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Blood sampling: two sides to the story

Pickup, Laura; Atkinson, Sarah; Hollnagel, Erik; Bowie, Paul; Gray, Sandra; Rawlinson, Sam; Forrester, Kate


Laura Pickup

Sarah Atkinson

Erik Hollnagel

Paul Bowie

Sandra Gray

Sam Rawlinson

Kate Forrester


This study aimed to investigate why there is variability in taking blood. A multi method Pilot study was completed in four National Health Service Scotland hospitals. Human Factors/Ergonomics principles were applied to analyse data from 50 observations, 15 interviews and 12-months of incident data from all Scottish hospitals. The Functional Resonance Analysis Method (FRAM) was used to understand why variability may influence blood sampling functions. The analysis of the 61 pre blood transfusion sampling incidents highlighted limitations in the data collected to understand factors influencing performance. FRAM highlighted how variability in the sequence of blood sampling functions and the number of practitioners involved in a single blood sampling activity was influenced by the working environment, equipment, clinical context, work demands and staff resources. This pilot study proposes a realistic view of why blood sampling activities vary and proposes the need to consider the system’s resilience in future safety management strategies.


Pickup, L., Atkinson, S., Hollnagel, E., Bowie, P., Gray, S., Rawlinson, S., & Forrester, K. (2017). Blood sampling: two sides to the story. Applied Ergonomics, 59A,

Journal Article Type Article
Acceptance Date Aug 27, 2016
Online Publication Date Sep 14, 2016
Publication Date Mar 31, 2017
Deposit Date Sep 6, 2016
Publicly Available Date Sep 14, 2016
Journal Applied Ergonomics
Print ISSN 0003-6870
Electronic ISSN 1872-9126
Publisher Elsevier
Peer Reviewed Peer Reviewed
Volume 59A
Keywords Blood sampling, Wrong Blood In Tube, Resilience
Public URL
Publisher URL
Copyright Statement Copyright information regarding this work can be found at the following address:


Blood sampling Two sides to the story.pdf (453 Kb)

Copyright Statement
Copyright information regarding this work can be found at the following address:

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