메뉴 건너뛰기




Volumn 78, Issue 6, 2011, Pages 854-864

Errors in transfusion medicine: Have we learned our lesson?

Author keywords

medical laboratory error; patient safety; transfusion medicine

Indexed keywords

ARTICLE; BLOOD DONOR; BLOOD TRANSFUSION; ERROR; HEALTH CARE; HUMAN; MEDICAL ERROR; MEDICINE; PATIENT IDENTIFICATION; PATIENT SAFETY; PHYSICIAN;

EID: 80855132426     PISSN: 00272507     EISSN: 19317581     Source Type: Journal    
DOI: 10.1002/msj.20296     Document Type: Article
Times cited : (23)

References (51)
  • 2
    • 79955618085 scopus 로고    scopus 로고
    • 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured
    • Classen DC, Resar R, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood) 2011; 30: 581-589.
    • (2011) Health Aff (Millwood) , vol.30 , pp. 581-589
    • Classen, D.C.1    Resar, R.2    Griffin, F.3
  • 4
    • 80855138639 scopus 로고    scopus 로고
    • Staff shortages in labs may put patients at risk
    • May 13
    • Landro L., Staff shortages in labs may put patients at risk. Wall Street Journal May 13, 2009: D1.
    • (2009) Wall Street Journal
    • Landro, L.1
  • 10
    • 0036782241 scopus 로고    scopus 로고
    • Haemovigilance network in France: Organization and analysis of immediate transfusion incident reports from 1994 to 1998
    • Andreu G, Morel P, Forestier F, et al. Haemovigilance network in France: organization and analysis of immediate transfusion incident reports from 1994 to 1998. Transfusion 2002; 42: 1356-1364.
    • (2002) Transfusion , vol.42 , pp. 1356-1364
    • Andreu, G.1    Morel, P.2    Forestier, F.3
  • 11
    • 0033787643 scopus 로고    scopus 로고
    • Transfusion errors in New York State: An analysis of 10 years' experience
    • Linden JV, Wagner K, Voytovich AE, et al. Transfusion errors in New York State: an analysis of 10 years' experience. Transfusion 2000; 40: 1207-1213.
    • (2000) Transfusion , vol.40 , pp. 1207-1213
    • Linden, J.V.1    Wagner, K.2    Voytovich, A.E.3
  • 12
    • 77954324675 scopus 로고    scopus 로고
    • Prevalence, incidence, and residual risk of human immunodeficiency virus and hepatitis C virus infections among United States blood donors since the introduction of nucleic acid testing
    • Zou S, Dorsey KA, Notari EP, et al. Prevalence, incidence, and residual risk of human immunodeficiency virus and hepatitis C virus infections among United States blood donors since the introduction of nucleic acid testing. Transfusion 2010; 50: 1495-1504.
    • (2010) Transfusion , vol.50 , pp. 1495-1504
    • Zou, S.1    Dorsey, K.A.2    Notari, E.P.3
  • 13
    • 78049417048 scopus 로고    scopus 로고
    • HIV transmission through transfusion-Missouri and Colorado, 2008
    • US Centers for Disease Control and Prevention.
    • US Centers for Disease Control and Prevention. HIV transmission through transfusion-Missouri and Colorado, 2008. MMWR Morb Mortal Wkly Rep 2010; 59: 1335-1339.
    • (2010) MMWR Morb Mortal Wkly Rep , vol.59 , pp. 1335-1339
  • 16
    • 29144504009 scopus 로고    scopus 로고
    • Getting the right blood to the right patient: The contribution of near-miss event reporting and barrier analysis
    • DOI 10.1016/j.tracli.2005.10.003, PII S1246782005001795
    • Kaplan HS., Getting the right blood to the right patient: the contribution of near-miss event reporting and barrier analysis. Transfus Clin Biol 2005; 12: 380-384. (Pubitemid 41802974)
