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Y A K I M A V A L L E Y M E MORIAL AWARD WINNING HOSPITAL

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Y A K I M A V A L L E Y M E MORIAL AWARD WINNING HOSPITAL

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    1. Y A K I M A V A L L E Y M E MORIAL AWARD WINNING HOSPITAL

    3. Nursing Student Orientation

    4. Soarian Paperless Documentation System

    5. MAK System

    6. MAK System of Medication Administration

    7. Students Make the Hospital World Go ‘Round’ You make a big difference in the lives of your patients. You are the hands, eyes, and ears of the RN– You actions could determine life and death in some circumstances. What you do everyday may seem mundane or boring, but it’s incredibly important!

    8. Memorial’s Mission and Values Our Mission The mission of Memorial is to “Improve the health of those we serve.”  Values ·     Compassion – means listening, anticipating, being attentive and perspective-shifting so other feel cared for and understood. ·     Respect – means recognizing our differences as strengths, affirming each other, and valuing each other’s contributions. ·     Accountability – means taking responsibility for our actions, being trustworthy and demonstrating integrity. ·     Safety – means taking responsibility for me and others to practice tools that ensure safety for all. ·     Teamwork – means working together, sharing our unique talents, perspectives, ideas and efforts. ·     Excellence – means implementing best practice; being creative, innovative, and flexible and setting and achieving bold goals.  Every time!

    9. Memorial’s Safety Principles Personal responsibility Commitment Questioning attitude Adhere to standardized processes Communicate clearly Best practices Support and trust each other

    10. Your Student Memorial Website www.nursingjobs.yakimanursingjobs.com Open page and click on “Information for Nurses” Scroll down to: “Student Nurse Orientation” “Student Nurse Training” - Computer based training (CBT) of MAK and Soarian system *Case Sensitive: Username: nursing Password: Training!

    11. Student Website Content “How to Survive the Jungle” Regulatory Information and Student Exams (Must be completed only once before starting clinical rotation) Clinical Orientation Manual (Must be completed each semester/or quarter -  HIPAA and Workforce Member Confidentiality Agreement) Information Systems Confidentiality Form (Must be completed each semester/or quarter. Emergency Codes:

    12. Student Website Content (Cont.) Student Policies: Clinical Protocols: Equipment and Supply Usage: Clinical Skills: **Print off and give to your primary nurse each day. Stay within scope of practice guided by specific semester/or quarter skills. Training Resources:

    13. Memorial Intranet Resources YVMH Intranet Resources Applications Tab: Ovid and ProQuest Up-to-date Policies & Procedures (New Format) Micromedex Zynx Red Rules for Safety:-Home Page Patient Safety Goals:-Home Page Imagining-Preparatory Instructions-Home Page Type and Duration of Precautions-Home Page Learn more of Hyperbaric Oxygen Therapy (HBOT) Access the Nutrition Care Manual-Home Page From Memorial Intranet: open the "Applications" tab. Then click on "UpToDate Online"   2.  UpToDate may open up with a "Subscription and License Agreement". Click "Accept".   3.  Click on the green "Patient Info" tab at the top of the screen.   4.  Click on the appropriate health category in the lower portion of the page.       Note: urinary concerns are under "Kidney Disease", while prostate concerns are under "Men's health issues"   5.  Click on the specific health concern or diagnosis that you want.   6.  Review the information to make sure it is appropriate for your patient.   7.  Click "print" in the upper right hand corner. The computer will open a "print view".       Then click the green "print" in the upper right hand corner again and choose your printer.   You can search for diseases and procedures using the green "New Search" tab, but the information under the "Patient Info" tab is written specifically with patients in mind.   From Memorial Intranet: open the "Applications" tab. Then click on "UpToDate Online"   2.  UpToDate may open up with a "Subscription and License Agreement". Click "Accept".   3.  Click on the green "Patient Info" tab at the top of the screen.   4.  Click on the appropriate health category in the lower portion of the page.       Note: urinary concerns are under "Kidney Disease", while prostate concerns are under "Men's health issues"   5.  Click on the specific health concern or diagnosis that you want.   6.  Review the information to make sure it is appropriate for your patient.   7.  Click "print" in the upper right hand corner. The computer will open a "print view".       Then click the green "print" in the upper right hand corner again and choose your printer.   You can search for diseases and procedures using the green "New Search" tab, but the information under the "Patient Info" tab is written specifically with patients in mind.   

    14. Sure Step Flexx Meter with Test Strips

    15. AcuDose-Rx

    16. What Is Documentation?

    17. What Is Documentation? Documentation means “to give written information that is proof or support of something that has been done or observed. A medical record is a legal and confidential record with pertinent information related to the care provided. Legal Implications: Admissible in court, the patient’s medical record must be documented in an accurate, complete, systematic, logical, concise, and timely manner.

    18. What Is Documentation? A well documented record can, and will most likely protect you legally. In a malpractice case, the jurors usually view the medical record as the best evidence of what really happened. Don’t use shorthand or abbreviations that are not accepted by Memorial Hospital Policy. Do not alter a chart….this is a criminal offense.

    19. DAR Documentation Focus charting using the DAR model: D = Subjective or Objective data that supports the focus or describing observations at the time of significant events. A = Action category reflects planning & implementation phase of the nursing process. Nursing interventions performed, planned to be performed, and/or protocols and procedures initiated. R = Patient response to the medical and/or nursing. Statement that the Action Plan of Care outcomes have been attained or are progressing toward attainment. **DAR notation tends to reflect the steps in the nursing process.

    20. Pull Policy : Patient Care Plans/ Focus Problem List Steps to follow to access YVMH Policy: Go to “Applications” on the YVMH Intranet Select “Policies and Procedures” Pull YVMH policy under “General Nursing Policy and Procedure Manual” Policy Name: Patient Care Plans/Focus Problem List and Print if needed.

    21. Sample of DAR Documentation YVCC Student Nurse Notes Reviewed By:__________RN 12/18/09: 0345: D (data) - Bladder distended 2 fingers above pubis. Patient has not urinated since foley catheter removed @ 1800. Patients reports abdominal discomfort above pubis 8/10 when palpated. 0400: A (action) – Patient assisted to toilet but remains unable to void. Dr. Johnson notified and orders received. # 14 straight catheter inserted without difficulty per orders. 0445: R (response)- Drained 700 mL of clear yellow urine per straight cath. No distention noted above pubis. Patient reports no bladder discomfort when palpated. L. Price, SN./ YVCC /Instructor L.. Daily, RN.

