Medical Facility Education Tracking and Reporting Software
2015 Annual Safety Education
Infection Control
The basic goal of an Infection Prevention & Control Program is to prevent the spread of infection and to eliminate the spread of microorganisms from one person to another. Patients frequently acquire infection while hospitalized. These are called hospital acquired infections. These healthcare-associated infections (HAIs) include central line-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia. Infections may also occur at surgery sites, known as surgical site infections.
Microorganism
It is important to understand that microorganisms exist in both bodily secretions such as saliva; as well as, in body fluids such as blood and on skin surfaces such as your hands. Microorganisms can also exist in your environment on surfaces such as countertops, door knobs and medical equipment.
Microorganisms are spread primarily three ways within a hospital setting: (1) Contact: direct contact via body surface -to-body surface contact, or indirect contact via contaminated articles, (2) droplet, and (3) airborne.
Hand Hygiene
Hand hygiene is the single most important way to prevent the spread of infections.
EFFECTIVE HAND HYGIENE PROCEDURES: Hand washing with soap and water: a. Wet hands with water and apply soap b. Rub hands together front and back, using friction for at least 15 seconds c. Pay particular attention to the area between fingers and finger nails d. Turn faucet off using a dry paper towels.
Hand washing with alcohol-based hand rub: a. Pump sufficient amount of hand rub gel on one palm b. Rub hands together, covering all surfaces, until DRY!!! c. Pay particular attention to the area between fingers and finger nails.
Safety Tips When Using Alcohol-based Hand-Rub • When using alcohol-based hand-rubs, rub hands until the alcohol has evaporated (i.e., hands are dry). • Alcohol-based hand-rubs are stored away from high temperatures or flames, in accordance with CDC and National Fire Protection Agency recommendations. • Supplies of alcohol-based hand-rubs are stored in cabinets or areas approved for flammable materials.
When to use alcohol hand gel
• Before and after each patient contact
• After glove removal
• Between different tasks on the same patient
• After contact with contaminated equipment or contact with the patient’s environment
• Before and after eating.
When to use soap and water
• When hands are visibly soiled or dirty
• After using the restroom
• When taking care of a patient with diarrhea (May be a C-difficile organism resistant to alcohol products).
STANDARD PRECAUTIONS:
According to CDC, Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These practices are designed to both protect HCP and prevent HCP from spreading infections among patients. Standard Precautions include: 1) hand hygiene, 2) use of personal protective equipment (e.g., gloves, gowns, masks), 3) safe injection practices, 4) safe handling of potentially contaminated equipment or surfaces in the patient environment, and 5) respiratory hygiene/cough etiquette. Each of these elements of Standard Precautions are described in the sections that follow.
Hand Hygiene
Handwashing
• If hands are visibly dirty, or using an antiseptic hand rub
• After touching blood, body fluids, secretions, excretions and contaminated items
• Immediately after removing gloves
Gloves
• For contact with blood, body fluids, secretions and contaminated items
• For contact with mucous membranes and non-intact skin.
• Masks, goggles, face masks
Gowns
• Protects skin from blood or body fluid contact
• Prevents soiling of clothing during procedures that may involve contact with blood or body fluids
Respiratory Protection
• Use particulate respirator (i.e. N-95 respirator) during aerosol-generating procedures when the aerosol is likely to contain M. tuberculosis, SARS-Cov, or avian or pandemic influenza viruses.
Linen
• Handle soiled linen in a manner to prevent touching skin or mucous membranes
• Do not pre-rinse soiled linens in patient care areas
Patient care equipment
• Handle soiled equipment in a manner to prevent contact with skin or mucous membranes and to prevent contamination of clothing
• Clean reusable equipment prior to reuse
Sharps
• Do not recap used needles
• Do not remove used needles from disposable syringes
• Do not bend, break or manipulate used needles by hand
• Place used syringes and needles, scalpel blades, and other sharps in puncture-resistant containers
Respiratory/Cough Etiquette
• Anyone who appears ill and is coughing should wear a mask while in public areas of the hospital and should not visit patients.
• Cover your mouth / nose with a tissue when coughing or sneezing
• Properly dispose of tissues.
• Perform proper hand hygiene.
• If a tissue is unavailable; cough or sneeze into your elbow or sleeve.
Droplet Precaution:
Designed to prevent droplet (larger particle) transmission of infectious agents when the patient talks, coughs, or sneezes
For documented or suspected:
• Adenovirus (droplet+contact)
• Group A step pharyngitis, pneumonia, scarlet fever (in infants, young children)
• H. Influenza meningitis, epiglottitis
• Infleunza, Mumps, Rubella
• Meningococcal infections Empiric Use of Droplet Precautions
• Meningitis
• Petechial/ecchymotic rash and fever
• Paroxysmal or severe persistent cough during periods of pertussis activity
According to CDC, Place the patient in an exam room with a closed door as soon as possible (prioritize patients who have excessive cough and sputum production); if an exam room is not available, the patient is provided a facemask and placed in a separate area as far from other patients as possible while awaiting care.
