2007-2008 ANNUAL UPDATE Employee Training Module ... -...

SECTION TITLE PAGE

I Mediscan Mission, Vision, Values & Goals 1II Safety Statement and Program 4III Corporate Compliance and Reporting to Joint Commission 9IV HIPAA 19V Team Building at Mediscan 23VI Cultural Diversity & Sensitivity 26VII Workstation Ergonomics 34VIII Workers’ Compensation 38IX Safe Medical Device Act 43X Emergency Management 47XI Fire Safety and Evacuation 63XII Radiation Safety 71XIII Personal Safety / Assaultive Behavior 75XIV Incident Reporting: Risk Management 81XV Abuse and Exploitation Reporting 85XVI Patient Rights 88XVII Impaired Physicians &Licensed Independent Practitioners 92XVIII Body Mechanics 95XIX Infection Control 102XX Electrical & Equipment Safety 111

XXI Hazardous Substances, Bio-Hazardous Materials, Medical & Pharmaceutical Waste 117

XXII Portable Oxygen Safety 127XXIII National Patient Safety Goals 132XXIV Medication Safety 138XXV Ethical Issues 142XXVI Needs of Dying Patients & End of Life Care 144XXVII Organ & Tissue Donation/One Legacy 147

2007-2008 ANNUAL UPDATEEmployee Training ModuleMediscan Staffing Services

TABLE OF CONTENTS

Introduction

Purpose: The purpose of this Annual Education Update is to:Provide valuable and important information for staff to be able to fulfill job responsi-•bilities

Update employees on current practices•

Educate staff on safety issues•

Increase awareness and enhance job specific training•

Annually: All staff members will have access to the Annual Education Update information and will be tested on its content. All employees are expected to read the content of the hand-book.

Italics: Throughout the Annual Update there are several areas that are italicized. These areas or sections pertain ONLY to Clinical Departments.

2007-2008 ANNUAL UPDATEEmployee Training Module

Mediscan JCAHO Training Module 1

SECTION I

Mediscan MISSION, VISION, VALUES & GOALS

Learning Objectives:

After reading this section on the Mediscan Mission, Vision, Values & Goals Statement, the learner will be able to:

Explain the organization’s mission, vision and values statement.1.

Discuss our goals for the year.2.


SECTION I: Mediscan MISSION, VISION, VALUES & GOALS

Our Mission

Our mission is to help people keep well in body, mind and spirit by providing quality health care services in a compassionate environment.

Our Vision for the Future

To deliver “world-class” community health care.

Our Statement of Values

Patients and their families are the reason we are here. We want them to experience excellence in all we do through the quality of our services, our teamwork, and our commitment to a caring, safe and compassionate environment.

Respect: We affirm the rights, dignity, individuality and worth of each person we serve and of each other.

Excellence: We maintain an unrelenting drive for excellence, quality and safety and strive to continually improve all that we do.

Compassion: We care for each person and each other as part of our family.

Integrity: We believe in fairness, honesty and are guided by our code of ethics.

Stewardship: We wisely care for the human, physical and financial resources entrusted to us.


Goal #1: Generate significant organization-wide, annual operating margins and cash flows, to sustain Mediscan’s mission and move forward..

Goal #2: Become the staffing employer of choice by: creating a work environment and compensation philosophy that attract and retain highly-qualified and motivated personnel who possess both technical skills and leadership qualities required to serve and direct the organization.

Goal #3: Continually refine and enhance organizational resources, structure, operating processes, clinical capabilities and systems of care to improve clinical outcomes, patient safety and achieve excellence in customer service.

Goal #4: Strengthen Mediscan’s position as a valued and indispensable staffing resource by enhancing quality of service.

Goal #5: Evolve mutually supportive, successful and sustainable relations to ensure future access and quality as well as to collaboratively plan for future opportunities.

Goal #6: Position Mediscan to achieve long-term excellence in its governance and leader-ship systems and capabilities.

Mediscan Goals


SECTION II

SAFETY STATEMENT AND PROGRAM


After reading this section on the Safety Statement and Program, the learner will be able to:

Perform their work duties in a safe and healthful environment.1.

Adhere to the rules and regulations of personal protective equipment use.2.

Discuss how to report any unsafe condition or work-related injury.3.


SECTION II: SAFETY STATEMENT AND PROGRAM

ANNUAL SAFETY STATEMENT

Mediscan is known as a top staffing employer in the community and this philosophy is ex-tended to all our staff. Our goal is to eliminate unnecessary loss. Everyone shares responsibil-ity. The conservation of our resources, including the safety of every employee, is a matter of greatest concern that demands maximum effort.

Awareness, attitude and commitment towards safety and accident prevention are the main elements in preventing accidents. Elimination of the contributing causes of injury and illness takes teamwork from all levels of our organization.

Injury/Illness Prevention Program

The Injury/Illness Prevention Program is intended to assist staff members in complying with all applicable health and safety standards, rules and regulations.

Statement of Commitment to Safety and Health

Mediscan is committed to providing a workplace that protects the safety, health and environ-ment of our staff, patients and surrounding community. Safety is a primary consideration in every aspect of our operations. Our training and communication programs emphasize safe work practices. Staff is trained to work, recognize and report unsafe conditions in the work-place.

Our safety and health programs conform to all applicable standards, rules and regulations. Implementation of these programs is the responsibility of Human Resources and the Safety Officer.


In collaboration with departments, this program is monitored to ensure goals and objectives are implemented according to the spirit and intent of this plan. Our objective is to reduce the number of work related injuries and illnesses by providing an environment that is condu-cive to achieving it.

Responsibility for Injury/Illness Prevention Program

All Mediscan staff members are responsible for working safely and maintaining a safe and healthful work environment.

Human Resources and the Safety Officer may assign all or some of these tasks to other indi-viduals within the Environment of Care Committee. Ultimately, Human Resources and the Safety Officer remain responsible for the implementation and maintenance of Mediscan’s Injury/Illness Prevention Program.

Department Directors/Supervisors Responsibilities

Maintain a working knowledge and ensure implementation of the Injury/Illness Pre-•vention Program.

Provide scheduled, regular safety updates through departmental meetings and docu-•ment minutes and attendance.

Investigate all industrial injuries and correct any problems that may exist.•

Inspect, recognize, and evaluate workplace on a continuing basis.•

Enforce Safety Policy and Procedures.•


Staff Responsibilities

Be familiar with and adhere to the Injury and Illness Prevention Program and all •safety rules for their department and position.

Report any industrial injuries as soon as they occur.•

Immediately report to their Director/Supervisor/Safety Officer or an Environment •of Care Committee member any unsafe condition or hazard that they discover in the workplace. The contact may be made by phone, memo, in person or through the Meditech System.

Mediscan has established a safety hotline for safety issues and/or unsafe conditions. •Staff may report any condition anonymously, by using the Safety Hot Line or by sending the Safety Officer a written request.

Personal Protective Equipment

Safety rules, regulations and the use of personal protective equipment (PPE) are •reviewed on a regular basis by the Environment of Care Committee to determine ef-fectiveness and necessity.

The Safety Officer, in collaboration with all Department Directors, will work towards •implementing engineering controls in order to reduce the need for personal protective equipment.

Adherence to PPE requirements and safe work practices is the responsibility of all •staff.

Department Directors will monitor staff to ensure compliance with safe work prac-•tices, PPE requirements, and safety rules and regulations.

All staff receives training at time of hire and yearly on all applicable safety rules, regu-•lations, PPE requirements, and reporting work related injuries/illnesses and fire safety.


Corrective Action

Mediscan maintains a progressive corrective action procedure to ensure a fair method of cor-recting staff.

Following safety rules, regulations, and safe work practices are conditions of contin-•ued employment. Failure to follow established standards may lead to corrective action up to and including termination.

The Department Director and Safety Officer will maintain documentation of safety •violations. Staff’s safety performance will be documented in performance reviews.


SECTION III

CORPORATE COMPLIANCE AND REPORTING TO JOINT COMMISSION


After reading this section, the learner will be able to:

List employees’ responsibilities to comply with the Corporate Compliance Program.1.

Name at least four components of the Code of Ethical Behavior.2.

Identify to whom to report potential or suspected compliance violations.3.

Discuss employee’s rights to report to Joint Commission.4.

Discuss the federal and state False Claims Acts.5.


SECTION III:

CORPORATE COMPLIANCE AND REPORTING TO JOINT COMMISSION

Integrity in all business, employment, and patient care delivery practices is at the heart of Mediscan’s Mission, Vision and Values. Mediscan considers ethical behavior to be its cor-porate responsibility. Mediscan’s Code of Ethical Behavior requires staff, representatives and partnering entities to act and perform their duties in compliance with all existing federal and state laws, statutes and government regulations.

It is the responsibility of every staff member to:

Avoid illegal or dishonest acts•

Take responsibility for his/her own actions•

Immediately report any potential or suspected compliance violations•

Cooperate with investigations of any suspected violations.•

CODE OF ETHICAL BEHAVIOR

Mediscan’s Code of Ethical Behavior is summarized below. The full text, titled “Mediscan Corporate Compliance Program,” can be obtained from Human Resources.

Compliance with Laws and Regulations - Mediscan will obey all laws and regulations that affect its business. Staff members are expected to learn and correctly follow any laws and regulations that relate to their jobs.

Financial Accounting and Records - Book entries must be accurate and provide a true representation of each transaction. All financial records must be in accordance with generally accepted accounting principles and other appropriate guidelines.


Conflicts of Interest - Personal interests must not influence employees’ business decisions. Staff members should act with integrity, honesty and fairness.

Example of a reportable suspected violation:A prospective vendor gives a $100 Nordstrom’s gift certificate to the purchasing agent as a “thank you” for meet-

ing with him and states that more gift certificates will be provided once his company’s product is used at the hospital.

Fraud and Abuse - Staff members must avoid violating any fraud and abuse laws. An error, despite lack of intent, can violate the law.

Examples of a reportable suspected violation:- Billing for supplies or services that were not rendered- Misrepresenting the services that were given- Falsely certifying that services were medically necessary- Failing to report overpayments or credit balances- Billing separately for services that should be a single service

Kickbacks and Self-Referral Statutes - Mediscan is prohibited from offering patients in-centives to accept services or receiving money, gifts, resources, or services with the intent to influence patient referrals or services covered by a federal or state health care program.

Example of a reportable suspected violation:An Extended Care Facility provides theater tickets for a Broadway show to physicians and employees who direct

patient discharges to their facility.

Physician Relations - Applications for medical staff privileges will be considered in a man-ner that is professional, fair, prompt and without discrimination of any lawfully protected category.

Patients’ Rights - Staff members are expected to provide quality care in a considerate, re-spectful and cost-effective manner. The patient’s right to make his/her own health care deci-sions after being informed of all relevant information must be preserved.

Examples of a reportable suspected violation:- Patient did not meet the surgeon, nor was advised of the risks or alternatives, before undergoing non-emergent

surgery.- Patient lacks capacity to make own healthcare decisions and has no family or conservator, so physician unilaterally

decides that patient will undergo a non-emergent operation.


Health Insurance Portability and Accountability Act (HIPAA) - Mediscan must protect a patient’s personal privacy and preserve the confidentiality of patients’ medical records. The “minimum necessary” amount of information should only be revealed for legitimate business or patient care purposes, such as treatment, payment or healthcare operations (“TPO”).

Examples of a reportable suspected violation:- An employee electronically accesses his neighbor’s medical record to see why the paramedics transported his neigh-

bor to the ED last night- Discarding patient ID bands in the regular trash- Leaving a patient’s chart in his/her room unattended- Looking up your relative’s medical information in Meditech without the patient’s authorization

Emergency Services - In accordance with the Emergency Treatment and Active Labor Act (EMTALA), Mediscan will provide medical screening examination and stabilization to pa-tients with an emergency medical condition without regard to the patient’s ability to pay.

Examples of a reportable suspected violation:- Refusing to treat a patient presenting to the emergency department because the patient does not have insurance.- Providing a medical screening examination but discharging the patient before he has been stabilized solely because

he does not have insurance.

Respect and Concern for Others - Mediscan prohibits all forms of harassment, including sexual harassment and harassment based upon race, ethnicity, age, gender, sexual orientation, disability or other characteristic, as prohibited by law.

Example of a reportable suspected violation:Supervisor Sandra tells Nurse Neil that he will be assigned the best shifts so long as he goes out on a date with her.

Antitrust and Trade Regulation - Mediscan avoids activities that illegally reduce competi-tion. Staff members are expected to follow all federal and state antitrust laws and regulations that apply to their work.

Environment - Staff members are required to work in a manner that presents the least pos-sible risk of hazardous conditions and to promptly notify supervisors of any actual or poten-tially unsafe conditions or practices.

Example of a reportable suspected violation:Employee refuses to post signage warning of isolation precautions.


Political Contributions - Mediscan will not use funds or resources for political purposes to contribute to political campaigns.

Example of a reportable suspected violation:Supervisor asks staff, during employees’ shifts, to print 300 fliers for a political candidate, using paper and copier

supplied by hospital.

Confidential Business Information - The inappropriate release of financial information, trade secrets, and other commercially sensitive information could be harmful. Unless there is a legitimate need and an agreement to maintain confidentiality, such information should not be shared.

REPORTING CONCERNS TO JOINT COMMISSION

An employee who has a concern about the safety or quality of care provided in the organiza-tion may, in good faith, report their concerns to the Joint Commission.

Complaints may be made to Joint Commission by:

using the web site www.jointcommission.org•

by FAX: (630) 792-5636•

call the toll free number to assist with filing complaints 1-800-994-6610•


REPORTING CLAIMS OR VIOLATIONS

Staff members are encouraged to speak with their Director or Supervisor to report concerns about violations of the Mediscan Code of Ethical Behavior or false claims and false state-ments.

The Mediscan Corporate Compliance Officer is also available to anyone who is uncomfort-able talking with his/her supervisor.

Additional Numbers to Know:

Corporate Compliance Officer’s direct line: (818) 462-0000 x206

Reports about false claims or statements may also be reported to the California Attorney General Hotline by calling either (800) 952-5225 or (916) 322-3360, or by calling the Of-fice of the Inspector General at (800) 447-8477.

FEDERAL AND STATE FALSE CLAIMS ACTS

Mediscan makes every reasonable effort to provide information to employees, contractors and agents about the federal and state false claims acts, remedies available under these acts, and how they may be utilized, including whistle blower protections available to anyone who claims a violation of the federal or state false claims acts. Mediscan is committed to maintain-ing an environment in which individuals feel encouraged to report all suspected incidents of illegal, unethical, or otherwise fraudulent conduct. Accordingly, Mediscan maintains a strong non-retaliation policy to protect employees and any others who make good faith reports regarding suspected inappropriate conduct. A good faith allegation is an allegation made honestly and without deception, and where the intention of the party making the allegation is not to deceive or defraud.

The following list provides a general overview of the multiple regulations pertaining to false claims act violations.


Civil False Claims Act:

The Civil False Claims Act imposes civil liability on any person or entity who:

Knowingly files a false or fraudulent claim for payments to Medicare, Medicaid or •other federally funded health care program,

Knowingly uses a false record or statement to obtain payment on a false or fraudulent •claim from Medicare, Medicaid or other federally funded health care program: or

Conspires to defraud Medicare, Medicaid or other federally funded health care pro-•gram by attempting to have a false or fraudulent claim paid.

A person or entity found liable under the Civil False Claims Act is subject to a civil money penalty of between $5,500 and $11,000, plus three times the amount of damages that the government sustained because of the illegal act. In health care cases, the amount of damages sustained is the amount paid for each false claim that is filed.

For a claim to be false, the entity must:Know the information on the claim is false, or•

Act in deliberate ignorance of the truth or falsity of the information, or•

Act in reckless disregard of the truth or falsity of the information.•

A private citizen may bring a qui tam (whistleblower) action under the Civil False Claims Act in the name of the United States in federal court if the citizen has direct and independent knowledge of the submission of a false claim. The Government will decide whether to take over the case or let the individual pursue the case on his/her own.


If the government proceeds with the case, the person who filed the action will receive be-tween 15 percent and 25 percent of any recovery, depending upon the contribution of that person to the prosecution of the case. If the government does not proceed with the case, the person who filed the action will be entitled to between 25 percent and 30 percent of any recovery, plus reasonable expenses and attorneys’ fees and costs.