    • (2005) Transfusion Clinique et Biologique , vol.12 , Issue.5 , pp. 380-384
    • Kaplan, H.S.1
  • 17
    • 0038012863 scopus 로고    scopus 로고
    • Biomedical Excellence for Safer Transfusion (BEST) Working Party of the International Society for Blood Transfusion. An international study of the performance of sample collection from patients
    • Dzik WH, Murphy MF, Andreu G, et al. Biomedical Excellence for Safer Transfusion (BEST) Working Party of the International Society for Blood Transfusion. An international study of the performance of sample collection from patients. Vox Sang 2004; 85: 40-47.
    • (2004) Vox Sang , vol.85 , pp. 40-47
    • Dzik, W.H.1    Murphy, M.F.2    Andreu, G.3
  • 18
    • 0031460284 scopus 로고    scopus 로고
    • Adherence to a strict specimen-labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens
    • Lumadue JA, Boyd JS, Ness PM., Adherence to a strict specimen labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens. Transfusion 1997; 37: 1169-1172. (Pubitemid 28018691)
    • (1997) Transfusion , vol.37 , Issue.11-12 , pp. 1169-1172
    • Lumadue, J.A.1    Boyd, J.S.2    Ness, P.M.3
  • 19
    • 0029878630 scopus 로고    scopus 로고
    • Why is the laboratory an afterthought for managed care organizations?
    • Forsman RW., Why is the laboratory an afterthought for managed care organizations? Clin Chem 1996; 42: 813-816. (Pubitemid 26142110)
    • (1996) Clinical Chemistry , vol.42 , Issue.5 , pp. 813-816
    • Forsman, R.W.1
  • 20
    • 0004223940 scopus 로고
    • Cambridge, UK: Cambridge University Press.
    • Reason J., Human Error. Cambridge, UK: Cambridge University Press; 1990.
    • (1990) Human Error.
    • Reason, J.1
  • 22
    • 80855138641 scopus 로고    scopus 로고
    • California Blood Bank Society e-Network Forum Published January 13, Updated January 27, 2003. Accessed October 28, 2011
    • California Blood Bank Society e-Network Forum. Failure to complete type and screen testing until surgery has started. Published January 13, 2003. Updated January 27, 2003. Accessed October 28, 2011.
    • (2003) Failure to Complete Type and Screen Testing until Surgery Has Started
  • 23
    • 0023203954 scopus 로고
    • Morning admission to the hospital for surgery the same day. A practical problem for the blood bank
    • Moore SB, Reisner RK, Losasso TJ, et al. Morning admission to hospital for same day surgery: a practical problem for the blood bank. Transfusion 1987; 27: 359-361. (Pubitemid 17106184)
    • (1987) Transfusion , vol.27 , Issue.4 , pp. 359-361
    • Moore, S.B.1    Reisner, R.K.2    Losasso, T.J.3    Brockman, S.K.4
  • 24
    • 0037740716 scopus 로고    scopus 로고
    • College of American Pathologists. Type and screen completion for scheduled surgical procedures
    • Friedberg RC, Jones BA, Walsh MK,; College of American Pathologists. Type and screen completion for scheduled surgical procedures. Arch Pathol Lab Med 2003; 127: 533-540.
    • (2003) Arch Pathol Lab Med , vol.127 , pp. 533-540
    • Friedberg, R.C.1    Jones, B.A.2    Walsh, M.K.3
  • 28
    • 41149111617 scopus 로고    scopus 로고
    • Blood transfusion administration - One- or two-person checks: Which is the safest method?
    • DOI 10.1111/j.1537-2995.2007.01605.x
    • Watson D, Murdock J, Doree C, et al. Blood transfusion administration-one- or two-person checks: which is the safest method? Transfusion 2008; 48: 783-789. (Pubitemid 351430351)
