USP<800> Compliance: A Hazardous Drug Safe-Handling Quality Improvement Project for Ambulatory Care Infusion Nurses
Date of Graduation
Doctor of Nursing Practice (DNP)
School of Nursing and Health Professions
Population Health Leadership
Elena Capella EdD, MSN/MPA, RN, CNL, CPHQ, LNCC
Carlee Balzaretti DNP, RN
Problem: The U.S. Pharmacopeia (USP, 2016) Convention Chapter 800: Hazardous Drugs: Handling in Healthcare Settings took effect on December 1, 2019. According to Polovich and Olsen (2017), " The implementation of the USP <800> Standards. will represent an important step forward to protect nurses and other potentially exposed healthcare workers (HCWs): (p.1).
Context: The Doctor of Nursing Practice (DNP) project implemented a hazardous drug (HD) safe-handling personal protective equipment (PPE) toolkit in accordance to USP <800>standards and hospital policies at an ambulatory cancer infusion center to improve nurses' adherence with PPE use.
Interventions: The project consisted of (a) a safe-handling PPE toolkit, (b) a PPE observation tool, (c) an expert panel discussion, (d) a nurses' skills session, (e) an online safe-handling survey, (f) an HD safe-handling checklist, and (g) a performance dashboard.
Measures: Outcome measures included a (a) 90% or higher compliance rate with PPE use during hazardous drug administration and (b) sustained adherence to USP <800> standards and hospital policies by February 1, 2020.
Results: A 90% compliance rate for PPE use during hazardous drug administration was achieved by February 1, 2020. Sustainability is at risk due to the COVID-19 pandemic and global PPE shortages, however, nurses were able to adapt to new processes to conserve vital resources and will be reassessed in six months.
Conclusions: A systems-thinking approach to the implementation of USP<800> was successful in improving compliance and adherence to PPE use among ambulatory care infusion nurses.
Huff, Cynthia, "USP<800> Compliance: A Hazardous Drug Safe-Handling Quality Improvement Project for Ambulatory Care Infusion Nurses" (2020). Doctor of Nursing Practice (DNP) Projects. 218.
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