Creating an Ergonomic Solution for Avoiding Errors in Blood Transfusion

Abstract

The Centre for Patient Safety of the Tuscany Region designs solutions for preventing adverse events in the 39 hospitals and 14 local trusts of the regional healthcare system. One of the most important risks in terms of consequences is the error in blood transfusion. The Centre for Patient Safety adopted an ergonomic approach centered on human factor in order to define the best solutions for clinicians. Thus, the definition of a patient safety practice on blood transfusion has been realized starting from: the analysis of the adverse events happened in the Tuscany healthcare system in the last year about this topic; the analysis of the main phases of the process and of the related potential risks, the analysis of the interaction among the clinicians and their working context. According to this analysis we produced some tools for supporting the promotion of a safer blood transfusion process: a check list with a design that can facilitate the support to the decision making process related to the transfusion; an algorithm that visualizes the most important actions to take to avoid errors during the transfusion; a poster to remind the key controls at the bedside; a patient's identification procedure based on wristbands which layout help an active identification of the patient;. All the tools have been designed with the final users and tested.The authors will present the tools and results about their application in one of the most complex teaching hospital of the Region.