Reporting of near‐miss events for transfusion medicine: improving transfusion safety

BACKGROUND: Half of the reported serious adverse events from transfusion are a consequence of medical error. A no‐fault medical‐event reporting system for transfusion medicine (MERS‐TM) was developed to capture and analyze both near‐miss and actual transfusion‐related errors.

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

[2]  Standards for blood banks and transfusion services. , 1977, QRB. Quality review bulletin.

[3]  N. J. Jensen,et al.  An automated system for bedside verification of the match between patient identification and blood unit identification , 1996, Transfusion.

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

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

[6]  J. Debeir,et al.  The French Haemovigilance System , 1999, Vox sanguinis.

[7]  R. Haynes,et al.  Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. , 1992, JAMA.

[8]  F. Mercuriali,et al.  Bedside Transfusion Errors: Analysis of 2 Years' Use of a System to Monitor and Prevent Transfusion Errors , 1996, Vox sanguinis.

[9]  P. Maurette,et al.  [To err is human: building a safer health system]. , 2002, Annales francaises d'anesthesie et de reanimation.

[10]  G. Ives.  Chapter 5 – “NEAR MISS” REPORTING PITFALLS FOR NUCLEAR PLANTS , 1991 .

[11]  T. W. van der Schaaf,et al.  Near Miss Reporting as a Safety Tool , 1991 .

[12]  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.

[13]  J. Linden,et al.  An overview of state efforts to improve transfusion medicine. The New York state model. , 2009, Archives of Pathology & Laboratory Medicine.

[14]  Vartanian,et al.  The BCSH guideline on addressograph labels: experience at a cardiothoracic unit and findings of a telephone survey , 2000, Transfusion Medicine.

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

[16]  Tjerk W. van der Schaaf.  Chapter 6 – DEVELOPMENT OF A NEAR MISS MANAGEMENT SYSTEM AT A CHEMICAL PROCESS PLANT , 1991 .

[17]  W. Harmsen,et al.  Errors in transfusion medicine. Detection, analysis, frequency, and prevention. , 1994, Archives of pathology & laboratory medicine.

[18]  L. Donaldson,et al.  An organisation with a memory. , 2002, Clinical medicine.

[19]  A. Wall,et al.  Book ReviewTo Err is Human: building a safer health system Kohn L T Corrigan J M Donaldson M S Washington DC USA: Institute of Medicine/National Academy Press ISBN 0 309 06837 1 $34.95 , 2000 .

[20]  B Wenz,et al.  Improvement in transfusion safety using a new blood unit and patient identification system as part of safe transfusion practice , 1991, Transfusion.

[21]  H. Cohen,et al.  Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports , 1999, BMJ.

[22]  J. Debeir,et al.  The French Hæmovigilance System , 1998 .

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

[24]  E. Dupont,et al.  Bedside Transfusion Errors , 1994, Vox sanguinis.

[25]  Lau,et al.  Improvement in transfusion safety using a specially designed transfusion wristband , 2000, Transfusion medicine.