Artigo Revisado por pares

Human error—a significant cause of transfusion mortality

2000; Wiley; Volume: 40; Issue: 7 Linguagem: Inglês

10.1046/j.1537-2995.2000.40070879.x

ISSN

1537-2995

Autores

Byron A. Myhre, David McRuer,

Tópico(s)

Quality and Safety in Healthcare

Resumo

TransfusionVolume 40, Issue 7 p. 879-885 Human error—a significant cause of transfusion mortality B.A. Myhre, B.A. Myhre From the UCLA School of Medicine, Harbor UCLA Medical Center, Torrance, California; and Systems Technology Inc., Hawthorne, California.Search for more papers by this authorD. McRuer, D. McRuer From the UCLA School of Medicine, Harbor UCLA Medical Center, Torrance, California; and Systems Technology Inc., Hawthorne, California.Search for more papers by this author B.A. Myhre, B.A. Myhre From the UCLA School of Medicine, Harbor UCLA Medical Center, Torrance, California; and Systems Technology Inc., Hawthorne, California.Search for more papers by this authorD. McRuer, D. McRuer From the UCLA School of Medicine, Harbor UCLA Medical Center, Torrance, California; and Systems Technology Inc., Hawthorne, California.Search for more papers by this author First published: 24 April 2002 https://doi.org/10.1046/j.1537-2995.2000.40070879.xCitations: 56 Address reprint requests to: Byron A. Myhre, MD, PhD, Harbor UCLA Medical Center, 1000 West Carson Street, Torrance, CA 90509-2910; e-mail: [email protected]. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL REFERENCES 1 Sazama K. Current good manufacturing practices for transfusion medicine. Transfus Med Rev 1996; 10: 286– 95. 2 Bogner MS. Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, 1994. 3 Kirwan B. Human error identification in human reliability assessment. Part 1: Overview of approaches. Appl Ergonomics 1992; 23: 299– 318. 4 Reason J. Human error. Cambridge, UK: Cambridge University Press, 1990. 5 Cognitive engineering. Aeronautical technology for the twenty-first century. Washington: National Academy Press, 1992. 6 Campbell DT. Systematic error on the part of human links in communication systems. Informat Control 1958; 1: 334– 69. 7 Edmondson AC. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human errors. J Appl Behav Sci 1996; 32: 5– 28. 8 Sussman MB, Haug MR. Human and mechanical error—an unknown quantity in research. Am Behav Sci 1967; 11: 55– 6. 9 Koepke JA. Some comments on errors on survey questionnaires. Pathologist 1971; 25: 193– 4. 10 Linden JV, Kaplan HS. Transfusion errors: causes and effects. Transfus Med Rev 1994; 8: 169– 83. 11 Schmidt PJ. Transfusion mortality; with special reference to surgical and intensive care facilities. J Fla Med Assoc 1980; 67: 151– 3. 12 Myhre BA. Fatalities from blood transfusion. JAMA 1980; 244: 1333– 5. 13 Honig CL, Bove JR. Transfusion associated fatalities: review of Bureau of Biologics reports 1976-78. Transfusion 1980; 20: 653– 61. 14 Camp FR Jr, Monaghan WP. Fatal blood transfusion reactions. An analysis. Am J Forensic Med Pathol 1981; 2: 143– 50. 15 Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990; 30: 583– 90. 16 Linden JV, Paul B, Dressler KP. A report of 104 transfusion errors in New York State. Transfusion 1992; 32: 601– 6. 17 McClelland DB, Phillips P. Errors in blood transfusion in Britain: survey of hospital haematology departments. BMJ 1994; 308: 1205– 6. 18 Renner SW, Howanitz PJ, Bachner P. Wristband identification error reporting in 712 hospitals. A College of American Pathologists' Q-Probes study of quality issues in transfusion practice. Arch Pathol Lab Med 1993; 117: 573– 7. 19 Gaydos JC, Cowant DN, Polk AJ, et al. Blood typing errors on U.S. Army identification cards and tags. Mil Med 1988; 153: 618– 20. 20 Schmidt PJ, Kevy SV. Sources of error in a hospital blood bank. Transfusion 1963; 3: 198– 201. 21 Kessler DA. Introducing MEDwatch, a new approach to reporting medication and device adverse effects and product problems. JAMA 1993; 269: 2765– 8. 22 Senders JW, Moray NP. Human error: cause, prediction and reduction. Hillsdale, NJ: Lawrence Erlbaum Associates, 1991. 23 Wallace EL, Sullivan MT. New beginnings: the National Blood Data Resource Center. Transfusion 1998; 38: 622– 4. 24 Sherwood WC. To err is human…(editorial). Transfusion 1990; 30: 579– 80. 25 McClelland DB. Treating a sick process (editorial). Transfusion 1998; 38: 999– 1103. 26 Kaplan HS, Battles JB, Van der Schaaf TW, et al. Identification and classification of the causes of events in transfusion medicine. Transfusion 1998; 38: 1071– 81. 27 Battles JB, Kaplan HS, Van der Schaaf TW, Shea CE. The attributes of medical event-reporting systems: experience with a prototype medical event-reporting system for transfusion medicine. Arch Pathol Lab Med 1998; 122: 231– 8. 28 Williamson LM, Love EM. Reporting serious hazards of transfusion: the SHOT Program. Transfus Med Rev 1998; 12: 28– 35. 29 Wenz B, Burns ER. Improvement in transfusion safety using a new blood unit and patient identification system as part of safe transfusion practice. Transfusion 1991; 31: 401– 3. 30 Jensen NJ, Crosson JT. An automated system for bedside verification of the match between patient identification and blood unit identification. Transfusion 1996; 36: 216– 21. Citing Literature Volume40, Issue7July 2000Pages 879-885 ReferencesRelatedInformation

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