Download Student Orientation 2010 - WellStar College of Health and Human

Orientation Education
Mission Statement
Cartersville Medical Center is committed to treating
all of our patients with compassion, kindness, and
dignity. We will collaborate with our stakeholders to
continuously improve patient care, evaluate and
establish services beneficial to our community, and
position our hospital as the preferred health care
provider and a desirable business partner.
960 Joe Frank Harris
Parkway
Cartersville, GA 30120
(770) 382-1530
Hospital opened September 1, 1985
112 Total Beds
14 Intensive Care
88 Med/Surg
10 OB/Maternity beds
31 Beds in the Emergency Department
8 Operating Rooms
7,157 Admissions
919 Births
An Overview of
Cartersville Medical Center
Personnel
750 Employees
300 Physicians
Volume (FY 2015)
57,501 ER Visits
37,328 Outpatient Visits
9,198 Surgeries
Cartersville Medical Center
Executive Management Team
Jan Tidwell, Associate Administrator
Ed Moyer, Chief Nursing Officer
Robbie Tatum, VP of Human Resources
Keith Sandlin, Chief Executive Officer
Benny McDonald, Chief Financial Officer
Lori Rakes, Chief Operating Officer
Phoebe Stieber, VP of Quality Resources
Customer Service and HCAHPS
Objectives
• Increase awareness of HCAHPS and its impact on
facility
• Discuss how patient loyalty impacts satisfaction
• Apply HCAHPS initiatives in your work setting to
help “move the bar” on current results
What is HCAHPS?
• Hospital Consumer Assessment of Healthcare
Providers and Systems
• The nation’s first standardized, publicly reported
survey of patients’ perspectives of hospital care.
Cliff Notes: It’s what our patients think about us after
they leave our hospital.
Why is HCAHPS Important?
The HCAHPS survey asks patients who have stayed at
our hospital (inpatients) 27 questions, including 18 items
about key aspects of their hospital experience.
These are broken down into the following domains:
 Communication with nurses and doctors
 The responsiveness of hospital staff
 Cleanliness and quietness of hospital environment
 Pain management
 Communication about medicine
 Discharge information
 Overall rating of the hospital
 And recommendation of the hospital
Caring Behaviors
It’s all about the things we do
Our collective acts of all hospital staff have important
consequences for patients, and directly affect their
perceptions of the quality of care they received.
AIDET
• A – Acknowledge
Say hello to patients, visitors and co-workers
• I – Introduce
Provide your name and info about your skills/training
• D – Duration
Describe how long an event will take
• E – Explain
Provide important details about the procedure/situation
• T – Thanks
Thank patients for choosing CMC
Diversity
Learning Objectives
• Describe the impact of the multi-language workplace on our
facility
• Identify your responsibility to respect different cultures in our
organization and patient base
• Identify your responsibility in ensuring that we do not exclude
others just because English is not their first language
• Describe how to apply a commonsense approach for
addressing situations in which language might tend to exclude
others
• Identify other ways in which our behaviors might exclude
others and strategies for demonstrating respectful, inclusive
behaviors
Core Concepts
and Definitions
Respect
Showing appreciation and regard
for the rights, values, and beliefs of
others
Culture
A system of shared beliefs, values,
customs, and behaviors
Diversity
The similarities and differences
among all groups that make up
HCA
Core Concepts and Definitions
Cultural Diversity
The differences and unique
characteristics of the various
groups that make up our business
environment
Workforce Diversity
The differences that are created by
HCA’s own structure and culture
Cultural Competence
Having the knowledge and ability
to recognize and respond
appropriately to our similarities and
differences and use that
knowledge and understanding to
make better decisions
Ethics and Compliance
Cartersville and HCA have a comprehensive, values
based Ethics and Compliance Program, which is a vital
part of the way we conduct ourselves. Because the
Program rests on our Mission and Values, it has easily
become incorporated into our daily activities and
supports our tradition of caring – for our patients, our
communities, and our colleagues. We strive to deliver
healthcare compassionately and to act with absolute
integrity in the way we do our work and the way we
live our lives. All work must be done in an ethical and
legal manner. It is your responsibility and your
obligation to follow the code of conduct and maintain
the highest standards of ethics and compliance.
Ethics and Compliance
 If you have questions or encounter any situation which you
believe violates the provisions of the code of conduct or the
corporate integrity agreement, you should immediately consult
your supervisor, another member of the management team,
the VP of HR (Robbie Tatum ext 1141), the Ethics and
Compliance Officer (Jan Tidwell ext 1070), or the HCA Ethics
Line (1-800-455-1996).
 Each employee and volunteer is required to attend two hours
of initial code of conduct training and a one hour annual
refresher training session. Leaders and individuals in key
jobs have additional annual education requirements.
Georgia False Claims Laws
 There is a federal False Claims Act, and there are also
Georgia laws that address fraud and abuse in the Georgia
Medicaid program.
 Any person or entity that knowingly submits a false or
fraudulent claim for payment of funds is liable for significant
penalties and fines.
