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

More documents

Recommendations

Info

NHO The future• Should not be the primary collector ofmandatory reactions and events. Role of NHOshould be help in investigation, advice,expertise if needed.• Primary collector should be IMB with dualreporting to NHO. Both should be online (UKmodel)• The NHO needs a Steering Group representingclinical and laboratory stakeholders
NHO should focus on patient safety• Champion introduction National Antibody Register• Help produce guidelines for appropriate use of blood– including CMV negative , irradiated product• Collect delays?NPSA 11 deaths in UK between 2006-2010, 83patients harmed• Collecting Mandatory Near Misses since Jan 2010Collect clinical near misses?All or subset? Wrong Blood in Tube ?• These will require IT resources and may havestaffing implications
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 and 18: Preassessment Clinics• Identify c
Page 19: Improvements due tohaemovigilance

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

Create successful ePaper yourself

Delete template?

Save as template?