Process controls to avert mistransfusion

Autor: J. P. AuBuchon
Rok vydání: 2007
Předmět:
Zdroj: ISBT Science Series. 2:253-256
ISSN: 1751-2824
1751-2816
Popis: The key to error reduction in medicine is to focus on the process being applied and not just those performing the process. As human error is inevitable, it is necessary to evaluate and re-design processes so that errors cannot happen or are reliably detected and interdicted before patient harm is the outcome. One tool that is useful to ensure that a process has been completed correctly is a ‘process control’, a step in a process the successful completion of which ensures that all preceding critical steps have been accomplished successfully. (An example from immunohematology is the use of ‘check cells’.) To reduce the risk of mistransfusion, for example, process controls can be applied by using bedside systems that apply to the patient's bar-coded identification to the label of a pretransfusion testing sample or by using a mechanical barrier system to ensure that the person who gave that sample is the one receiving the transfusion. Other approaches include the use of remote-release refrigeration systems or the use of only Group O red cells for transfusion until the patient's ABO group has been confirmed on a second sample. Applying techniques like this would significantly reduce the ongoing – but avoidable – catastrophes of acute hemolytic transfusion reactions.
Databáze: OpenAIRE
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