and wrong blood given. The RCA for each event was reviewed and studied. The RCAs had a crossover of multiple causes; lack of a formal process, communication barriers, and technology barriers were the most frequent.
Conclusion
These RCAs express great variation between VHA facilities, such as process created, number of staff reports, and number of RCAs completed. Lack of standard practices nationwide, training barriers, and technology barriers may explain the variation of transfusion errors throughout the VHA. This study brings to light questions about standardization of transfusion protocols. Future study regarding such standardization is necessary to determine its plausibility. |
| first_indexed | 2024-03-12T09:40:12Z |
| format | Article |
| id | doaj.art-877117079cc04109a405ffd7928042ce |
| institution | Directory Open Access Journal |
| issn | 2641-4716 |
| language | English |
| last_indexed | 2024-03-12T09:40:12Z |
| publishDate | 2021-06-01 |
| publisher | Patient Safety Authority |
| record_format | Article |
| series | Patient Safety |
| spelling | doaj.art-877117079cc04109a405ffd7928042ce2023-09-02T13:19:50ZengPatient Safety AuthorityPatient Safety2641-47162021-06-013210.33940/med/2021.6.6Blood Transfusion Errors Within a Health System: A Review of Root Cause AnalysesElizabeth A. Lancaster0Elizabeth K. Rhodus1Mary B. Duke2Andrew M. Harris3Lexington Veterans Affairs Health Care SystemLexington Veterans Affairs Health Care System, University of Kentucky Sanders-Brown Center on AgingLexington Veterans Affairs Health Care System Lexington Veterans Affairs Health Care SystemIntroduction Blood transfusions are lifesaving treatments which require critical attention to processes and details. If processes are not followed, grievous errors can lead to sentinel events. A review of investigations completed due to reported events will show the error trends associated with systems used throughout the blood transfusion process. Methods This study employed root cause analyses (RCAs) within the Veterans Health Administration (VHA) to review the events leading to blood transfusion errors. Data was pulled from the RCA databases within the VA National Center for Patient Safety. The time frame was October 2014 to August 2019. A total of 53 RCAs and aggregated reviews were included in the study. These were reviewed for common themes and gaps present within processes. Results The most common events fell within the categories of incorrect or delayed blood orders, incorrect or lack of patient identification, and wrong blood given. The RCA for each event was reviewed and studied. The RCAs had a crossover of multiple causes; lack of a formal process, communication barriers, and technology barriers were the most frequent. Conclusion These RCAs express great variation between VHA facilities, such as process created, number of staff reports, and number of RCAs completed. Lack of standard practices nationwide, training barriers, and technology barriers may explain the variation of transfusion errors throughout the VHA. This study brings to light questions about standardization of transfusion protocols. Future study regarding such standardization is necessary to determine its plausibility.https://patientsafetyj.com/index.php/patientsaf/article/view/465 |
| spellingShingle | Elizabeth A. Lancaster Elizabeth K. Rhodus Mary B. Duke Andrew M. Harris Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses Patient Safety |
| title | Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses |
| title_full | Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses |
| title_fullStr | Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses |
| title_full_unstemmed | Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses |
| title_short | Blood Transfusion Errors Within a Health System: A Review of Root Cause Analyses |
| title_sort | blood transfusion errors within a health system a review of root cause analyses |
| url | https://patientsafetyj.com/index.php/patientsaf/article/view/465 |
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