Korean J Blood Transfus.  2017 Aug;28(2):140-148. 10.17945/kjbt.2017.28.2.140.

Experience of Failure Mode and Effect Analysis in Transfusion Medicine

• Shin KH
• Lee SM
• Lee HJ
• Kim H
• Song D
• Yang EJ
• Kim IS
• Kim HH
• Chang CL

• KMID: 2391231
• DOI: http://doi.org/10.17945/kjbt.2017.28.2.140

Abstract

BACKGROUND
Blood transfusions are complicated procedures, and are highly sensitive to mistakes that could seriously endanger the life of patients. The failure mode and effect analysis (FMEA) can be used to inspect and improve high risk processes. Here, we aimed to identify the risk factors of a blood transfusion process and to improve its safety by optimizing the process.
METHODS
We conducted a weekly meeting from March to April 2014. We investigated the frequency of events for 2013 (before FMEA) and 2015 (after FMEA). The FMEA process was performed in eight steps and the improvement priorities were determined in accordance with the magnitude of calculated fatalities (multiplied by severity, occurrence, and detection scores).
RESULTS
The whole process of blood transfusion was analyzed by detailed steps: Decision of blood transfusion, blood transfusion request, pre-transfusion test, blood product discharge, delivery, and administration process. Then, we identified the types of failures and likelihood of occurrence, discovery, and severity. Based on the calculated risk priority number, strategies to improve the highest failure modes were developed. Eleven transfusion-related events occurred before FMEA, and three events occurred after FMEA.
CONCLUSION
In this study, we analyzed the failure modes that may occur during a transfusion procedure. The FMEA was a useful tool for analyzing and reducing the risks associated with a blood transfusion procedure. Continuous efforts to improve the failure modes would be helpful to further improve the safety of patients undergoing blood transfusion.

Keyword

Patient safety; Failure mode and effect analysis; Transfusion

MeSH Terms

Blood Transfusion
Healthcare Failure Mode and Effect Analysis*
Hematologic Tests
Humans
Patient Safety
Risk Factors
Transfusion Medicine*