Root-cause analysis of a potentially sentinel transfusion event: lessons for improvement of patient safety

Errors prevention and patient safety in transfusion medicine are a serious concern. Errors can occur at any step in transfusion and evaluation of their root causes can be helpful for preventive measures. Root cause analysis as a structured and systematic approach can be used for identification of underlying causes of adverse events. To specify system vulnerabilities and illustrate the potential of such an approach, we describe the root cause analysis of a case of transfusion error in emergency ward that could have been fatal. After reporting of the mentioned event, through reviewing records and interviews with the responsible personnel, the details of the incident were elaborated. Then, an expert panel meeting was held to define event timeline and the care and service delivery problems and discuss their underlying causes, safeguards and preventive measures. Root cause analysis of the mentioned event demonstrated that certain defects of the system and the ensuing errors were main causes of the event. It also points out systematic corrective actions. It can be concluded that health care organizations should endeavor to provide opportunities to discuss errors and adverse events and introduce preventive measures to find areas where resources need to be allocated to improve patient safety.

Role of surgeon in length of stay in ICU after cardiac bypass surgery

We presumed that the surgeon himself has an impact on the results after coronary artery bypass grafting [CABG] as there is no unique protocol for the discharge of post-operative cardiac patients at our institution. Therefore, we examined whether the surgeon himself has an impact on the intensive care unit [ICU] stay of isolated CABG patients. We prospectively studied a total of 570 consecutive patients undergoing elective CABG. Length of stay in the ICU was defined as the number of days in the ICU unit post-operatively. Seven operating surgeons were classified in 3 categories on the basis of the mean hospital stay of their patients [1, 2 and 3 if the mean total patients' stay in hospital was <8 days, between 8 to 10 days, and longer than 10 days; respectively]. Using a multivariable regression model, we determined the independent predictors of length of stay in the ICU [> 48 hours] and examined the role of surgeon in this regard. Incidence of post-operative arrhythmia and length of ICU stay were higher in the patients of surgeon category 3 than those of surgeon categories 1 and 2. Surgeon category 3 also operated on patients with higher Euro SCOREs than did surgeon categories 1 and 2. With the aid of a multivariable stepwise analysis, three variables were identified as independent predictors significantly associated with ICU length of stay: age, history of cerebrovascular accident, and surgeon category. Surgeon category may independently predict a prolonged length of stay in the ICU. We suggest that a unique discharge protocol for post-CABG patients be considered to restrict the role of surgeon in the ICU stay of these patients