| Document
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Author Nicola Swarbrick, Jennifer Davies, Emma Milser, Alison Watt, Debbi Poles & Shruthi Narayan |
| Abstract Effective incident investigation is an integral part of the provision of a safe blood transfusion service, with the aim to prevent recurrence of adverse events and harm to patients. Determining how an incident has taken place allows understanding of the gaps or failures within the system and identification of effective corrective and preventive measures that can be implemented to reduce risk of recurrence. Consideration of human factors supports a more sophisticated understanding of the factors that cause incidents, optimising human performance through better understanding of human behaviour and the factors that influence this behaviour, thus improving patient safety. |
