Intramuscular Injection

Welcome to Kaiser Permanente Southern California Student Unpaid Field Experience and Training

Inpatient/Hospital and Outpatient/Ambulatory

1 Table of Contents

1 Policy: Student Unpaid Field Experience and Training- SC.QRM.PCS.026 Pg. 3 Appendix A. Onboarding Process 2 Policy: Drug-Free Workplace- NATL.HR.030 Pg. 13 3 Principles of Responsibility (Compliance) Respect Confidentiality, Privacy, and Security Pg. 20 Focus Resources on Member and Patient Care Protect Our Assets and Information 4 2020 Ambulatory Health Care and Hospital National Patient Safety Goals Pg. 31 5 Situation, Background, Assessment and Recommendation (SBAR) Pg. 33 6 Emergency Codes Pg. 34 Student Nurses Continue with Items 7-11 7 KP Nursing Professional Practice Model Pg. 36 8 KP Nursing Professional Practice: Nursing Vision and Values Pg. 37 9 Medication Administration Pg. 38 Policy/Practice Excerpts: Student Un-Paid Field Experience/ Regional High-Alert Medication Safety Practices

Safe Medication Practices, General; Oral Drug Administration; Enteral Drug Administration; Intramuscular Injection; Subcutaneous Injection; Metered Dose Inhaler Use; IV Secondary Line Drug Infusion; Rectal suppository Administration 10 Bar Code Scanning Medication Administration- Instructions for Students Pg. 55 11 Nurse Knowledge Exchange + Pg. 56

2 3 4 5 6 7 8 Appendix A 1.0 Onboarding Process 1.1 All participating Schools agree to adhere to a standardized process for Program Participant prerequisites. 1.1.1 Student/Faculty prerequisites website address: http://kpnursing.org/_SCAL/professionaldevelopment/orientation/index.html 1.1.2 Refer to Nursing Pathways website for Medical Center specific requirements. 1.2 Prior to the start of unpaid field experience and training, the School will verify and attest to KP in writing that the following information is on file for assigned Program Participants:

1.2.1 Criminal Record Search (Background Check): A criminal record search (felony and misdemeanor) encompassing the seven (7) years preceding the start of their unpaid field experience and training will be conducted for all Program Participants unless a greater or lesser search period is permitted or required by state law as per KP policy. If a Program Participant is convicted of a crime during their unpaid field experience and training, it is the School’s responsibility to notify KP within five (5) business days. The Program Participant’s return to the unpaid field experience and training will be determined by KP. Background screening performed by the vendor is valid for 90 days from the start of the program.

1.2.2 Drug Testing: Program Participants will be tested for the following substances: amphetamines, barbiturates, benzodiazepines, benzoylecgonine (cocaine), cannabinoids (marijuana), meperidine (Demerol), methadone, opiates, oxycodone, phencyclidine (angel dust), and propoxyphene. Drug testing is valid for 90 days from the start of the program.

1.2.2.1 Program Participants whose first test results are reported “negative- dilute minor”, will be given the opportunity to retake the test within 48 hours of notification. If the second test is “negative-dilute minor”, the results will be considered satisfactory. 1.2.2.2 A minimum duration of 12 months must elapse before a Program Participant whose results were unsatisfactory will be reconsidered for participation in unpaid field experience and training at a KP facility.

1.2.3 If a Program Participant shows signs of being under the influence of drugs and/or alcohol during their unpaid field experience and training in a KP Facility, the incident must be reported immediately to the Faculty/School and the KP Chief Nurse Executive, or Department Manager. The Faculty will remove the Program Participant from the patient care area and follow necessary school protocol to dismiss the Program Participant from the premises. 1.2.4 Factors which may establish a reasonable suspicion include, but are not limited to: 1.2.4.1 Sudden unexplained changes in behavior which adversely impact work performance.

1.2.4.2 Discovery of presence of alcohol or drugs in a Program Participant’s possession or near the Program Participant’s assigned KP Facility.

1.2.4.3 Odor of alcohol and/or residual odor suspicious for alcohol or drugs.

1.2.4.4 Personality changes or disorientation.

9 1.2.4.5 Violation of safety policies, involvement in an onsite accident or near accident, in combination with any of the above factor(s).

1.2.5 All significant or unusual incidences during the unpaid field experience and training must be reported to the KP Chief Nurse Executive or Department Administrator/Manager, Director of PD&E/Education Lead, the Academic Liaison and/or designee, and documented on the KP Unusual Occurrence Report (UOR) system.

1.2.6 The initial background check and drug screening will satisfy the screening requirement during continuous matriculation of the Program Participant for the duration of their participation in the unpaid field experience and training. If the Program Participant discontinues participation in the program for more than one consecutive semester, a new background check and drug screening will be required.

1.2.7 A current AHA and BLS certification is required and/or other certifications as requested.

1.2.8 Immunizations are current and include:

1.2.8.1 Tuberculosis Screening (TB) – Program Participants are required to demonstrate evidence of screening for TB. 1.2.8.1.1 If Tuberculin Skin Test (TST) or Interferon-Gamma Release Assays (IGRA) are negative: 1.2.8.1.1.1 Provide one TST within 1 year and another TST within 2 years or 1.2.8.1.1.2 One negative IGRA within 1 year 1.2.8.1.2 If Tuberculin Skin Test (TST) or Interferon-Gamma Release Assays (IGRA) are positive: 1.2.8.1.2.1 Provide documentation of positive screening test or history of isonicotinic acid hydrazide (INH) or other TB therapy and a negative chest x-ray within one (1) year from the start of their current academic program. In addition, a negative history since the date of the chest x- ray by completing health screening questionnaire is required. More recent screening may be required if clinically appropriate. 1.2.8.2 Measles, Mumps, and Rubella (MMR)- Program Participants are required to demonstrate evidence of immunity to measles, mumps, rubella by either: 1.2.8.2.1 Documentation of 2 MMR vaccines or 1.2.8.2.2 Positive immune titers to measles, mumps, rubella or 1.2.8.2.3 Laboratory confirmation of disease

1.2.8.3 Varicella Zoster - Program Participants are required to demonstrate evidence of immunity to varicella by either: 1.2.8.3.1 Documentation of 2 varicella vaccines or 1.2.8.3.2 Positive immune titer to varicella or 1.2.8.3.3 Laboratory confirmation of varicella disease, or diagnosis of a history of varicella or herpes zoster (shingles) by a healthcare provider.

10 1.2.8.4 If non-immune or equivocal to measles, mumps and varicella in the absence of appropriate vaccination documentation, Program Participants will be required to receive one dose of the appropriate vaccine before being cleared to start their unpaid field experience and training. Documentation of the second required dose, 4 weeks later, must be provided. If non-immune or equivocal to rubella, Program Participants will require only one dose of MMR.

1.2.8.5 Hepatitis A - Hepatitis A is required for Program Participants whose main duties involve food preparation or serving food within any KP Facilities. Program Participants are required to demonstrate evidence of screening for immunity to Hepatitis A by either: 1.2.8.5.1 Documentation of 2 Hepatitis A vaccines or 1.2.8.5.2 Positive immune titer to Hepatitis A or

1.2.8.6 Hepatitis B - Program Participants are required to be screened for immunity to Hepatitis B by either: 1.2.8.6.1 Demonstrate immunity by a positive Hepatitis B antibody after a complete Hepatitis B Vaccine series or 1.2.8.6.2 Present proof of past infection (i.e. positive HBcAb or HBsAg) or 1.2.8.6.3 Begin/complete Hepatitis B vaccination series followed by Hepatitis B antibody testing

1.2.8.7 Influenza (Flu) Vaccine - Program Participants are required to demonstrate evidence of Flu Vaccination during the current flu season. If current seasonal flu vaccine is not available at the start of the rotation (i.e. July or August), documentation must be provided within 30 days of the current season’s flu vaccine’s availability.

1.2.8.8 Tetanus, Diphtheria and Acellular Pertussis (Tdap) Vaccine- Program Participants are required to demonstrate a Tdap vaccine by immunization record signed by a qualified health provider.

1.2.8.9 Other - Other immunizations and health screenings, as required by law or reasonably requested by Kaiser Entities in accordance with Kaiser Entities’ applicable policies and procedures, may be unilaterally amended by Kaiser Entities by a written notice to the School.

1.2.8.10 Declinations - Immunization declinations will not be accepted at any Facility.

1.3 Faculty whose classifications require current California professional licensure and/or certification must provide proof to KP in writing.

1.4 KP HealthConnect Access – Program Participants, who are expected to access patient records, must submit the Common Provider Master (CPM) form to KP at least four (4) weeks prior to the start of the unpaid field experience and training to obtain access to the HealthConnect documentation system.

