The public's perception of the risk of HIV infection by blood transfusion has greatly intensified the concern regarding safety of the blood supply, thus, making transfusion safety a matter of national priority. A major constraint in transfusion safety is that there is no means for the systematic collection and analysis of indicents of transfusion medicine errors. However, incident reporting systems have been developed in other error-critical fields including aviation, nuclear power, and anesthesiology. These systems can be used as guiding models for the development of an similar reporting system in transfusion medicine. Therefore, the specific aims of this project are to: (l) design a prototype reporting system for the collection and classification of incidents with the potential for compromising the safety of the blood supply, (2) develop and construct an operational prototype reporting system based upon the design criteria, (3) demonstrate the effectiveness of the reporting system in collecting, storing, and classifying information related to safety and human error at multiple sites through implementation testing, (4) derive rational strategies for enhancement of human performance and safety based upon the analysis of the classification of error types contained in the prototype data system, (5) evaluate the prototype reporting system's effectiveness, document the development process, and report project outcomes. This project will be carried out as an interdisciplinary effort involving experts from the fields of transfusion medicine, education and training, cognitive psychology, artificial intelligence, aviation safety, and nuclear power. This will be achieved using consensus development. The system will be implemented and tested in three blood centers (Blood Care of Dallas, Dallas, Texas; New York Blood Center, New York City, NY; Oklahoma Blood Institute, Oklahoma City, OK) and three hospital transfusion services (Parkland Memorial Hospital, Dallas, TX; New York University Medical Center, New York City, NY; University of Southern California Medical Center, Los Angeles, CA). This prototype system may well serve as a national model for improving safety of the nation's blood supply.