ADMINISTRATIVE REMEDIES FOR FALSE CLAIMS OR FALSESTATEMENTS

The Program Fraud and Civil Remedies Act (PFCRA) creates administrative remedies for making false claims and false statements. These penalties are separate from and in addition to any liability that may be imposed under the Civil False Claims Act.

The PFCRA imposes liability on people or entities who file a claim that they know or have reason to know:

Is false, fictitious, or fraudulent;•

Includes or is supported by any written statement that contains false, fictitious, or •fraudulent information;

Includes or is supported by a written statement that omits a material fact, which •causes the statement to be false, fictitious, or fraudulent, and the person or entity sub-mitting the statement has a duty to include the omitted fact; or

Is for payment for property or services not provided as claimed.•

A violation of this section of the PFCRA is punishable by a $5,000 civil penalty for each wrongful filed claim, plus an assessment of twice the amount of any unlawful claim that has been paid.


In addition, persons or entities violate the PFCRA if they submit a written statement that they know or should know:

Asserts a material fact that is false, fictitious or fraudulent; or•

Omits a material fact that they had a duty to include, the omission caused the state-•ment to be false, fictitious, or fraudulent, and the statement contained a certification of accuracy.

A violation of this section of the PFCRA carries a civil penalty of up to $5,000 in addition to any other remedy allowed under other laws.

California False Claims Act:

The California False Claims Act prohibits eight types of conduct:

Knowingly presenting or causing to be presented to the government a false claim for •payment or approval

Knowingly making, using, or causing to be made or used a false record or statement •to get a false claim paid or approved by the government

Knowingly conspiring to defraud the government by getting a false claim allowed or •paid

Knowingly delivering or causing to be delivered less public property or money that is •reflected on a receipt or certificate

Knowingly making or delivering a receipt by an authorized person that falsely repre-•sents the property to be used by the government

Knowingly buying or receiving a pledge of public property from any person who law-•fully may not sell or pledge it

Knowingly making, using, or causing to be made or used a false record or statement •to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government-also known as a reverse false claim

Being the beneficiary of an inadvertent false claim who discovers its falsity and fails to •disclose it to the government within a reasonable time.

The term claim is broadly defined to include any request or demand for money, property, or services made to any employee or representative of state or local government.


In addition, claims include requests or demands made to a contractor, grantee, or other recipient when any portion of the money, property or services was provided by the govern-ment.

With the exception of conspiracy and inadvertent beneficiary violations, the FCA expressly requires that a defendant act knowingly-with actual knowledge, in deliberate ignorance of truth or falsity, or in reckless disregard of the truth or falsity.

A person who violates the State FCA is liable for three times the amount of damages sus-tained by the government.

A qui tam (whistleblower) plaintiff is entitled to 25 to 50 percent of the proceeds of the ac-tion or settlement when the government declines to intervene and 15 to 33 percent when the government elects to intervene. In addition, violators may also be liable for civil penalties of up to $10,000 for each false claim.


SECTION IV

Health Insurance Portability and Accountability Act “HIPAA”


After reading this section, the learner will be able to:

Define Protected Health Information (PHI).1.

Identify when an authorization is required to disclose PHI.2.

Describe the standard for disclosure of PHI.3.

Identify at least three patients’ rights related to HIPAA.4.

Describe three ways to protect patient privacy.5.

Identify whom to report potential or suspected HIPAA violations.6.


SECTION IV: HIPPA

Health Insurance Portability and Accountability Act referred to as HIPAA, is federal legisla-tion that includes provisions designed to protect the confidentiality and security of health data.

Protected Health Information (PHI) is any information, including demographics, that identifies an individual. Examples of PHI include:

- Name- Employer- Email address- Address - Telephone no. - Fax no.- Date of birth - Social Security Number (SSN)- Account number - Medical record number

Verbal discussions, written communications and electronic communications are all protected under the HIPAA regulations.

Authorization is required to use or disclose PHI for any purpose other than for Treatment, Payment or Operations, unless:

Reporting to public health services•

Reporting of abuse, neglect, or domestic violence•

Law enforcement or judicial proceedings•

Emergency circumstances (e.g. natural disaster)•

Other disclosures as required by law•

Treatment - Those who have a treating relationship with a patient may have access to the patient’s PHI without written authorization. If a referral is made to another provider, then a treating relationship is established and that provider may access the patient’s PHI. External providers who do not have a treating relationship with the patient may not access that pa-tient’s PHI without a signed authorization.

Payment - Companies who pay for the provision of health care (e.g. Medicare) may access a patient’s PHI. They will ask for and should only be provided the “minimum necessary” amount of information to do their job.

Operations - Employees in non-patient care departments within the organization (e.g. Performance Improvement, Risk Management) may access patient PHI to perform necessary operational functions.


Disclosure of Information

The standard to disclose PHI is the “Minimum Necessary.” Providers must make a reason-able effort to disclose or use only the minimum necessary PHI in order to do their jobs. (Ex-ample: A Registered Nurse will need access to more patient information than a Transporter, however, a Registered Nurse will only need access to the patients that s/he is assigned.)

Patient Rights

Under HIPAA, patients have the following rights:

Inspect and copy their medical record•

Request an amendment (if a patient disputes an entry in the medical record, the pa-•tient may write their disputed issue on a separate piece of paper that will be attached to the medical record. Under no circumstances shall the medical record be altered!)

An accounting of disclosure (a list of all people and institutions given access to the •patient’s medical information within six years of the last date of service)

Request Restrictions (For example, the patient may ask not to be included in the Hos-•pital Directory or restrict visitors.)

Confidential Communication•

Receive a copy of the Notice of Privacy Practices (Patients are given a copy upon regis-•tration.)

A patient has the right to file a complaint if the patient believes the hospital has infringed upon the patient’s privacy rights.


Protecting Patient Privacy:

When possible, close doors while discussing diagnosis, treatment, prognosis and/or •discharge plans.

Close curtains and speak softly, when possible, in semi-private rooms.•

Avoid discussing patients in public areas of the hospital.•

Do not leave PHI unattended and secure patients charts.•

Log off Meditech, and any other computer system, after you complete accessing elec-•tronic PHI. Keep monitors turned away from visitors during use. (Audits are con-ducted periodically to check whether PHI is accessed inappropriately.)

Do not post or share passwords.•

Always re-check fax number and email addresses before sending information.•

Discard ID bands and name plates in the shredder.•

Contact the HIPAA/Compliance Officer when there are:

Questions about HIPAA•

Questions regarding patients’ requests to exercise their privacy rights•

Concerns about possible • improper use or disclosure of PHI


SECTION V

TEAM BUILDING AT Mediscan


After reading this section on Team Building at Mediscan, the learner will be able to:

Define a team.1.

List at least three Mediscan teams.2.


SECTION V: TEAM BUILDING

Teams Can:

Make decisions and solve problems within the organization.•

Provide single voice solution(s) to meet customer needs.•

Improve day-to-day operations.•

Meet the need for quick and effective change.•

Increase employee satisfaction.•

Help people work together more effectively and efficiently.•

Group versus Team:

Work groups are not teams. Work groups rely on individual contributions to accomplish group performance. In contrast, teams are distinguished by the individual’s commit-ment to group performance, collective work products, and mutual accountability.

The members of a department are not a team. The members of a surgical unit are a team. The members have a purpose, which gives them an identity. Each member has a unique function or position that must be combined with that of the other members. Team members are aware and supportive of the need for interdependent interaction. Lastly, the team operates within the framework of a larger organization - the hospital.

How is ‘Team’ defined?A team is a group of interdependent individuals organized and committed to achieving com-mon purpose.

In a successful team, members:

Have a purpose for working together•

Benefit from each other’s experience, ability and commitment to arrive at mutual •goals

Function as a unit within a larger organizational context•

Are accountable to themselves and to the team•

Together make decisions and are held accountable for the results•


Elements of Effective Teamwork:

Commitment - Team members must be committed to the idea that working together •as a group leads to more effective decisions than working in isolation.

Common Purpose - the team must have a reason for working together.•

Organized - Individual team members are organized to be accountable as a function-•ing unit within a larger organizational context.

Interdependence - Members of the team must be interdependent. They need each •other’s experience, ability and commitment in order to arrive at mutual goals.

Our organization is committed to developing multidisciplinary teams that can meet the vari-ous goals of the organization. Each team member and team contributions are treated with dignity and respect. Please feel free to communicate your concerns or suggestions to your immediate supervisors.

Examples of Mediscan multidisciplinary teams include:

The Employee Recruitment and Retention Committee1.

Employee Activity Committee2.

Environment of Care Committee3.

Pain Management Committee4.

Patient & Family Education Committee5.

Unit-specific Multidisciplinary Patient Rounds6.

Examples of team building training programs provided by Mediscan:

Supervisor’s Quarterly Meetings1.

Directors’ Monthly Meetings2.

Assertiveness Training3.

Unit Specific Staff Meetings4.

Quarterly Administration Rounds5.


SECTION VI

CULTURAL DIVERSITY & SENSITIVITY


After reading this section on Cultural Diversity & Sensitivity, the learner will be able to:

Define cultural diversity and sensitivity.1.

Name at least 5 factors that may influence an individual’s cultural identity.2.

Discuss guidelines for relating to individuals from different cultures.3.


SECTION VI: CULTURAL DIVERSITY & SENSITIVITY

Definition

Culture is a patterned behavioral response that develops over time due to social, religious, intellectual and artistic influences. Culture is shaped by values, beliefs, norms and practices that are shaped by members of the same cultural group. Each of us has a unique culture that developed from a mixture of various influences. Cultural development starts at conception. An individual’s cultural identity may stem from the following influences:

Ethnicity - the ethnic group with which the individual identifies himself1.

Race - the racial group (s) with which the individual identifies himself2.

Religion - the organized religion, with which the person adheres, has been taught or-3. rejects

Education - the level and type of education the person has experienced4.

Profession/field of work - the type of work the person is trained to do5.

Organizations - groups, associations and organization to which the individual belongs 6. or has belonged

Parents - the messages, both verbal and nonverbal, given by our parents about (but 7. not limited to) ethnicity, religion, values, cultural identity and prejudices

Other influencing factors including gender, family, peers and place of birth.8.

Since we all have our unique cultures and we live in such a multicultural environment, it is important that we learn how to interact with one another as respectfully as possible. The first step is by understanding what our own culture is. Interaction is not limited to the patient-caregiver interaction, but also includes the interaction we have among the staff members. In-dividualizing our interaction is important, so each staff member must master a certain degree of information.


Phenomena that Reflect Culture

Communication is the sharing of common information. This definition implies and em-braces all human interaction and behavior. All behavior, including verbal or nonverbal, in thepresence of another individual is communication. Communication is a continuous process by which one person may affect another through written or oral language, gestures, facial expressions, body language, pronunciation, silence, voice quality, space or other symbols.

Personal space is the area and objects that surrounds a person’s body. Personal space is con-sidered an extension of the body.

Social Organization -- Cultural behavior is socially acquired, not inherited. Children learn to behave by watching adults in social organizations or groups including family, religious, ethnic, racial, tribal, kinship, clan and other special interest groups. Different interactions orreactions an individual has towards certain situations are a reflection of the individual’ssocial group.

Concept of Time -- The concept of the passage of time is very familiar to most people re-gardless of cultural heritage, i.e. days and nights come and go. However developing an aware-ness of the concept of time is not a simple phenomenon. Time and the passing of time are different from one culture to another and from one individual to another.

Environmental control refers to the individual’s perception of his ability to direct factors in the environment and in nature. Health practices such as eating nutritiously and getting adequate sleep are examples of controlling the environment.

Biological Variation - People in various racial groups differ tremendously as evidenced by both their external appearance and internal biogenetic variations. For example, some racial groups are more sensitive to alcohol intake than others.


GUIDELINES FOR RELATING TO INDIVIDUALS FROM DIFFERENT CULTURES

1. Assess your personal beliefs surrounding persons from different culture.2. Assess communication variables from a cultural perspective.3. Plan care based on the communicated needs and cultural background4. Modify communication approaches to meet cultural needs.5. Understand that respect for others and communication is central to a working

relationship6. Communicate in a non-threatening manner.7. Use validating techniques in communication.8. Be considerate of reluctance to talk when the subject involves sexual matters.9. Adopt special approaches when the patient speaks a different language.10. Use interpreters to improve communication.


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SECTION VII

WORKSTATION ERGONOMICS


After reading this section on Workstation Ergonomics, the learner will be able to:

Identify correct sitting posture.1.

Explain the correct computer and keyboard set-up.2.

Identify correct use of workstation accessories.3.


SECTION VII : WORKSTATION ERGONOMICS

Ergonomics is the science of arranging and adjusting your work environment to fit you and your body. It is the key to comfort and safety. An appropriately arranged workstation can increase staff productivity by increasing staff comfort.

Workstation computer access affects all personnel in the hospital setting. Each staff member is required to access Meditech in one capacity or another. Some jobs require computer work throughout the day. All staff will benefit from an appropriate workstation set-up, and a regu-lar routine of exercise.

Guidelines for an appropriate workstation

Chair

The backrest should fit snugly against your lower back.•

Height of your chair should place your forearms parallel to the floor. Your feet should •rest firmly on the floor with 3-6 inches of leg room between your lap and desk or keyboard tray.

You should be able to fit your fist between the front edge of the chair and the back of •your bent leg.

Sitting posture

Sitting incorrectly can produce a great amount of strain on the lower back. It is important to maintain the normal inward curve of the spine while sitting to avoid this inward strain.

Sit with your hips against the back of the chair.•

Adjust the height of your chair so your hips and knees are at the right angles to the •ground.

Keep your head and shoulders in good alignment.•

Sit close to your work. Your back muscles work harder when you lean forward.•


Maintain the curve in the small of your back. When sitting, your buttocks should be •at the back of the chair, feet flat on the floor, and your upper back supported.

Take frequent, brief standing rests to avoid the build up of pressure.•

Computer set-up

The computer should be placed directly in front of the worker.•

The top of your monitor should be at or slightly below eye level.•

The screen should be 18-30 inches from your eyes, or at about arms length.•

The keyboard should be positioned to allow your wrists to be straight and relaxed, •elbows should be at a 90 degree angle.

Arms should • not be stretched out in front of you to reach the keyboard.


Workstation accessory arrangement

Keep your mouse at the same level as your keyboard.•

Put your primary work materials/input devices in front of you.•

Put frequently accessed items (telephones, manuals, etc.) in an easy to reach location.•

Use an adjustable document holder to hold reference materials that are referred to •frequently.

If you use the telephone frequently, use a headset. DO NOT use your shoulder to •hold the telephone in place.

Work habits

Take short and frequent breaks throughout the day.•

Rotate tasks to decrease prolonged sitting and typing.•

Exercise regularly throughout the day.•

Avoid twisting during daily activities.•


SECTION VIII

WORKERS’ COMPENSATION


After reading this section on Workers’ Compensation, the learner will be able to:

Discuss who is covered under Workers’ Compensation.1.

Discuss what benefits are and are not covered under Workers’ compensation.2.

Describe how to access benefits.3.

Report a worker illness or injury correctly.4.


SECTION VIII: WORKERS’ COMPENSATION

WORKERS’ COMPENSATION BENEFITS

Who Is Covered?

Almost every staff member in California is protected by workers’ compensation, but there are a few exceptions. People in business for themselves and unpaid volunteers may not be covered. Coverage begins the first minute you are on the job and continues anytime you are working.

What Is Covered?

Any injury or illness caused by the job is covered. The key is whether the injury or illness is caused by your job.

How Do I Access Benefits?

Report your work-related injury or illness immediately to your Director or Supervisor to determine if you need to be evaluated by the Emergency Department physician or Employee Health Nurse. Timely reporting is imperative to assure benefits are not delayed as much as 90 days. If you fail to report your injury/illness, it will result in the loss of benefits.

What Are The Benefits?

California Law guarantees three types of workers’ compensation benefits:

Medical care to cure the injury or illness•

Temporary disability payments to help replace lost wages. Benefits are generally two-•thirds of your wages, up to a maximum set by the State Legislature. Compensation is not paid for the first three days you are unable to work, unless you are hospitalized or unable to work for more than 14 days


Additional benefits in the form of permanent disability may be warranted. These pay-•ments are based on the result of the doctor’s evaluation and factors such as age and pre-injury occupation

Job displacement re-training may be necessary to return to work and is considered an •extension of medical treatment

Workers’ compensation fraud is a felony. Mediscan Partners will prosecute anyone •who knowingly files, or assists, in the filing of a false workers’ compensation claim. If convicted, you may be fined up to $50,000 and sent to prison for up to five years.

