Improving Nursing Documentation Compliance for IV Medication Titration in ICUs at University of Utah Health

Accurate nursing documentation of intravenous (IV) medication titration is critical for patient safety, regulatory compliance, and quality improvement in intensive care units (ICUs). At University of Utah Health, baseline compliance with IV titration documentation was only 16%, posing risks for patient care and institutional adherence to Centers for Medicare & Medicaid Services (CMS) guidelines. To address this, a multidisciplinary team implemented targeted enhancements to electronic health record (EHR) medication order, simplifying documentation workflows and improving clarity and standardization in regard to titration practices. Additionally, focused education sessions were provided to ICU nursing staff to reinforce best practices and regulatory requirements. These interventions led to a significant increase in compliance, reaching 89% over 2 years. This poster will detail the strategies employed, barriers encountered, and lessons learned. This will provide a model for other institutions seeking to improve nursing documentation in high-acuity settings.