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JCOM Abstract

J Clin Outcomes Manage 
2007 Aug;14(8):441-446
Prospective risk assessment and intervention to reduce blood transfusion errors
Stanton JE, Korus G, Israelite CL, Fogt F

Abstract Objective: To describe a failure modes and effects analysis (FMEA) and subsequent process changes to reduce risk of clerical errors of blood transfusion and to reduce same-day surgery delays due to absence of adequate data or lack of product. Methods: A multidisciplinary team mapped the steps involved in ordering and administering blood products for surgical procedures. A risk priority index score was calculated for each failure mode. For the top 10 failure modes, corrective actions were initiated and reviewed. Results: There was an overall reduction of 53% in the risk priority index score for the 10 modes addressed. Hazard risk values decreased by 37% in the preoperative phase, 88% in the operative phase, 76% in the postanesthesia care unit phase, and 17% in the unit/floor phase. Conclusion: An FMEA can be applied to blood banking to identify and address weaknesses within the blood banking system.

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