According to Shi et al. (2022), many past blood transfusion errors were in part related to human error, meaning it used to be that most errors were an individual’s performance error, however, to reduce these errors new systems have been developed to create fewer user errors with the use of barcodes leading to more system errors. According to Aly et al. (2020), the system for preventing blood administration errors starts with physician orders and can continue to any part of the process from transportation, checking practice, nursing practice during preparation and administration, and finally to improper monitoring. As a nurse manager it is important to identify the part of the system where errors are occurring and according to Hollingsworth and Reynolds (2020), the strengths, weaknesses, opportunities, and threats (SWOT) analysis tool can be helpful to identifying critical internal and external problems. SWOT calls for the user to identify how the system performs well or could perform better, what parts of the system are prone to error, the role the individual plays within the system and how processes can be carrier out better, and what potential external factors an individual can be facing while operating within the system. As a nurse manager, one would identify what piece of the system needs improvement or iteration, for example if provider orders were not being entered correctly, whether the provider requires education on order sets or if nurses are entering orders for the provider incorrectly. Necessary steps would be taken to reduce user error by working closely with the information technology department to streamline blood ordering processes while education provided to both nursing and physician staff the importance of provider entered orders. According to Aly et al. (2020), periodic training about blood administration protocols and procedures proved to be an effective method of reducing blood administration errors.

Aly, N., El-Shanawany, S., & Ghoneim, T. (2020). Using Failure Mode and Effects Analysis in Blood Administration Process in Surgical Care Units: New Categories of Errors. Quality Management in Health Care, 29(4), 242–252. https://doi-org.lopes.idm.oclc.org/10.1097/QMH.0000000000000273

Hollingsworth, A., & Reynolds, M. (2020). The ed nurse manager’s guide to utilizing SWOT analysis for performance improvement. Journal of Emergency Nursing, 46(3), 368–372. https://doi.org/10.1016/j.jen.2020.02.006

Shi, Y., Ye, C., Wang, H., Cao, D., Liu, M., Xu, J., Yang, R., Shen, L., Liu, G., & Zhai, X. (2022). The impact of a closed-loop electronic blood transfusion system on transfusion errors and staff time in a children’s hospital. Transfusion Clinique et Biologique, 29(3), 250–252. https://doi-org.lopes.idm.oclc.org/10.1016/j.tracli.2022.03.004