The root cause of many adverse events in healthcare is attributed to “human factors”. Processes can be changed to reduce the possibility of mistakes, but no system is completely human proof. In this session we will investigate perception errors and demonstrate how our brain’s normal functions cause our perception to be blinded to inconsistencies in details. The session will include discussion of cases where errors occurred which could have been avoided and recommendations to improve recognition of inconsistencies. Types of error to be discussed are those which relate to the confirmation of information, this could be confirming the patient details when taking a sample or administering blood. Especially pertinent is the comparison on auditory and visual information such as asking the patient to state their name or checking with a colleague This can cover the entire pre-transfusion process but is also applicable to other situations such as checking drugs. Delegates were encouraged to share their own experiences of errors and examine how perception errors have contributed to his or her blood banking experiences.
To view Spanish or English subtitles, click the "CC" box in the video player. Para ver subtítulos en español o inglés, haga clic en el cuadro "CC" en el reproductor de video.
Recognize areas of their own practice where perception errors can occur and assess the risk of errors going undetected.
Integrate strategies to reduce the likelihood of perception errors into procedures, training and working practice.
Identify areas to improve processes that require patient or product identification.
Discuss the relevant neurological functions and social science theory surrounding the causes of perception errors and the experiments which demonstrate these.
Assistant Professor of Pathology, Director of Therapeutic Apheresis and Associate Director of Transfusion Medicine,
Department of Pathology, St. Louis University School of Medicine
All relevant financial relationships have been mitigated. By completing the evaluation, you are attesting to watching the presentation in its entirety. A certificate will be immediately provided after submission.
AM21-66: Bloody Errors - How Humans Are Hardwired to Make Mistakes and What Steps We Can Do in the Blood Bank to Prevent Them Evaluation