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LASER PROGRAM PROGRAM
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SECTION LSR |
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Laser Safety Committee |
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Credentialing Obtaining Laser Privileges |
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Proctorship |
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Argon Laser Therapy |
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Laser Maintenance |
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Safety in Laser Surgery |
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Assisting with Ophthalmic Laser Surgery |
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Orientation to Lasers |
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Smoke Evacuation and Odor Control During Laser Surgery |
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Management of Tracheal Fires During Laser Use |
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LASIK Surgery |
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Laser Log |
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Calibration Procedure |
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Key Storage for Laser Units |
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Standards of Care |
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Standards of Professional Performance |
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Guidelines for Non-Physician Laser Use |
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Laser Training Course
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MATERIALS MANAGEMENT PROGRAM
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SECTION MM |
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Materiels Management Goals and Objectives |
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Materiels Management Duties |
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Materiels Management Continuum |
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The Ordering Process |
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SECTION MP |
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Cost Containment
Establishing the Reorder Point
Ordering Supplies
Stockless Purchasing
Reception and Business Area
PACU, Discharge and Pre-Op Inventory
Purchase Orders
Vendor Sources
Use of Product Information Cards/Files
Receipt of Ordered Supplies
Filing Inventory Information
Product Substitution
Returned Goods
Recall Policy
Restocking of Drugs and Supplies
Receiving and Storage
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SECTION E |
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Request for Capital Equipment |
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Vendor’s Checklist - Capital Equipment |
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Budgeting Capital Equipment |
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SECTION INV |
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Master Supply and Drug Inventories |
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Master Equipment and Instrument List and Inventory
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MEDICATION SAFETY PROGRAM |
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SECTION D |
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Medication Safety Program |
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Medication Guidelines
Risk Reduction in High Alert Medications |
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Drug Inventory |
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Sample and Investigational Drugs |
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Drug Labels and Packaging |
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Procurement, Preparation and Storage of Drugs |
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Drug Procurement (Ordering Drugs) |
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Ordering Schedule II Drugs |
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Drug and Solution Recall |
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Drug Product Shortages |
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Crediting Excess Drug Inventory |
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Expired Drugs, Solutions, and Implants |
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Drug Product Problem Reporting Program |
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Administration of Medications |
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Medication Orders |
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Medication Reconciliation |
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Multi-Dose Vials |
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Adding Adrenalin, Gentamicin and Vancomycin to BSS |
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IV Drugs Licensed Nurse Not Allowed to Give |
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Expiration Dates on Medications |
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Adverse Drug Reactions |
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IV Additives |
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IV Solution Preparation |
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Administration of Anti-Aspiration Drugs |
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Medication Errors |
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Controlled Substance Records and Counts |
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Controlled Substance Waste Report |
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Maintenance of Records |
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Substance Abuse Program |
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Medication from Home |
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Infusion Pump |
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Schedules of Controlled Substances |
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Use of the Formulary |
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List of Drugs That May Interfere in Coagulation |
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Sample Problematic Drugs List |
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Pre-Operative Guidelines for Medications |
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Administration of RhoGam |
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Medication Practices in the OR |
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Antineoplastic Agents |
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Safe Management of Vaccines |
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Use of Diprivan |
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Herbal Side Effects or Drug Interactions |
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Anticoagulant Therapy |
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Oxygen Therapy |
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Hazardous Drugs, Chemicals and Agents Safety Program |
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Handling and Disposal of Cytotoxic Medications |
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“Immediate Use” – Compounding of Sterile Drugs |
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Administration of Vancomycin |
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Pharmacy Consultant |
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Safe Injection Practices |
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NURSING PROCEDURES PROGRAM |
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SECTION NP |
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Taking the Blood Pressure |
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Use of the Pulse Oximeter |
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Taking Temperature, Pulse and Respiration |
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Vital Signs Monitor |
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Venipuncture |
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Electrocardiography |
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Obtaining Pre-Operative Laboratory Specimens |
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BOTOX Injection for Blepharospasm |
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Instillation of Ear Drops |
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Instillation of Eye Drops |
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Instillation of Nose Drops |
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Testing the Pulse Oximeter |
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Patient Lead Equipment Checks |
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Monitoring Diabetes Mellitus |
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Vascular Access Lines |
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Accessing An implanted Venous Access Device/Port |
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LPN Role in IV Therapy |
