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Safety Extravaganza:
Creating a Culture of Environmental
and Patient Safety
This packet provides support information for the Safety
Extravaganza test required of all associates & volunteers annually, as
well as students. Please review this packet, then complete the test
provided by your hospital contact.
Safety Extravaganza supports our organization’s compliance with a number of regulatory agency
requirements, including:
- OSHA (Occupational Health and Safety Administration),
- TJC (The Joint Commission), and
- CMS (Centers for Medicare & Medicaid Services)
Penrose-St. Francis Health Services
Centura Health
TABLE of CONTENTS
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Page 1
1. Emergency Preparedness
4–5
2. Fire/Life Safety
6–7
3. Electrical Safety
8
4. Infection Control
9 – 14
5. Hazard Communication
15 – 16
6. Patient Safety
17 – 18
7. HIPAA
19 - 20
8. Abuse & Neglect
20 - 21
Emergency Preparedness
Emergency Codes are standardized throughout the Centura system. The codes used within Centura
are recommended by the Colorado Hospital Association for use at all Colorado hospitals.
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It is the responsibility of each associate, volunteer and student to know the Emergency Codes and to
respond appropriately as detailed in the department Emergency Operations Plan Manual.
All emergency codes are activated by calling the
OPERATIONS CENTER
at ext. 1234
Code Pink – is announced in the event of a missing child/person or potential infant/child/person
abduction. Required response:
1. Initial response—call “1234” and request overhead page “Code Pink”.
2. Give the age, gender, description of the child/adult, where last seen and,
if applicable, a description of the abductor if known.
3. Secondary response—all units will immediately secure their designated stairways and
exit doors. Question any adult with an infant/child in event of an abduction.
4. Call the Operations Center at 1234 with reports of activity and concerns. The
Operations Center will initiate an “All Clear” announcement when appropriate.
Code Grey – indicates an external disaster in the area in which PSF may become involved OR an
internal disaster. There are three phases:
1. Code Grey – Standby
2. Code Grey – Go
3. Code Grey – All Clear
Consult the Emergency Operations Plan Manual for the meaning and actions taken during
each phase.
Code Blue – announced when a person is found unresponsive and not breathing . In the event of a
Code Blue:
1. Call for help and activate Code Blue (Extension 1234) after determining unresponsiveness.
State “Code Blue Pediatric” if a pediatric patient.
2. Initiate CPR if trained to do so.
3. RN will coordinate activities until Code Blue Team arrives.
4. All resources will use personal protective equipment as indicated.
5. For associates at PSF ancillary facilities, see departmental guideline for additional actions.
Code Orange – is activated in the event of a hazardous material spill in the hospital. If you
experience a spill, remember to S. I. N.
1. Safety—protect yourself and others
Isolate—leave area (if necessary) and close door behind you
Notify—your supervisor and/or nursing supervisor, when appropriate
2. If small known substance – clean yourself per MSDS
3. If large or unknown, SIN and have nursing supervisor notify Safety Officer to initiate assistance with clean-up
Code Black – announced in the event of a bomb threat, to be followed by the location of the bomb.
Associates are urged to stay clear of the area in question until proper personnel have safely searched
and cleared the area. If you receive a bomb threat:
1. Have a co-worker call the Code to the Op Center, x1234, while you stay on the phone with
the caller.
2. Try to obtain as much information as possible to include gender, background noises,
familiar voices – any information will help find the bomb and the caller.
3. Report immediately to your supervisor (or nursing supervisor after hours).
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Code Red – announced in the event of a fire or fire drill. A flashing red light indicates a fire drill in
your area. To activate a Code Red:
1. Pull the nearest fire alarm station
2. Call the Operations Center (Extension 1234) and identify your facility and location
3. Follow R.A.C.E. (see Fire Safety section for details)
Code Green - activated for assistance in securing an out-of-control person who presents an
immediate danger to self or others:
If a patient:
1. Dial ext. 1234. Advise the Operations Center of patient location and explain the
situation in detail.
2. Security determines when enough staff has arrived and will assist with intervention.
If an associate or visitor:
1. Dial extension 1234. Advise Operations Center of incident location and explain the
situation in detail
2. Security will assist with intervention.
For Civil disturbances in the immediate vicinity of hospital:
1. Patients are to remain in their rooms. Reassure patients.
2. Personnel are to remain in own area of assignment
3. Close patient room doors, blinds and drapes.
4. Use telephone for emergencies only.
5. Await further instructions from Security/Administration.
Code Silver – controlled access or area lockdown. Staff will limit their movement around the facility
and ensure they are properly displaying their hospital identification—upper right hand chest area.
Encourage visitors to stay where they are. Visitors will check in and out at nurses’ station. If
visitors/staff are not allowed to leave building, a staging area will be assigned for visitors.
Code White - OB Hemorrhage.
