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- Title
Evaluation of error reporting system in blood banking: A five year experience.
- Authors
Shah, R.; Mathur, A.; Harimoorthy, V.; Tulsiani, S.; Patel, T.; Shah, P.; Choudhury, N.
- Abstract
Background and Objectives: Safety and reliability of blood transfusion is not static, but are dynamic non events. Since performance deviation continually occurs in complex systems, their detection and correction must accomplished over and over again. Non performance must be detected early enough to allow for recovery and mitigation. Near-miss events afford early detection of possible system weaknesses and provide an early chance of correction. Error reporting system is the key function to guide whether Standard Operating Procedures (SOPs) are followed at every step and by every employee. Errors is failure (deviation) in the performance of a SOP. Materials and Methods: The retrospective study has been carried out about errors reported by the staff of regional blood transfusion centre (RBTC) from January 2002 to July 2006. The RBTC is accredeted by ISO:15189 and is having 135 SOPs for all procedures. Each deviation from SOP has been recorded to the technical authority of the blood transfusion service (BTS). Data has been analyzed for different parameter including the type of error, the functioning area of BTS etc. Employees were encouraged to record all sorts of errors. Immediate corrective action was taken at level of head of unit, error committee used to meet once in every month. Wide range of errors were recorded ranging from delay reporting at blood donation site, administration, house keeping, IT related problems, wrongly accepted the donor, behavior of the staff to even near-miss events. Result: During the period of 55 months, 175 errors (including major and minor error) were reported. Majority of the errors 68 (38.8%) were related to blood collection area which includes errors related to timings, screening, phlebotomy and post donation care. Second major contributor was problems related to the IT department with 26 errors (14.86%) which includes both software and hardware related errors. Other technical areas from where errors were reported are component lab 6(3.4%), cross match and issue laboratory 14 (8%). In the component lab it includes errors in component preparation, quality control and bulk issue to the storage centre, in the cross match and issue lab includes errors in grouping of patient, error in cross match and issue of product. Errors also reported for reception desk 10 (5.7%), societal marketing section 9 (5.7%), finance 6 (3.4%), human resource management 3 (1.7%), administration 17 (9.7%), distribution desk 10 (5.7%). True technical errors were only 3 (1.7%). Conclusion: Majority of the errors reported were non-technical. But even this can be managed by the proper follow-up of the formulated SOPs. For errors to be prevented, there must be an effective system for consistently sorting, characterizing and cataloging errors in a timely fashion. Minimization of errors leads to increase our capacity to get the right blood to the right patient. For the management of errors, there has to exist a quality culture that makes it plain that quality is not the prerogative of a few designated quality technologists or a quality team, but is the responsibility of each employee.
- Subjects
INDIA; MEDICAL errors; BLOOD transfusion reaction; RISK management in blood banks; BLOOD collection
- Publication
Asian Journal of Transfusion Science, 2007, Vol 1, Issue 2, p93
- ISSN
0973-6247
- Publication type
Article