A comprehensive assessment program to improve blood-administering practices using the FOCUS-PDCA model

BACKGROUND: The Joint Commission on the Accreditation of Healthcare Organizations requires that hospitals have a planned approach to systematically collect data on processes related to the use, ordering, and administering of blood components. This study describes how a comprehensive blood‐administering assessment program and the FOCUS‐PDCA approach improved overall blood‐administering practices. STUDY DESIGN AND METHODS: Nurses were trained to observe blood issuance, blood administering, and patient monitoring steps, and to audit patient's charts to measure compliance with blood‐ordering procedures. The observations were recorded on a standardized scannable form, which allowed automatic entry of recorded data directly into a computer database. RESULTS: A total of 982 assessments were completed during the 51‐month study period. Documentation of informed consent improved from 80 percent to 100 percent. Compliance with a California law that requires patients to receive information on the risks, benefits, and alternatives to transfusion rose from 30 percent to 100 percent. Physicians’ compliance in specifying the rate of blood administration improved from 30 percent to 100 percent, and verification of information on the patient's identification band with the patient's self‐identification rose from 50 percent to 100 percent. For all other blood‐administering steps, compliance remained high throughout the study period. For the past 9 months, 100‐percent compliance has been maintained for all transfusion processes, and during this period no mistransfusions or blood administration near‐misses have been reported. CONCLUSION: The blood‐administering assessment program described above has improved transfusion practice, reduced the number of near‐miss events, and may have prevented mistransfusions.