Sorra Joann, Nieva Veronica, Fastman Barbara Rabin, Kaplan Harold, Schreiber George, King Melissa
Westat, Rockville, Maryland, USA.
Transfusion. 2008 Sep;48(9):1934-42. doi: 10.1111/j.1537-2995.2008.01761.x. Epub 2008 May 23.
Little is known about how transfusion service staff view issues pertaining to event reporting and patient safety. The goal of this study was to assess transfusion service staff attitudes about these issues.
A survey was developed and administered to 945 transfusion service staff from 43 hospital transfusion services in the United States and 10 in Canada. The overall response rate was 73 percent (693 responses), with a mean of 15 respondents per site.
While events resulting in patient harm are reported (91%) as well as mistakes not corrected that could cause harm (79%), less than one-third of respondents report deviations from procedures with no apparent potential to harm (31%) and mistakes that staff catch and correct on their own (27%). Staff indicated that the main reasons mistakes happen are interruptions (51%) and staff in other departments not knowing or understanding proper procedures (49%). Staff had overall positive attitudes about event reporting, but a significant minority were afraid of punitive consequences. Most were positive about their supervisor's safety actions and believed that their transfusion service tries to identify causes of mistakes. Only 31 percent, however, agreed that nursing staff would work with the transfusion service to reduce mistakes.
Overall, the transfusion services had very positive attitudes about event reporting and safety culture. Transfusion services do well recording events that result in patient harm or have the potential for harm, but there is a need to increase reporting of deviations from procedures and mistakes that staff catch and correct on their own. In addition, there are a few areas of safety culture that warrant improvement, particularly the transfusion service's work relationship with nursing staff. The study provides useful descriptive information about how staff view event reporting and safety-related issues and identifies strengths and areas for improvement.
关于输血服务人员如何看待与事件报告和患者安全相关的问题，我们知之甚少。本研究的目的是评估输血服务人员对这些问题的态度。
我们设计了一项调查问卷，并对来自美国43家医院输血服务部门和加拿大10家医院输血服务部门的945名输血服务人员进行了调查。总体回复率为73%（693份回复），每个地点平均有15名受访者。
虽然导致患者伤害的事件（91%）以及未纠正的可能导致伤害的错误（79%）都得到了报告，但不到三分之一的受访者报告了无明显潜在危害的程序偏差（31%）以及工作人员自行发现并纠正的错误（27%）。工作人员表示，错误发生的主要原因是干扰（51%）以及其他部门的工作人员不了解或不理解正确的程序（49%）。工作人员对事件报告总体持积极态度，但有相当一部分人担心会受到惩罚。大多数人对其主管的安全行动持积极态度，并认为他们所在的输血服务部门试图找出错误原因。然而，只有31%的人同意护理人员会与输血服务部门合作以减少错误。
总体而言，输血服务部门对事件报告和安全文化持非常积极的态度。输血服务部门在记录导致患者伤害或有潜在危害的事件方面做得很好，但需要增加对程序偏差以及工作人员自行发现并纠正的错误的报告。此外，安全文化的一些方面需要改进，特别是输血服务部门与护理人员的工作关系。该研究提供了关于工作人员如何看待事件报告和安全相关问题的有用描述性信息，并确定了优势和改进领域。
