Usin Mary F, Ramesh Prathiba, Lopez C G
Transfusion Medicine Unit, University Malaya Medical Center, Kuala Lumpur, Malaysia.
Malays J Pathol. 2004 Jun;26(1):43-8.
Event reporting can provide data to study the failure points of an organization's work process. As part of the ongoing efforts to improve transfusion safety, a Medical Event Reporting System Transfusion Medicine, (MERS - TM) as designed by Kaplan et al was implemented in the Transfusion Medicine Unit of the University Malaya Medical Centre to provide a standardized means of organized data collection and analysis of transfusion errors, adverse events and near misses. An event reporting form was designed to detect, identify, classify and study the frequency and pattern of events occurring in the unit. Events detected were classified according to Eihdhoven Classification model (ECM) adopted for MERS - TM. Since our system reported all events, we called it Event Reporting System - Transfusion Medicine (ERS-TM). Data was collected and analyzed from the reporting forms for a period of five months from January 15th to June 15th 2002. The initial half of the period was a process of evaluation during which 118 events were reported, coded, analyzed and corrective measures adopted to prevent the recurrence of the same event. The latter half saw the reporting of 122 events following the adoption of corrective measures. There was a reduction in the occurrence of some events and an increase in others, which were mainly beyond the organization's control. A longer period of evaluation is necessary to identify the underlying contributory causes that can be useful to develop plans for corrective and preventive action and thereby reduce the rate of recurrence of errors through proper training and adoption of just culture.
事件报告可为研究组织工作流程的故障点提供数据。作为持续改进输血安全工作的一部分，由卡普兰等人设计的医学事件报告系统——输血医学（MERS - TM）在马来亚大学医学中心输血医学科实施，以提供一种标准化方法，用于有组织地收集和分析输血差错、不良事件及险些发生的差错。设计了一份事件报告表，用于检测、识别、分类并研究该科室发生事件的频率和模式。检测到的事件根据MERS - TM采用的埃因霍温分类模型（ECM）进行分类。由于我们的系统报告了所有事件，我们将其称为事件报告系统——输血医学（ERS - TM）。从2002年1月15日至6月15日的五个月期间，从报告表中收集并分析了数据。该时间段的前半期是一个评估过程，在此期间报告了118起事件，进行了编码、分析，并采取了纠正措施以防止同一事件再次发生。后半期在采取纠正措施后报告了122起事件。一些事件的发生率有所下降，而另一些事件的发生率则有所上升，这主要超出了组织的控制范围。需要更长时间的评估来确定潜在的促成因素，这有助于制定纠正和预防行动计划，从而通过适当培训和采用公正文化来降低差错的复发率。
