Blood productadministrationis a safety critical, complex dynamic sociotechnicalprocess. This study aimsto combinelean analysis with Functional ResonanceAnalysis Method to understand blood product administration at a large pediatric health system. We identified a number of resonance phenomenon and variabilitywithin functionsthat can lead to waste in the process.The results from the study can help with process simplification and developing interventions to reduce safety risks associated with transfusion.
Get full access to this article
View all access options for this article.
References
1.
Carter-GrahamS.TuckleyV.FlannaganJ.BakerP.Mark BellamyP.BentleyA.BirchallJ.Bolton-MaggsP.BoothC.BrailsfordS.DiamondP.ClarkeH.DanaeeA.DaviesJ.GreyS.HarvalaH.HaynesS.KellyA.LathamT. … Barbara FounderMember John Lumley J. (2020). Annual SHOT Report 2020. https://www.shotuk.org/wpcontent/uploads/myimages/SHOT-REPORT-2020.pdf
2.
DamenN. L.de VosM. S.MoeskerM. J.BraithwaiteJ.de Lind van WijngaardenR. A. F.KaplanJ.HammingJ. F.Clay-WilliamsR. (2021).Preoperative Anticoagulation Management in Everyday Clinical Practice: An International ComparativeAnalysis of Work-as-Done Using the FunctionalResonance Analysis Method. Journal of Patient Safety, 17(3), 157–165. https://doi.org/10.1097/PTS.0000000000000515
3.
De CarvalhoP. V. R. (2011). The use of FunctionalResonance Analysis Method (FRAM) in a mid-air collision to understand somecharacteristics of the air traffic management system resilience. Reliability Engineering & System Safety, 96(11), 1482–1498. https://doi.org/10.1016/J.RESS.2011.05.009
4.
ErikH. (2017). FRAM: The Functional Resonance AnalysisMethod: Modelling Complex Socio-technical Systems.FRAM: The Functional Resonance Analysis Method. https://doi.org/10.1201/9781315255071
5.
LeeJ.ChungH. (2018). A new methodology for accidentanalysis with human and system interaction based on FRAM: Case studies in maritime domain. Safety Science, 109, 57–66. https://doi.org/10.1016/J.SSCI.2018.05.011
6.
LundbladK.SpezialiJ.WoltjerR.LundbergJ. (2008).FRAM as a risk assessment method for nuclear fuel transportation. Proceedings of the 4th International Conference Working on Safety, 1, 221–223.