How Do I Report a Work-related Injury or Illness?

Notification Process at Mediscan

The staff member is to notify the Department Director for authorization for treat-ment in the Employee Health or Emergency Department. The staff member is under no obligation to be treated and may decline treatment. Declination of treatment shall be documented.

Notification Process at Mediscan

During Employee Health business hours:The staff member must report to the Employee Health Department for triage and authorization to treat. The staff member is under no obligation to be treated and may decline treatment. Declination of treatment shall be documented.

All facilities:

After hours, the staff member must report to Nursing Administration for triage and 1. authorization to treat by the Emergency Department physician. The staff member is under no obligation to be treated and may decline treatment. Declination of treat-ment shall be documented.


2. The staff member must complete all required forms/documentation that is specific to the injury/illness regardless of whether or not they are treated:

Injury/Illness Report. This form provides the staff member and the Director •the opportunity to explain how the injury occurred; body partes) involved and action plan to correct the hazard that caused the injury/illness. This form must be completed even if the staff member declines medical treatment.

State of California’s Employee’s Claim for Workers’ Compensation benefits •(DWC). This form provides the staff member with information regarding their rights and benefits under workers’ compensation and the name of the workers’ compensation carrier for Mediscan.

If the staff member sustains a body substance exposure and/or a sharps injury, •the staff member is required to follow up with the Employee Health Nurse to complete the Body Substance Exposure form.

3. After the initial visit to the Employee Health or Emergency Department, the staff member must return to their Department Director.


Continued Treatment Process:

If the staff member requires additional visits to Employee Health, Emergency Department, Physical Therapy or a referral to a designated specialist, the following guidelines must be fol-lowed:

Mediscan participates in a Medical Provider Network. If a referral is indicated, Oc-•cupational Health Employee Health or Minor Care and Treatment Department will refer the staff member to a physician within the Medical Provider Network.

Occupational Health or Employee Health and the carrier, will contact the staff mem-•ber by telephone with the referral information. The carrier will also provide the staff member notice by mail. The employee is obligated to notify the Department Director of impending evaluation so that the staff member’s work schedule (if they are work-ing) may be appropriately adjusted. At Mediscan notification will be done by the Em-ployee Health Department. All subsequent visits will follow the process listed below:

After each subsequent visit with the Emergency Department or referral to a specialist, •the staff member must return to Occupational Health or Employee Health with the status report. If the staff member fails to provide the status report, benefits and com-pensation may be delayed.

The staff member must also provide the Department Director with a copy of the sta-•tus report. The status report contains the time that the staff member checked in and checked out of ED/Urgent Care/Doctor’s office. Employee Health Department will be responsible for authorizing and notifying payroll of the leave of absence.


SECTION IX

SAFE MEDICAL DEVICE ACT


After reading this section on Safe Medical Device Act, the learner will be able to:

Explain what the Safe Medical Device Act is.1.

State reporting procedure for faulty medical devices.2.


SECTION IX: SAFE MEDICAL DEVICE ACT

Federal law requires that information concerning events involving medical devices which may have caused or has contributed to the death, serious injury, or illness of a patient/staff member be reported to the FDA and/or the manufacturer of the device. This includes events occurring as a result of use error.

Serious injury is defined as an illness or injury that is life threatening, or results in permanent impairment of a body function Or~ permanent damage to the body structure, or necessitates medical or surgical intervention to preclude impairment of a body function or permanent damage to the body structure.

A voluntary report may be sent to the FDA for events involving a medical device, which does not cause serious injury/illness or death.

Examples of medical devices are:

Hospital beds•

Heart valves•

Ventilators•

Patient restraints•

X-ray machines•

Defibrillators•

Patient monitors•

IV pumps•

Bandages•

Generally, any item used in medical practice other than a drug is considered a device. Investi-gation devices (diagnostic testing equipment) are exempt from the reporting requirements.


If any equipment or device is suspected to be defective:

The equipment or device must be immediately red tagged by staff, noting the defect.•

It should then be impounded for investigation and to protect others from inadver-•tently using it.

Notify Bio-Medical Services, Department Director or Nursing Supervisor and the •Risk Manager of the event and complete an Event Reporting Form/Incident Report.

If the device has electronic memory, keep it plugged in so it maintains its memo-•ry.

Keep any packaging, tubing or other accessories that may help investigators recon-•struct the event. The manufacturer may need to inspect the device.

All employees are responsible for promptly reporting these events so reports to the FDA/manufacturer can be made, as required, within 10 workdays. The appropriate means of noti-fying Risk Management is by telephone call, followed by an Event Reporting Form/Incident Report. At time of notification of a suspected medical device incident, the Risk Management Staff, in conjunction with the Director of Bio-Medical Services, will conduct the investiga-tion.

If you have any questions, contact the Engineering Department or Risk Management De-partment.


SAFE MEDICAL DEVICE FLOW CHART

Equipment/Device Failure

Tag Equipment/Device

Notify Bio-Medical Services

Report to FDA Manufacturer

Remove Equipment/Device from Service

Death, Serious Injury, Injury or Illness Occurred

Notify Supervisor &Risk Mangement Event Reporting Form

Director of Performance Improvement/Risk Management Services,

Director of Engineering & Safety OfficerTo Conduct Investigation

No Patient Harm Occurred


SECTION X

EMERGENCY MANAGEMENT


After reading this section on Emergency Management, the learner will be able to:

Define the emergency codes that are paged in the hospital.1.

Initiate emergency codes appropriately.2.

Respond appropriately whenever emergency codes are activated.3.

Identify the different types of disaster events either man-made or natural that can 4. disrupt the Environment of Care.

Indicate the location of various posts/stations during a disaster.5.


SECTION X: EMERGENCY MANAGEMENT

EMERGENCY CODES

Most of the emergency codes may be initiated by the person who discovers the problem. Staff has immediate access to the switchboard operator from any hospital telephone. Staff will state code name and location of the situation. The Operator will overhead page the code.

A few of the emergency codes may only be initiated by the administrative person in charge, or designee. These include Code Triage and Code Yellow.

Inside the Hospital

If you are inside the hospital report the situation to the operator.

Outside the Hospital

If you are in an outlying building, dial 9-911 and report the situation. If it is safe and time allows, call the operator to report the situation. The Operator will notify Administration, Nursing Supervisor and Engineering.

Give the following information when reporting the situation:

State the code name which indicates the type of emergency.•

Location of the emergency•

Your name•

ALLOW THE OPERATOR TO TERMINATE THE CALL.


CODE PROCEDURES

CODE BLUE - Cardiac/Pulmonary Arrest for an Adult (over 8 years of age)CODE WHITE - Cardiac/Pulmonary Arrest for an Child (0 to 8 years of age)

Activated by:

Any staff person

To Activate:

If it happens in the hospital:

Dial “6”•

Indicate Code Blue or Code White and your exact location•

If it happens in the off-site buildings & parking lots:

Call the paramedics by dialing “9-911.”•

State medical emergency and exact location.•

Response by:

Emergency Department staff will respond and provide first aid to individuals in need •of emergency medical care within the hospital property.

Emergency Medical Services will respond to off site buildings and parking lots.•


CODE YELLOW - A Bomb Threat that is received by verbal or written communication.

Activated by:

Hospital administration, Nursing Supervisor or designee

To Activate:

Notify hospital administration, Nursing Supervisor or designee, who will then deter-•mine the need for a CODE YELLOW page. Do not leave message on voice mail!

Response by:

All Staff to survey their immediate areas and report any unusual or suspicious objects •within their area to their supervisor.

Close all doors and remain on your unit until an all clear is announced.•


CODE TRAUMA - Notification that potential life threatening trauma patient(s) may be ar-riving to the Emergency Department.

Activated by:

This code is usually activated by a designated individual. Most often the Emergency •Department Physician or staff.

To Activate:

Dia1”6.”•

Response by:

Immediate response is required by designated nursing and ancillary service staff to •deliver needed treatmentI eqUipment and supplies.

CODE RED - Fire (Review Section on Fire Safety)

Activated by:

Any staff person that discovers the fire.•

To Activate:

Dia1”6.”•

Indicate “Code Red” and the exact location.•

Response by: All hospital staff


CODE ORANGE - Hazardous Materials (HAZMAT) situation.(Review Section on Hazardous Substances, Bio-Hazardous Materials, Medical and Pharma-ceutical Waste)

Activated by:The person who discovers the spill or leak.

To Activate:Dial “6.”•

Indicate “Code Orange” and the exact location.•

Response by:Designated personnel•

Avoid the area unless you are otherwise instructed and•

If you are in the area do not leave until instructed to do so.•

CODE ORANGE CHEMO - Hazardous Materials - Chemotherapy Spill(Review Section on Hazardous Substances, Bio-Hazardous Materials, Medical and Pharma-ceutical Waste)

Activated by:

Any staff person that discovers the spill•

To Activate:

Dial “6.”•

Response by:

Avoid area unless otherwise specified•

Pharmacy and Chemotherapy Nursing Staff to respond•


CODE PINK - Notification of a possible infant abduction from the hospital.

Activated by:

Nursing personnel on the floor where the abduction has occurred.

To Activate:

Dia1”6.”•

Indicate “Code Pink” and the exact location.•

“Code Pink and the location” will be paged.•

The facility will be secured.•

The local Police Department will be notified if an actual abduction has occurred.•

Response by:

All hospital staff to secure all exits from the facility and to keep all staffI patients and •visitors in the facility until an all clear is sounded.

Staff will report any suspicious activities to security or police.•

CODE PURPLE - Notification of a possible Child/Infant abduction from the hospital.

Activated by:

Nursing personnel on the floor where the abduction has occurred.•

To Activate:

Dial “6.”•

Indicate “Code Purple” and the exact location.•


“Code Purple and the location” will be paged.•

The facility will be secured.•

The local Police Department will be notified if an actual abduction has occurred.•

Response by:

All hospital staff to secure all exits from the facility and to keep all staff, patients and •visitors in the facility until an all clear is sounded.

Staff will report any suspicious activities to security or police.•

CODE GRAY - Security Code to help manage and or control a violent or potential violent situation. (Review Section on Personal Safety/Assaultive Behavior).

Activated by:

Any staff I volunteer or physician who identifies the situation as needing a security •response.

To Activate:

Dial “6”•

Indicate Code Gray and your exact location.•

Response by:

Security and trained staff to respond.•


CODE SILVER - Security code in the event that a weapon is being used or hostage has been taken.

Activated by:

•Anystaff,volunteerorphysicianwhoidentifiesthesituationasneedingasecurityresponse.

To Activate:

Dial “6.”•

Indicate “Code Silver” and the exact location.•

Evacuate area if safe to do so.•

Response by:

Operator -- will dial 9-911 to notify police.•

Police Department -- will be in charge upon arrival.•

Security -- will assist police.•

All uninvolved staff -- to stay away from the area.•

EMERGENCY MANAGEMENT PLAN- (Disaster Plan)

T-Packets are located in every hospital department. This packet outlines the departmental disaster plan for quick access. Every staff member has the responsibility to know the location of this material in his/her department. Read this information before a disaster strikes!


CODE TRIAGE - (Internal, External, Internal/External) Unexpected incident or event that can affect normal hospital operations such as fire, earthquake, flood, riot, toxic cloud, hazardous materials incident, etc.

Internal and External

Activated by:

•InitiatedbyHospitalAdministrator,NursingSupervisorordesignee

Response by:

All hospital staff•

Activate department specific emergency management plan.•

The person in charge in each department will assume the duties as outlined in the “T-•Packets”.

Send any pre-assigned personnel to report to treatment areas as outlined in the “T-•Packets”.

Utilize reporting forms as outlined in the “T-Packets”.•

CODE TRIAGE - STAND-BY Standby for verification of disaster.

Activated by:

Initiated by Hospital Administrator, Nursing Supervisor or designee•


Response by:


Stand-by for possible arrival of patients/victims.•

Review departmental disaster plan.•

Plan assignments.•

Review “T-packets”.•

Prepare treatment areas.•

CODE TRIAGE - IN EFFECT Disaster verified. Emergency Management Plan in effect.

Activated by:

Initiated by Hospital Administrator, Nursing Supervisor or designee•

Response by:


Report to assigned posts•

Fulfill responsibilities as instructed or as outlined in the “T-Packets”.•

CODE TRIAGE ALL CLEAR - The disaster is no longer impacting hospital.

Begin to resume normal operations.•


TREATMENT LOCATIONS

Incident Command• Nursing Administration - MediscanAdministration Conference Room - Medis-can

Triage - Emergency• Ambulance DrivewayInclement Weather• GI Hallway

Immediate Care Area• Emergency Department

Delayed Care Area• Physical Therapy Department,Ambulatory Care Center

Minor Care Area• Hospital Lobby - Mediscan

Labor Pool• Out Patient Physical TherapyWaiting Room,Ponderosa Room/Conference Room - Me-discan

Maternity Holding Area• Labor & Delivery,Emergency Department

Deceased• Annex 7,Basement/Morgue


TYPES OF DISASTERS THAT CAN AFFECT THE FACILITY INCLUDE:

EARTHQUAKE

Immediate Action:

Take cover - immediately get under a desk, table, bed or other piece of furniture to •prevent falling debris from landing on you.

Avoid windows, doorways, hanging items, file cabinets, and bookshelves.•

When the Shaking Stops:

Check on those in immediate area.•

Reassure one another.•

Make rounds to each patient room.•

Check patients and reassure them.•

Check for, and assist, any injured persons. Take to Triage Area if able.•

Check equipment and utilities for operational status.•

Check for broken gas or water lines•

Dial “6” to report emergency situations to the operator•

Notify Engineering of any non-emergency situations•

Check furniture, wall mounted TVs and other items for damage and security of fit-•tings.


Telephone System

Leave lines open for emergency calls•

Pay telephones are usually the first telephones back on line. Have “change” available-•for pay telephones.

Use alternate means of communication if the telephones are down. (cell phones, •walkie- talkies, runner)

CODE YELLOW OR BOMB THREAT

The Person who receives bomb threat:

Remains calm•

Does not interrupt caller•

Signals a Co-worker to notify the Administration and Security.•

Prolongs the conversation as long as possible to gain details; i.e., type and location of •device, time of detonation, etc.

Notification of personnel:

Administration/Nursing Supervisor•

Security•

Administrator or designee will determine the need to activate the•

Code Yellow page.•


Staff actions if Code Yellow is announced:

Remain calm and alert. Do not alarm patients or visitors.•

All staff to survey their immediate areas and report any unusual or suspicious objects •within their area to their supervisor

Close all interior fire doors.•

If a suspected object or bomb is found:

DO NOT TOUCH! Do not allow anyone to handle suspected object under any •circumstance.

Evacuate anyone in the immediate area.•

Isolate the area and notify police.•

OTHER TYPES OF DISASTERS THAT MAY REQUIRE INITIATION OF THE EMERGENCY MANAGEMENT PLAN:

RIOT OR CIVIL UNREST/DISTURBANCE•

FLOODING•


TOXIC CLOUD•

BIOTERRORISM•

CHEMICAL OR RADIATION EXPOSURES•

It is important to participate in all drills in order to prepare for many types of emergencies that could affect the hospital.Practice makes perfect!


SECTION XI

FIRE SAFETY & EVACUATION


After reading this section on Fire Safety & Evacuation, the learner will be able to:

Explain how to report a fire in your area.1.

List the order of actions to effectively deal with a fire.2.

Explain evacuation priorities.3.

Explain how to use a fire extinguisher.4.


SECTION XI: FIRE SAFETY & EVACUATION

Introduction

A potentially catastrophic threat to patients and health care professionals is a fire. Hospital fires are especially dangerous because workers must evacuate large numbers of patients and also protect themselves. The key to safety is prevention and being prepared. This training update contains general information about life safety. For more detailed information onpolicies and procedures refer to the Mediscan Life Safety Management Plan and Life Safety Program in your department’s Environment of Care Manual.