1. Dial extension “1234” and state “Code White”
2. Phlebotomist will respond.
Tornado Watch/Warning – indicates the presence of severe weather in the area in which one of the
PSF sites may become involved. See Emergency Operations Plan Manual for additional information.
Did you know? Internal Hallways and bathrooms are probably the safest areas in a tornado
because there are few windows and usually more building structure in those areas.
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Fire/Life Safety
It is important to understand that hospital fire safety requirements differ dramatically from home fire safety. A
hospital’s fire fighting and evacuation strategies are complicated by the fact that many patients cannot be
moved without assistance and/or life-supporting machinery. Because of this we make every effort to move
associates, visitors, and patients to places of safety within the facility before evacuation.
Code Red is announced in the event of a fire or fire drill
v If you see fire or smoke or in the event of a fire drill, remember to follow the RACE protocol.
v A flashing red light will indicate a fire drill in your area.
v To activate Code Red:
1. Pull the nearest fire alarm station….and,
2. Call the Operation Center (Extension 1234) and identify your facility and location
R.A.C.E. stands for the four basic steps you should follow during a fire:
R = Rescue or remove everyone from immediate danger
A = Activate the alarm or turn in an alert followed by a phone call. Turning in the alarm is a
priority because the fire department can be on its way while other activities are being
performed. Thus, while one employee is turning in the alarm, another can be removing a
patient, employee, or visitor from danger.
C = Contain or control the fire. All doors and windows should be closed to prevent the
spread of smoke and flames. Fire doors are marked with a red squiggle.
E = Extinguish the fire. This should only be done in the case of a manageable fire, such as a
fire in a wastebasket. Immediately available equipment such as a blanket, sheet, or bedside
water pitcher should be utilized to extinguish the fire. If possible, two employees should fight
the fire together using two fire extinguishers. Evacuation is done if a fire is not manageable
P.A.S.S. stands for the four basic steps for using a fire extinguisher.
P = Pull the pin.
A = Aim the nozzle
S = Squeeze the handle
S = Sweep from side to side
Evacuation may be partial or complete and is accomplished in one of two ways:
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Horizontally: This involves moving patients to a safe area on the same floor.
Vertically: This involves moving patients downward to other floors or to the outside. Patients
should be evacuated to higher floors only under extreme emergency conditions.
** Should the need to evacuate the hospital arise, the “Disaster Plan” will be activated and the Emergency
Operations Center will direct the evacuation. **
Did You Know?
Smoke is the most common cause of death in a fire.
Medical Gas Safety
v Know the location of Oxygen/Medical gas shut-off valves on your unit. In an emergency, these
valves are to be closed only under the direction of the area supervisor or Fire Department.
v Never put more than *12* E-type oxygen cylinders in a single smoke zone. Contact your
supervisor or safety if you have questions.
v If you have a medical gas alarm panel.
Medical Equipment
v Medical equipment is used in the diagnosis, treatment, and monitoring of the patient.
v This equipment must be maintained and inspected by Clinical Engineering Department at least
annually as part of the Preventative Maintenance Program. The equipment will have a sticker
placed on it that indicates the last inspection date and the initials of the technician performing
the test. The large number in the center is the month due and the due line shows the last two
digits of the year due.
BIOMEDICAL ENGINEERING
6
DUE BY DATE
v If equipment is not functioning properly:
1. Remove it from service
2. Complete a *pink* faulty equipment tag and
3. Call Clinical Engineering (also known as “Biomed”) or enter a work request on-line in My
Virtual Workplace. Volunteers are to report faulty equipment to your department
supervisor for repair/removal follow-up since you do not have on-line reporting access.
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Electrical Safety
v General Precautions
1. Check connection for damage (receptacle, plug, cord) before using equipment.
2. Equipment must be inspected by the user on a regular basis to ensure its safety.
3. Each unit has a Safety Monitor who assists the Environment of Care Committee with
inspection of the facility.
v Electrical Outlets
1. Hospital grade receptacles will have a green dot.
2. Emergency power receptacles are red. In the event of a power failure these
receptacles will still have power.
v Extension Cords
1. The use of extension cords in any PSF facility is discouraged. If necessary, follow
these guidelines:
Extension cord must be no longer than 6 feet.
Extension cord must be hospital grade. (Green dot)
Do NOT link power strips together
2. To obtain a hospital grade extension cord, contact Facilities (ext 2111).
v Portable Heaters
3. The use of portable heating devices in any PSF facility is highly discouraged. If use is
necessary, follow these guidelines:
- Use only in well-controlled area.
- Facilities need to verify its safety before its initial use (no exposed heating
elements)
- Maintain a clear zone of three feet from other materials.
2. DO NOT use in patient treatment areas, like patient rooms.
In the event of an electrical shock emergency:
v Don’t touch the person until the power source has been disconnected.
v Call for help.
