Mistakes
Were
Almost Made
In
1956, NBC and CBS radio joined ABC in banning a hit song called "Transfusion."
Said
an NBC executive, "There's nothing funny about a blood transfusion."
Sometimes,
in fact, transfusions are downright unfunny.
Giving
people red blood cells that are incompatible with their blood type is
a primary cause of preventable deaths during transfusions. Moreover,
accidentally collecting blood from people infected with HIV or hepatitis
affects the overall safety of the nation's blood supply.
That's why KU's Costas Tsatsoulis is in the hunt for ways to reduce
errors in both the collection and transfusion of blood.
Tsatsoulis'
work is part of a $3.2 million National Institutes of Health grant overseen
by Columbia University. KU will receive $350,000 over four years to
establish a way for hospitals and other health care providers to report
near-miss errors within transfusion medicine.
Near-miss reporting -- gathering data on mistakes that almost happened
-- already is standard in fields like aviation or nuclear power.
"The
hope is that we can change blood procedures," says Tsatsoulis, whose
lab is part of the Information and Telecommunication Technology Center
on KU's west campus. "Errors aren't only caused by humans. Errors can
come from the environment, such as bad lighting. Or they can come from
a certain business culture, such as employees who say, 'We never call
our supervisor on the weekend.' The data analysis will identify where
the faults lie."
More
than 25 organizations -- from small and large hospitals to blood collection
sites and the Red Cross -- will forward to Tsatsoulis and his students
error and near-miss data they gather.
Data could show that more near misses occur at certain times of day
or on holidays. Perhaps a blood procedure itself may be the root cause
of near misses. A case in point: As a result of near misses, blood-bag
labels are now color-coded by blood type to reduce the chance that a
patient will be given the wrong blood.
Information
provided by
Judith Galas,
Information and Telecommunication Technology Center
