Date of Graduation
Master of Science in Nursing (MSN)
School of Nursing and Health Professions
On a 28 bed post-surgical unit, reviewing patient records revealed only 26% had thorough patient controlled analgesia (PCA) documentation. A pre-quiz no staff knew all of the required components for documentation or which policies to reference and, on average, the staff were only able to correctly answer 30% of the questions. Therefore, a project utilizing the clinical nurse leader improvement theme of clinical outcomes management was initiated to standardize the documentation of PCA medication administration to improve post-operative pain management, improve patient satisfaction, and improve patient safety.
The current process was determined using a fishbone diagram, a SWOT analysis was conducted to maximize the strengths and opportunities and minimize the weaknesses and threats, in-services were provided, and individual feedback was given as needed. Copies of policy TX-35: Pain Management, the Pain Reassessment policy, the PowerPoint, and quick reference guides on clearing the shift totals and retrieving cleared data were provided to staff.
After the in-services, the nursing staff answered 84% of the quiz questions correctly and chart reviews revealed a documentation compliance of 60%. These results demonstrated an increased awareness of facility policy. Furthermore, 100% of the staff stated they were clear on the requirements of pain documentation.
West, Collyn, "The Development of Standardized Patient Controlled Analgesia Documentation to Improve Patient Care" (2016). Master's Projects and Capstones. 278.