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Blood Transfusion Errors Within A Health System: A Review Of Root Cause Analyses, Elizabeth A. Lancaster, Elizabeth K. Rhodus, Mary B. Duke, Andrew M. Harris
Blood Transfusion Errors Within A Health System: A Review Of Root Cause Analyses, Elizabeth A. Lancaster, Elizabeth K. Rhodus, Mary B. Duke, Andrew M. Harris
Sanders-Brown Center on Aging Faculty Publications
Introduction
Blood transfusions are lifesaving treatments which require critical attention to processes and details. If processes are not followed, grievous errors can lead to sentinel events. A review of investigations completed due to reported events will show the error trends associated with systems used throughout the blood transfusion process.
Methods
This study employed root cause analyses (RCAs) within the Veterans Health Administration (VHA) to review the events leading to blood transfusion errors. Data was pulled from the RCA databases within the VA National Center for Patient Safety. The time frame was October 2014 to August 2019. A total of 53 …