Once again I am sharing an anonymised report with the agreement of the reporting hospital as a good example of what can be achieved with a thorough investigation. I'm not posting this as an example of how to investigate the issue of non-irradiated blood as such, but the investigation not only identified members of staff needing to take personal responsibility for their actions, but more importantly recognises areas where the QMS can be improved.

In the report, it identifies a member of staff who'd recently returned to work, but was having to deal with significant personal issues which might affect their ability to work. Although the QMS had recognised this in advance of the error, and adjustments made, an error was still made. Rather than making the staff solely responsible for the error, the investigators recommended improvements to the "back-to-work" process they had developed.

Additionally, the investigation recognised that issues regarding reagent supply earlier in the week and caused a backlog in testing which had increased the workload. Again, measure were taken to address this instead of holding a different member of staff solely responsible.

Everyone needs to take personal responsibility for their actions, but staff should not be made to feel guilty falling victim to human factors. Always seek to improve your QMS to learn and prevent future errors.

DWI-110149 Near Miss irradiated incident report Anonymous.doc