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Intravenous Infusion Rate |
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Moving the Patient |
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Preparation of 1% Betadine Solution |
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Allograft Protocol |
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Dropped Grafts |
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Insertion of Triple Lumen Catheter |
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Patient Care in Local Anesthesia |
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Patient Undergoing Histamine Phosphate Infusion |
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Honan Pressure Application |
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Use of the Mercury Bag |
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Pinky Ball |
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Pediatric Feeding Schedule |
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Making an Unoccupied Stretcher Bed |
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Directions For Use of Hand-Operated Resuscitator Bag |
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Cleaning Ambu Resuscitators |
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NT Suctioning |
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Application of the T.E.D. Stocking |
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Applying Cold Treatment |
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Applying Elastic Wraps |
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Care of Casts |
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Cast Cutting and Removal |
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Use of the Bedpan or Urinal |
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Care of the Patient with a Retention Catheter |
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Urinary Catheterization of Female Patient |
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Urinary Catheterization of Male Patient |
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Insertion of a Retention Catheter – Female |
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Insertion of a Retention Catheter – Male |
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Irrigating a Foley Catheter |
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Removal of the Retention Catheter |
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Maintaining Peripheral IV Catheter Patency |
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Clean Catch Urine Specimen – Adult |
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Safe Use of Tourniquets |
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Safe Use of Cryosurgical Unit |
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Nursing Management of the Pediatric Patient |
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Sequential Compression Device |
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Pledget Application (Ophthalmology) |
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Corneal Grafts |
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Amniotic Membrane Transplantation (ATM) |
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Log Rolling a Patient
CVP Line Flush
Preventing Deep Vein Thrombosis |
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Care of the Patient with a Tracheostomy |
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ENDOSCOPY PROCEDURES |
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SECTION GI |
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Setting Up GI Rooms |
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Inspecting and Preparing Endoscopes |
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Esophagogastroduodenoscopy |
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Foreign Body Removal Upper |
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EGD with Sclerotherapy |
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Esophageal Dilation with Maloney Dilators |
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EGD with Esophageal Dilation using Balloons |
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Esophageal Dilation using Savory-Type Dilators |
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Percutaneous Endoscopic Gastrostomy (PEG) |
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Gastrostomy Tube Change |
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Cytology Brushings |
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Endoscopic Biopsies |
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Injection Coagulation Bleeding Sites |
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Liver Biopsy |
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Flexible Fiberoptic Sigmoidoscopy |
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Colonoscopy |
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Use of Colonoscopy Injection Needle |
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Tap Water Enemas Colon Preps |
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Polypectomy |
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Indications for Gastrointestinal Endoscopy
Capsule Endoscopy
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NURSING PROGRAM |
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SECTION P |
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Loaning and Borrowing Equipment |
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Double Procedures |
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Care of the Psychiatric Patient |
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Unlicensed Assistive Personnel in the Peri-Operative Setting |
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SECTION NA |
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CPR Certification and Drills |
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CPR Code Blue |
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CPR Report |
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Broselow/Hinkle Kit |
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Foreign Body Airway Obstruction |
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Emergency Tracheostomy |
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Defibrillation Procedure |
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Defibrillation Procedure – AED |
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Testing Defibrillator |
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Checking the AED |
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Checking the Emergency Cart |
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Anaphylactic Shock |
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Respiratory Distress |
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Insulin Reaction |
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Shock |
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Hypoglycemia |
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Postmortem Care Time out in the OR
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Time out in the OR
Patient Identifiers
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Surgical Site Identification
Hand-Off Communication
Care of the Morbidly Obese Patient
Death in the Facility
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SECTION OR |
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The Patient In Isolation |
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Skin Preparation |
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Skin Preparation for Eye Surgery |
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Counts |
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Procedures Not Requiring Counts |
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Selection and Verification of IOL Prior to Surgery |
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Liposuction Surgery (FLORIDA) |
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SECTION PRN |
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Purpose of the Pre-Op Unit |
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Pre-Op Staffing and Responsibilities |
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Equipment for Patient Station
Daily Routine Preop Greeting
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Pre-Operative Counseling and Assessment |
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Patient/Family Education |
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Falls Prevention Program |
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Latex Allergic Patients (IF NOT DOING LATEX ALLERGIC) |
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Latex Allergy, Nursing Care and Management |
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Reducing Latex Allergies |
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Admitting the Patient to the Pre-Operative Area |
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Documenting Pre-Operative Care |
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Xylocaine and Marcaine Skin Testing |
