Identification of operational errors in the stages of the hemovigilance program with the guidance of the Global Trigger Tool and comparing it with the reported errors

Transfusion of blood and its products is one of the necessary and life-saving interventions for patients, and errors in any of its steps can be life-threatening. The aim of this study was to identify operational errors according to the voluntary reported errors compared to the guidelines of the Global Trigger Tool.

The study is of a descriptive-analytical and applied type and was conducted retrospectively at one of the Hospital in Tehran on 88 cases with a history of blood transfusion and its products with a checklist. Comparison of the average number of errors by section was done using the Kruskal-Wallis rank test as well as chi-square analysis using SPSS22 software. A significant level p value <0.05 was considered.

From the 88 cases, 346 errors were obtained from the checklist, which was much higher compared to 2 cases of voluntarily reported errors.The reported error was unique to category B and C, in which the accident related to blood transfusion and its products was not reported.

Conclusions:

  Identification of errors using the global clue tool was significantly higher than voluntary reporting of errors, indicating that it is a more accurate tool for identifying adverse events. The use of this tool and planning and preventive measures can improve the safety of patients and improve the quality of care in hospitals.