1.5 KP HealthConnect Training – The School will facilitate access to approved KP HealthConnect training.

11 1.6 Program Participants will read, complete, and submit all prerequisites prior to the start of the unpaid field experience and training.

1.7 Faculty must verify the completion of the prerequisites as stated in this policy. KP may validate compliance by auditing Student files.

12 Human Resources

Policy Title: Drug-Free Workplace Policy Number: NATL.HR.030 Owner Department: Human Resources Effective Date: 8/1/17 Custodian: Chair, National HR Policy Page: 1 of 7 Roundtable

1.0 Policy Statement Kaiser Permanente (KP) is committed to protecting the safety, health and well-being of employees and other individuals in KP’s workplace and provides an environment that is free from the abuse of alcohol and drugs. KP recognizes that alcohol abuse and drug use pose a significant threat to KP’s goals. KP also acknowledges that alcohol abuse and chemical dependency may be chronic diseases that require rehabilitative treatment, counseling, and/or access to employee assistance programs.

2.0 Purpose This policy is consistent with requirements of the federal Drug-Free Workplace Act of 1988, applicable state drug-free workplace requirements, and with KP’s obligation to provide a safe work environment.

3.0 Scope/Coverage 3.1 This policy applies to all employees working in any of the following entities (collectively referred to as “Kaiser Permanente”): 3.1.1 Kaiser Foundation Hospitals and Kaiser Foundation Health Plan, Inc. (together, KFH/HP); 3.1.2 KFH/HP’s subsidiaries; 3.1.3 The Permanente Medical Group, Inc. (TPMG) [NOTE: This policy does not apply to physicians, podiatrists or Vice Presidents of TPMG, who are covered by separate TPMG policies]; and 3.1.4 Southern California Permanente Medical Group (SCPMG) [NOTE: This policy does not apply to physicians of SCPMG]. 3.2 All organizations who supply temporary or registry personnel, students or trainees to KP will be held accountable for providing personnel who meet the same drug-free standard imposed by KP on its own employees. Volunteers are also required to meet this drug-free standard. Violation of applicable provisions or refusal to cooperate in the implementation of this Policy can result in contract personnel or volunteers being barred from company premises or from working in its operations. 3.3 Employees whose jobs require them to drive KP fleet vehicles are subject to the drug and alcohol testing requirements in the applicable Fleet Management policies. In addition, employees whose jobs require commercial driver’s licenses are subject to a drug and alcohol testing program that fulfills the requirements of the U.S. Department of Transportation (DOT) Regulations. (See the Addendum to REGL.HR.02a and REGL.HR.02b, Drug and Alcohol Testing.)

4.0 Definitions 4.1 Alcohol – means ethanol alcohol in any consumable form (e.g., beer, wine, liquor).

Policy Title: Drug-Free Workplace Policy Number: NATL.HR.030 Owner Department: Human Resources Effective Date: 8/1/17 Custodian: Chair, National HR Policy Page: 2 of 7 Roundtable

4.2 Being under the influence – means an individual is impaired by alcohol or a drug, or the combination of alcohol and drugs, regardless of the level detected. A determination of “under the influence” can be established by a professional opinion, a medically accepted drug or alcohol screening test, and/or based on lay observations by supervisors, co-workers, or others. 4.3 Company premises -- includes parking lots, vehicles and other facilities and property owned, leased or operated by KP, as well as off-site premises used for company-sponsored events. 4.4 Drug -- means: 4.4.1 any drug which is not legally obtainable: any “illicit” drug or “controlled substance” the possession or use of which could result in arrest or other legal sanction according to state or federal statute. Examples include but are not limited to, marijuana, cocaine, crystal methamphetamines (ice), and hallucinogens. [NOTE: Although "medical marijuana" or marijuana use laws may exist in some states, because marijuana is a Schedule I drug and possession or use of it is unlawful under federal law, marijuana is an illicit drug for all purposes under this policy.]; 4.4.2 any drug which is legally obtainable but has not been legally obtained; 4.4.3 prescribed drugs not being used for prescribed purposes or at prescribed dosages; and/or 4.4.4 any non-prescription substances that are used contrary to manufacturer’s recommendations. 4.5 Work Time -- time during which an employee is representing or conducting business for KP, or is required or scheduled to be on duty.

5.0 Provisions 5.1 Pre-Employment Drug Testing In accordance with NATL.HR.029, Pre-Employment Drug Testing, KP requires that all individuals external to KP who have been offered employment complete pre- employment drug testing demonstrating the absence of illegal drugs or prohibited use of legal drugs. 5.2 Employees with Drug and Alcohol Problems 5.2.1 KP supports the use of treatment and programs to address alcohol or drug abuse and will provide them when warranted by conditions and circumstances. However, KP must balance respect and concern for individuals experiencing these problems with KP’s commitment to maintain an alcohol and drug-free environment. KP encourages employees to voluntarily seek help with drug and alcohol problems. (See Addendum for California employees.) 5.2.2 KP encourages any employee covered by this policy who is experiencing alcohol or drug dependency to seek professional assistance, including the

Policy Title: Drug-Free Workplace Policy Number: NATL.HR.030 Owner Department: Human Resources Effective Date: 8/1/17 Custodian: Chair, National HR Policy Page: 3 of 7 Roundtable

use of KP’s confidential Employee Assistance Program. Whenever practical, KP will assist employees in overcoming drug, alcohol, and other problems which may affect employee job performance, provided that such assistance is requested prior to violation of this policy. 5.2.3 Employees' voluntary participation in chemical dependency recovery programs or other rehabilitation services will be kept confidential and will not affect their employment as long as they are meeting the terms and conditions of the program. Both KP policy and existing laws protect the confidentiality of persons who seek treatment for chemical dependency. 5.2.4 Depending on the circumstances, an employee’s return to work, reinstatement, and/or continued employment may be conditioned on the employee's successful participation in and/or completion of any and all evaluations, counseling, treatment, rehabilitation programs, or other appropriate conditions as determined by KP. 5.3 Employees Taking Prescribed Medication The use of prescribed medication at prescribed dosages and for prescribed purposes under the direction of a physician or other appropriate licensed person on either a long-term or short-term basis may affect the safety of the employee, co-workers or members, the employee's job performance, or the safe or efficient delivery of services. Therefore, any employee who experiences an impairment of performance that could impact his/her work duties due to the use of such medication (e.g., vision impairment, lack of balance, loss of reflexes, impaired judgment) must report this to his or her supervisor. If the use of such medication affects the safety of the employee, co-workers or members, the employee's job performance, or the safe or efficient delivery of services, the employee may be required to be away from work temporarily using sick leave, PTO, ETO, medical leave, personal leave, or other time off benefits. 5.4 Prohibited Conduct and Penalties 5.4.1 It is a violation of this policy to use, possess, sell, purchase, trade, and/or offer for sale or to purchase drugs (as defined in this policy) during work time or at any time on KP premises. Being under the influence of a drug by any employee on KP premises or during work time is prohibited. 5.4.2 Being under the influence of alcohol by any employee while on KP premises or during work time is prohibited. The consumption, sale, purchase, or offer for sale or to purchase of alcohol on KP premises is prohibited. Possession or transfer of an open container of alcohol on KP premises is a violation of this policy, except in circumstances in which consumption of alcohol is specifically authorized at a KP sponsored or sanctioned function. 5.4.3 Being at work and failing to report to the supervisor that prescribed medication is impairing the employee’s motor functions is a violation of this policy. 5.4.4 Theft, diversion or unauthorized removal of drugs maintained or dispensed on KP premises is a violation of this policy.

