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KMID : 0387720190300030212
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Korean Journal of Blood Transfusion
2019 Volume.30 No. 3 p.212 ~ p.218
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Experience with Analyzing Patient Safety Incident Reports and Applying Corrective Action in a Blood Bank
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Kim Moon-Kyung
Lee Hyun-Ji
Kang Soo-Hwa
Lee Sun-Min
Kim In-Suk
Chang Chul-Hun
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Abstract
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Background: Blood transfusion poses high risks and has a high probability of error because of the complexity and involvement of several people in the process. The purpose of this study was to share our experience in classifying reports related to blood transfusions. We included patient safety reports that were prepared over a 10-year period that began from the opening of the hospital. We then analyzed the causes and the corrective actions.
Methods: We analyzed 125 reports related to blood transfusions, and these reports were included in the patient safety reports received from November 2008 to December 2018. The events were categorized as sampling error, inspection error, testing error, issue error, disposal error, transfusing blood components error, or others error, depending on the stage of the blood transfusion process. Regardless of the cause, the event that led to an inappropriate transfusion was classified as a transfusion incident.
Results: The number of blood transfusions per year increased, and the rate of blood transfusion accidents ranged from 0.00% to 0.05% per year. A total of 125 reports were prepared over a 10-year period, and these included 8 blood sampling errors, 11 testing errors, 2 issuing errors, 94 disposal errors, 3 others errors, and 7 errors associated with the transfusing of blood components. After the transfusion incident, PDA was applied as a solution. Transfusing the wrong blood components did not occur, and the incidence of taking blood from the wrong patients was decreased.
Conclusion: We applied corrective actions according to the cause of the event and we confirmed that the blood transfusion incidents decreased.
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KEYWORD
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Blood transfusion, Adverse event, The patient safety report
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