PPE use:
• Wear a facemask, such as a procedure or surgical mask, for close contact with the patient; the facemask should be donned upon entering the exam room
• If substantial spraying of respiratory fluids is anticipated, gloves and gown as well as goggles (or face shield in place of goggles) should be worn
• Perform hand hygiene before and after touching the patient and after contact with respiratory secretions and contaminated objects/materials; note: use soap and water when hands are visibly soiled (e.g., blood, body fluids)
• Instruct patient to wear a facemask when exiting the exam room, avoid coming into close contact with other patients, and practice respiratory hygiene and cough etiquette
Airborne Precautions
According to CDC
Apply to patients known or suspected to be infected with a pathogen that can be transmitted by airborne route; these include, but are not limited to:
• Tuberculosis
• Measles
• Chickenpox (until lesions are crusted over)
• Localized (in immunocompromised patient) or disseminated herpes zoster (until lesions are crusted over)
Have patient enter through a separate entrance to the facility (e.g., dedicated isolation entrance), if available, to avoid the reception and registration area
Place the patient immediately in an airborne infection isolation room (AIIR)
If an AIIR is not available:
• Provide a facemask (e.g., procedure or surgical mask) to the patient and place the patient immediately in an exam room with a closed door
• Instruct the patient to keep the facemask on while in the exam room, if possible, and to change the mask if it becomes wet
• Initiate protocol to transfer patient to a healthcare facility that has the recommended infection-control capacity to properly manage the patient
PPE use:
• Wear a fit-tested N-95 or higher level disposable respirator, if available, when caring for the patient; the respirator should be donned prior to room entry and removed after exiting room
• If substantial spraying of respiratory fluids is anticipated, gloves and gown as well as goggles or face shield should be worn
Perform hand hygiene before and after touching the patient and after contact with respiratory secretions and/or body fluids and contaminated objects/materials; note: use soap and water when hands are visibly soiled (e.g., blood, body fluids)
Instruct patient to wear a facemask when exiting the exam room, avoid coming into close contact with other patients , and practice respiratory hygiene and cough etiquette
Once the patient leaves, the exam room should remain vacant for generally one hour before anyone enters; however, adequate wait time may vary depending on the ventilation rate of the room and should be determined accordingly
If staff must enter the room during the wait time, they are required to use respiratory protection
Contact Precautions
According to CDC contact precautions:
Apply to patients with any of the following conditions and/or disease:
• Presence of stool incontinence (may include patients with norovirus, rotavirus, or Clostridium difficile), draining wounds, uncontrolled secretions, pressure ulcers, or presence of ostomy tubes and/or bags draining body fluids
• Presence of generalized rash
Prioritize placement of patients in an exam room if they have stool incontinence, draining wounds and/or skin lesions that cannot be covered, or uncontrolled secretions
Perform hand hygiene before touching patient and prior to wearing gloves
PPE use:
• Wear gloves when touching the patient and the patient’s immediate environment or belongings
• Wear a gown if substantial contact with the patient or their environment is anticipated
Perform hand hygiene after removal of PPE; note: use soap and water when hands are visibly soiled (e.g., blood, body fluids), or after caring for patients with known or suspected infectious diarrhea (e.g., Clostridium difficile, norovirus)
Clean/disinfect the exam room accordingly.
Instruct patients with known or suspected infectious diarrhea to use a separate bathroom, if available; clean/disinfect the bathroom before it can be used again.
Blood borne Pathogens
According to OSHA - Blood borne pathogens are infectious microorganisms present in blood that can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), the virus that causes AIDS. Workers exposed to blood borne pathogens are at risk for serious or life-threatening illnesses.
Methods of Exposure
1. A stick with a contaminated sharp object (i.e., needle)
2. A splash to the eyes, nose, or mouth (i.e., mucous membrane)
3. A contact with non-intact skin (i.e., cut on hand)
4. Prolonged contact with intact skin
Procedure for Exposures in Workplace
• Wash Immediately
• Appropriate First Aid
• Report to designated person
• Complete the Occupational Bloodborne Pathogens Exposure Incident form immediately after exposure and return form back to Infection control on the third floor.
• Occurrence report –Located in the emergency department
• Treatment Options
o Blood from the source individual will be tested as soon as feasible after consent is obtained for HBV, HCV, and HIV testing. If the source individual’s blood is available, and the individual’s consent is not required by law, the blood shall be tested and the results documented. The exposed employee will be informed of the results of the source individual’s testing and the vaccination, if needed, will be offered free of charge.
o The exposed employee’s blood shall be collected as soon as feasible after consent is obtained, and tested for HBV, HCV and HIV serological status. If the employee consents to baseline blood collection, but does not give consent at the time for HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible.
o The exposed employee will be offered post-exposure prophylaxis, when medically indicated, as recommended by the U.S. Public Health Service. The exposed employee will be offered counseling and medical evaluation of any reported illnesses.
Tuberculosis:
According to Centers for Disease Control and Prevention Division of Tuberculosis, tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. If not treated properly, TB disease can be fatal.
Symptoms of TB disease include:
• a bad cough that lasts 3 weeks or longer
• pain in the chest
• coughing up blood or sputum
• weakness or fatigue
• weight loss
• no appetite
• chills
• fever
• sweating at night
There are two kinds of tests that are used to detect TB bacteria in the body: the TB skin test (TST) and TB blood tests. These tests can be given by a health care provider or local health department. If you have a positive reaction to either of the tests, you will be given other tests to see if you have latent TB infection or TB disease.
If Exposed
If you think you have been exposed to someone with TB disease, contact infection control department or health care provider or local health department to see if you should be tested for TB infection
Corporate Compliance
What is Corporate Compliance?
