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Special Section on Event Analysis and Risk Management

Using Failure Mode and Effects Analysis in Blood Administration Process in Surgical Care Units: New Categories of Errors

Aly, Nagah Abd El-fattah Mohamed PhD; El-Shanawany, Safaa M. PhD; Maher Ghoneim, Tamer A. PhD

Author Information
doi: 10.1097/QMH.0000000000000273
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Abstract

Blood administration is an essential part of patient care and safety.1 Although blood administration is a lifesaving and health-promoting measure in many circumstances, its use is associated with a significant risk to the patient and escalating costs to the blood system and hospitals.2 In US hospitals (2015), blood administration failures constitute 2.9% of all hospital ward admissions and have been listed as adverse events.3 Adverse outcomes associated with blood administration are reactions, circulatory overload, infection, acute lung injury, blood group incompatibility, and incorrect transfusion of blood products.4–6

Blood administration errors may occur during any step in the blood administration process (BAP) beginning with the physicianʼs orders and ending with the actual administration of the blood ordered.7 These errors may occur as a result of problems in transportation of blood, improper checking practice, inappropriate nursing practices during preparing and administering blood, and improper monitoring of patients during and after the transfusion process.4–6 Nurses play a vital role in reducing adverse outcomes, intercepting blood administration errors before they happen, and ensuring blood safety in hospitals. This role involves performing a safe BAP and ongoing patient monitoring. Nurses' skills and knowledge are crucial for safely and efficiently administering blood components. Therefore, nurses need to receive the appropriate training in a safe BAP.7,8

Nowadays, many efforts have been made to reduce errors and hazards associated with the BAP, as blood administration safety is of utmost concern among health care organizations around the world.1 These organizations have been developing blood administration strategies and guidelines for ensuring a safe BAP in a health care setting, and requiring them to establish blood administration policies and procedures for safe handling and using blood products.9–12 Each health care setting should have a proactive risk management program focusing on risk assessment of BAPs. This program includes a safety tool called failure modes and effects analysis (FMEA).13–16 The FMEA is a well-organized, proactive technique based on teamwork and workforce involvement. It can be used for assessing a process to identify where and how it might fail, understanding the contributing factors involved in this failure, and identifying parts of the process that are in greatest need for improvement.3 It also aims to enhance clinical practice among health care providers with the reduction in adverse events, thus improving patient safety and raising hospital efficiency and effectiveness.

PURPOSE OF THE STUDY

Worldwide, although a few studies addressed blood transfusion failures and transfusion errors in hospital settings, research studies on failures in the BAP among nurses were lacking.3,7,13–15 To our knowledge, no previous studies in Egypt have dealt with applying FMEA in assessing failure modes in the administration of blood and classifying blood administration errors among nurses. Blood administration failures or errors are more common in surgical care units than in other inpatient and outpatient care units.16 Therefore, the present study attempted to initiate a project using health care failure mode and effect analysis (HFMEA) to assess potential failure modes associated with the BAP, develop a categorization of blood administration errors, identify the reasons for potential failure modes in the BAP, and suggest preventive safety measures to reduce or prevent the identified failure modes as well as to detect corrective actions to reduce the identified high-risk failures in the BAP in surgical care units.

MATERIAL AND METHODS

The study setting was the surgical care units within the Main Alexandria University Hospital. A descriptive cross-sectional study was used. The sample size included (1) 100 nurses who agreed to informed consent and (2) blood transfusions. Assuming an average blood transfusion rate in surgical care units to be 20% of total blood transfusions in the hospital for 1 year, an α of .05 and absolute precision of 5% are required. In total, 125 blood transfusions were chosen to obtain an adequate number of observations. The actual observed blood transfusions amounted to 150 transfusions.