Personal electrical equipment will be approved for use by the supervisor or safety monitor. It must
be in good operating condition at all times. Equipment may be non-grounded (2-wire type); however,
it must have UL approval markings on the case.
Associates/Volunteers/Students will not wear headphones, ear buds, ear plugs or other earpieces
while on duty unless this equipment is required for the job or is worn for medical purposes. Wearing
these devices limits one’s ability to hear and respond to overhead messages and/or emergency
situations. Furthermore, wearing earpieces is not conducive to assisting our customers and meeting
our Standards of Behavior.
Contact Facilities, x2111, for problems with heating/cooling, electrical, plumbing, beds, nurse call
lights, medical gases and room/area repairs.
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INFECTION CONTROL
All policies regarding Infection Control are found in IDP I-04-a
STANDARD PRECAUTIONS
v Standard Precautions are a set of Infection Prevention practices used at ALL times, for ALL
patients, every day.
v With Standard Precautions, one assumes all blood and body substances from all people are
infectious.
This includes any body fluid visibly contaminated with blood, semen, vaginal secretions, cerebrospinal
fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, urine, fecal material,
respiratory secretions and blood.
v Standard Precautions provide you with a standard system of safeguards against blood borne
infections. This reduces the risk of transmitting blood borne diseases and protects both the
patient and the associate.
Practices included in Standard Precautions are: Hand Hygiene, Cough Etiquette, Use of Personal
Protective Equipment, Patient Placement Procedures, Equipment Cleaning Procedures and
Care of the Environment
A. HAND HYGIENE
Hand Hygiene is the single most important measure to reduce the risk of spreading infection
from one person to another or from one site to another on the same patient.
Hand Hygiene
=
Cleaning Your Hands
It also includes use of Artificial Nails, Fingernail Care & Jewelry Considerations
Wearing gloves does not replace the need for hand washing because:
1. Gloves may have small unapparent defects or be torn during use
2. Hands can become contaminated during removal of the gloves
Hand Hygiene is either:
1. Hand washing with soap & water
or
2. Use of alcohol-based hand sanitizer
1. One MUST wash hands with soap and water:
•
If visibly soiled with blood or other body fluids
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•
•
•
Before eating
After using the restroom
For patients with C. difficile infection
When washing hands with soap and water, wet hands first with water, apply amount of product recommended by the
manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands
and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet.
Avoid using hot water as it may increase the risk of dermatitis.
2. Use alcohol-based Instant Hand Sanitizer to decontaminate hands:
•
•
•
•
•
•
•
Before direct patient contact
After contact with patients intact skin (i.e., vital signs, repositioning)
After contact with objects in the patient’s environment
After removing gloves
If moving from a contaminated-body site to a clean-body site during patient care
Before donning sterile gloves
Any time soap and water is not required
When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands
together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer’s recommendations
regarding the volume of product to use.
3. Moisturizing
• Use Hospital Approved products available in your work area (call Infection Control if you do not
have access to products or need additional dispensers)
• Moisturizers selected by the Infection Control Committee are compatible with soap products,
gloves and other equipment
• Moisturize hands after hand washing
4. Intact Skin
• Every effort should be made to keep skin on the hands intact by use of proper products and
performing hand hygiene correctly
• Use warm not hot water
• Always completely dry your hands and apply moisturizer (at least twice a shift)
• Rub alcohol-based hand sanitizer into your skin until is completely dry
• Do not wash hand and then apply alcohol-based hand sanitizer (this will cause excessive
drying)
• If hands are cracked or you feel you have an allergic reaction to any products see Employee
Health for evaluation and recommendations
5. Artificial Nails
• NO form of artificial nails, including extenders, gels, appliqués or anything other than natural
nail, are allowed for associates who have direct patient care (this means if they routinely touch
patients as part of their work duties)
•
Artificial nails have been linked to outbreaks (some fatal) in patients
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•
•
•
Associates who are unsure of their status should consult with their manager or supervisor, if
the manager or supervisor is unsure if the policy is applicable to this job classification, they
should call Infection Control for clarification
Nail polish is allowed but must be maintained in good condition and not chipped
Nails may not be over ¼” in length beyond the finger. They must be clean, neat and
professional in appearance (HR Dress Code)
6. Jewelry
• Jewelry must not impair the associate’s ability to perform job functions or pose safety hazards
to patient or self. No facial jewelry or jewelry in the mouth is permitted. Tattoos are
discouraged. The manager may request tattoos to be covered while on duty. (HR Dress Code)
• Wash hands with jewelry on. Do not take off dirty jewelry wash hands and then put jewelry
back on clean hands
7. Frequently Touched Items/Reusable Equipment
• Items frequently touched (e.g., keyboards, phones, charts etc.) should be cleaned with hospital
approved disinfecting wipes at least once a shift and whenever they are visibly soiled or known
to have been contaminated
• Items used on more than one patient (e.g., stethoscope, pulse ox, machines used to take
vitals) should be disinfected using hospital approved disinfecting wipes when practical
8. Cough Etiquette: To decrease the spread of respiratory illness
•
•
•
•
Cover your mouth/nose with cough or sneeze. If a tissue is used as cover, dispose of
promptly.
