Reflection on 10 years of NHO Reporting - Irish Blood Transfusion ...

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% Total Corrective/Preventative Action Taken/Suggested5%27%50%18%Audit Training Policy/Procedure amendment New Initiative
Examples of some of the newinitiatives relating to sampling.• In response to the increase in sample errorsthere has been an extension of the phlebotomyservices to cover weekends.• Evaluation of extension of pre-admission clinicswhere blood transfusion samples can be taken• There is a recommendation for extension ofBloodTrack® Tx sampling in certain areas of thehospital.
Page 1 and 2: ‘To err is human,but to report is
Page 3 and 4: 350300Breakdown of NHO incidents ac
Page 5 and 6: Changing profile of SAE/IBCT report
Page 7 and 8: The user friendly Root Cause method
Page 9 and 10: The blood transfusion laboratory an
Page 11 and 12: • There were 59 events with high
Page 13: Breakdown of Sample errors 2008-201
Page 17 and 18: Preassessment Clinics• Identify c
Page 19 and 20: Improvements due tohaemovigilance
Page 21 and 22: NHO should focus on patient safety

Reflection on 10 years of NHO Reporting - Irish Blood Transfusion ...

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