 The False Claims Act has a “qui tam” or “whistleblower”
provision. This allows a private person with knowledge of a
false claim to bring a civil action on behalf of the US
Government. If the claim is successful, the whistleblower may
be awarded a percentage of the funds recovered.
 For additional information please see the Georgia False
Claims Statutes Policy.
Infection Prevention
 Our goal is to identify and reduce risks of healthcare
associated infections in patients, visitors, and healthcare
workers
 Hand hygiene is the single most effective way to prevent
the spread of infection.
 Hand hygiene with an alcohol based products is
preferred as long as hands are not visibly soiled. Rub
hands together for 15-20 seconds, covering all surfaces
of the hands.
 Hand hygiene with soap and water is required if hands
are visibly soiled. Wet hands with water, add soap, and
rub vigorously for 15-20 seconds, covering all surfaces
of the hand. Rinse under running water, and turn the
faucet off with a paper towel
Hand Hygiene
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Indications for hand hygiene with an alcohol-based hand rub
(unless hands are visibly soiled):
GEL IN – GEL OUT!
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Before having direct contact with patients, including between patient
contacts.
Before donning sterile gloves when inserting a central intravascular
catheter.
Before inserting indwelling urinary catheters, peripheral vascular
catheters, or other invasive devices that do not require a surgical
procedure.
After contact with a patient’s intact skin (e.g. when taking a pulse or blood
pressure, and lifting a patient).
After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings.
If moving from a contaminated body site to a clean body site during
patient care.
After contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient.
After removing gloves and/or other personal protective equipment.
After handling trash and/or infectious waste.
Hand Hygiene
 Indications for hand hygiene with plain soap and water,
or antimicrobial soap and water:
◦ If hands are visibly dirty, contaminated with proteinaceous
material or visibly soiled with blood or other body fluids.
◦ Before eating.
◦ After using a restroom.
◦ After covering the nose and mouth when coughing and
sneezing.
◦ If exposure to Bacillus anthracis (anthrax) spores is
suspected or proven. This is because alcohol hand rubs
have poor activity against spores and the action of washing
and rinsing hands is needed to physically remove spores
from the hands.
Hand Hygiene
Compliance
• Infection Prevention champions monitor hand
hygiene in our facility. The use of gloves does not
eliminate the need for good hand hygiene.
• Patients have the right to ask if you performed hand
hygiene before you take care of them.
• Our goal for hand hygiene is 100%
Prevention of Surgical
Site Infections
 All healthcare workers must perform hand hygiene
before and after contact with the patient
 Appropriate patient skin preparation
 Clipping of hair instead of shaving
 Timely administration of antibiotics
 Surgical team wears masks, cap, gown, and gloves
during surgery
 Surgical hand scrubs before procedure
Prevention of
Bloodstream Infections
 Insert central lines only when necessary using sterile
technique, follow “central line insertion bundle” which
includes special skin prep, inserter wearing gown, mask,
sterile gloves, patient fully draped, choose safest site for
insertion.
 Central line maintenance:
◦ Perform hand hygiene prior to touching line or giving
medication through the line
◦ “Scrub the hub” using purposeful friction for 15-20 seconds.
◦ Sterile dressing changes and tubing changes per hospital
policy.
 Remove line when no longer necessary.
Prevention of Multi-Drug
Resistant Organisms
 Hand hygiene before and after patient contact
 Gown and glove when caring for patients under contact
and special contact precautions. Gowns and gloves
required for entry into rooms of patients on these
precautions.
 Patients are placed in private rooms whenever possible.
 Certain patients are screened for MRSA upon
admission.
 Meticulous cleaning of hospital equipment.
 Patients are educated regarding disease transmission.
Examples of Multi-Drug
Resistant Organisms (MDROs)
 Methicillin Resistant Staph aureus (MRSA)
◦ Staph aureus are commonly found in nose and on skin of healthy people.
◦ MRSA can be present without causing disease. This is called colonization. If MRSA is
causing disease (e.g. fever, pneumonia), it is called infection.
◦ MRSA is spread by contact; therefore, “Contact” precautions are used.
◦ Hand hygiene is the best prevention for spread of MRSA.
 Clostridium difficile
◦ Causes severe diarrhea
◦ Spread by contact; requires “Special Contact” precautions
 “Special” refers to additional requirements for environmental services for cleaning
the room
◦ Hand hygiene is the best prevention for spread.
 Vancomycin Resistant Enterococci (VRE)
◦ VRE can be present without causing disease. This is called colonization. If VRE is
causing disease, it is called infection.
◦ VRE is spread by contact; therefore, “Contact” precautions are used.
Prevention of Urinary Tract
Infections Related to
Foley Catheters
 Hand hygiene prior to inserting a Foley catheter.
 Catheters are inserted only when medically necessary
following established indications.
◦ Inserted with sterile technique
◦ Skin prep with antiseptic prior to insertion
 Maintenance
◦ Involves daily perineal care, catheter securement, Foley
bag below level of bladder, no kinks in tubing, aseptic
collection of specimen
 Prompt removal of Foley when no longer medically
indicated.
