Providing feedback to users on unacceptable practice in the delivery of a hospital transfusion service--a pilot study

The Serious Hazards of Transfusion Scheme's (SHOT) annual report continues to emphasize the importance of investigating serious transfusion errors. It is now recognized that lessons can also be learnt from near-miss events as these occur more frequently than serious errors in transfusion. One of the key features in developing a culture that can promote safety in relation to transfusion is providing feedback to staff on what is acceptable and unacceptable practice. We have developed a scoring system based on the number of serious errors and near misses that occur in the transfusion service to provide feedback to staff on their performance in relation to the administration of blood components and blood products. This was developed as part of an ongoing error logging system that we have previously described. The implementation of this feedback has resulted in an increased awareness within our organization of safety issues in relation to transfusion, and has highlighted the importance of the detection and correction of less serious errors.