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Root Cause Analysis for identified cases of wrong blood in tube (WBIT)

A transfusion medicine physician in the Midwest asks if it is standard practice to perform a Root Cause Analysis for identified cases of wrong blood in tube (WBIT). Do the FDA, CAP, AABB and/or JCAHO expect that such an analysis be done?

ADDENDA June 17, 2008

1. According to Michael Breard, the AABB's Division Director of Consulting Services (attribution used with permission), it is not so much a matter of who might or might not require a root cause analysis to solve a problem, it is more an issue of common sense. Mr. Breard asks "How do you know what to 'fix' if you don't perform a root cause analysis?" He adds, "too frequently, solutions to a problem not properly identified only 'fix' symptoms and not the real problem (root cause). By some means the true root cause must be identified, a solution applied and the result tracked to assure that it truly fixed the problem."

 

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator

W. Tait Stevens, MD
CBBS e-Network Forum Assistant Editor & Moderator
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Posted: June 16, 2008

Addenda: June 17, 2008

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