    22. Sample of DAR Documentation WSU Student Nurse Notes Reviewed By:__________RN 12/18/07 0630: D (data) –Patient reports she started vaginal bleeding yesterday and she is passing clots. –Four maxi pads saturated with dark red drainage and 8 quarter clots in 60 minutes. BP 102/68, P 108, R 24, T 34.1C, SpO2 98%RA 0645: A (action) – Status reported to Dr. Miller. IV started with 18g. angiocath, 1000 ml of 0.9% Normal Saline hung @ 200 ml/hr per orders. Continue to monitor bleeding and pad count and vital signs. Dr. Miller will see the patient in one hour. 0700: R (response)- Patient understands rationale for IV fluids and continuous monitoring. BP 120/72, P 88, R. 20, T. 34, SpO2 99% RA. V.Smith, SN./WSU/Instructor D. Hudzinski, RN

    23. Patient Teaching Remember: Teach your patient/and families something each day. Chronic Illness Acute Illness Therapies Medications Patient education can become part of your DAR charting.

    24. What is SBAR?

    25. S – B – A - R S=Situation – the problem B=Background – brief, related, to the point A=Assessment - what you found, what you think R=Recommendation – what you want

    26. Review SBAR Policy-YVMH Intranet Steps to follow to access YVMH SBAR Policy Go to “Applications” on the YVMH Intranet Select “Policies and Procedures” Pull YVMH policy under “Interdisciplinary Policy and Procedures” Policy Name: Report/Patient Hand Off and Print if needed.

    27. SBAR When to use SBAR? Calls to Providers “Hand-Off” report to other staff or disciplines. Nurses are transferring patients to other facilities or to other levels of care Goal Improved Pt. Management/Safety

    28. Why SBAR Recommended? 17% RNs believe there is lack of communication when providing efficient pt care. 75% of MDs believe RNs lack knowledge about pts condition. 50% of MDs believe RNs are not timely in the follow thru of written orders. 33% of MDs encourage more MD/RN communication/rounds/education/& discharge planning

    29. SBAR-Improved Outcomes ? Pt Mortality ? Transfers ICU ? Quality of Care ? Costs ? LOS ? RN Autonomy ? RN Retention ? Job Satisfaction ? RN/MD Collaboration

    30. S = Situation State Your Name & Position “I am calling about (Pt name & unit) The Current PROBLEM I am calling about…. Clearly & Concisely State Current Problem What it is When it happened or started How Severe

    31. B = Background State: Date of Admission with Admitting & Secondary Diagnosis Allergies and Code Status Level of Injury if applicable Pertinent Medical History Brief Synopsis of Treatments and Tests to date.

    32. A = Assessment Head-To-Toe Physical Assessment Most Recent V/S (TPR, BP, SaO2, etc) Pain Status Drains, Tubes, Wound Assessment and Care Restrictions, Isolation, Fall and Bleeding Precautions, Diet, Activity, ADL’s Current Therapy (IVs, Line site, O2, Vent Settings etc) Response to Treatments Changes from Prior Assessment

    33. R = Recommendations “ Would you like me to______(state what you would like to see done)” “Are any Tests Needed?” If Change in Treatment Ordered How often do you want V/S? If No Improvement, Parameters of When to Call Again? Orders Pending Completion, Pending Treatment and Tests Discharge Planning, Issues, Barriers

    34. Example Call to a Physician Using SBAR Situation: Dr. Lewis, this is Mary Jones RN, I am calling from YVMH about your patient Jane Cole. Mrs. Cole is having increasing dyspnea and is complaining of chest pain @ 4/10. Background: She had a total knee replacement two days ago. About two hours ago she began complaining of chest pain 2/10 and shortness of breath. Assessment: She has expiratory wheezes in all lung fields, her oxygen saturation is 85% on RA and she is very restless and short of breath. Her B/P is 132/52, P- 120, and R- 32. Other clinical information you would want to give???? Recommendation (Nurse Request) I would like you to see her immediately and can we start her on 02 @ 4L/NC, some stat ABGs, Coag studies, & CXR Why implement SBAR in your organization? Improved Pt. Management/Safety=BETTER OUTCOMES

    35. SBAR-“Before You Call The Provider” Assess Pt. Review Call Schedule for Appropriate Provider to Call. Know Admitting & Secondary Dx. Read Most recent Progress Notes & Assessment from nurse of the prior shift. Have available chart, allergies, Meds, IV fluids, Labs

    36. SBAR-“Emergency Code Blue” S: Why Called Code B: Dx, Recent Complications, Recent Tx, Meds, Previous Behavior A: What you Believe Happened R: Recommendations for Management based on Your Knowledge of Pt

    37. SBAR-“Hand-Off” Communication Use SBAR To Structure Information this person will need to provide Continuity of Care in a Safe Manner while they are caring for the patient. Common Core Values of SBAR Respect Trust Open Communication Teamwork Equality PATIENT FIRST!

    38. Pull Policy : Report/Patient Hand Off Steps to follow to access YVMH Policy Go to “Applications” on the YVMH Intranet Select “Policies and Procedures” Pull YVMH policy under “Interdisciplinary Policy and Procedures” Policy Name: Report/Patient Hand Off and Print if needed.

    39. A Deadly Dose of Human Error 44,000 to 98,000 patient deaths per year due to medical error (IOM To Err Is Human, 2000) 298,865 patient deaths in from 2001-2003 due to patient safety incidents (HealthGrades, 2005) 380,000-450,000 preventable adverse drug events in hospitals each year (IOM Preventing Medication Errors, 2006) Recommended care received about 54.9% of the time based on chart reviews (Rand / New England Journal of Medicine, 2003) SAFETY STARTS WITH ME!

