The application of human factors to the blood transfusion process

There are serious safety problems in blood transfusion and a Human Factors (HF) approach has great potential to address these safety issues, but has so far been underutilised. The overall aim of the PhD is to investigate how HF could contribute to improvements for the safety of patients receiving a blood transfusion. The main objectives are to apply and evaluate HF-based methods that could improve transfusion safety and in particular to introduce an enhanced learning process by using HF-based reporting of adverse transfusion incidents and a Safety II-based resilience assessment of the transfusion process in UK hospitals. This thesis attempts to address the following three questions in three studies:(1) What can we learn about human and organisation factors contributing to transfusion incidents and near misses from the existing incident database? (2) Can incident reporting be improved using a newly created human factors investigation tool (HFIT) combined with educational interventions? (3) Can a Safety-II approach improve clinical audit and maximise system resilience throughout the end to end blood transfusion process? [Continues.]