Electronic Transfusion Safety System: Characterization of Patient Safety Incidents.

Q3 Medicine
Marta Haro, Susana Ramos, Teresa Magalhães
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引用次数: 0

Abstract

Introduction: The healthcare system is complex and dynamic, and the implementation of information technology is seen as an important aid to patient safety. Data reveal that 1 in every 10 patients in developed countries is affected by a clinical error. The transfusion process involves several stakeholders and multiple stages with various critical points within the hospital. This study aims to understand patient safety incidents caused by failures in the Electronic Transfusion Safety System (ETSS) based on barcode technology in a hospital setting, from storage to the administration of blood components to the patient.

Methods: A retrospective study spanning 3 years (2021-2023) with a mixed-methods approach was chosen. A Focus Group with six experts was conducted, and 136 reports from the anonymized incident reporting database with the typology "Blood and Blood Products" from a hospital in Lisbon were analyzed.

Results: The ETSS diagram using barcodes allowed for the identification and description of all stages and their stakeholders. The critical points identified were patient identification, multiple relabeling, and transportation. A higher incidence rate of near-miss events was observed during sample collection and prescription.

Discussion: This ETSS is hybrid, meaning that it has both human and technological components. Since 96% of the incidents did not cause harm to the patient, error detection and prevention mechanisms are being activated. This study has demonstrated the importance of IT in the transfusion process, as well as the relevance of continuous investment and the involvement of all stakeholders for a better patient safety environment.

电子输血安全系统:病人安全事件的特征。
简介:医疗保健系统是复杂和动态的,信息技术的实施被视为对患者安全的重要帮助。数据显示,在发达国家,每10名患者中就有1人受到临床错误的影响。输血过程涉及多个利益相关者和多个阶段,在医院内有不同的关键点。本研究旨在了解基于条码技术的电子输血安全系统(ETSS)在医院环境中,从血液成分的储存到给患者的管理,因故障而引起的患者安全事件。方法:采用混合方法进行为期3年(2021-2023)的回顾性研究。由6名专家组成的焦点小组对来自里斯本一家医院的“血液和血液制品”类型的匿名事件报告数据库中的136份报告进行了分析。结果:使用条形码的ETSS图允许识别和描述所有阶段及其利益相关者。确定的关键点是患者识别、多次重新标记和运输。在样品采集和处方过程中观察到较高的未遂事件发生率。讨论:这个ETSS是混合的,这意味着它既有人力又有技术成分。由于96%的事故没有对患者造成伤害,因此正在启动错误检测和预防机制。这项研究证明了信息技术在输血过程中的重要性,以及持续投资和所有利益相关者参与的相关性,以创造更好的患者安全环境。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Portuguese Journal of Public Health
Portuguese Journal of Public Health Medicine-Health Policy
CiteScore
2.60
自引率
0.00%
发文量
20
审稿时长
55 weeks
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