In the immediate wake of a CMS investigation, all aspects of blood administration were evaluated to ensure the safety of patients during the blood transfusion. The Clinical Informatics department developed a multi-phased strategy to address the workflow concerns and implement changes before a full CMS survey. Blood Administration and documentation within an Electronic Medical Record provides a number of safety features including barcode technology and decision support. While there is evidence to support the efficacy of these tools, evidence on the bedside practices and humanistic factors are not well documented.  The event revealed a closer examination of bedside practices which warranted the needs to make modifications of the system. Coupled with leadership support, this yielded an increase in  blood administration documentation compliance.