2009 Safety and Compliance Education/Test
The 2009 Safety and Compliance Education Test (Safety Fair) is now available. All AMH
employees hired before January 1, 2009 must pass this quiz with a minimum score of 80% by
December 31, 2009. If you were hired on January 1, 2009 or later, you are NOT required to
take this quiz.
2009 Safety and Compliance Education/Test ....................................................... 1
Index .................................................................................................................. 1-2
Environment of Care ........................................................................................ 3-13
Emergency Management Codes ....................................................................... 3
Fire Prevention/Life Safety ................................................................................ 5
∞ CODE RED............................................................................................. 5
∞ R.A.C.E. Procedures .............................................................................. 5
∞ Know How to Use a Fire Extinguisher .................................................... 4
∞ Egress Safety & Compliance .................................................................. 6
∞ Interim Life Safety: What is Interim Life Safety?.................................... 7
Utilities ............................................................................................................... 8
∞ CODE GREEN........................................................................................ 8
∞ These are Our Utilities ............................................................................ 8
∞ Scope of Problem ................................................................................... 8
Secure Our Buildings! ....................................................................................... 9
Medical Equipment .......................................................................................... 10
∞ User Error ............................................................................................. 10
∞ Abuse.................................................................................................... 10
∞ Safe Medical Device Act of 1990.......................................................... 10
Hazardous Materials & Waste ......................................................................... 11
∞ CODE ORANGE................................................................................... 11
∞ Material Safety Data Sheets ................................................................. 11
∞ Do You Know If Your Department Has or Needs a Spill Kit? ............... 11
The Plan for Safety.......................................................................................... 12
∞ Employee Injury Reporting ................................................................... 12
∞ Oxygen Tank Safety ............................................................................. 12
∞ MRI (Magnetic Resonance Imaging) Safety ......................................... 13
Risk Management .......................................................................................... 14-16
Patient Rights .................................................................................................. 14
1
It takes a Village when it comes to Victims ..................................................... 14
Patient Safety ................................................................................................. 15
National Patient Safety Goals from The Joint Commission ........................... 17-20
Patient Safety is our #1 Priority ....................................................................... 16
Infection Control .................................................................................................. 18
Precautions / Education .................................................................................. 18
Isolation Education .......................................................................................... 18
Patient Education ............................................................................................ 18
Family and Visitor Personal Protection ........................................................... 18
Personal Protective Equipment (PPE) ............................................................ 18
Influenza ......................................................................................................... 19
Tuberculosis & Bloodborne Pathogens............................................................... 21
Tuberculosis .................................................................................................... 21
Employee TB Skin Testing .............................................................................. 21
Annual N-95 Fit Testing................................................................................... 21
Bloodborne Pathogen Control ......................................................................... 21
Prevention of Exposure at Work...................................................................... 21
Engineering Practices ..................................................................................... 21
Work Practices ................................................................................................ 21
Warning Labels ............................................................................................... 22
Blood and Body Fluid Exposure Follow-Up ..................................................... 22
Hand Hygiene ..................................................................................................... 22
New Information: Hand Hygiene Alert!!! ......................................................... 23
Sharps Safety ..................................................................................................... 23
Fit For Duty? ...................................................................................................... 25
Ergonomics ......................................................................................................... 26
Safe Patient Handling...................................................................................... 27
Safe Lifting Basics ........................................................................................... 28
Corporate Compliance ........................................................................................ 30
Tips for Protecting Patient Privacy .................................................................. 30
Language Interpretation .................................................................................. 31
TIPS For Effective Use of An Interpreter ......................................................... 31
Celebrating Cultural Diversity ............................................................................. 32
S.H.A.R.E.......................................................................................................... 333
2
ENVIRONMENT OF CARE SAFETY
Emergency Management
CODES - When the Alarm Sounds . . . Know Your Emergency Codes
Code Triage is the emergency code that tells us to expect an influx of patients. The command center
opens and communication flows from the command center to the managers by pager, e-mail or courier.
