Harold S. Kaplan

Identification and classification of the causes of events in transfusion medicine

BACKGROUND: Transfusion medicine lacks a standard method for the systematic collection and analysis of event reports. Review of event reports from the Food and Drug Administration (FDA) showed a relative paucity of information on event causation. Thus, a causal analysis method was developed as part of a prototype Medical Event Reporting System for Transfusion Medicine (MERS‐TM). STUDY DESIGN AND METHODS: MERS‐TM functions within existing quality assurance systems and utilizes descriptive coding and causal classification schemes. The descriptive classification system, based upon current FDA coding, was modified to meet participant needs. The Eindhoven Classification Model (Medical Version) was adopted for causal classification and analysis. Inter‐rater reliability for the MERS‐TM and among participating organizations was performed with the development group in the United States and with a safety science research group in the Netherlands. The MERS‐TM was then tested with events reported by participants. RESULTS: Data from 503 event reports from two blood centers and two transfusion services are discussed. The data showed multiple causes for events and more latent causes than previously recognized. The distribution of causes was remarkably similar to that in an industrial setting outside of medicine that uses the same classification approach. There was a high degree of inter‐rater reliability when the same events were analyzed by quality assurance personnel in different participating organizations. These personnel found the method practical and useful for providing new insights into conditions producing undesired events. CONCLUSION: A generally applicable and reliable method for identifying and quantifying problems that exist throughout transfusion medicine will be a valuable addition to event reporting activity. By using a common taxonomy, participants can compare their experience with that of others. If proven as readily implementable and useful as shown in initial studies, MERS‐TM is a potential standard for transfusion medicine.

Reporting of near-miss events for transfusion medicine: improving transfusion safety

BACKGROUND: Half of the reported serious adverse events from transfusion are a consequence of medical error. A no‐fault medical‐event reporting system for transfusion medicine (MERS‐TM) was developed to capture and analyze both near‐miss and actual transfusion‐related errors.

Patient safety and blood transfusion: new solutions

Current risk from transfusion is largely because of noninfectious hazards and defects in the overall process of delivering safe transfusion therapy. Safe transfusion therapy depends on a complex process that requires integration and coordination among multiple hospital services including laboratory medicine, nursing, anesthesia, surgery, clerical support, and transportation. The multidisciplinary hospital transfusion committee has been traditionally charged with oversight of transfusion safety. However, in recent years, this committee may have been neglected in many institutions. Resurgence in hospital oversight of patient safety and transfusion efficacy is an important strategy for change. A new position, the transfusion safety officer (TSO), has been developed in some nations to specifically identify, resolve, and monitor organizational weakness leading to unsafe transfusion practice. New technology is becoming increasingly available to improve the performance of sample labeling and the bedside clerical check. Several technology solutions are in various stages of development and include wireless handheld portable digital assistants, advanced bar coding, radiofrequency identification, and imbedded chip technology. Technology-based solutions for transfusion safety will depend on the larger issue of the technology for patient identification. Devices for transfusion safety hold exciting promise but need to undergo clinical trials to show effectiveness and ease of use. Technology solutions will likely require integration with delivery of pharmaceuticals to be financially acceptable to hospitals.

Staff attitudes about event reporting and patient safety culture in hospital transfusion services

BACKGROUND: Little is known about how transfusion service staff view issues pertaining to event reporting and patient safety. The goal of this study was to assess transfusion service staff attitudes about these issues.

Is there A malignant freckle

The malignant freckle diagnosis is best suited to the clinical pattern of an indolent facial pigmented lesion of the elderly. The histopathology of such tumors is variable and not diagnostic. The use of the histopathologic diagnosis of malignant freckle is not advised, especially in extrafacial lesions, where its unjustifiable implied good prognosis is misleading. These conclusions are based on a review of 23 cases of so‐called malignant freckle diagnosed pathologically at Presbyterian Hospital. Of the 18 extrafacial lesions studied 17 proved on “second look” to be invasive malignant melanoma. The 5 facial lesions, despite their clinical similarities, demonstrated variable pathology.

Prevalence and cost of hospital medical errors in the general and elderly United States populations

Abstract Objective: The primary objective of this study was to quantify the differences in the prevalence rate and costs of hospital medical errors between the general population and an elderly population aged ≥65 years. Methods: Methods from an actuarial study of medical errors were modified to identify medical errors in the Premier Hospital Database using data from 2009. Visits with more than four medical errors were removed from the population to avoid over-estimation of cost. Prevalence rates were calculated based on the total number of inpatient visits. Results: There were 3,466,596 total inpatient visits in 2009. Of these, 1,230,836 (36%) occurred in people aged ≥ 65. The prevalence rate was 49 medical errors per 1000 inpatient visits in the general cohort and 79 medical errors per 1000 inpatient visits for the elderly cohort. The top 10 medical errors accounted for more than 80% of the total in the general cohort and the 65+ cohort. The most costly medical error for the general population was postoperative infection (

Effects of ‘Blue-Regulated’ Full Spectrum LED Lighting in Clinician Wellness and Performance, and Patient Safety

569,287,000). Pressure ulcers were most costly (

Transfusion-Related Hazards

347,166,257) in the elderly population. Limitations: This study was conducted with a hospital administrative database, and assumptions were necessary to identify medical errors in the database. Further, there was no method to identify errors of omission or misdiagnoses within the database. Conclusions: This study indicates that prevalence of hospital medical errors for the elderly is greater than the general population and the associated cost of medical errors in the elderly population is quite substantial. Hospitals which further focus their attention on medical errors in the elderly population may see a significant reduction in costs due to medical errors as a disproportionate percentage of medical errors occur in this age group.

Infectious Disease Testing for Blood Transfusions: NIH Consensus Development Panel on Infectious Disease Testing for Blood Transfusions

Lighting has been recognized in the fields of human factors, ergonomics, and systems engineering, as an environmental factor that can affect wellness and performance, and the occurrence of medical error. Short wavelength (‘blue’) light is known to influence ‘non-visual’ effects of light in humans. These effects, that go beyond the pure ‘visual’ function, can affect human wellness and performance, as has been reported in previous scientific research. The aim and novelty of this research is to study the potentially beneficial ‘non-visual’ effects of lighting in the clinical environment to advance patient safety, and improve clinician wellness and performance.

Economic Measurement of Medical Errors Using a Hospital Claims Database

Transfusion medicine represents a complex field within health care that is prone to error and ripe for safety barriers. This chapter describes in detail the multiple failures that led to two events involving blood and stem cell transfusions, along with possible solutions. In the first event, the incorrect labeling of a unit of stem cells during the preparation and freezing process, and the lack of verification upon thawing and preparation for infusion led to the release of a pooled unit which was appropriately labeled, but which may have contained a unit from another patient. Discussion includes human fallibility and the tendencies in health care to blame, shame, and/or train in response to an error, as well as issues of safety culture, the value of verification, and second-person checks, high reliability and normal accident theories, form design, and other human factors. The second event involves the repercussions of a misperceived verbal handoff leading to selection of an incorrect patient in a hospital’s computerized physician order entry (CPOE) system and nearly resulting in the mis-transfusion of red blood cells. Discussion in this case comprises communication and handoff issues, resident duty hours, interruptions, and computer interfaces and alerts. The building of causal trees provides a realistic view of how a system is functioning and can facilitate the creation of effective solutions. The causal tree building method of root cause analysis is described and illustrated in both of the case studies, including the classification of causes that leads to solution discovery.