Date of Graduation

Summer 8-16-2022

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Dr. Sara Horton-Deutsch

Second Advisor

Dr. Cathy Coleman



Problem: Improvement in the donor bank milk (DBM) administration workflows is required to reduce documentation errors and discrepancies. Increased awareness of errors and their impact on quality, safety, and risk management is imperative to optimize clinical, operational, and financial outcomes, as well as a hospital’s reputation.

Context: Research shows human milk is beneficial to the growth of premature and medically-diagnosed term infants. Regulatory agencies recommend standards and guidelines to handle human milk and to monitor compliance and safety practices of healthcare organizations.

Intervention: An audit tool and process map were created to internally monitor the current process for DBM administration.

Measures: The process measures focused on decreasing errors and discrepancies in DBM documentation. For example, the DBM inventory log and the patient electronic medical record. The target goal aimed to decrease errors and discrepancies in documentation by 25%, from 6.75 to 5.00 errors per month.

Conclusion: Evidence shows administration and handling of DBM to be complex, but steps to simplify the process can help prevent errors. Information from the audit tool, staff survey, and unit policy and procedures was useful in creating a process map as a staff reference tool. DBM process map implementation resulted in a 20% decrease in errors, with 5.5 errors in June 2022. The detailed and evidence-based tool is recommended for nursing staff to utilize as a guide for best practice.

Available for download on Thursday, August 08, 2024

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