AHRQ Patient Safety Network

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Transfusion Complications

Origin/Sponsor

•North America (23)

Resource Types

•Book/Report (1)

•Journal Article (25)

•Meeting/Conference (1)

•Newspaper/Magazine Article (1)

•Tools/Toolkit (3)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (13)

•Active Errors (8)

•Latent Errors (4)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (8)

•Legal and Policy Approaches (2)

•Error Reporting and Analysis (14)

•Communication Improvement (3)

•Human Factors Engineering (6)

•Specialization of Care (1)

•Logistical Approaches (4)

•Culture of Safety (1)

•Technologic Approaches (12)

•Education and Training (4)

Clinical Areas

•Medicine (30)

•Pharmacy (1)

Target Audience

•Health Care Providers (21)

•Health Care Executives and Administrators (21)

•Non-Health Care Professionals (4)

•Patients (1)

Setting of Care

•Hospitals (15)

•Ambulatory Care (1)

1 - 20 of 32

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STUDY

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.

Dunn EJ, Moga PJ. Arch Pathol Lab Med. 2010;134:244-255.

COMMENTARY

Transfusion "Slip".

Kaplan HS. AHRQ WebM&M [serial online]. February 2004.

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.

MULTI-USE WEBSITE

National Comparative Audit of Blood Transfusion.

National Blood Service Hospitals.

REVIEW

Barcode identification for transfusion safety.

Murphy MF, Kay JD. Curr Opin Hematol. 2004;11:334-338.

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

Current and emerging infectious risks of blood transfusions.

Busch MP, Kleinman SH, Nemo GJ. JAMA. 2003;289:959-962.

STUDY

Quality improvement to decrease specimen mislabeling in transfusion medicine.

Quillen K, Murphy K. Arch Pathol Lab Med. 2006;130:1196-1198.

COMMENTARY

No Blood, Please.

Liang BA. AHRQ WebM&M [serial online]. May 2004.

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

Interruptions and blood transfusion checks: lessons from the simulated operating room.

Liu D, Grundgeiger T, Sanderson PM, Jenkins SA, Leane TA. Anesth Analg. 2009;108:219-222.

COMMENTARY

Root cause analysis of transfusion error: identifying causes to implement changes.

Elhence P, Veena S, Sharma RK, Chaudhary RK. Transfusion. 2010;50:2772-2777.

GLOSSARY

MERS-TM Glossary.

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

STUDY

Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.

Snijders C, van Lingen RA, Klip H, Fetter WP, van der Schaaf TW, Molendijk HA, NEOSAFE study group. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210-F215.

STUDY

Analysis of adverse events in pediatric surgery using criteria validated from the adult population: justifying the need for pediatric-focused outcome measures.

Rice-Townsend S, Hall M, Jenkins KJ, Roberson DW, Rangel SJ. J Pediatr Surg. 2010;45:1126-1136.

COMMENTARY

New technology for transfusion safety.

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

COMMENTARY

Reducing adverse events in blood transfusion.

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

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

Evaluation of the contributions of an electronic web-based reporting system: enabling action.

Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;5:9-15.

NEWSPAPER/MAGAZINE ARTICLE

An interdisciplinary approach to safer blood transfusion.

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

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