Blood-error reporting system tracks medical mistakes

November 18, 1999

DALLAS - November 19, 1999 - When a hospital employee's error results in a patient's death, it's news. But when an error is caught before something bad happens, it's not news.

A group of UT Southwestern Medical Center at Dallas and Columbia-Presbyterian Medical Center researchers, however, thinks that every mistake, even those caught before tragedy, provides important lessons that could prevent the next headline.

The Medical Event Reporting System for Transfusion Medicine, MERS-TM, is a UT Southwestern- and Columbia-based, National Institutes of Health-funded project that seeks to stop blood- transfusion errors before they happen.

Dr. James Battles, professor of biomedical communications, oversees the project at UT Southwestern in the Office of Medical Education.

Battles said there are 46,000 deaths due to auto accidents a year. But it is estimated 180,000 people die each year due to medical error, some of which are blood transfusion errors.

"We want to identify how to prevent these deaths," Battles said. "We want to find and reduce patient risk."

With a $4 million grant over the next four years, the research team is working with several affiliated organizations -- including Parkland Health & Hospital System, Carter Bloodcare and the American Red Cross -- to track transfusion error through a no-fault, standardized reporting system. After testing the model in a small prototype, the group recently began testing it nationally through organizations such as the Red Cross. The project has caught the attention of Congress and the Surgeon General.

"There has not been a study of this scope in medicine," Battles said. "The whole purpose is to save as many lives as possible."

Doctors, nurses and other health-care personnel involved in transfusion errors or near misses report the problems within their local organizations, which then transfer their data to the MERS-TM team.

"Fatal accidents get our attention because they are a rare event," Battles said. "But for every accident, there are many, many near misses."

By tracking and comparing the near misses, the team hopes to learn how the errors and near errors are happening. For example, by analyzing near misses at one clinic, researchers learned some patients were using false identification to receive medical attention.

Most hospitals already track such errors, but Battles said hospital personnel often do not report near misses in order to avoid punishment. In the new reporting model, those who file reports are not punished.

"The problem is that not reporting the event doesn't reduce the risk," Battles said. "The more information we have, the more likely it is we can prevent the event."

Another goal of the program is to standardize transfusion-reporting systems nationwide. Currently, every organization has its own reporting system.

"That makes it very difficult to trend and track the events," said Quay Mercer, research study coordinator at UT Southwestern. "The completed reports are filed, and the information is not used. We want to create a nationwide databank where information can be stored and easily analyzed."

Such nationwide systems have long been in place in other potentially risk-prone fields like aviation. Ultimately, UT Southwestern researchers said, they hope the MERS-TM project will encompass all transfusion services and blood centers and eliminate common errors. This news release is available on our World Wide Web home page at

To automatically receive news releases from UT Southwestern via e-mail, send a message to Leave the subject line blank and in the text box, type SUB UTSWNEWS

UT Southwestern Medical Center

Related Medicine Articles from Brightsurf:

An ultrasonic projector for medicine
A chip-based technology that modulates intensive sound pressure profiles with high resolution opens up new possibilities for ultrasound therapy.

A new discovery in regenerative medicine
An international collaboration involving Monash University and Duke-NUS researchers have made an unexpected world-first stem cell discovery that may lead to new treatments for placenta complications during pregnancy.

How dinosaur research can help medicine
The intervertebral discs connect the vertebrae and give the spine its mobility.

Graduates of family medicine residencies are likely to enter and remain in family medicine
This study provides an overview of the characteristics of physicians who completed family medicine residency training from 1994 to 2017.

Nuclear medicine and COVID-19: New content from The Journal of Nuclear Medicine
In one of five new COVID-19-related articles and commentaries published in the June issue of The Journal of Nuclear Medicine, Johnese Spisso discusses how the UCLA Hospital System has dealt with the pandemic.

Moving beyond 'defensive medicine'
Study shows removing liability concerns slightly increases C-section procedures during childbirth.

NUS Medicine researchers can reprogramme cells to original state for regenerative medicine
Scientists from NUS Medicine have found a way to induce totipotency in embryonic cells that have already matured into pluripotency.

Protein injections in medicine
One day, medical compounds could be introduced into cells with the help of bacterial toxins.

Study reveals complementary medicine use remains hidden to conventional medicine providers
Research reveals that 1 in 3 complementary medicine (CM) users do not disclose their CM use to their medical providers, posing significant direct and indirect risks of adverse effects and harm due to unsafe concurrent use of CM and conventional medicine use.

Study of traditional medicine finds high use in Sub-Saharan Africa despite modern medicine
Researchers who have undertaken the first systematic review of into the use of traditional, complementary and alternative medicines (TCAM) in Sub-Saharan Africa found its use is significant and not just because of a lack of resources or access to 'conventional medicine'.

Read More: Medicine News and Medicine Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to