Use hand hygiene after cough or sneeze.
Refer visitors to our Hygiene stations for supplies and information.
Use “No-Touch” trash cans
All Soap or Hand Sanitizer products, used in PSFHS facilities, must be hospital approved
prior to use. Products stocked in Central Services have been approved for use.
B. PERSONAL PROTECTIVE EQUIPMENT
v Equipment that protects you from contact with potentially infectious materials may include:
Gloves
Masks
Gowns
Aprons
Lab coats
Faceshields
Protective eyewear
Mouthpieces
Resuscitation bags or other ventilator devices
Gloves:
n Wear gloves when contact with blood or other potentially infectious materials is possible
n Remove gloves after caring for a patient
n Change gloves when contaminated and in between patients
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n Do not wash gloves
n Do not contaminate the environment with soiled gloves
Masks:
n To protect associates’ nose and mouth from splashes or sprays of blood, body fluids,
secretions and excretions
n To protect associates from diseases that are transmitted via Airborne (use N95 face mask) or
Droplet (regular mask) modes of transmission
n For patients/visitors who are coughing
Gowns:
n Should be worn to protect associates’ skin and clothing during procedures and patient care
activities that are likely to generate splashes or sprays of blood, body fluids, secretions and
excretions
n Should be placed on patients if patient must leave room for necessary medical care
Eye Protection: Goggles/Face Shields
n To protect eyes during activities or procedures that are likely to generate splashes or
sprays of blood or other potentially infectious materials
n When working within 6 feet of patient who is coughing or has loose respiratory secretions
C. EQUIPMENT and SUPPLIES
Equipment
n Patient care equipment that touches intact skin: handle in a manner that prevents skin and
mucous membrane exposure, contamination of clothing and transfer of microorganisms to
other patients or environments
n Ensure that reusable equipment is properly disinfected prior to use on another patient (pulse
ox, glucometer, scissors, stethoscopes, tape measures, pens)
n Non-Patient care equipment should also be disinfected (Phones, Keyboards)
Supplies
n Linen: should be handled in a manner that will prevent personal contamination or transfer of
microorganisms to patients, personnel or environments. All soiled linen should be placed in a
blue plastic bag and sent to Laundry.
n Infectious waste: place in a red plastic bag. This includes disposable towels and materials
soiled with blood/body fluids. Red bags are never to be put into the trash chutes; they are kept
in the red barrels in the soiled utility room.
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n Sharps: Only disposable syringes, needles and other sharp items should be placed in Sharps
containers. These puncture resistant containers have a Biohazard label on them.
n Needles should not be recapped or manipulated. When recapping is absolutely necessary,
use the “one hand scoop” technique or a mechanical device.
n Dishes: if dishes or trays are contaminated with any body substance, clean with a disinfectant
wipe prior to placing back on the cart. Dietary personnel wear gloves when handling all
dishes.
n Specimens: treat all as potentially infectious. Close all containers securely and place in a
plastic bag.
Did you know? Patients with HIV or Hepatitis (HBV) may not have noticeable symptoms, so
always use standard precautions to protect you!
v Your risk of contracting HBV or HIV with an exposure to infectious material:
HBV is as high as 30%
HIV is only 0.4%
TRANSMISSION BASED PRECAUTIONS:
v Used in addition to Standard Precautions for specified patients with known infections with the
following routes of transmission:
n Airborne
n Droplet
n Contact
A. Airborne Precautions
n Diseases spread by droplet nuclei (tiny particles) that remain suspended in the air for long
periods of time or dust particles containing the infectious agent carried on air currents
n Requires Negative Pressure Room
n Requires N95 respiratory protection (HEPA respirator)
- Tuberculosis/Varicella/Measles/Smallpox
B. Droplet Precautions
n Droplets contacting the conjunctivae or mucous membranes of the nose or mouth
n Droplets are generated when the person coughs, sneezes, speaks or during suctioning or
bronchoscopy
n Requires close contact, usually 3 feet or less, droplets do not stay suspended for long periods
of time. (Bacterial meningitis, Pertussis, Mumps, Influenza)
C. Contact Precautions
n Direct Contact includes hand or skin to skin contact (vitals, positioning)
n Indirect Contact occurs when touching environmental surfaces or patient care items (telemetry
unit, linen, tubing, bed rails, over-bed table)
n Patients with previous history or current infection/colonization of the following have door
marked with:
- MRSA
- VRE
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- EBSL
- MDRO (multiple drug resistant organisms)
n Everything in the room should be considered contaminated.
