Date of Graduation

Fall 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


Problem: The USP General Chapter <800> guidelines protect healthcare workers from hazardous drugs (HD) and are enforceable by hospital regulatory organizations. Hospitals should increase their safe handling and administration of these drugs to be compliant and protect their workers. This quality improvement project aimed to improve nurse compliance with the safe handling of USP <800> drugs on the medical-surgical microsystem within 16 weeks.

Context: This clinical nurse leader (CNL) quality improvement project was implemented on two medical-surgical microsystems in a San Francisco Bay Area hospital system.

Interventions: The team conducted passive observational data collection and active observation in the form of a questionnaire for nursing staff within two weeks.

Measures: The tools focused on USP <800> signage, personal protective equipment (PPE), use of USP <800> PPE carts, nurse knowledge, comfortability, frequency of HD administration, and awareness of unit procedures.

Results: 24.8% of patients were on USP <800> medications. Twenty-seven nurses completed the questionnaire. Key findings included: 7.5% of door signages present, 44% of nurses surveyed reported always following PPE recommendations, and nurses self-reported high knowledge of HD. PPE was donned and doffed correctly 97% of the time.

Conclusion: Continued efforts are necessary to increase USP <800> compliance in the microsystem. Compliance with the safe handling and administration of HDs is essential to prevent adverse health outcomes in healthcare workers.