Date of Graduation

Spring 5-19-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


By far the greatest risk to patients is human error; receiving the wrong blood component or one that is not compatible. A fatality subsequent to a blood transfusion is a devastation one cannot quantify. Blood transfusions are a routinely performed life saving intervention in the inpatient acute care hospital setting. Although blood transfusions can be extremely beneficial when delivered correctly, the risks associated with receiving incorrect blood components are severe and potentially fatal. The blood component administration process in the inpatient acute care hospital setting is dependent upon the systematic function of both communication and interaction technology. Therefore, the Institute for Healthcare Improvement’s Idealized Design of Clinical Practice (IDCOP) program (IDCOP), Interaction, provided the clinical framework for this project. A mixed closed, thirty-four bed critical care unit, was utilized for this project, which presented many opportunities to evaluate and trial the blood component administration process. Lewin’s change theory, unfreeze, move, and refreeze provided the methodology for this project. We determined, enhanced communication was needed and implemented a checklist to be dispensed along with the blood component to assist healthcare workers in completing all steps in the process. Real time audits were conducted of dispensing, administering, and monitoring of blood components after administration, yielding quantitative data for further analysis. Multiple PDSA’s were conducted each time the checklist was revised and implemented.

A transfusion navigator was put into the electronic charting system to assist healthcare workers with the steps associated with blood component administration. To aid in sustainability a teach-back process to confirm competency was implemented for nurses to be initiated in the event of fallouts or errors improve knowledge retention and improve outcomes. The interventions put in place during this project were both effective and sustainable as the goal to reduce blood component administration errors by 50% by the end of the first quarter of 2016 was attained and the new process has been included in new policies.