Date of Graduation

Summer 8-4-2026

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

Kaiser cohort MSN capstone

First Advisor

Cathy Coleman

Second Advisor

Sara Horton-Deutsch

Abstract

Problem

Effective debriefing following code blue events is a cornerstone of quality improvement (QI).  Following transition from paper-based to digital debrief documentation in a community hospital, significant breakdowns occurred in code blue workflow.  The QI department was inadvertently omitted from the process, leaving the Code Blue Committee and unit teams without actionable data and feedback.

Context

A QI project was implemented over 4 months in the adult ICU.  House Supervisors and Assistant Nurse Managers are primary facilitators of debriefs.  A baseline survey of nursing leadership (n=23) identified three barriers: competing priorities (68.5%), unclear role expectations (43.4%), and limited administrative follow-up (52.2%).

Interventions

Utilizing two change-management frameworks, a redesigned workflow was developed, including a standardized digital debrief tool with QR code access, targeted education using a new flowchart and updated procedure for reporting findings to frontline staff.

Measures

Monthly submission rates included a target of ≥80% and form completion times less than 12 minutes.  Pre/post leadership surveys (n=23) addressed levels of comfort and confidence.

Results

Submission rates increased from 42% to 75% after implementation.  Median form completion time was 9.1 minutes across 16 submissions.  Levels of leadership confidence and comfort increased from 69.5% to 81.8%.

Conclusions

A standardized digital debriefing workflow improved submission rates without significant staff burden.  Clearly, debriefing frequency alone does not improve resuscitation outcomes; most essential is organizational data sharing and communication among microsystems.  This project reinforced that code blue events become not only occasions for reflection, but also reliable drivers of learning and improvement across healthcare systems.

Download

To download restricted works from off campus you must have a USF email address and use it to create an account for the repository.

  Contact Author

Share

COinS