PREPARE FOR A FIRE

If there is a fire in your department, be prepared to know:•

Location of fire extinguishers•

Location of fire pull stations•

Location of the next horizontal fire compartment (ask your supervisor for clarifica-•tion)

How to evacuate vertically (to the floor below or outside the building)•

Evacuation priorities•

Patient carries•

R-A-C-E guidelines to remember what action to take during a fire•

P-A-S-S guidelines for fire extinguisher use•


CREATION OF FIRE

A fire requires that the following three elements (known as the fire triangle) are present at the same time to burn:

Heat•

Fuel•

Oxygen•

If the sides of the triangle are not allowed to meet - if the triangle does not form - there will be no fire.

CAUSES OF FIRE

Most hospital fires originate in patient rooms with the following as the most common cause:

Electrical Equipment•

Matches•

Smoking•

Fires also originate from malfunctioning or misused equipment such as:

Hot plates•

Coffeepots•

Toasters•

Plugging too many things into same outlet•

COMMON HOSPITAL FIRES BY LOCATION

Patient rooms (smoking material and faulty equipment such as patient’s grooming •devices)

Storage areas (linens, maintenance equipment, compressed gas cylinders, flammable •liquids, smoking materials, welding heaters, and trash)

Machinery and Equipment areas (solvents, oily rags, and faulty equipment)•


R - A - C - E GUIDELINES

R Remove anyone from danger

A Activate the nearest fire alarm. If you are inside the hospital, activate the alarm by pulling down on the lever on the fire alarm box and dial 6.

If you are in an outlying building, dial 9-911 and report the situation, If it is safe and time allows, dial 6 to report the situation. The Operator will notify Administration, Nursing Su-pervisor and Engineering.

Give the following information when reporting a fire.

Location of the fire•

Type of fire•

Size of fire•

Your Name•

ALLOW THE OPERATOR TO TERMINATE THE CALL.

C Confine the fire by closing windows and doors, this will help to slow the fire.

E Extinguish the fire if it is safe to do so or begin evacuation. Obtain a fire extinguisher from the immediate area and return to the fire room. Check the door to the fire room for heat. IF IT IS HOT, DO NOT OPEN THE DOOR! If it is not hot proceed to open thedoor SLOWLY. Smoke and fumes may be present and caution should be exercised when en-tering the location. Prepare the fire extinguisher for use and then enter the room only if safe to do so and after you have notified others of your actions.

Evacuation should be by order of Management or Fire Officials.


P - A- S - S GUIDELINES

P Pull the pin.

A Aim at the base of the fire.

S Squeeze the handle

S Sweep the hose from side to side.

EVACUATION PRIORITIES

1st Ambulatory2nd Semi-Mobile3rd Non-Ambulatory


EVACUATION ROUTES

Hospitals are designed to defend in place by evacuating to the next fire compartment.

Horizontal evacuation should be done first. Horizontal evacuation is moving patients •to the next fire compartment. Ask your supervisor where the next fire compartment is in your area.

Vertical evacuation is taking refuge down one floor or outside the building if it is not •safe to evacuate horizontally.

•

INTERIM LIFE SAFETY MEASURES (ILSM)

Mediscan maintains a program of Interim Life Safety Measures (ILSM) to minimize the pos-sibility of injury or damage due to fire, smoke, fumes or other threat. These measures are in addition to or exceed standard life safety practices. When life safety deficiencies are identified or when construction, or remodeling activities occur that affect the function of life safety sys-tems at this facility for more than 4 continuous hours, the local fire department will be noti-fied and additional actions will be taken to compensate for any hazards posed by life safety deficiencies up to and including a fire watch. Additionally, measures will be taken to provide for handicapped accessibility. The Safety Officer or Construction Manager will ensure that the interim measures are followed.

PATIENT CARRIES

Pack Strap Carry

Used for the conscious patient who is unable to walk.

Bring the person to a sitting position.•

Place your back squarely against the patient’s chest and bed.•

Move forward and carry the person on the upper portion of your back.•

Put the patient’s arms across your shoulders and cross their arms in front of your •chest.

Pull downward on the arms, leaning forward bending only at your shoulders.•


Swing Carry

Used with two carriers.

The person at the head sits the person up; the person at the feet swings the legs to the •side of the bed.

The carriers join their arms under the patient’s knees and the carriers lock their arms •behind the back of the patient and lean forward.

Extremity Carry

Used with a patient who is immobilized with a cast or traction.

The person at the head of the bed will lock his/her arms around the patient’s chest.•

The person at the foot of the bed will slide one leg out, step between the legs, and •grasp each leg securely in each arm.

Both carriers then move forward and away from the bed.•

The Cradle Drop

Used for an unconscious patient.

Place blanket on the floor.•

Grip the patient under shoulders and knees.•

Slide the patient to the end of the bed. Bending on one knee, pull the patient toward •you and onto the blanket.

Wrap the blanket around the patient.•

Pull the patient out headfirst on the blanket.•


The Infant Evacuation Stretcher

Ask your supervisor where the stretchers are located.

Unfold stored stretcher to outstretched position and lock.•

Mummy wrap the infant’s hands and feet for ease of insertion and to protect the •infant.

Open pocket and insert each infant, feet first.•

Position infants back-to-back on their sides in groups of two in each pocket.•

Term infants: Utilize both upper and lower Velcro straps to secure infants, ensuring •infants’ faces/airway clear the top of the pocket.

Small or Preterm Infants: Utilize the lower Velcro strap to shorten the depth of the •pocket to accommodate their small size and still maintain their faces/airway above the top of the pocket.

Tip bottom of stretcher slightly down when transporting infants in a stairway or on •a ramp to prevent infants from sliding out of the pockets. Maintain “heads up” posi-tion.

Wipe stretcher and pockets down with hospital-approved antimicrobial solution after •use.

FIRE ALARM RINGING

If you hear a fire alarm:

Close all doors - patient rooms and offices.•

Do not use the elevators.•

Give instructions to visitors.•

Check that automatic fire doors are closed.•

Listen for instructions.•


SECTION XII

RADIATION SAFETY


After reading this section on Radiation Safety, the learner will be able to:

Define natural and man-made sources of radiation.1.

Practice safe radiation protection principles.2.

Identify sources of radiation in the medical environment.3.

Know the contact person for Radiation Safety issues.4.

Define key words for Radiation Safety.5.


SECTION XII: RADIATION SAFETY

RADIATION:

Radiation is electromagnetic and atomic particulate energy that exists in our environment as natural or man-made sources. Natural sources come from sunshine, cosmic rays and radio-active materials deposited in the earth during its formation. These sources contribute to a normal “background” level of radiation that everyone is constantly being exposed to every day. Man-made sources such as those used in X-ray, CT and Nuclear Medicine are ionizing sources of radiation with much potential to cause harmful effects.

RADIATION PROTECTION:

There is a definite correlation between the amount of radiation exposure received and dam-age done to body tissues. This “threshold” effect simply means the more you get, the higher the probability for damage. Keep in mind there is no safe dose of radiation. While it is highly unlikely small exposures will cause damage, there are no guarantees it will not. For thisreason hospital personnel must be aware of radiation sources in the medical environment to help keep their exposure “as low as reasonably achievable”.

This policy is termed “ALARA”. There are three main rules of radiation protection:

TIME-Less is better.1.

DISTANCE-Far is good.2.

SHIELDING-More is best.3.

The less time spent near a source and the more distance between you and the source will help keep your exposure ALARA. Always wear a lead apron while in or near an X-ray field and always face towards the X-ray source. Also, always wear your dosimetry badge, if issued one.


RADIATION SOURCES IN HOSPITAL:

Patients who have had an X-ray, CT, MRI, or Ultrasound procedures are not radioactive. Patients who have had a Nuclear Medicine scan are radioactive and remain so for hours to days depending upon the radiopharmaceutical used. Nuclear Medicine patients pose minimal risks from exposure and no special precautions are necessary.

The exception is nuclear therapy patients treated with Iodine-131 or radioactive implants. These patients are highly radioactive and precautions must be taken to keep exposure lev-els ALARA. These patients must be isolated in a separate room and radiation warning signs posted and room access restricted to nursing staff caring for the patient. These patients will be cleared for discharge by the Radiation Safety Officer (RSO).

Always remember that NOTHING may be removed from a nuclear therapypatient room until checked and cleared by the RSO.

RADIATION SAFETY ISSUES:

The TREFOIL sign, which appears here, is the international symbol for radiation warning. It may be magenta on a yellow background or black on yellow. This sign will be posted at entrances of all areas where radiation is being used.

Pregnant personnel or those who think they might be pregnant should be especially careful during the 1st trimester and always proceed with the ALARA concept in mind. Pregnant personnel are restricted from caring for nuclear medicine therapy patients.

The Radiation Safety Officer and the Radiation Safety Committee are responsible for ra-diation safety throughout Mediscan. Dennis Cuocco, CNMTCRT is the RSO for QVH campus and Liz Reilly, CNMT is the RSO for Mediscan campus. Dennis can be reached at extension 22465 and Liz at extension 12891. They are available to answer any concerns you might have about radiation and safe radiation practices.


GLOSSARY:

ALARA: As Low As Reasonably Achievable.

DOSIMETRY BADGE: Measures your radiation exposure.

THRESHOLD: The exposure level highly probably for harm.

BACKGROUND: Naturally occurring radiation.

REMS or RADS: A unit of measurement of radiation.

MILLIREMS or MILLIRADS: l,OOOth of a unit.

MICRO REMS or MICRO RADS: l,OOOth of a l,OOOth.


SECTION XIII

PERSONAL SAFETY/ASSAULTIVE BEHAVIOR


After reading this section on Personal Safety/Assaultive Behavior the learner will be able to:

State how to assess situations for potential violence.1.

Explain how to prevent problems from escalating.2.

State how to get help fast I if needed.3.

List ways to protect yourself in assaultive situations.4.

If someone doesn’t helpme soon, I’m going toexplode. I don’t knowhow much more of this Ican take!


SECTION XIII: PERSONAL SAFETY/ASSAULTIVE BEHAVIOR

We are all exposed to the impulsive, inappropriate behavior of our patients and visitors. We must learn to be alert and sensitive to people in crisis. In times of stress, our self-control be-comes weak and impulsiveness increases.

We can prevent most injury, abusive treatment and involvement in compromised situations by preventive action.

1. Learn to assess the situation:

Give yourself time for assessment (stand near the door).•

Make eye contact.•

Say “hello” and introduce yourself. Wear your ID badge on the right side/upper body.•

2. If a person or situation makes you uncomfortable, look for clues. What is going on?

Are they anxious, agitated, confused, and angry?•

What is their posture?•

What are they saying?•

Are they under the influence of drugs or alcohol? If so, approach in pairs or call secu-•rity to standby.

3. What are you communicating by your presence?

Your uniform implies authority or lack of authority•

Silence can be perceived as:•

RudenessIndifferenceUncaringIgnoring their sufferingJudgmental


Your behavior or presence can be thought of as suggestive or seductive.•

You have entered their personal space.•

Are you communicating helplessness or anger? What is your body language?•

Are you presenting yourself as a friend or in a staff role? (Remember that you are •always in a staff role while at work).

Explain what you plan to do for them or what you plan to do to them.•

4. What can you do to prevent problems? You have the control of one person - YOU.

Review Customer Service practices.•

Get information and give information to appropriate person.•

Get assistance.•

Share your concern.•

Remain calm and firm. Do not argue. Repeat yourself (i.e., “you are upset. I will get •the Charge Nurse/Supervisor to assist you”).

Retreat from a real physical threat. Run, crawl, back away, block the aggressive person •with chairs, tables, laundry carts, etc.

If the situation is something you cannot handle, initiate a•

Code Gray or Code Silver.•

5. Do’s and Don’ts of taking care of yourself:

Do not get cornered. Keep your personal space.•

Avoid physical contact.•

Do not make threats.•

Do not lie. Be truthful.•

Stand tall.•

Make eye contact but do not stare.•

Confront with, “When you yell, I get scared. I will return with a Charge Nurse, Di-•rector, etc. to help understand your concerns”.


Don’t wait to call for help until someone has his/her hands on you. It may be too late.•

Call Security for assistance and/or initiate a Code Gray or•

Code Silver.•

Always watch the hands.•

Be observant and aware of your surroundings.•

6. You have a right to take care of yourself by:

Thinking•

Avoiding•

Planning•

Resisting•

Running•

Blocking•

Guarding•

Cooperating: when a weapon is being use against you (gun, knife, etc.).•

Using weight, not muscle•

Taking P.A.R.T. or Assaultive Behavior Training•

There are two levels of training available for employees. Check with your Director to see what level you need to complete and the education required on an annual basis.

SECURITY AWARENESSSecurity provides escorts to parking lots and any other part of the campus 24 hours a day, 7 days a week. This service is intended to provide safety to staff and others who must walk to and from their vehicles during late and unusual hours, or must transport valuable equipment on or about the Mediscan properties.

Security responds to many calls each day. Most calls are non-urgent in nature; however, some need immediate response from security. If you have a situation that is very urgent, you should call security to respond STAT. Let Security know what the situation is, where you are calling from (department) and your name.


Explosive devices do not always look like bombs. They often are placed and/or hidden in let-ters, parcels, luggage, tote bags, etc. If you hear a Code Yellow (Bomb Threat) paged, close all doors and visually inspect all rooms in your area for strange items that are not ordinarily in your area and notify Security right away if any suspicious package or activity is discovered.

It is very important that each staff member wear his/her hospital ID badge at all times. ID badges are required and used to restrict access (entrance) to sensitive areas. At Mediscan these areas include: Emergency Department, Pharmacy, NICU, The Family Birth & Newborn Center, and cash areas. If you forget your ID badge, request a temporary badge from Secu-rity.

Code Gray is a very serious security emergency requiring all Security Officers, as well as able-bodied staff trained in managing assaultive behavior, to respond when hearing a Code Gray paged.

Code Silver means a weapon is being brandished and/or a hostage has been taken. The Op-erator will notify the police and once they arrive, are in charge. Security will assist the police as necessary. All other staff is to stay away from the area.

The Security Department takes reports on a daily basis on a wide variety of incidents, acci-dents, and injuries to staff and visitors. Security must always be called when a staff member or a visitor is involved in an accident or injury.


The Security Department makes rounds throughout all Mediscan campuses on a continual basis; however, Security is unable to be in all places at the same time. If a staff member ob-serves a suspicious person walking around their unit, he/she should contact Security imme-diately.

Mediscan - Dial #0, Mediscan- Dial 22474 Mediscan - Dial 0

All exterior buildings are patrolled by Security on a continuous basis.Anything unusual, such as an open door, is investigated by Security.


SECTION XIV

INCIDENT REPORTING: RISK MANAGEMENT


After reading this section on Incident Reporting: Risk Management, the learner will be able to:

Explain the purpose of an Event Reporting Form/Incident Report.1.

List the guidelines to use when completing an Event Reporting Form/Incident Re-2. port.

Define “Sentinel Event.”3.

Explain purpose of Sentinel Event Alert.4.


SECTION XIV: INCIDENT REPORTING: RISK MANAGEMENT

Even in an environment where people work hard and do their best, errors can occur. As an organization, we are responsible to investigate errors to be sure that the systems and processes we have in place are the correct ones. We are also responsible to be sure everyone understands that there are different types of errors. These include:

Error:1. An unintended act, either of omission or commission, or an act that does not achieve its intended outcome.

Sentinel Event:2. An event that has resulted in unanticipated death or major perma-nent loss of function not related to the natural course of the patient’s illness or un-derlying condition. (Suicide, Infant Abduction, Rape, Surgery on wrong patient or wrong body part, health acquired infection, etc.) A Sentinel Event must be immedi-ately reported to your Director or Supervisor.

Refer to your hospital policy on Sentinel Events for the appropriate procedures to follow.

Near Miss:3. An event which did not affect the outcome, but if it occurred again might carry a significant chance of a serious adverse outcome.

An Event Reporting Form or an Incident Report is used whenever an adverse event occurs, as a risk management tool to assist:

Reporting occurrences like falls, malfunctioning equipment, or delays in treatment/•surgery

Identifying policies and procedures that are not being followed.•

Identifying sentinel events or near miss events: any unexpected adverse outcome•

Security concerns like lost/stolen items or suspicious behavior•

Complaints by staff, patients/families, or physicians•

When ever an event occurs that results, or could have resulted in, injury to a patient •or visitor.


