Experience of Failure Mode and Effect Analysis in Transfusion Medicine / 대한수혈학회지
Korean Journal of Blood Transfusion
; : 140-148, 2017.
Article
in Ko
| WPRIM
| ID: wpr-18198
Responsible library:
WPRO
ABSTRACT
BACKGROUND:
Blood transfusions are complicated procedures, and are highly sensitive to mistakes that could seriously endanger the life of patients. The failure mode and effect analysis (FMEA) can be used to inspect and improve high risk processes. Here, we aimed to identify the risk factors of a blood transfusion process and to improve its safety by optimizing the process.METHODS:
We conducted a weekly meeting from March to April 2014. We investigated the frequency of events for 2013 (before FMEA) and 2015 (after FMEA). The FMEA process was performed in eight steps and the improvement priorities were determined in accordance with the magnitude of calculated fatalities (multiplied by severity, occurrence, and detection scores).RESULTS:
The whole process of blood transfusion was analyzed by detailedsteps:
Decision of blood transfusion, blood transfusion request, pre-transfusion test, blood product discharge, delivery, and administration process. Then, we identified the types of failures and likelihood of occurrence, discovery, and severity. Based on the calculated risk priority number, strategies to improve the highest failure modes were developed. Eleven transfusion-related events occurred before FMEA, and three events occurred after FMEA.CONCLUSION:
In this study, we analyzed the failure modes that may occur during a transfusion procedure. The FMEA was a useful tool for analyzing and reducing the risks associated with a blood transfusion procedure. Continuous efforts to improve the failure modes would be helpful to further improve the safety of patients undergoing blood transfusion.Key words
Full text:
1
Index:
WPRIM
Main subject:
Blood Transfusion
/
Risk Factors
/
Patient Safety
/
Transfusion Medicine
/
Healthcare Failure Mode and Effect Analysis
/
Hematologic Tests
Type of study:
Etiology_studies
/
Prognostic_studies
/
Risk_factors_studies
Limits:
Humans
Language:
Ko
Journal:
Korean Journal of Blood Transfusion
Year:
2017
Type:
Article