A Medical Event Reporting System in Transfusion Medicine: An error management approach

The public's perception of the risk of HIV infection by blood transfusion has greatly intensified concerns regarding the safety of the blood supply, thus making quality assurance and safety a matter of high priority. The Medical Event Reporting System for Transfusion Medicine (MERS-TM) was developed as a near miss reporting system to collect and classify incidents with the potential for compromising the safety of the blood supply. MERS-TM has the following components: detection, selection, description, classification, computation, interpretation, and local evaluation. Its unique features include no-fault reporting initiated by a report by the individual discovering an event, investigation by local quality assurance personnel, and the forwarding of data to a nonregulatory central system for computation and interpretation. Events are classified by type of event or what occurred and well as to why it happened or the root causes. A near miss reporting such as MERS-TM incorporated into present quality assurance and risk management efforts can provide useful information to organizations in addressing system structural and procedural weakness where the potential for error can adversely effect the out comes of health care.