Ardenghi Diego, Martinengo Marina, Bocciardo Laura, Nardi Paola, Tripodi Gino
Servizio di Immunoematologia e Medicina Trasfusionale, Istituto Giannina Gaslini, Genova, Italy.
Blood Transfus. 2007 Nov;5(4):210-6. doi: 10.2450/2007.0010-07.
The monitoring of near miss errors, in other words events that cannot be classified as substantial errors, but whose occurrence suggests that there is probably a critical point in a working procedure, can be useful in order to prevent these 'almost errors' from occurring again or to prevent them evolving into 'relevant errors'.
The methods for picking up and studying near miss errors use widely tested systems that have recently also been applied to medicine. These systems are based on the process of identifying the risk through spontaneous notifications of events (incident reporting). In our Service of Immunohaematology and Transfusion Medicine (SIMT) these reports were assessed using root cause analysis, allowing us to introduce corrective actions to eliminate or reduce the risk.
We report the distribution, type and frequency of near miss errors, divided according to the stage of the working procedure in which they occurred, and for each of them describe the possible causes and corrective actions identified. We show how the possibility of an error, with potentially harmful consequences for the patient, is present throughout the whole transfusion chain. Near miss errors in Transfusion Medicine can be included in the wider field of 'clinical risk, a problem that concerns not only SIMT, but also numerous other sectors of health care.
The instruments identified through this study can lower the threshold of clinical risk in a Transfusion Service.
对险些失误进行监测，即那些不能归类为重大失误，但这些事件的发生表明在工作流程中可能存在一个关键点，这对于防止这些“险些失误”再次发生或防止其演变为“相关失误”可能是有用的。
发现和研究险些失误的方法采用了经过广泛测试的系统，这些系统最近也已应用于医学领域。这些系统基于通过事件的自发报告（事件报告）来识别风险的过程。在我们的免疫血液学和输血医学服务部（SIMT），使用根本原因分析对这些报告进行评估，使我们能够采取纠正措施以消除或降低风险。
我们报告了险些失误的分布、类型和频率，根据其发生的工作流程阶段进行划分，并针对每一项描述了确定的可能原因和纠正措施。我们展示了在整个输血链中都存在对患者有潜在有害后果的失误可能性。输血医学中的险些失误可纳入“临床风险”这一更广泛的领域，这不仅是SIMT关注的问题，也是众多其他医疗保健部门关注的问题。
通过本研究确定的工具可降低输血服务中的临床风险阈值。
