Seven hundred and fifty‐nine (759) chances to learn: a 3‐year pilot project to analyse transfusion‐related near‐miss events in the Republic of Ireland

Background  The National Haemovigilance Office has collected and analysed reports on errors associated with transfusion since 2000. A 3‐year pilot research project in near‐miss event reporting commenced in November 2002.

[1]  J. Battles,et al.  Identification and classification of the causes of events in transfusion medicine , 2008, Transfusion.

[2]  M F Murphy,et al.  Current performance of patient sample collection in the UK , 2004, Transfusion medicine.

[3]  A. Casbard,et al.  Barcode technology: its role in increasing the safety of blood transfusion , 2003, Transfusion.

[4]  H S Kaplan,et al.  The attributes of medical event-reporting systems: experience with a prototype medical event-reporting system for transfusion medicine. , 1998, Archives of pathology & laboratory medicine.

[5]  J. Lumadue,et al.  Adherence to a strict specimen‐labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens , 1997, Transfusion.

[6]  M. Murphy,et al.  An international study of the performance of sample collection from patients , 2003, Vox sanguinis.

[7]  J. Linden,et al.  A report of 104 transfusion errors in New York State , 1992, Transfusion.

[8]  Urbaniak,et al.  Comparing near misses with actual mistransfusion events: a more accurate reflection of transfusion errors , 2000, British journal of haematology.

[9]  J. Callum,et al.  Reporting of near‐miss events for transfusion medicine: improving transfusion safety , 2001, Transfusion.

[10]  Janet M. Corrigan,et al.  Near-Miss Analysis , 2004 .

[11]  pTools National Haemovigilance Office , 2008 .

[12]  H. Kaplan Getting the right blood to the right patient: the contribution of near-miss event reporting and barrier analysis. , 2005, Transfusion clinique et biologique : journal de la Societe francaise de transfusion sanguine.

[13]  A E Voytovich,et al.  Transfusion errors in New York State: an analysis of 10 years' experience , 2000, Transfusion.

[14]  Walter H Dzik,et al.  Emily Cooley Lecture 2002: transfusion safety in the hospital , 2003, Transfusion.

[15]  P. Barach,et al.  Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems , 2000, BMJ : British Medical Journal.

[16]  J. Callum,et al.  The Medical Event Reporting System for Transfusion Medicine: will it help get the right blood to the right patient? , 2002, Transfusion medicine reviews.

[17]  K. Sazama,et al.  Reports of 355 transfusion‐associated deaths: 1976 through 1985 , 1990, Transfusion.