Data collection

The data were collected through the HFMEA tool, which was based on direct observation and brainstorming sessions. The tool was designed to identify potential failure/errors in the BAP. HFMEA was carried out according to the McDermott et al17 steps. These steps are as follows:

  • Creating the HFMEA team: The researchers created an HFMEA team of 6 members (2 researchers acting as HFMEA facilitators, 2 nurses, and 2 physicians), who were selected on the basis of their experience. They had a minimum of 2 yearsʼ experience in surgical care units. The researchers explained the purpose of the study and the HFMEA technique, brainstorming method, and flowchart to the rest of team members. The HFMEA members hold regular meetings every 2 weeks, thus conducting 12 sessions to accomplish complete analysis over 6 months.
  • Reviewing BAP among nurses: The researchers observed nurses during the administration of blood to patients and took notes regarding all nursing activities/steps involved in the BAP in surgical care units (pre-, during, and post-transfusion). Accuracy of the overall process and subprocess in the administration of blood was verified and confirmed in brainstorming sessions by the HFMEA members. They also designed a flowchart that was a graphic presentation drawn by using its standard symbols to show the actual process of administration of blood components among nurses in the study units (Figure 1).
  • Identifying potential failures and errors in the BAP: The HFMEA members identified and listed potential failure modes and errors in each BAP. They were collected by brainstorming sessions and recorded on the HFMEA worksheet. The HFMEA members listed and categorized possible failures/errors in the BAP. Based on this categorization and literature reviews,8,15,18,19 the newly designed 11 types of errors in the BAP among nurses were developed.
  • Estimating scores of potential failure modes: The HFMEA members assigned their scores to each failure/error in the HFMEA worksheet. The assigned scores described in the failure probabilty scale sheet included 3 criteria (Table 1) as follows: (1) Severity (S) is the effect of failure mode; (2) Occurrence (O) is the frequency of failure; and (3) Detection (D) is the probability of detecting and controlling failure mode when it occurs. The severity of the potential effect for the patient, the likelihood of occurrence for each failure mode, and the likelihood of detecting failure were classified on a scale of 1 to 10. The Risk Priority Number (RPN) for each failure mode was calculated by multiplying all 3 criteria scores together (RPN = S × O × D).
  • Prioritizing failure modes: All evaluated failures were sorted on the basis of the Pareto principle. (Failures/errors in administering blood transfusion caused 80% of total RPN scores.) The members identified the failures with high RPN using Pareto analysis.
  • Analyzing the reason for failure and identifying suggested actions: The HFMEA members identified reasons for failure and suggested actions to eliminate or reduce potential failure modes and identified high-risk failures in the BAP. This step was achieved through brainstorming sessions and recorded on the HFMEA worksheet.
  • Evaluation of corrective actions for identified high-risk failures: RPN was recalculated after the corrective actions were carried out in surgical care units. The HFMEA team designed and used an observational checklist to calculate the failures and errors associated with the BAP (pre- and postcorrective actions).
Figure 1.
Figure 1.:
Standard symbols of the flowchart of the blood administration process.
Table 1. - Failure Probability Scales (Severity, Occurrence, and Delectability)
Score Severity Occurrence Detection
1 No influence on the patient and may influence the hospital system One time each 3 y Almost (≥90)
2 Very minor: may influence the patient One time each year Very high (80%)
3 Minor: may influence the patient One time each 9 mo High (70%)
4 Very low: may influence the patient One time each 6 mo Highly moderate (60%)
5 Low: may influence the patient One time each 3 mo Average (moderate) (50%)
6 Average (moderate): may influence the patient One time each month Low (40%)
7 High: may influence the patient with a minor injury One time each week Very low (30%)
8 Very high: may influence the patient with major injury One time each 3 d Minor (20%)
9 Dangerous: may influence the patient with a terminal injury One time a day Very minor (10%)
10 Dangerous with a warning: may influence the patient with death One time in 1 shift No (0%)

RESULTS

BAP, HFMEA, and prioritization of potential failure modes

The blood transfusion process involved 11 major practical steps. These steps were prescription, transcription, blood sampling, transportation, checking, preparation, administration, documentation, monitoring, storage, and discarding (Figure 2).

