 |
 |
 |
 |
 |
 |
 |
he Medical Event Reporting System for Transfusion Medicine (MERS-TM) is an event reporting system developed for transfusion services and blood centers to collect, classify, and analyze events that could potentially compromise transfusion safety.
MERS-TM provides the opportunity to study and monitor both actual and near-miss events to facilitate process improvement efforts.
MERS-TM will be most successful in organizations that provide a "just" safety culture which encourages event reporting while affording a safe environment in which to report. The goal is not to punish people for errors, but rather to prevent the events from recurring.
What is a medical event?
Why Is event reporting important?
Is medical event reporting mandatory?
Who manages the MERS-TM system?
How does MERS-TM work?
What data collection/analysis forms are used?
How would MERS-TM help my transfusion service/blood center?
Why should we adopt MERS-TM?How do I learn more?
What is a medical event?
A medical event refers to any error, incident, deviation, variance, or sentinel/adverse event related to blood components and transfusion procedures.
MERS-TM is designed to collect information on both near-miss and actual events. Near-miss events, which are more frequent, are a valuable source of data because they share many of the characteristics and causes of actual events. They present opportunities to learn from mistakes and improve the overall safety of the transfusion service.
Why is event reporting important?
The best way to prevent errors is to understand their real causes and learn from mistakes.
Industries such as aviation, nuclear power, and petrochemicals have established reporting systems to detect, prevent, and better manage error. Until now, there has been no standardized event reporting system in transfusion medicine for this purpose.
A system that detects events and analyzes their causes will facilitate the development of corrective actions to reduce future risk of harm.
Is medical event reporting mandatory?
On November 7, 2000, the U.S. Food and Drug Administration (FDA) published a final rule expanding the requirement for the reporting of errors and accidents in the manufacturing of biological products to include unlicensed registered blood establishments and transfusion services, in addition to licensed manufacturers.
The rule, effective May 7, 2001, requires that hospitals and blood centers maintain a method to report, investigate, and track errors and accidents.
MERS-TM, developed under a grant from the National Heart, Lung, and Blood Institute, meets and exceeds these requirements.
Who manages the MERS-TM system?
The MERS-TM project is primarily based at Columbia University, with Harold S. Kaplan, MD as the Principal Investigator.
Dr. Kaplan is Professor of Clinical Pathology at the College of Physicians and Surgeons of Columbia University, and Director of Clinical Laboratories, New York Presbyterian Hospital, Columbia-Presbyterian site. A graduate of Oberlin College, he earned his medical degree from The Albert Einstein College of Medicine. His postgraduate training in Pathology was at the Columbia-Presbyterian Medical Center. He has a long-standing interest in systems to prevent medical error.
The web-based MERS-TM reporting system is developed and maintained by Ron Levitan and Vincent Dobrev at the International Center for Health Outcomes and Innovation Research (InCHOIR) at Columbia University.
The project directors are Quay Mercer and Barbara Rabin Fastman. These are the individuals that you reach when you choose to "contact us" directly from this web site.
Quay Mercer, MT(ASCP), based at UT Southwestern, has been involved with the project since 1995. Her expertise in the project is related to the application of the event and causal codes, the building of causal trees, and in training others in the use of the event reporting system. Her research interest is the relationship between the success of event reporting programs and organizational safety culture.
Barbara Rabin Fastman, MS, MT(ASCP) BB is currently an Officer of Research at Columbia University. Previously she held the position of Director of Quality Assurance at the New York Blood Center. It was in that role that her interest and experience in event reporting systems began, as she was responsible for the organization’s incident reporting and management systems as well as the monitoring of corrective actions and continuous improvement efforts.
Other team members have expertise in the areas of data mining and case-based reasoning, statistics, informatics, adult learning, web site design, survey development and analysis, simulation models, organizational culture, and organizational behavior.
How does MERS-TM work?
The MERS-TM process includes the following steps:
- Detection: Identify, report, and record the event.
- Selection: Determine the extent of investigation needed.
- Investigation: Find out more about the context in which the event occurred, and conduct a root cause analysis, if necessary.
- Description & Classification: Assign standardized codes to describe the event and root causes.
- Computation: Analyze the aggregate data to identify patterns and trends.
- Interpretation: Use the results to guide organizational risk reduction efforts.
What data collection / analysis forms are used?
-
Event Discovery Report (pdf)
This form consists of two sections. The first section is designed to capture information about how the event was discovered and the immediate action taken. The second section captures preliminary information about the event itself.
-
QA SysOp Investigation Report (pdf)
This form captures both event and causal codes, as well as information on risk assessment and follow-up action taken.
-
MERS-TM Root Cause Analysis Report (pdf)
The causal "tree" that is a result of a root cause analysis is transferred onto this form to provide a computerized version of the information. The form also allows for a brief description of the consequent event, each antecedent event, and the root causes
How would MERS-TM help my transfusion service/blood center?
Incorporating MERS-TM into your present Quality Assurance and risk management units can:
- Provide valuable information for addressing system problems and reducing potential risk.
- Raise staff awareness that patient safety can be increased through event management.
- Increase an existing QA program's effectiveness without undue burden.
- Facilitate compliance with FDA mandatory reporting requirements.
Why should we adopt MERS-TM?
MERS-TM has already been successfully implemented in both hospitals and blood centers. It has adapted lessons learned about successful event reporting systems from other industries and applied them to the medical arena. This federally funded program is being disseminated at no charge by Columbia University under its NHLBI grant.
MERS-TM has developed many easy to use tools to facilitate the implementation, utilization, and success of the system in your establishment, no matter what size, including:
- Standardized error classification and event categories
- Tools to determine the potential risk of an event, extent of investigation necessary, and actions to be taken
- Guidelines for achieving a "just" organizational culture
- Standardized data collection forms
- Standardized root cause classification and analysis methodology
- Computerized query functions that identify similar events
- Standardized and user-defined reporting options.
In addition, the standardization provided by MERS-TM allows users to compare their experience with that of other organizations. Ultimately, this will promote learning across the entire transfusion medicine community.
How do I learn more?
To learn more about using MERS-TM for reporting events in transfusion medicine,
- Review the MERS-TM Online Tutorial.
- Check out the MERS-TM Reference Manual – read it online or print a copy.
- Find peer-review articles about MERS-TM.
- .
About MERS-TM | Training | Support / Materials | Database Functions | Articles/Links | How Do I Start? | Glossary
Site Index | Security/Privacy Policy | | Home
