6th Edition of World Nursing Science Conference 2026

Abstract

Background/Significance:  Vasoactive drugs are high-alert medications that are commonly administered in critical care units to maintain hemodynamic stability in critically ill patients.    Due to their rapid and potent physiologic effects, strict adherence to titration protocols and accurate documentation are essential for patient safety and regulatory compliance.  The Joint Commission (TJC, 2026) identifies safe medication management, including appropriate titration practices, as a critical standard for high-risk medications.
Purpose/Objectives:   We identified a significant gap in compliance with TJC standards related to vasoactive medication titration during our last visit three years ago.  Baseline auditing revealed titration compliance of 46% with inconsistencies in adherence to ordered parameters, documentation accuracy, and timely hemodynamic reassessment.  Recognizing the patient safety and regulatory implications, a targeted quality improvement (QI) initiative was implemented.
Methodology:  The project centered on structured real-time auditing and bedside coaching.  Nurse leaders, including charge nurses, and our educator conducted concurrent audits during active vasoactive infusions, providing immediate feedback and corrective guidance.  We tracked the physician order, order parameters, and titration compliance based on those physician order parameters.  We utilized an audit sheet we created that highlighted the metrics we were tracking.  Coaching was performed in real time which reinforced clarity of titration parameters, alignment with provider orders, frequency of reassessment, and proper documentation within the electronic medical record (EMR).  This just-in-time intervention model promoted accountability, strengthened clinical judgment, and improved standardization of practice.

Results/Implications:  Following implementation, compliance with vasoactive titration standards increased from 46% to 93%.  The initiative not only aligned practice with TJC expectations but also enhanced staff confidence and reinforced a culture of safety within the ICU.  Sustained auditing, ongoing education, and leadership engagement remain critical to maintaining high reliability in the management of high-alert medications.
Conclusion:  This PI project demonstrates that just-in-time coaching, ongoing education, and sustained auditing of charts increased compliance of vasoactive drug titration protocols.