Serious-incident prevention case study

IMPLEMENTATION OF THE SERIOUS-INCIDENT PREVENTION PROCESS PIPELINE OPERATIONS CASE STUDY... 

Record review revealed a by now familiar finding 11 % of patients suffered an adverse event, with about a tenth (11 cases) of these being serious and preventable. However, 23% of patients reported an adverse event and there was little concordance between the two methods. Patient reports revealed an additional 21 serious and preventable events (Table 15.1), in addition to the 11 found in medical records, thus tripling the rate revealed by record review. The true rate of incidents potentially reportable by patients may be higher still, as some interviews took place several months after discharge and patients who died or were very sick post discharge were excluded from the study. As the examples show, many of the incidents reported by patients were serious untoward events that should have been described in the medical record. 

Management of adverse drug reactions Preferential use of male donor plasma for FFP transfusions has led to a substantial reduction in the incidence of TRALI [6, 12 ]. Serious Hazards of Transfusion (SHOT) data suggest a 50% reduction in the risk of TRALI when 99% of FFP is from male donors only [33 ]. In another study, 12 of 21 allo-immune TRALI cases implicated plasma from female donors, suggesting that theoretically 57% of all allo-immune TRALI cases could be prevented by using male plasma only [14 ]. In another study there was no statistically significant difference in pulmonary morbidity between patients who received units from female or male donors, but these results were limited by the small number of morbid outcomes [11 ]. 

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