Date of Graduation

Spring 5-17-2024

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions



Problem Effective pain management with opioids when ensuring proper documentation presents a major challenge in medical-surgical settings. Poor documentation threatens patient safety and compliance standards of care. Context An urban community hospital’s medical-surgical Unit A and B hosted this quality improvement (QI) project, which was conducted from January to April of 2024. The need for various focused interventions to improve compliance and patient outcomes was demonstrated by the continuously low pain assessment and reassessment documentation rates below the 90% hospital standard. Interventions The project included strategies for staff engagement through observations, systems tutorials of the electronic health record (EHR), chart audits and pre- and post-surveys. Stakeholders from management, information technology (IT) specialists, and nursing worked together to guarantee complete implementation. MeasuresQuarterly data to monitor rates for pain assessment and reassessment compliance were utilized to track if the hospital was reaching the 90% goal. Results Preliminary data indicated gains for Unit B as it reached 74.2% for assessment and 88.1% for reassessment, respectively, and Unit A achieved compliance rates of 66.2% for assessment and 87.5% for reassessment. Both units were below the 90% goal, even with the improvements. Conclusion This QI project emphasizes that organized interventions can greatly improve opioid pain management and documentation procedures that are necessary for patient safety and efficient pain treatment. The differences between units highlight the requirement of customizing plans to the dynamics of each unit. To promote a culture of constant development and high-quality treatment, future efforts should implement ongoing education, thorough data collection, specifically prioritizing technology.

Keywords: Pain management, Quality Improvement, Assessment and Reassessment, Medical-Surgical

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