BACKGROUND: Half of the reported serious adverse events from transfusion are a consequence of medical error. A no‐fault medical‐event reporting system for transfusion medicine (MERS‐TM) was developed ...to capture and analyze both near‐miss and actual transfusion‐related errors.
STUDY DESIGN AND METHODS: A prospective audit of transfusion‐related errors was performed to determine the ability of MERS‐TM to identify the frequency and patterns of errors.
RESULTS: Events and near‐miss events (total, 819) were recorded for a period of 19 months (median, 51/month). No serious adverse patient outcome occurred, despite these events, with the transfusion of 17,465 units of RBCs. Sixty‐one events (7.4%) were potentially life‐threatening or could have led to permanent injury (severity Level 1). Of most concern were 3 samples collected from the wrong patient, 13 mislabeled samples, and 22 requests for blood for the wrong patient. Near‐miss events were five times more frequent than actual transfusion errors, and 68 percent of errors were detected before blood was issued. Sixty‐one percent of events originated from patient areas, 35 percent from the blood bank, and 4 percent from the blood supplier or other hospitals. Repeat collection was required for 1 of every 94 samples, and 1 in 346 requests for blood components was incorrect. Education of nurses and alterations to blood bank forms were not by themselves effective in reducing severe errors. An artifactual 50‐percent reduction in the number of errors reported was noted during a 6‐month period when two chief members of the event‐reporting team were on temporary leave.
CONCLUSION: The MERS‐TM allowed the recognition and analysis of errors, determination of patterns of errors, and monitoring for changes in frequency after corrective action was implemented. Although no permanent injury resulted from the 819 events, innovative mechanisms must be designed to prevent these errors, instead of relying on faulty informal checks to capture errors after they occur.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background
This report provides a comprehensive analysis of transfusion errors occurring at a large teaching hospital and aims to determine key errors that are threatening transfusion safety, despite ...implementation of safety measures.
Study Design and Methods
Errors were prospectively identified from 2005 to 2010. Error data were coded on a secure online database called the Transfusion Error Surveillance System. Errors were defined as any deviation from established standard operating procedures. Errors were identified by clinical and laboratory staff. Denominator data for volume of activity were used to calculate rates.
Results
A total of 15,134 errors were reported with a median number of 215 errors per month (range, 85‐334). Overall, 9083 (60%) errors occurred on the transfusion service and 6051 (40%) on the clinical services. In total, 23 errors resulted in patient harm: 21 of these errors occurred on the clinical services and two in the transfusion service. Of the 23 harm events, 21 involved inappropriate use of blood. Errors with no harm were 657 times more common than events that caused harm. The most common high‐severity clinical errors were sample labeling (37.5%) and inappropriate ordering of blood (28.8%). The most common high‐severity error in the transfusion service was sample accepted despite not meeting acceptance criteria (18.3%). The cost of product and component loss due to errors was $593,337.
Conclusion
Errors occurred at every point in the transfusion process, with the greatest potential risk of patient harm resulting from inappropriate ordering of blood products and errors in sample labeling.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
The Medical Event Reporting System for Transfusion Medicine (MERS-TM) collects, classifies, and analyzes events that potentially could compromise the safety of transfused blood to facilitate system ...improvement. This system is designed to collect data on near misses as well as actual events. Near-miss events are a valuable source of data because they occur more frequently than, but share many characteristics and causes of, actual events. Further, although most current reporting efforts describe only what has occurred with little attention to what caused the event, MERS-TM includes a standardized method of causal analysis. The standardization provided by MERS allows users to compare their experivided by MERS allows users to compare their experience with that of other organizations, which speeds learning across the entire transfusion medicine community. Important features of the MERS-TM system are that it is able to capture threats, hazards, near misses, injuries, and deaths; characterizes failures and recoveries systematically; identifies and provides causal codes for the entire range of system defects including technical, organizational, cultural, and human factors; raises staff awareness about error management; is easily integrated with existing quality assurance programs; has a consistent and straightforward classification method; enables compliance with mandatory Food and Drug Administration reporting and accreditation requirements; has features to deal with a high volume of reports; supplies Web-based training, data entry, and analysis; and provides comparative benchmarks from comparable institutions.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background: The MERS-TM assists hospital transfusion services to identify, analyze, and correct system events relating to the delivery of blood to patients.
Methods: The MERS-TM system was used from ...February of 1999 to December 2002. All reported near-miss and actual events were recorded and analyzed.
