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

Nneka Chukwu, DNP-HCSL, MBA, RN, CLNC, CNL


Problem: This quality improvement project is dedicated to increasing the safe handling and administration of United States Pharmacopeia (USP) General Chapter Hazardous Drugs (HDs) within the Medical/Surgical unit to minimize the risk of exposure to patients, healthcare personnel, and the environment.

Context: The quality improvement project was implemented in two Medical/Surgical units in Hospital A in the San Francisco Bay Area. The patient population of these units has the highest receipt of HDs outside of a traditional Hematology/Oncology unit.

Intervention: The proposed intervention is the use of active and passive observation to assess compliance with USP protocols within the two units. It is expected that observation will increase nurse compliance with the intervention over time.

Measures: The intervention included qualitative and quantitative questionnaires administered in an “elbow to elbow” format at Hospital A. Questionnaires were used to gather evidence concerning staff input, knowledge, and compliance concerning USP HDs. Recommendations based on the data collection were presented to Hospital A stakeholders.

Results: Analysis of data collected during this process showed that out of 27.7% of patients on HDs, only 7.5% had appropriate door signage, and 1.7% had proper bathroom door signage. Questionnaires revealed a high mean of reported knowledge and comfortability with USP. Out of 37 donning and doffing occurrences witnessed, 97% were performed correctly.

Conclusions: A deficit in USP compliance remains within the microsystem. However, questionnaires administered to the staff revealed a high mean of reported knowledge and comfortability with USP HDs. In summary, the data identified an incongruence because staff may not have had correct information or seen the complete picture of their risk. As awareness of the project and the need to use and stock the USP cart supplies became more well-known, this translated to better USP cart preparation. Further audits should be implemented throughout the microsystem to improve USP compliance.

Available for download on Saturday, December 23, 2023

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