Prevention of Ventilator
Associated Events,
Including Pneumonia
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Hand hygiene prior to care
Mouth care every two hours
Head of bed at 30 degrees unless contraindicated
Daily evaluation of readiness to remove from
ventilator
• Peptic ulcer disease prophylaxis
• Deep venous thrombosis prophylaxis
Personal Protective Equipment
 Personal protective equipment (PPE) is provided at no cost.
 PPE includes, but is not limited to: gloves, gowns, masks,
N95 respirators, and goggles. Appropriate PPE is available in
each department.
 At a minimum, gloves must be worn when it can be
reasonably anticipated that there may be hand contact with
blood, body fluids, mucous membranes (e.g. eyes, nose,
mouth), non-intact skin, or contacted with contaminated items
or surfaces. Replace gloves if torn or punctured or if their
ability to function as a barrier is compromised. Disposable
gloves are single patient use only.
 Other PPE must also be worn as appropriate.
Personal Protective Equipment
 Wear appropriate face and eye protection when
splashes, sprays, splatters, or droplets of blood or body
fluids may pose a hazard to the eye, nose, or mouth.
 Any garment contaminated with blood or body fluids
must be removed immediately or as soon as feasible.
 PPE must be removed prior to leaving the patient’s
room. Hand hygiene must be performed after glove
(and other PPE) removal.
 PPE may be disposed of in the regular trash unless
contaminated with blood. If contaminated, they must be
disposed of in red biohazard bags.
Standard Precautions
 Standard Precautions means that we assume every
patient is potentially infected or colonized with an
organism (germ) that could be transmitted in the
healthcare setting and requires the application of
standard infection prevention practices during the
delivery of healthcare.
 Standard Precautions applies to blood, all body fluids,
secretions, and excretions, mucous membranes, nonintact skin.
 By using standard precautions, you will substantially
reduce your risk of acquiring an infection from a patient.
Isolation Precautions
 Used for patients known or suspected to be infected or
colonized with highly transmissible or epidemiologically
important microorganisms (germs) for which additional
precautions are needed to prevent transmission.
 Used in ADDITION to Standard Precautions
 5 categories (patients may need more than 1 category):
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Contact
Special Contact
Droplet
Airborne
Protective
Contact Precautions and
Special Contact Precautions
• Transmission occurs by direct contact or by contact
with a contaminated environment.
• Patient placed in private room.
• Requires gown and gloves for entering room.
• Patients should wear an isolation gown and perform
hand hygiene prior to leaving the room.
Droplet Precautions
 Transmission occurs when droplets are generated from
the infected patient primarily through coughing,
sneezing, talking, and during certain procedures like
bronchoscopy.
 Droplets are propelled a short distance and are
infectious if they enter the eyes, nose, or mouth. Can
also occur if you touch a surface recently contaminated
with droplets and then touch your eyes, nose, mouth.
◦ Short distance = usually 3 feet or less
 Patient placed in private room.
 Requires standard procedure mask to enter.
 Patients must wear a standard procedure mask if they
need to leave the room.
Airborne Precautions
 Transmission occurs by dissemination of airborne droplet
nuclei (5 micron or smaller) that remain suspended in the
air for long periods of time. Can be dispersed by air
currents over long distances and be inhaled by others.
 Patient in private room with special ventilation (negative air
flow).
 N95 required to enter room.
◦ Requires fit test in advance
 Patient to wear a standard procedure mask if they must
leave the room for medical purposes.
 Persons not immune to Rubella (German Measles) or
Mumps should not enter if other immune caregivers are
available. Pregnant women who are not immune should
not care for patients with Rubella.
Protective Precautions
• Used for patients who are immuno-compromised (e.g.
leukemia, lymphoma, severe burns, organ
transplants, low white blood cell count).
• Patient placed in private room.
• If ill, should not enter room.
• Patient should wear a standard procedure mask if
they need to leave the room.
For all MRDOs
 Use disposable equipment (e.g. BP cuffs, stethoscopes,
tourniquets) as much as possible.
 Any equipment taken into the room must be disinfected
prior to removing it from the room
 Receiving departments must be notified that patient is
on precautions.
 Procedures should be scheduled when there are fewer
patients in the area.
 When leaving the room, patients should wear a clean
gown and perform hand hygiene prior to leaving the
room.
Tuberculosis (TB)
 TB is spread from person to person through air droplets
from someone who has TB.
 Symptoms of TB include: cough greater than 3 weeks,
unexplained fever, weight loss, night sweats, coughing
up blood.
 TB infection: a positive PPD skin test, no illness. Germ
is in body, but not causing disease. Cannot spread to
others, but there is a risk if untreated that can progress
to TB disease.
 TB disease: signs and symptoms of disease. May be
contagious.
Tuberculosis (TB)
 Upon hire, associates are required to have a PPD
skin unless they have ever had a positive skin test.
 Cartersville Medical Center is a “low risk” facility for
TB. This means that an annual PPD test is not
required. Our risk is re-evaluated yearly and can
change.