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Pre-Operative History & Physical Changes/Additions by Admitting RN |
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Nursing Care Plans |
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Patient Instructions for Sedation (moved here from Medication Management and renamed |
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SECTION AT |
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Purpose of the OR/Procedure Suite |
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OR/Procedure Suite Staffing |
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Equipment in the OR/Procedure Rooms |
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Documenting OR Care |
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daily routine Surgery Suite
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Supplies in the Surgical Suite |
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Turning the Room |
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Procedure Cards |
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Use of the Procedure Room |
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Admitting the Patient to the Operating/Procedure Room |
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The Nurse During the Beginning of Anesthesia |
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Local Anesthetic |
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Nurse Administered IV Conscious Sedation |
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Toxic Reactions to Local Anesthetic Agents |
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Positioning of the Patient |
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Use of the Electrosurgical Unit |
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Care if the Patient with an IED |
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Safe Use of the Cryosurgical Unit |
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SECTION PACU |
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Purpose of the Unit - Acute Recovery |
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Acute Recovery Equipment |
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ASA Standards for Post-Anesthesia Care |
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Acute Recovery Staffing |
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Daily Routine PACU |
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Post-Anesthesia Policies |
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Recovery Admission Routines |
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The PACU Record |
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Use of the Aldrete Scoring System |
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Standing Orders Laryngospasms |
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Emergencies Not Requiring CPR |
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Purpose of the Unit - Discharge Recovery |
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Discharge Recovery Equipment |
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Discharge Recovery Staffing |
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Daily Routine - Discharge Recovery |
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Discharge Recovery Admission and Care |
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Recovery Care - Regional Block Anesthesia |
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Recovery Care - Local Anesthesia |
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Pain Management |
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Pain Assessment |
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Post-Op Dietary Intake |
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Discharge Criteria & Procedure |
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Discharge Planning & Education |
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Post-Operative Follow-up |
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Electronic Post-Operative Follow-Up by Email |
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Patient Transfer |
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Additional Discharge Criteria for Regional Anesthesia
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PAIN MANAGEMENT PROGRAM
SECTION PM
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Pain Center
Patient Admission/Pain Management
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Admission/Discharge Policy |
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Adhesion Lysis w/Fluoroscopy |
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Adjunctive Support |
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Axillary Block |
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Bier Block |
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Caudal Epidural Steroid Injection (Caudal EPSI) |
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Celiac Plexus Block |
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Cervical Epidural Steroid Injection (Cervical EPSI) |
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Differential Epidural /Spinal Blocks |
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Epidural Differential |
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Epidural Steroid Injection (ESI) |
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Epidural Sympathetic Block |
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Facet Nerve Block Injection |
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General Nerve Block Orders |
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Ilioinguinal Nerve Block |
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Infraorbital Block/Supraorbital Block |
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Intrathecal Morphine Injection |
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Intercostal Nerve Block |
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Lumbar Sympathetic Block (LSB) |
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Occipital Nerve Block |
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Pain Management Setup w/Continuous Racz Catheter |
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Percutaneous Dorsal Column Stimulator |
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Peripheral IV Local Anesthesia |
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Pre-Lumbar Facet Injection |
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Radiofrequency Lesion |
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Sacro Iliac Joint Injection (SI Joint Injection) |
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Selective Epidural Steroid |
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Spinal Accessory Nerve Block |
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Stellate Ganglion Block |
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Sub-Arachnoid Block |
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Supraclavicular Nerve Block |
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Sympathetic Block |
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Synchromed Pump – Surgery or Refill |
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Trigeminal Nerve Block |
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Trigger Points Injections |
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Continuous Peripheral Nerve Blocks
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QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT / RISK MANAGEMENT PROGRAM |
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SECTION QI/RM |
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Affirmation of Responsible Committee |
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Mission and Goals of the Quality Assessment and Performance Improvement Committee |
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Affirmation of Responsible Persons |
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QA/PI/RM Organizational Circle |
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Cycle of Continuous Improvement |
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Closing the Loops |
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Introduction |
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Definitions |
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TQM/ A Shift in Management Paradigms |
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Differences |
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Strengths |
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Fundamental Total Quality Questions |
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QA/PI/RM Committee |
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SPDCA Tracking Method for Improvement |
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Quality Assessment/Performance Improvement Program |
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Institutional Review Committee |
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TQM Objectives, Discontinued 3/10