• The rules and regulations that govern hospitals.
• A program to assist in maintaining and promoting specific ethical questions.
• The purpose of the program is to make sure we do the “right thing” in all aspects of our work.
What does OakBend Medical Center’s Corporate Compliance Program ensure?
• Compliance with federal, state, and insurance regulations.
• Completion of our work according to written policy.
• Using the highest moral and ethical standards in all our interactions with others.
• Creating an environment where our personal behavior reflects what we promise to our customers.
What should you report?
Every employee, volunteer and/or contract employee has a duty to report violations of corporate compliance. The following are examples of possible issues to report:
• Patient care issues
• Questionable billing practices
• Conflicts of interest
• Vendor relationships
How can Corporate Compliance issues be reported?
The choices for reporting violations are as follows:
• Call the anonymous Corporate Compliance Hotline-ext. 3016
• Contact the hospital’s Corporate Compliance Officer- Eileen Gamboa
Please remember:
• Confidentiality can be requested!
• Anonymous reporting when desires!
• There is no retaliation for reporting!
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OakBend Medical Center
HIPAA…A concern for All
➢ Healthcare workers are morally, ethically and legally obligated to create a secure environment for patient information.
➢ Ethically, we have the Hippocratic Oath and professional standards, Legally, there are state and federal laws (HIPAA)
WHAT IS HIPAA
The Health Insurance Portability and Accountability Act of 1996 is a federal law that regulates the use and disclosure of patient information and creates substantial new patient rights. There are three components to HIPAA:
1. Transactions and Code Sets (this pertains to insurance and billing)
2. Privacy of Health Information
3. Security of Electronic Health Information
WHO IS AFFECTED?
All healthcare providers and organizations, hospitals, doctor’s offices, pharmacies and insurance companies.
WHY COMPLY?
HIPAA calls for severe civil and criminal penalties for noncompliance, including fines up to $25,000 per incident and/or imprisonment.
WHAT IS THE DIFFERENCE BETWEEN PRIVACY & SECURITY?
PRIVACY: The Privacy standards cover health information in any form and how an organization may use this information.
SECURITY: The Security standards cover information that is stored or transmitted electronically and how an organization must take steps to keep this information safe.
KEY CONCEPTS OF THE PRIVACY RULE
➢ PHI – Protected Health Information is any information that applies to a patient’s health condition now, in the past or in the future. If health information includes data that would identify the patient it is PROTECTED HEALTH INFORMATION.
➢ Minimum Necessary Information – The least information you need to do your job.
WHAT INFORMATION CAN I SHARE WITH COWORKERS?
Any healthcare provider must have a “need to know”. The information shared should only be minimal and necessary for that healthcare provider to accomplish care or service.
CAN A PATIENT REQUEST A COPY OF THEIR MEDICAL RECORD?
Yes, no patient authorization is needed. This is considered part of the continuum of care and normal operational procedures.
THINGS TO REMEMBER…
➢ Limit what you say in public areas. Patient information should NOT be discussed in hallways, elevators, cafeteria, and restaurants or at social events.
➢ If you are a direct caregiver, do not discuss your patients with other employees who work on a different floor or department.
➢ Fax patient information only in an emergency.
➢ Just because you are an employee does not give you the right to view patient information unless you are a direct caregiver to that patient.
➢ Make sure computer screens are situated so as not to be seen by visitors or other patients.
➢ Do NOT share computer passwords.
➢ Make sure patient medical records are in a secure location at all times.
➢ Log off computer systems when you leave the computer, if an automatic log-off is not an option.
➢ Remember, if you breach patient confidentiality, you may be terminated from employment at OakBend Medical Center.
PATIENT CONFIDENTIALITY IS EVERYONE’S RESPONSIBILITY
Carol Bartek is our Privacy Officer. Carol can be reached at 281-341-2803.
The confidential HIPAA Hotline number is 281-633-4070.
Environment Of Care
OakBend Medical Center has a safety program in place to provide a safe environment of care for patients, visitors, volunteers and staff. Our goal is to keep everyone safe in accordance with organizational needs and regulatory requirements. The Environment of Care Safety Program includes a plan for the following topics:
1. Safety/Security
2. Hazardous Materials & Waste
3. Fire Safety
4. Medical Equipment
5. Utility Management
Below is a brief description of each of the plans:
1. Safety/Security
OakBend Medical Center will take action to minimize or eliminate identified safety and security risks in the physical environment through proactive identification of risk, daily surveillance by staff, environment of care rounds, and other management tools.
Examples of how we keep everyone safe:
1) Monthly Environment of Care Tracers
2) Monthly OakBend Medical Center Safety Bulletin
3) Safety Committee
4) Product notices and recalls
Who is the Safety Officer? Tim McCarty
The Safety Program includes assessment of the physical plant, grounds, and equipment through building inspections, environmental rounds, safety inspections, and various performance improvement initiatives.
The environment of care tracer tool is utilized to reduce safety hazards. The tracer teams do monthly tracers hospital wide. Please be prepared to participate when a tracer is in progress. Monthly meetings are held to review results of the environment of care tracers and to address any identified problems. Results are reported to the Safety Committee. The Safety Committee meets monthly to oversee and address any safety concerns to provide a safe environment for everyone while they are at OakBend Medical Center.
Examples of our security measures:
1) Infant Security (Code Stork)
2) Name Badges: Employee name badges must be worn anytime you are on duty.