 Associates with active TB are not allowed to work
until they are cleared as no longer being infectious
and are healthy enough to perform their work
duties.
Tuberculosis (TB)
 Patients suspected of having active TB are placed
on “Airborne” precautions in a private room with
negative air flow. The door must remain closed at
all times except when entering and exiting the
room.
 Anyone entering the room is required to wear an
N95 respirator.
 A “fit check” must be done each time the mask is
put on. If mask doesn’t fit, contact Occupational
Medicine for a repeat fit test.
Influx of Infectious
Patients
• The hospital is prepared should there be an influx of
infectious patients.
• We would activate our emergency preparedness
plan.
• This plan addresses staffing, supplies, and other
issues that might occur as a result of increased
patient load.
Bloodborne Pathogens
 Bloodborne pathogens are germs that are present
in blood that can cause disease.
 Includes, but it not limited to: HIV, Hepatitis B, and
Hepatitis C
 The hospital has a written plan that explains what
bloodborne pathogens are, how to minimize risk of
exposure, and what steps to take should an
exposure occur.
 A copy is available to all associates .
Bloodborne Pathogens
 The following body fluids are considered to be potentially
infectious for bloodborne pathogens:
◦ Blood or any other body fluid containing visible blood
◦ Other potentially infectious materials
 Semen, vaginal secretions, cerebrospinal fluid, synovial fluid,
peritoneal fluid, pericardial fluid, amniotic fluid, pleural fluid,
saliva in dental procedures, all body fluids where it is difficult or
impossible to differentiate between body fluids, any unfixed
tissue or organ (other than intact skin) from a human (living or
dead), cell or tissue cultures, organ cultures, and culture medium
or other solutions which may contain bloodborne pathogens, HIVcontaining cell or tissue cultures, organ cultures, and HIV or HBV
containing culture medium or other solutions, and blood, organs,
or other tissues from experimental animals infected with HIV or
HBV
Bloodborne Pathogens
 Occupational modes of transmission of bloodborne
pathogens:
◦ Percutaneous exposure (needlesticks or other sharp object
injuries) to infected blood or other potentially infectious materials
◦ Mucous membrane (eyes, nose, mouth) exposure to infected
blood or other potentially infectious materials.
◦ Open lesion exposure to infected blood or other potentially
infectious materials
◦ Intact skin exposure to infected blood or other potentially
infectious materials if it involves an extensive area or is
prolonged.
What is HIV?
 Human Immunodeficiency Virus (HIV) is the virus that
causes the disease Acquired Immune Deficiency
Syndrome (AIDS).
 HIV damages the immune system and makes a person
more likely to get serious infections and other diseases.
 To become infected with HIV, the virus must get into
your body and enter your bloodstream.
 Many people who have HIV do not have symptoms for
years. Persons who are HIV positive or have AIDS can
spread the disease to others.
 Currently, there is no vaccine to prevent HIV infection.
What is Hepatitis B?
• Hepatitis is a disease of the liver.
• Hepatitis B virus (HBV) is just one of many things
that can cause liver disease.
• Symptoms include jaundice, fatigue, fever, nausea,
and abdominal pain.
• A vaccine is available that is very effective in
preventing Hepatitis B infection.
What is Hepatitis C?
• Hepatitis is a disease of the liver.
• Hepatitis C virus (HCV) is just one of many things
that can cause liver disease.
• Many people with Hepatitis C do not have any
symptoms. If there are symptoms, they are very
similar to those of Hepatitis B infection.
• Currently, there is no vaccine to prevent Hepatitis C
virus infection.
How to Reduce the Risk of
Exposure to Bloodborne
Pathogens
 Use Universal Precautions when caring for ALL patients. This
means that we assume every patient that we are caring for has a
bloodborne illness and take the same reasonable precautions to
prevent exposure to infectious materials.
 Use engineering controls (controls that remove the risk from the
workplace). These include sharp safety devices, sharps disposal
containers, and biohazard waste cans, for example.
 Observe good work practice controls such as never recapping
needles, performing hand hygiene, no eating or drinking or
applying cosmetics or lip balm where there is a potential for
exposure.
 Use appropriate personal protective equipment.
◦ Know the job tasks in your department that may involve exposure
to blood or other potentially infectious materials.
Post Exposure to Blood or Other
Potentially Infectious Materials
 If your skin is exposed to blood or other potentially
infectious materials, wash the area with soap and
water as soon as possible (even if the exposure
was a needlestick). If mucous membranes are
exposed, flush with large volumes of water.
 If the injury is serious, go immediately to the
Emergency Department. Otherwise, notify your
immediate supervisor of the exposure. You will be
provided information on appropriate follow up
procedures.
Risk of Acquiring a Bloodborne
Pathogen from an Exposure
 Risk varies based on pathogen involved, type of
exposure, amount of blood/body fluid involved in the
exposure, the amount of virus present in the patient’s
blood at the time of exposure.
