Analyse d’un incident de la chaîne transfusionnelle et gestion du retour d’expérience |
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Authors: | P. Roussel M.-C. Moll B. Lassale J. Ragni |
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Affiliation: | aInstitut national de la transfusion sanguine, 6, rue Alexandre-Cabanel, 75739 Paris cedex 15, France;bDélégation qualité-risque, direction générale, centre hospitalier universitaire, 4, rue Larrey, 49933 Angers cedex 9, France;cUnités d’hémovigilance et de gestion des risques, Assistance publique–Hôpitaux de Marseille, 249, boulevard de Sainte-Marguerite, 13274 Marseille cedex 09, France |
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Abstract: | Analysing adverse events is part of the medical practice in so far as the part it plays is outstanding in terms of feedback and improved healthcare safety. The integrated implementation of this practice is based on a four-dimensional system: strategic (corporate policies), cultural (safety-oriented cultural mindset), structural (dedicated organization and resources) and technical (methodologies and utilities). Two case studies illustrate the sequencing process from selecting the to-be-analyzed event down to figuring out the appropriate action plan. Beyond the visible and obvious origin, thanks to the implemented methods such as causal tree or ALARM method, far-fetched analysis elements and identified factors likely to explain events can be discovered. Comments on the role and terms of feedback are also hereto expressed. |
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