As part of the emergency preparedness and infection control plans, a broad range of options can be
implemented to accommodate a large number of patients at one time and for weeks to come.
Such options are to:
∞ Temporarily stop or limit services like outpatient tests or surgeries
∞ Increase patient discharge to home with home health support
∞ Transfer patients to other hospitals or nursing homes
∞ Limit visitors
∞ Allow only necessary staff and others to enter the hospital
Communication with emergency responders, public health authorities and staff at the hospital are very
important.
Adventist Midwest Health Hospital
Code
Description
Triage Disaster conditions exist; incoming patients
Gray Security Assistance
Yellow Trauma Team
Green Utilities Failure
Brown Bomb Threat
Orange Hazardous material spill
Blue Cardiac/Pulmonary Arrest
Purple Patient Elopement
Pink Infant or Child Abduction
Red Fire, smoke or smell of something burning
Black Severe Weather
Some of our facilities use Code Silver to alert staff that
Silver
someone has displayed a deadly weapon
Environment of Care Safety
3
Fire Prevention/Life Safety
CODE RED
It is each employee’s responsibility to know and participate in drills for their
department’s fire and evacuation plan. Read it….review it often….practice…..be
ready to put into action if it becomes necessary!
If you discover a fire, smell or see smoke, you should LOUDLY call out CODE RED
and with your departmental coworkers, immediately implement R-A-C-E procedures.
R.A.C.E. Procedures
R
A
=
RESCUE anyone in immediate danger of being burned by the fire
=
ACTIVATE the ALARM by pulling the closest fire alarm pull station, AND report the fire
by calling your facility’s emergency telephone extension below:
Adventist Bolingbrook Hospital = x555
Adventist GlenOaks Hospital = x555
Adventist Hinsdale Hospital = x555
Adventist La Grange Memorial Hospital = x555
Non-Hospital Departments = 9-911 (If hospital based phone system is utilized)
x911 (If NO hospital based phone system is utilized)
C
E
=
CONTAIN the smoke by closing all corridor/hall doors
=
EXTINGUISH the fire if possible, and be prepared to EVACUATE to a safe area as
needed
Know How to Use a Fire Extinguisher
P
A
S
S
=
=
=
=
Pull the safety pin
Aim the hose/horn at the base of the fire
Squeeze the handle to discharge the extinguisher
Sweep the hose/horn at the base of the fire
Egress Safety & Compliance
4
Who do we need to comply with?
Joint Commission
EGRESS SAFETY & COMPLIANCE
Life Safety Code 7.1.10 Means of Egress
Reliability
What about the 30 minute rule?
There is no written rule by any of the
Regulatory Agencies. Surveyors do
understand that items may be in the
hallway or in a doorway momentarily, but
they monitor how long the object stays
there. Some surveyors have been
known to time on this time boundary
7.1.10.1 Means of egress shall be continuously
maintained free of all obstructions or
impediments to full instant use in the case of
fire or other emergency.
7.1.10.2.1 No furnishings, decorations, or
other objects shall obstruct exits, access
thereto, egress therefrom, or visibility thereof.
What about items in use?
What does this mean for your department?
•
All egress of (pathway to any exit – you
should see an exit sign) must be clear at all
times.
•
Any time the FIRE ALARM sounds, all
items in the means of egress shall be
removed immediately.
•
See the 30 minute rule question.
However, charging items in the corridor
and then calling them “in use” is
unacceptable and a violation of egress.
Surveyors will watch to see if an item has
moved, even the shortest distance.
Can crash carts remain in the means
of egress?
Other unacceptable commonly found items
in corridor: items charging, WOWs not in
use, chairs at countertops located in the
hallway, transportation items left
unattended, any obstructions that expands
beyond 7” from the wall, decorations, items
stored in alcoves that go beyond the
designated space of the alcove.
Crash carts can remain in the means of
egress, but a permanent location is
preferred since items cannot be charged
in the means of egress. Isolation carts
and Latex Free carts for clinical need
patients only can remain right outside the
room. However, please remove out of
the means of egress if FIRE ALARM
sounds.
