Please use this identifier to cite or link to this item:
Full metadata record
DC FieldValueLanguage
dc.contributor.authorMora, Asunción
dc.contributor.authorAyala, Luis
dc.contributor.authorBielza, Rafael
dc.contributor.authorAtaúlfo González, F
dc.contributor.authorVillegas, Ana
dc.description.abstractOne of the medical areas where errors can have more serious consequences is the process of blood transfusion. We used failure mode and effect analysis (FMEA) for evaluating potential failures and improving transfusion safety in a medium-size urban hospital with a highly complex transfusion service. Each failure mode was evaluated using the likelihood of occurrence, severity of the effect, and probability of detection. The obtained results allowed each failure to be prioritized and decisions to be made in an organized manner to determine solutions. We define measures and indicators that allow the comparison of their results in a longer time period than most of the previous studies. The most important failures were those regarding 1) transmitting information about the transfusion request, 2) patient identification, 3) sample identification, 4) cross-matching ordered tests, 5) transfusing blood components, 6) completing and sending the transfusion control document, and 7) reporting of transfusion reactions. The application of the FMEA methodology allowed implementation of safety measures and monitoring of the measures using indicators, including the mandatory records of the hemovigilance system. There was a 56% improvement in the risk prioritization numbers in the second stage of the FMEA. FMEA allows for identification of factors that reduce safety in this hospital, analysis of the causes and consequences of these errors, design of corrective measures, and establishment of indicators to monitor their application. The FMEA methodology can help other institutions to identify their own specific vulnerabilities.
dc.subject.meshBlood Transfusion
dc.subject.meshHealthcare Failure Mode and Effect Analysis
dc.subject.meshMedical Errors
dc.subject.meshTransfusion Reaction
dc.titleImproving safety in blood transfusion using failure mode and effect analysis.
dc.pubmedtypeJournal Article
dc.pubmedtypeResearch Support, Non-U.S. Gov't
Appears in Collections:Hospitales > H. U. Clínico San Carlos > Artículos
Fundaciones e Institutos de Investigación > FIIB H. U. Infanta Sofía y H. U. Henares > Artículos
Fundaciones e Institutos de Investigación > IIS H. U. Clínico San Carlos > Artículos
Hospitales > H. U. Infanta Sofía > Artículos

Files in This Item:
The file with the full text of this item is not available due to copyright restrictions or because there is no digital version. Authors can contact the head of the repository of their center to incorporate the corresponding file.

Items in DSpace are protected by copyright, with all rights reserved, unless otherwise indicated.