Journal of Iranian Blood Transfusion

  Abstract

 Background and Objectives

 Pediatric emergency departments are high-risk areas in the healthcare setting and blood transfusion is known as the unique clinical measure. This study aims to investigate the prospective risk assessment of blood transfusion in the Pediatric Emergency Department of Ghaem Hospital by the Health Failure Mode and Effects Analysis (HFMEA) methodology. 

 Materials and Methods

 A mixed method ) quantitative and qualitative analysis ( was used to analyze failure modes and their effects with HFMEA. For identify and analysis, the potential errors of the transfusion process were used by the “Health Failure Mode and Effects Analysis (HFMEA)” methodology. The study was undertaken using a consensus development panel to which the HFMEATM process was applied.

 Results

 The HFMEA team identified 8 processes, 24 sub-processes, and 77 possible failures. Thirteen failure modes (hazard score >= 8) were identified and entitled as "failures with non-acceptable risk” and were moved into the decision tree. Among the influencing factors, the most common reasons for error were related to educational factors (27.2%), and the less common reasons for error to patient factors (2%). Action types were classified as acceptance (11.6%), control (74.2%), and elimination (14.2%).

 Conclusions

 Applying the re-engineering process for the required changes, standardizing and updating the blood transfusion procedures, detecting the root causes of blood transfusion adverse events, using patient identification bracelets, providing training classes and educational pamphlets to raise awareness of the personnel, and holding the monthly transfusion medicine committee have been considered as practical strategies in the work flow of Ghaem Hospital.