J Clin Outcomes Manage
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.
Reports from the Field
Search the Turner White index to find abstracts of articles published in JCOM.