I have been reading about error prevention and creating an environment conducive to risk assessment and self reporting. Our institution uses the Just Culture algorithm. I am curious as to how many others are using this. One of the premises of this program is that 'to err is human' and that to expect perfection is unrealistic. However, it is incumbent upon management to create a system that is as fail-safe as possible. So where is the line between personal responsibility and system failure? 2 situations that I have encountered recently were: 1) expired antisera was used and 2) no crossmatch was done subsequent to an emergency release. The only way this is caught is on work review. How far do folks go to try to put stop-gap measures in place to prevent errors? The form error has only happened once in 2 and half years but the 2nd one has happened 2 or 3 times for sure. Thanks for your input!