    40. Memorial Safety Behaviors & Human Error Prevention Toolkit

    41. Safety Tool # 1: Critical Thinking Critical Thinking Validate & Verify Compliance Continuous Use Job Aids Reference Use Policies & Protocols Red Rules for Safety Communication 3-Way Repeat Back Ask Questions Phonetic & Numeric Clarifications Team Work Peer Coaching Speak Up Using ARCC Attention on Task Self-Check Using STAR

    42. Safety Tool #1: Critical Thinking Validate & Verify: Validate-consistent with my knowledge? What is typical or expected? What is outside of the norm? How do I know this is correct? Verify-check with credible source

    43. V&V Technique Validate & Verify is a two-step technique for processing raw information into fact. The first step, Validate, is an internal check that we perform in our heads – does what is actually happening fit with what I know should be happening? The second step, Verify, is an action step that we take if what’s happening does not make sense to us – we check it out with an expert source. Here’s an easy tip to remember which comes first – “Va” in Validate comes before “Ve” in Verify. We’re going to talk a little more now about each step…Validate & Verify is a two-step technique for processing raw information into fact. The first step, Validate, is an internal check that we perform in our heads – does what is actually happening fit with what I know should be happening? The second step, Verify, is an action step that we take if what’s happening does not make sense to us – we check it out with an expert source. Here’s an easy tip to remember which comes first – “Va” in Validate comes before “Ve” in Verify. We’re going to talk a little more now about each step…

    44. Validate – An Internal Check Our internal smoke detector… Does this make sense to me? Is it right, based on what I know? Is this what I expected? Does this information “fit-in” with my past experience or other information I may have at this time? Get in the habit of asking these questions all the time… it takes only seconds. The smoke detector in your home is always on. When an alarm sounds, you check to determine what made the alarm sound. Was it smoke from a dangerous fire, from a piece of bread that got caught in the toaster oven, or the smoke from birthday candles? Or is the battery getting weak? Validate is your internal smoke detector, and it should always be on. Whenever you receive information or observe a situation, you should be asking yourself the questions shown on this slide. Validation is about comparing a situation or information to what you know to be correct and true. The key to validation is that you do it before you act. You should validate every situation and all information that you encounter. It takes only a few seconds to run this check in your head. Always think…does it make sense to me? Just like the smoke detector, it costs little but can save thousands of lives each year. Here’s one example from another hospital of someone that failed to validate. A maintenance worker was heading into an MRI suite with a blower. His coworker’s smoke detector went off: “The MRI is a magnet. Can we take a blower into the MRI suite?” “Sure,” said the maintenance worker, “it’s plastic.” So they proceeded into the MRI suite. The blower – having a metal motor – immediately flew to the center of the magnet, causing significant damage to the machine. The smoke detector in your home is always on. When an alarm sounds, you check to determine what made the alarm sound. Was it smoke from a dangerous fire, from a piece of bread that got caught in the toaster oven, or the smoke from birthday candles? Or is the battery getting weak? Validate is your internal smoke detector, and it should always be on. Whenever you receive information or observe a situation, you should be asking yourself the questions shown on this slide. Validation is about comparing a situation or information to what you know to be correct and true. The key to validation is that you do it before you act. You should validate every situation and all information that you encounter. It takes only a few seconds to run this check in your head. Always think…does it make sense to me? Just like the smoke detector, it costs little but can save thousands of lives each year. Here’s one example from another hospital of someone that failed to validate. A maintenance worker was heading into an MRI suite with a blower. His coworker’s smoke detector went off: “The MRI is a magnet. Can we take a blower into the MRI suite?” “Sure,” said the maintenance worker, “it’s plastic.” So they proceeded into the MRI suite. The blower – having a metal motor – immediately flew to the center of the magnet, causing significant damage to the machine.

    45. Verify – An External Check With an Expert When should you verify? When your detector goes off In every high-risk situation When there is a change in the patient condition or plan of care While Validate is an internal check that you perform, Verify is an external check. You perform verification by finding an independent qualified source to verify that the situation or information is correct. What are some qualified sources that you rely on to verify information? Policies, procedures, and job aids Clinical protocols and guidelines of care Reference manuals (PDR, Lippincott’s nursing manual) Expert individuals (Supervisors, Clinical Nurse Specialists, Pharmacists) When using other professionals as your source, make sure that the person really is an expert. (Coworkers are not always the best expert, as people who work closely together tend to share the same bad information.) Should you verify all information you receive? No. While validation takes only a few seconds, verification takes time. There are 3 specific instances, however, when you must verify information: 1. High-risk situations 2. When your plan of action changes 3. When you note an inconsistencyWhile Validate is an internal check that you perform, Verify is an external check. You perform verification by finding an independent qualified source to verify that the situation or information is correct. What are some qualified sources that you rely on to verify information? Policies, procedures, and job aids Clinical protocols and guidelines of care Reference manuals (PDR, Lippincott’s nursing manual) Expert individuals (Supervisors, Clinical Nurse Specialists, Pharmacists) When using other professionals as your source, make sure that the person really is an expert. (Coworkers are not always the best expert, as people who work closely together tend to share the same bad information.) Should you verify all information you receive? No. While validation takes only a few seconds, verification takes time. There are 3 specific instances, however, when you must verify information: 1. High-risk situations 2. When your plan of action changes 3. When you note an inconsistency

    46. Safety Tool # 2: Compliance Critical Thinking Validate & Verify Compliance Continuous Use Job Aids Reference Use Policies & Protocols Red Rules for Safety Communication 3-Way Repeat Back Ask Questions Phonetic & Numeric Clarifications Team Work Peer Coaching Speak Up Using ARCC Attention on Task Self-Check Using STAR

    47. Safety Tool #2: Compliance What should we do? Know the rules and apply them to the task at hand Why should we do this? So that our work practices adhere to standards and result in the best outcomes Error Prevention Tools: Continuous Use Documents Reference Use Documents Red Rules for Safety Safety Behavior #2: COMPLIANCE Rules are a light unto our path – the best practices, evidence based methods, and proven techniques for performing a task in a manner that gets the best result. Compliance means that we know the rules for the task at hand, we actively think to recall the rules when we are performing the task, and we make a decision to follow the rules. Good compliance makes good process design work!! What does that mean to you?? We make have outlined a work process that reflects best thinking and best practices, yet if we are sometimes-followers of the process, we’ll get sometimes best outcomes. Some work rules are easy to learn and remember, and other work rules guide a task that may be more complex or less frequently performed. We make decision when to apply certain work rules, and other work rules, because they are safety critical in nature, require exact compliance each and every time to keep our patients and employees from harm. There are three compliance concepts that we’ll review in this section: 1. Continuous Use Documents 2. Reference Use Documents 3. Red Rules for Safety Safety Behavior #2: COMPLIANCE Rules are a light unto our path – the best practices, evidence based methods, and proven techniques for performing a task in a manner that gets the best result. Compliance means that we know the rules for the task at hand, we actively think to recall the rules when we are performing the task, and we make a decision to follow the rules. Good compliance makes good process design work!! What does that mean to you?? We make have outlined a work process that reflects best thinking and best practices, yet if we are sometimes-followers of the process, we’ll get sometimes best outcomes. Some work rules are easy to learn and remember, and other work rules guide a task that may be more complex or less frequently performed. We make decision when to apply certain work rules, and other work rules, because they are safety critical in nature, require exact compliance each and every time to keep our patients and employees from harm. There are three compliance concepts that we’ll review in this section: 1. Continuous Use Documents 2. Reference Use Documents 3. Red Rules for Safety