Figure 2.
Figure 2.:
Flowchart of the BAP in surgical care units. BAP indicates blood administration process; IV, intravenous.

It was seen that nurses administered blood products to the patient through 11 main practical steps and there were 11 major errors associated with the administration of blood transfusions. Administration (39.4%), monitoring (21.5%), sampling (12.6%), preparation (12.0%), and checking (4.6%) errors were at high percentages, whereas prescription (3.0%), documentation (2.4%), transcription (1.7%), storage (1.0%), and discarding (0.6%) showed a lower percentage. The total scores of RPN for failure modes in all blood transfusion processes summed to 3725. The root cause analysis and suggested proactive measures were put in place for 38 failure modes (Table 2).

Table 2. - Health Care Failure Mode and Effects Analysis for the BAP and Its Errors
Steps Risk Analysis Suggested Actions to Reduce Failure Mode
Description of Failure Mode S O D RPN Errors Total and % Errors Reason for Failure
1. The physician prescribed transfusion order Inappropriate transfusion order, eg, missing kind, amount, rate, duration of transfusion 7 7 1 49 Prescription errors (112, 3.0%) Illegible physicianʼs order
Verbal order
Standardize prescription orders
Legible handwriting
Illegible prescription 7 7 1 49 Lack of communication Co-sign and date the verbal or telephone order within 24 h
Write order in the wrong patient's file 7 2 1 14 Establish effective medical and nursing records
2. The nurse transcribed transfusion order in patient files and the request form Inappropriate transcription, eg, wrong/missing patientʼs name, kind, amount, duration, time, rate of transfusion 4 6 2 48 Transcription errors (64, 1.7%) Illegible transcription
Lack of reviewing the patient record
Legible handwriting
Carefully review physician orders
Wrong patient's file 4 2 2 16
3. The nurse
  1. Drew sampling and labeled sampling container

  2. Then sent the request form and blood sampling to the blood bank

Inappropriately written request form, eg, missing the patient's name and ID, amount, kind of transfusion 4 5 2 40 Sampling errors (470, 12.6%) Difficulties in vein insertion
Interruption and distraction
Writing label before taking a sample
Assign sampling to well-trained and competent nurses expert in vein insertion
Regulate the visitor time
Missing label information on sampling container 8 2 7 112
Insufficient blood sample for matching test 4 9 3 108 Lack of rechecking practice
Workload
Avoid prelabeled sample
Sign label and request form from the nurse collecting a sample
Outdated sampling 5 5 2 50 Pay attention to rechecking practice with senior shift nurses
Draw sample from the wrong patient 4 3 1 12 Assign clerical work to fill the label and request form as well as delivering blood sample and request form to the blood bank
Delay in delivery of the blood sample or request form to the blood bank 7 7 2 98
Mismatching between the label on the tube and the request form 5 5 2 50
4. The nurse transported and handled blood products from the blood bank to the ward Inappropriate transportation condition 2 2 1 4 Transportation errors (46, 1.2%) Insufficient blood delivery system
Shortage of nurses
Provide sufficient blood delivery system
Provide adequate staff
Damage or loss of blood products 7 2 2 28 Tardiness to transport blood product on time to the patientʼs unit Encourage blood bank staff and nurses to deliver blood products on time to the patientʼs unit
Delay in the transportation of blood product from the blood bank to ward 7 1 2 14
5. The nurse checked the patient file and blood bags Inappropriate checking practice 9 10 1 90 Checking errors (174, 4.6%) Poor double-check by 2 nurses Establish double-checking practice by 2 nurses
No double-checking by 2 nurses 7 6 2 84 Lack of rechecking practice
Misidentifying patients
Two patients might have a similar name
Pay attention to rechecking practice with senior shift nurses
Use a printed patient's identification band
Register the patient's data in patient records
6. The nurse prepared blood products for transfusion Mismatching of blood group between the product and patients 7 5 2 70 Preparation errors (446, 12.0%) Distraction and interruptions
Inadequate resources, staff and poor working condition
Maintain attention and concentration during the preparation of transfusion
Provide adequate staff, resources, and a safe environment
Preparation time takes more than 30 min 8 6 2 96 Nonadherence to safe nursing practice Encourage nurses to adhere to safe preparation practice
Inappropriate warming method of blood products 8 10 2 160 Perpetuating wrong practice from one nurse to another Train the nursing staff on safe preparation practice
Inadequate aseptic technique 5 8 3 120
7. The nurse administered blood products to patients Wrong patient 8 1 9 72 Administration errors (1466, 39.4%) Absence of blood administration protocol Develop and disseminate the blood administration protocol in all hospital units
Wrong transfusion time 8 4 8 256 Difficulties in vein insertion Monitor practice to ensure compliance with the protocol
Wrong dose/amount (over- or under amounts) 9 3 9 243 Untrained and inexperienced nurses The blood transfusion safety poster should be posted in surgical care units
Wrong kind of blood products 7 2 8 112 A deficit in nursesʼ knowledge Assign practice to well-trained and competent nurses
Inappropriate duration 8 4 9 288 Perpetuating wrong practice from one nurse to another
Inadequate aseptic technique 5 9 3 135 Lack of supervision Train the nursing staff on safe transfusion practice
Wrong administration technique 8 9 5 360 Distraction and interruptions
Nonadherence to safe nursing practice

