[Improving blood safety: errors management in transfusion medicine]

Area of Science:

• Transfusion Medicine
• Patient Safety
• Quality Management Systems

Background:

• Blood safety encompasses the entire transfusion chain, from donor collection to patient transfusion.
• Quality management systems are crucial for monitoring adverse events and incidents.
• Near-miss error monitoring identifies critical process points to improve transfusion safety.

Purpose of the Study:

• To analyze adverse and unexpected events in transfusion practices.
• To identify potential risks to blood donor and patient health.
• To evaluate the effectiveness of error reporting in transfusion medicine.

Main Methods:

• A one-year retrospective study was conducted.
• Analysis and interpretation of written medical error reports.
• Errors were categorized by type, frequency, and process phase.

Main Results:

• No errors with direct health consequences for donors or patients were found.
• Errors with potential patient harm occurred throughout the transfusion chain.
• The preanalytical phase accounted for the majority of errors, with human factors being the primary cause.

Conclusions:

• Error reporting systems are vital for managing transfusion-related risks.
• Ongoing analysis reveals process strengths and weaknesses, guiding necessary improvements.
• Transfusion errors are largely preventable through cost-effective, systematic interventions.