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Battles JB, Kaplan HS, Van der Scaaf TW, Shea CE. Arch Pathol Lab Med. 1998;1222:231-238.
This article describes an effort to design, develop, and implement a medical event reporting system for transfusion medicine-related incidents and errors. Using a combination of methods, a working prototype went into use with seven distinct components, including detection, selection, description, classification, interpretation, and local evaluation. The authors conclude that developing event-reporting systems can help organizations address systems issues, while input from end users drives both the model and the necessary improvements.