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ORION, a new method for root cause analysis of blood and body fluid exposures

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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.

Author information

Correspondence to C Bervas.

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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Keywords

  • Time Slot
  • Occupational Medicine
  • Organizational Factor
  • Breast Biopsy
  • Complex Sequence