Preferred Name

Jennifer A. Martin

Creative Commons License

Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.


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Date of Graduation

Fall 2016

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing


Maria G. DeValpine

Jeannie Garber

Julie T. Sanford


Diagnostic and invasive procedures performed outside of the operating room with nurse- administered procedural sedation are increasing. As procedural sedation practice national guidelines are evolving, there are inconsistent state regulations and a great deal of variability in staff training. These challenges lead to potential knowledge gaps and practice variation that create unsafe patient environments. A local hospital has continued to experience near miss events when procedural sedation is administered. In an attempt to investigate this issue and create improved practice, an organizational policy analysis was conducted. The aims of this project were to: 1) analyze current hospital policy content compared with AORN's Guideline for Care of the Patient Receiving Moderate Sedation/Analgesia; 2) propose policy changes based on content gaps and barrier analysis; 3) assess current team members' knowledge with hospital policy for procedural sedation patient monitoring and knowledge of common procedural sedation medications; and 4) develop a plan for implementing policy changes and knowledge deficits identified. The Knowledge to Action framework activation cycle was used to guide policy analysis and practice change. The institution's Procedural Sedation Committee served as the discussion forum and decision making body regarding policy change. A staff survey yielded information specific to medication knowledge and procedural sedation. Policy analysis identified the following gaps in the organizational policy: a lack of objective patient assessment scoring for discharge readiness; the need for potential extended recovery times for specific patient populations; patient monitoring with capnography; pre-procedural patient education components; nurse knowledge expectations and nursing involvement in performance improvement activities. Results of the project include implementation of the Aldrete discharge readiness assessment tool, a change in policy specific to extended recovery for specific patient populations and implementation of a decision tree to determine when procedural sedation was occurring. During this project, it was discovered that additional exploration is needed regarding nurse’s procedural sedation medication and practice knowledge in order to create the next intervention that will lead to best practice.

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