Unit Date

Situation
Background
What has been tried before
Will remind staff in person at
January staff meetings and
answer questions.
Meetings to be held
1/21/14 & 1/23/14
Expected Outcome Timeline
The Oncology (OMG) and Bone Marrow Transplant (BMT) units are not meeting the goal of "70% of all patients
receiving a pain intervention are reassessed within one hour."
The percentage of patients reassessed within one hour was 51% for November, 2013. The units have expanded
from 36 beds to a total of 72 beds in the last 6 months. During this time there was also an influx of new staff,
travelers, and new grad RNs. There was also a gap in the unit's membership on the Pain Champions of Change
Committee; there was only one champ for several months, and during October, there was no champion at all.
Due to the gap in committee membership, it is unclear what has been attempted before. There are no prior action
plans on file.
Recommendation
Aurora Davis
What Will Be Done Responsible Person
Pain Champions Reassessment Audit Action Plan
Oncology/BMT 4-Jan-14
Completed 12/8/13 Improved reassessment rates.
Aurora Davis, Katie
Donovan (shared)
An email has been sent to all
RNs reminding them of their
duties re: reassessments.
Improved reassessment rates,
RN education and feedback to
committee members.