For more information on egress safety &
compliance or reporting of any safety hazards
contact your hospital Safety Officer.
Environment of Care
5
What is Interim Safety?
Interim Life Safety
∞
Change in normal exit routes;
∞
Special direction or caution signage;
∞
Temporary construction partitions;
∞
More fire extinguishers;
∞
Special training for the staff in and around the area;
∞
Extra daily inspections to ensure the environment remains safe;
∞
Extra Fire Drills;
∞
Stay out of construction areas;
∞
Only those with hard hats may enter the area;
∞
Employees must participate in extra fire drills;
∞
Be aware of exit and evacuation route changes;
∞
Be aware of who is in the department – construction workers should display appropriate
identification at all times;
∞
Follow the Interim Life Safety Plan developed for your area;
∞
Keep corridors and exits free from obstacles;
∞
Employ your best housekeeping practices at all times;
∞
Immediately report any concerns or problems to your Safety Officer.
Environment of Care
6
Utilities
CODE GREEN
When a utility fails in the hospital, we call a Code Green. It is your responsibility to report utility failures
to your supervisor, administrator on-call, or by checking any Quick Response Wall Cards or emergency
manuals and following the directions.
These are Our Utilities
“Utilities” includes many things, some the same as you have in your home. In a hospital, utilities
include:
∞ Oxygen
∞ Heat
∞ Vacuum
∞ Air conditioning
∞ Medical air
∞ Ventilation
∞ Nurse call
∞ Elevator
∞ Intercom system
∞ Electricity
∞ Telephone
∞ Water
∞ Computers
∞ Sewage
Scope of Problem
∞ If a utility fails in one department, the problem will be resolved without calling a Code Green.
There is a difference in resolving a sink drain back-up in one department from a sewer back-up
that affects multiple departments.
∞
A Code Green will only be called when there is the potential for significant impact on the health
and safety of our patients.
Secure Our Buildings!
7
Since we work in a facility that is open 24-hours every day, you have a responsibility to ensure security
measures are followed for the protection of patients and employees. To help create a more secure
environment:
∞
Wear your photo identification badge at all times while in the building;
∞
Know and follow the Non-Employee Identification Policy –
business visitors, repair persons, construction workers must all
wear one of two types of identification IDs – a temporary badge
if they are here for one day or less; a photo ID if they are here
more than one day;
∞
Immediately report any suspicious people or activities to
Security;
∞
Know your Security Department employees – use the
appropriate method of contact based on the situation – call a
“Code” for emergency situations – contact a security officer for
routine business activities;
∞
Know and respect security-sensitive departments (areas with an
elevated element of risk due to the nature of their business): the
Birth Center, the Emergency Department, Pharmacy, Pediatrics, H.I.M.;
∞
Guide patients, visitors and other guests to appropriate entrances. Do not allow nonemployees through secured doors;
∞
Be aware of people trying to enter a secured entrance behind you. Do NOT open secured
doors for anyone;
∞
Do NOT use your Employee I.D. Badge to provide secured area access to non-employees;
∞
Call Security if someone enters a secured area behind you. Be prepared to give a description
of the individual(s).
8
Environment of Care
Damaged or Malfunctioning?
How is your equipment failing?
Medical Equipment
User Error
User error is using a device against the recommendations of the original manufacturer, resulting in a
failure or misdiagnosis in the clinical environment.
If you are unclear about the proper use of any device - ask questions or request training from your
supervisor.
Abuse
Physical abuse is damage caused by usage against the recommendations of the equipment
manufacturer, or intentional destruction or damage of a device (e.g., sabotage).
Physical abuse service events are reportable to the safety committees of the facilities of Adventist
Midwest Health. Any device that has been involved in a physical abuse event requires a complete
performance test of all operations and alarms prior to clinical use.
If the error or abuse has compromised patient care or hospital operations, then it must be reported
immediately to your supervisor or manager. A Risk Management Event Report Form is completed and
submitted online. All user errors and physical abuse are reported to the Environment of Care Safety
Committees on a monthly basis.