Frequent round by the senior nursing staff for close supervision during blood administration
Maintain attention and concentration during blood administration
Encourage nurses to adhere to safe nursing practice
8. The nurse documented transfusion data Illegible documentation 1 9 1 9 Documentation errors (90, 2.4%) Weak inter-nurse communication
Poor design of the nursing record
Immediately documenting transfusion data on the appropriate record and according to the hospital policies
Missing critical documentation data such as time, amount, rate, duration, kind of transfusion, site of venous access used during transfusion 3 9 3 81 Provide a well-designed nursing record
9. The nurse monitored the patientʼs condition during transfusion Failure to monitor reaction signs within the first 15 min 10 7 3 210 Monitoring errors (801, 21.5%) Absence of the monitoring protocol Develop a monitoring protocol
Failure to monitor signs and symptoms of circulatory overload 10 8 3 240 Failure to detect adverse effects of transfusion, eg, reaction, overload Monitor practice to ensure compliance with protocol
Train the nursing staff in monitoring practice
Failure to monitor vital signs every hour during transfusion 9 6 3 162 Inexperienced nursing staff
Lack of supervision and education
Engage well-trained and experienced nurses
Failure to monitor the IV line for swelling or signs of inflammation every 23 h 7 9 3 189 Nurses spent too much time on non-nursing duties
Many procedures to be performed by a nurse at one time
Long-hour shifts
Senior nurses should mentor new nurses
Exclude non-nursing task from nursesʼ work
Increase nurse to patient ratio
10. The nurse stored blood products for operation or next transfusion Inappropriate storage condition such as using unapproved stored in a food or drug refrigerator or extended the time of storage 6 5 1 30 Storage errors (36, 1.0%) Nonadherence to infection control precautions
Unavailability of blood transfusion refrigerator in the clinical areas
Encourage nurses to adhere to infection control precautions
Provide a blood bank refrigerator in clinical areas
Store outdated blood products 3 6 1 6 Unawareness of storage precautions Train the nursing staff on safe storage practice
11. The nurse discarded blood bags Improper discarding of blood product bags and transfusion sets 1 8 2 16 Discarding errors (20, 0.6%) Nonadherence to infection control precautions Encourage nurses to adhere to infection control precautions
Blood product bags and transfusion sets were discarded in the area accessible to visitors 1 2 2 4 Unavailability of a suitable disposal bag The empty transfusion bag should be discarded as the disposal of clinical waste
Availability of the suitable disposal bag
Total RPN 3725 100.0
Abbreviations: BAP, blood administration process; D, Delectability; IV, intravenous; O, Occurrence; S, Severity; RPN, risk priority number.

