Date of Award

Summer 2023

Project Type


College or School




Program or Major

Direct Entry Masters Nursing

Degree Name

Master of Science

First Advisor

Kaitlynn Liset

Second Advisor

Pamela Kallmerten




On the Post Anesthesia Care Unit mobile X-Rays were necessary on site for confirmation of medical device placement. There was an unofficial procedure in place which consisted of announcing when an X-Ray was to be taken, and which bay it was taken in.

Local Problem

Upon observation it was noted that the mobile X-Ray unofficial procedure was only being adhered to for approximately 25% mobile X-Rays taken on the PACU, unnecessarily exposing staff to ionizing radiation. There was also no written procedure or standardized training policy available at the facility.


Baseline ionizing radiation knowledge was assessed using a pre-assessment consisting of five multiple choice and five true or false questions. Participants then viewed an educational powerpoint, and were administered a post-assessment to gather data on whether learning occurred. The scores on the assessments were averaged and the standard deviation was calculated to determine if the interventions were successful.


Participants in the radiology department averaged 74% on the pre-assessment and 92% on the post-assessment. Participants in the PACU averaged 80% on the pre-assessment and 93% on the post-assessment. All participants completed the knowledge checkoff for the standardized procedure.


While the interventions in this quality improvement project were successful the results are not sustainable due to no facility standardized safety training policy at onboarding, not including safety protocols in yearly education, and not having a written safety policy available for staff to access. In a future quality improvement project these deficiencies could be addressed for sustainability.