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Safety Office
 ext.
57189
 Where
to find safety information:
Saint Francis Medical Center
Policy Manual
located on
Medical Center web-site
Safety Champions
 We
have a Safety Champion Program with
approximately 140 departments and 160
champions.
 The off-site facilities are included in this
number.
 Please learn who your Champion is.
We are ALL
by learning how to be
safe at work!
What is Peminic?
 Peminic
is an electronic event reporting system
located on the Medical Center Intranet home
page for reporting safety issues.
Reporter Name (First MI Last)
Reporter Type
Reporter‘s Facility (choice)
Reporters Department
Date Event Occurred (MMDDYYYY)
Time Event Occurred (Military Time) Blank=unknown
PATIENT / PERSON INFORMATION
Type of Patient / Person Involved
Highlights of Peminic
 Real-time
application
 Accessible
to all staff; anyone could report an
event
 Central
database for tracking & trending events
and near misses
Healthcare Building Design

Firewalls separate buildings into smoke compartments.
A smoke compartment is a space within a building that is
enclosed by smoke barriers on all sides, including the top
and bottom. Smoke compartments protect people from
smoke and fire for at least 1.5 hours. The floors and
ceilings of a smoke compartment contain smoke and fire
for 2 hours.

Each stairwell is a separate smoke compartment.

Patient rooms are within smoke compartments. The door
to a patient room protects from smoke and fire for about
20 minutes.

Area shutoff valves for oxygen lines are provided in
patient areas.

Not all buildings have these features check your
department specific safety plan.
Category: General Safety
Which of the following overhead pages
(announcements) means there is a fire?
A. Code Pink
C. Green Alert
B. Red Alert
D. Blue Alert
Category: General Safety
Which of the following overhead pages
(announcements) means there is a fire?
A. Code Pink
(Infant/Child Abduction)
C. Green Alert
(Chemical Spill)
B. Red Alert (Fire)
D. Blue Alert
(Cardiac arrest)
Category: General Safety
What key word tells you what to do in
case of fire?
A. RICE (Rescue,
Inform, Control,
Evacuate)
B. REST (Remember,
Eliminate the Smoke
Threat)
C. RACE (Rescue,
Alarm,
Confine/Contain,
Extinguish/Evacuate)
D. RATS (Run Away
To Safety)
Category: General Safety
What key word tells you what to do in
case of fire?
A. RICE (Rescue,
Inform, Control,
Evacuate)
B. REST (Remember,
Eliminate the Smoke
Threat)
C. RACE (Rescue,
Alarm,Confine (Defend in
Place), Extinguish)
D. RATS (Run Away To
Safety)
Fire Safety


If a fire is located in a patient care room or
cubicle the equipment connected to the
oxygen wall outlets should be turned off
and disconnected from the oxygen wall
outlet, and the occupants moved to safety.
Should an oxygen enriched fire be
discovered in a patient care room or cubicle
the oxygen zone valve serving the affected
space shall be turned off by the Clinical
Nurse Manager, or Unit Charge Person or
their designee, or a Respiratory Therapist.
Category: General Safety
What key word tells you how to use a
fire extinguisher?
A. PASS (Pull, Aim,
Squeeze, Sweep)
C. PAST (Point, Aim,
Squeeze Trigger)
B. PANIC (Pull, Aim
Nozzle, In Circles)
D. PLANE (Point,
Lock, Aim Nozzle,
Extinguish)
Category: General Safety
What key word tells you how to use a
fire extinguisher?
A. PASS (Pull, Aim,
Squeeze, Sweep)
C. PAST (Point, Aim,
Squeeze Trigger)
B. PANIC (Pull, Aim
Nozzle, In Circles)
D. PLANE (Point,
Lock, Aim Nozzle,
Extinguish)
PASS
Using a Fire Extinguisher







P – Pull the pin
A – Aim at the base of the fire
S – Squeeze the handle
S – Sweep the nozzle from side to side across the base of
the fire
Make sure you are able to exit the room, keep your back
towards the exit.
If the fire is bigger than a small garbage can an
extinguisher will not put out the fire
Do not enter a room if the fire is too large. If a door is
warm, do not open it.
Fire Alarm Pull Boxes
Located near exits and
stairwells
 Look for them in
your department
and know where
they are.
Keep Hallways Clear
Clutter in corridors will make it difficult to evacuate. You must
maintain an 8 foot clearance in all patient care areas. Never block
pull boxes, fire doors, fire extinguishers, exits, or any other life
safety features. Electrical panel require 3 ft clearance.
Which one of these items should not be used
in the facility without approval from the
Safety Office because they can increase the
risk of fire?
A.
B.
C.
D.
Door Wedges
Extension Cords
Space Heaters
Decorations that are not
found in the OSF policies
E. All of the above
Which one of these items should not be used in the
facility without approval from the Safety Office
because they can increase the risk of fire?
A. Door Wedges
B. Extension Cords
C. Space Heaters
D. Decorations that are not
found in the OSF policies
E. All of the above
Interim Life Safety Measures


