2020 Annual SHOT Report supplementary information - Chapter 8: Human Factors (14 July 2021)

Summary

Serious Hazards of Transfusion (SHOT) introduced a new Human Factors Investigation Tool (HFIT) in 2021. The tool can be used to investigate and capture systemic as well as individual factors where there has been an error.

This case study uses the updated Human Factors Investigation Tool and Systems Engineering Initiative for Patient Safety (SEIPS) framework to work through an ABO incompatible red cell transfusion case reported to SHOT.