Root cause analysis of transfusion error: identifying causes to implement changes.
Elhence P, Veena S, Sharma RK, et al. Root cause analysis of transfusion error: identifying causes to implement changes. Transfusion (Paris). 2010;50(12 Pt 2):2772-2777. doi:10.1111/j.1537-2995.2010.02943.x.
This case review discusses how root cause analysis of human and systems failures can identify areas for improvement to prevent clinical adverse events.