Can we learn about human and organisation factors from past transfusion errors?

Abstract

Seven human factors models were evaluated using a small number of historical transfusion error reports to explore learning from human and organisation factors and decide the best model for a planned larger retrospective study. Insufficient information given in many reports led to subjectivity in categorisation, but the conclusion was that systems engineering initiative for patient safety 2.0 may be the best single system to use. Analysing the human factors effectively in transfusion incidents could provide some insights into process improvement.