Analysis and process improvement concerning adverse events to insufficient plasma transfusion
10.13303/j.cjbt.issn.1004-549x.2021.09.011
- VernacularTitle:血浆输注量不足不良事件分析及流程改进
- Author:
Li LV
1
;
Wenjun QUE
1
;
Xin LI
1
;
Tingxi ZHAN
1
;
Qing LI
1
;
Pan QIN
1
;
Huan TU
1
;
Zebo YU
1
;
Xue HU
1
Author Information
1. Department of Blood Transfusion, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
- Publication Type:Journal Article
- Keywords:
insufficient plasma transfusion;
adverse events;
healthcare failure mode and effect analysis;
root cause analysis
- From:
Chinese Journal of Blood Transfusion
2021;34(9):978-982
- CountryChina
- Language:Chinese
-
Abstract:
【Objective】 To analyze the root causes of adverse events to insufficient plasma transfusion, so as to explore improvement measures, optimize the transfusion strategy and avoid such adverse events. 【Methods】 The root causes of insufficient plasma transfusion were analyzed by health care failure mode and effect analysis, the targeted improvement measures were formulated and the effect was evaluated. 【Results】 After the improvement, the incidence of adverse events to insufficient plasma transfusion decreased significantly.The risk priority value affecting the safety of blood transfusion decreased from 70 to 8, and the proportion of coagulation function test after blood transfusion increased from 44.61%(1 309/2 934)in 2012 to 80.55% (2 187/2 715)in 2019, and plasma transfusion volume per capital increased from 300 mL to 528 mL. PT and APTT values after plasma transfusion in 2019 significantly increased compared with those in 2012. Meanwhile, the proportion of plasma transfusion in hospitalized patients decreased from 3.16% (2 934/92 838)to 2.12%(2 715/128 352). 【Conclusion】 Risk management of quality and safety of blood transfusion by combing healthcare failure mode, effect analysis and root cause analysis(RCA) can improve the risk awareness of clinical blood transfusion, optimize the proportion of plasma transfusion, and is essential to ensure the safety and effectiveness of blood transfusion and improve the prognosis of transfused patients.