Policy Title: Drug-Free Workplace Policy Number: NATL.HR.030 Owner Department: Human Resources Effective Date: 8/1/17 Custodian: Chair, National HR Policy Page: 4 of 7 Roundtable

5.4.5 It is a violation of this policy for employees to unlawfully manufacture, distribute, dispense, possess, sell, purchase, or use an illegal drug while off duty or off premises, where the conduct adversely affects the employment relationship or KP’s business interests. 5.4.6 Violation of this policy will subject employees to corrective/disciplinary action, up to and including termination of employment, and may result in a referral to law enforcement agencies for possible criminal prosecution. 5.5 Notification of Convictions 5.5.1 Any employee who is convicted of a criminal offense for a drug violation must, as a condition of employment, notify Human Resources within five days of that conviction. Failure to provide timely notification will result in corrective/disciplinary action, up to and including termination of employment. 5.5.2 Federal contracting agencies will be notified of employee convictions when appropriate. 5.6 Reasonable Suspicion of Prohibited Alcohol or Drug Use 5.6.1 A supervisor may have a “reasonable suspicion” that an employee is under the influence based upon observation of conduct and/or events. Factors which may establish reasonable suspicion include, but are not limited to: 5.6.1.1 Sudden unexplained changes in behavior which adversely impact work performance. 5.6.1.2 Discovery or presence of alcohol or illegal drugs in an employee’s possession or near the employee’s work space. 5.6.1.3 Odor of alcohol and/or residual odor peculiar to alcohol or controlled substances. 5.6.1.4 Personality changes or disorientation. 5.6.1.5 Violation of safety policies, or involvement in an on the job accident or near accident. 5.6.2 When reasonable suspicion has been established to indicate an employee is under the influence of alcohol or drugs, the employee will be asked, at the sole discretion of management, to provide breath, blood and/or urine specimens for laboratory testing. Employees are required to follow regional policies/procedures regarding drug and alcohol testing. (See REGL.HR.02a and REGL.HR.02b, Drug and Alcohol Testing.) 5.6.3 Where there is reasonable suspicion that employees possess or their personal effects (including vehicles, purses, briefcases, clothing, personal containers) contain an illegal drug or an open container of alcohol, KP may, with consent, search such individuals or their personal effects. Refusal to consent to such searches may be considered insubordination (see NATL.HR.014, Corrective/Disciplinary Action). Illegal drugs which are confiscated will be turned over to local law enforcement agencies. 5.7 Confidentiality

Policy Title: Drug-Free Workplace Policy Number: NATL.HR.030 Owner Department: Human Resources Effective Date: 8/1/17 Custodian: Chair, National HR Policy Page: 5 of 7 Roundtable

KP recognizes the importance of maintaining confidentiality in any situation where current and former employees covered by this policy are suspected of alcohol or drug related infractions. Every effort will be made to assure the privacy of suspected employees throughout investigatory and corrective/disciplinary action proceedings. 5.8 Policy Attestation At a minimum, this policy is communicated and reviewed at New Employee Orientation. New employees are required to sign an attestation that they acknowledge, understand, accept, and agree to comply with this policy, and that they understand that failure to comply with this policy may result in corrective/disciplinary action up to and including termination. 5.9 State Requirements In addition to the federal requirements regarding a drug-free workplace some states have related laws or statutes that KP must comply with in applicable regions (e.g., see Addendum). 5.10 Additional Employee Obligations and Responsibilities Employees who abuse drugs and/or alcohol often affect the performance of other employees. KP cannot provide quality health care without the cooperation and assistance of all employees. As discussed in the "Principles of Responsibility”, employees who observe activities prohibited by this policy are responsible for alerting their supervisors or whatever management is necessary to resolve the issues. Failure to report violations may result in corrective/disciplinary action.

6.0 References/Appendices 6.1 Addendum – Alcohol & Drug Rehabilitation for California employees 6.2 Drug-Free Workplace--Employee Acknowledgement 6.3 REGL.HR.02a and REGL.HR.02b, Drug and Alcohol Testing 6.4 NATL.HR.011, Employment Screening 6.5 NATL.HR.014, Corrective/Disciplinary Action 6.6 NATL.HR.029, Pre-Employment Drug Testing 6.7 Employee Assistance Program: http://xnet.kp.org/hr/ca/eap/index.htm 6.8 Federal Drug-Free Workplace Act of 1988 6.9 California Drug-Free Workplace Act of 1990 6.10 Cal Govt Code § 8355 et seq. 6.11 Virginia Drug-free Workplace Act 6.12 Virginia Code § 2.2-4312

7.0 Approval

Policy Title: Drug-Free Workplace Policy Number: NATL.HR.030 Owner Department: Human Resources Effective Date: 8/1/17 Custodian: Chair, National HR Policy Page: 6 of 7 Roundtable

Update approval 7/21/17 In accordance with the charter of the National HR Policy Roundtable, this policy update was approved by the National HR Policy Roundtable members, as chaired by Derek Reimer.

Policy Revision History Original Approvals Update Approvals Revision Approvals

Approval Date: 10/30/12; Approval Date: 1/28/10 11/29/12; 4/30/15; Approval Date: 9/9/10 7/21/17

Effective Date: 10/30/12; Effective Date: 4/5/10 11/29/12/ 4/30/15; Effective Date: 11/3/10 8/1/17

Communicated Date: n/a Communicated Date: n/a

Policy Title: Drug-Free Workplace Policy Number: NATL.HR.030 Owner Department: Human Resources Effective Date: 8/1/17 Custodian: Chair, National HR Policy Page: 7 of 7 Roundtable

Addendum

Alcohol & Drug Rehabilitation For employees working in California

Time Off Employees may take time off work to voluntarily enter and participate in an alcohol or drug rehabilitation program. The amount of time off must be reasonable and not create an undue hardship on KP operations. Nothing in this policy prohibits KP from refusing to hire or discharging an employee due to current use of drugs or alcohol, inability to perform his or her duties due to drug or alcohol use, or inability to perform his or her duties without endangering the health or safety of the employee or others. Eligibility Any employee who voluntarily enters and participates in an alcohol or drug rehabilitation program. Notice & Documentation Requirements Time off for this purpose will be granted if an employee provides reasonable notice of the request and a doctor’s note to his/her manager. In the alternative, the employee may provide notice to his/her local Human Resources Representative. Paid or Unpaid Time Off Employees are required to use available paid time off for this purpose (sick leave, vacation, Paid Time Off or Earned Time Off) before taking leave without pay. Confidentiality Any records and information regarding an employee’s absence for participation in an alcohol or drug rehabilitation program will be maintained as confidential. Managers and supervisors will take all reasonable steps to safeguard the privacy of an employee regarding participation in an alcohol or drug rehabilitation program. Law/statute California Labor Code, Sections 1025-1028

20 PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS

2. Respect Confidentiality, Privacy, and Security Much of the information we collect from patients — including medical condition, history, medications, and family illnesses — is very sensitive and protected under privacy and information security laws. In addition, we must abide by any business associate agreements that we have with self-funded health plans, which further restrict our access to and use of protected health information (PHI). Keeping data confidential, private, and secure is essential to: • Preserving the trust of our members and patients. • Providing quality health care. • Complying with federal and state regulations and Kaiser Permanente policies. • Protecting our reputation.

21 12 PRINCIPLES OF RESPONSIBILITY PRESERVE THE TRUST 13 , co-workers, and, co-workers, 22 . It’s great that you want to help your that you want great . It’s including your family including

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PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS THE TRUST OF OUR MEMBERS, PATIENTS, PRESERVE have a right to privacy have a right

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If there is a business need to access the PHI of a family member, friend, or is a business need to access the PHI of a family member, If there follow all laws party (such as a co-worker), or your own medical record, third that apply to your job. and policies and procedures Access the minimum amount of information necessary to do your job, whether The performing and/or business role. you are a clinical, administrative, by a to or requests does not apply to disclosures minimum necessary standard purposes. for treatment provider health care Personal fines. Termination of employment. Termination attorneys by state general or U.S. attorneys.Criminal prosecution Sanctions. by your applicable licensing board(s). to and/or discipline Disclosure Disciplinary action.

• • • • • • • • identified and disciplined and our organization both you inappropriately, If you access medical records could face government access endangers penalties and fines. Unauthorized in Kaiser Permanentethe trust our members and patients have and our good standing in the community. colleague, but it’s against the law for you to look at a medical record unless look at a medical record against the law for you to colleague, but it’s the informationyou need access to to do your job. and refer to your policies and procedures to your area, For guidance specific guidance, need more If you or immediate supervisor. check with your chief officer. or compliance and security officer speak with your privacy a business need to know is against without records Looking up medical checks look. Kaiser Permanente regularly so play it safe and don’t the law, Physicians, dentists, and logs of what data has been accessed. electronic have been inappropriately accessed medical records employees who have No. All members and patients No. All members public figures My co-worker Abraham has missed a lot of work lately and, quite frankly, he frankly, and, quite work lately a lot of has missed Abraham My co-worker for him. to be there he is sick and I want I’m worried that look so well. doesn’t for me to check his for him, is it okay caring I’m not officially Even though help? any way I can doing in case there’s he’s to see how medical record Consider This…Consider We must comply with federal and state privacy laws and protect all confidential and state privacy laws and protect must comply with federal We result in: result information, and Kaiser Permanente to do so may business information. Failure information Physicians, dentists, and employees should always: Physicians, dentists, and employees should PRESERVE THE TRUST policy or Permanente DentalAssociatespolicy.policy orPermanente Physicians anddentistsshouldrefer MedicalGroup totheapplicablePermanente 14 • • • • • • • • • • • •

