Volume 21, Issue 4 (Winter 2024)
Sci J Iran Blood Transfus Organ 2024, 21(4): 318-329 |
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Mojahed M, Besharati S, Farzanegan B, Mahmoudian S, Hosseini M, Yarinejad M, et al . Identification of Operational Errors in the Stages of the Hemovigilance Program with the Guidance of the Global Trigger Tool and Comparing it with the Reported Errors. Sci J Iran Blood Transfus Organ 2024; 21 (4) :318-329
URL: http://bloodjournal.ir/article-1-1557-en.html
URL: http://bloodjournal.ir/article-1-1557-en.html
Mojgan Mojahed 
, Saeed Besharati 
, Behrooz Farzanegan , Saeed Mahmoudian , Mastooreh Hosseini , Maryam Yarinejad , Seyedeh Kobra Mousavi , Azam Rahimzadeh Kalaleh *
, Saeed Besharati , Behrooz Farzanegan , Saeed Mahmoudian , Mastooreh Hosseini , Maryam Yarinejad , Seyedeh Kobra Mousavi , Azam Rahimzadeh Kalaleh *
Abstract: (452 Views)
A B S T R A C T
Background and Objectives
Blood transfusion and its components are vital and life-saving interventions in which errors can be life-threatening. The aim of this study was to identify administrative errors in blood transfusion and its components and compare the errors voluntarily reported with the rate of errors identified based on the guidance of the Global Trigger Tool. The Global Trigger Tool is a simple and cost-effective method for reviewing medical records and identifying and recording errors by identifying and tracking patient injuries.
Materials and Methods
The study was descriptive-analytical, applied and conducted retrospectively on 88 cases within one month, all with a history of blood transfusion. A 30-question checklist was designed based on hemovigilance protocols. Each case’s documentation was thoroughly reviewed to identify errors at hemovigilance steps, with the severity of potential harm assessed and recoded for each detected error. Furthermore, voluntary error reporting in this center was examined and was then compared to findings from the Global Triger Tool. The number of errors in different sections was analyzed using Dunn's Post Hoc test, and data analysis was performed by Chi-square and SPSS 22 softwares, significance level set at p< 0.05.
Results
A total of 346 errors were identified in the hemovigilance system across 88 cases, guided by Global Trigger Tool. However, only 2 errors were reported in the error registration system. The most common errors identified involved incomplete documentation, including, failure to record the start and end times of blood transfusion and product volume, and the most frequent error (87.5%) was failure to record vital signs and patient’s clinical conditions from the report sheet. The number of errors reported during the morning shift was significantly higher compared to the evening and night shifts (p< 0.01).
Conclusions
The Global Trigger Tool, compared to the traditional voluntary reporting system, enables more precise and comprehensive identification of implementation errors in the homovigilance processes. By using this tool along with strategic planning and preventive measures, patient safety and the quality of care in hospitals settings can significantly enhance.
Background and Objectives
Blood transfusion and its components are vital and life-saving interventions in which errors can be life-threatening. The aim of this study was to identify administrative errors in blood transfusion and its components and compare the errors voluntarily reported with the rate of errors identified based on the guidance of the Global Trigger Tool. The Global Trigger Tool is a simple and cost-effective method for reviewing medical records and identifying and recording errors by identifying and tracking patient injuries.
Materials and Methods
The study was descriptive-analytical, applied and conducted retrospectively on 88 cases within one month, all with a history of blood transfusion. A 30-question checklist was designed based on hemovigilance protocols. Each case’s documentation was thoroughly reviewed to identify errors at hemovigilance steps, with the severity of potential harm assessed and recoded for each detected error. Furthermore, voluntary error reporting in this center was examined and was then compared to findings from the Global Triger Tool. The number of errors in different sections was analyzed using Dunn's Post Hoc test, and data analysis was performed by Chi-square and SPSS 22 softwares, significance level set at p< 0.05.
Results
A total of 346 errors were identified in the hemovigilance system across 88 cases, guided by Global Trigger Tool. However, only 2 errors were reported in the error registration system. The most common errors identified involved incomplete documentation, including, failure to record the start and end times of blood transfusion and product volume, and the most frequent error (87.5%) was failure to record vital signs and patient’s clinical conditions from the report sheet. The number of errors reported during the morning shift was significantly higher compared to the evening and night shifts (p< 0.01).
Conclusions
The Global Trigger Tool, compared to the traditional voluntary reporting system, enables more precise and comprehensive identification of implementation errors in the homovigilance processes. By using this tool along with strategic planning and preventive measures, patient safety and the quality of care in hospitals settings can significantly enhance.
References
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