RESUMO
Event reporting can provide data to study the failure points of an organization's work process. As part of the ongoing efforts to improve transfusion safety, a Medical Event Reporting System Transfusion Medicine, (MERS - TM) as designed by Kaplan et al was implemented in the Transfusion Medicine Unit of the University Malaya Medical Centre to provide a standardized means of organized data collection and analysis of transfusion errors, adverse events and near misses. An event reporting form was designed to detect, identify, classify and study the frequency and pattern of events occurring in the unit. Events detected were classified according to Eihdhoven Classification model (ECM) adopted for MERS - TM. Since our system reported all events, we called it Event Reporting System - Transfusion Medicine (ERS-TM). Data was collected and analyzed from the reporting forms for a period of five months from January 15th to June 15th 2002. The initial half of the period was a process of evaluation during which 118 events were reported, coded, analyzed and corrective measures adopted to prevent the recurrence of the same event. The latter half saw the reporting of 122 events following the adoption of corrective measures. There was a reduction in the occurrence of some events and an increase in others, which were mainly beyond the organization's control. A longer period of evaluation is necessary to identify the underlying contributory causes that can be useful to develop plans for corrective and preventive action and thereby reduce the rate of recurrence of errors through proper training and adoption of just culture.