The purpose of an Event Reporting Form (ERF) or an Incident Report (IR), is to provide early notification that an event has taken place allowing early investigation/action to be taken.

All incidents, particularly clinical errors, need to be reported within 48 hours. Events result-ing in patient injury need to be reported as soon as possible.

The computerized Confidential Incident Report form for Mediscan (Mediscan and QVH) can be accessed in the Meditech system. Instructions for completing a report are in the MOX Library.

The Event Reporting Form (ERF) for Mediscan is available from Nursing Administration, Department Directors, or the Risk Manager.

When completing an ERF or IR, there are certain guidelines, which should be followed:

Provide all information requested.1.

Document completely and objectively; 2. state only the facts.

Document any patient or visitor injury.3.

Do not speculate4. or assign blame.

Do not make copies5. of the report.

Do not mention the ERF or IR in the Patient Record6. .

Give the completed report to your Director or Supervisor, who will review it and then 7. report to the Risk Management Department.


Any employee having first hand knowledge of an incident or actual patient injury is •responsible for completing an ERF/IR.

In order to keep the report confidential and protect it from discovery in the event of •litigation, the report may not be shared with other employees, other than your Direc-tor or Supervisor.

It may not be copied under any circumstances; nor can it be placed in the medical •record.

Incident reports are internal, confidential documents for the hospital’s use only and •are protected under the attorney-client privilege.

Incidents in which a medical device may have caused or contributed to the death or •serious injury or illness of a patient or staff member must be reported to the manu-facturer or Food and Drug Administration under the Safe Medical Device Act. It is important to note in the report the equipment serial number and/or hospital property tag number with an explanation of how equipment functioned.

Individual mistakes that are reported via an ERF/IR will be handled without threat of •punitive action. The focus is on systems, not individuals.

Patient safety issues may be reported anonymously through:

Mediscan Safety Hotline x 12303

OR

Mediscan Physician Hotline x 22799


SECTION XV

ABUSE & EXPLOITATION REPORTING


After reading this section on Abuse &Exploitation Reporting, the learner will be able to:

Verbalize the legal obligation healthcare workers have to report any suspected or 1. actual child abuse or neglect, domestic abuse, or elder and dependant adult abuse or neglect.

Identify potential or actual signs or symptoms of abuse.2.

State the procedure to report suspicions to appropriate agency.3.


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SECTION XVI

PATIENT RIGHTS


After reading this section on Patient Rights, the learner will be able to:

List three patient rights.1.

Explain how patients are advised of their rights.2.

Describe behavior expected of patients, their relatives and friends.3.


SECTION XVI: PATIENT RIGHTS

Patient Rights

Patients have the same basic human rights as all other individuals. These basic rights are guar-anteed in the Constitution and in both state and federal laws. A number of state and federal laws have established particular patients’ rights. These include the right to considerate care, the right to privacy, the right to accept or decline medical treatment, the right to appoint another person to make health care decisions if the patient is unable to make these decisions and the right to register a complaint about the care received. Respecting these rights while providing care and services will contribute to more effective patient care and greater satisfac-tion for the patient and the health care team. Considerate, safe and respectful care is provided without discrimination and regardless of the ability to pay. Family members and/or signifi-cant other will be included in the patient’s care, with the consent of the patient.

Both state and federal law and the Joint Commission require that hospitals provide patients with information about their rights. A list of these rights is posted in Registration areas, in the hospital lobby and on individual nursing units. Patients are also given a copy of their rights at the time of admission.

Patients will be encouraged to ask questions about any aspect of their care that they do not understand.

A complete list of patients’ rights is attached.


PATIENT RIGHTS

Considerate and respectful care, and to be made comfortable. You have the right to respect for your 1. personal values and beliefs.

Have a family member (or other representative of your choosing) and your own physician notified 2. promptly of your admission to the hospital.

Know the name of the physician who has primary responsibility for coordinating your care and the 3. names and professional relationships of other physicians and non-physicians who will see you.

Receive information about your health status, course of treatment, prospects for recovery and out-4. comes of care (including unanticipated outcomes) in terms you can understand You have the right to participate in the development and implementation of your plan of care. You have the right to participate in ethical questions that arise in the course of your care, including issues of conflict resolu-tion, withholding resuscitative services, and forgoing or withdrawing life-sustaining treatment.

Make decisions regarding medical care, and receive as much information about any proposed treat-5. ment or procedure as you may need in order to give informed consent or to refuse a course of treat-ment. Except in emergencies, this information shall include a description of the procedure or treat-ment, the medically significant risks involved, alternate courses of treatment or non-treatment and the risks involved, and the name of the person who will carry out the procedure or treatment.

Request or refuse treatment, to the extent permitted by law. However, you do not have the right to 6. demand inappropriate or medically unnecessary treatment or services. You have the right to leave the hospital even against the advice of physicians, to the extent permitted by law.

Be advised if the hospital/personal physician proposes to engage in or perform human experimen-7. tation affecting your care or treatment. You have the right to refuse to paticipate in such research projects.

Reasonable responses to any reasonable requests made for service.8.

Appropriate assessment and management of your pain, information about pain, pain relief measures 9. and to participate in pain management decisions. You may request or reject the use of any or all modalities to relieve pain, including opiate medication, if you suffer from sever chronic intractable pain. The doctor may refuse to prescribe the opiate medication, but if so, must inform you that there are physicians who specialize in the treatment of severe chronic intractable pain with methods that include the use of opiates.

Formulate advance directives. This includes designating a decision maker if you become incapable of 10. understanding a proposed treatment or become unable to communicate your wishes regarding care. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patients’ rights apply to the person who has legal responsibility to make decisions regarding medi-cal care on your behalf.


Have personal privacy respected. Case discussion, consultation, examination and treatment are confi-11. dential and should be conducted discreetly. You have the right to be told the reason for the presence of any individual. You have the right to have visitors leave prior to an examination and when treat-ment issues are being discussed. Privacy curtains will be used in semi-private rooms.

Confidential treatment of all communications and records pertaining to your care and stay in the 12. hospital. You will receive a separate “Notice of Privacy Practices” that explains your privacy rights in detail and how we may use and disclose your protected health information.

Receive care in a safe setting, free from verbal or physical abuse or harassment. You have the right to 13. access protective services including notifying government agencies of neglect or abuse.

Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or 14. retaliation by staff.

Reasonable continuity of care and to know in advance the time and location of appointments as well as the 15. identity of the persons providing the care.

Be informed by the physician, or a delegate of the physician, of continuing health care requirements fol-16. lowing discharge from the hospital. Upon your request, a friend or family member may be provided this information also.

Know which hospital rules and policies apply to your conduct while a patient.17.

Designate visitors of your choosing, if you have decision-making capacity, whether or not the visitor 18. is related by blood or marriage, unless:

No visitors are allowed.•

The facility reasonably determines that the presence of a particular visitor would endanger the health •or safety of a patient, a member of the health facility staff or other visitor to the health facility, or would significantly disrupt the operations of the facility.

You have told the health facility staff that you no longer want a particular person to visit. However, •a health facility may establish reasonable restrictions upon visitation, including restrictions upon the hours of visitation and number of visitors.

Have your wishes considered, if you lack decision-making capacity, for the purposes of determining 19. who may visit. The method of that consideration will be disclosed in the hospital policy on visitation. At a minimum, the hospital shall include any persons living in your household.

Examine and receive an explanation of the hospital’s bill regardless of the source of payment.20.

Exercise these rights without regard to sex, economic status, educational background, race, color, reli-21. gion, ancestry, national origin, sexual orientation or marital status or the source of payment for care.

File a grievance.22.

You may also file a complaint with the state Department of Health Services regardless of whether 23. you use the hospital’s grievance process. The Department of Health Services’ phone number is 323/869-8500 and address is 5555 Ferguson Drive, Suite 320, Commerce, CA 90022.

These Patient Rights combine Title 22 and other California laws,Joint Commission and Medicare Conditions of Participation Requirements.


SECTION XVII

IMPAIRED PHYSICIANS & LICENSED INDEPENDENT PRACTITIONERS (LIP)


After reading this section on Impaired Physicians and Licensed Independent Practitioners (LIP), the learner will be able to:

Explain what risks physicians and licensed independent practitioners may develop as 1. they provide oversight of quality of care, treatment and services.

Recognize behaviors that suggest impairment.2.

Verbalize how to report observations of actual/potential impairment.3.


SECTION XVII: Impaired Physicians and Licensed Independent Practitio-ners (LIPs)

The physicians (MDs) and licensed independent practitioners (LIPs, such as Physician As-sistants and Nurse Practitioners) have a critical role in the process of providing oversight of quality of care, treatment, and services. But like the general population, they are also at risk of developing conditions that may hamper their ability to provide quality and safe care to ourpatients. As staff members, it is our responsibility to recognize behavior that suggests impair-ment AND report our observations to our IMMEDIATE SUPERVISORS.

IMMEDIATE SUPERVISORS.The American Medical Association defines an impaired physician as: A physician who is “unable to practice medicine with reasonable skill and safety to patients because of physical or mental illness, including deterioration through the aging process or loss of motor skill, or excessive use or abuse of drugs, including alcohol.“

In the hospital, a physician may display abnormal behavior during rounds or give inappropri-ate orders. His/her charting may deteriorate or show a handwriting change. The physician may be unavailable to the emergency room or on call. Staff may allege inappropriate behavior by the physician, and patient complaints may result.


The following changes in personal behavior may be observed:

Deterioration in personal hygiene, clothing, and dressing habitsA.

Multiple physical signs and complaintsB.

AccidentsC.

Disheveled personal appearanceD.

Poor eating and sleeping habitsE.

Inappropriate behaviorF.

Prescriptions for self and familyG.

Self medicating to change moodH.

IsolationI.

The following emotional symptoms may be observed:DepressionA.

Mood swingsB.

Poor concentrationC.

ConfusionD.

Sleep disturbanceE.

Anxiety/agitationF.

Medical Staff and Administration handle any such reports confidentially and with tact and diplomacy. Report your observations to your immediate supervisor ONLY! Do not discuss with anyone else, in order to maintain their privacy. It is not betraying trust, but acting re-sponsibly to contain and prevent the problem of impairment. You are saving a career, andpossibly a life, not ending it.


SECTION XVIII

BODY MECHANICS


After reading this section on Body Mechanics, the learner will be able to:

Identify techniques to avoid back strain and injury.1.

Explain proper lifting, sitting and standing techniques.2.

Discuss correct sleeping posture.3.

List ways to be effective in assisting patients.4.


SECTION XVIII: BODY MECHANICS

Health care workers perform a variety of movements during the course of the day. If com-pleted with the proper body alignment and movement, your work will be easier and you will reduce the chance of injury to your patient and yourself.

Eight out of ten Americans will injure their back severely enough to need some type of medi-cal attention. Therefore, it is extremely important to understand and perform proper body mechanics.

GOOD BODY ALIGNMENT

The center of gravity in the human body is the lumbar or low back region. This can put a great amount of strain on the low back and increase the risk for injury. The lower back has a built-in protection against excessive strain on muscles, ligaments and discs. This protection is the natural inward curve of the spine. This curve helps distribute body weight and excessive forces more effectively to decrease potential for injury. The normal posture of your back al-lows for a small arch in the low back. Maintaining the normal inward curve of the low back during all activities is the number one principle behind proper body mechanics and avoid-ing back injury.

Another very important concept to remember is that back injury occurs as an accumulation process, not just with a one-time movement. Every time an incorrect movement is per-formed, this adds to the potential for injury. The more often we use proper body mechanics, the more likely we are to have healthy, pain free backs.


GUIDELINES FOR BODY MECHANICS

Healthcare jobs require physical activity. To eliminate unnecessary strain, the following gen-eral guidelines should be observed.

I. Maintain alignment and balanceStart from a good base of support with feet apart and one foot in front of the other to •provide stability.

Avoid twisting your back by keeping your feet pointed in the direction you are mov-•ing. The worst position for your back is bending forward and twisting.

Prevent straining the muscles of the back by maintaining your inward curve and keep-•ing your trunk in good alignment.

II. Work at a comfortable heightThe most comfortable height for most people is between waist level and the level •about 6 inches below the hip joint.

Working at too low of a level causes strain on the muscles and produces fatigue.•

Working at too high of a surface adds to the demands on the arms and shoulders.•

III. Keep the work close to your bodyReduce strain and fatigue by working close enough to your body to avoid stretching •and reaching.

Carry objects close to your center of gravity.•

IV. Use smooth, coordinated movements. Smooth, coordinated movements can help you avoid discomfort, pain or injury to the body.


POSTURE GUIDELINES

CERVICAL POSTURE

Bring your shoulders down and back.•

Tuck in your chin.•

Imagine a string at the crown of your head pulling you up into good alignment.•

While sitting at a computer monitor, the monitor should be at eye level directly in •front of you.

Do not use your shoulder to hold the telephone in place. Use a wedge or cradle to •protect your neck from injury.

STANDING POSTURE

Keep your head, shoulders and feet in correct alignment. Keeping them in a straight •line will help balance the segments of the body so that a single portion of the body does not bear more weight or stress than necessary.

Protect your low back by tightening your stomach muscles and your buttocks.•

Keep the knees slightly bent to create a shock absorber effect.•

Stand with equal weight on both feet, or place one foot forward on a step or stool •(change feet placement every 15 minutes).

Work close to the counter.•

Do not lean over the counter/work area. Raise the counter if possible, or lower your-•self by bending your knees or by sitting down.

If the counter or shelf is too high, use a stool.•


SITTING POSTURE

See SECTION VII Workstation Ergonomics•

LIFTING

Stand close to the object with feet apart and one foot slightly in front of the other.•

Bend at the knees, not at the waist, so that the inward curve of the back is main-•tained.

Lift using your strong leg muscles.•

Carry the object close to your waist.•

If the object is too heavy, get help. Attempting to lift it alone is very likely to cause •injury.

Although it is more likely to have a back injury lifting very heavy objects incorrectly, •it is very possible to injure your back lifting something light.

REACHING, PUSHING & PULLING

When reaching for an object above your head, avoid standing on tiptoes as this may •cause loss of balance.

Always use a footstool and try to keep feet slightly apart, with one foot in front of the •other.

Lower the object with smooth coordinated movements.•

When faced with the option of pushing or pulling an object, always choose pushing. •This will allow you to maintain the normal inward curve of your back.

Slightly bend your knees and allow the legs to do most of the work, rather than the •back.


SIT TO STAND/STAND TO SIT POSTURE

Slide your buttocks to the edge of the chair. Keep your back in good al ignment and •your abdominal muscles tight. Shift your weight forward by bending at the hips (do not curl your trunk forward).

Use your arms and legs to lift your body up to standing. Reverse the process when go-•ing from standing to sitting.

MOVING FROM LYING DOWN TO SITTING POSITION

Move close to the edge of the bed.•

Use log rolling techniques to get onto your side.•

Keep your hips and knees bent, dropping your legs off to the side.•

Use your arms to push yourself up to the sitting position.•

Reverse the process when going from sitting to lying down.•

SLEEPING POSTURE

Back lying:Use a small pillow under your head to keep head in good alignment.•

Bend your knees; use a pillow under your knees for support.•

Side lying:Use a pillow to support your head in good alignment.•

Keep hips and shoulders in alignment.•

Hips and knees should be bent with a pillow between your knees.•

Stomach lying:This position is not recommended for sleeping due to the fact that it puts a great deal of stress on your neck, if this position is utilized:

Place a pillow under your lower abdomen/hips.•

Use a small pillow under your head and one under your shins.•


TRANSFERRING PATIENTS

When possible, advise the patient how they can assist with the transfer. Give the patient •specific directions.

Prepare for the transfer by making sure all lines attached to the patient are free and will •come along with the patient.

Do not allow the patient to grab onto you. They should push up from where they are sit-•ting.

While performing transfers, bend your knees and move at least one foot in the direction you •are going to avoid twisting.

Try to transfer the patient toward their strong side.•

Do not be afraid to get help.•

If another staff member is assisting you with the movements, plan how you will execute the •task.

Check to make sure the bed or wheelchair is locked or stable.•

Remember the job you may be able to do early in your shift you may not be able to do later when you are fatigued.


SECTION XIX

INFECTION CONTROL


After reading this section on Infection Control, the learner will be able to:

Recognize that Standard Precautions are to be used for all patients, regardless of diag-1. nosis or presumed infection status.