In total, 38 failure modes were identified in this process. According to Pareto analysis, 17 of 38 failures were considered as high-risk failures and significant errors in the BAP among nurses. These failures began with rank number one, which was a wrong administration technique (RPN score = 360), and ended with rank number 17, which was an inappropriate checking practice (RPN score = 90) (Table 3).

Table 3. - Ranking Detected Potential Failures/Errors in the BAP According to RPN Scores and Pareto Analysis
Failure\Error RPN Rank Failure\Error RPN Rank
Wrong administration technique 360a 1 Wrong patient 72 20
Inappropriate duration 288a 2 Mismatching of blood group between product and patients 70 21
Wrong transfusion time 256a 3 Outdated sampling 50 22
Wrong dose/amount 243a 4 Mismatching between the label on the tube and the request form 50 23
Failure to monitor signs and symptoms of circulatory overload 240a 5 Inappropriate transfusion order 49 24
Failure to monitor reaction signs within the first 15 min 210a 6 Illegible prescription 49 25
Failure to monitor IV lines for swelling or signs of inflammation every 2-3 h 189a 7 Inappropriate transcription 48 26
Failure to monitor vital signs every hour during transfusion 162a 8 Inappropriate written request form 40 27
Inappropriate warm method of blood products 160a 9 Inappropriate storage condition 30 28
Inadequate aseptic technique during the administration 135a 10 Damage or loss of blood products 28 29
Inadequate aseptic technique during preparation 120a 11 Wrong patient's file 16 30
Missing label information on sampling container 112a 12 Improper discarding of blood product bags and transfusion sets 16 31
Wrong kind of blood products 112a 13 Write order in wrong patient's file 14 32
Insufficient blood sample for matching test 108a 14 Delay in transportation of blood product from the blood bank to ward 14 33
Delay of delivery of blood sample or request form to the blood bank 98a 15 Draw sample from the wrong patient 12 34
Preparation time takes >30 min 96a 16 Illegible documentation 9 35
Inappropriate checking practice 90a 17 Store outdated blood products 6 36
No double-checking by 2 nurses 84 18 Inappropriate transportation condition 4 37
Missing critical documentation data 81 19 Blood product bags and transfusion sets were discarded in the area accessible to visitors 4 38
Abbreviations: BAP, blood administration process; IV, intravenous; RPN, risk priority number.
aHigh-risk failures.

Evaluation of corrective actions of 17 high-risk failures

Corrective actions were taken for 17 high-risk failure modes. Failure modes associated with errors were reduced after the corrective actions were carried out in surgical care units (Table 4).

Table 4. - Evaluation of Corrective Actions of 17 High-Risk Failure Modes
Error Failure Mode RPN (Pre) RPN (Post) % Improvement Corrective Actions
Sampling Missing label information on the sampling container 112 45 59.8 Assign sampling to well-trained and competent nurses expert in vein insertion
Insufficient blood sample for the matching test 108 58 46.3 Avoid prelabeled sample
Delay of delivery of blood sample or request form to the blood bank 98 34 65.3 Sign label and request form from the nurse collecting a sample
Rechecking practice with senior shift nurses
Checking Inappropriate checking practice 90 44 51.1 Rechecking practice with senior shift nurses
Use printed patient's identification band
Register patient's data in patient records
Preparation and administration Wrong administration technique 360 144 60 Train the nursing staff
Inappropriate duration 288 153 46.9 Develop and disseminate the blood administration protocol
Wrong transfusion time 256 119 53.5 Monitor practice to ensure compliance with protocol
Wrong dose/amount 243 70 71.2 Post the blood transfusion safety poster
Inappropriate warm method of blood products 160 52 67.5 Assign practice to well-trained and competent nurses
Inadequate aseptic technique during the administration 135 67 50.4 Frequent round by the senior nursing staff
Inadequate aseptic technique during preparation 120 60 50.0
Wrong kind of blood products 112 50 55.4
Preparation time takes more than 30 min 96 50 47.9
Monitoring Failure to monitor: Develop a monitoring protocol
• Signs and symptoms of circulatory overload 240 160 33.3 Train the nursing staff in monitoring practice
• Reaction signs within the first 15 min 210 115 45.2 Engage well-trained and experienced nurses
• IV lines for swelling or signs of inflammation every 2-3 h 189 94 50.3 Senior nurses should mentor new nurses
Exclude non-nursing task from nursesʼ work
• Vital signs every hour during transfusion 162 92 43.2 Increase nurse to patient ratio
Abbreviation: IV, intravenous.

