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Learning Objective 1: The learner will be able to identify vulnerabilities, “perfect” performance and adherence to regulations and policies across the care continuum.
Learning Objective 2: The learner will be able to discuss steps in developing culture change supporting individual professional accountability and healthcare system performance.
Practitioners often perceive care delivered as “excellent” whereas a regulatory agency expects “perfect” care. “A perfect storm is a convergence of independent events that form an environment never experienced before” (Fields, 2006). Three prevailing winds or barriers to exemplary blood and blood product administration practice, “failure to see,” “failure to move,” and “failure to finish” converged to create the perfect storm that threatened our culture of excellence (Kerfoot, 2010).
Materials and Methods
Evidence supporting “perfect” blood product administration practice was collected during a 24 week period. An organizational culture of transparency broke through staff “failure to see” the need for change. Clinical audits mitigated “failure to move” by making the “perfect” clinical practice destination clear for all departments. Audits created movement to ensure staff adhered to the “no failure” regulatory and professional blood administration standards related to consent, verification, documentation, teaching and adverse reactions (Patel, 2010). Fatigue inherent to “failure to finish” was diminished through motivating and energizing champions of change placed to reinforce, encourage and reward professional accountability.
Results
Sixteen patient care areas audited 100% (n = 2638 units) of blood products administered for adherence to regulatory standards between June 11 and December 1, 2010. “No failure” or “perfect” care was no deviation from regulatory standard without exception. “Perfect” care was hardwired and enculturated into clinical practice by week 18.
Conclusions
A “perfect storm” environment brought about redesign of leadership roles, performance measures and professional accountability. Utilization of a detailed audit strategy led to a no-fail practice culture and global improvements in blood administration safety throughout a healthcare system.
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