List the major modes of transmission of healthcare associated infections.2.

Describe the Exposure Control Plan.3.

List the signs and symptoms of active tuberculosis and the mode of transmission.4.

State the staff member’s responsibility following a body substance exposure.5.


SECTION XIX: INFECTION CONTROL

STANDARD PRECAUTIONS REVIEW

Standard PrecautionsStandard Precautions is to be used for all patient care regardless of the patient’s diagnosis or presumed infection status. Standard Precautions apply to:

Blood1.

All body fluids, secretions and excretions (regardless of whether or not they contain 2. visible blood)

Non-intact skin3.

Mucous membranes4.

Standard Precautions Components

Private Room: A private room is not necessary.

Hand Hygiene: When hands are visibly dirty or soiled with blood or body substanc-es, wash hands with soap and water. If hands are not visibly dirty or soiled with blood or body substances, a waterless alcohol-based hand cleaner may be used. When using an alcohol-based hand cleaner/rub, i.e. Prevacare, please allow the alcohol cleaner/rub to ad-equately dry before contact with a potential source of electrostatic discharge or potential burns to the hands can occur.

Gloves: Disposable gloves must be worn when touching blood, body fluids, secretions, excretions, mucous membranes, non-intact skin and other contaminated items.

Gowns: Disposable gowns must be worn when performing procedures and patient-care activities which are likely to soil clothing through the generations of splashes or sprays of blood or body fluids.

Masks, Goggles,Face Shields:

A disposable surgical mask and goggles or a face shield must be worn when performing procedures and patient-care activities, which are likely to generate splashes or sprays of blood or body fluids.

Remember:No artificial nails

for direct care givers!


TRANSMISSION PRECAUTIONS

Transmission- Based PrecautionsTransmission-Based Precautions are used for specific patients and are used in addition to Standard Precautions. Transmission-Based Precautions are used for patients documented or suspected to be infected or colonized with highly transmissible or epidemiologically impor-tant pathogens that can be transmitted by airborne or droplet transmission or by contact with skin or contaminated surfaces.

Airborne Isolation PrecautionsIn addition to Standard Precautions, Airborne Precautions are used for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include:

Tuberculosis (use N95 Mask)•

Measles•

Chicken Pox (including disseminated herpes zoster)•

Small Pox (use N95 Mask)•

Airborne Isolation Precaution Components

Private Room: A private negative pressure room is required Keep the room door closed and the patient in the room.

Signage: Place an ‘’Airborne Precautions” sign on the door.

Hand Hygiene: When hands are visibly dirty or soiled with blood or body substances, wash hands with soap and water. If hands are not visibly dirty or soiled with blood or body substances, a waterless alcohol-based hand cleaner may be used.

Gloves: Disposable gloves must be worn when touching blood, body fluids, secre-tions, excretions, mucous membranes, non-intact skin and other contami-nated items.

Gowns: Disposable gowns must be worn when performing procedures and pa-tient-care activities which are likely to soil clothing through the genera-tions of splashes or sprays of blood or body fluids.


A disposable high efficiency particulate filter (HEPA) N95 respirator mask must be worn when entering the patient’s room.


A HEPA N95 respirator mask and goggles or a face shield must be worn when perform-ing procedures and patient-care activities, which are likely to generate splashes or spraysof blood or body fluids.

Contact Isolation PrecautionsIn addition to Standard Precautions, Contact Precautions are used for patients known or sus-pected to be infected or colonized with epidemiologically important microorganisms that can be easily transmitted by direct contact or by contact with items in the patient’s environment.Examples of such illnesses include but are not limited to:

Multiply Drug Resistant Organism (MDRO)•

MRSA (Methicillin Resistant Stapholococcus Aureus)•

VRE (Vancomycin Resistant Enterococcus)•

Other multiply resistant organisms•

Herpes Zoster (localized)•

Lice•

Scabies•

Impetigo•

Major (non-contained) abscesses, cellulitis or pressure ulcers•

Clostridium Difficile with clinical symptoms, e.g. diarrhea•

Respiratory Syncytial Virus (RSV)•

Contact Precautions Components


Signage: Place a “Contact Precautions” sign on the door.

Hand Hygiene: When hands are visibly dirty or soiled with blood or body substances, wash hands with soap and water. If hands are not visibly dirty or soiled with blood or body substances, a waterless alcohol-based hand cleaner may be used



Droplet Isolation PrecautionsIn addition to Standard Precautions, Droplet Precautions are used for patients known or suspected to be infected with epidemiologically important pathogens that can be transmitted by large particle droplets.

(Large particle droplets do not remain suspended in air and generally travel only short dis-tances, usually 3 feet or less). Examples of such illnesses include but are not limited to:

Invasive Neisseria Meningtidis (meningococcemia, meningitis)•

Diphtheria (pharyngeal)•

Influenza•

Mumps•

Pertussis•

Rubella•

Respiratory Syncytial Virus (RSV)•

Droplet Precautions Components

Hand Hygiene: Disposable gowns must be worn whenever entering the patient’s room. Soiled gowns must be removed as soon as possible. Hands must be washed immediately after removing gowns to avoid the transfer of microorgan-isms between patients. After gown removal, ensure that your clothing does not contact potentially contaminated environmental surfaces in the patient’s room.

Gloves: A disposable surgical mask and goggles or a face shield must be worn when performing procedures and patient-care activities, which are likely to generate splashes or sprays of blood or body fluids.


Signage: Place a “Droplet Precautions” sign on the door.

Hand Hygiene: When hands are visibly dirty or soiled with blood or body substances, wash hands with soap and water. If hands are not visibly dirty or soiled with blood or body substances, a waterless alcohol-based hand cleaner may be used


EXPOSURE CONTROL PLAN

It is policy to provide a safe and healthy work environment for all staff members. The Expo-sure Control Plan has been implemented to meet the OSHA regulations on prevention of occupational tuberculosis and bloodborne pathogens.

The Exposure Control Plan is located in the Meditech MOX Library; hard copies are main-tained in the General Hospital Operations Manual and the Infection Control Office.

TuberculosisTuberculosis (TB) is a disease that is spread from person to person through the air (airborne). TB usually affects the lungs. The germs are put into the air when a person with TB of the lung coughs, sneezes, laughs or sings. TB can also affect other parts of the body, such as the brain, the kidneys or the spine.

Signs and Symptoms of active TB diseaseA productive cough lasting more than 3 weeks•

Fever/night sweats•

Loss of appetite/weight loss•

Hemoptysis (bloody sputum)•

Fatigue/Malaise•


Gowns: Disposable gowns must be worn when performing procedures and pa-tient-care activities which are likely to soil clothing through the genera-tions of splashes or sprays of blood or body fluids.


A disposable surgical mask and goggles or a face shield must be worn when performing procedures and patient-care activities, which are likely to generate splashes or sprays of blood or body fluids.


Precautions for Patients with Suspected or Confirmed TBA patient with suspected or confirmed TB is placed in a negative air pressure room.•

An ‘’Airborne Precautions” sign is placed on the door.•

Staff must wear an N95particulate respirator mask when entering the room and car-•ing for patients with suspect or confirmed TB.

Staff members will undergo TB screening/evaluation at time of hire, annually and fol-•lowing exposure to patients with TB who were not in airborne precautions.

Staff members must be fit tested upon hire, annually and if there are significant facial •changes (e.g. significant weight loss organ, dental surgery) or addition of facial hair (beard, mustache, etc.).

Bloodborne PathogensStandard Precautions (which includes Body Substance Isolation/Universal Precautions and Transmission-Based Precautions) will be followed by all employees in the performance of all departmental and patient care activities to prevent contact with blood or other potentially infectious materials (OPIM).

All human blood and body substances are handled as if they are infectious for Hepatitis B (HBV), Hepatitis C(HCV), and HIV. These are the three most serious viral risks to health care workers.

The Exposure Control Plan includes engineering and work practice controls such as provid-ing safety needles and devices with sharp injury protection to staff members, information on personal protective equipment, handling contaminated sharps, waste and also on the Hepati-tis B vaccination program.

A Sharps Injury Log is maintained by the Employee Health Department on all sharps inju-ries as well as the OSHA 300 log for all injuries.

BODY SUBSTANCE EXPOSURE POLICY/PROCEDURE

The Body Substance Exposure policy provides a system for reporting exposures in order to quickly evaluate the risk of infection from exposure, counsel the staff member about recom-mendations for treatment to prevent infection and monitor side effects of treatment. This may involve testing the staff member’s blood and that of the source patient.

The Body Substance Exposure Policy is a dual policy with Employee Healthand Infection Control.


Definition

Exposure is defined as any percutaneous, mucous membrane or non-intact skin contact with blood or body fluids or a patient. Contact may be direct or indirect, i.e., human bite, splash, or injury with contaminated sharp, etc.

Prevention

Many sharps injuries can be prevented by using medical devices with safety features designed to prevent injuries, by using safer techniques (e.g., not recapping needles by hand) and by disposing of used needles in appropriate sharps disposal containers. Many sharps injuries oc-cur due to carelessness or haste on the staff member’s part. Attention to proper handling anddisposal of sharps will prevent most sharps injuries. Staff not trained in handling medical sharps, should not touch these, but notify the closest nursing personnel.

Using appropriate barriers (e.g. gloves, gowns, eye and face protection) when contact with blood is expected can prevent many exposures to the eyes, nose, mouth or skin. It only takes seconds to put personal protective equipment on in an emergency.

All staff members at risk for occupational exposure to bloodborne pathogens are encouraged to receive the Hepatitis B vaccine. The Hepatitis B vaccine is extremely safe and effective in preventing Hepatitis B. Information regarding the Hepatitis B vaccine may be obtained from the Employee Health Nurse.

Currently, there is no vaccine or post exposure prophylaxis available for Hepatitis C. Stud-ies are being conducted in patients receiving a combination of Ribavirin and Interferon that have demonstrated some reduction in the virus, however, both of these medications have significant side effects that require careful monitoring. Prevention remains the most effective method for decreasing the risk of transmission of Hepatitis C.


ResponsibilityIt is the responsibility of the staff member to report and document all exposures immediately to their Director/Supervisor or the Nursing Supervisor, and the Employee Health Nurse or Employee Health Department. If post exposure prophylaxis is indicated, therapy is best initi-ated with hours, rather than days (CDC Guidelines).

Procedure Following an Exposure:Care of Exposed Skin 1. Percutaneous/Skin Wash puncture wounds/cuts with soap and water Mucous Membranes Flush oral and nasal membranes with water Irrigate eyes with clean water, saline or appropriate sterile irrigants

Take Rapid Action 2. Notify Director/Supervisor and report to Employee Health Nurse or Employee Health Department for appropriate evaluation and treatment during office hours, Monday through Friday. After office hours, the staff member must notify the Nursing Supervisor and report to the Emergency Department (ED). The ED physician will be responsible for em-ployee evaluation and treatment. The employee will be referred back to the Employee Health Nurse or Employee Health Department for continuing care when office hours resume. (The ED physician may refer the staff member to the Infectious Disease phy-sician on call).

Complete appropriate forms (e.g. Injury/Illness Report, Sharps Injury Report, etc.)3.

It is the responsibility of the staff member to use the safety needles and devices that 4. are provided to prevent exposure to bloodborne pathogens.


SECTION XX

ELECTRICAL & EQUIPMENT SAFETY


After reading this section on Electrical &Equipment Safety, the learner will be able to:

List general rules to maintain electrical safety.1.

Name common electrical hazards.2.

Explain what happens when you are shocked.3.

Discuss how to rescue a shock victim.4.

Explain how to report equipment malfunctions.5.


SECTION XX: ELECTRICAL & EQUIPMENT SAFETY

ELECTRICAL SAFETY

A safety ground path is provided within the hospital electrical wall outlet circuits. This is to safely conduct stray electrical current to earth/ground, so they do not go through your body and cause a harmful or potentially fatal electrical shock.

The general rules to maintain safety are:All electrical plugs must be three prongs and have an intact ground pin. Exceptions: •Equipment certified as being “double insulated” or equipment that will only be used in office areas and will not come into contact with patients.

All medical equipment must have specially approved • hospital grade plugs on their power cords.

Fused multi-outlet plug strips cannot be used to provide power to additional fused •multi-outlet plug strips.

Generally, all electrical appliances are required to be Underwriter Laboratory (UL) •listed and approved for individual service, safe device usage.

Home and personal care electrical devices are not to be used in patient care areas. •Exceptions must be approved by Nursing Administration and may correspond to a doctor’s directive.

Home medical devices, even if prescribed by a doctor, must meet hospital electrical •safety requirements.

All electrical items must undergo an electrical safety check done by “BioMed” or the •engineering department prior to use.


EMERGENCY POWEREmergency Power is the supply of emergency electrical power generated by the hospital. If for any reason, power company is not able to supply electricity to the hospitals, electrical power will be provided by the hospital emergency generator. The generator will come on line im-mediately after the loss of normal power. California Title Code 22 requires that you have a hospital grade flashlight quickly at hand.

In some hospitals • only the red emergency power outlets are supported by the emer-gency generators. Life support equipment should always be plugged into the red emergency power outlets.

In most hospitals all outlets are supported by the hospital emergency generators. This •eliminates the need for designated emergency outlets.

EXTENSION CORDSExtension cords can be an electrical hazard as well as a trip hazard due to their exces-•sive length, tendency to curl while on the floor, potential presence of frayed insula-tion, exposed wires, etc.

Electrical extension cords are not allowed in the hospital.•

EQUIPMENT POWER CORDSThe following applies to electrical cord handling and wear conditions:

Replace any cord when the insulation is cracked or torn, when there are exposed •wires, when an electrical spark occurs, or there is evidence that an electrical spark has occurred.


Replace any cord or plug that appears damaged, is missing the ground prong, or heats •up when used.

Keep cords away from heat and water. Do not run them under rugs or through door-•ways, windows or hole in walls.

To remove a plug from an outlet, grasp the plug and pull. DO NOT hold the power •cord and pull/yank the power cord to unplug the unit.

Never break off or bend the third prong on a grounded plug.•

Plugging too many cords into one outlet can overload the circuit. Multi-outlet adapt-•ers are not allowed in the hospital.

Never attach device cords to floor, wall or other object with metal tacks or pins.•

COMMON ELECTRICAL HAZARDSPower cords with frayed or exposed wires•

Broken or cracked plugs•

Plugs with missing or damaged grounding pins•

Three or to two-wire adapters•

Too many plugs in one power outlet•

Faulty lamp sockets•

Burned out indicator lights or liquid spilled on equipment•

Using damaged or dropped equipment•

Any equipment that gives a shock, becomes overheated to smell or touch•

ELECTRICAL SHOCKAn electrical shock is the flow of electrical current through your body, onward to earth ground. Usually, this passing of electricity through your body occurs from touching a “hot” electrical source, perhaps inbound to your hand, and then outbound through your feet-shoe (damp) soles to ground.

The shock may cause you to be thrown back from the electrical energy source, which •in turn may limit the severity of the shock to your body. This is caused by human muscle reaction and body response.


The electrical current may cause your hand muscles to contract and clench the electri-•cal contact point tightly, keeping you from letting go. This is a very dangerous situation even at low voltages.

Leather shoe soles are especially dangerous when wet and are therefore more condu-•cive to electrical current than rubber soles.

RESCUING A SHOCK VICTIM:To rescue someone who is getting an electrical shock and is unable to let go of the circuit, remember the following critical points:

Call a qualified person to shut off power at the main service panel.•

Don’t touch the victim or the source of the electrical shock.•

If you do so safely, disconnect the equipment by unplugging the plug or turning off •the wall switch.

If power cannot be shut off immediately, use a non-conductive item, such as a rope, •rolled sheet, wooden broom handle, chair, etc, to pull or push the victim free. Never use your bare hands to free a victim who is frozen by electric shock, otherwise you may also receive the same electrical shock and become a victim too!

When you have freed the victim from the power source, send for medical assistance.•

While waiting for help to arrive: • •tendtothevictim •checkforaregularpulse •makesurebreathingisregular •checkforbleedingandbrokenbones


REPORTING ELECTRICAL/EQUIPMENT HAZARDS/MALFUNCTIONSRemove equipment from service.•

Be sure to tell your supervisor and inform your department personnel as soon as pos-•sible.

