Table 4.

Interventions to Improve the Process of Nursing Blood Sampling Process

Theme	Intervention	Targeted Failure Modes
Process and Responsibility Modifications	The assigned nurse becomes responsible for many steps in the preparation phase (2nd phase)	Missed test and Informing wrong information
	Single Piece Flow was utilized instead of batch Flow.	Missed test, and Wrong patient and test
Resource and Information Technology Utilization	A new report was designed in the electronic medical records to determine pending blood sampling orders	Missed test, and Wrong patient and test
	Using one printers in each nursing station for printing the labels	Wrong patient and test
Patients and Families Engagement	Patient and family education about sampling process and time and important of their engagement in the process to prevent errors and ensure providing care according their preferences	Wrong patient
Safety Culture	Reporting the event report and near miss error related to blood sampling	All failure modes
	Good catch award
	Tracking the errors through adoption of new indicators named “ Blood sampling mixed up” and “ Nursing Blood sampling Errors”.
	Regular nursing quality rounds
Education and Training	Providing nursing education about the new process for new and old nurses.	All failure modes
	Training nursing using simulation lab approach.
	Nursing Guideline in Phlebotomy /Reanimation was developed