Date of Award

Fall 2026

Abstract

Abstract

Background: The escalating opioid epidemic in the United States demands the widespread implementation of Medication-Assisted Treatment (MAT) and buprenorphine serves as a primary pharmacological intervention. Despite its efficacy in reducing mortality, transmucosal formulations present inherent safety risks, including accidental pediatric exposure, medication diversion, and suboptimal therapeutic outcomes due to improper administration. At Kolmac Integrated Behavioral Health, a preliminary assessment identified a critical deficiency in standardized patient safety education. Prior to this intervention, educational delivery was fragmented and lacked a unified, evidence-based curriculum. This inconsistency resulted in significant gaps in patient knowledge and a lack of verifiable documentation within the electronic health record (EHR). Addressing these systemic gaps is essential to mitigate the risks associated with transmucosal buprenorphine in an outpatient setting and to align clinical practice with national safety standards.

Purpose: The primary objective of this Quality Improvement (QI) project was to implement a standardized "Education and Documentation Bundle" focused on the safe use, storage, and disposal of transmucosal buprenorphine. The project aimed to bridge the gap between clinical guidelines and actual practice by focusing on staff competency and documentation compliance. Specific targets included a 25% increase in staff knowledge, a 90% documentation compliance rate and a rise from an estimated baseline of 50% in patient education. By establishing a formalized "Education and Documentation Bundle," the project intended to foster a culture of safety and accountability among the interdisciplinary clinical team, the QI initiative sought to foster a culture of clinical accountability. Ultimately, the project intended to ensure that every patient receiving treatment was equipped with the necessary knowledge to prevent adverse events, thereby enhancing the overall safety and quality of the facility’s behavioral health services.

Methods: This project utilized the Plan-Do-Study-Act (PDSA) framework over an eight-week implementation period and involved an interdisciplinary team of 14 clinicians at an outpatient facility in Baltimore, Maryland. The intervention consisted of 3 important parts: a mandatory 60-minute virtual training module which emphasized the "Teach-Back" method, the development of a standardized patient education handout, and the integration of a streamlined documentation template within the EHR. This template was designed to facilitate efficient recording of safety teaching during patient encounters. Data collection employed a pre-test/post-test design to evaluate staff knowledge acquisition and retention. Additionally, retrospective and prospective audits of 40 patient charts were conducted to measure the impact of the standardized bundle on documentation accuracy and process adherence throughout the implementation period.

Results: Quantitative results demonstrated significant improvements across all primary metrics. Following the intervention, 100% of the participating staff achieved perfect scores on knowledge assessments, with full retention maintained at the eight-week follow-up. Documentation audits revealed that general patient education documentation rose from 80% to 95%. Most notably, documentation regarding "safe storage" protocols, a critical factor in preventing pediatric exposure, increased from 60% to 95%. Furthermore, Naloxone counseling documentation reached 95% compliance. Qualitative feedback from clinicians indicated that the new EHR template significantly reduced administrative burden while ensuring comprehensive safety coverage. These findings suggest that the standardized education bundle successfully integrated essential safety protocols into the routine clinical workflow without compromising operational efficiency or provider time.

Conclusion: The implementation of a standardized education and documentation bundle for transmucosal buprenorphine effectively enhanced patient safety protocols and clinical accountability. The project’s success, evidenced by perfect staff knowledge retention and near-universal documentation compliance, provides a sustainable and reproducible model for addiction treatment centers. By addressing systemic barriers to consistent education, this initiative mitigated the risks of medication errors and accidental exposures. It is recommended that this education bundle be scaled across regional sites to ensure organizational consistency. However, future efforts should focus on longitudinal monitoring and the inclusion of patient-reported outcomes to further validate the impact of standardized education on patient behavior. Overall, this project reinforces the necessity of structured, evidence-based clinical pathways in providing safe, high-quality care for individuals with opioid use disorder.

Document Type

Clinical Doctorate

First Advisor

Catheleen Colleran

Second Advisor

Joseph H. O’Leary

College or School

CHHS, School of Nursing

Department or Program

DNP

Degree Name

Doctor of Nursing Practice

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