- Appropriate barrier PPE for activities
- Remove PPE prior to leaving
- Hand Hygiene
- Leave Clean
Order of PPE Matters:
n On:
- Hand hygiene, Gown (tie behind back), Mask, Gloves.
n Off:
- Gloves, Gown, Mask, Hand Hygiene
Detailed information about infection control issues and PPE necessary for you to perform your job is
available in your work area in the IDP guideline book and Infection Control Manual.
GUIDELINES FOR EMPLOYEE POST EXPOSURE FOLLOW UP TO BLOOD
AND BODY FLUIDS:
If an associate sustains a Blood/Body Fluid Exposure, s/he should obtain an Exposure packet
immediately from Occupational Health Office, the Emergency Department or Surgery and follow
the instructions in the packet. Completion of packet and submission to Occupational Health fulfills
requirement for reporting.
Post-Exposure blood work is offered to the exposed associate per Occupation Health protocol for
Blood/Body Fluid Exposures.
HAZARD COMMUNICATION
In the 1970s OSHA enacted a law requiring employers to provide
information and training to employees on the hazards of the chemicals they
work with. This was called the “HAZCOM” or “Right-to-Know” standard.
Key elements of the HAZCOM standard:
§
You must receive adequate training before working with hazardous chemicals. (This training
plus training from your supervisor)
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§
§
§
§
§
§
You must have access to the institutions Chemical Hygiene Plan. (It’s in the small Green Book
on each unit)
Material Safety Data Sheets (MSDS) must be made available to you. (They’re available in your
work area or in my virtual workplace under PSF-MSDS Online)
You must be informed of hazardous chemicals present in your work area and of operations in
which they are involved. (Training by your supervisor and the chemical inventory for your
area)
You should know how to detect the presence or release of a hazardous chemical. (Training by
your supervisor).
You must be provided personal protective equipment and engineering controls. (Located in
your area).
You must know the proper procedures for responding to emergencies. (In the red book)
Material Safety Data Sheet (MSDS)
§
Manufacturers prepare Material Safety Data Sheets for each chemical they produce. It
describes the physical and chemical properties of the product, the health hazards, and
appropriate emergency response procedures. And, it can tell you of acute and chronic
effects that can be caused by exposure to hazardous chemicals. The MSDS provides
specific information on a hazardous substance. Each MSDS may look different but all
provide the same information.
Sections:
- Chemical identification – Substance name, company that provides the substance, hazardous components of the
substance.
- Composition – Ingredients and common names of the substance.
- Hazards – Appearance, health effects and symptoms of exposure.
- First Aid Measures – Emergency procedures and first aid protocol prior to professional help.
- Fire Fighting Measures – Explosive properties, proper extinguisher devices, and firefighting guidelines.
- Accidental Release Measures – Clean-up/spill protocols.
- Handling/Storage – Handling and storage protocols for the substances.
- Exposure Control/Personal Protection – Engineering controls and personal protective equipment needed to
handle the substance.
- Physical/Chemical Properties – Substance characteristics and other characteristics like odor,
boiling/freezing/melting points.
- Stability/Reactivity – Conditions that could result in a hazardous chemical reaction; and information or
contact/reaction to other chemicals/environmental conditions.
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Each work area that uses or stores hazardous chemicals will have a listing of the chemicals
they use and copies of each chemicals MSDS.
§ Copies of all of our MSDS’s are available through My Virtual Workplace
§
Haz Mat Classification
NFPA Hazard
Classifications
HEALTH
HAZARD
4 Deadly
3 Extreme
Danger
2 Hazardous
1Slighly
Hazardous
0 Normal
Material
HEALTH
FIRE HAZARD
Flash Points
4 Below 73 F
3 Below 100 F
2 Above 100 F
Not Exceeding
200 F
1 Above 200 F
0 Will not burn
4 Can cause death or major injury
despite
medical treatment.
3 Can cause serious injury despite
medical
treatment.
2 Can cause injury. Requires prompt
treatment.
1 Can cause irritation if not treated.
0 No hazard.
FLAMMABILITY
SPECIFIC
HAZARD
Oxidizer – OX
Acid – ACID
Alkali – ALK
Corrosive – COR
Use NO WATER
-W
Radioactive
- å
REACTIVITY
4 May detonate
3 Shock and
heat may
detonate
2 Violent
chemical
change
1 Unstable if
heated
0 Stable
4 Very flammable gases or very volatile
flammable liquids
3 Can be ignited at all normal
temperatures.
2 Ignites if moderately heated.
1 Ignites after considerable preheating.
0 Will not burn.
REACTIVITY
4 Readily detonates or explodes.
3 Can detonate or explode but requires
strong
initiating force or heating under
confinement.
2 Normally unstable but will not
detonate.
1 Normally stable. Unstable at high
temperature
and pressure. Reacts with water.
0 Normally stable. Not reactive with
water.
