Alleviating Error During the Blood Administration Process in the Clinical Setting

The ability to safely administer blood products to patients, relies on the knowledge of the clinical staff and the accuracy of the electronic medical administration record (EMAR) (Lotterman & Sharma, 2023). EMARs streamline real time clinical documentation, deploy safety checks, and allow health care workers to better care for patients (Lotterman & Sharma, 2023). A hospital in the intermountain west was seeing incidences of documented errors in barcode scanning during the blood administration process. These errors were causing nurses to improvise during the blood administration process to administer blood products, while still performing all the needed safety checks. There was no standardized workflow for administering blood without the use of scanning, deeming this a need to maintain safety during the blood administration process. Nursing staff plays a key role in improving and maintaining patient safety surrounding blood administration. Secondary to nursing, the safety checks of an EMAR act as a second set of eyes to ensure that patient safety standards are being followed. Methods: A quality improvement project was developed to review and analyze RL6 error reports surrounding blood product administration in the clinical setting. The topic of focus of the reviewed RL6 reports was errors involving the scanning process of blood products when being administered to patients by bedside registered nurses. The data from the errors' reports were reviewed and scanning errors were isolated. The causes of the scanning errors were then analyzed, and results were distinguished based on categories of cause. Top areas of improvement were then isolated and education for nursing staff was developed to assist in the navigation of these scenarios. This education was evaluated for its effectiveness by end users and then analyzed. Results: After distribution of the workflow, LMS module, and survey, the data was collected. An insufficient number of surveys were completed to draw any meaningful conclusions to the workflow's effectiveness. Ten total surveys were distributed to registered nurses in the inpatient setting, and only two were received back for analysis. Surveys were analyzed for user feedback and functionality of the workflow. Conclusions: Due to the insignificant amount of feedback received from end users, adequate conclusions could not be established to evaluate the workflows effectiveness. Further distribution of surveys and analysis of the results need to be completed to determine the effectiveness of this standardization process. Further analysis of RL6 error reporting must also be done to continue to track these errors and the number of their occurrences.