Volume 21, Issue 4 (Winter 2024)
Sci J Iran Blood Transfus Organ 2024, 21(4): 330-332 |
Back to browse issues page
Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Mojahed M, Besharati S, Farzanegan B, Mahmoudian ُ, 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) :330-332
URL: http://bloodjournal.ir/article-1-1557-en.html
URL: http://bloodjournal.ir/article-1-1557-en.html
M. Mojahed 
, S. Besharati 
, B. Farzanegan , ُS. Mahmoudian , M. Hosseini , M. Yarinejad , S.K. Mousavi , A. Rahimzadeh Kalaleh *
, S. Besharati , B. Farzanegan , ُS. Mahmoudian , M. Hosseini , M. Yarinejad , S.K. Mousavi , A. Rahimzadeh Kalaleh *
Abstract: (315 Views)
Abstract
Background and Objectives
Transfusion of blood and its products is one of the necessary and life-saving interventions for patients, and errors in any of its steps can be life-threatening. The aim of this study was to identify operational errors according to the voluntary reported errors compared to the guidelines of the Global Trigger Tool.
Materials and Methods
The study is of a descriptive-analytical and applied type and was conducted retrospectively at one of the Hospital in Tehran on 88 cases with a history of blood transfusion and its products with a checklist. Comparison of the average number of errors by section was done using the Kruskal-Wallis rank test as well as chi-square analysis using SPSS22 software. A significant level p value <0.05 was considered.
Results
From the 88 cases, 346 errors were obtained from the checklist, which was much higher compared to 2 cases of voluntarily reported errors.The reported error was unique to category B and C, in which the accident related to blood transfusion and its products was not reported.
Conclusions
Identification of errors using the global clue tool was significantly higher than voluntary reporting of errors, indicating that it is a more accurate tool for identifying adverse events. The use of this tool and planning and preventive measures can improve the safety of patients and improve the quality of care in hospitals.
Background and Objectives
Transfusion of blood and its products is one of the necessary and life-saving interventions for patients, and errors in any of its steps can be life-threatening. The aim of this study was to identify operational errors according to the voluntary reported errors compared to the guidelines of the Global Trigger Tool.
Materials and Methods
The study is of a descriptive-analytical and applied type and was conducted retrospectively at one of the Hospital in Tehran on 88 cases with a history of blood transfusion and its products with a checklist. Comparison of the average number of errors by section was done using the Kruskal-Wallis rank test as well as chi-square analysis using SPSS22 software. A significant level p value <0.05 was considered.
Results
From the 88 cases, 346 errors were obtained from the checklist, which was much higher compared to 2 cases of voluntarily reported errors.The reported error was unique to category B and C, in which the accident related to blood transfusion and its products was not reported.
Conclusions
Identification of errors using the global clue tool was significantly higher than voluntary reporting of errors, indicating that it is a more accurate tool for identifying adverse events. The use of this tool and planning and preventive measures can improve the safety of patients and improve the quality of care in hospitals.
References
1. Delaney M, Wendel S, Bercovitz RS, Cid J, Cohn C, Dunbar NM, et al. Transfusion reactions: prevention, diagnosis, and treatment. Lancet 2016; 388(10061): 2825-36. [DOI:10.1016/S0140-6736(15)01313-6] [PMID]
2. Vuk T, Politis C, Laspina S, Lozano M, Haddad A, de Angelis V, et al. Thirty years of hemovigilance-achievements and future perspectives. Transfus Clin Biol 2023; 30(1): 166-72. [DOI:10.1016/j.tracli.2022.09.070] [PMID]
3. McCullough J. Transfusion-transmitted diseases. Transfus Med 2021: 422-52. [DOI:10.1002/9781119599586.ch17] [PMID]
4. Moradi M, Besharati S, Moghaddam MM, Fasihi-Ramandi M, Azad ZM, Mirnejad R. A concise review on the antimicrobial peptides and their critical activity against intracellular targets of bacteria. Journal of microbiology, biotechnology and food sciences. 2023;12(4):e6006-e. [DOI:10.55251/jmbfs.6006]
5. Agnihotri N, Agnihotri A. Active hemovigilance significantly improves reporting of acute non-infectious adverse reactions to blood transfusion. Indian J Hematol Blood Transfus 2016; 32: 335-42. [DOI:10.1007/s12288-015-0568-4] [PMID] []
6. Rodziewicz TL, Hipskind JE. Medical error prevention. StatPearls Treasure Island (FL): StatPearls Publishing; 2020. p. 36.
7. Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, et al. Global trigger tool'shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff 2011; 30(4): 581-9. [DOI:10.1377/hlthaff.2011.0190] [PMID]
8. Henriksen K, Battles JB, Marks ES, Lewin DI, editors. Advances in Patient Safety: From Research to Implementation (Volume 3: Implementation Issues). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb.
9. Fathi M, Hariri T, MarkaziMoghaddam N. Recognition and analysis of medical errors in the intensive care unit in a public hospital in Tehran by GTT (Global Trigger Tool) in 2019. Journal of Hospital 2020; 18(4): 31-40.
10. Kurutkan MN, Usta E, Orhan F, Simsekler M. Application of the IHI Global Trigger Tool in measuring the adverse event rate in a Turkish healthcare setting. Int J Risk Saf Med 2015; 27(1): 11-21. [DOI:10.3233/JRS-150639] [PMID]
11. Bisht A, Marwaha N, Kaur R, Gupta D, Singh S. Haemovigilance Programme of India: Analysis of transfusion reactions reported from January 2013 to April 2016 and key recommendations for blood safety. Asian J Transfus Sci 2018; 12(1): 1-7. [DOI:10.4103/ajts.AJTS_5_18] [PMID] []
12. Payandeh M, Zare ME, Kansestani AN, Pakdel SF, Jahanpour F, Yousefi H, et al. Descriptions of acute transfusion reactions in the teaching hospitals of kermanshah university of medical sciences, Iran. Int J Hematol Oncol Stem Cell Res 2013; 7(2): 11-6.
13. Payandeh M, Zare ME, Kansestani AN, Pakdel SF, Jahanpour F, Yousefi H, et al. Descriptions of acute transfusion reactions in the teaching hospitals of Kermanshah University of Medical Sciences, Iran. Int J Hematol Oncol Stem Cell Res 2013; 7(2): 11.
14. Hendrickson JE, Roubinian NH, Chowdhury D, Brambilla D, Murphy EL, Wu Y, et al. Incidence of transfusion reactions: a multicenter study utilizing systematic active surveillance and expert adjudication. Transfusion 2016; 56(10): 2587-96. [DOI:10.1111/trf.13730] [PMID] []
15. Yousefian N, Nikbakht R, Fazeli K, Nootizehi A, Salehinia H, Yaghoobi M, et al. Awareness of health care staff in hospitals of Zahedan about blood transfusion. Sci J Iran Blood Transfus Organ 2015; 11(1): 71-6. [Article in Farsi]
16. Seirfar N, Afsharmanesh J, Dousari AS, Behzadi A, Khalilabad RM. Noninfectious complications of blood transfusion in the south of Kerman province: a 4-year retrospective study. Disease and Diagnosis 2022; 11(3): 111-5. [DOI:10.34172/ddj.2022.21]
17. Tajalli S, Amiri M, Fallahi M. Auditing nursing care regarding haemovigilance in Mofid Hospital, 2014. Sci J Iran Blood Transfus Organ 2016; 13(1): 61-71. [Article in Farsi]
18. Jember A, Hailu M, Messele A, Demeke T, Hassen M. Proportion of medication error reporting and associated factors among nurses: a cross sectional study. BMC Nursing 2018; 17: 1-8. [DOI:10.1186/s12912-018-0280-4] [PMID] []
19. Vazin A, Zamani Z, Hatam N. Frequency of medication errors in an emergency department of a large teaching hospital in southern Iran. Drug Healthc Patient Saf 2014: 179-84. [DOI:10.2147/DHPS.S75223] [PMID] []
20. Hajibabaee F, Joolaee S, Peyravi H, Alijany‐Renany H, Bahrani N, Haghani H. Medication error reporting in Tehran: a survey. Journal of Nursing Management 2014; 22(3): 304-10. [DOI:10.1111/jonm.12226] [PMID]
21. Joolaee S, Hajibabaee F, Peyrovi H, Haghani H, Bahrani N. The relationship between incidence and report of medication errors and working conditions. International Nursing Review 2011; 58(1): 37-44. [DOI:10.1111/j.1466-7657.2010.00872.x] [PMID]
Send email to the article author
| Rights and permissions | |
 |
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