 The following factors are associated with an increased
risk of getting HIV from an exposure from an infected
patient:
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Deep injury
Visible blood on device that caused the injury
Device was in the infected patient’s vein or artery
The patient is end-stage AIDS
Risk of Acquiring a Bloodborne
Pathogen from an Exposure
 If patient is HIV+:
◦ The average risk of infection is 0.3%.
 If patient is HBV+:
◦ If you have completed the series of Hepatitis B
vaccine and developed immunity, you are at virtually
no risk for infection.
◦ If you are unvaccinated, the risk if 6-30%.
 If patient is HCV+
◦ The average risk of infection after a needlestick is
about 3%.
Post-Exposure Treatment
 HIV:
◦ Treatment involves starting anti-HIV medications as soon
as possible after the exposure.
 HBV:
◦ Treatment involves starting the Hepatitis B vaccine or
receiving “HBIG”.
 HCV:
◦ There is no vaccine and no recommended treatment after
exposure.
◦ Following infection prevention practices and preventing
exposure is imperative.
Preventing Sharp Object Injuries
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Receive appropriate training on using the sharps safety devices available to you.
Keep the exposed sharp in view.
Keep you hands behind the sharp/needle at all times.
Be aware of people around you. Stop if you feel rushed or distracted.
Focus on your task.
Avoid hand-passing or sharps (e.g. use a tray) and use verbal alerts when moving
sharps.
Watch for sharps in linen, beds, on the floor, or in waste containers.
Don’t recap used needles.
Do not use a needle with a needleless IV system.
Activate safety mechanism immediately after use.
Never remove the safety feature.
Never force an item into a sharps container.
Do not overfill a sharps container; they are to be replaced when they are ¾ full.
Do not reach by hand into containers where sharps are placed.
If you identify a sharp item without a safety device, discuss this with your
supervisor, Employee Health, or Infection Prevention.
Latex Allergies
• Latex allergies pose a serious problem for nurses, other health care
workers, and for 1% to 6% of the general population. Anaphylactic
reactions to latex can be fatal.
• Health care workers’ exposure to latex has increased dramatically
since universal precautions against blood borne pathogens were
mandated in 1987. Latex can trigger three types of reactions: irritant
contact dermatitis, allergic contact dermatitis, and immediate
hypersensitivity.
• Many medical devices contain latex that might trigger serious
systemic reactions by cutaneous (skin) exposure, (i.e. ECG
electrodes, masks, bandages, catheters, gloves, and tape.)
There are some diagnostic tests to determine if a person has an
allergy to latex. If a patient tells you they are allergic to latex,
notify Materials Management and they will provide a cart with
latex-free products. Need more information? Contact the
Nursing House Supervisor at ext. 6910. For associates with
latex allergies, contact Employee Health Services ext. 2129.
Employee Health
Body Mechanics
• Use mechanical help when
possible
• Ask for help if needed
• Remember to push, not pull
• Bend your knees
• Avoid twisting
Potential Hazard
Increased potential for employee
injury exists with awkward
postures with include:
• Twisting while lifting
• Bending over to lift
• Lateral of side bending
• Back hyperextension or flexion
Forces on the spine increase
When lifting, lowering or handling
objects with the back bent or
twisted. This occurs because the
muscles must handle your body
weight in addition to the weight of
the object being lifted.
This is unsafe lifting
back posture.
CMC is a
Drug Free Workplace
• CMC drug screens for the following:
• Pre-Placement drug screen
• Reasonable Suspicion drug screen
• Any time you have an injury at work you will have
to complete a post accident urine drug screen as
soon as possible prior to the end of your shift.
12 Principles of Ergonomics
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Keep everything in easy reach
Work at proper heights
Reduce excessive forces
Work in good postures
Reduce excessive repetition
Minimize fatigue
Minimize direct pressure
Provide adjustability and change of position
Provide clearance and access
Maintain a comfortable environment
Enhance clarity and understanding
Improve work organization
Ergonomics:
The “Do Not’s”
• Upper Extremity
• Shoulder
• Reaching over 90 degrees (vertical flexion)
• External rotation of greater than 45 degrees
• Elbow
• Avoid static hold time of flexion
• Lower Extremity
• Sitting position
• The hip, knee, and ankle should be placed at 90 degrees
• Body positions to avoid
• Deep knee bends
• Constant standing in hip and knee extension
• Walking with feet externally rotated
Performance Improvement
Continual Quality Improvement
• What is PI?
• PI is a work philosophy that encourages
every employee to find new and better
ways of doing things. All accredited
healthcare organizations are required to
have an improvement program. Cartersville
is accredited by The Joint Commission.
Performance Improvement
Continual Quality Improvement
 Key Points to Remember
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Customers come first.
Every employee is important.
Communication is essential.
Tasks (processes) are streamlined whenever
possible.
 Ongoing improvement is crucial.
 Improvement should be maintained.
We want to improve everything we do! We owe
this to our ultimate customer - the patient.
2016 National Patient Safety
Goals for Hospitals
• The purpose of the National Patient Safety Goals is
to improve patient safety.
• The Goals focus on problems in health care safety
and how to solve them.