    • (2008) Transfusion , vol.48 , Issue.4 , pp. 783-789
    • Watson, D.1    Murdock, J.2    Doree, C.3    Murphy, M.4    Roberts, M.5    Blest, A.6    Brunskill, S.7
  • 29
    • 0030965010 scopus 로고    scopus 로고
    • Practical methods to improve transfusion safety by using novel blood unit and patient identification systems
    • Wenz B, Mercuriali F, AuBuchon JP., Practical methods to improve transfusion safety by using novel blood unit and patient identification systems. Am J Clin Path 1997; 107 (4 suppl 1): S12-S16.
    • (1997) Am J Clin Path , vol.107 , Issue.4 SUPPL. 1
    • Wenz, B.1    Mercuriali, F.2    Aubuchon, J.P.3
  • 30
    • 80855131402 scopus 로고    scopus 로고
    • Examples of mistake-proofing in health care (example 7.8, the BloodLoc)
    • Rockville, MD: Agency for Healthcare Research and Quality
    • Examples of mistake-proofing in health care (example 7.8, the BloodLoc). In:, Grout J., Mistake-Proofing the Design of Health Care Processes. Rockville, MD: Agency for Healthcare Research and Quality; 2008: 120.
    • (2008) Mistake-Proofing the Design of Health Care Processes. , pp. 120
    • Grout, J.1
  • 31
    • 34447636029 scopus 로고    scopus 로고
    • Application of bar code technology at the bedside: The Oxford experience
    • DOI 10.1111/j.1537-2995.2007.01366.x
    • Murphy MF., Application of bar code technology at the bedside: the Oxford experience. Transfusion 2007; 47: 120S-124S. (Pubitemid 47094133)
    • (2007) Transfusion , vol.47 , Issue.SUPPL. 2
    • Murphy, M.F.1    MacPherson, J.2
  • 32
    • 34447620453 scopus 로고    scopus 로고
    • Radiofrequency identification for prevention of bedside errors
    • Dzik W., Radiofrequency identification for prevention of bedside errors. Transfusion 2007; 47 (2 suppl): 125S-131S.
    • (2007) Transfusion , vol.47 , Issue.2 SUPPL.
    • Dzik, W.1
  • 33
    • 34247638656 scopus 로고    scopus 로고
    • Prevention of bedside errors in transfusion medicine (PROBE-TM) study: A cluster-randomized, matched-paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check
    • DOI 10.1111/j.1537-2995.2007.01189.x
    • Murphy MF, Casbard AC, Ballard S, et al.; BEST Research Collaborative. Prevention of bedside errors in transfusion medicine (PROBE-TM) study: a cluster-randomized, matched-paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check. Transfusion 2007; 47: 771-780. (Pubitemid 46668989)
    • (2007) Transfusion , vol.47 , Issue.5 , pp. 771-780
    • Murphy, M.F.1    Casbard, A.C.2    Ballard, S.3    Shulman, I.A.4    Heddle, N.5    AuBuchon, J.P.6    Wendel, S.7    Thomson, A.8    Hervig, T.9    Downes, K.10    Carey, P.M.11    Dzik, W.H.12
  • 36
    • 0142057422 scopus 로고    scopus 로고
    • Medical Care - Is More Always Better?
    • DOI 10.1056/NEJMe038149
    • Fisher ES., Medical care-is more always better? N Engl J Med 2003; 349: 1665-1667. (Pubitemid 37288573)
    • (2003) New England Journal of Medicine , vol.349 , Issue.17 , pp. 1665-1667
    • Fisher, E.S.1
  • 37
    • 0028058189 scopus 로고
    • The necessary and the unnecessary transfusion: A critical review of reported appropriateness rates and criteria for red cell transfusions
    • Hasley PB, Lave JR, Kapoor WN., The necessary and the unnecessary transfusion: a critical review of reported appropriateness rates and criteria for red cell transfusions. Transfusion 1994; 34: 110-115. (Pubitemid 24059103)
    • (1994) Transfusion , vol.34 , Issue.2 , pp. 110-115
