Please use this identifier to cite or link to this item: https://hdl.handle.net/20.500.12530/55642
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dc.contributor.authorMora, Asunción
dc.contributor.authorAyala, Luis
dc.contributor.authorBielza, Rafael
dc.contributor.authorAtaúlfo González, F
dc.contributor.authorVillegas, Ana
dc.date.accessioned2022-10-04T07:16:20Z-
dc.date.available2022-10-04T07:16:20Z-
dc.date.issued2019-01-04
dc.identifier.citationTransfusion.2019;(59)2:516-523
dc.identifier.urihttps://hdl.handle.net/20.500.12530/55642-
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.language.isoen
dc.subject.meshBlood Transfusion
dc.subject.meshHealthcare Failure Mode and Effect Analysis
dc.subject.meshHumans
dc.subject.meshMedical Errors
dc.subject.meshSafety
dc.subject.meshTransfusion Reaction
dc.titleImproving safety in blood transfusion using failure mode and effect analysis.
dc.typeArtículo
dc.identifier.pubmedID30609064
dc.format.volume59
dc.format.page516-523
dc.identifier.e-issn1537-2995
dc.identifier.journalTransfusion
dc.identifier.journalabbreviationTransfusion
dc.identifier.doi10.1111/trf.15137
dc.format.number2
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

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