(1) When fire or environmental safety is affected by
construction or deficiencies, alternate means are
implemented to temporarily compensate. These means are
known as Interim Life Safety Measures (ILSM)
(2) All construction jobs shall be evaluated for their affect
on fire and environmental safety and the appropriate ILSM
determined. This process shall be documented. Throughout
the construction period, the ILSM shall be continued and
inspected. The results of the inspections shall be
documented
Category: General Safety
Which of the following overhead pages (announcements)
means there is an infant/toddler/child/teen abduction?
A. Gray Alert
C. Code Pink
B. Brown Alert
D. Orange Alert
Category: General Safety
Which of the following overhead pages
(announcements) means there is an
infant/toddler/child/teen abduction?
A. Gray Alert (Tornado
C. Code Pink
within 65 miles of Medical
Center)
B. Brown Alert
(Utility Failure)
D. Orange Alert
(Mass Casualty Incident)
Category: General Safety
Which of the following overhead pages/
announcements means there is a missing
person 18 years of age or older who is
confused and disoriented?
A. Blue Alert
C. Condition Purple
B. Green Alert
D. Silver Alert
Category: General Safety
Which of the following overhead announcements
means there is a missing person 18 years of age
or older who is confused and disoriented?
A. Blue Alert
(Medical Emergency)
B. Green Alert
(Chemical spill)
C. Condition Purple
(Radioactive materials emergency)
D. Silver Alert
Category: General Safety
Number to call to report Red Alert:
A.
B.
C.
D.
5-3701
5-2131
5-3333
5-7189
Category: General Safety
What would be announced overhead if there
were a radioactive materials emergency?
A. Orange Alert
B. Condition purple
C. Blue Alert
D. Yellow Alert
CONDITION PURPLE
AN INCIDENT INVOLVING RADIOACTIVITY
CONDITION PURPLE
 Remember
– Anyone working around Radiation are
considered the “experts in Radiation Safety”.
 Remove everyone from the area and contain it – (Time,
Distance, Shielding)
 Call
Security and Page the RSO through PALS
CONDITION PURPLE
CONDITION PURPLE
 Four
•
•
•
•
Categories of Radiation
Unsealed Source Therapeutic
– I-131 Therapy
Brachytherapy
– Radioactive Seeds
Nuclear Medicine
– Examine Body anatomy and Function,
Radioisotopes
External Beam
– X-ray, Computed Tomography, Interventional
Labs
Category: General Safety
Why would a Black Alert be announced?
A.
B.
C.
D.
Tornado within 10 miles
Tsunami in 10 minutes
Earthquake
Thick smoke in the hall
Category: General Safety
What number would be called to report a
utilities failure?
A.
B.
C.
D.
5-3701
5-3333
5-2131
5-7189
Category: Electrical Safety
How do you treat faulty, broken, or
malfunctioning medical equipment?
A. Stick a post-it note on
it to Bio Med indicating
“broken - please repair”
B. Discard it immediately
until the purchase of new
equipment
C. Keep using equipment
D. Complete a work order
request to Bio-med and
place on broken equipment
Category: Electrical Safety
How do you treat faulty, broken, or
malfunctioning medical equipment?
A. Stick a post-it note on
it to Bio Med indicating
“broken - please repair”
B. Discard it immediately
until the purchase of new
equipment
C. Keep using equipment
D. Complete a work order
request to Bio-med and
place on broken equipment
Orange Alert Defined as:

Potential emergent situations when the quantity or
degree of injuries, illnesses, or staffing needs may
overwhelm the Medical Center’s ability to respond.
This may be due to an internal or external disaster.
The Incident Command Center may be activated
during the alert.

In the event of an all hazards emergency the procedures
below should be followed.
ORANGE ALERT



LEVEL I Potential emergent situation is developing and there is
currently no impact or interruption to the medical center. Staff should
continue normal activity
LEVEL II The situation has a noticeable impact to the medical center.
The staff on duty should be prepared to work extra hours and assist
with duties assigned that would not normally be one of their assigned
job functions. Departments should start faxing census and staffing
information to the Patient Care Services Office at 624-8734. The need
for setting up the Incident Command Center is being evaluated.
LEVEL III The situation has a major impact to the medical center.
Conditions necessitate the requirement for on duty staff to be retained
until additional relief staff arrives. Departments need to activate calling
trees for additional staff. Please access your Unit Specific Safety Plan
for more specific department needs and requirements.
HICS
 What
can the Hospital Incident Command
System do for you?
Emergency Preparedness
Incident Command Center activities include making
arrangements for:
•
•
•
•
•
•
Medical Supplies
Food and Water
Sanitation Facilities
Emergency Power
Extra Space
Support Services
Emergency Preparedness
Incident Command Center Activities
Other Incident Command Center
activities include:
 Ensuring delivery of patient
care and treatment
 Protecting patient medical
records
 Arranging for human and/or
vehicle traffic control
Emergency Preparedness
Employee Rehab and Employee
Pool Areas:


The Incident Commander will activate
the employee rehab and employee pool
areas
 The employee pool area is a
collection point for staff to be
allocated where and when needed.
 The employee rehab area is an area
where employees can relax while on
break during an emergency event.
The employee pool will be staffed by an
assigned person from the incident
command center.
Hazardous Materials




Chemical Waste
Infectious Waste
Radioactive Waste
Hazardous Drug
Waste
Communication of Information
on Hazardous Materials
MSDS
 Material Safety Data Sheet
(Personal Protective Equipment)
 MSDS sheets are obtained by calling
3E at 1-800-451-8346
 Each area has a Safety Plan with a
hazardous chemical inventory list
Category: Hazardous Materials

A.
B.
C.
D.
The first place to look for hazardous
information about a product is:
Yellow pages in phone book.
Policy Procedure Manual
On the product label
None of the above
Category: Hazardous Materials

A.
B.
C.
D.
The first place to look for
hazardous information
about a product is:
Yellow pages in phone
book.
Policy Procedure Manual
On the product label
None of the above
Green Alert-Toner
Special Safety
Issues
Latex Balloons
 Due to the potential of patients, visitors, and staff having
possible latex allergies, latex balloons are not to be brought
into the hospital.
MRI Special Safety:
 Due to MRI special
magnet process, no metal
can go into the MRI
process area. Always stop
at desk and check with
MRI staff.
MRI Magnet

The MRI unit contains a
very powerful magnet
• The magnet is ALWAYS
turned on, even when the
machine is not scanning,
including all night, every
night, every weekend, and
even holidays.
MRI Safety Zones
Zone 1
• This region includes all areas that
are freely accessible to the general
public.
• Signage is posted at the public
entrance to the facility
MRI Safety Zones
Zone 2
• Zone 2 acts as a buffer between Zone 1 and
the more restrictive Zone 3.
• Patients are under the general supervision of
MR personnel. Normally, these areas are also
safe from all magnetic field hazards.
• Zone 2 may include the reception area,
dressing room and interview room.
MRI Safety Zones
Zone 3
• Only approved MR personnel and
patients that have undergone a
medical questionnaire and interview
are allowed inside Zone 3.
• The MR control room and/or
computer room are located within
Zone 3.
MRI Safety Zones
Zone 4
• The room within which the MR
scanner is located.
• This area is clearly marked as
being potentially hazardous due
to the presence of very strong
magnetic fields
• Barriers are in place to prohibit
entrance without being escorted
by MRI personnel
What drugs are hazardous at
SFMC?
Drugs defined by the National Institute for
Occupational Safety and Heath (NIOSH)
 Drugs used to treat cancer.
 Drugs used to treat transplant patients.
 Drugs that can cause fetal harm or demise

How can I be exposed
to drugs?

Transportation of drugs

Administration of drugs

Disposing/wasting of drugs

Removing or disposing of personal protective
equipment
How will I know what
is hazardous?
 Green
is the official hazardous drug color at
SFMC (some packaging may also be in
yellow).
• All hazardous drugs will be labeled with the
official label per policy
• Compounded hazardous drugs dispensed from
Pharmacy will be placed in Yellow Chemotherapy,
ziplock bags.
– These same bags will be used for disposal.
Transport of Hazardous Drugs
 The
pneumatic tube system
• NOT for any liquid hazardous drug preparation.
• OK for oral, non-liquid, hazardous drugs (ie. solid
doses  tablets, capsules, etc)
 Unit
personnel pick up:
• All hazardous drugs that are injected, infused or
implanted.
• All on-call hazardous drugs.
What are the risks?



Routinely working with or near hazardous drugs in health care
settings may cause skin rashes, infertility, miscarriage, birth
defects, and possible blood disorders or cancers.
Employees who are pregnant will not handle hazardous drugs
at SFMC
• Should you become pregnant during your employment,
contact your manager. This discussion will be confidential
and appropriate measures will be taken to maintain your
safety.
Medical surveillance offered through Occupational Health
• Annual, optional monitoring for all employees that come in
routine contact with hazardous drugs
Although some packaging may also be in
yellow what is the official hazardous drug
color at SFMC?
A.
B.
C.
D.
E.
black
red
orange
green
fuchsia
Routinely working with or near hazardous
drugs in health care settings may cause:
A.
B.
C.
D.
E.
skin rashes
infertility
birth defects
blood disorders
all the above