Reference: NFPA 704, National Fire Protection
Association, Boston MA
Reorder No. 10336
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PATIENT SAFETY GOALS
Patient Safety is at the center of Health Care
Patient Safety Officer = Jeff Oram-Smith, MD, Chief Medical Officer
Patient Safety is every Associate/Volunteer/Students Responsibility!
Patient Safety Plan is in IDP S-01-b
2010 Patient Safety Goals – Established by The Joint Commission (TJC)
1. Improve the accuracy of patient identification:
- Correctly identify all patients. Use at least 2 identifiers before any procedure,
surgery, test, or service. (IDP I-02-a) This is PSF Red Rule #1!
- Eliminate transfusion errors related to patient misidentification.
2. Improve the effectiveness of communication among caregivers:
- Report Critical results of tests and procedures on a timely basis (IDP C-08-e)
3. Improve the safety of using medications:
- Label all medications, medication containers (for example, syringes, medicine
cups, basins), or other solutions on and off the sterile field in perioperative or
other procedural settings (IDP L-01-n)
- Reduce patient harm associated with anticoagulation therapy
4. Reduce the risk of healthcare-associated infections:
- Follow CDC hand hygiene guidelines (IDP I-04-a)
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-
Manage as sentinel events all identified cases of unanticipated death or major
permanent loss of function associated with a health care related infection
- NEW! Implement evidence-based practices to prevent:
~ Healthcare-associated infections due to multi-drug resistant organisms.
~ Central line-associated bloodstream infections.
~ Surgical site infection
5. Accurately and completely reconcile medications across the continuum of care. (IDP M-05-h)
- Compare the patient’s current medications with those ordered
- A complete list is communicated to the next provider of service and provided to the
patient on discharge
6. Identify patients at risk for suicide (admission assessment & ongoing screening)
7. Follow Universal Protocol with all surgical patients (IDP S-07-a):
- Conduct pre-operative verification
- Mark the operative site
- Conduct a “time-out” immediately before a procedure
**IDP = Interdisciplinary Practices
Located with Nursing Guideline Book and on Shared Drive.**
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Patient Privacy - HIPAA
1. What is HIPAA?
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is the first comprehensive
federal protection law for the privacy of health information. It provides patients rights and control
over their information by setting limits on the use and disclosure of their health information.
Additionally, it establishes safeguards to protect the privacy of the information in all forms, including
paper records, oral communications, and electronic information.
• Patient privacy is an individual’s right to limit the use and disclosure of personal health
information.
• Confidentiality is the safekeeping of data and information so as to restrict access to
individuals who have a need, reason, and permission for such access.
2. Patients Rights
•
•
•
•
•
•
Right to receive a copy of the Notice of Privacy Practices. This document describes how
patient’s medical information may be used and disclosed and how they can get access to this
information.
Right to access health information.
Right to authorize how health information is used and disclosed.
Right to request restrictions on how health information is used and disclosed.
Right to request amendments or corrections to their health information.
Right to an accounting of disclosures.
3. Workforce Members’ Responsibilities
•
•
•
•
•
•
Preserve, protect and safeguard patient privacy and confidential health information at all times.
Use care and consideration when discussing patient information and treatment, as others may
be able to hear your conversation.
Do not share patient information with others unless necessary for the treatment of the patient
and required to do your job.
Do not write your password down, post it near your workstation or share it with anyone verbally
or written.
When you walk away from your workstation remember to log off the system so other members
are not accessing patient information under your log on because you will be held accountable
for the information accessed.
Use care when it is necessary and appropriate to discard patient health information. Please
place confidential materials in a shred box/container. There are designated shred boxes or
containers in all departments throughout the hospital. Please see your supervisor if you are not
aware of where to place “to be shredded” materials.
4. Privacy Official and Complaints
Gail Decker, Director of Health Information Management, is the Privacy Officer for PSF.
If patients have questions relating to their HIPAA privacy rights or complain that their
privacy has been violated, they may
§ Contact the Integrity Helpline at 1-888-424-2458
§ File an electronic complaint – www.integrityhelpline.org
§ Go to Centura’s Compliance website – www.myvirtualworkplace.org
• Select “About Centura” tab, select “Compliance Program”, select Integrity
Helpline
§ Contact the PSF Privacy Officer, Gail Decker, Director of Health Information
Management at 776-5088.
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5. Penalties/Sanctions
Penalties for breaking the HIPAA privacy rules are twice the penalty of Medicare and Medicaid
fraud and abuse. Associates who fail to comply with the HIPAA privacy and confidentiality
policies and procedures will be disciplined to include termination. Additionally, the federal
government can impose monetary penalties as low as $100 per violation up to $250,000 and
ten years in prison.
6. How does HIPAA affect PSFHS?
HIPAA complements PSFHS existing confidentiality policies, procedures and practices and will
require all workforce members to take a few extra steps to ensure the safety and protection of
patient health information.
