Mora Asunción, Ayala Luis, Bielza Rafael, Ataúlfo González F, Villegas Ana
Hospital Clínico San Carlos, Servicio de Hematología y Hemoterapia, Madrid, Spain.
Universidad Rey Juan Carlos, Facultad de Ciencias Jurídicas y Sociales, Madrid, Spain.
Transfusion. 2019 Feb;59(2):516-523. doi: 10.1111/trf.15137. Epub 2019 Jan 4.
One of the medical areas where errors can have more serious consequences is the process of blood transfusion. We used failure mode and effect analysis (FMEA) for evaluating potential failures and improving transfusion safety in a medium-size urban hospital with a highly complex transfusion service.
Each failure mode was evaluated using the likelihood of occurrence, severity of the effect, and probability of detection. The obtained results allowed each failure to be prioritized and decisions to be made in an organized manner to determine solutions. We define measures and indicators that allow the comparison of their results in a longer time period than most of the previous studies.
The most important failures were those regarding 1) transmitting information about the transfusion request, 2) patient identification, 3) sample identification, 4) cross-matching ordered tests, 5) transfusing blood components, 6) completing and sending the transfusion control document, and 7) reporting of transfusion reactions. The application of the FMEA methodology allowed implementation of safety measures and monitoring of the measures using indicators, including the mandatory records of the hemovigilance system. There was a 56% improvement in the risk prioritization numbers in the second stage of the FMEA.
FMEA allows for identification of factors that reduce safety in this hospital, analysis of the causes and consequences of these errors, design of corrective measures, and establishment of indicators to monitor their application. The FMEA methodology can help other institutions to identify their own specific vulnerabilities.
错误可能产生更严重后果的医学领域之一是输血过程。我们使用失效模式与效应分析（FMEA）来评估一家拥有高度复杂输血服务的中型城市医院中的潜在失效情况，并提高输血安全性。
使用发生可能性、效应严重程度和检测概率对每种失效模式进行评估。所获得的结果使每种失效能够被排序，并能以有组织的方式做出决策以确定解决方案。我们定义了一些措施和指标，以便在比大多数先前研究更长的时间段内比较其结果。
最重要的失效涉及以下方面：1）传达输血请求信息；2）患者识别；3）样本识别；4）交叉配血医嘱检测；5）输注血液成分；6）完成并发送输血控制文件；7）输血反应报告。FMEA方法的应用使得能够实施安全措施，并使用指标对这些措施进行监测，包括血液警戒系统的强制记录。在FMEA的第二阶段，风险排序数字有56%的改善。
FMEA能够识别该医院中降低安全性的因素，分析这些错误的原因和后果，设计纠正措施，并建立指标以监测其应用情况。FMEA方法可帮助其他机构识别自身的特定薄弱环节。
