Date of Graduation

Winter 12-16-2022

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Dr. Nneka Chukwu, DNP-HCSL, MBA, RN, CLNC


Problem: United States Pharmacopeia (USP) developed a set of standards to minimize exposure risks to patients, healthcare workers, and the environment when preparing, handling, and administering hazardous drugs (HDs) known as USP <800> HDs. The guidelines became effective December 1, 2019, but additional information is needed to ensure healthcare personnel are complying with the standards.

Context: Two medical surgical units from Hospital A were included in this project. Currently mandatory online modules about USP <800> standards are provided annually to every healthcare worker, but it is unknown if the policies and procedures are being followed appropriately.

Interventions: Active and passive observations as well as inspections were used to compile data regarding the compliance of USP <800> standards of both healthcare workers and within the hospital setting. Surveys were conducted through informal ‘elbow-to-elbow’ interviews with hospital employees, primarily nurses, to collect subjective evidence.

Measures: The measures can be divided into two categories: personnel and atmosphere compliance. Measures to determine personnel compliance include determining a current level of knowledge and comfortability, collecting self-reported compliance to the standards, and observing personal protective equipment (PPE) donning and doffing techniques. Atmosphere compliances are measured by calculating the total number of patients taking USP <800> HDs, evaluating the accuracy and efficiency of notifications in the electronic health record (EHR), documenting the frequency of correctly displayed signage on patient doors, and assessing supplies located on USP <800> carts.

Results: Nurses self-reported a high level of knowledge and comfortability regarding safe handling and administration practices of USP <800> HDs. However, despite over a quarter of the patients being on at least one USP <800> drug, compliance with proper PPE recommendations, signage, and accessibility of supplies was low.

Conclusions: This project determined that healthcare employees at Hospital A are not consistently following the recommended USP <800> standards. It also provided a baseline knowledge for future education to ensure safety of patients, healthcare employees, and the environment.