Root-Cause Analysis of a Potentially Sentinel Transfusion Event: Lessons for Improvement of Patient Safety

  • Hossein Adibi Department of Health Services Management, School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran.
  • Nader Khalesi Mail Department of Health Services Management, School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran.
  • Hamid Ravaghi Department of Health Services Management, School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran.
  • Mahdi Jafari Department of Health Services Management, School of Health Management and Information Sciences, Tehran University of Medical Sciences, Tehran, Iran.
  • Ali Reza Jeddian Department of Clinical Governance, Shariaty Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
Keywords:
Adverse event, Patient safety, Root cause analysis, Transfusion

Abstract

Errors prevention and patient safety in transfusion medicine are a serious concern. Errors can occur at any step in transfusion and evaluation of their root causes can be helpful for preventive measures. Root cause analysis as a structured and systematic approach can be used for identification of underlying causes of adverse events. To specify system vulnerabilities and illustrate the potential of such an approach, we describe the root cause analysis of a case of transfusion error in emergency ward that could have been fatal. After reporting of the mentioned event, through reviewing records and interviews with the responsible personnel, the details of the incident were elaborated. Then, an expert panel meeting was held to define event timeline and the care and service delivery problems and discuss their underlying causes, safeguards and preventive measures. Root cause analysis of the mentioned event demonstrated that certain defects of the system and the ensuing errors were main causes of the event. It also points out systematic corrective actions. It can be concluded that health care organizations should endeavor to provide opportunities to discuss errors and adverse events and introduce preventive measures to find areas where resources need to be allocated to improve patient safety.

References

Goodnough LT, Viele M, Fontaine MJ, Jurado C, Stone N, Quach P, Chua L, Chin ML, Scott R, Tokareva I, Tabb K, Sharek PJ. Implementation of a two-specimen requirement for verification of ABO/Rh for blood transfusion. Transfusion 2009;49(7):1321-8.

Sorra J, Nieva V, Fastman BR, Kaplan H, Schreiber G, King M. Staff attitudes about event reporting and patient safety culture in hospital transfusion services. Transfusion 2008;48(9):1934-42.

The Joint Commission: 2011-2012 National Patient Safety Goals. Oakbrook Terrace, IL: The Joint Commission. [Internet] 2011 [cited 2012 Jul 15]; Available from: http://www.jointcommission.org/assets/1/18/2011- 2012_npsg_presentation_final_8-4-11.pdf

Serious Reportable Events in Healthcare: A Consensus Report. Washington, DC: National Quality Forum (NQF); 2002.

California Department of Public Health: Health andHuman Services Agency. Sacramento, CA: California Department of Public Health. [Internet] 2007 [cited 2012 Jul 15]; Available from: http://www.cdph.ca.gov/certlic/facilities/documents/LNCAFL-07-10.pdf

Linden JV, Wagner K, Voytovich AE, Sheehan J. Transfusion errors in New York State: an analysis of 10 years' experience. Transfusion 2000;40(10):1207-13.

Chiaroni J, Legrand D, Dettori I, Ferrera V. Analysis of ABO discrepancies occurring in 35 French hospitals. Transfusion 2004;44(6):860-4.

Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324(6):370-6.

Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324(6):377-84.

de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospitaladverse events: a systematic review. Qual Saf Health Care 2008;17(3):216-23.

Kaplan HS, Battles JB, Van der Schaaf TW, Shea CE, Mercer SQ. Identification and classification of the causes of events in transfusion medicine. Transfusion 1998;38(11-12):1071-81.

Callum JL, Kaplan HS, Merkley LL, Pinkerton PH, Rabin Fastman B, Romans RA, Coovadia AS, Reis MD. Reporting of near-miss events for transfusion medicine: improving transfusion safety. Transfusion 2001;41(10): 1204-11.

Dzik WS, Beckman N, Selleng K, Heddle N, Szczepiorkowski Z, Wendel S, Murphy M. Errors in patient specimen collection: application of statistical process control. Transfusion 2008;48(10):2143-51.

Garnerin P, Schiffer E, Van Gessel E, Clergue F. Rootcause analysis of an airway filter occlusion: a way to improve the reliability of the respiratory circuit. Br J Anaesth 2002;89(4):633-5.

Saillour-Glénisson F, Tricaud S, Mathoulin-Pélissier S, Bouchon B, Galpérine I, Fialon P, Salmi LR. Factors associated with nurses' poor knowledge and practice of transfusion safety procedures in Aquitaine, France. Int J Qual Health Care 2002;14(1):25-32.

Reza PA, Aziz SV, Ali MA, Marjan MH, Reza TM.Evaluation of knowledge of healthcare workers in hospitals of Zabol city on proper methods of blood and components transfusion. Asian J Transfus Sci 2009;3(2):78-81.

Fastman BR, Kaplan HS. Errors in transfusion medicine:= have we learned our lesson? Mt Sinai J Med 2011;78(6):854-64.

Stainsby D, Jones H, Asher D, Atterbury C, Boncinelli A, Brant L, Chapman CE, Davison K, Gerrard R, Gray A, Knowles S, Love EM, Milkins C, McClelland DB, NorfolkDR, et al; SHOT Steering Group. Serious hazards of transfusion: a decade of hemovigilance in the UK. Transfus Med Rev 2006;20(4):273-82.

Furillo J. Ensuring safe nurse-to-patient ratios: Safe Staffing Bill mandates ratios based on patients' needs rather than budgets. West J Med 2001;174(4):233-4.

Ellis J, Clements D. Nurse staffing and patient safety: ratios and beyond. Healthc Q 2006;9(3):18, 20.

Minnick AF, Mion LC. Nurse labor data: the collection and interpretation of nurse-to-patient ratios. J Nurs Adm 2009;39(9):377-81.

Coffman JM, Seago JA, Spetz J. Minimum nurse-topatient ratios in acute care hospitals in California. Health Aff (Millwood) 2002;21(5):53-64.

Myhre BA, McRuer D. Human error-a significant cause of transfusion mortality. Transfusion 2000;40(7):879-85.

Aslani Y, Etemadyfar S, Noryan K. Nurses' knowledge of blood transfusion in medical training centers of Shahrekord University of Medical Science in 2004. Iran J Nurs Midwifery Res 2010;15(3):141-4.

Liumbruno GM, Rafanelli D. Appropriateness of blood transfusion and physicians' education: a continuous challenge for Hospital Transfusion Committees? Blood Transfus 2012;10(1):1-3.

Aprili G. Safety in transfusion medicine. Blood Transfus 2008;6(3):121-6.

Dzik WH, Corwin H, Goodnough LT, Higgins M, Kaplan H, Murphy M, Ness P, Shulman IA, Yomtovian R. Patient safety and blood transfusion: new solutions. Transfus Med Rev 2003;17(3):169-80.

How to Cite
1.
Adibi H, Khalesi N, Ravaghi H, Jafari M, Jeddian AR. Root-Cause Analysis of a Potentially Sentinel Transfusion Event: Lessons for Improvement of Patient Safety. Acta Med Iran. 50(9):624-631.
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