AHRQ Patient Safety Network

The Collection > Hematology

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Safety Target

•Device-related Complications (2)

•Diagnostic Errors (1)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (2)

•Medication Safety (11)

•Medical Complications (6)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (1)

•Transfusion Complications (15)

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•Australia and New Zealand (1)

•Central and South America (1)

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•Journal Article (29)

•Newspaper/Magazine Article (2)

•Tools/Toolkit (2)

Error Types

•Epidemiology of Errors and Adverse Events (12)

•Active Errors (8)

•Latent Errors (4)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (7)

•Legal and Policy Approaches (1)

•Error Reporting and Analysis (9)

•Communication Improvement (5)

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•Specialization of Care (3)

•Logistical Approaches (4)

•Culture of Safety (1)

•Technologic Approaches (12)

•Education and Training (3)

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Hematology

Target Audience

•Health Care Providers (22)

•Health Care Executives and Administrators (26)

•Non-Health Care Professionals (8)

Setting of Care

•Hospitals (18)

•Residential Facilities (1)

•Ambulatory Care (3)

1 - 20 of 33

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STUDY

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.

McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.

STUDY

Error in body weight estimation leads to inadequate parenteral anticoagulation.

Dos Reis Macedo LG, de Oliveira L, Pintão MC, Garcia AA, Pazin-Filho A. Am J Emerg Med. 2011;29:613-617.

STUDY

Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project to analyse transfusion-related near-miss events in the Republic of Ireland.

Lundy D, Laspina S, Kaplan H, Rabin Fastman B, Lawlor E. Vox Sang. 2007;92:233-241.

STUDY

Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).

Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012;52:1687-1695.

STUDY

Increasing patient safety and efficiency in transfusion therapy using formal process definitions.

Henneman EA, Avrunin GS, Clarke LA, et al. Transfus Med Rev. 2007;21:49-57.

COMMENTARY

Preventable errors in organ transplantation: an emerging patient safety issue?

Ison MG, Holl JL, Ladner D. Am J Transplant. 2012;12:2307-2312.

COMMENTARY

Dealing honestly with an honest mistake.

Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.

COMMENTARY

New technology for transfusion safety.

Dzik WH. Br J Haematol. 2007;136:181-90.

GLOSSARY

MERS-TM Glossary.

Medical Event Reporting System for Transfusion Medicine (MERS-TM).

STUDY

Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry.

Rana R, Afessa B, Keegan MT, et al; Transfusion in the ICU Interest Group. Crit Care Med. 2006;34:1892-1897.

STUDY

An engineered solution to the maladministration of spinal injections.

Lawton R, Gardner P, Green B, et al. Qual Saf Health Care. 2009;18:492-495.

STUDY

Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction.

Salisbury AC, Reid KJ, Alexander KP, et al. Arch Intern Med. 2011;171:1646-1653.

STUDY

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

Field TS, Tjia J, Mazor KM, et al. Am J Med. 2011;124:179.e1-179.e7.

COMMENTARY

What Was in Those Platelets?

Yomtovian R. AHRQ WebM&M [serial online]. July 2008.

STUDY

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.

STUDY

Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors.

Askeland RW, McGrane S, Levitt JS, et al. Transfusion. 2008;48: 1308-1317.

STUDY

Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma.

Haut ER, Lau BD, Kraenzlin FS, et al. Arch Surg. 2012;147:901-907.

STUDY

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.

Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida A. Jt Comm J Qual Patient Saf. 2010;36:195-202.

NEWSPAPER/MAGAZINE ARTICLE

An interdisciplinary approach to safer blood transfusion.

LaRocco M, Brient K. Patient Safety & Quality Healthcare. March-April 2008;5:22-26.

COMMENTARY

Reducing adverse events in blood transfusion.

Stainsby D, Russell J, Cohen H, Lilleyman J. Br J Haematol. 2005;131:8-12.

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