    48. Continuous Use Documents Do lists, checklists, flowsheets that list tasks or action steps for infrequently performed or high-risk procedures Performance Expectation We have the job aid in hand while performing the task We perform the tasks or steps as written Why It’s A Good Thing Helps ensure that we don’t forget a step Keeps us out of knowledge-based performance and puts us in rule-based performance, reducing the probability that we’ll experience an error! Examples of Continuous Job Aids Biomedical equipment checklist EOC rounds checklist Restraint flowsheet Anesthesia record What are examples of continuous use documents in your department? Examples of Continuous Job Aids Biomedical equipment checklist EOC rounds checklist Restraint flowsheet Anesthesia record What are examples of continuous use documents in your department?

    49. Reference Use Documents Guidance documents that provide information about standards and procedure expectations Performance Expectation Learn the standards or procedure expectations for the work we do Know where to find the guidance documents If we’re ever not sure – or can’t remember – look it up-As the policies and protocols become knowledge “in the head, ”we don’t need to refer to the document. They are “reference use” documents Examples of Reference Use Policies & Protocols MSDS manual Dress code policy Medical restraint procedure Examples of Reference Use Policies & Protocols MSDS manual Dress code policy Medical restraint procedure

    50. What Is A Red Rule? An act that has the highest level of risk or consequence to patient or employee safety if not performed exactly, each and every time. “Red” designated the highest priority for exact compliance. Focus attention and align beliefs around these acts as safety critical Elevate acts to ingrained work habits to achieve highest level of compliance and reliability Find RED RULE on Memorial Intranet

    51. RED RULE Patient Identification – verify and match using 2 identifiers before acting Name Birthday (May Use) Medical Record Number NEVER USE Bed number Diagnosis

    52. Safety Tool # 3: Communication Critical Thinking Validate & Verify Compliance Continuous Use Job Aids Reference Use Policies & Protocols Red Rules for Safety Communication 3-Way Repeat Back Ask Questions Phonetic & Numeric Clarifications Team Work Peer Coaching Speak Up Using ARCC Attention on Task Self-Check Using STAR

    53. Communication What should we do? Communicate complete and accurate information in a timely and appropriate manner Why should we do this? To ensure that we hear things correctly To ensure that we understand things correctly To prevent wrong assumptions and misunderstandings that could cause us to make wrong decisions Error Prevention Tools: 3-Way Repeat Backs Ask Questions Phonetic & Numeric Clarifications Safety Behavior #3: COMMUNICATE This behavior is about making sure that we give and receive accurate and complete information. We act on information that others give us, and our coworkers act on information that we give them. When we communicate poorly, inaccurate and incomplete information can lead us to make decision-making errors, or poor choices. When a poor choice is made, it’s called a mistake (not a slip or a lapse). Mistakes are intended errors. That means that the person intended to take the action because they thought the act was the correct one, not because they intended to make the mistake. Can you recall an time when you were involved in an error that resulted from poor communication? There are three error prevention tools for this Safety Behavior: 1. 3-Way Repeat Backs 2. Ask Questions 3. Phonetic & Numeric Clarifications Safety Behavior #3: COMMUNICATE This behavior is about making sure that we give and receive accurate and complete information. We act on information that others give us, and our coworkers act on information that we give them. When we communicate poorly, inaccurate and incomplete information can lead us to make decision-making errors, or poor choices. When a poor choice is made, it’s called a mistake (not a slip or a lapse). Mistakes are intended errors. That means that the person intended to take the action because they thought the act was the correct one, not because they intended to make the mistake. Can you recall an time when you were involved in an error that resulted from poor communication? There are three error prevention tools for this Safety Behavior: 1. 3-Way Repeat Backs 2. Ask Questions 3. Phonetic & Numeric Clarifications

    54. 3-Way Repeat Backs When information is transferred... Sender initiates communication using Receivers Name. Sender provides an order, request, or information to Receiver in a clear and concise format. Receiver acknowledges receipt by a repeat-back of the order, request, or information. Sender acknowledges the accuracy of the repeat- back by saying, That’s correct! If not correct, Sender repeats the communication. The Repeat Back is a three-way communication technique. Review the three steps of the repeat back. Here’s what a repeat back looks like… Sender (Laboratory Technologist): “I’m calling with a lab value for Mark Greene in Room 214. The INR value is 5.4.” Receiver (Nurse): “The INR for Mark Greene in Room 214 is 5.4.” Sender (Laboratory Technologist): “That’s correct.” That third step in which the Sender acknowledges the accuracy of the repeat back is an important one. The Receiver must listen for the words, “that’s correct.” If the information is not correct, the Sender repeats the communication. Repeating back information ensure the authenticity of the information – you heard it the way I said it. Repeating back does not ensure that the Sender sent accurate information or that the Receiver understood the information. For that, our second error prevention tool is needed. The Read Back – A JCAHO Patient Safety Standard JCAHO requires read backs for all telephone orders and telephone reporting of critical lab values. To read back information, the Receiver must write it down. When the Sender communicates a telephone order or a critical lab value, the Receiver first writes it down. Then, the Receiver reads back the information and awaits confirmation or correction of the information by the Sender. The Repeat Back is a three-way communication technique. Review the three steps of the repeat back. Here’s what a repeat back looks like… Sender (Laboratory Technologist): “I’m calling with a lab value for Mark Greene in Room 214. The INR value is 5.4.” Receiver (Nurse): “The INR for Mark Greene in Room 214 is 5.4.” Sender (Laboratory Technologist): “That’s correct.” That third step in which the Sender acknowledges the accuracy of the repeat back is an important one. The Receiver must listen for the words, “that’s correct.” If the information is not correct, the Sender repeats the communication. Repeating back information ensure the authenticity of the information – you heard it the way I said it. Repeating back does not ensure that the Sender sent accurate information or that the Receiver understood the information. For that, our second error prevention tool is needed. The Read Back – A JCAHO Patient Safety Standard JCAHO requires read backs for all telephone orders and telephone reporting of critical lab values. To read back information, the Receiver must write it down. When the Sender communicates a telephone order or a critical lab value, the Receiver first writes it down. Then, the Receiver reads back the information and awaits confirmation or correction of the information by the Sender.

