Introduction
Blood and Body Fluid Exposures (BFFEs) involve a complex sequence of events combining technical, human and organizational factors. Performing root cause analysis (RCA) of these events is promoted to improve safety. We conducted a RCA of a BBFE in a radiology unit using a recently developed French method called Orion.
Objectives
The objective was to identify how the BBFE had happened and to implement actions to prevent its reoccurrence.
Methods
The starting point of the RCA was the report of a BBFE by a radiologist to occupational medicine. BBFE occurred during a non scheduled breast biopsy. Analysis was conducted in collaboration with occupational medicine and the Southwestern Centre for Healthcare Associated Infection Control. ORION comprises six steps: collecting data; rebuilding the chronology; identifying gaps; identifying contributing and influential factors; proposing actions to implement; writing the analysis report.
Results
The detailed chronology of events before, during and after the BBFE identified many gaps. The main influential factor was a sub-optimal organization during the breast biopsy: no protocol, inadequate room and time slot. Three corrective measures were retained: providing adequate safety container closer to the care procedure; providing adequate medical device to drag the carrot, reorganizing the care with an additionnal microbiopsy session close to RMI session.
Conclusion
This first use of the ORION method to analyse a BBFE proved successful. This method seems quasi-intuitive and easier to conduct than previously described methods because it relies on a detailed chronology. It allows the implementation of BBFEs preventive measures and promotes collaborative teamwork.
Disclosure of interest
None declared.