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SECTION QA |
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Product Evaluation and Selection |
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Equipment Purchasing and Selection |
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Cost Analysis Studies |
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Cost Monitoring |
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Financial Accountability |
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Perception of Care Assessment |
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Staff and Physician Satisfaction Questionnaire |
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Quality Reviews |
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QA/PI in Medication Safety |
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Medical Record Review |
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Anesthesia Review |
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Tissue Review |
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Abnormal Lab/Test Review |
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QA/PI Studies |
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QA/PI Report Tools and Forms |
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Credentialing and Privileging |
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Re-Credentialing and Re-Privileging |
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Private Staff Activities |
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Adding New Procedures or Services |
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Proctoring of Physicians |
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Utilization Review Plan |
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Communication with the Sensory Impaired |
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Use Of Interpreter Services For Limited English Speaking Persons (LESP) |
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Monthly Statistics |
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Use Of Gel-Filled Breast Implants |
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Special Privileges Request |
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Standards of Ethical Practice |
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Patient Outcomes in Pain Management |
SECTION RMP |
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Introduction to the Risk Management Program |
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Risk Management Plan |
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Risk Management Program |
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Risk Management Terms |
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The Risk Management Process |
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Risk Management Goals |
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Statement of Commitment |
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Annual Report to the State |
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Risk Management Orientation |
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Risk Management Inservice Education |
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Self Assessment/Benchmarking |
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Patients’ Rights and Responsibilities |
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Incident Reports |
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Incident Report Logs |
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Reporting to State |
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Sentinel Events (formerly Sentinel/Adverse Events) |
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Adverse Events |
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Reporting Adverse Events |
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Preventing Patient Adverse Events |
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System for Notifying a Patient of a Serious Adverse Incident |
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Adverse Event – Tissue Transplantation |
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Reporting Adverse Experiences with Equipment Malfunctions |
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National Practitioner Data Bank |
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Failure Mode and Effects Analysis |
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Patient Grievance and Investigation of Complaints |
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Peer Review Program |
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Staff Peer Review |
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Clinical Practice Guidelines/Medical Necessity |
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Reporting Child, Parent or Spouse Abuse |
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Vulnerable Adult |
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Photographing of Suspected Abuse Victims |
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Definition of Abuse |
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Occupational Injury Log |
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Sexual Discrimination, Harassment and Misconduct Toward Employees |
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Sexual Misconduct Towards Patients |
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Physician Incapacitation |
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Incompetent Staff Member |
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Impaired Staff Person |
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Disruptive Behavior in the Workplace |
SECTION CC |
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Standards for Business Conduct and Corporate Compliance
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RADIOLOGY PROGRAM |
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SECTION RA |
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Radiology Services |
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Fluorescein Angiograms |
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Radiology and Ultrasound Safety |
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X-Ray Request Form |
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Interpretation of Mammography Studies |
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Staffing for Radiographic Studies |
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Storage of Films |
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Radiation Exposure of Pregnant Patients |
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Monthly Dosimeter Reports |
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Radiation Exposure Badges |
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Physicians Procedure Cards – Radiology |
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Angiogram, Aortogram and Arteriogram Care |
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Pain Management for Radiology per Lumbar Facet Block |
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Approved Radiology Procedures |
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Education Program for Radiology Staff |
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Staff Instructions |
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X-Ray Examination Orders |
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Film Development |
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Radiology Reports |
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Radiation Protection Rules |
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Restricted and Unrestricted Zones |
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Exposure of Minors |
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Occupational Exposure Limits |
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External Sources of Radiation |
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Maintenance of Radiology Equipment |
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Dispensation of Radiographic Waste |
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Corrective Action |
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Aspects of Care |
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Identifying Indicators |
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Evaluation of Care |
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Data Collection and Organization |
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Common Problems and Possible Causes-Radiology Services |
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C-Arm Use |
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Use of X-Ray Equipment for Diagnostic and Interventional Procedures
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RECOVERY PROGRAM |
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SECTION RC |
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Admission to Twenty-Three Hour Stay |