    55. Ask Questions Ask one to two clarifying questions: In all high risk situations When information is incomplete When Information is not clear Why… To make sure that you really understand what’s being communicated so that you don’t make a decision based on a wrong assumption. Asking clarifying questions can reduce the risk of making an error by 2½ times Asking Questions probes for understanding. Questions can be asked by the sender or by the receiver. Do you always have to ask clarifying questions? No. Pick your spots. Most certainly ask clarifying questions in these situations: When in high-risk situations When information is incomplete When information is ambiguous Studies have shown that the probability of making a wrong assumption is reduced 2½ times when you ask 1.63 clarifying questions when receiving critical information. Okay, so let’s say 1 to 2 clarifying questions. One question usually isn’t enough, but more than 3 clarifying questions can become a bit annoying. Recall that the repeat back technique does not ensure that the Sender sent accurate information or that the Receiver understood the information. So it’s always a good practice to use repeat backs and clarifying questions together. When you receive information, repeat it back and then ask 1 or 2 clarifying questions to make sure that you understood the information. The Sender may also ask clarifying questions to confirm understanding of the information. Asking Questions probes for understanding. Questions can be asked by the sender or by the receiver. Do you always have to ask clarifying questions? No. Pick your spots. Most certainly ask clarifying questions in these situations: When in high-risk situations When information is incomplete When information is ambiguous Studies have shown that the probability of making a wrong assumption is reduced 2½ times when you ask 1.63 clarifying questions when receiving critical information. Okay, so let’s say 1 to 2 clarifying questions. One question usually isn’t enough, but more than 3 clarifying questions can become a bit annoying. Recall that the repeat back technique does not ensure that the Sender sent accurate information or that the Receiver understood the information. So it’s always a good practice to use repeat backs and clarifying questions together. When you receive information, repeat it back and then ask 1 or 2 clarifying questions to make sure that you understood the information. The Sender may also ask clarifying questions to confirm understanding of the information.

    56. Phonetic and Numeric Clarifications For sound alike words and letters, say the letter followed by a word that begins with the letter. For example: A Alpha B Bravo C Charlie D Delta When communication involves sound alike numbers, say the number and then the digits. For example: 15…that’s one-five 50…that’s five-zero Phonetic Clarification is a good practices to use when communicating verbally. Words transmitted via early radio communications were often difficult to understand. Since radio became an important tool of military operations, the US armed forces have used several different phonetic alphabets to aid in clear communications. The phonetic alphabet shown on this slide has been in use since 1957. Four different versions of the phonetic alphabet preceded this 1957 version. That’s why when you watch old World War II movies you hear characters saying "Able Baker Charlie" while present-day soldiers say "Alpha Bravo Charlie" for the same ABC. But it’s not that important that we memorize this particular phonetic alphabet. It doesn’t matter whether your “D” is Dog, David, or Delta. What is critical is that we use phonetic clarification when we are communicating important information such as drug names, patient names or physician names. Phonetic Clarification is a good practices to use when communicating verbally. Words transmitted via early radio communications were often difficult to understand. Since radio became an important tool of military operations, the US armed forces have used several different phonetic alphabets to aid in clear communications. The phonetic alphabet shown on this slide has been in use since 1957. Four different versions of the phonetic alphabet preceded this 1957 version. That’s why when you watch old World War II movies you hear characters saying "Able Baker Charlie" while present-day soldiers say "Alpha Bravo Charlie" for the same ABC. But it’s not that important that we memorize this particular phonetic alphabet. It doesn’t matter whether your “D” is Dog, David, or Delta. What is critical is that we use phonetic clarification when we are communicating important information such as drug names, patient names or physician names.

    57. Safety Tool # 4: Team Work Critical Thinking Validate & Verify Compliance Continuous Use Job Aids Reference Use Policies & Protocols Red Rules for Safety Communication 3-Way Repeat Back Ask Questions Phonetic & Numeric Clarifications Team Work Peer Coaching Speak Up Using ARCC Attention on Task Self-Check Using STAR

    58. Team Work What should we do? Help others to do the right thing, and expect that they will help us to do the right thing, too Why should we do this? To help everyone perform at their individual best To help our team perform at it’s best Error Prevention Tools: Peer Coaching Speak Up Using ARCC Safety Behavior #4: Peer Coaching Team Work is all about helping others do the right thing and expecting that they will help us to do the right thing, too. There are three error prevention tools for this Safety Behavior: 1. Peer Coaching 2. Speak Up Using ARCC Safety Behavior #4: Peer Coaching Team Work is all about helping others do the right thing and expecting that they will help us to do the right thing, too. There are three error prevention tools for this Safety Behavior: 1. Peer Coaching 2. Speak Up Using ARCC

    59. Peer Coaching Look out for your team member… Offer to check the work of others Point out unintended slips and lapses Point out work conditions that your team member might not have noticed Encourage safe and productive behaviors Correct unsafe and unproductive behaviors

    60. Tips for Peer Coaching Be willing to coach others…and be willing to have others coach you! Point out the good things! (5 positives to 1 negative) Provide feedback based on observations Use the “lightest touch” possible to obtain the desired results Delivering the message: Invitation: “May I point something out…” Observation: “I observed that you…” Expectation: “The expectation is that we… because…” Facilitation: “Is there something that can help…” Commitment: “Next time…” Coaching isn’t just the responsibility of a department manager. In fact, about 50% of effective coaching should come from our peers. We spend a lot of time together, we observe each others’ behaviors, and we value the opinions of our peers. As peers, we can have a lot of influence in either promoting good behaviors or discouraging bad behaviors. Does the thought of “coaching” your peers make you uncomfortable? Well, it gets easier the more coaching your give and the more coaching you receive. Coaching isn’t just the responsibility of a department manager. In fact, about 50% of effective coaching should come from our peers. We spend a lot of time together, we observe each others’ behaviors, and we value the opinions of our peers. As peers, we can have a lot of influence in either promoting good behaviors or discouraging bad behaviors. Does the thought of “coaching” your peers make you uncomfortable? Well, it gets easier the more coaching your give and the more coaching you receive.

