Related Experiment Video
Updated: Apr 19, 2026
A Precision Medicine Tool for Measurement and Monitoring of Hemoglobin S in Sickle Cell Disease Patients Receiving Transfusion Therapy
Proactive risk assessment of blood transfusion process, in pediatric emergency, using the Health Care Failure Mode
Reza Dehnavieh1, Hossein Ebrahimipour, Yasamin Molavi-Taleghani
1Research Center for Health Services Management, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran. rdehnavi@gmail.com.
Insights
Healthcare Failure Mode and Effects Analysis (HFMEA) identified 13 high-risk failure modes in pediatric emergency blood transfusions. Strategies were developed to improve patient safety and transfusion processes.
Area of Science:
- Pediatric Emergency Medicine
- Healthcare Quality Improvement
- Patient Safety
Background:
- Pediatric emergency departments are high-risk environments.
- Blood transfusion is a critical but unique clinical intervention.
- Proactive risk assessment is essential for safe transfusion practices.
Purpose of the Study:
- To proactively assess risks in the pediatric emergency blood transfusion process.
- To utilize the Healthcare Failure Mode and Effects Analysis (HFMEA) methodology.
- To identify and analyze potential failures in transfusion procedures.
Main Methods:
- A cross-sectional study employing a mixed quantitative-qualitative approach.
- Proactive HFMEA was used to identify and analyze potential process failures.
- Expert consensus was achieved through interviews and focus group discussions.
Main Results:
- 77 failure modes were identified across 8 blood transfusion processes and 24 sub-processes.
- 13 failure modes were classified as unacceptable risks (hazard score > 8).
- Recommended actions included acceptance (11.6%), control (74.2%), and elimination (14.2%).
Conclusions:
- Re-engineering processes, standardizing procedures, and root cause analysis are key strategies.
- Enhancing patient identification and personnel awareness through training are crucial.
- Establishing a monthly transfusion medicine committee meeting is recommended for ongoing improvement.
Introduction:
Pediatric emergency has been considered as a high risk area, and blood transfusion is known as a unique clinical measure, therefore this study was conducted with the purpose of assessing the proactive risk assessment of blood transfusion process in Pediatric Emergency of Qaem education- treatment center in Mashhad, by the Healthcare Failure Mode and Effects Analysis (HFMEA) methodology.
Methodology:
This cross-sectional study analyzed the failure mode and effects of blood transfusion process by a mixture of quantitative-qualitative method. The proactive HFMEA was used to identify and analyze the potential failures of the process. The information of the items in HFMEA forms was collected after obtaining a consensus of experts' panel views via the interview and focus group discussion sessions.
Results:
The Number of 77 failure modes were identified for 24 sub-processes enlisted in 8 processes of blood transfusion. Totally 13 failure modes were identified as non-acceptable risk (a hazard score above 8) in the blood transfusion process and were transferred to the decision tree. Root causes of high risk modes were discussed in cause-effect meetings and were classified based on the UK national health system (NHS) approved classifications model. Action types were classified in the form of acceptance (11.6%), control (74.2%) and elimination (14.2%). Recommendations were placed in 7 categories using TRIZ ("Theory of Inventive Problem Solving.")
Conclusion:
The re-engineering process for the required changes, standardizing and updating the blood transfusion procedure, root cause analysis of blood transfusion catastrophic events, patient identification bracelet, training classes and educational pamphlets for raising awareness of personnel, and monthly gathering of transfusion medicine committee have all been considered as executive strategies in work agenda in pediatric emergency.
Related Concept Videos
01:15Blood Transfusion
Blood Transfusion Overview
A blood transfusion is a medical procedure used to replace blood lost due to injury, surgery, or to treat conditions such as anemia or cancer. During a transfusion, donor blood is...
02:45Blood Transfusion and Agglutination
History
The history of blood transfusion dates back to the 17th century, when early attempts were made in animals. In 1818 James Blundell, a British doctor, performed the first successful human blood transfusion. Later in 1900, Karl...
01:10Pre-Procedural Guidelines for Assessing Blood Pressure
01:25Transmission-based Precautions II: Airborne and Protective Environment
Airborne precautions:
Use airborne precautions when treating patients known or suspected to have diseases that spread through the air—for example, tuberculosis or measles. These organisms are present in smaller droplets expelled by an infected person and...