Date of Graduation

Summer 8-11-2026

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

Kaiser cohort MSN capstone

First Advisor

David Ainsworth

Second Advisor

Sarah Horton-Deutsch, Ph.D, RN, FAAN,ANEF

Abstract

Abstract  

Problem: Inconsistent IV tubing labeling compliance on a telemetry unit was identified as a gap in central line maintenance practices that could affect adherence to the CLABSI prevention bundle.

Intervention: A quality improvement project reinforced existing IV tubing labeling practices through a visual job aid, staff education, and peer verification during Nursing Knowledge Exchange (NKE) bedside handoff.

Outcome Measure: The primary outcome measure was IV tubing labeling compliance, with a goal of increasing compliance from 86.5% to at least 95% on 24 bed Telemetry unit.

Results: The project did not achieve the desired improvement in compliance. Multiple concurrent quality initiatives, CMS-related action plans, competing organizational priorities, staff burnout, and change fatigue likely limited successful implementation.

Conclusion: Although the desired outcomes were not achieved, the project identified important barriers to practice change and reinforced the importance of organizational readiness, leadership support, and sustained staff engagement when implementing quality improvement initiatives to strengthen CLABSI prevention efforts.

Keywords: CLABSI, central line maintenance, IV tubing labeling, quality improvement, patient safety, Nursing Knowledge Exchange (NKE), evidence-based practice.

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