    61. Speak Up for Safety Using ARCC A responsibility to protect in a manner of mutual respect –an assertion and escalation technique Use the lightest touch possible… Ask a question Make a Request Voice a Concern…..A Memorial Safety Phase “I have a concern…..” If no success….. If we see or perceive a safety concern – if we think that a condition or action may cause harm to a patient or employee – we have a responsibility for raising that concern. ARCC is a communication technique that can help us assert a concern in a non-threatening way and help us escalate the concern if it is not addressed. ARCC can be especially helpful if we feel hesitant or intimidated to raise a concern to someone we perceive to be in a position of higher authority (a nurse speaking with a physician, a transporter speaking with a nurse). An example of an ARCC application is shown below. Time Out – OR Nurse to Surgeon Ask a Question: Dr. Jones, aren’t we supposed to complete a time out prior to beginning the case? (Dr. Jones says time outs are useless.) Make a Request: Dr. Jones, I am requesting that the team take a couple of seconds to complete the time out before beginning. (Dr. Jones says he doesn’t have time.) Voice a Concern: Dr. Jones, I am concerned about the safety of our patient – we need to complete the time out. (Dr. Jones goes on asking for the scalpel.) Chain of Command: Dr. Jones, before I can begin assisting with this procedure, I need to speak with my supervisor. Can you think of a situation in your job where this tool would have helped them feel empowered to stand up for the safety of a patient or employee? If we see or perceive a safety concern – if we think that a condition or action may cause harm to a patient or employee – we have a responsibility for raising that concern. ARCC is a communication technique that can help us assert a concern in a non-threatening way and help us escalate the concern if it is not addressed. ARCC can be especially helpful if we feel hesitant or intimidated to raise a concern to someone we perceive to be in a position of higher authority (a nurse speaking with a physician, a transporter speaking with a nurse). An example of an ARCC application is shown below. Time Out – OR Nurse to Surgeon Ask a Question: Dr. Jones, aren’t we supposed to complete a time out prior to beginning the case? (Dr. Jones says time outs are useless.) Make a Request: Dr. Jones, I am requesting that the team take a couple of seconds to complete the time out before beginning. (Dr. Jones says he doesn’t have time.) Voice a Concern: Dr. Jones, I am concerned about the safety of our patient – we need to complete the time out. (Dr. Jones goes on asking for the scalpel.) Chain of Command: Dr. Jones, before I can begin assisting with this procedure, I need to speak with my supervisor. Can you think of a situation in your job where this tool would have helped them feel empowered to stand up for the safety of a patient or employee?

    62. Safety Tool # 5: Attention on Task Critical Thinking Validate & Verify Compliance Continuous Use Job Aids Reference Use Policies & Protocols Red Rules for Safety Communication 3-Way Repeat Back Ask Questions Phonetic & Numeric Clarifications Team Work Peer Coaching Speak Up Using ARCC Attention on Task Self-Check Using STAR

    63. Attention on Task

    64. Ever Experience One of These?

    65. Self Checking Using STAR Stop: Think Act Review: Pause for 1 to 2 seconds to focus on what you’re about to do Think about what you’re about to do – focus on the action Concentrate and perform the task Check to see if the task was done right

    66. Student Clinical Tips for the Units Shift Report: Report to begin at 0700, 1500, 2300 Listen to report prior to patient care No Chit chat, reading paper or magazines (be a role model) When listening to report write down pertinent information on all patients. Code status-Isolation-Diagnosis-Diet-Allergies Activity/Toileting New Orders and Diagnostic Exams Brief Review of Patient Condition

    67. What to Report to Primary Nurse and Instructor?? Report any vital signs that are outside patient’s normal range-Unsure?- Ask RN and Instructor Temp greater than 37.5, less then 36 BP: Systolic BP less than 90 or greater then 140, Diastolic BP less than 60 or greater than 90 Respiratory rate- if less than 12 or greater than 28 O2 saturation less than 92% Heart Rate/Pulse: greater than 110 or less than 60 Pain Report any deviation from expected plan of care to RN and Instructor-Unsure?- Ask RN and Instructor Patient condition Any patient or family complaints, skin changes, wound/or incisional concerns, ambulation concerns, change in mentation

    68. What Do I Have to Chart? Required charting on every patient in a shift includes: ‘Head-to-Toe”, “Fall Risk”, “Braden Scale”, Clinical Notes, Vital Signs Intake and Output (I&O) on every patient. Remember: Every patient’s care plan will be reviewed and updated

    69. Vital Signs Temp, pulse, respirations, blood pressure, O2 sat, pain level Use manual cuffs for BP – they’re more accurate. Checking 02 saturation on post op patient’s. Check with NRB mask on, once mask is removed wait 10 minutes then recheck 02 saturation on room air (RA). Must leave saturation monitor on for about 1 min. to get accurate reading Unless ordered differently should be done Q4 When PCA initiated need to be done every two hours X 24 hours, then every four hours Check with RN if needed more often

    70. Daily Weights All patients are weighed on Admission. All weights shall be documented in Kilograms on Soarian and the pink weight card. Patients who are to be weighed daily shall be weighed at approximately same time each day according to established routine on each unit. Patients must be weighed in a gown and/or pajamas each time. Dialysis patients must be weighed each morning at 6am.

    71. Activity What is the patient’s activity level (BR, ambulatory, up to chair, assist, ad lib) Ad lib: check with the RN/Instructor to make sure patient is safe to go outside if requesting to do so. (narcotics, PCA) Consider: first time ambulating after surgery, weakness, dizziness, vital signs) How often should the patient be up? Bed rest: reposition every two hours Relieve pressure areas (heels, elbows, coccyx) with repositioning, elevation, use of pillows Offer bedpan, urinal, change attends every two hours

    72. Hourly Rounding Mark door chart check list each hour: Call light within reach Bed in low position Wheels locked on bed/chair All items within reach i.e., tissues, phone, cup All clutter removed or put away Bed alarm on if indicated No slip socks on patient Offer patient toileting Yellow Arrow protocol Skin Assessment

    73. Yellow Arrow Protocol Yellow wrist band Yellow grip sox Yellow arrow on door Yellow sign on door All employees are to look into patient room. If patient is walking in the room or climbing out of bed without assistance, report to nursing staff immediately.

    74. Restraints Hospital goal: No Restraints Only legal justifications are Danger to self Danger to others Maintenance of therapy Restraints are uses as last resort ONLY after Least Restrictive Alternatives have failed.

