Date of Graduation


Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Jennifer H. Zesati

Second Advisor

Alicia Kletter .


Problem: Pain management in in-patient care, particularly involving opioids, is critical due to the associated risks. Proper pain assessment is essential to ensure safe medication administration and mitigate adverse effects.

Context: This quality improvement (QI) project aimed to improve opioid assessment and documentation rate above 90% compliance in two medical-surgical units, focusing on bedside nurses who play a crucial role in patient safety and effective pain management.

Interventions: A baseline survey provided nurses' understanding on compliance criteria and assessment timing. Interventions included visual reminders, informational posters, and instructions on how to access individual compliance reports.

Measures: A post intervention survey evaluated the effectiveness and gathered nurses feedback. Manual chart auditing of the Electronic Health Record (EHR) monitored preliminary improvement and official quarterly report data assessed final compliance rates.

Results: The quality report for April, 2024, revealed Unit A pre-assessment compliance at 61.5% and Unit B at 76.7% with post-assessment scores of 89.6% and 88.7% respectively. Unit A saw a 7% pre-assessment decrease and 0.5% post-assessment increase, while Unit B increased by 6.3% and 3.5% respectively.

Conclusions: Despite falling short of the targeted compliance rate, the project provided valuable insights, revealing varying success levels between units dependent on participation. Moving forward, aligning hospital policy with the quality data team is essential to enhance clarity, data accuracy, and stakeholder engagement, thus improving patient care and safety in future initiatives.

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