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Related Experiment Video

Updated: Jun 6, 2026

Treatment of Platelet Products with Riboflavin and UV Light: Effectiveness Against High Titer Bacterial Contamination

Treatment of Platelet Products with Riboflavin and UV Light: Effectiveness Against High Titer Bacterial Contamination

Published on: August 24, 2015

Root cause analysis of transfusion error: identifying causes to implement changes.

Priti Elhence¹, S Veena, Raj Kumar Sharma

¹Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. pelhence@sgpgi.ac.in

|December 7, 2010

Summary

This summary is machine-generated.

Implementing a Medical Event Reporting System-Transfusion Medicine (MERS-TM) identified system failures in transfusion safety. This error reporting system is crucial for detecting and rectifying issues to enhance patient care.

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Last Updated: Jun 6, 2026

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Published on: August 24, 2015

Area of Science:

Transfusion Medicine
Patient Safety
Healthcare Quality Improvement

Background:

A hospital-based transfusion medicine unit implemented an error reporting system to enhance transfusion safety.
The system, based on the Medical Event Reporting System-Transfusion Medicine (MERS-TM), captures near misses, no-harm events, and misadventures.
Analysis of an innocuous error revealed system weaknesses, guiding necessary improvements for transfusion safety.

Purpose of the Study:

To demonstrate the utility of an error reporting system in identifying and addressing transfusion-related failures.
To analyze the root causes of a specific mistransfusion event and implement corrective actions.
To highlight the importance of system-level analysis for improving patient safety in transfusion medicine.

Main Methods:

An error was investigated, classified, coded, and analyzed using a modified MERS-TM prototype.
Root cause analysis was performed to identify contributing factors to the transfusion error.
Corrective actions were initiated based on identified human, organizational, and patient-related factors.

Main Results:

A 'mistransfusion' occurred, classified as a 'no-harm event' due to correct blood group matching.
The event was categorized as high severity (level 1), with multiple preceding errors identified.
Human, organizational, and patient-related factors were identified as root causes.

Conclusions:

Error reporting systems are vital for uncovering unnoticed human and system failures in transfusion processes.
Such systems enable targeted resource allocation to critical areas for enhancing patient safety.
The study underscores the value of MERS-TM in improving transfusion safety protocols.