[pic]Name Badge
3) Parking lot surveillance
4) Keypads to control access to sensitive areas
5) Access to the building after hours (key cards)
6) Contractor/Vendors receive visitor badges after checking in at the front desk.
After hours, visitors are given access through the ECC. Security maintains a visitor log and issues name tags.
Examples of security sensitive areas in the hospital are: Pharmacy, Nursery, Emergency Care Center, Cashier, Medical Records, and Nuclear Medicine. Examples of security measures in use in a security sensitive area: Cameras, Panic Buttons, and Security Locks.
Know the overhead codes:
Code Stork: Someone is attempting to take a baby from the nursery
Code Adam: A missing infant, child, adolescent or adult, could be a patient or visitor
Code Purple: Threatening/abusive situation
Code Yellow: Active Shooter in the building
Code Black: Bioterrorism Event
Code Orange: Bomb Threat
Code Red: Fire
Code Grey: Disaster
In the event of any emergency or code situation please dial 7411 to notify the operator.
2. Hazardous Materials and Waste
OakBend Medical Center will take action to minimize or eliminate risks associated with the use, waste, storage or generation of hazardous materials as well as those risks associated with handling, storing, transporting, using and disposing of radioactive materials.
Examples of how we keep everyone safe from hazardous materials:
1) Safety Data Sheets (SDS)
2) Hazardous Material Spill/Exposure Procedure
5) Radiation Waste Management
4) Red Bags (Biohazardous medical waste only)
5) Chemical Spill kits
6) Chemo administration precautions (chemo cart) [pic]
Red bags are used for items that have any blood or body fluids (sputum, urine, vomit, feces, pus, drainage) on them. Examples of items that go in the red biohazard bags are:
1) Urinals/foley catheters after patient use
2) Blood administration bags/IV tubing/IV bags
3) Bed pans after patient use, all soiled blue pads and diapers go in a red bag
4) Gloves soiled with blood
5) Gloves that have come in contact with bodily waste such as vomit, urine, feces, etc.
6) Sharps containers that are 2/3 full (sealed)
Items that should go in large (18 gallon) sharps boxes:
1) glass vacutainers
2) guide wires
3) trocar
Hazardous Material Spill Procedures:
If you detect a hazardous material spill– Notify PBX, dial “7411”
Contain and Evacuate – Get others out of the area and close off traffic to that area.
Assess and Cleanup – The Safety Officer will determine what is needed for cleanup and supervise the cleanup by Building Services and Facilities Management. The Safety Officer along with Administration will notify the Richmond Fire Department if the spill is too large for us to handle.
Who is responsible for overseeing the spill and cleanup procedures? Safety Officer (Shift Supervisor and Security if after hours)
Safety Data Sheets (SDS) can be found through the SDS icon on the desktop. [pic]
A binder of all SDS is stored in the Material Management office.
3. Emergency Management
OakBend Medical Center is committed to being prepared for emergencies and disaster situations such as hurricanes, fires, loss of power, etc. by planning, practicing (drills) and working closely with our community partners such as Police, EMS, and Fort Bend Office of Emergency Management.
Our primary goal is to remain open to the community to provide needed services while at the same time maintaining a high level of safety for our patients and staff.
1. Where do I report to if a disaster is declared (Code Grey)
If you are already on duty report to your specific department/unit and await further instructions. If you are called to come to work you will be instructed to either report to your department/unit or to the labor pool.
2. Where is the labor pool located?
The location of the labor pool may vary depending on the situation. When you arrive at the Jackson Street location, go to Human Resources where the location of the labor pool will be posted. At Williams Way, the labor pool will be established in Administration. Under no circumstances should you report to the Emergency Department.
3. Where is Incident Command established?
At the Jackson Street location, incident command is established in the boardroom. At Williams Way it is in Administration.
4. What happens if the hospital phone system stops working?
Many areas of the hospital have the Red Emergency phones which are connected as direct outside lines. The phone number of the Red Emergency Phone is posted on the phone. It is not necessary to dial a “9” when making an outside call. The ringer volume should never be turned off/down. In addition, hand held radios will be distributed to key areas of the hospital for internal communication.
5. Am I an essential employee and what does that mean?
Upon hire you are informed if you are considered an essential or non-essential employee. An essential employee is one who has specific responsibilities before, during or after a declared emergency. Always have your name badge with the Essential Personnel sticker on the back. This will allow you to travel to the hospital.
6. If I am called in and must remain in the hospital during a declared emergency can I bring pets?
No. OakBend will not provide services for the care of pets
7. If I am called in and must remain in the hospital during a declared emergency can I bring family members?
No. OakBend cannot provide services for the care of family members. Our main goal is to provide a safe environment for our patients and staff.
6. Where can I find the Emergency Management Plan?
The plan is located on the “O” drive under Policies and Procedures within the Safety Manual.
Code Orange = Bomb Threat Code Grey = Internal/External Disaster Code Black = Bioterrorism
4. Fire Safety
OakBend Medical Center has a written plan to manage fire safety and risk.
Code Red = Fire
When responding to a fire remember to RACE; Rescue anyone in immediate danger, Activate the alarm, Contain the fire by closing doors, and Extinguish if possible or Evacuate the area.
Rescue, Activate, Contain, Extinguish/Evacuate
To properly use a fire extinguisher remember to PASS; Pull the pin, Aim the hose at the base of the fire, Squeeze the handle, and move the hose in a Sweep motion.