DISCUSSION

Blood administration is a nursing responsibility and a complex high-risk procedure.20 Therefore, it is necessary to carry out proactive safety analysis techniques for identifying weaknesses in the BAP.14 FMEA is one of the proactive safety methods that are used for preventing errors, ensuring patient safety, and improving medical processes.21 Therefore, the present study attempted to use HFMEA to: assess potential failure modes associated with the BAP; develop a categorization of blood administration errors; identify the reasons for potential failure modes in the BAP; and recognize preventive safety measures to reduce or prevent the potential failure modes and the identified high-risk failures in the BAP in surgical care units.

The present study identified 11 blood administration steps and 38 potential failure modes in the BAP. In total, 17 high-risk failures were detected in administering, monitoring, blood sampling, preparation, and checking steps that accounted for 80% of RPN scores according to Pareto analysis. This study was supported by 2 studies in the United Kingdom (2004)22 and Georgia (2009),23 which revealed that blood administration failures usually start with the time of sample collection and end with the actual blood administration.

The present study pointed out that sampling errors in this work may have occurred from missing label information on sampling containers, an insufficient blood sample for matching tests, and delay in delivery of the blood sample or request form to the blood bank. Similar results were reported in other countries such as the United Kingdom,24 Italy,25 and India,26 which concluded that sampling and labeling errors were incidents during the BAP in hospital settings.

In the current study, potential failures and errors in preparing and administering blood may have resulted when some nurses failed to adhere to safe transfusion and nursing practice during preparing and administering blood to the patient. At the same time, errors may have occurred when some nurses failed to monitor the patientʼs condition during transfusion. This faulty practice was also shown in other studies in different countries such as the United Arab Emirates (2010),27 China (2013),14 Iran (2017),13 and Nepal (2018).28

In this regard, it was also noteworthy in the current study that some nurses in the study units did not pay full attention to rechecking practice during preparation and blood administration, although there were enough nursing staff members and presence of senior nurses in the morning shift. The rechecking practice provides a comprehensive list of what to check during the BAP and ensures that the right blood product is administered to the right patient. If there are any discrepancies at this point, the transfusion must not start until they are resolved. The rechecking practice is also a proactive intervention that could help prevent errors and detect up to 95% of errors.29–31 These findings of the present study were consistent with other studies in Australia (2002),29 UK (2004),22 Canada (2010),32 and Egyptian hospitals (2009 and 2015),33,34 which concluded that although double-check by 2 nurses is an efficient preventive practice, improper application may mitigate its effect.

In addition, blood administration failures had been associated with multiple errors.13 The present study showed that 11 categories of blood administration errors were identified in the BAP and associated with 38 potential failure modes. These categories were newly developed in this study. Errors in the BAP can be critical and may occur in 1 or more procedural steps from physician prescription to the actual blood administration.19 The present study agreed with other studies in UK hospitals from 2004 to 201715,22,35 and Greek (2011)25 hospitals, which found that nearly all BAPs can be complicated by life-threatening mistakes having occurred during prescribing, requisition, checking, drawing samples, preparation, administration, and monitoring of blood administration.