Attach an “Out of Order” or “Defective Equipment” tag to the equipment, describe •the problem, add name of person reporting the problem and the date.

Send work order through Order Entry on the Meditech system to BioMed or Engi-•neering depending on the type of repair.

List the importance of the repair using.•

AT Mediscan USE THE FOLLOWING GUIDELINES

A - ASAP Repair to be completed as soon as possible. T - TODAY Repair to be completed within 24 hours. W- THIS WEEK Repair to be completed this week. N - NEXT WEEK Repair to be completed next week. M - THIS MONTH Repair to be completed this month.You must validate ASAP repair requests with a call to the EngineeringDepartment or have them paged Engineering extension is 33106.

Put a copy of the work order on equipment to alert co-workers.•

AT Mediscan USE THE FOLLOWING GUIDELINES

ROUTINE Repair to be completed within 3 days ASAP Repair to be completed within 24 hours STAT Repair to be completed immediately

You must validate the STAT repair requests with a call to the Engineering Department or have them paged.

Mediscan Campus Mediscan Campus Engineering Dept Engineering Dept. Extension 12323 Extension 22400

Put a copy of the work order on the equipment to alert co-workers.•


SECTION XXI

HAZARDOUS SUBSTANCES, BIO-HAZARDOUS MATERIALS, MEDICAL AND PHARMACEUTICAL WASTE


After reading this section on Hazardous Materials & Medical Waste Procedures, the learner will have a heightened sense of safety awareness and:

Discuss safety procedures on the proper handling and disposal of hazardous materials, 1. toxic substances, medical and pharmaceutical waste materials.

Explain the Hazard Communication Program (HCP) and disclosure related to em-2. ployee Right-To-Know information.

Be able to access the manufacturers’ MSDS using two methods of request.3.

Be able to read the MSDS and follow warning information. Use required protection, 4. report any spills or leaks immediately and initiate clean up procedures as necessary.

Locate nurse station work areas with color coded guideline information (wall-chart) 5. on handling and disposal of Pharmaceutical Medical Waste.


SECTION XXI: HAZARDOUS SUBSTANCES, BIO-HAZARDOUS MATERIALS, MEDICAL AND PHARMACEUTICAL WASTE

SYMBOLSHazardous materials (hazmat) have reminders identifying various classes of hazardous materi-als, hazardous conditions or recognizing materials that may be found in the workplace, com-munity or at home. These reminders are represented by some of these symbols.

Mediscan provides safety policies and procedures to assist staff with a level of knowledge and awareness toward the proper handling and disposal of hazardous materials, toxic substances, medical and pharmaceutical waste. Safety procedure familiarity is necessary to preserve your welfare and that of fellow employees to avoid conditions that may result in personal injury, harm to patients, visitors or the community.

Hazard Communications Program (HCP)Hazardous Materials safety awareness and procedures is dependant on supervisor and staff member vigilance. Mediscan has established a written Hazard Communications Program (HCP) This program defines:

The continued practice of workplace safety•

The process of disclosing information•

Awareness on the handling and disposal of hazardous material substances and medical •waste

Annual safety awareness training•

Personnel education providing safe workplace recommendations and practices.•


Mediscan Hazard Communication Program

The following written programs are available for review either in your department, Environ-ment of Care manual or in the Engineering Department.

Hazard Communication Program•

Hazardous Material and Waste Management Plan•

Hazardous Material and Medical Waste Management Program•

Pharmaceutical Waste Management (a Mediscan written program overseen by the •State Department of Health Services.)

You will find more detailed information on the Hazard Communication Program, by con-tacting your Department Supervisor Safety Officer or the Engineering Department.

Worker’s Right to Know

The Hazard Communication Standard also known as the Workers’ Right-To- Know Stan-dard contains written information about workplace hazards, hazardous chemical and mate-rial substances. The manufacturer’s product label and MSDS is a fast and easy way to obtain information about how to work safely with a specific product.

Material Safety Data Sheets (MSDS)Manufacturer’s Information Found on the MSDS1. Identification of Product You will find the product name; manufacturer’s

name; address; telephone and emergencycontact numbers.

2. Hazardous Ingredients Lists all the ingredients in the product.3. Physical Data Provides information on how to work with the

chemical and describes the physical characteristics.4. Fire and Explosion Hazard Data Specifies if the material may present a fire or ex-

plosive hazard, what hazard conditions exist.5. Health Hazard Data Identifies symptoms related to over exposure (nau-

sea, vomiting, and dizziness).6. Reactivity Data Describes what materials will react with the

chemical you are using (e.g. ammonia mixed with bleach).

7. Spill/Leak Priocedures Addresses how to respond to an accidental spill or leak.

8. Handling and Storage Precautions Describes how to safely store and handle materials.9. Control Measures Specifies the type of personal protective equipment

(PPE) to wear.


The MSDS is a source important of information where you may find the manufacturer’s printed disclosure on a variety of important chemical substance concerns, safe usage, and health hazards.

Working safely includes:Following common sense procedures•

Employing safe handling practices while abiding the safety guidelines on physical and •health hazards.

The M.S.D.S. can also obtained by telephoning the 3E Company at 1-800-451-8346 or 760-602-8703.

Give 3E the product name, manufacturer and your fax number. You will have to •know some exact particulars before calling 3E Company, after which they will re-spond by sending you a fax of MSDS document pages.

At Mediscan (Mediscan and Mediscan)Call Engineering or Nursing Administration to request a computer search of the MSDS hard copy from the Mediscan master MSDS library.

At Mediscan access the MSDS in the MSDS Manual located in each department.

PHYSICAL HAZARDSThe coverage of physical properties usually associated with specific industrial materials may include the following hazard information.

Flammable or combustible1. - substance that burns easily such as alcohol.Compressed gas2. - such as high pressure oxygen and nitrous oxide cylindersOrganic peroxide3. - derivative of hydrogen peroxide.Pyrophoric4. - ignites spontaneously in air under certain conditions. Unstable5. - reactive substance.Water reactive6. - such as strong acids and bases when mixed with water .Explosive7. - substance that can explode under certain conditions of release.

HEALTH HAZARDSCertain liquids and solids identified on an MSDS; hazardous chemical substances may be listed as chronic or acute health hazards and are categorized as:1. Carcinogens These cause cancer, reproductive toxicity in males or females, reproduc-

tive toxins can result in fetus damage.2. Toxic a substance that acts as a poison3. Irritants these may cause irritation to any body part4. Corrosives these can cause damage to body tissue5. Sensitize these can cause allergic reaction6. Hepatoxin this is a liver poison7. Nephrotoxin this is a kidney poison8. Neurotoxin this is a nerve poison


ACUTE AND CHRONIC EXPOSUREAn acute exposure - is a short-term exposure to a substance and can cause dermatitis, head-aches, or rashes.

A chronic exposure - is long-term exposure and can cause cancer or permanently damage a biological system.

ROUTES OF ENTRYThrough inhalation1. - painting, stripping floors, anesthesia gas waste.

Through absorption2. - handling formaldehyde and glutaraldehyde.

Through ingestion3. - this can occur if you handle poisonous chemicals and do not wash your hands before eating, smoking or applying cosmetics

Through injection4. - accidental needle sticks!!!

EXAMPLE: Gloves, leakage (porous membrane material), due to selecting an incorrect glove type for the job.

A Standard set up by the Office of Safety and HealthAdministration (OSHA) of federal and state origin addresses gloves as select wearing apparel and is on the list of Personal Protection Equipment as an item within a minimal protection category.Selection of proper protection apparel is indicated on a chart of PPE items tested and estab-lished suitable for guarding against a particular type of material handling hazard.

9. Hematopoietic System acts on the system resulting in blood poisoning10. Substance Compounds a damaging to lungs, skin, eyes or mucous membrane upon con

A hazardous substance is one, which causes physical or related health hazards, that may be found on published Lists issued by the State of California such as: “List of Regulated Sub-stances”, “Pesticide 200 Ingredients” and/or “The Safe Drinking Water and Toxic Enforce-ment Act of 1986” which is also popularly known as “Proposition 65”. These ‘lists’ provide identification of hazardous chemicals and are useful when searching labels in indicating of contents, ingredients, etc.


Hazardous Materials Awareness & Safety

TrainingEach staff member is to be trained at the New Staff General Orientation, at the time of initial assignment, through the Annual Update, and whenever a new chemical is introduced into the workplace. Training and hazard awareness is the responsibility of your Director.

Mediscan Responsibilities are:Have a written Hazard Communication Program.•

Provide awareness and safety training.•

Provide product safety information.•

Make a MSDS available for each manufactured chemical.•

Provide appropriate personal protective equipment (PPE).•

Staff Responsibilities are:Read the label and MSDS of new chemicals that you are working with.•

Follow warnings and safe practices, instructions.•

Use appropriate Personal Protective Equipment (PPE).•

Learn emergency procedures for the chemicals with which you work.•

Act in a sensible manner, be a safe and responsible worker.•

General Responsibility of Everyone:Never use hazardous material substances you’re not trained to use.•

Never place a chemical substance into an UNLABELED container.•

Never mix substances without asking your supervisor first.•

Always ask your supervisor if you have a question about any substance.•

Responsibility for Proper Container LabelsIf chemicals are dispensed into another container it is the responsibility of the user to label the new container as follows:

Chemical name: identity of hazardous ingredient(s).•

Cautions: appropriate hazard warnings, • physical and health, acute and chronic.

Name and address of manufacturer or other party.•


Hazardous Material or Waste SpillYou are to immediately inform your supervisor of a spill condition. Spill procedures are found in your department Environment of Care Manual (EOC).

At Mediscan refer to Code Orange or Code Chemo response guidelines.At Mediscan refer to the Fire and Emergency Preparedness manual under the De-contamination tab in your department EOC manual.

Code Orange/ Code Orange (Internal)Call a Code Orange (Mediscan) by dialing “6” or a Code Orange Internal (Mediscan) by dialing “600” and report the exact location if you find a hazardous spill or chemical leak and:

You are not trained to clean up the spill.•

You do not have the proper equipment (spill kit and personal protective equipment).•

You do not know the chemical or substance.•

You think the chemical is extremely hazardous (strong acid or base, reactive, flam-•mable explosive and/or toxic).

It is a • Major spill is more than 10 inches (25 cm) in diameter, smaller is considered Minor.

For minor spills follow department specific policies and procedures.•

California Recycling Of Spent Battery & Electronic WasteCalifornia and federal Environment Protection Agency (EPA) have laws governing the dis-posal of hazardous materials into landfills. Laws are on the books that promote proper recy-cling, disposal, labeling, and mercury battery phase out. It is unlawful to dispose heavy metal containing items into landfills. Heavy metals from rechargeable batteries have the potential to leach slowly into the soil, ground water, and surface water.

The EPA believes that some manufacturers of rechargeable batteries and rechargeable con-sumer products may not be complying with the Mercury-containing Rechargeable Battery Management Act, (“Battery Act”) while others may be unaware of the Act’s requirements.

The Battery Act’s importance is in protecting human health and the environment, and its requirements for the collection, disposal, recycling, labeling and easy removal of regulated batteries.


Mediscan complies with California State Department of Toxic Substances Control (DTSC) and other state agencies, in maintaining an ongoing compliance with universal waste, e-waste collection and mandates for the recycle of spent batteries and electronic devices. Fax and copier machine subassemblies, printers, fluorescent lamps and televisions may contain lead and regulated heavy metals. It is against the law to throw batteries in the trash since trash subsequently goes into a landfill. Batteries may contain a hazardous material which requires recycling. Periodic dry-cell battery collection is an ongoing hazardous materials waste collec-tion process, which responds to mandatory recycling of e-waste heavy metals. California and federal law prohibits heavy metals from being deposited into landfills.

Medical Waste - Bio Hazardous Waste

Definition: Medical Waste is waste containing fluid, blood, needles, syringes, blades, broken glass, laboratory specimen or microbiologic cultures, and isolated waste, as determined by Infection Control Department.

In California, Medical Waste includes Bio-hazardous Waste, Chemotherapeutic Waste and Pharmaceutical Waste; all are governed by guidelines issued by the State of CaliforniaDepartment of Health Service (DHS), Medical Waste Management Act.

The following are minimal guideline procedures for the handling, transportation, signage and legal disposal of Medical Waste.

Wear gloves and appropriate clothes/coverings as necessary.•

Place in red bags (except sharps).•

Sharps are disposed of in a specially designed sharps container.•

Pharmaceutical medical waste, bio-hazardous wastes, are segregated, handled, pro-•cessed and disposed of separately from hazardous waste. See the handling guide (wall chart) displayed within appropriate Nurse Station work areas.

Transporting of medical waste is performed by the Environmental Services•

Department (EVS) personnel. Anatomical parts are disposed of by contractor,•

Bio-Hazard waste is then transported to an off-site treatment facility for final disposal •by a commercial company.


Chemotherapeutic Waste

Definition: Any waste containing residual amounts of or contaminated with, anti-neoplastic (chemotherapeutic) drugs which are toxic. Trace amounts of chemotherapy waste also applies.

Processing:Waste is placed in a • yellow container that is covered and made of hard plastic marked, “Caution Chemotherapy Waste”

Waste is transported in a covered cart marked “• Bio-hazardous Waste” to a secured area by (EVS) personnel for post-disposal.

Chemotherapeutic waste is transported to an off-site treatment facility for final dis-•posal by a commercial company.

Licensure

Medical facilities generate medical, bio-hazardous waste and pharmaceuticals wastes, and must maintain licensure issued by the California State Department of Health Services (DHS) and hold both Permits and Licenses.

California Poison Control System

Dial: 1-800-876-4766 Public Access Number1-800-411-8080 Health Professionals Use 1-800-222-1222 National Poison Control Center

Pesticide Ingredients

In California there are regulations covering economic poisons, and that you be made aware of the existence of certain ingredients found in some cleaning products that are not normal to your suspicion and concern, these may contain a low-level not generally known content, (one well known cleaning product that contains a pesticide ingredient is Borax). Pesticide Safety Information Series (PSIS) is similar to the MSDS reviewed on previous pages, but for pesticides.

Pesticide Safety Information Series (PSIS)

The PSIS applies to training and hazardous material notification for Non-Agricultural Work-ers handling janitorial, sanitizing, disinfectant and cleaning supplies. Information for pesti-cide poisons is printed in what is designated as the Pesticide Safety Information Series (PSIS) information disclosure, sheet(s).


Economic Poisons

The State of California, Department of Agriculture, regulates economic poisons (or pesticides) that are used in the workplace.

These poisons are defined as chemicals that kill insects and bugs. A chemical pesticide •would be an economic poison.

Any area where economic poisons are used must train employees on the safe use, haz-•ards and safe handling of these chemicals within that department. Goggles and gloves will be located in any area where economic poisons are used.

Injury from Chemical Substances and Treatment:

If inhaled:Remove patient to fresh air.•

If breathing is a difficulty, go to the Emergency Department•

If substance comes in contact with skin:Immediately wash skin with soap and plenty of water for five minutes.•

Remove contaminated clothing and shoes.•

Go to the Emergency Department•

If ingested:Treatment is based on what the substance is.•

Mandatory, Go to the Emergency Department•

If substance comes in contact with eye(s):Immediately flush eye(s) with plenty of water for at least 15 minutes.•

Go to the Emergency Department•


SECTION XXII

PORTABLE OXYGEN SAFETY


After reading this section on Portable Oxygen Safety, the learner will be able to:

Explain the purpose of using the portable oxygen cylinders.1.

Describe the sequence for removal and replacement of the ‘E’ cylinder oxygen regula-2. tor.

Identify the proper methods of storing ‘E’ cylinders3.


SECTION XXII: PORTABLE OXYGEN SAFETY

Portable oxygen cylinders are designed for use in order to provide patients with a continuous source of oxygen during their course of treatment when it is necessary for them to be away from the main piped gases located in their room. (Diagnostic treatments, i.e. GI Lab, Radiol-ogy, etc.)

PORTABLE CYLINDERS

When transported or ambulating patients require a source of oxygen while away from their room, the oxygen is supplied to them from a small portable oxygen cylinder. At this facility we utilize the ‘E’ size cylinder to accomplish this.

