eHospital Safety Net ProgeHospital Safety Net Program: Defining the Transfusion Care Gap

The eHospital Safety Net Program is designed to remotely monitor gaps in adult patient care across the 21 hospitals in Northern California to reduce risk and prevent harm. A physician team identified transfusions as a care gap, however, the initial definition was broad and did not provide actionable data. This project used the PDSA model for change developed by W. Edward Deming, to test and refine the transfusion care gap definition. The eHospital team of nurses evaluated the frontline nursing documentation tool in the electronic medical record and developed a list of critical documentation items related to safe transfusion administration. A series of five PDSA cycles were conducted during February, 2015, to refine the critical items and standardize the care gap definition. As of April, all 21 hospitals were enrolled in the eHospital Safety Net Program. The preliminary results display the raw count for each critical item missing from frontline documentation. These results afford the adult care services team actionable data to assist in providing safe care. In addition, results can be used for comparison between hospitals for the purpose of identifying high performers and sharing knowledge on successful improvement strategies to benefit patients.