What Went Wrong? A Quiz and Interactive Presentation
Program Code: 9110-QE
Saturday, October 24, 2009
10:30 AM to 12:00 PM (ET)

MODERATOR
Visalam Chandrasekaran, MD, New York Blood Center, New York

SPEAKERS
Visalam Chandrasekaran, MD, New York Blood Center, New York
Eldad Hod, MD, NY Blood Center
Vivien Powell, MSc, FIBMS, NYBC

DESCRIPTION
This session is designed to give a brief overview of Quality System Essentials in a transfusion service setting followed by case presentations. This will involve audience participation to determine what went wrong, to identify the root and contributing causes and to discuss how best to prevent these errors in the future. Following the case reviews, a brief presentation will focus on how to include and involve the staff in error detection and prevention processes and how to change the staff mindset to target 'error' as the common enemy instead of the person who made or identified the error. The goal is to mobilize individual responsibility and to form collective responsibility as we work towards improving quality and thus patient care.