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Service Meal Trays |
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IV Line Dressing Changes |
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Changing IV Administration Sets |
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Maintaining Peripheral IV Catheter Patency |
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Converting Continuous IV to IV Capped Lock |
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Removing IV Cannula |
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Ice Pack, Ice Collar |
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Intake and Output |
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Intravenous Infusion Rate |
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Administration of Blood or Blood Products |
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Blood Consent/Refusal Forms |
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Standing Orders for Blood Filter Usage |
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Transfusion Reaction |
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Guidelines for Immediate Management of Transfusion Reaction |
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Abnormal Test Results |
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Collection of Blood for Type and Crossmatch |
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Testing of Blood Storage Refrigerator Alarms |
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Specimen Collection |
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Clean Catch Urine Specimen – Adult |
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Afternoon Care |
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NT Suctioning |
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Urinary Catheterization of Female Patient |
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Urinary Catheterization of Male Patient |
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Retention Catheter, Insertion of Female |
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Retention Catheter, Insertion of Male |
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Care of Patient With a Retention Catheter |
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Removal of Retention Catheter |
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Back Rub |
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Complete Bed Bath |
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Patient Showers |
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Oral Hygiene and Dental Care |
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Making An Occupied Bed |
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Use of the Bedpan/Urinal |
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Bedtime Care |
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Applying Elastic Wrap |
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Care of Casts |
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Cast Cutting and Removal |
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Application of T.E.D. Stocking |
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Traction, Bucks Extension |
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Warm Moist Packs |
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Sterile Dressing Changes |
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Oxygen Therapy |
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Colostomy and Ileostomy |
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Irrigation: Colostomy |
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Irrigating a Foley Catheter
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ENVIRONMENT OF CARE PROGRAM formerly (SAFETY & MAINTENANCE) |
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SECTION SA |
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The Safety Program and Committee |
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The Safety and Security Management Plan |
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General Safety Rules |
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Safety and Security Orientation |
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Safety and Security Inspection |
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Weapons in the Workplace |
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Aggressor in the Center |
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Policy For Smoking |
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Grounds Maintenance |
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Building Maintenance |
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Pest Control |
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Staff Safety Program |
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Burns, Cuts and Punctures |
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Recycling |
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SECTION SG |
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Patient Safety Program |
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Pediatric Safety |
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Volunteer Safety |
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Visitor Safety |
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Safety in OR |
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Safety in Anesthesia |
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Safety in Pharmaceuticals |
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Safety in Support Services |
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Safety Education and Promotion Program |
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Prisoners as Patients |
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Risk of Harm to Self and/or Others
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SECTION SP |
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Safe Body Mechanics |
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Side Rails and Body Straps |
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Use of Protective Restraints
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Transporting the Patient Within the Facility |
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Transporting on Patient Bed |
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Wheelchair Safety |
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Assisting Patient to Walk |
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Assisting Patient to Car |
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SECTION SE |
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Safe Use of Electrical Equipment |
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Interruption of Electrical Services |
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Checking Electrical Receptacles |
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Elevator Inspections |
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Defective Equipment and Instrumentation
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| |
The Use of Power Strips in Patient Care Rooms
Operating Room Designations as Wet or Dry Locations
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SECTION SM |
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Equipment Management Plan |
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QA/PI in Equipment Maintenance |
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Inspection Schedules |
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Equipment Inspection Prior to Use |
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Preventive Maintenance Program |
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Scheduling Biomedical Safety Checks |
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Medical Device Tracking – Implants |
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Safe Use of Sterilizers |
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Safety in Radiology Services |
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Safety Requirements for Ultrasound Scanners |
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Safety Requirements for Mammography |
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Monitoring Blanket and Solution Warmers |
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Proper Storage Consideration for Chemicals and Incompatibility Chart |
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Storage of Compressed Gases |
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Safety Check Schedule for Gases and Vacuum Lines |
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Medical Gas Precautions |
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Anesthetic Gas Waste Management |
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Accidents and Emergencies |
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Safety Checking New Equipment |
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Lockout-Tagout Energy Control Plan
Relative Humidity-Equipment and supplies |