Pull, Aim, Squeeze, Sweep [pic]
Examples of how the hospital manages fire safety and risk:
Fire Drills
Testing and maintaining fire safety equipment (i.e. alarm system; exit signs; sprinklers)
Fire Extinguishers
Maintain free and unobstructed access to all exits/egress. No beds can be stored in corridors or behind elevators.
5. Life Safety
The hospital designs and manages the physical environment to comply with the Life Safety Code.
Examples of how the hospital complies with the Life Safety Code are:
Testing of Fire Alarm Systems
Testing of Fire Sprinkler System
Written Fire Response Plan
Running Fire Drills
Environment of Care (EOC) rounds, semi annually in patient care areas & annually in non-patient care areas ( business
office, accounting)
ILSM (Interim Life Safety Measures)
Building features such as automatic sprinkler systems, walls & doors
Means of egress
Exits
Flame retardant fabrics & decorations
ILSM are used when a component of fire safety is in need of repair and cannot be immediately corrected during the shift it is discovered or during construction/renovation. Temporary measures are put in place during this time to compensate for the life safety deficiency.
Fire doors are located at various locations throughout the hospital and will automatically close once the fire alarm is activated. Doors that close automatically during a Code Red also create a smoke compartment. These doors should remain closed until the Code Red is over and all staff have been notified. Fire doors are specially constructed to restrict the spread of fire and smoke. All employees should know the location of fire extinguishers, alarm pull stations and fire doors.
Our fire sprinklers are engineered to provide comprehensive sprinkler coverage. We must have 18 inches of free space between the sprinkler head and any equipment stored on a shelf to ensure the sprinklers will function properly during a fire. Please look around your locker room, work space and unit storage rooms. Do you note 18 inches of free space between items stored on a shelf and the sprinkler head? We cannot store anything directly on the floor.
Hallways and exits must remain unobstructed in order to maintain a means of egress. This is why beds and equipment should not be stored in the hallways or behind elevators.
6. Medical Equipment
The hospital inspects, tests, and maintains medical equipment.
Examples of how OakBend ensures that all medical equipment utilized will comply with appropriate safety and operational standards prior to initial use and on an ongoing basis:
1) Medical device tracking
2) Safety testing and inspection of non-clinical equipment
3) Inspection of non-clinical equipment – incoming
What do you do if a piece of medical equipment fails? Immediately take it out of service and tag it as defective.
Who do you notify if a piece of medical equipment fails? David Grigar, Clinical Engineer, ext 4843. or through the operator.
7. Utility Equipment
The hospital manages risks associated with its utility systems.
Examples of hospital utility systems:
1) Air Conditioning/Heating 4) Electrical
2) Oxygen/Medical Gases 5) Communication (telephone)
3) Plumbing 6) Emergency (Power) Generators
The hospital maintains an inventory of all operating components of utility systems. All components are on a schedule for preventative maintenance, testing, and inspection. An internet based preventative maintenance program (SiteFM) is used to track and maintain all utility systems throughout the hospital.
This program is also used for inputting work requests as needed. All employees have access to the SiteFM program. High priority requests can be made by calling 3077.
What are the red outlets used for? Any equipment that must have power during a power failure. These outlets are backed up by our generators that function during a power outage. Generators provide backup of electricity should the hospital lose power.
Examples of a backup source of communication if the telephone system fails: two-way radios, cell phones, power failure phones (red phones).
Hazard Communication Standard Pictogram
As of June 1, 2015, the Hazard Communication Standard (HCS) will require pictograms on labels to alert users of the chemical hazards to which they may be exposed. Each pictogram consists of a symbol on a white background framed within a red border and represents a distinct hazard(s). The pictogram on the label is determined by the chemical hazard classification.
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Back To Basics/Back Safety
A Guide to Injury Prevention
Understanding Your Back
Our spine or backbone is made up of small bones called vertebrae that are stacked up on each other to form a column. Between each vertebra is a cushion called a disc, which acts like a shock absorber. The vertebrae are held together by ligaments, and muscles which are attached to the vertebrae by tendons. Openings in each vertebra form a canal. The spinal cord runs through this canal from the base of the brain to the tailbone. Nerves branch out through spaces between the vertebrae. The lower part of the back holds most of the body’s weight. Even a minor problem with any of the back’s components can cause pain when a person stands, bends, or moves around. Problems with a disc can pinch or irritate nerves causing pain down the leg called sciatica.
Back Injuries are costly
Back injuries are cited as the most common reason for absenteeism in the general workforce after the common cold. About 80% of adults are estimated to experience a back injury in their lifetime, and about 10% will suffer re-injury. In the healthcare field, injuries caused by overexertion, occur at a very high rate. Healthcare workers sustain 4.5 times more overexertion injuries than other workers.
What Caused This Pain in My Back?
Back injuries are rarely the result of a single accident or injury. Every time you bend over, lift a heavy object, or sit leaning forward you put stress on the components of your spine and back. Repetitive lifting and bending can quickly cause back problems, especially if the lift is performed incorrectly.
Almost all back injuries are the result of:
1. Poor physical condition- Routine exercise helps to decrease this risk factor.
2. Poor posture- Sitting and standing straight while tightening the abdominal muscles, helps to improve posture.
3. Extra weight- Extra weight, especially in the abdominal area, changes our center of gravity, and increases stress forces on your back.