2016 National Patient Safety
Goals for Hospitals
• Identify patients correctly
• Use at least two ways to identify patients. For example, use
the patient’s name and date of birth. This is done to make
sure that each patient gets the correct medicine and
treatment.
• Make sure that the correct patient gets the correct blood
when they get a blood transfusion.
2016 National Patient Safety
Goals for Hospitals
• Improve staff Communication
• Get important test results to the right staff person on time.
• Use medicines safely
• Before a procedure, label medicines that are not labeled. For
example, medicines in syringes, cups and basins. Do this in the
area where medicines and supplies are set up.
• Take extra care with patients who take medicines to thin their
blood.
• Record and pass along correct information about a patient’s
medicines. Find out what medicines the patient is taking.
Compare those medicines to new medicines given to the patient.
Make sure the patient knows which medicines to take when they
are at home. Tell the patient it is important to bring their up-to-date
list of medicines every time they visit a doctor.
2016 National Patient Safety
Goals for Hospitals
• Use alarms safely
• Make improvements to ensure that alarms on medical equipment
are heard and responded to on time.
• Prevent infection
• Use the hand cleaning guidelines from the Centers for Disease
Control and Prevention or the World Health Organization. Set
goals for improving hand cleaning. Use the goals to improve
hand cleaning.
• Use proven guidelines to prevent infections that are difficult to
treat.
• Use proven guidelines to prevent infection of the blood from
central lines.
• Use proven guidelines to prevent infection after surgery.
• Use proven guidelines to prevent infections of the urinary tract
that are caused by catheters.
2016 National Patient Safety
Goals for Hospitals
• Identify patient safety risks
• Find out which patients are most likely to try to commit suicide.
• Prevent mistakes in surgery
• Make sure that the correct surgery is done on the correct patient
and at the correct place on the patient’s body.
• Mark the correct place on the patient’s body where the surgery
is to be done.
• Pause before the surgery to make sure that a mistake is not
being made.
Patient Rights
• We believe that most patients want to understand and
participate in their care. Therefore, it is important that each
patient understand his or her rights and responsibilities while at
Cartersville. It is also necessary as healthcare workers that we
understand patient rights and responsibilities to ensure that
quality care is provided.
• How are patients informed of their rights?
• Upon admission, each patient is given a handbook, which
includes a list of patient rights and responsibilities. This
patient bill of rights tells a patient and his or her family what
they can expect of caregivers and what caregivers expect of
them.
Patient Rights
• What is your role in patient rights?
• Everyone is involved in protecting the rights of patients, not
just those involved in direct patient care. For example, the
right to confidentiality means not telling your friends and/or
relatives when someone you know has been a patient.
Also, you provide privacy for patients by making sure you
always knock before entering a patient’s room or any room
where a patient might be having a procedure.
• Patients have a right to a secure environment, which
means you should know how to respond during a disaster
or fire in the building. Patients are informed of their right to
establish advance directives.
• Patients also have a right to file a grievance. You can assist
with the investigation and response by contacting Risk
Management (Clair Williams) at ext. 1004 or Administration
at ext. 8161 should you have a question.
Patient Rights
• Where can you find a list of patient rights?
• In facility Policy HW362 Rights and Responsibilities of
Patients, the Patient Handbook, posted beside the elevator
in the front lobby and at outpatient services, and on
Cartersville’s Intranet site.
• Access the Ethics and Compliance Officer at 770-607-1070
• Access the grievance process. Express complaints or
concerns regarding care or services, including discharge.
• Facility contact: 770-606-2206
• Corporate Ethics Line: 1-800-455-1996
Reportable Events
• State (Georgia) Reportable Events:
• The following type events should be reported to the State of Georgia
Office of Regulatory Services:
• Any unanticipated patient death not related to the natural course of
the patient’s illness or underlying condition;
• Any surgery on the wrong patient or the wrong body part of the
patient;
• Any rape of a patient which occurs in the hospital.
• Cartersville Medical Center’s employees and the medical staff should
report to the appropriate department leader and Risk Management at
1004 or Regulatory Compliance at 3038 in the event that any of the
above situations occur to a patient at Cartersville. A multidisciplinary
group will review the situation, complete the State forms, and provide
them to the Office of Regulatory Services within 24 hours of knowledge
that the event meets one of the State definitions.
Occurrence Reporting
• 3 Types
• Patient: All patients
• Non Patient: Visitors, Contractors, Students,
Physicians
• Employee: CMC Employees
•
•
•
•
•
•
•
Completed in the Meditech Module
Completed ASAP prior to the end of your shift
Risk Assessment: Prevent/Limit harm to the patient
Never print report!
Never write statements that point fingers
Be factual, brief, and objective
Tell the end of the story if known
What should I report?