    75. Least Restrictive Alternatives Change lighting in room, dimmer or lighter Change sound environment, usually quieter Have patient ambulate with assistance or sit up in chair Arrange for family members to sit with patient. A belt rather than a vest A hand mitt rather than a wrist restraint

    76. Monitor Restraint Every 2 hours for Medical Surgical Restraints Chart under Vital signs Date and time Restraints Applied Circulation/Skin integrity Fluids (food) Elimination Activity/Comfort Restraint type Environment Restraints Discontinued (check box if applicable) Restraints continued related to Maintenance of Therapy Restraints Reapplies (check box if applicable)

    77. Monitor Restraint Every 15 minutes for Behavioral Restraints Chart under Vital signs Date and time Restraints Applied Circulation/Skin integrity Fluids (food) Elimination Activity/Comfort Restraint type Environment Restraints Discontinued (check box if applicable) Restraints continued related to Patient/Staff Safety Restraints Reapplies (check box if applicable)

    78. Save Your Back! Remember to call the lift team if you need help. Use bariatric equipment

    79. Protect Yourself and “Our” Patients Contact Precautions Work together to keep isolation carts stocked (think about the next shift) Wear required gear each time entering room Remove gear just prior to leaving room and wash hands Do not hang gowns on hooks for later use Save time by being organized before entering room It’s our responsibility to protect all patient’s from cross contamination and to follow precautions Wipe down equipment after use on a patient, including between pt,’s (stethoscopes, thermometers, BP cuffs, etc.) Use disposable equipment when available

    80. The Neutropenic Patient Neutropenia is when a patient does not have a functioning immune system and is extremely susceptible to infection. Frequent hand washing by US! Hepa filtration if needed (these filters are on 2E) Keep environment clean If you are sick, take a different assignment. If you are running a fever or are unable to contain your own secretions- DON’T COME TO WORK No fresh vegetation- fruit, vegetables, plants, flowers

    81. Thrombocytopenia Low platelets = High risk of bleeding!! Always cover feet when patient is ambulating If patient is unsteady instruct them to ask for assistance when ambulating, always make sure call light is within reach Keep bed position on low Notify the RN/Instructor if you notice any bleeding or a change in mental status

    82. Oncology Specific Chemo goes into the patient, then out in their urine and other body fluids. For 72 hours after chemo, the pt needs to be in “chemo” precautions to protect you-chemo is in the patient’s urine and body fluids. It is recommended that pregnant women not take care of patients in chemo precautions.

    83. Chemotherapy Precautions Cytotoxic Precautions: Purple Nitrile Gloves should be worn when Emptying commode or urinal Changing attends Emptying retention catheter bags Discarding emesis bags Removing soiled linen from bed If you are discarding waste in the toilet you must DOUBLE flush.

    84. Nasogastric (NG) Tubes and Canisters Mark tube with red tape at 10cm from where tube exits tip of nose. Record amount of drainage at 0600 and 1400 by marking at level of drainage contents and writing time at this level using sharpie pen. Document output on door chart. Evening Shift puts up a new canister and tubing for the next 24 hours at 2200 with I&O totals documented. If canister is full before 24 hours then replace with new canister.

    85. Patient Controlled Analgesia PCA Document every 2 hours for first 24 hours Pain Vital signs Oximetry Sedation scale --- NEW!! Nurses: Chart under ‘assessments’ Then document every 4 hours until PCA is discontinued Patient may become slightly drowsy, but easily aroused. It’s OK ? Notify nurse immediately if patient becomes difficult to arouse, has slurred speech, has minimal or no response to mild stimulation.

    86. Charting Patient Pain When completing vital signs remember to chart pain level. Report to RN and Instructor Obvious discomfort, express discomfort, any rating > 3/10 What the RN and Instructor needs to know Pain level (0-10, faces) Location of pain Intensity

    87. Information about PCA Pumps Resuscitation equipment should be readily available. Be prepared to administer reversal agent - see Naloxone (Narcan) Administration Orders for reversal protocol Reversal of Morphine Sulfate: Narcan 0.1 - 0.4 mg IV Reversal of Hydromorphone: Narcan 0.1 – 0.4 mg IV Reversal of Fentanyl: Narcan 0.1 – 0.4 mg IV Documentation of medication to include: Total dose in mg/mcg under shift total in MAK every 8 hours (0600-1400-2200). Any changes in analgesic dosage in MAK and document patient response in Soarian Clinical Notes. Order written for dosage change Documentation of pain to include: Post-operative patients: every 2 hours X 24 hours then every 4 hours and PRN Medical/Chronic: every 4 hours and PRN

    88. Memorial Codes You may call any code as necessary. Dial 8-123 State code and room number or area Code RED – Fire R.A.C.E. Code BLUE – Cardiopulmonary arrest. Begin CPR immediately-Never Leave the Patient Code RAPID RESPONSE TEAM - Response for patients whose medical condition seems to be declining prior to the heart or breathing stopping Code ORANGE – Hazardous materials spill

    89. Memorial Codes Code GRAY – Combative/Abusive person Patient, family, visitor, staff, physician Code SILVER – Person with a weapon or hostage situation Think “silver bullet” AMBER ALERT – Infant or child is missing or abducted Code EXTERNAL TRIAGE - External disaster Code INTERNAL TRIAGE – Internal disaster Code CLEAR - Hospital page the “code name” and then announce “clear” to indicate the emergency situation is over. Examples: Code Blue – clear Code Red – clear Code Amber Alert – clear

    90. Questions?

    91. Policies and Procedures

    92. Memorial Student Policies Human Resources Personnel Guidelines Students: Personal Appearance Guidelines and Expectations 2. General Nursing Policy and Procedure Education Nursing Students: Documentation 3. General Nursing Policy and Procedure Education Guidelines for Instructors and Students Utilizing Clinical Facilities 4. General Nursing Policy and Procedure Nursing Students: Medication Administration In The Clinical Departments *Print these Student Policies and Review.

    93. Student Policy: Personal Appearance Guidelines and Expectations School’s uniform when on the hospital units. If not in uniform must wear lab coat with ‘business casual attire’ (nice blouse/shirt and non-jean slacks). Name tags shall be worn at all times while on duty and when doing patient research.

    94. Student Policy: Personal Appearance Guidelines and Expectations In clinical areas, socks and shoes must cover toes and heels for protection and to allow for safe mobility at all times. Flip flops are not allowed.

