[Professional-practice evaluation of the medical and nursing dysfunctions observed during the transfusion chain at the University Hospital of Brest].

The haemovigilance unit decided to set up since 2003 an evaluation of professional practices of blood transfusion chain from the prescription of blood products to the transfusion act and follow-up of receivers in several health care services. We have founded that the medical and nurse dysfunctions are the same in all cases. We have decided to analyze the causes of these dysfunctions and to propose actions to perform practices using a "problem-solving system model". We followed the next stages: (1) characterization of the problem in "QQOQCCP" form (What? Who? Where? When? How? How many? Why?), (2) analysis of the causes presented in Ishikawa's cause-and-effect diagram form and (3) search and selection of solutions of improvements.