    • Hasley, P.B.1    Lave, J.R.2    Kapoor, W.N.3
  • 39
    • 79951972309 scopus 로고    scopus 로고
    • Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion, International Consortium for Evidence Based Perfusion. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines
    • Ferraris VA, Brown JR, Despotis GJ, et al.; Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion, International Consortium for Evidence Based Perfusion. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91: 944-982.
    • (2011) Ann Thorac Surg , vol.91 , pp. 944-982
    • Ferraris, V.A.1    Brown, J.R.2    Despotis, G.J.3
  • 40
    • 80855131400 scopus 로고    scopus 로고
    • Liaison between laboratory, medicine and nursing staffs. UAB Synopsis
    • New position: Transfusion Safety Officer. Liaison between laboratory, medicine and nursing staffs. UAB Synopsis 2009; 28.
    • (2009) New Position: Transfusion Safety Officer , pp. 28
  • 41
  • 45
    • 10644278130 scopus 로고    scopus 로고
    • Patient safety-how much is enough?
    • Warburton RN., Patient safety-how much is enough? Health Policy 2005; 71: 223-232.
    • (2005) Health Policy , vol.71 , pp. 223-232
    • Warburton, R.N.1
  • 46
    • 56849086417 scopus 로고    scopus 로고
    • Baltimore, MD: Centers for Medicare and Medicaid Services; July 31, ?Counter=3219&in tnumperpage=10&che ckdate= &checkkey=&srch ty pe=1&num days=3500&srchopt= 0&srchdata=&t ype= All&chknewstype=1%2C+2%2C+ 3%2C+4%2C+5&intpage=&sho wall=&pyear=&year= &desc=&cb oorder=date. Accessed October 28, 2011.
    • Medicare and Medicaid move aggressively to encourage greater patient safety in hospitals and reduce never events [press release]. Baltimore, MD: Centers for Medicare and Medicaid Services; July 31, 2008. ?Counter= 3219&intnumperpage=10&checkdate= &checkkey=&srchtype= 1&numdays=3500&srchopt= 0&srchdata=&type=All&chknewstype= 1%2C+2%2C+ 3%2C+4%2C+5&intpage=&showall=&pyear=&year= &desc=&cboorder=date. Accessed October 28, 2011.
    • (2008) Medicare and Medicaid Move Aggressively to Encourage Greater Patient Safety in Hospitals and Reduce Never Events [Press Release]
  • 47
    • 55349134132 scopus 로고    scopus 로고
    • The Joint Commission Effective January 1, Published 2010. Accessed October 28, 2011
    • The Joint Commission. Accreditation Program: Hospital, National Patient Safety Goals. Effective January 1, 2011. Published 2010. Accessed October 28, 2011.
    • (2011) Accreditation Program: Hospital, National Patient Safety Goals
  • 48
    • 0028222119 scopus 로고
    • The evolution of the current blood banking regulatory climate
    • Solomon JM., The evolution of the current blood banking regulatory climate. Transfusion 1994; 34: 272-277. (Pubitemid 24109658)
    • (1994) Transfusion , vol.34 , Issue.3 , pp. 272-277
    • Solomon, J.M.1
  • 50
    • 80855138638 scopus 로고    scopus 로고
    • AABB Accessed October 28, 2011
    • AABB. Biovigilance Update, Winter 2011. Accessed October 28, 2011.
    • (2011) Biovigilance Update, Winter
  • 51
    • 0002950169 scopus 로고
    • Nothing recedes like success? Risk analysis and the organizational amplification of risks
    • Freudenburg WR., Nothing recedes like success? Risk analysis and the organizational amplification of risks. Risk Issues Health Safety 1992; 3: 1-35.
    • (1992) Risk Issues Health Safety , vol.3 , pp. 1-35
    • Freudenburg, W.R.1


* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.