Errors in Transfusion Medicine: Have We Learned Our Lesson?
Errors in Transfusion Medicine: Have We Learned Our Lesson?
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DOI：
10.1002/msj.20296
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发表时间：
2011-11-01
影响因子：
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通讯作者：
Kaplan, Harold S.
中科院分区：
文献类型：
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作者：
Fastman, Barbara Rabin;Kaplan, Harold S.
短语“患者安全性”表示不会因医疗保健环境中发生的事件而造成意外或可预防的伤害。从业者的目标是减少，如果不是防止，医疗差错和不良后果。然而，从多个角度进行的研究表明，医疗差错是一个严重的世界性问题。输血医学具有跨学科的复杂性和致命后果的危险，是吸取经验教训的典范。复杂系统中出错的机会是巨大的，尽管错误传统上归咎于人类，但它们往往是由预先存在的因素造成的。输血具有固有危害，例如临床脆弱性（例如，感染传染性病原体或发生输血反应），但也存在与过程错误相关的危害的可能性。样本采集错误或分析前错误可能发生在献血期间从献血者采集样本时，以及在输血相关检测之前从患者采集样本时，约占输血事件的三分之一。输血链分析阶段的错误、实验室失误和错误占患者安全相关输血事件的近三分之一。多达40%的错误输血是由于分析后阶段的错误：通常是在床边对正确的血液和正确的患者进行最终检查时失败。条形码标签，射频识别标签，甚至手掌静脉扫描技术越来越多地用于患者身份识别。输血的最后阶段，仔细监测受者是否有不良体征或症状，如果认真执行，可以帮助预防或管理由早期过程错误或不可避免的生理状况引起的潜在致命反应。我们可以和处理输血的潜在危害的方法进行了讨论，包括一种称为固有的安全设计的危害减少的方法。这种方法旨在减少风险，主要是消除危害或减少其发生。在输血过程中，消除和明显减少了一些危害，收到了良好的效果。然而，在构成输血链各阶段的基本上手动步骤中，仍然严重依赖程序方法。一些医院已经设立了输血安全官员的新角色，以协助监测，识别和解决可能降低安全性的条件。Mt Sinai J Med 78：854-864，2011. (C)2011年西奈山医学院
The phrase "patient safety" represents freedom from accidental or preventable harm due to events occurring in the healthcare setting. Practitioners aim to reduce, if not prevent, medical errors and adverse outcomes. Yet studies performed from many perspectives show that medical error constitutes a serious worldwide problem. Transfusion medicine, with its interdisciplinary intricacies and the danger of fatal outcomes, serves as an exemplar of lessons learned. Opportunity for error in complex systems is vast, and although errors are traditionally blamed on humans, they are often set up by preexisting factors. Transfusion has inherent hazards such as clinical vulnerabilities (eg, contracting an infectious agent or experiencing a transfusion reaction), but there also exists the possibility of hazards associated with process errors. Sample collection errors, or preanalytic errors, may occur when samples are drawn from donors during blood donation, as well as when drawn from patients prior to transfusion-related testing, and account for approximately one-third of events in transfusion. Errors in the analytic phase of the transfusion chain, slips and errors in the laboratory, comprise close to one-third of patient safety-related transfusion events. As many as 40% of mistransfusions are due to errors in the postanalytic phase: often failures in the final check of the right blood and the right patient at the bedside. Bar-code labels, radiofrequency identification tags, and even palm vein-scanning technology are increasingly being utilized in patient identification. The last phase of transfusion, careful monitoring of the recipient for adverse signs or symptoms, when performed diligently can help prevent or manage a potentially fatal reaction caused by an earlier process error or an unavoidable physiologic condition. Ways in which we can and do deal with potential hazards of transfusion are discussed, including a method of hazard reduction termed inherently safer design. This approach aims to lessen risk, with elimination of a hazard or the reduction of its occurrence as primary. In blood transfusion, elimination and marked reduction of some hazards has been employed to good effect. However, there is still a heavy reliance on procedural methods in the essentially manual steps constituting the phases of the transfusion chain. Some hospitals have created a new role of transfusion safety officer to assist in the effort of monitoring, identifying, and resolving conditions that may lessen safety. Mt Sinai J Med 78:854-864, 2011. (C) 2011 Mount Sinai School of Medicine