PRINCIPLES OFRESPONSIBILITY and sending. there are nohiddencolumns,rows, ortabsinspreadsheets before attaching Make sure electronic documentsdonotcontainunnecessary data.Ensure fromRemove allnon-essentialinformation anemailbefore youforward it. entityorbusinessassociateunderHIPAA).Permanente if itcreates, receives, maintainsand/ortransmitsPHI onbehalfofaKaiser followed (forexample,avendormustsignbusinessassociateagreement Restrict accessbyvendorstoPHIunlessanappropriate process hasbeen it sootherscannotusewithyouruseridentification. Log off ofashared computerorlockyour before walkingawayfrom readable byothers. Use aprivacyscreen onyourcomputermonitorifthescreen isvisibleand printers. Retrieve printoutscontainingPHIpromptly from shared faxmachinesand Make sure doorstorestricted areas are withsensitiveinformation keptlocked. that thefaxnumberyouare sendingtoiscorrect. or,send sensitiveemailinanencryptedformat verify whenfaxinginformation, Click onthe‘SendSecure’emailsystemto buttonintheKaiserPermanente HealthConnect Permanente Keep emailcommunicationswithpatientsinsecured channelssuchasKaiser Keep electronic devicessecure andpasswords protected. only whenitisrequiredDiscuss patientinformation foryourjob. your job. payment systems,followalllawsandpoliciesprocedures thatapplyto credit etc.)orworkingwithour card accountinformation, information, (e.g., When handlingconfidentialpatientormemberpaymentinformation of care andallowedbythepoliciesthatapplytoyou. ® unlessotherwisenecessarytoensure continuity 23 PRESERVE THE TRUST 15 24 PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS THE TRUST OF OUR MEMBERS, PATIENTS, PRESERVE

Data saved on a Kaiser Permanente computer’s desktop or C drive doesn’t get desktop or C drive doesn’t Data saved on a Kaiser Permanente computer’s backed up. desktop or C drive, it is not backed up If you save data to your computer’s means you could lose that data. Also, if you store to our servers. This regularly technical problems are data on a device (like a thumb drive or CD) and there with the device or the device is lost or stolen, you could lose the data because servers. it is also not backed up on our secured on data correctly saving you’re Check with your IT Help Desk to make sure network servers. We mail printouts of patients’ lab results and sometimes the results accidentally the results sometimes and results lab of patients’ mail printouts We can just We member. to a different and mailed envelope addressed go into an right? belong to them, that don’t results away the to throw ask the individuals or a member from PHI without authorization revealing Improperly Wrong. If accidental. even if it’s privacy, of that person’s a serious violation patient is as you become aware as soon as officer notify your compliance this happens, must take place.several notifications containing member When mailing documents preventable. this are like Errors matches the time to check that the name on the document or patient PHI, take multiple to address a mail merge on the envelope. If you use name and address in the mail merge time to verify that no errors envelopes, take additional time to perform By taking extra you can these checks, occurred. have process of PHI to one individual or to hundreds. disclosure improper an prevent that apply to procedures to the policies and refer For additional guidance, how to handle PHI your chief or immediate supervisor on you and check with appropriately. Did You Know… Did You Consider This…Consider if the device is lost or stolen. password-protecting the device, to protect against the information the device, to protect being misused password-protecting encrypted and you must take other special physical and security steps, such asencrypted and you must take other special If you get approval to store data on an electronic device, the data must be device, the data data on an electronic to store If you get approval authorization as required by applicable policy or policies. authorization as required than the systems located on the Kaiser Permanentethan the systems located on the Kaiser network, you must obtain any electronic device (such as thumb drives, laptops, clinical devices, etc.) other device (such any electronic If you have an essential business need to store confidential patient information on to store If you have an essential business need secured network servers rather than on electronic devices. than on electronic network servers rather secured You should store confidential information such as PHI on Kaiser Permanente’s confidential information on Kaiser Permanente’s such as PHI should store You 2.1 Store Confidential Information Confidential Correctly 2.1 Store PRESERVE THE TRUST waste, andabuse. Many ofouractivitiesatworkare monitored toprevent anddetectfraud, physician, dentist,andemployeebeinvolved,committed,participate. health care. Thisispartofourmissionandvaluesrequires thatevery and preserves ourresources toreduce costsandhelpsusprovide affordable Kaiser Permanente’s fraudcontrol program protects ourmembersandpatients 3.1 DetectandPrevent Fraud,Waste, andAbuse 3. FocusResources onMemberandPatientCare 16 Find OutMore: Legally Speaking... falsifying timecards. vendor billing,memberfraud,mailbackdatingdocuments, and theft, medicalidentityfalseworkers’compensation claims,fraudulent reporting, software piracy, credit card fraud, expense accountfraud,identity Examples: Embezzlement,falseclaims,kickbacks,bribery, falsefinancial unauthorized benefittotheperpetrator, anotherindividual,oranentity. disregard ofthetruth,knowingthatdeceptioncouldresult insome Fraud isadeceptionormisrepresentation madeintentionallyorwithreckless National Fraud Control Program. kp.org/compliance EmployeesandPhysicians> >KaiserPermanente moreLearn aboutKaiserPermanente’s fraudcontrol program at: PRINCIPLES OFRESPONSIBILITY 25

PRESERVE THE TRUST 17 Section for more on your protections on your protections for more 26 PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS THE TRUST OF OUR MEMBERS, PATIENTS, PRESERVE

Section 8.3.8: Patient Referrals, Section 8.3.9: Anti-Kickback Laws, and Referrals, Section 8.3.9: Anti-Kickback Section 8.3.8: Patient for more for more Assets and Information and Use Our Properly Safeguard Section 5.1: Section 10.1: Report Potential Compliance Issues Section 10.1: Report

If successful, the government can recover up to three times the amount at issue. up to three If successful, the government can recover fraud and potentially receive a portion of any money that is recovered in the case. a portion of any money that is recovered fraud and potentially receive a “whistleblower” provision that allows people outside the government to report a “whistleblower” provision of the claims submitted also can lead to violations. The False Claims Act includesof the claims submitted also can lead claim to the government. Deliberate or reckless disregard for the truth or falsity disregard claim to the government. Deliberate or reckless anyone who knowingly submits, or causes the submission of, a false or fraudulentanyone who knowingly submits, or causes For example, the federal False Claims Act provides for civil financial penalties for Act provides For example, the federal False Claims very important that it is accurate. other activities, including billing, quality reporting, and financial forecasting, so it is and financial forecasting, reporting, other activities, including billing, quality requirements. This documentation is the basis for regulatory reporting and many reporting the basis for regulatory This documentation is requirements. supporting medical record documentation must comply with all applicable coding must comply with all applicable documentation record supporting medical patient care provided in an accurate, complete, and timely manner. Claims and complete, and timely manner. in an accurate, provided patient care Physicians, dentists, and employees must document and code (where applicable) code (where and employees must document and Physicians, dentists, when reporting suspected fraud. when reporting See for more on avoiding fraud. and Contract Fairly for more 8.5.1: Purchase See on fraud, waste, and abuse prevention. on fraud, waste, and See Compliance Hotline at 1-888-774-9100. Compliance services, controller, human resources representative, or the Kaiser Permanente or the Kaiser representative, human resources services, controller, report it to your chief or immediate supervisor, compliance officer, internal audit officer, compliance supervisor, or immediate it to your chief report for our members and patients. If you are aware of any fraudulent activity, you must you activity, of any fraudulent aware If you are and patients. for our members work. We must preserve our resources to provide the most affordable health care health care affordable the most to provide our resources preserve must We work. Physicians, dentists, and employees must never participate in fraudulent activity at activity fraudulent in never participate must employees and dentists, Physicians, 3.2 Follow Anti-Fraud Laws Follow Anti-Fraud 3.2 PRESERVE THE TRUST human resources representative. immediate supervisor, complianceofficer, auditservices,controller, internal or If youare aware ofanyfraudulentactivity, youmustreport ittoyourchiefor Physicians, dentists,andemployeesmustprotect KaiserPermanente’s assets. assets. Kaiser Permanente immediate supervisortoobtaintheappropriate approvals before youdonate practices regardless oftheirconditionorvalue.Consultwithyourchief assets forpersonalgainorbenefit,disposeofoutsideauthorized ofmisuse,waste,damage,andloss.DonotuseKaiserPermanente all forms business purposesonly. Theymustbehandledwithcare andprotected against Kaiser Permanente’s assetsare healthcare tobeusedforKaiserPermanente and 5.1 Safeguard Properly andUseOurAssetsInformation 5. Protect OurAssetsandInformation 20 Consider This… Consider This… Assistance Programs orotherprograms. supervisor. ofavailableMedicalFinancial Patientsshould beinformed policies andprocedures regarding copaycollectionorcontactyourimmediate If patientscannotmaketheir copayatthetimeofservice,followyourarea’s What shouldIdo? an appointmentbecausethey can’t afford to,but I’mquitesure Ican’t dothis. so badbecauseIdon’t wanttoberesponsible foramembernotcomingin job. AfewofthemhaveaskedmeifIcanwaivetheregistration copay. Ifeel because they’vehadtheirworkhoursreduced orafamilymemberhaslost In thepastfewyearsI’veseensomeofourregular patientsstrugglefinancially PRINCIPLES OFRESPONSIBILITY 27 PRESERVE THE TRUST 21

