Root cause analysis of an aberrant thromboelastogram tracing – Lessons learnt
Thromboelastography is a viscoelastic test which uses whole blood sample for routine coagulation screening purpose. Even though it is an easy procedure, many critical steps affect the final result of the test and we describe such an incident in this report. The root cause analysis of two aberrant TE...
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Wolters Kluwer Medknow Publications
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doaj-bbca3aa9cda84b8989b1e70684ba32ad2020-11-25T02:58:12ZengWolters Kluwer Medknow PublicationsGlobal Journal of Transfusion Medicine2468-83982455-88932020-01-0151808310.4103/GJTM.GJTM_73_19Root cause analysis of an aberrant thromboelastogram tracing – Lessons learntGanesh MohanShamee ShastryDhivya KandasamyP A PrethikaChenna DeepikaThromboelastography is a viscoelastic test which uses whole blood sample for routine coagulation screening purpose. Even though it is an easy procedure, many critical steps affect the final result of the test and we describe such an incident in this report. The root cause analysis of two aberrant TEG reports on two different occasions was initiated; the tracing initially was normal but developed an abnormal pattern toward the middle portion. The graph suddenly dropped to the baseline and from there, it was demonstrating an abnormal pattern. This can be due to power failure, vibrations during the test, cup dislodging from the pins during run, no validation prior to each test, and out of calibration. The root cause was identified as improper fixing of cups and pins leading to dislodging from the pins during the run and prevention of such incidents can be achieved by individual training of the staffs and periodical evaluation of their competency.http://www.gjtmonline.com/article.asp?issn=2468-8398;year=2020;volume=5;issue=1;spage=80;epage=83;aulast=Mohancoagulationhemostasisquality assuranceroot cause analysisthrombelastography (teg) |
collection |
DOAJ |
language |
English |
format |
Article |
sources |
DOAJ |
author |
Ganesh Mohan Shamee Shastry Dhivya Kandasamy P A Prethika Chenna Deepika |
spellingShingle |
Ganesh Mohan Shamee Shastry Dhivya Kandasamy P A Prethika Chenna Deepika Root cause analysis of an aberrant thromboelastogram tracing – Lessons learnt Global Journal of Transfusion Medicine coagulation hemostasis quality assurance root cause analysis thrombelastography (teg) |
author_facet |
Ganesh Mohan Shamee Shastry Dhivya Kandasamy P A Prethika Chenna Deepika |
author_sort |
Ganesh Mohan |
title |
Root cause analysis of an aberrant thromboelastogram tracing – Lessons learnt |
title_short |
Root cause analysis of an aberrant thromboelastogram tracing – Lessons learnt |
title_full |
Root cause analysis of an aberrant thromboelastogram tracing – Lessons learnt |
title_fullStr |
Root cause analysis of an aberrant thromboelastogram tracing – Lessons learnt |
title_full_unstemmed |
Root cause analysis of an aberrant thromboelastogram tracing – Lessons learnt |
title_sort |
root cause analysis of an aberrant thromboelastogram tracing – lessons learnt |
publisher |
Wolters Kluwer Medknow Publications |
series |
Global Journal of Transfusion Medicine |
issn |
2468-8398 2455-8893 |
publishDate |
2020-01-01 |
description |
Thromboelastography is a viscoelastic test which uses whole blood sample for routine coagulation screening purpose. Even though it is an easy procedure, many critical steps affect the final result of the test and we describe such an incident in this report. The root cause analysis of two aberrant TEG reports on two different occasions was initiated; the tracing initially was normal but developed an abnormal pattern toward the middle portion. The graph suddenly dropped to the baseline and from there, it was demonstrating an abnormal pattern. This can be due to power failure, vibrations during the test, cup dislodging from the pins during run, no validation prior to each test, and out of calibration. The root cause was identified as improper fixing of cups and pins leading to dislodging from the pins during the run and prevention of such incidents can be achieved by individual training of the staffs and periodical evaluation of their competency. |
topic |
coagulation hemostasis quality assurance root cause analysis thrombelastography (teg) |
url |
http://www.gjtmonline.com/article.asp?issn=2468-8398;year=2020;volume=5;issue=1;spage=80;epage=83;aulast=Mohan |
work_keys_str_mv |
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