Results: During these 47 months, 4670 events were reported by the transfusion service. Of these events, 94% were classified as a near-miss event and 93% were detected before the blood product was administered. No ABO-incompatible transfusions were detected despite transfusion of 50,137 units of red blood cells. High severity events with the
potential for patient harm accounted for 241 (5%) of the 4670 events. Nursing related events accounted for 188 (78%) of the high severity events. In one out of 4430 (0.023%) samples tested, a high severity sample-testing event was detected. In one out of 1550 (0.06%) samples collected, a high severity sample-collection event was detected.
Conclusion: An event reporting system is essential if one is to determine where and how often events are occurring within the transfusion process.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The use of skin allografts to temporarily replace lost or damaged skin is practiced worldwide. Naturally occurring contamination can be present on skin or can be introduced at recovery or during ...processing. This contamination can pose a threat to allograft recipients. Bacterial culture and disinfection of allografts are mandated, but the specific practices and methodologies are not dictated by standards. A systematic review of literature from three databases found 12 research articles that evaluated bioburden reduction processes of skin grafts. The use of broad spectrum antibiotics and antifungal agents was the most frequently identified disinfection method reported demonstrating reductions in contamination rates. It was determined that the greatest reduction in the skin allograft contamination rates utilized 0.1 % peracetic acid or 25 kGy of gamma irradiation at lower temperatures.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
It has become increasingly apparent that publishing research on child development from certain countries is especially challenging. These countries have been referred to collectively as the Majority ...World, the Global South, non‐WEIRD (Western, Educated, Industrial, Rich, and Democratic), or low‐ and middle‐income countries. The aim of this paper is to draw attention to these persistent challenges, and provide constructive recommendations to contribute to better representation of children from these countries in child development research. In this paper, we outline the history of publication bias in developmental science, and issues of generalization of research from these countries and hence where it ‘fits’ in terms of publishing. The importance of explaining context is highlighted, including for research on measurement child development outcomes, and attention is drawn to the vicious publication‐funding cycle that further exacerbates the challenges of publishing this research. Specific recommendations are made to assist child development journals achieve their stated goals of creating a more inclusive, equitable, diverse, and global field of child development.
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T cell acute lymphoblastic leukemia (T-ALL) is an aggressive hematologic malignancy with inferior outcome compared with that of B cell ALL. Here, we show that Runt-related transcription factor 2 ...(RUNX2) was upregulated in high-risk T-ALL with KMT2A rearrangements (KMT2A-R) or an immature immunophenotype. In KMT2A-R cells, we identified RUNX2 as a direct target of the KMT2A chimeras, where it reciprocally bound the KMT2A promoter, establishing a regulatory feed-forward mechanism. Notably, RUNX2 was required for survival of immature and KMT2A-R T-ALL cells in vitro and in vivo. We report direct transcriptional regulation of CXCR4 signaling by RUNX2, thereby promoting chemotaxis, adhesion, and homing to medullary and extramedullary sites. RUNX2 enabled these energy-demanding processes by increasing metabolic activity in T-ALL cells through positive regulation of both glycolysis and oxidative phosphorylation. Concurrently, RUNX2 upregulation increased mitochondrial dynamics and biogenesis in T-ALL cells. Finally, as a proof of concept, we demonstrate that immature and KMT2A-R T-ALL cells were vulnerable to pharmacological targeting of the interaction between RUNX2 and its cofactor CBFβ. In conclusion, we show that RUNX2 acts as a dependency factor in high-risk subtypes of human T-ALL through concomitant regulation of tumor metabolism and leukemic cell migration.
ABSTRACT
Research in cognitive development has highlighted that early numeracy skills are associated with later math achievement, suggesting that these skills should be targeted in early math ...education. Here we tested whether tools used by researchers to assess mathematical thinking could be useful in the classroom. This paper describes a collaborative project between cognitive scientists and school board researchers/educators implementing numeracy screeners with kindergarten students over the course of three school years. The Give‐N task (Wynn, 1990) was used with first‐year kindergarten students and the Numeracy Screener (Nosworthy, Bugden, Archibald, Evans, & Ansari, 2013) with second‐year kindergarten students. Results indicated that educators (N = 59) found the tools feasible to implement and helpful for exploring their students' thinking and targeting instruction. The educators' feedback also helped inform improvements to the implementation of the tools and future directions for both the schools and the researchers. This work emphasizes the importance of transdisciplinary collaboration to address the research‐practice gap.
Lay
We investigated educators' experiences implementing numeracy assessment tools. Through a 3‐year collaboration between a research lab and school board, we learned that educators found the tools relatively easy to implement and useful for their teaching practice. Educator feedback was helpful for making improvements to the tools' implementation and future directions for the schools and the researchers. This work highlights the importance of collaboration between researchers and educators to address the gap between research and practice.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
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