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Course Project

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Critical actions carried out by health care providers to prevent health care errors include accurate patient identification and blood specimen labeling. With a goal of zero harm, improperly identified blood specimens drawn by nurses employed in the acute care setting and Emergency Department at Albert Einstein Medical Center Philadelphia were tabulated and revealed labeling errors. The Nursing Department launched a rapid improvement nurse education plan that resulted in decreased specimen errors compared to baseline counts and suggested the need to sustain error reduction strategies. This initiative was followed by the creation of a policy- and evidence-based checklist and its associated implementation process that built on targeted blood and blood bank blood specimen labeling error reduction strategies and might sustain specimen error reductions. This doctoral project created a policy-based checklist for bedside nurses and a process improvement team-supported sustainability process improvement plan oriented in content analysis of empirical and theoretical literature on blood specimen errors and sustainability of quality improvement strategies. Long-term sustainability will be evaluated following continuation of the previous initiative and implementation of the sustainability process improvement plan.



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