28 PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS THE TRUST OF OUR MEMBERS, PATIENTS, PRESERVE , email, voicemail, instant messaging, the Kaiser Permanente, email, voicemail, ® Section 2: Respect Confidentiality, Privacy, and Security to learn more Privacy, Section 2: Respect Confidentiality, Downloading and/or running external software not approved by not approved Downloading and/or running external software use. Downloading music and videos for personal Gambling. derogatory, Viewing discriminatory, pornography or any other offensive, Sending mass emails asking co-workers to support personal or professional to support personal or professional Sending mass emails asking co-workers causes. or exploitative content. Kaiser Permanente IT.

• • • • • about accessing information systems appropriately and the safeguards in and the safeguards about accessing information systems appropriately their health information. patients and place to protect See For additional guidance, refer to the policies and procedures that apply to apply that and procedures the policies to refer guidance, For additional to direct on where or immediate supervisor with your chief you and check assistance. and patients for financial members Find Out More: Find Out More: Find Out More: Find environment. environment. professional, respectful, and lawful manner that is appropriate in a business manner that is appropriate and lawful respectful, professional, on Kaiser Permanente-owned in a hand-held devices, must be conducted with applicable policies. All communications, including electronic communications All communications, including electronic with applicable policies. and to conduct Kaiser Permanenteand to conduct Kaiser accordance business. They must be used in employees to use in providing care to Kaiser Permanente and patients members care providing employees to use in Kaiser Permanente’s information systems are tools for physicians, dentists, and tools for physicians, dentists, information systems are Kaiser Permanente’s intranet, and access to the Internetintranet, and access over the Kaiser Permanente network. Internet on Kaiser Permanente devices: The following activities are not allowed when using email, the intranet, or the The following activities are activities that are illegal, illicit, or violate Kaiser Permanente illegal, illicit, policies. activities that are Kaiser Permanente information never be used to engage in systems should KP HealthConnect Kaiser Permanente has many different information include systems. Examples Kaiser Permanente has many different 5.1.1 Use Information5.1.1 Use Systems Appropriately quality patient care and services. quality patient care reasons should never interfere with your job duties or detract from providing providing with your job duties or detract from should never interfere reasons Use of personal electronic devices or Kaiser Permanente devices devices for non-businessUse of personal electronic PRESERVE THE TRUST websites) and your access to information systems andtools websites) andyouraccesstoinformation usage(includingthefrequency and Internet duration ofvisitstospecific tomonitoryouremail dentists, andemployees,itislegalforKaiserPermanente and reviewed.respects WhileKaiser Permanente theprivacyofphysicians, messages systems, alldataandcommunications 22 information. to discloseitfrom someonewhoisadecision makerforthatconfidential outside theorganization, includingmembers,unless you havereceived approval shouldnotbe shared and othercompetitivelysensitive information, withanyone non-public businessandclinical strategiesandinitiatives,pricinginformation, suchasKaiserPermanente’sConfidential information, financial dataand reports, 5.1.2 Safeguard ConfidentialInformation consent orpriornotice. Also, you should know that when you use Kaiser Permanente information information Also, youshouldknowthatwhenuseKaiserPermanente Find OutMore: Consider This… Consider This… systems. you andcheckwithyourchieforimmediatesupervisoronusinginformation For additionalguidance,refer tothepoliciesandprocedures that applyto business. systemstopromote information ormaintainapersonal use KaiserPermanente scheduling appointmentsorfollowingupwithteachers,itisnotacceptableto to handlesomepersonalmattersduringworkfrom timetotime,suchas be usedforpersonalbenefit.Whileit’s understandablethatyoumayneed systems,includingcomputers,cannot information No. KaiserPermanente to communicatewithhiscustomers.Isthisokay? My co-workerhasafamilyownedbusiness.Ioftenseehimusinghiscomputer never interfere withyourjobduties. Useofdevicesforpersonalreasons expected atKaiserPermanente. should You are right.Thesecallsare detractingfrom theservicequalitythatis to me.Isit? in process whilecontinuingherpersonalconversation.Thisdoesn’t seemright talking onthephonewhenamemberarrivesatdeskandbeginscheck personal phonecallswhenthere isnoonewaiting.However, she continues I havenoticedoneofthereceptionists inmydepartmentoftenmakes PRINCIPLES OFRESPONSIBILITY

—

become thepr operty of Kaiser Permanente andcanbemonitored operty ofKaiserPermanente

— 29

including emailandvoicemail

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PRESERVE THE TRUST ; 23 ® , and Thrive ® , KP HealthConnect ® 30 PRESERVE THE TRUST OF OUR MEMBERS, PATIENTS, AND CUSTOMERS THE TRUST OF OUR MEMBERS, PATIENTS, PRESERVE . kp.org trademark registrations for Kaiser Permanente trademark registrations property at Kaiser Permanente include our research methods and results; our methods and results; at Kaiser Permanente research include our property copyrights, trademarks, trade dress, and trade secrets. Examples of intellectual secrets. and trade trade dress, copyrights, trademarks, protected by law by several forms of intellectual property rights, including patents, rights, including by law by several forms property of intellectual protected technical know-how; and words, phrases, symbols, and designs. These assets are and designs. These assets are phrases, symbols, and words, technical know-how; the mind such as musical, literary, and artistic works; discoveries, inventions, and works; discoveries, and artistic literary, the mind such as musical, Intellectual property is a legal concept which refers to and protects creations of creations to and protects which refers is a legal concept property Intellectual 5.1.3 Protect Intellectual Property Property Intellectual 5.1.3 Protect Relations Act or any other applicable law. Act or any other applicable Relations employment or that otherwise are legally protected under the National Labor under the National protected legally are or that otherwise employment communications concerningcommunications terms or other benefits, wages, ofand conditions unrelated to Kaiser Permanente, lawful off-duty conduct, or prohibit or prohibit conduct, Permanente, to Kaiser off-duty lawful unrelated This requirement is not intended to limit communications regarding matters regarding communications to limit intended is not requirement This remains current. remains physicians, dentists, and employees and should review this list to ensure that it this list to ensure should review physicians, dentists, and employees and Chiefs and immediate supervisors should have a current list of all assets held by have a current Chiefs and immediate supervisors should dentist, or employee is promoted, is transferred, or leaves Kaiser Permanente. is transferred, dentist, or employee is promoted, Permanente assets should be returned according to policy when a physician,Permanente assets should be returned according issued to physicians, dentists, and employees in their unit or department. Kaiserissued to physicians, dentists, and employees Chiefs and immediate supervisors have a responsibility to keep track of the assets a responsibility Chiefs and immediate supervisors have 5.1.5 Keep Track of Assets 5.1.5 Keep Track business purposes and cannot be used for personal charges. business purposes and cannot be used Permanente policies. Corporate credit cards must be used only for authorized cards Permanente policies. Corporate credit value, must be handled responsibly, honestly, and in strict compliance with Kaiser honestly, value, must be handled responsibly, Kaiser Permanente funds, which include anything that has or represents financial Kaiser Permanente that has or represents funds, which include anything 5.1.4 Use Funds Appropriately Kaiser Permanente Compliance Hotline at 1-888-774-9100. immediate supervisor, human resources representative, compliance officer, or the compliance officer, representative, human resources immediate supervisor, inappropriately, stolen, or lost, you should report it right away to your chief or stolen, or lost, you should report inappropriately, If you suspect that any intellectual property has been used or disclosed If you suspect that any intellectual property property of Kaiser Permanente. property in the course and scope of your employment with Kaiser Permanente of your employment with Kaiser in the course and scope is the body of knowledge that advances health care. All intellectual property generated All intellectual property that advances health care. body of knowledge These assets help to keep Kaiser PermanenteThese assets help to to the competitive and contribute on and our copyright-protected educational materials and photographs in print and educational materials and our copyright-protected 2020 Hospital National Patient Safety Goals The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them.