The present study also highlighted that administration, monitoring, sampling, preparation, and checking errors were considered the most important and significant potential errors in the BAP. The study units had a higher rate of administration errors (39.4%) in the BAP than in the studies in the United Kingdom (2005)35 (27.2%), Australia (2010)36 (6%), and Iran (2015)3 (15.1%). The percentage of sampling errors in the current study (12.6%) was less than that found in the study of Stainsby et al (2005)35 (18.0%) and Shimizu37 (21.6%). At the same time, checking errors (4.6%) were much lower than those found in the study of UK hospitals in 2005 (17.1%).35 These differences between this study and other studies can be explained by the fact that the nature and characteristics of the factors contributing to the BAP were different. These factors were patients' illnesses, nursing workload, patient to nurse ratio, nursesʼ qualification, training, and knowledge, using new medical technological equipment and devices, the nature of the hospital, as well as physiciansʼ qualification and training.

The present study showed that 38 potential failure modes associated with 11 categories of errors were not solely caused by direct nursesʼ actions but also a range of organizational, managerial, and patient factors. In this study, many of these factors were perceived by the HFMEA members as causes of blood administration failures among nurses in the study units. The nursing factors that facilitated the occurrence of these failures in blood administration were a shortage and inexperience of the nursing staff, exhaustion due to heavy workload and long shifts, as well as the distraction of and lack of supervision.

Other contributing factors identified in the present study were difficulties in vein insertion, misidentified patient, illegible physiciansʼ order and transcription, verbal order, perpetuating the wrong practice from one nurse to another, nonadherence to safe nursing practice, the absence of rechecking practice, an absence of transfusion and monitoring protocol, lack of appropriate training and education, inadequate resources, and dissatisfaction with working conditions. Similar results were reported in several studies in the UK (2004)22,38 and Iranian hospitals (from 2013 to 2017).3,13,39

The present study revealed that failures resulting in an inappropriate BAP among nurses remained the largest risk to the patient. Efficient proactive measures should be taken to reduce errors and failures in administering blood and ensure safe blood administration to patients. In total, 38 potential failure modes and 17 high-risk failures pointed out by the current study were considered as crucial failures and errors in administering blood to patients; however, they could be prevented by proactive measures and corrective actions.

Suggested proactive actions and corrective actions in this study were necessary to promote proper nursing practice during the blood-sample-drawing, preparing and administering, and checking and monitoring steps. Suggested and corrective actions in this study were identified as developing a blood administration protocol and procedure with a periodic training program for the nursing staff. Knowledge of blood transfusion practice would improve the administration process and provide safe blood administration to patients.19 Other suggested actions addressed in this study were implementing a double-checking practice during the BAP, enhancing nursing working conditions, engaging well-experienced nurses, excluding non-nursing practice, and providing proper resources. Similar findings to this study were reported by other studies of hospitals in the UK (2000, 2004, and 2005)38,40,41 and Iran (2015 and 2017).3,13

CONCLUSION

The present study concluded that HFMEA was an efficient and well-organized risk management tool. It could be used in the BAP in surgical care units for identifying causes of failures and taking suggested quality improvement actions in nonpunitive culture. These actions were suggested on the basis of identifying, evaluating, prioritizing, and investigating all previous potential failure modes as well as discovering reasons for failure and errors.

The present study revealed that 38 potential failure modes associated with 11 categories of blood administration errors occurred in 11 major BAP steps. These categories of blood administration errors were newly developed in this study. The new categories can be used for estimating blood administration error rates in clinical units. These rates will help identify a failure in any steps of the BAP and improve safety of the BAP in hospital settings. This study also pointed out that 17 of 38 potential failures were considered as high-risk failures and significant errors having occurred during the steps of drawing samples, checking, administering, preparing, and monitoring the blood administration practical process.

This study also showed that potential failure modes associated with 11 categories of errors were caused by not only deficits in nursing practice but also other factors such as organizational, management, physician, and patient factors. Thus, these failures could only be prevented and reduced by focusing on improving the system as a whole, not just individual nurses alone. The presence of an adequate number of nurses and the availability of a blood administration protocol in each unit, together with establishing blood administration training, were the most suggested solutions identified by the HFMEA members in the present study.

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Keywords:

blood transfusion; HFMEA; medical errors; nurses; risk assessment

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