Identification of Patient Abuse & Neglect:
Everyone’s Responsibility!
1. Definitions:
Abuse is the infliction of injury, unreasonable confinement, intimidation, or cruel punishment
upon another person with resulting physical or emotional harm or pain.
Neglect is the failure to provide the goods or services (food, clothing, hygiene,
medications, etc.) which are necessary to avoid physical or emotional harm or pain
**Both result in physical or emotional harm or pain**
2. There are many different types of Abuse/Neglect:
ü
ü
ü
ü
ü
ü
Physical - hitting, slapping, pinching, kicking, spitting, burning, etc.
Verbal - oral, written, or gestured language that is derogatory
Emotional - humiliation, threats, harassment, punishment, or deprivation
Sexual - harassment, coercion, or assault
Financial - misuse of funds (elderly are protected in Colorado)
Misappropriation - taking what belongs to someone else without permission and using it for
one’s own gain(s)
3. The associate must be aware of the many different signs that might mean abuse or
neglect is occurring:
ü Unexplained injuries
ü Bruises of different colors
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ü
ü
ü
ü
ü
ü
Delays in seeking care
Inappropriate clothing (i.e., no coat on a cold day)
Hunger
Lack of supervision (i.e., near drowning, scalding burns)
Interactions that make you uncomfortable
and so on!
4. Trust your gut instinct: if something strikes you as odd or uncomfortable, believe your gut!
5. Anyone could be a victim of abuse/neglect:
o Men as well as women
o Rich as well as poor
o Any age
6. WHAT TO DO if you suspect abuse or neglect:
Call Care Management Services
776 – 5173
if you are suspicious or concerned
The Care Management Services is the department designated as having the primary
responsibility of interviewing, reporting, and coordinating care efforts for patients
suspected of being abused, neglected or endangered.
7. As a health care institution, we are required by law to report patient abuse & neglect
8. Interdisciplinary Practice (IDP) A-02-a has more detailed information on this subject
9. TESSA (633-3819) and DHS (636-0000) are two community resource agencies.
10. Hospital associates also have EAP benefits if abuse/neglect affects them personally.
LIFE SAFETY
1
What is the most common cause of death in a fire?
_____________________
2
What are the four basic steps to follow in the event of a fire?
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_____________________
__________________________
_____________________
__________________________
3
What are the four steps to follow in using a fire extinguisher?
_____________________
__________________________
_____________________
__________________________
4
To activate Code Red in the event of a fire, what two steps should be taken?
_____________________
__________________________
5
In the event of a fire, under whose direction would you shut off or close an oxygen valve?
_____________________________________________________________
6
Code Red is announced in the event of a fire or ____________________
7
If medical equipment is not functioning properly, what three steps should be taken?
_____________________
.
______________________
_____________________
8
All medical equipment used for patient care should be inspected at least every two years.
True or False
9
Extension cords used at PSF must be hospital grade (identified by a green dot) and may be any
length.
True or False
10 Portable heaters may be used in patient areas.
True or False
11 Emergency electrical receptacles, identified by red templates and used for all critical patient
related functions, will still have power in the event of a power failure.
True or False
12 If a co-worker is being electrocuted by a piece of electrical equipment, the first step would be to
disconnect the power source.
True or False
13. Facilities is responsible for checking every piece of electrical equipment and all outlets.
True or False
INFECTION CONTROL
1.
_______ ________ is the system of isolation to be used by all personnel regardless of the
patients’ diagnosis and provide barriers against exposure to blood, secretions, and excretions.
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2. _________ ________ is the single most important measure to reduce the risk of transmitting
microorganisms from one person to another or from one site to another on the same patient.
3. The times you must wash hands with soap and water are:
a. _______________
b. _______________
c. _______________
4. Blood or body fluid exposures should be reported how soon? ______________________
5. You can obtain a Blood/Body Fluid Exposure packet from the Occupational Health Office, OR, or
ER at PH and SFMC.
True or False
6. Transmission Based Precautions consist of Airborne Precautions, Droplet Precautions, and
Contact Precautions and are used ____ ______________ ____ to Standard Precautions.
7. Individuals with HIV or Hepatitis may not have any noticeable symptoms.
True or False
8. Alcohol based Instant Hand Sanitizer should be used; before direct patient contact and after
contact with patients intact skin or contact with inanimate objects in the immediate vicinity of the
patient.
True or False
9. Healthcare workers caring for a patient with active TB must wear an N95 respirator.
True or False
10.Detailed information about infection control issues and any personal protective equipment
necessary for you to perform your job are available in your work area.
True or False
HAZARD COMMUNICATION
1. Which sections of an MSDS sheet would provide you with the following
information about a chemical? (Please provide the name of the section.)
a. Health effects and symptoms of exposure: _________________________
b. Protective equipment needed: ________________________
c. Proper handling of the substance or chemical: ______________________
2. An “0” rating listed in the red “Fire Hazard” section of the multi-colored diamond indicates a high
degree of flammability.