    95. Student Policy: Personal Appearance Guidelines and Expectations (Cont.) Tattoos must be covered. Jewelry must be removed from exposed body-pierced areas, other than the ears, while on duty. Small posts for pierced ears are acceptable.

    96. Student Policy: Personal Appearance Guidelines and Expectations (Cont.) Perfume, cologne, after shave, and scented lotions are not permitted. Underwear must be worn and must be covered by clothing that does not allow for “see-through” exposure

    97. Student Policy: Documentation Clinical Focus Notes made using the D.A.R. format Primary nurse shall document their patient assessment/DAR notes in addition to student’s charting Primary Nurse and/or Clinical Faculty shall evaluate and supervise student documentation prior to computer entry by the student. Failure to have DAR charting reviewed/approved by primary nurse or clinical faculty will result in student dismissal from the clinical site.

    98. Student Policy: Documentation The student will identify the nurse reviewer of the DAR note by documenting the first initial and last name of the professional nurse within the required ‘Header.’ Name of School/Type of Student/Name of Nurse Reviewer in top line -Complete note using DAR format -Conclude the DAR note by signing your first initial and last name followed by SN (Student Nurse); Name of the Nursing Program, followed by the name of the Clinical Instructor.

    99. Sample: Student DAR Computer Documentation See Header example listed below: YVCC Student Nurse Notes Reviewed By:__________RN D (data) – Patient reports she started vaginal bleeding yesterday and she is passing clots. Four maxi pads saturated with dark red drainage and 8 quarter clots in 60 minutes. BP 102/68, P 108, R 24, T 34.1C, SpO2 98% on RA. A (action) – Status reported to Dr. Miller. IV started with 18g. angiocath, 1000 ml of 0.9% Normal Saline hung @ 200 ml/hr. per Dr.’s order. Will continue to monitor bleeding, pad count and vital signs. Dr. Miller to see the patient in one hour. R (response)- Patient understands rationale for IV fluids and continuous monitoring. BP 120/72, P 88, R. 20, T. 34, SpO2 99% @ RA. J. Smith, SN/YVCC/Instructor L. Daily, RN.

    100. Student Policy: Documentation The patient’s record is private and confidential. Personnel who give direct care shall document this care on the patient record. Documentation shall be pertinent, concise and reflect current standards of nursing practice. See Policy For: Standards of Patient Care and Clinical Practice. Patient information on the computer screen is confidential. Whenever leaving a terminal, the person using the terminal must sign off. Under no circumstances are a patient’s records to be photocopied or removed from the hospital premises. When researching assigned patient(s), the student may print the Medication Record ONLY for use in the hospital. Removal of any patient information constitutes a HIPAA Violation and possible student dismissal from the clinical site

    101. Student/Faculty Policy: Guidelines for Instructors and Students Utilizing Clinical Facilities Students and Faculty may park in designated employee parking lots as outlined in the Memorial Orientation Manual Meals are not to be eaten in the clinical area (Nurses Station)-break room only. Students shall take one 30 minute lunch break and two 10 minute breaks during a clinical day. Students will not leave the hospital campus for lunch, unless authorized by their Clinical Instructor. Students shall immediately notify the primary nurse and the faculty regarding any changes in their patient (s) condition

    102. Student/Faculty Policy: Guidelines for Instructors and Students Utilizing Clinical Facilities Student behavior and language should reflect professionalism at all times. Students shall introduce themselves to their selected patients. Students shall not utilize staff badges for any reason. Students shall not leave their assigned clinical area to observe another experience without prior authorization from their clinical instructor. Students shall not be allowed to use cell phones or make personal phone calls from the nursing unit unless approved by the instructor.

    103. Student/Faculty Policy: Guidelines for Instructors and Students Utilizing Clinical Facilities Read and sign the Information Systems Confidentiality Form (Website) BEFORE they receive their computer log-in. Return completed form to Instructor 2 weeks prior to clinical experience. Students will maintain the same computer log-in throughout their entire clinical experience. EMPLOYEE? Read and sign a HIPAA Education Statement and Protected Information Confidentiality Agreement (Website), 2 weeks prior to clinical rotation. Located at the back of the Memorial Orientation Manual. The Instructor will return these to the Memorial Education Department.

    104. Nursing Students: Medication Administration In The Clinical Departments Research all medications before administering to the patient. Never give any Medication without understanding !

    105. Nursing Students: Medication Administration In The Clinical Departments A check of the “7 Rights” will occur when the barcode on the medication is scanned just prior to administration. Right Patient Right Medication Right Dose Right Time Right Route Right Documentation Right to Refuse

    106. Nursing Students: Medication Administration In The Clinical Departments At no time shall students administer medications without supervision. Instructors must be available to observe their students administer medications. If the instructor is unavailable, the student must gain authorization from their instructor to administer medications with the primary RN. If the RN is unavailable or unwilling and the instructor is unavailable, the student must pass up the opportunity.

    107. Nursing Students: Medication Administration In The Clinical Departments Prior to each shift report and/or patient care, all nursing students shall review their assigned patient(s) medication list and physician orders for any changes via the Soarian System. When researching assigned patient medications, the student may print the Medication Record ONLY to only use in the hospital. Removal of any patient information constitutes a HIPAA Violation and possible student dismissal from the clinical site.

    108. Nursing Students: Medication Administration In The Clinical Departments The following medications must always be double checked with the primary nurse or clinical faculty before student administration: Insulin Heparin Coumadin Intravenous Push and Secondary Medications Narcotics Sedatives

    109. Accessing Additional Memorial Policies Print and read the following policies from the Memorial Intranet: General Nursing Policy and Procedure Manual: Standards of Patient Care and Clinical Practice. Infection Control Plan Isolation: STANDARD, CONTACT, DROPLET or AIRBORNE guidelines; Type and Duration of Precautions. Interdisciplinary Policy and Procedures: Report/Patient Hand Off

    110. YVMH Student Guidelines At no time are students expected to assume the total responsibility for a patient’s care. Students shall complete a clinical evaluation tool for each individual clinical unit after the completion of their clinical rotation. Print off Evaluation form from Student Website-give to Instructor. Rule of Thumb: Stay within your scope of practice as you seek out new experiences.

    111. Student Parking When attending clinical rotations or orientation, please isolate your parking to the far North parking lot…….North of West Pavilion II.  All other parking areas are reserved for employees.

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