4. Stress- Find a way to unwind after work, and address any issues when they arise.
5. Faulty body mechanics- Follow the correct technique to reduce torque forces on your spine.
Common Causes of Back Injuries
1. Heavy lifting.
2. Twisting at the waist while lifting or holding a heavy load.
3. Reaching and lifting
4. Working in an awkward, uncomfortable position.
5. Sitting or standing in one position too long.
6. Not adequately preparing to perform a safe patient assist or patient transfer.
7. Slipping on a wet floor.
How to Prevent Back Injuries
1. Avoid lifting and bending whenever you can – Use tables or carts to avoid sitting objects on the floor.
2. Stretch first – If you know that you are going to be doing work that might be hard on your back. This will help you avoid painful sprains and strains.
3. Slow down – If you are doing heavy repetitive lifting, take it slowly, allow recovery time between lifts.
4. Rest your back – Take frequent short (micro) breaks. Stretch for 1 minute whenever you begin to feel your muscles tighten up.
5. Get in shape – Strengthen our stomach muscles, lose excess weight, increase flexibility.
6. Is it better to push or pull a load? – It is better to push if possible. If you must pull, tighten your stomach muscles and use good body mechanics.
Proper Lifting Technique
1. Plan the lift before you begin. Clear a path around the area that the lift will be performed.
2. Stand close to the load, facing the way you intend to move.
3. Use a wide stance to gain balance.
4. Ensure that you have a good grip on the load. Use a gait belt if you are transferring a patient.
5. Tighten abdominal muscles.
6. Tuck chin in to the chest.
7. Bend your knees, while maintaining the natural curves of the back.
8. Lift with the load close to the body.
9. Lift smoothly, don’t jerk.
10. Avoid twisting and side bending while lifting.
11. Do not lift if you are not certain you can handle the load safely. If you are at all in doubt, ask for help.
12. Keep patient’s safety in mind as well as your own.
Patient Safety, Quality & Performance Improvement and Risk Management
• Patient Safety, along with Employee Safety, is VERY important.
• We try to reduce errors by:
o Training/Orientation
o Policies and Procedures
o Compliance with Regulations (The Joint Commission and CMS)
o Unusual Occurrence Reporting System
o Proactive Risk Assessments (FMEA)
o Review of Sentinel Events/Root Cause Analysis (RCA)
o Coordinating with Performance Improvement and Measure of Success
Unusual Occurrence Reporting System-Unusual Occurrence is any occurrence involving a patient, staff, or visitor, which is not consistent with the routine delivery of patient care or hospital operations.
When do I complete an Unusual Occurrence Report?
Medication errors, Falls, Any Injury to a Patient, Unexpected Clinical Complications, Unexpected Death, Unsecured Narcotics or Narcotic Discrepancies, Hazardous Spills, Medical Device Malfunction, Patient Complaint/Dissatisfaction, Disruptive Personal Behavior, Hazards in the Environment of Care
How do I complete an Unusual Occurrence Report?
The Unusual Occurrence Report can be completed by any OBMC employee using the Organization’s Computer-Based Reporting System (Quantros) located in Org Drive
• Sentinel Event – is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. A sentinel event includes an event that has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of a patient’s illness or underlying condition.
• Proactive Risk Assessment (FMEA) – Failure Mode and Effects Analysis (FMEA) is a methodology for proactively identifying and reducing risks that could compromise safety of patients. The intended goal of conducting proactive risk assessment is to prevent adverse events rather than reacting when they occur.
• RCA – Root Cause Analysis – A process for identifying the basic or causal factor(s) that underlies variation in performance, including the occurrence or possible occurrence of Sentinel Event or near miss.
o Include staff from all departments and areas involved
o The Task Force investigates and understands the causes that underlie the event by answering all the “why” questions
o A Root Cause Analysis focuses primarily on systems and processes, not individual performance.
o Identify changes and improvements that could be made in systems and processes that would reduce the risk of event occurrence.
• Documentation is very important in Risk Management and Performance Improvement.
Poor Documentation Can Make Good Care Look Bad!!
Performance Improvement (PI) The purpose of PI plan is to provide a systemic process that allows for coordinated and continuous approach for performance measurement and analysis, with focus placed on safety, outcomes, and other aspects that address the mission, vision, values, and strategic plans of the hospital.
• PI plan reflects the total organizational commitment to continuously improve the quality of governance, management, clinical processes, and support processes, which is the central focus of the performance improvement effort.
• Performance Improvement priorities are identified by organization leaders as identified by The Joint Commission
• The PI plan is dynamic, undergoing continuous quality review and enhancement.
• What methodology does OBMC use for its Performance Improvement plans? PSDCAE (Plan, Show, Do, Check, Act, Evaluate)
The Joint Commission is a template for healthcare that provides guidance in ensuring safe, quality patient care.
In 2002, accredited hospitals began collecting data on standardized—or “core”—performance measures. In 2003, The Joint Commission and the Centers for Medicare and Medicaid Services began working together to align measures common to both organizations. These standardized common measures, called “Hospital Quality Measures,” are integral to improving the care provided to hospital patients. Numerous studies have shown that when these measures are in place, patients’ health outcomes and quality of life improve.
Core Measures are required by the Joint Commission for accredited hospitals and by CMS. The results are publicly reported. Quality measures give us a way to rate our performance in comparison to other hospitals, state or national trends, and different departments within the organization. In the future, our funding will be related to our compliance to these measures.
HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)
This patient survey is required by the Joint Commission and indicates a patient’s perception of care, treatment, and services. The expectation is that OMC staff and practitioners will “always” provide quality care. The survey focuses on eight key elements:
• Communication with doctors
• Communication with nurses
• Responsiveness of hospital staff
• Pain management
• Communication – Education on medications
• Discharge information
• Cleanliness of hospital
• Quietness of hospital.
• Would recommend hospital to family & friends
• As the Joint Commission surveys hospitals around the country and gather data, they sometimes find issues that are affecting patient care nationwide. They release this information as National Patient Safety Goals and expect each hospital to address them at their institution. A list of the current national goals is attached.
• The Joint Commission Office of Quality Monitoring: If anyone has concerns about safety or quality of care provided in the hospital, they may report these concerns to the Joint Commission without fear of disciplinary action from the hospital. The number is: 1-800-994-6610.
• The Joint Commission provides the public with detailed quality hospital reports at .
• The Core Measures, HCAHPS and other quality measures are available at hospitalcompare.
▪ ED – Emergency Department
▪ ARRIVAL Date and Time – When the patient signs into the ECC.
▪ Decision to ADMIT Date and Time – Physician Admit Orders
▪ DEPARTURE Date and Time – When the patient LEAVES ECC
▪ IMM – Immunization
▪ Pneumococcal Vaccination
▪ Influenza Vaccination
▪ ALL inpatients 6 months and older discharged between October 1st through March 31st
▪ Perinatal Care
▪ Documentation of:
▪ Weeks of gestation completed at the time of delivery
▪ Parity (live number of births the patient had)
▪ If the patient was in labor.
▪ Spontaneous rupture of membranes before induction and or C-section.
▪ Prior uterine surgery.
▪ Antenatal steroid therapy started before the delivery.
▪ Birth weight of newborn
▪ Encourage breastfeeding for health of baby & mother
▪ VTE
o Prophylaxis
▪ All patients ≥ to 18 years of age in inpatient status needs to be screened for the need for VTE prophylaxis
▪ If the patient is transferred to the ICU or if there is a change in condition must be re-screened.
▪ Any of the following types of VTE prophylaxis are acceptable as long as it is documented by day after admission (unless contraindicated or patient refusal documented):
• Low dose unfractionated heparin (only if given SQ)
• Low molecular weight heparin (ex: Lovenox)
• SCD
• TED hose
• Factor Xa inhibitor
• Warfarin
• Venous Foot Pumps
• Oral Factor Xa Inhibitor
o Diagnosis and Treatment
▪ Diagnosis of a DVT/PE confirmed on the current admission to the hospital.
▪ Overlap therapy with Warfarin and Parenteral anticoagulant during hospital stay.
▪ Overlap therapy for 5 days and INR >2 for 24 hours before discontinuing parenteral anticoagulant or must be discharged home on both Warfarin and the Parenteral anticoagulant.
▪ If discharged home on Warfarin- discharge instructions must address all of the following:
• Compliance with taking warfarin
• Dietary advice
• Follow up monitoring of INR, where and when
• Potential for adverse drug reactions and interactions
▪ Stroke
▪ Venous Thromboembolism Prophylaxis by day after admission (TED Hose alone not acceptable)
▪ Antithrombotics on discharge
▪ Anticoagulation Therapy at discharge for atrial fibrillation/flutter
▪ Thrombolytic therapy within 3 hours of Last known Well
▪ Antithrombotics by end of Day 2
▪ Discharged on Statin Medication
▪ Stroke Education including all of the following:
o Risk factors for stroke
o Signs and Symptoms of stroke
o Activate EMS upon discovery of signs and symptoms of stroke
▪ Rehabilitation assessment
▪ Sepsis
o TO BE COMPLETED WITHIN 3 HOURS
▪ Measure lactate level.
▪ Obtain blood cultures prior to administration of antibiotics.
▪ Administer broad spectrum antibiotics.
▪ Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4mmol/L (36mg/dL).
o TO BE COMPLETED WITHIN 6 HOURS
▪ Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) 65 mm Hg.
▪ In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥ 4 mmol/L (36 mg/dL):
▪ Measure central venous pressure (CVP).
▪ Measure central venous oxygen saturation (SvO2).
▪ Remeasure lactate if initial lactate was elevated
▪ AMI – Acute Myocardial Infarction
▪ Aspirin at arrival and prescribed at discharge unless documented as NOT indicated.
▪ EKG on arrival.
▪ Fibrinolytic within 30 minutes of arrival for STEMI or LBBB (Unless contraindicated)
▪ Primary PCI received within 90 minutes of arrival for STEMI or LBBB
▪ Left ventricular failure (LVF) assessment
▪ Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD) (Ejection Fraction of less than 40%)
▪ Beta Blocker prescribed at discharge unless documented as NOT indicated.
▪ PN – PNEUMONIA
▪ Appropriate antibiotics within 24 hours of arrival to ICU and AFTER blood culture.
