Date of Doctor of Nursing Practice Project Completion

Summer 2025

Faculty Advisor

Dr. Rashmi Momin

Abstract

Purpose/Background: Underreporting of occupational bloodborne pathogen (BBP) exposures remains a significant patient and employee safety issue. At UT Health, outdated paper-based systems hindered accurate tracking, timely follow-up, and reporting compliance. The aim of this quality improvement (QI) project was to achieve a 30% increase in quarterly BBP exposure reports, from 30 to 39, by implementing an electronic reporting system between January 1 and March 31, 2025.

Methodology: Guided by the Health Belief Model and using the Implementation and Improvement Science (IIS) Framework, the project replaced the existing paper form with an external, user-friendly digital system. Staff received structured training, and standardized protocols for post-exposure prophylaxis (PEP) and follow-up care were developed. Data collection included pre- and post-implementation report volume, reporting timeliness, and employee satisfaction surveys. Quantitative analysis included descriptive statistics and time-series comparisons; qualitative feedback was reviewed thematically. Limitations included temporary workflow disruption and challenges integrating external data sources.

Results: Preliminary findings showed a 100% increase in BBP reports in Q1 2025 compared to the same period in 2024, exceeding the initial aim. Early improvements were also noted in timeliness of reporting and expected adherence to follow-up care. Staff feedback indicated high satisfaction and engagement with the new system.

Implications for Practice: Electronic reporting significantly improved reporting compliance and identified previously unreported exposures. This project underscores the importance of streamlined systems, staff education, and leadership support in sustaining safety practices. Future work will focus on EMR integration and long-term monitoring of adherence outcomes.

Keywords

Bloodborne pathogens, Occupational exposure, Electronic reporting systems, Health Belief Model, Quality improvement, Reporting compliance, Post-exposure prophylaxis, Implementation and Improvement Science Framework, Employee safety, Workflow integration

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