True or False
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3. A “4” rating listed in the blue “Health Hazard” section on the multi-colored diamond indicates
normal health hazard.
True or False
EMERGENCY MANAGEMENT
Please match the description on the right with the appropriate description on the left:
1. __________Code Orange
A. Missing Child / Person
2. __________Code Blue
B. External Disaster
3. __________Code Red
C. OB Hemorrhage
4. __________Code Grey
D. Cardiac or Respiratory Arrest
5. __________Phases of a Code Grey
E. Lockdown
6. __________Code Black
F. Chemical Spill
7. __________ Code Pink
G. Combative Person
8. __________ Code Green
H. Standby, Go, All Clear
9. __________ Code White
I. Fire or Fire Drill
10. __________ Code Silver
J. Bomb Threat
11. What is the phone number to activate all emergency codes and obtain emergency assistance
from Security? _______
12. In the event of a tornado warning or alert, hallways and bathrooms are probably the safest areas.
True or False
13. In the event of a bomb threat, there will be an immediate all-out evacuation of the building.
True or False
14. S.I.N., used in Code Orange, stands for “Safety”, “Isolate”, “Notify”
True or False
PATIENT SAFETY
1. Hand Hygiene measures are for Infection Control and are not part of the National Patient Safety
Goals (NPSG).
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True or False
2. The purpose of PSF Red Rule #1 is to correctly identify all patients before a service is provided
(including test, surgery or procedure) and is in place to accomplish the NPSG on Patient
Identification.
True or False
3. The hospital has practices in place to improve patient safety in the area of medication use.
True or False
4. Marking the operative site of a patient having surgery is part of the National Patient Safety Goals.
True or False
5. Patient safety is the center of healthcare.
True or False
6. The National Patient Safety Goals are important to patient care providers, but do not affect our
non-patient care staff or volunteers.
True or False
7. The hospital identifies patients who are at risk for suicide as part of the National Patient Safety
Goals.
True or False
8. Keeping patients safe is a TOP priority for Penrose-St. Francis.
True or False
9. The hospital’s Interdisciplinary Policies (IDP) includes the Patient Safety Plan.
True or False
10. National Patient safety Goals are established by OSHA – the Occupational Safety and Health
Administration.
True or False
11. New NPSG require implementation of practices to prevent specific infections related to surgical
site, central line and multi-drug resistant organisms.
True or False
HIPAA
1. A friend of yours knows a patient that is being treated at Penrose Hospital, and asks you to find out his
prognosis. What should you do?
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a. Ask a nurse on the floor how the patient is doing and pass the information along to your friend
b. Ask your friend how well she knows the patient and then decide how much to tell her
c. Explain that it’s a violation of the patient’s privacy for you to discuss the patient’s condition
d. None of the above
2. Under what circumstances are you free to repeat to others private health information that you hear on
the job?
a. After you no longer work at PSF
b. After a patient dies
c. Only if you know the patient would not mind
d. When your job requires it
e. None of the above
3. What document describes how patient’s medical information may be used and disclosed and how they
can get access to this information?
a. Notice of Privacy Practices
b. Consent for Medical Treatment
c. Authorization To Disclose Protected Health Information
d. Patients Rights and Responsibilities
e. None of the above
4. Which of the examples below is NOT a common work practice that protects the confidentiality of patient
information?
a. Keeping computers logged out of the patient information system when not in use
b. Storing paper records in a locked file room.
c. Limiting the number of visitors who can see a patient
d. Pointing computer screens away from the public
5. True or False: Penalties can be incurred for violating the HIPAA privacy rule to include $100 penalty
per incident up to $250,000 fine and 10 years in prison.
True or False
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6. What rights do patients NOT have under the Health Insurance Portability and Accountability Act
(HIPAA) of 1996?
a. Access to their health information
b. Authorize how their health information is used and disclosed
c. Request restrictions on how their health information is used and disclosed
d. Request an amendment or corrections to their health information
e. Request specific health information be permanently removed from their medical record
when an amendment or correction is agreed to
f. Accounting of disclosures
7. What should you do if a patient has questions about his/her privacy rights or complains that her privacy
was violated during his/her stay?
a. Tell the patient to contact the person responsible for handling complaints listed on the Notice of
Privacy Practices –Centura Health Helpline at 1-888-424-2458
b. Contact the Privacy Officer – Gail Decker, Director of Health Information at 776-5088
c. A or B
d. None of the above
Abuse & Neglect Questions
1. Abuse needs to be reported; Neglect does not:
True or False
2. You are suspicious that a patient has been abused or neglected. Who would you report this to?
3. Only associates who provide direct patient care are responsible for recognizing and reporting
abuse or neglect.
True or False
Name: ______________________________________________
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