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

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‘Improvements canonly take place ifeveryone working inthe health service isprepared to work inan open and honestway thatacknowledges ourfailures in order tolearn from them’Minister for Health & Children MaryHarney launching Patient SafetyFirst initiativeSept 2010
Improvements due tohaemovigilance• Better patient identification in hospitals• Improved bedside checking for blood transfusion• Data to support electronic sample taking andadminstration systems• Data to support HIQA recommendation onpatient Unique ID• Appropriate management of warfarin reversal• Reduction in TACO with FFP/SD plasma• Reduction in TRALI• Reduction of AA/FNHTR with platelets in PAS
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 and 14: Breakdown of Sample errors 2008-201
Page 15 and 16: Examples of some of the newinitiati
Page 17: Preassessment Clinics• Identify c
Page 21 and 22: NHO should focus on patient safety

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

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