▪ HF – Heart Failure
▪ Left Ventricular Systolic Functioning (LVSF) assessment documented
▪ SCIP – Surgical Care Improvement Project
▪ Appropriate antibiotic selected and started within 1 hr of incision (2 hours for vancomycin)
▪ Antibiotic discontinued within 24 hours of surgery end (48 hours for cardiac surgeries)
▪ Appropriate hair removal-clippers (No RAZORS- no documentation of shaved)
▪ Venous thromboembolism (VTE) prophylaxis initiated within 24 hours prior to surgery to 24 hours after surgery
▪ Urinary Catheter discontinued by Post-op day 2
▪ Patients on a Beta Blocker at home, receive it day before OR day of surgery AND POD1 or POD2
▪ Outpatient – Acute Myocardial Infarction (ED Patients)
o Aspirin at arrival or has documentation for a reason as NOT indicated.
o EKG on arrival
o Fibrinolytic therapy initiated in the ED (Unless contraindicated)
o Transfer to another facility for acute coronary intervention
▪ Outpatient – Chest Pain (ED Patients)
o Aspirin at arrival or has documentation for a reason as NOT indicated.
o EKG completed prior to transfer to another facility.
▪ Outpatient – Emergency Department Throughput
o ARRIVAL Date and Time – When the patient signs into the ECC.
o DEPARTURE Date and Time – When the patient LEAVES ECC
o Door to Diagnostic Time – Time of arrival to time seen by Qualified Medical Personnel (MD/NP/PA)
▪ Outpatient – Pain Management (ED Patients)
o Patients ≥ 2 years of age who are seen in the ED with long bone fractures
o ARRIVAL Date and Time – When the patient signs into the ECC.
o Date and Time oral, intranasal, or parenteral pain medication was administered for patients 2 years of age to less than 18 years of age OR parenteral pain medication administered for patients 2 years of age or greater.
▪ If patient arrives by EMS, document any Pain medication given prior to arrival! This is Important we don’t want to overdose our patients!
▪ Outpatient – Stroke (ED patients transferred to another facility)
o ARRIVAL Date and Time – When the patient signs into the ECC.
o Date and Time documented of Last known Well time
o Head CT or MRI scan interpreted within 45 minutes of arriva
|2015 National Patient Safety Goals in Action! |
|This is what WE do at OakBend Medical Center |
| |
|GOAL 1. Improve the accuracy of patient identification |
|What we do: |We always check for two patient identifiers: Patient NAME and DATE OF BIRTH whenever administering medications or blood products, |
| |taking blood samples and other specimens for testing, or before providing any other treatments or procedures. |
| |We LABEL all specimens in the presence of the patient. |
| |We use a double check system to ensure the right patient receives the right blood and blood products. |
| | |
|GOAL 2. Improve the effectiveness of communication among caregivers |
|What we do: |We report critical test results immediately to a responsible caregiver and document it in the medical record. We monitor our process|
| |to identify opportunities for improvement. |
|GOAL 3. Improve the safety of using medications |
| |We label all medications, appropriately including in all units, both on and off the sterile field. Including medication containers |
| |or other solutions. |
|What we do: |We use the “VTE” Protocol before initiating anticoagulants. We check PT/PTT and INR before administering anticoagulants. |
| |Medication Reconciliation: We attempt to obtain a current home medications list from patient and documents in the patient profile. |
| |Upon discharge, patients and they are given a list of their medications and provided with education on how to manage them. |
|GOAL 6. Use Alarms Safely |
|What we do: |The hospital will evaluate and improve alarm management for medical equipment to make sure that they are heard and responded to |
| |appropriately. |
|GOAL 7. Reduce the risk of health care-associated infections |
|What we do: |We comply with CDC hand hygiene guidelines – staff use alcohol hand gel or wash hands before and after every patient contact. Direct |
| |care staff DO NOT wear artificial nails or nail tips. We do not sneeze or cough on others and stay home when we are sick. We get |
| |immunized, and make sure our immunizations are current. |
| |We educate healthcare personnel, patients and family on Multidrug-resistant organisms (MDRO’s) and prevention. |
| |We use a central line checklist to prevent central line-associated bloodstream infections (CLABSI). We monitor both the use of the |
| |protocol and outcomes to ensure compliance. |
| |We use the Surgical Care Improvement Project (SCIP), to guide our practice and prevent surgical site infections. This includes NOT |
| |using razors to remove hair and giving the appropriate antibiotic within an hour of surgery. |
| |We use evidence base practice for inserting, managing and monitoring urinary catheters to prevent catheter-associated urinary tract |
| |infections (CAUTI). We ONLY use catheters when necessary and discontinue their use as soon as medically possible. We use aseptic |
| |technique in inserting, secure catheters so they drain and the flow is not obstructed. We keep the drainage system intact and only |
| |change when required. |
|GOAL 15. Identifies safety risk inherent in our population |
|What we do: |We assess patients to find out those who are at risk for suicide, and closely monitor these patients to keep them safe. |
| |We assure physical stability and make efforts to transfer to a psychiatric facility when needed. |
|UNIVERSAL PROTOCOL: Prevent wrong patient, procedure, side/site surgeries |
|What we do: |We perform preoperative verification of correct patient, procedure, site/side. We confirm that clinical documentation, x-ray films, |
| |implants or special equipment are available. |
| |We mark the operative site before surgery, while the patient is awake. |
| |We conduct a final TIME OUT just before starting the procedure to confirm correct patient, procedure, and site/side. The procedure |
| |does not begin until everyone present is in agreement. |
| |
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Aim
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OBMC Core “Inpatient” Measures are:
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Our Core “Outpatient” Measures are:
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