-Downtime Form: BMC-767

-Policy: Adult Procedural Sedation,7.01.08

•Refer to policy 7.10.01

•Glove use is not a substitute for performing hand hygiene

•Use soap and water if hands or gloves are visibly soiled and if the patient has C. difficile infection

•Use only hospital-approved hand hygiene products (including lotions) while at work

•Reminder to move from clean to dirty sites during patient care and/or environmental cleaning

•Artificial nails are not permitted per policy

•Hand hygiene compliance is monitored via Swipe Sense electronic monitoring system

• Hazardous Drug Risk Assessment
• NIOSH List of Hazardous Medications
• ASHP Guidelines on Handling Hazardous Drugs
• Extravasation Management Reference
• Safete Data Sheets (SDS)
• Chemotherapy Hazardous PPE A Medications Flowchart
• Hazardous PPE B Medications Flowchart

• Abbreviations (Approved and NOT Approved)

Record of Care

• Accurate and Timely Documentation

• Record Retention

• H&P and Post-Op Procedure Note Requirements

• Archiving Paper Documents: Filebridge and Access

• Obtain medication order from a licensed practitioner 
• Verify correct patient with 2 identifiers (name & birth date) 
• Order reviewed timely, questions clarified with prescriber 
• Verify no contraindications, allergies, or drug interactions exist. Verifies medication is not expired. Uses Bar code scanning 
• Verify Patient Rights: right patient, right medication, right does, right time, right route, right indication, right documentation 
• Follow the medication order titration parameters 
• Visually inspect medication for particulates, discoloration, or other loss of integrity. Verifies med matches the order 
• Provide education to patient on expected effect, possible side effects/adverse effects

• Ensure prn medication administration matches the ordered parameters and that the parameters are documented.
• Example: If a PRN pain medication is ordered for MODERATE pain, the patients pain score should bein the MODERATE pain level range.

• Policy: Infection Control in Pharmacy 7.10.41
• Punctured multi-dose vials may be used for a maximum of 28 days or per manufacturer recommendations. Label with the beyond use date once opened/accessed.
• Multi-dose vials opened in the presence of a patient are considered single dose vials and disposed of.

• Click Here for more information regarding Baptist Health's Collaborative Culture of Safety
• Click Here for more information regarding Baptist's Safety Trending And Action Reporting System (STARS)

• Unless otherwise specified, supplies should be labeled with the date they expire after being opened.
• Helpful Tip: Use Google to accurately count how many days to expiration after opening.

• Label with the date the solutions will expire. Do not use marker of any kind.
• Helpful Tip: Use Google to accurately count how many days to expiration after opening.

• Insights Leadership Audit Tracking and Resources Guide

• Converge Training Resources

• New Converge User Accounts

• Converge FAQs

• Adding Converge to the Baptist and Mobile Home Screens

TIMER LAB 3INX3INX1 1/8IN SP ORG TRCBL .25IN,  $40.37

Click Here for the EMR Tipsheet.

Click Here for the EMR Tipsheet.

Policy: Restraints, Care of the Non-Violent or Violent Patient, 7.03.10

Seclusion, Care of Violent Patient in, PSY-14.42.1

Seclusion, Care of Violent Patient in, PSY-14.42.1

2. Some nurses are in the habit of charting all meds/assessments at set times on the hour like 0800, 1200,
etc. This may “look” nice in the flowsheet, but you should chart your work at the time it was
completed. 

• Use the Nursing – My Impact Dashboard to review your proficiency in Epic