Identify patients correctly NPSG.01.01.01 Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.

Improve staff communication NPSG.02.03.01 Get important test results to the right staff person on time.

Use medicines safely NPSG.03.04.01 Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. NPSG.03.05.01 Take extra care with patients who take medicines to thin their blood. NPSG.03.06.01 Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Give the patient written information about the medicines they need to take. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.

Use alarms safely NPSG.06.01.01 Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

Prevent infection NPSG.07.01.01 Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.

Identify patient safety risks NPSG.15.01.01 Reduce the risk for suicide.

Prevent mistakes in surgery UP.01.01.01 Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.

UP.01.02.01 Mark the correct place on the patient’s body where the surgery is to be done. UP.01.03.01 Pause before the surgery to make sure that a mistake is not being made.

This is an easy-to-read document. It has been created for the public. The exact language of the goals can be found at www.jointcommission.org. 31 2020 Ambulatory Health Care National Patient Safety Goals

The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them.

Prevent mistakes in surgery

UP.01.01.01 Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body. UP.01.02.01 Mark the correct place on the patient’s body where the surgery is to be done. UP.01.03.01 Pause before the surgery to make sure that a mistake is not being made.

This is an easy-to-read document. It has been created for the public. The exact language of the goals can be found at www.jointcommission.org. 32 33 Emergency Codes

Standardized Healthcare Emergency Codes for California:

34 Stop Here Unless You Are a Student Nurse

Student Nurses Please Continue Reading

35 KP Nursing Professional Practice Model 4 Key pillars that support work/practices KP Nursing Values (underpin our work)

Core of work

36 What are the Kaiser Permanente Nursing Values?

Professionalism We believe in the value of our profession and maintain standards of excellence when it comes to the delivery of care.

Patient and Family Centric Honoring the essential role of the patient and family in all aspects of care, we create memo- rable moments through extraordinary care.

Compassion What is the Kaiser Permanente We realize the difference we make in the lives of our patients and their families when they Nursing Vision? are most vulnerable, and we focus on providing individualized care with a personal touch. As leaders, clinicians, researchers, innovators and scientists, Kaiser Permanente nurses are advancing the delivery of excellent, compassionate care for our members across the continuum, and KAISER PERMANENTE boldly transforming care to improve the health of our communities and nation Teamwork NURSING Extraordinary Nursing Care. We respect the collective contributions of Every Patient. each member of the team and view our team Every Time. PROFESSIONAL members as our partners in success. PRACTICE Why is this important? Excellence We embrace the art and science of nursing by Nursing Vision & integrating the ANA's "Scope and Standards of Achieving a consistent superior care experience requires an Practice" with compassionate care and an integrated approach that encompasses the engagement of Values evidence-based practice. the patient, family, staff, physicians, and leaders. This is about creating a culture of extraordinary nursing practice at Kaiser Permanente. One that is driven by an inspirational vision, animated by powerful core values, and 1 Integrity guided by a shared nursing model. We acknowledge the autonomy and dignity of the patient and promote the patient's right to choose and control his or her environment.

37 Medication Administration

Kaiser Permanente Southern California

• KPSC Region Wide Policy/Practice Excerpt: o Student Unpaid Field Experience and Training: Medication Administration o Regional High-Alert Medication Safety Practices

• Medication Administration (Lippincott Procedures) • Safe Medication Practices, General • Oral Drug Administration • Enteral Drug Administration • Intramuscular Injection • Subcutaneous Injection • Metered Dose Inhaler Use • IV Secondary Line Drug Infusion • Rectal Suppository Administration

38 Key Take Aways:

 Faculty or authorized KP Staff Nurse must co-sign with students for allowable medications  Pre-licensure students may not give a High-Alert medication

39 Safe Medication Administration Practices, General

Avoid distractions and interruptions.

Verifying the medication order • Follow a written or typed order or an order entered a computer order-entry system. • Make sure that the prescriber's order contains a diagnosis, condition, or indication for the medication. • Verify essential elements of the medication order. • Review the practitioner's order to make sure that the prescribed infusion solution or medication, dose, rate, and route of administration are appropriate for the patient's age, condition, and access device (if applicable). Address concerns about the order, as directed by your facility. • Reconcile the patient’s medications when the practitioner orders a new medication.

Identifying the patient • Check the patient's medical record. • Perform hand hygiene. • Confirm the patient's identity. • Explain important medication information to the patient.

Obtaining an accurate medication listing • Ensure that a complete listing of the patient's current medications and known drug or food allergies has been obtained. • Ensure that the medication list is readily available in the patient's medical record. • Send a copy of the patient's medication list and new medication orders to the pharmacy

Checking for medication contraindications • Obtain and update the patient's allergy information and current medications during each admission or transfer. • Communicate the patient's current allergy information to all members of the health care team. • Send medication orders to the pharmacy before administering the medication. • Have all health care providers review the list of current medications and allergies at each patient encounter. • Contact the pharmacist with any questions about a medication.

Ensuring accurate dosage calculations • Make sure that the patient's most recent weight (in kilograms) is documented. • Have a weight conversion chart readily available. • Calculate the correct dosage of medications. • Use automated dosage calculations whenever possible, especially with IV pumps.

Lippincott Procedures (2020). Safe Medication Administration Practices, General. Revised November 15, 2019 https://procedures.lww.com/lnp/view.do?pId=1820552&hits=safely,medication,safe,practices,administration,g eneral,practice,medications&a=false&ad=false

40 Safe Medication Administration Practices, General cont.

Administering scheduled medications in a timely manner • Maintenance doses administered according to a standard repeated cycle of frequency are considered scheduled medications. • Identify a time-critical list of common scheduled medications specific to the patient population of the facility unit. • Identify a time-critical list for scheduled medications that might be used on all units. • Establish guidelines to facilitate the administration of time-critical medications. • Establish guidelines to facilitate the administration of daily, weekly, and monthly medications that are non–time-critical. • For medications that are administered more frequently than daily but not more than every 4 hours, you should administer them no more than 1 hour before or after the scheduled time.

Completing the procedure • Monitor and document the effectiveness of all medications administered • Document any medication errors or adverse effects • Dispose of all containers • Perform hand hygiene

Evaluating the medication management process • Make sure that there's a defined method for the review and update of any preprinted order sheets or standing orders • Routinely review the medication management process • Make sure that the pharmacy annually reviews the high-risk medications and look-alike and sound-alike medications being stored and used. You should remove medications if you aren't using them • Be sure to regularly update a list of "Do Not Use" abbreviations, symbols, and acronyms and post it prominently where you prepare medications

41 Oral Drug Administration

Oral drug administration

• Verify the practitioner's order

• Reconcile the patient's medications when the practitioner prescribes a new medication

• Perform hand hygiene

• Gather and prepare the equipment and supplies

• Compare the medication label to the order in the patient's medical record

• Check the patient's medical record for an allergy or a contraindication

• Check the expiration date on the medication. Obtain new medication, as needed

• Visually inspect the medication for loss of integrity

• Discuss unresolved concerns about the medication with the practitioner

• Perform hand hygiene

• Confirm the patient's identity

• Provide privacy

• Explain the procedure

• If the patient is receiving the medication for the first time, teach about concerns related to the medication (indication and possible medication side effects)

• Assess the patient's condition

• Observe the patient carefully for signs of an adverse reaction to a previously administered medication

• Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route

• If your facility uses bar-code technology, use it

• Administer the medication to the patient along with an appropriate vehicle or liquid, as needed

• If the patient can't swallow a whole tablet or capsule, consult the pharmacist

• Stay with the patient until the patient has swallowed the medication

• Monitor the patient for adverse reactions; respond appropriately

• Discard used supplies appropriately

• Perform hand hygiene

• Document the procedure

Lippincott Procedures (2020). Oral Drug Administration. Revised August 21, 2020. https://procedures.lww.com/lnp/view.do?pId=1820088&hits=oral,administration,drug,drugs&a=false&ad=false

42 Enteral Drug Administration

Enteral tube drug instillation

• Verify order

• Review the patient's medical record to verify the location of the distal tube tip

• Gather the prescribed medication and equipment

• Compare the medication label to the order

• Check the patient's medical record for an allergy or a contraindication. If either exists, don't administer the medication; notify the practitioner

• Check the expiration date on the medication. If it is expired, obtain new medication

• Inspect the solution for particles, discoloration, or other loss of integrity. Don't administer the medication if its integrity is compromised

• Discuss any unresolved concerns with the practitioner

• Consult the pharmacist to determine the safest dosage form of the drug before administration, if needed. Use medications prepared by the pharmacy under controlled conditions, whenever possible

• Use the available liquid dosage form if it's appropriate for enteral administration. Further dilute the drug before administration, as directed by the pharmacist

• If the liquid form of a medication isn't appropriate or available, substitute only immediate-release dosage forms and prepare them according to the pharmacist's instructions

• Perform hand hygiene

• Confirm the patient's identity

• Provide privacy

• If the patient is receiving the medication for the first time, teach about concerns related to it

• Explain the procedure

• Verify that you're administering the medication at the proper time, in the prescribed dose, and by the correct route

• If your facility uses bar-code technology, use it as directed

• Raise the patient's bed to waist level

• Place a fluid-impermeable pad or towel across the patient's chest

• Elevate the head of the patient's bed to at least 30 degrees; if contraindications exist, then consider the reverse Trendelenburg position

Lippincott Procedures (2020). Enteral Tube Drug Instillation. Revised November 15, 2019 https://procedures.lww.com/lnp/view.do?pId=1820088&hits=oral,administration,drug,drugs&a=false&ad=false 43 Enteral Drug Administration, cont.