These cylinders hold 24 cubic feet of compressed oxygen at a pressure of 2,100 pounds per square inch (PSI). With this high pressure being applied inside the cylinder it makes these cylinders a potential missile if they are mishandled/abused/mistreated. This is why the use of these cylinders must be taken very seriously.

Regulatorattaches here,to the cylinder


STORAGE OF THE CYLINDERS

Oxygen cylinders are secured in appropriate holders at all times.1.

“Tank banks” (metal racks) or chains attached to a wall are used for storage of multiple oxygen a. cylinders.Wheelchair holderb. Gurney holderc. Portable cart or stroller is used when ambulating patients.d.

No more than 12 full cylinders are to be stored in one compartment at anyone time.2.

NOTE: If oxygen cylinder is found standing upright, lay it down and find appropriate holder immediately.

USE OF THE REGULATORS AND CYLINDERS

It is important to be aware of the danger of fires at the interface of oxygen regulators and cylinder valves. The following are steps to be taken each and every time staff is handling these items.

The flow meter and supply to regulators are turned off when oxygen is not in use.1.

Regulators, tanks and flow meters are inspected for any damage prior to use. Look for leaks, 2. cracked seal, any visible signs of oil, grease, tapes/adhesives, petroleum jelly or paint. Use the new regulator gasket that comes with the oxygen cylinder.

Prior to use on a patient, the care giver must check to see if the oxygen cylinder is full or 3. empty by using the wrench (or key) to open the tank (For crash carts, gauge should be in the green zone). If the gauge is in the red zone, it should be marked empty.

Flow meter gauge


Each oxygen cylinder should be tagged with a card indicating “Full” or “Empty”, so quan-4. tity of oxygen remaining in it can be identified. User will tear off a perforated section as the oxygen is used.

When an empty oxygen tank is returned to the tank bank, the regulator will be removed 5. and placed on a full tank.

Cylinders and regulators will be handled with clean, non-oily hands, no fresh hand lotion 6. to prevent possible ignition.

TO ATTACH A REGULATOR

Use new regulator gasket (“Oil ring) that comes with the oxygen cylinder.1.

Slip regulator over stem and line up the pins.2.

Tighten the side handle screw.3.

Gauge dial must be on 0 (off).4.

To open valve, stand to right or left, NEVER in front, behind or right above cylinder.5.

Use wrench to open cylinder stem VERY SLOWLY counter clockwise. (One full turn is 6. enough).

Use the dial on the left to dial in the liter flow, from 1 to 15 liters per minute.7.


TO STOP USE

Turn the flow meter dial to 0.1.

Use the wrench to close the cylinder by turning the stem clockwise until it stops.2.

Bleed out the pressure from the gauge by briefly turning the flow meter to 3 or 4 3. liters, let the pressure leak out, then turn the flow meter back to 0.

TO REMOVE REGULATOR

Replace when cylinder is in the red zone.1.

Remove label so remaining tag reads “Empty.”2.

Follow the directions “To Stop Use” as stated above.3.

Loosen the side handle screw and lift the regulator up off of the cylinder stem.4.

Wrench or “key”


SECTION XXIII

NATIONAL PATIENT SAFETY GOALS


After reading this section on National Patient Safety Goals, the learner will be able to:

List the National Patient Safety Goals.1.

State two ways of meeting the National Patient Safety Goal requirements.2.


SECTION XXIII: NATIONAL PATIENT SAFETY GOALS

The Joint Commission has National Patient Safety Goals that are requirements for accredita-tion.

Goals have been updated for 2007 - 2008 and include the following:(Note - new goals for 2007 are indicated in bold).

C = Communication among caregivers

Read Back• : for verbal or telephone orders or for telephonic reporting of critical test results verify the complete order or test result by having the person receiving the order or test result “write it down and read back” the complete order or test result.

Do Not Use Abbreviations• : Standardize a list of abbreviations, acronyms and sym-bols that are not to be used throughout the organization.

Critical Test Results• : Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed care-giver, of critical test results and values.

Hand-Off Communication• : Implement standardized approaches to “handoff” pa-tient care information to other healthcare practitioners. Implementation expectations are as follows:

Interactive communication that allows the opportunity for questioning between A. the giver and receiver of patient information.

Include up-to-date information regarding the patient’s care, treatment and ser-B. vices, condition and recent changes.

Interruptions are limited to minimize the possibility that information would fall C. to be conveyed or would be forgotten.

Reminder: Do Not Use Abbreviations are:u, IU, QD, QOD, XOmg or ,Xmg, MS, MS04,MgS04, ug, TIW, AS, AD, AU, OS, OD,OU


H =Health Care-Acquired Infection (HAI) Reduction

Handwashing• : Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines (hand washing and use of hand sanitizers).

Deaths from HAI’s• : Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

A = Assess and Reassess and prevent falls/suicides

Fall Assessments• : Assess and periodically reassess each patient’s risk for falling, in-cluding the potential risk associated with the patient’s medication regimen and take action to address any identified risks.

Fall Reduction Program• : Implement a fall reduction program and evaluate the ef-fectiveness of the program. (This would include patient ID bands and care plans that help reduce falls and monitoring fall rates over time).

Fall PreventionRisk/fall assessment upon admission•

Patient/family education - frequent reminders to ask for help•

Plan of care initiated•

Signage indicating “High Risk for Fall” (sign on door)•

Bed in low position•

Call light in reach•

Move close to nursing station or in camera monitored bed•

Consider peak effect of medication that affect CNS, vital signs and toileting needs.•

Non-slip footwear when ambulating•

Night light on (evening and night shift)•

Elimination needs checked every 1-2 hours•

Commode at bedside if needed•

Wheelchair/gurney/bed locked before transfer•

Report slippery floors/wipe spills immediately•

Stay with patient if in danger of harming self•

Consider restraints when alternative measures are not effective•


Suicide Assessment• : Patients are assessed and reassessed for risk of suicide as indi-cated.

M= Medications

Standardize and Limit the Number of Drug Concentrations• : Drugs are stored and mixed only in the Pharmacy.

Look Alike/Sound Alike Drugs• : Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.

Label All Medications on a Sterile Field: All medications and medication con-•tainers (for example, syringes, medicine cups, basins) or other solutions must be labeled even if there is only one medication used. Also labels are required when transferring a medication or solution from an original container to another.

Labels must include:•

Drug NameA.

StrengthB.

AmountC.

Expiration date and timeD.

Reminder:The acronym “HIPPO” can help you remember the high-alert medications.H HeparinI InsulinP Potassium ChlorideP Phosphate ConcentratesO Opiates and NarcoticsAND Chemotherapy


P = Protocols, Universal

Pre-Operative Verification• : An ongoing process of information gathering and verifi-cation, beginning with the determination to do the procedure, continuing through all settings and interventions involved in the preoperative preparation of the patient, up to and including the “time out” just before the start of the procedure,

Marking the Operative Site• : For procedures involving right/left distinction, multiple structures (such as fingers and toes), or multiple levels (as in spinal procedures), the intended site must be marked such that the mark wI’ll be visible after the patient has been prepped and draped

Time Out• : Active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a “fail-safe” mode, that is, the procedure is not started untt’l any questions or concerns are resolved

I = ID - Accurate Patient Identification

Two Patient Identifiers• : Use at least two patient identifiers (neither to be the patient’s room number) whenever administering medications or blood products; taking blood samples, specimens for clinical testing, delivering meal trays or providing any other treatments or procedures.

Containers used for blood and other specimens are to be labeled in front of the patient

Label Reminder:•Patientname&•Dateofbirth


O = Obtain and Document Complete List of Medications

Reconciling Medications on Administration• : Obtain and Document a complete list of the patient’s current medications from home upon the patient’s admission to the organization, with the involvement of the patient. Medications on the list are com-pared to medications ordered

Reconciling Medications on Transfers and Discharge• : A complete list of the pa-tient’s medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization.

N = (I) N volve = Involve the patient in their own care and inform them of how to report concerns.


SECTION XXIV

MEDICATION SAFETY


After reading this section on Medication Safety, the learner will be able to:

Explain what a medication error is.1.

List common sources of medication errors.2.

Discuss how medication errors can be prevented.3.

Indicate how to report medication errors when they happen and route appropriately.4.


SECTION XXIV: MEDICATION SAFETY

WHAT ARE MEDICATION ERRORS?

Medication errors are mishaps involving medications that cause/ or could cause/ harm to a patient. They may be errors in prescribing/ dispensing/administering/ or monitoring and they include both errors that reach the patient as well as errors that do not reach the patient. They can occur in any patient care area or in the Pharmacy.

WHAT ARE COMMON SOURCES OF MEDICATION ERRORS?

Lack of knowledge about drugs: Many new drugs are being developed each year. It •has never been more important to understand what each drug can do and how to use it properly.

Lack of patient information: It is important to know key information about each •patient/ including his/her age/ weight/ sex/ clinical status/known drug allergies/ and current list of medications/ including herbs/ supplements/ vitamins/ other holistic remedies. This is considered to be the ‘’minimum information” needed before admin-istering medication.

Poor communication: Problems can result from things such as:•

Not using standardized abbreviations.•

Handwriting that is hard to read•

Verbal miscues (for example/ mispronouncing a drug’s name).•

Unclear decimal points.•

Poor verbal or telephone communication.•

Storage and stocking of drugs: For example/ the risk of someone picking up the •wrong drug is higher when two different drugs are similarly packaged

Equipment used to administer drugs: Variations in the design of IVs and infusion •pumps can cause confusion. Poor maintenance and not understanding how to pro-gram automated equipment also increases the risk of medication errors.

Patient identification: Failure to use two identifiers before administering any medica-•tions.

Failure to use 7 rights during medication administration.•

Distractions.’ Ringing telephones/ too much conversation/ and interruptions can •cause even the most careful healthcare worker to lose concentration.


HOW CAN MEDICATION ERRORS BE PREVENTED?

Most medication errors are not due to a careless individual act but are related more directly to some type of system failure or inefficiency.Medication errors can be prevented! Everyone in the organization must:

Work together across departments/ including physicians/pharmacists/ nurses/ support •staff and administrators.

Focus on systems and processes. This means improving procedures to help prevent •mistakes and following procedures that are in place to decrease errors.

Help patients understand their medications/ follow their treatment plans/ and take an •active role in their care at every step along the way.

Use benchmarks to compare challenges and successes of other health care organiza-•tions with our own.

Report errors voluntarily so that a root cause analysis can be done when necessary. •A Root cause analysis is a step-by-step method to understand what went wrong and why. It allows us to make improvements in a system and monitor changes to see how well they are working.

WHY DO MEDICATION ERRORS HAVE TO BE REPORTED?

Reporting medication errors is a crucial part of preventing future mistakes. We need to be able to identify where a system has failed so that we can work on changing and improving it. It is only in this way that the organization can effectively address the issue of medication er-rors. Reporting is not for the purpose of blaming individuals.


HOW DO WE REPORT MEDICATION ERRORS?

Any drug error that harms; or could harm; a patient should be reported as soon as possible. Timely reporting makes it easier to determine what went wrong because the event is still fresh in people’s minds.

Medication errors should be reported on a Medication Error Report and given to your •Director/Supervisor for review.

Medication errors should be reported through Meditech as a Report of Unusual Oc-•currence. A hard copy is then given to your Director/Supervisor for review.

These reports are then forwarded to Risk Management.•

Pharmacy uses this information to track and trend problems in order to identify areas that need improvement.

Remember: Medication error of all types can be reduced or eliminated While no one is per-fect; steps can be put in place to help everyone learn from past mistakes and improve patient safety.


SECTION XXV

ETHICAL ISSUES


After reading this section on Ethical Issues, the learner will be able to:

Recognize that sometimes patient beliefs and principles conflict with medical decision 1. making.

Discuss what resources are available to assist and advise the patient, the patient’s fam-2. ily or significant other when ethical issues in patient care arise.


SECTION XXV: ETHICAL ISSUES

Complex moral, social, economic and factors in health care, force upon the healthcare provider, a host of ethical issues and potential dilemmas.

The way we, as individuals, see ourselves is determined by our beliefs and principles. These princi-ples guide our choices about how we relate to each other individually, as a community and spiritu-ally. Sometimes these principles conflict with medical decision making. Ethical concerns in medical care arise from differing goals, beliefs and perspectives. The Ethics orBioethics Committee is available to assist and advise the patient, the patient’s family or significant others and the healthcare team when patient care situations present complex medical/ethical issues that warrant further discussion and/or clarification.

Request for a meeting of the Ethics or Bioethics (at FPH) Committee can be made at any time. During regular business hours notify the Medical Staff Office. During off-hours and weekends, the request may be made by contacting the Administrative Nursing Supervisor.

The Ethics or Bioethics Committee membership may include representatives from: Social Services, Nursing, Administration, Medical Staff Community, Chaplaincy, Ethicists, Attorneys, Board of Directors and Risk Management.

All patient information that is shared in an Ethics or Bioethics Committee meeting is kept com-pletely confidential.


SECTION XXVI

NEEDS OF DYING PATIENTS & END OF LIFE CARE


After reading this section on Needs of Dying Patients & End of Life Care, the learner will be able to:

Discuss the need to meet physical, spiritual and emotional needs of the dying patient.1.

State resources available to help meet the needs of the dying patient.2.


SECTION XXVI: NEEDS OF DYING PATIENTS & END OF LIFE CARE

We are committed to caring for our patients ALL the days of their lives. Part of that care includes end-of-life care.

It is our responsibility to meet the needs of the dying patient, physically, spiritually and emo-tionally.

Excellent culturally competent end-of-life care is the physical, emotional and spiritual care we provide to our patients in the last years of their lives, not just the last days. Pain and symp-tom management is every patient’s right, along with education about their disease process.

In addition to our Nursing Services, Social Services and Chaplains, patients often require additional support in the last years and months of life. To meet this need, there is Palliative Care (in hospital for patients receiving treatment) and Hospice (at home and Hospice unit for comfort and symptom management).

We also provide grief support for adults and children after a loss.


“The Needs of the Dying” by David Kessler is a book written as a guide for bringing hope, comfort, and love to life’s final chapter. Quoted from the beginning of the book, with per-mission from David:

The Needs of the Dying

The need to be treated as a living human being.•

The need to maintain a sense of hopefulness, however changing its focus may be.•

The need to be cared for by those who can maintain a sense of hopefulness, however •changing this may be.

The need to express feelings and emotions about death in one’s own way.•

The need to participate in decisions concerning one’s care.•

The need to be cared for by compassionate, sensitive, knowledgeable people.•

The need for continuing medical care, even though the goals may change from “cure” •to “comfort” goals.

The need to have all questions answered honestly and fully.•

The need to seek spirituality.•

The need to be free of physical pain.•

The need to express feelings and emotions about pain in one’s own way.•

The need of children to participate in death.•

The need to understand the process of death.•

The need to die in peace and dignity.•

The need not to die alone.•

The need to know that the sanctity of the body will be respected after death.•


SECTION XXVII

ORGAN AND TISSUE PROCUREMENT


After reading this section on Organ and Tissue Procurement, the learner will be able to:

Provide the opportunity for patients and their families to donate organs and/or tissues 1. to potential recipients.

State the process to refer potential donors to Organ and Tissue Referral Agency.2.

Discuss what has done to improve conversion rates.3.


SECTION XXVII: ORGAN AND TISSUE DONATION/ONE LEGACY

Over 6,000 people per year die whl1e waiting for an organ or tissue transplant/ whl1e poten-tial donors slip through the system without ever even being offered the chance to participate or get information about this process. Our organization wants to make sure that we provide this opportunity to all of our patients and their faml1ies.

The main role of the healthcare provider in this area is simple: provide patients and fami1ies with a link to organ and tissue donation information via Organ Procurement Organization/ (OPO).

This is done by calling all deaths into a referral center/ where these calls are then screened and, if necessary, sent to the appropriate donor organization. The goal is to have the donor organization involved as early as possible/ initiating the call as soon as death is anticipated.

A designated requestor (someone who has completed a special course) makes the approach to family members. Our staff is NOT trained to do this! If a family member approaches you or asks you about this topic/ assure them that a representative will be coming in or will be available by telephone to discuss it with them. OPO will then work with all potential donor families in coming to a decision.

Conversion Rate is an important indicator when it comes to organ donation. The conversion rate is calculated by taking the number of actual organ donors over the number of potential organ donors. It is important that you do your part to improve the conversion rate. There are educational programs and regular site visits from the OPO.

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