Medical error continues to be a problem bedeviling the practice of transfusion medicine (TM). Whether the major contributor to error is 'systems error' or 'human error' is not fully understood. However, eliminating or mitigating different kinds of errors will require different approaches and specific strategies. This session will focus on strategies for mitigating human error in TM. Speakers in this session will present three different strategies. One speaker will discuss the topic cognitive bias as source of error and present a range of bias mitigation approaches that have been implemented with some success to reduce error in other medical specialties. A second speaker will present a recent innovative approach of User-Centered Design (UCD) that was successfully implemented at a major academic medical center to reduce errors in blood product orders and order sets. A third speaker will present a range of strategies implemented by the SHOT (Serious Hazards of Transfusion) group in the United Kingdom over a period of years to mitigate human error. The session will provide attendees with an enhanced understanding of the nature of human error, and with a range of strategies to mitigate this form of error. The audience will be invited to participate by describing their own experiences with human error in TM, and to suggest strategies for mitigating it.
Describe the nature and kinds of human errors that are most prevalent in transfusion medicine
Review three different approaches towards mitigating human error in transfusion medicine
Generate audience participation in a discussion (via audience response system) on other approaches for mitigating human error in transfusion medicine