Root cause analysis of an aberrant thromboelastogram tracing – Lessons learnt
نویسندگان
چکیده
منابع مشابه
Root cause analysis of non-infectious transfusion complications and the lessons learnt.
BACKGROUND Transfusion of blood and blood products can be associated with hazards which may be at times fatal. Timely reporting of transfusion reactions is imperative for root cause analysis and their prevention in future. METHODS We retrospectively reviewed the transfusion reactions at our institution during last seven years. The data was retrieved from our computerized blood bank informatio...
متن کاملRoot Cause and Error Analysis
Error is an inevitable part of life and cannot be completely eliminated, but it can be minimized. A root cause analysis is a technique for understanding the systematic error causes that is involved beyond a person or people to implement an errors and including field and environmental causes of errors when occur in this situation too. An important factor of an error occurrence is a root cause (c...
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Background: The purpose of this work is to discover and analyze errors and incidents in some radiotherapy centers, and to introduce methods that could reduce their occurrences, especially those which had happened due to the use of improper and inadequate equipment. This work is a first step toward clarifying the role of education in a risk-conscious culture, and changing the attitude of radioth...
متن کاملroot-cause analysis of a potentially sentinel transfusion event: lessons for improvement of patient safety
errors prevention and patient safety in transfusion medicine are a serious concern. errors can occur at any step in transfusion and evaluation of their root causes can be helpful for preventive measures. root cause analysis as a structured and systematic approach can be used for identification of underlying causes of adverse events. to specify system vulnerabilities and illustrate the potential...
متن کاملWrong-side thoracentesis: lessons learned from root cause analysis.
IMPORTANCE Despite the recognized value of the Joint Commission's Universal Protocol and the implementation of time-outs, incorrect surgical procedures are still among the most common types of sentinel events and can have fatal consequences. OBJECTIVES To examine a root cause analysis database for reported wrong-side thoracenteses and to determine the contributing factors associated with thei...
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ژورنال
عنوان ژورنال: Global Journal of Transfusion Medicine
سال: 2020
ISSN: 2468-8398
DOI: 10.4103/gjtm.gjtm_73_19