PATIENT SAFETY ARTICLE
October 7, 2024

So Many Barcodes, So Little Time: A Quality Improvement Project to Improve Scanning of Blood Product Bags

​​​​BIOGRAPHIES

Kelly O'Neill, MSN, RN, Mount Sinai Health System
Kelly O’Neill is an associate director of Nursing Informatics at Mount Sinai Health System with a robust background in medical-surgical nursing and over seven years of experience in nursing informatics. Dedicated to patient safety and workflow efficiency, O’Neill bridges clinical needs with information technology solutions to optimize electronic documentation and enhance care delivery. She holds a Master of Science in nursing (executive leadership) from Felician University and is committed to advancing nursing innovation and informatics to drive transformative change in healthcare.

Michelle Dunn, MSN, RN, Mount Sinai Health System
Michelle Dunn (michelle.dunn@mountsinai.org) is an accomplished healthcare professional with extensive experience in patient-centered care and nursing quality improvement within adult acute care settings. With a career spanning over four decades, Dunn has developed and led numerous initiatives to enhance patient safety, quality, and performance. Currently serving as the director of Nursing Quality Improvement at Mount Sinai Morningside and Mount Sinai West, Dunn excels in driving hospitalwide performance improvement and ensuring compliance with regulatory standards. Her expertise in nursing quality metrics, Lean Six Sigma Green Belt certification, and proficiency in data analysis and reporting have significantly contributed to improved patient outcomes and operational efficiency. She has master’s degree in nursing from the University of Phoenix and a bachelor’s from Long Island University.

*Corresponding author

Kathleen Parisien Dory, MA, RN, Mount Sinai Health System
Kathleen Parisien Dory is a director of Nursing Education, Professional Practice and Research at Mount Sinai Health System. She is a nurse leader with 25 years of experience in medical-surgical nursing, education, and professional practice. She is committed to high-quality patient care, implementation of evidence-based practice, and service excellence. She is recognized for being a strategic systems thinker, developing high-performing teams, executing large scale hospitalwide training and evidence-based solutions, and leading change at the system level. She holds a Bachelor of Arts from Mount Holyoke College and a Bachelor of Science and Master of Arts in nursing from New York University.


Abstract

Background
Incorrect administration of blood products is a critical concern, occurring once in every 12,000 units transfused in the United States. Blood product documentation and scanning are vital for patient safety, yet difficulties in scanning multiple barcodes on blood transfusion bags often lead to delays and the need for manual overrides.

Methods
This quality improvement project utilized the PDCA (Plan-Do-Check-Act) cycle of improvement to address blood product scanning in a 495-bed hospital in New York City.

Results
The scanning rate for blood products increased significantly from 69% in January 2021 to 96% in May 2021, representing a 39% improvement. Subsequently, increased compliance in 2022 demonstrated sustainment of best practices.

Conclusions
Implementation of the PDCA method led to increased compliance in scanning blood product bags following barcode scanner recalibration.

Visual abstract on So Many Barcodes.