Application of root cause analysis in the management of pediatric transfusion adverse events

Abstract

Objective To investigate the application of root cause analysis (RCA) in the management of pediatric transfusion adverse events,in order to reduce the occurrence rate of adverse events in pediatric transfusion.Methods Root cause analysis method was used from October 2011 to March 2012.Occurrence rate of adverse events,double check and accuracy of transfusion were compared before and after the implementation of RCA.Results Six months before RCA,the occurrence rate of adverse events was 0.32％ and six months after RCA was 0.03％,and the difference was statistically significant (x2 =19.146,P ＜ 0.01).The rate of double check and accuracy of transfusion were respectively 100％ and 98％ after RCA,which were higher than those before RCA (74％ and 83％),and the differences were statistically significant (x2 =29.885,13.085,respectively; P ＜ 0.01).Conclusions Root cause analysis can effectively control related factors during pediatric transfusion,reduce the occurrence rate of adverse events and improve transfusion safety. Key words: Hospital, pediatrics; Safety management; Root cause analysis; Transfusion adverse events