• Perform hand hygiene

• Put on gloves and other personal protective equipment, as needed

• Trace the tubing from the patient to its point of origin

• Unclamp the enteral tube if not in continuous use, or (if not already done) stop the continuous enteral feeding, clamp the enteral administration set, and cap the distal end of the tubing. Verify enteral tube placement

• Notify the practitioner if tube placement is in doubt. Arrange for an X-ray, if ordered

• After verifying proper tube placement, flush the tube with at least 15 mL of purified water. Monitor the patient closely throughout instillation. Stop the procedure immediately and notify the practitioner if the patient shows signs of distress

• Administer the medication using an enteral syringe

• Flush the enteral tube again with at least 15 mL of purified water

• Repeat the procedure with the next medication, if prescribed

• Flush the enteral tube one final time with at least 15 mL of purified water

• Clamp the enteral tube and detach the syringe

• Replace the cap at the tip of the enteral tube. Alternatively, attach the enteral administration set tubing to the end of the enteral tube, unclamp the tube, and restart the enteral feeding, if ordered. Hold the feeding for 30 minutes or more after medication administration only if separation is indicated. Consult a pharmacist, as needed

• Discard the fluid-impermeable pad or towel

• Return the bed to the lowest position

• Clean and dry reusable equipment

• Discard used supplies in the appropriate receptacle

• Remove and discard your personal protective equipment

• Perform hand hygiene

• Store the equipment away from potential sources of contamination

• Perform hand hygiene

• Document the procedure

Lippincott Procedures (2020). Enteral Tube Drug Instillation. Revised November 15, 2019 https://procedures.lww.com/lnp/view.do?pId=1820088&hits=oral,administration,drug,drugs&a=false&ad=false

44 Intramuscular Injection

Intramuscular injection

Verify order

Perform hand hygiene Gather and prepare the equipment and obtain the medication

Compare the medication label to the order

Check the patient's medical record for an allergy or other contraindication. If a contraindication exists, don't administer the medication; instead, notify the practitioner

Check the expiration date on the medication; if it's expired, obtain new medication Inspect the solution for signs of loss of integrity; don't administer the medication if its integrity is compromised Discuss unresolved issues with the practitioner

Perform hand hygiene

Carefully calculate the dose

Read the medication label again as you draw up the medication for injection if necessary Perform hand hygiene

Confirm the patient's identity Provide privacy

 Explain the procedure to the patient If the patient is receiving the medication for the first time, teach about concerns related to the medication

Verify that you're administering the medication at the proper time, in the prescribed dose, and by the correct route If your facility uses bar-code technology, use it, as directed Raise the bed to waist level

Lippincott Procedures (2020). Intramuscular Injection. Revised August 21, 2020 https://procedures.lww.com/lnp/view.do?pId=1820051&hits=intramuscular,inject,injection,injections,injecting, injectable&a=false&ad=false 45 Intramuscular Injection

Perform hand hygiene

Put on gloves

Select an appropriate injection site Position and drape the patient appropriately

Clean the injection site with an alcohol pad; allow the skin to dry

Remove the needle sheath

Displace the skin and subcutaneous tissue of the injection site by pulling the skin laterally Position the syringe at a 90-degree angle. Tell the patient to expect a needlestick

Insert the needle quickly and smoothly deep into the muscle Support the syringe with your nondominant hand if you prefer Inject the medication slowly Withdraw the needle slowly

Wait 10 seconds and then withdraw the needle slowly at a 90-degree angle. Activate the needle's safety mechanism Release the displaced skin and subcutaneous tissue Cover the site with a gauze pad and apply gentle pressure Inspect the site for signs of bleeding or bruising. Apply pressure or ice, as necessary

Apply an adhesive bandage, as necessary Return the bed to the lowest position Monitor for adverse reactions for 10 to 30 minutes after the injection

Discard all equipment in the appropriate receptacles Remove and discard your gloves if you wore them Perform hand hygiene Document the procedure

Subcutaneous injection

 Verify the order

 Gather the medication and supplies

 Compare the medication label with the order in the patient's medication administration record

 Check for allergies and other contraindications; don't administer the medication if any exist; instead, notify the practitioner

 Check the medication's expiration date; obtain new medication if the medication is expired.

 Inspect the medication for signs of loss of integrity; don't administer the medication if its integrity is compromised.

 Discuss unresolved concerns with the patient's practitioner.

 Choose appropriate equipment for the medication and injection site

 Calculate the dosage; have another nurse verify your calculations if necessary

 Perform hand hygiene

 If you need to draw up the prescribed medication, read the label again as you draw it up

 Perform hand hygiene

 Confirm the patient's identity

 Provide privacy

 Explain the procedure and answer any questions

 Discuss concerns related to the medication

 Verify that you're administering the medication at the proper time, in the prescribed dose, and by the correct route

 If your facility uses bar-code technology, use it as directed by your facility

 Assess the patient's condition

 Select an appropriate injection site

 Position the patient and expose the injection site. If appropriate, raise the bed to waist level.

Lippincott Procedures (2020). Subcutaneous Injection. Revised August 21, 2020. https://procedures.lww.com/lnp/view.do?pId=1820150&hits=injections,subcutaneous,injection,injects,inject,in jecting&a=false&ad=false 47 Subcutaneous Injection, cont.

 Perform hand hygiene

 Put on gloves if necessary

 Clean the injection site; allow it to dry

 Remove the needle sheath

 Grasp the skin around the injection site to form a fat fold

 Position the syringe in your dominant hand with the bevel up while still grasping the skin around the injection site with your other hand. Don't touch the needle

 Tell the patient to expect to feel a needle prick

 Insert the needle quickly at the appropriate angle

 Release the skin

 Inject the medication

 Remove the needle at the same angle you used for insertion

 Cover the site with a gauze pad and apply gentle pressure

 Remove and discard the gauze pad

 Check the site for bleeding and bruising

 Observe the patient for a rash, pruritus, cough, and other signs of an adverse reaction

 If appropriate, return the bed to the lowest position

 Discard the injection equipment in an appropriate receptacle

 Remove and discard your gloves if worn

 Perform hand hygiene

 Document the procedure

Metered-dose inhaler use

 Avoid distractions and interruptions when preparing and administering the medication

 Verify the order

 Reconcile the patient’s medications when the practitioner prescribes a new medication

 Perform hand hygiene

 Compare the medication label with the order

 Check the patient's medical record for a contraindication to the prescribed medication. I one exists, don't administer the medication

 Check the expiration date on the medication. If the medication has expired, obtain a new medication

 Inspect the medication container and metered-dose inhaler (MDI) for any loss of integrity

 Discuss unresolved concerns about the medication with the practitioner

 Perform hand hygiene

 Confirm the patient's identity

 Provide privacy

 Explain the procedure

 If the patient is using the medication for the first time, teach the patient and family (if appropriate) about potential adverse reactions and other concerns

 Verify that you're administering the medication at the proper time, in the prescribed dose, and by the correct route

 If your facility uses bar-code technology, use it as directed by your facility

 Raise the patient's bed to waist level

 Perform hand hygiene

 Put on gloves if needed

 Assess the patient's respiratory status

 Insert the metal stem on the prescribed MDI into the small hole on the flattened portion of the mouthpiece

 Shake the prescribed MDI

 Prime the prescribed MDI, as necessary

Lippincott Procedures (2020). Metered Dose Inhaler Use. Revised February 21, 2020 https://procedures.lww.com/lnp/view.do?pId=1820721&hits=metered,inhaler,inhaled,dose,mdi,inhalers,mdis&a= false&ad=false 49 Metered-dose Inhaler, cont.

