THE ATTRIBUTES OF MEDICAL EVENT-REPORTING SYSTEMS - EXPERIENCE WITH APROTOTYPE MEDICAL EVENT-REPORTING SYSTEM FOR TRANSFUSION MEDICINE

Objective.-To design, develop, and implement a prototype medical event -reporting system for use in transfusion medicine to improve transfusi on safety by studying incidents and errors. Methods.-The IDEALS concep t of design was used to identify specifications for the event-reportin g system, and a Delphi and subsequent nominal group technique meetings were used to reach consensus on the development of the system. An int erdisciplinary panel of experts from aviation safety, nuclear power, c ognitive psychology, artificial intelligence, and education and repres entatives of major transfusion medicine organizations participated in the development process. Setting.-Three blood centers and three hospit al transfusion services implemented the reporting system. Results.-A w orking prototype event-reporting system was recommended and implemente d. The system has seven components: detection, selection, description, classification, computation, interpretation, and local evaluation. It s unique features include no-fault reporting initiated by the individu al discovering the event, who submits a report that is investigated by local quality assurance personnel and forwarded to a nonregulatory ce ntral system for computation and interpretation. Conclusions.-An event -reporting system incorporated into present quality assurance and risk management efforts can help organizations address system structural a nd procedural weakness where the potential for errors can adversely af fect health care outcomes. Input from the end users of the system as w ell as from external experts should enable this reporting system to se rve as a useful model for others who may develop event-reporting syste ms in other medical domains.