•
•
•
•
•
•
•
Patient, visitor, and employee falls or injury
Sentinel Events
Medication events and near misses, ADRs*
Equipment and supply related events
Lost/damage to personal belongings
Adverse surgical/procedural outcomes
Behavioral issues
• Against Medical Advice, Left Without Being Treated, Refusal
of treatment, Elopement
• Other events that may result in injury or potential
unfavorable outcome such as disruptive behavior
• Complaints regarding patient care or treatment
Recognizing Abuse & Neglect
Signs of Abuse
• History inconsistent with nature and extent of injury
• Delay in seeking medical treatment
• Frequent Emergency Room visits
• Accident prone
• Discrepancy in patient’s and family’s story
• Bruises in various stages of healing
• History of previous trauma in patient or sibling
Signs of Neglect
• Failure to thrive
• Poor hygiene
• Dehydration
• Malnutrition
• Poor social skills
Reporting Abuse
•
•
Nursing Interventions:
• Routinely screen during each patient encounter.
• Screen one-on-one in a private environment.
• Assess patient’s immediate safety.
• Listen with a non-judgmental attitude.
• Document in the medical record the following: abuse
history (subjective and objective), results of safety
assessment, authorities notified, family notified,
treatment given, and any safety instructions provided.
The person suspecting the abuse should notify Social
Services during weekday hours and the House Supervisor
at night and on weekends to inform them of the situation.
These resource persons will assist with the notification of
the authorities.
Reporting Abuse
• Reporting Responsibilities:
• Notify the MD.
• Notify DFACS or Adult Protective Services (APS) of the
possibility and the appropriate authorities.
• GA has general mandatory reporting laws. MUST report to law
enforcement the following: injuries resulting from general
violence and injuries inflicted by gun, firearm, knife, or other
sharp object.
• Resources:
Department of Family and Children Services (DFACS):
(770) 720-3610
Police Department: 911
Battered Woman/Domestic Violence Hotline:
1-800-334-2836
Prevent Child Abuse GA:
1-800-532-3208
Adult Protective Services:
1-888-774-0152
Environment of Care
• Safety and Security
• Fire Safety
• Hazardous Materials and
Waste
• Medical Equipment
• Utilities
• Other Physical Environment
Requirements
• Floors and Walking Surfaces
• MSDS
Safety and Security
• EC.02.01.01, EC.02.01.03
• The hospital identifies and manages safety and
security risks
• Electrical Safety
• Incident/Accident and Near Miss Reporting
• Infection Control Precautions
• Storage (medical gas, supplies ETC.)
Your Role:
• Wearing Proper ID
• Knowing the Location of Emergency Plans and your
role in them
• How to Respond to and Document
Incidents/Accidents
• Access Control
• How to obtain an MSDS
Floors & Walking
Surfaces
•
•
•
•
•
•
•
Dry, Level, Clear of Obstructions / Debris
Well Lit
Appropriate Mat Placement
Condition of Carpet
Walk to Center or Right
Watch Intersections
Keep hallways clear of clutter
Material Safety Data Sheets
(MSDS)/Safety Data Sheet (SDS)
• The MSDS/SDS is used
by chemical
manufacturers and
vendors to convey hazard
information to users.
• They should be obtained
when a chemical is
purchased.
• A chemical inventory list,
and MSDS/SDS, for each
chemical are required to
be maintained
Hazardous Materials
Management
• OSHA Hazard Communication Standard Right-toKnow (R2K)
• Material Safety Data Sheets (MSDS’s)/Safety Data
Sheets (SDS)
• Training and Labeling Requirements
• Storage, Handling and Disposal of Hazardous
Materials
• Jan Tidwell 770-607-1070
• John Coley 770-387-8168
Medical Equipment
• Avoid use of extension cords
• If you don’t know how to
safely use equipment, don’t.
• Make sure all electrical
equipment has been
inspected by the biomed
department before use.
• Make sure all Medical
Equipment has a current
inspection sticker
Hazardous Materials
and Waste
• Radiation Safety
• International radiation symbol will be used
near sources of radiation
• Radiation used in x-rays is known to cause
harm at large doses.
• If you work in an area where x-rays are
being performed, you should wear all
required PPE
• The use of radioactive material is
overseen by the Radiation Safety Officer
and the Radiation/Laser Committee
• Frank Homiller – 678-721-5580
Hazardous Materials and Waste
• Biohazard Waste - Standard
Precautions
• Use gloves, masks, shoe coverings,
eye protection, fluid resistant gowns
when appropriate.
• Sharps must be discarded in sharps
containers.
• Seal and discard sharps
containers when ¾ full
Hazardous Materials and Waste
• Biohazard Waste
• Biohazard waste that cannot
be disposed of in the
Municipal Waste System
must be discarded in leak
proof, break resistant
containers
• Red Bags – What can and
cannot go in them
• Needle boxes – What can
and cannot go in them
Utility Systems
• Code White
• Utility system failure
• Power
• Water
• Communication
systems
• HVAC System
Security
• Security of the hospital requires a
cooperative effort and is a
responsibility of each employee.
• Wear ID badges at work
• Secure valuables and
belongings
• Be alert. Report any suspicious
activity
• Assure secured areas stay that
way
Cartersville Medical Center
Communication
• Telephone use:
• Dial “0” for the PBX
operator
• Dial “9” for outside line
• Dial “66” for emergency
phone
• Departments located
outside the main
hospital building must
call 911 for
emergencies.