 Remove the mouthpiece cap

 Attach the prescribed MDI to the spacer, as indicated, making sure not to touch the mouthpiece

 Instruct the patient to exhale fully, hold the prescribed MDI as instructed, and then place the MDI or spacer into the mouth and close the lips around it

 Instruct the patient to press down on the prescribed MDI once as the patient starts breathing in slowly through the mouth. (If the patient is using a spacer, instruct the patient to press down on the prescribed MDI first and then to begin to breathe in slowly within 5 seconds)

 Instruct the patient to continue breathing in slowly and as deeply as possible

 Remove the mouthpiece from the patient's mouth and instruct the patient to hold the breath

 Instruct the patient to exhale slowly through pursed lips

 When you're administering inhaled corticosteroids, instruct the patient to rinse and gargle with water and then to expectorate using an emesis basin if necessary

 When administering inhaled quick-relief medications, wait about 15 to 30 seconds between inhalations

 After administration of all prescribed inhalations, remove the spacer (if used) from the prescribed MDI and wash it and the mouthpiece according to the manufacturer's instructions

 Put the cap back on the prescribed MDI after each use

 Store the prescribed MDI and spacer (if used) with the patient's medication

 Assess the patient's respiratory status.

 Allow the patient to gargle with water, if desired

 Return the bed to the lowest position

 Remove and discard your gloves, if worn. Perform hand hygiene

 Clean and disinfect your stethoscope

 Perform hand hygiene

 Document the procedure

IV secondary line drug infusion

 Gather and prepare the equipment and supplies.

 Avoid distractions and interruptions.

 Review the order and discuss any unresolved concerns with the patient's practitioner.

 Reconcile the patient's medications when the practitioner prescribes a new medication.

 Compare the medication label to the order.

 Check the patient's medical record for a contraindication to the prescribed medication. If one exists, don't administer the medication.

 Check the expiration date on the medication. If it's expired, return it to the pharmacy and obtain new medication.

 Visually inspect the solution for loss of integrity; don't administer the solution if integrity is compromised.

 Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.

 Perform hand hygiene.

 Confirm the patient's identity.

 Provide privacy.

 Explain the procedure and teach about potential adverse reactions of the medication.

 If your facility uses bar-code technology, use it as directed.

 Perform hand hygiene.

 Put on gloves.

 If the prescribed drug is incompatible with the primary IV solution, replace the primary solution with a fluid that's compatible with both solutions as ordered.

 Assess the patient's IV site.

 If a disinfectant-containing end cap is in place, remove and discard it.

 Perform a vigorous mechanical scrub of the needleless connector with an antiseptic pad. Allow it to dry completely.

Lippincott Procedures (2020). IV Secondary Line Drug Infusion. Revised May 15, 2020 https://procedures.lww.com/lnp/view.do?pId=1821062&hits=line,iv,infusions,secondary,intravenous,lines,drug ,infusion,infused,intravascular,infusing&a=false&ad=false51 IV Secondary Line Drug Infusion, cont.

 While maintaining sterility of the syringe tip, attach a syringe containing preservative-free normal saline solution to the needleless connector and aspirate for a blood return.

 If a blood return is obtained, slowly flush the device with preservative-free normal saline solution.

 If necessary, insert a new IV catheter.

 Hang the secondary set's container.

 Perform a vigorous mechanical scrub of the needleless connector of the primary line that's closest to the vascular access catheter with a disinfectant pad. Allow it to dry completely.

 Trace the tubing from the patient to the point of origin, route in a standardized direction if the patient has other tubing and catheters having different purposes and label the tubing at the distal and proximal ends.

 Insert the needleless adapter from the secondary line into the needleless connector, verify a proper connection, and secure it to the primary line as needed.

 To run the secondary set's container by itself, lower the primary set's container with an extension hook. To run both containers simultaneously, place them at the same height.

 Open the clamp and adjust the rate.

 Discard used supplies appropriately.

 Remove and discard your gloves.

 Perform hand hygiene.

 Monitor the infusion regularly, inspect the IV insertion site for complications, and evaluate the patient's response to therapy.  Document the procedure

Rectal suppository administration

 Avoid distractions and interruptions.

 Verify the order.

 Reconcile the patient’s medications when the practitioner prescribes a new medication.

 Compare the medication label to the order in the patient's medical record.

 Check the patient's medical record for an allergy or contraindication. If one exists, don't administer the medication.

 Check the medication's expiration date. Obtain new medication, as needed.

 Visually inspect the medication for loss of integrity; don't administer the medication if integrity is compromised.

 Discuss unresolved concerns about the medication with the practitioner.

 Perform hand hygiene.

 Confirm the patient's identity.

 Provide privacy.

 Explain the procedure.

 If the patient is receiving the medication for the first time, teach about potential concerns related to the medication.

 Verify that you're administering the medication at the proper time, in the prescribed dose, and by the correct route.

 If your facility uses bar-code technology, use it as directed.

 Raise the bed to waist level.

Lippincott Procedures (2020). Rectal Suppository Administration. Revised August 21, 2020 https://procedures.lww.com/lnp/view.do?pId=1820128&hits=rectal,suppository,suppositories&a=false&ad=false 53 Rectal Suppository Administration, cont.

 Perform hand hygiene

 Put on gloves

 Place the patient on the left side in the Sims position

 Drape the patient, exposing only the buttocks

 Unwrap the suppository and lubricate it with water-soluble lubricant

 Lift the patient's upper buttock with your nondominant hand

 Have the patient take several deep breaths through the mouth

 Insert the suppository using the index finger of your dominant hand, insert the suppository

 Ensure the patient's comfort. Encourage quiet resting and retention of the suppository, if appropriate. Keep a bedpan close by in case the patient has difficulty retaining the suppository, as appropriate

 Return the bed to the lowest position

 Remove and discard your gloves

 Perform hand hygiene

 Document the procedure

BARCODE SCANNING MEDICATION ADMINISTRATION Instructions for Students

Tips:

Ø Hand held barcode scanners are programmed to specific individual computers. Therefore, you must use the computer and scanner in the patient’s room or, if needed, you must bring the entire mobile cart with computer/scanner into a patient’s room. Ø Meds are NOT to be opened until they are scanned at the patient’s bedside. Ø Three (3) beeps will sound when an item is successfully scanned. Ø Do not place anything close to the scanner when it is not in use because the scanner light will remain on, thereby using up the battery. DO NOT face scanner close to or against the bedside table or wall.

Procedure at Patient Bedside:

1. Scan UCI (unique contact identifier) number on the patient’s armband. This will automatically open up the computer & eMAR (electronic medication administration record) screen.

v Please Note: Patients do not have armbands in Outpatient/ Ambulatory setting. You will verify patient using 2 patient identifiers. (Name and DOB (date of birth) or MRN (medical record number)) 2. Scan drug that is to be administered, drug order will show in eMAR. Click “accept” and eMAR will automatically label the med as given. 3. KP pharmacy barcode labels will be placed on any medication that comes with their own manufacturer barcode. Make sure to scan the KP barcode label. 4. If patient has a medication ordered with 2 different administrative routes identified, make sure you select the correct route on the eMAR. 5. If you scan an item that is not showing on the eMAR, the order may not have been completed by Pharmacy yet. You will receive a notice “No orders for--were found for this patient.” Please follow up with Pharmacy to verify order. 6. If a scanner does not read the medication’s barcode, BUT the med is listed on the eMAR and is there is an order for it to be given, call the Pharmacy for assistance. 7. For intravenous (IV) piggy back, scan the vial of medication that is to be mixed, not the IV solution bag. 8. For IV bags, please be aware that there needs to be dark color contrast behind the IV bag, in order for the barcode to be picked up by the scanner.

The armband maker is available at the Nurses’ Station for any patient in need of a new armband. HOWEVER, NO ONE CAN MAKE DUPLICATE COPIES OF ARMBANDS.

55 Nurse Knowledge Exchange Plus (NKE+) Inpatient/Hospital Shift Change Communication

NKE+ is an evidence-based Shift Change Communication framework designed to enhance safety, communication and efficiency. It incorporates proactive measures to structure and support nurses during shift changes.

Proactive preparation to prepare of the oncoming shift Establishes a standardized last hourly round and pre-shift assignments to help the unit prepare for oncoming shifts.

Coordinated roles to minimize disruptions during shift change The unit works together to minimize interruptions to nurses, allowing them to get off to a strong hand-off and a strong start-of-shift.

In-room patient engagement Incorporates the use of a careboard, in-room SBAR, and an in-room safety check to engage patients and drive safety.

56 Thank You