Designing Property Specifications to Improve the Safety of the Blood Transfusion Process

References 

1. Institute of Medicine . A new health system for the 21st century: Crossing the quality chasm. Washington (DC): National Academy Press; 2001;
2. Callum JL, Kaplan HS, Merkley LL, et al. Near-miss event reporting for transfusion medicine: Improving transfusion safety. Transfusion. 2001;41:1204–1211
3. General OoI . Reporting process for blood establishments to notify the Food and Drug Administration of errors and accidents affecting blood. Washington, DC: US Department of Health and Human Services; 1995;[Report No.: CIN:A-03-93-00352]
4. Mintz P. Quality assessment and improvement of transfusion practices. Transfus Med. 1995;9:219–232
   • MEDLINE
   • CrossRef
5. Kaplan H, Callum J, Fastman B, et al. The Medical Event Reporting system for transfusion medicine: Will it help get the right blood to right patient. Transfus Med Rev. 2000;16:86–102
   • Abstract
   • Full-Text PDF (1453 KB)
   • CrossRef
6. Battles JB, Kaplan HS, Van der Schaaf TW, et al. The attributes of Medical Event Reporting systems for transfusion medicine. Arch Pathol Lab Med. 1998;122:231–238
   • MEDLINE
7. Rebibo D, Hauser L, Slimani A, et al. The French Haemovigilance System: Organization and results for 2003. Transfus Apheresis Sci. 2004;145–153
8. Berte L. Tools for improving quality in the transfusion service. Am J Clin Pathol. 1997;107:S36–S42[4 Suppl 1]
   • MEDLINE
9. Galel S, Richards C. Practical approaches to improve laboratory performance and transfusion safety. Am J Clin Pathol. 1997;107:S43–S49[4 Suppl 1]
   • MEDLINE
10. Voak D, Chapman J, Phillips P. Quality of transfusion practice beyond the blood transfusion laboratory is essential to prevent ABO-incompatible death. Transfus Med. 2000;10:95–96
    • MEDLINE
    • CrossRef
11. Henneman EA, Avrunin GS, Clarke LA, et al. Increasing patient safety and efficiency in transfusion therapy using formal process definitions. Transfus Med Rev. 2007;21:49–57
    • Abstract
    • Full Text
    • Full-Text PDF (439 KB)
    • CrossRef
12. Deming WE. Out of the crisis. Cambridge: MIT Press; 1982;
13. Osterweil LJ, Schweik CM, Sondheimer N, et al. Analyzing processes for E-government development: The emergence of process modeling languages. J E-Government. 2004;1:63–89
14. Malone TW, Lai K-Y, Fry C. Experiments with oval: A radically tolerable tool for cooperative work. In: CSCW'92. New York: ACM; 1992;p. 289–297
15. Cass AG, Osterweil LJ. Design guidance through the controlled application of constraints. In: Tenth International Workshop on Software Specification and Design. San Diego, CA: ACM and IEEE Computer Society; 2000;p. 195–199
16. Cass AG, Sutton SM, Osterweil LJ. Formalizing rework in software processes. In: Oquenda F editors. Ninth European Workshop on Software Process Technology; 2003 September. Vol 2786, Lecture Notes in Computer Science. Helsinki, Finland: Springer-Verlag; 2003;p. 16–31
17. Cass AG, Lerner BS, McCall EK, et al. Little-JIL/Juliette: a process definition language and interpreter. In: International Conference on Software Engineering. Limerick, Ireland: ACM and IEEE Computer Society; 2000;p. 754–758
18. Shojania KG, Duncan BW, McDonald KM, et al. Making healthcare safer: A critical analysis of patient safety practices. Rockville, MD: Agency for Healthcare Research and Quality; 2001;
19. Leape L, Epstein A, Hamel MB. A series on patient safety. N Engl J Med. 2002;347:1272–1274
    • CrossRef
20. Kaplan HS, Battles JB, Van der Schaaf TW, et al. Identification and classification of events in transfusion medicine. Transfusion. 1998;38:1071–1081
21. Baele PL, Debruyere M, Deneys V, et al. Bedside transfusion errors. A prospective survey by the Belgium SAnGUIS Group. Vox Sang. 1994;66:117–121
    • MEDLINE
    • CrossRef
22. Linden JV, Paul B, Dressler KP. A report of 104 transfusion errors in New York State. Transfusion. 1992;32:601–606
23. Sharma PR, Kumar S, Agnihotri SK. Sources of preventable errors related to transfusion. Vox Sanuinis. 2001;81:37–41
24. Myhre BA, McReur D. Human error—A significant cause of transfusion mortality. Transfusion. 2000;40:879–885
25. Sazama K. Reports of 355 transfusion associated deaths: 1976-1985. Transfusion. 1990;30:583–590
26. Novis DA, Miller KA, Howanitz PJ, et al. Audit of transfusion procedures in 660 hospitals: A College of American Pathologists Q-Probe study of patient identification and vital sign monitoring frequencies in 16494 transfusions. Arch Pathol Lab Med. 2003;127:541–548
27. Williamson L, Cohen H, Love E, et al. The Serious Hazards of Transfusion (SHOT) initiative. The UK approach to hemovigilance. Vox Sang. 2000;78:291–295
28. Lumadue JA, Boyd JS, Ness PM. Adherence to a strict specimen labeling policy decreases the incidence of erroneous blood grouping of blood bank specimens. Transfusion. 1997;37:1169–1172
29. Rouger PH, Noizat PF, Le Pennec PY. Hemovigilance and transfusion safety in France. Vox Sanguinis. 2000;78:287–289
30. Michlig C, Vu DH, Wasserfallen JB, et al. Three years of haemovigilance in a general university hospital. Transfus Med. 2003;13:63–72
    • MEDLINE
    • CrossRef
31. Foss ML, Moore SB. Evolution of quality management: integration of quality assurance functions into operations, or “quality is everyone's responsibility”. Transfusion. 2003;43:1330–1336
32. Burgmeier J. Failure mode and effect analysis: An application in reducing risk in blood transfusion. Quality Improvement. 2002;28:331–339
33. Turner C, Casbard A, Murphy M. Barcode technology: It's role in increasing the safety of blood transfusion. Transfusion. 2003;43:1200–1209
34. Davies A, Staves J, Kay J, et al. End-to-end electronic control of the hospital transfusion process to increase the safety of blood transfusion: strengths and weaknesses. Transfusion. 2006;46:352–364
35. Jensen NJ, Crosson JT. An automated system for bedside verification of the match between patient identification and blood unit identification. Transfusion. 1996;36:216–221
36. Murphy MF, Casbard AC, Ballard S, et al. BEST Research Collaborative. Prevention of Bedside Errors in Transfusion Medicine (PROBE-TM) study: A cluster-randomized, matched-paired clinical areas of a simple intervention to reduce errors in the pretransfusion bedside check. Transfusion. 2007;47:771–780
37. Dzik WH. New technology for transfusion safety. Br J Haematol. 2007;136:181–190
    • MEDLINE
    • CrossRef
38. Reid PP, Compton WD, Grossman JH, et al. Building a Better Delivery System: A New Engineering/Health Care Partnership. National Academies Press; 2005;