Fire Safety Code Red
• Using a fire extinguisher:
• P-A-S-S
• Pull the retaining pin
• Aim the fire extinguisher at
the base of the fire
• Squeeze the handle to
release contents
• Sweep the nozzle from side
to side
Fire Safety
RACE Fire Response Plan
Remove
Anyone in immediate danger
Alarm
Pull closest alarm; Dial “66”
Confine
Close doors and windows
Turn off air moving equipment
Extinguish
Use closest proper
extinguisher
Security Code Gray
Alerts Security to
the department
where the code is
being called
Security Code Silver
A–D–D
A – Avoid the shooter, gather as many
people as you can and run from the area and
leave the hospital.
D – Deny. If you can’t leave, find a hiding
place and lock the doors and or barricade
yourself in.
D – Defend. If you can’t leave or find a hiding
place, you will have to defend yourself with
whatever weapons you can find regardless if
what you find is designed to be a weapon,
make what you find into a weapon and use it
as a weapon and fight.
Code Blue
• Cardiopulmonary Arrest (adult or
child) – Code Blue
• Dial “66” and tell the PBX operator
to page “Code Blue” to your location
• Code Blue response team: Charge
and primary nurse from the floor
where the code was called, charge
nurse from ICU, ER, respiratory
therapy, and the ED MD.
• Other personnel will be called if
needed
Code Neonate
• Cardiopulmonary Arrest
(neonate) – Code Neonate
• Dial “66” and tell the PBX
operator to page “Code
Neonate” to your location
• Code Neonate response team:
Charge nurse from OB, ER and
2C, respiratory therapy, and the
ER MD.
• Other personnel will be called if
needed
Code Pink
•
•
•
•
•
Infant/Child Abduction
All hospital staff on alert
Dial “66” to report
Secure all exits and entrances
Advise leaving staff, visitors,
and contractors
• Do not physically stop anyone
Code Triage
• External Disaster – Code Triage
• Code Triage Standby: employees
will be notified and called to
hospital as needed
• Code Triage Activate: employees
will immediately activate disaster
plan
Code Weather
• Sighting of Tornado: Code Weather
• Notification by civil defense radio, 911,
or weather channel.
• Administration will notify and ask PBX
to page “Code Weather”
• Move visitors into internal hallways or
patient rooms.
• Reassure and calm patients
• Updates will be communicated by
Administration via PBX
Code Runner
• Patient Elopement -“flight risk”
patient is missing
• “Flight Risk” is defined as any
patient who is assessed to be
confused, disoriented, or
demented and mobile
• Dial “66” and tell the PBX operator
to call Code Runner
Code Orange
• Chemical or large
biohazard spill or event.
• Dial “66” and ask the
PBX operator to call
Code Orange
• Secure the area
Code Medic
• Visitor or employee injury
or severe illness
• Dial “66” and ask PBX
operator to page Code
Medic.
• ED RN and security will
respond
Information Security
Cartersville Medical Center relies heavily on computers to meet its
operational, financial, and informational requirements. The computer
systems, related data files, and the derived information are important
assets of the company. Cartersville has established a system of internal
controls to safeguard these valuable assets by processing information
in a secure environment. As a Cartersville employee, you are expected
to share the responsibility for the security, integrity, and confidentiality of
this information.
• Policy Enforcement
Any employee who has knowledge of a violation of the IT & S Security
policy must immediately report the violation to his/her supervisor.
Anyone who violates the policy is subject to:
• Suspension
• Termination
• Civil and/or criminal prosecution
• Other Disciplinary action
Secure your workstation at all times!
Information Security
• CMC standards and policies include information about:
• Individual accountability for the use of any computing and
network resources
• The authentication process to allow access to, and use of,
systems and networks
• Audit trails of sensitive security events
• A means to ensure the integrity of systems, networks, and
processes
• The design and implementation of security controls with
adequately met identified risks
• The controls necessary to interface Carterville computer
systems/networks with foreign computer systems/networks
• Please refer to policies IS.SEC.001 – 005 for additional
information.
HIPAA & HIM-Health
Information Management
“Medical Records”
Lakeba Wallace, HIM
Manager, ext 1106
HIPAA Privacy Policies
Policies can be located on Cartersville’s Intranet
1. Notice of Privacy Practices
2. Patient’s Right To Opt Out of Facility
Directory
3. Right to Request Confidential
Communications
4. Patient’s Right To Access
5. Patient’s Right To Amend
Practicing Privacy
1.
2.
3.
4.
Treat all information as if it were about you or
your family
Access only those systems you are officially
authorized to access
Use only your own User ID & Password to access
system(s)
Access only the information you need to do your
job
Practicing Privacy
5.
6.
7.
8.
Only share sensitive & confidential information
with others that have a “need to know”
Refrain from discussing patient info in public
places
Create “hard to guess” passwords & never share
them
Log-off when finished
Thank you!
HR/Orientation/Oreintationeducation/July2016