The Joint Commission requires us to have a plan for equipment needs in an emergency situation. Talk
with your supervisor or manager about procedures to follow in the event of an emergency equipment
failure in your department!
Safe Medical Device Act of 1990
You MUST report incidents that reasonably suggest a medical device has caused or contributed to a
patient’s death, serious illness, or serious injury.
Actions Required:




Tag and Remove from service – the equipment and any disposable items used with the
equipment involved in the incident (i.e. administration sets, syringes, etc.) NOTE: DO
NOT clean, repair, change settings, test operation, or dispose of the item until
specifically authorized by Risk Management.
Report the incident to your supervisor or manager immediately;
Report the incident to Risk Management immediately if a patient was injured;
Identify the following:
- Type of equipment / supplies
- Manufacturer’s name with
device. Include:
- Model / Serial number
- Settings of controls when
incident was discovered
- Alarms on / off

- Sterility control number
- Hospital inventory / prevention
maintenance number
- Last preventative maintenance
check indicated on equipment
- Power supply
- List of disposable supplies used
in conjunction with device
(include lot number)
- Condition of equipment / supplies
- Location of equipment / supplies
Complete the online Risk Management Event Report Form
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Environment of Care
Hazardous Materials & Waste
CODE ORANGE
Material Safety Data Sheets
The Government Says You have a Right to Know!



the chemicals in your department
how to protect yourself when using those chemicals
how to safely handle hazardous materials
The healthcare setting is not the place to play loose and carefree with
all of the chemicals and wastes that can be harmful to employees as
well as patients.
You have a responsibility to know
∞
Where do I find MSDS Information?
What is MSDS?
o Material Safety Data Sheet
On the Adventist Midwest Health
Intranet under "Online
Applications"
What information is on a MSDS?
Not all MSDS look the same but they are required to contain the same data.
Here are some of the items that are included:
∞
∞
∞
∞
∞
Full Chemical Name
Manufacturer Name
Manufacturer Contact Information
First Aid Procedures
Types of Personal Protective Equipment Needed
Do you know if your department has or needs a spill kit?
Any department that handles or stores hazardous materials should have an appropriate spill kit(s) for
their area.
Department Managers should train their employees annually on the location and use of these spill kits.
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Environment of Care
The Plan for Safety
AMH hospitals follow a plan to reduce your risk of injury at work.
1. Safety Information
∞ In Orientation: fire, hazardous chemicals, body fluid exposure, infectious disease
∞ In Your Department: equipment, safety devices, safe practices.
2. Finding and reducing job-related hazards, including use of safety devices, respirators, and
safety equipment
3. Following safe work practices
4. Investigating incidents that occur
5. Everyone is responsible for the plan. YOU, your SUPERVISOR, the SAFETY OFFICER, the
SAFETY COMMITTEE
Report unsafe conditions immediately to Plant Operations/Building Services or the appropriate
person/department
Use all safety and protective equipment appropriately
EMPLOYEE INJURY REPORTING
1. NOTIFY your supervisor immediately
2. FILL OUT the Online Employee Incident Report completely including WHO you are, WHAT
happened, WHEN it happened, and HOW you feel (where does it hurt). The employee Incident
Report is found on the Adventist Midwest Health Intranet
3. BRING a printed copy of the Report to Employee Health if possible.
(when closed, leave a voicemail & bring later)
4. DO NOT go to the Emergency Room UNLESS your injury requires emergency care (AFTER
regular Employee Health hours)
5. CONTACT Employee Health within 24 hours and the nurses will help you to evaluate your
need for follow-up. If the office is closed, leave a detailed message for us and we will be in
touch.
OXYGEN TANK SAFETY
∞
∞
∞
∞
∞
∞
∞
NEVER let patients hold O2 tanks in their arms
NEVER lay an O2 tank on a patient’s bed or carrier
ALWAYS store O2 tanks in the approved storeroom, at
least 5 feet away from anything else in the room
REMEMBER--Empty tanks are still a hazard—some
O2 is still inside
RETURN empty tanks to tank room, place in a holder,
mark “EMPTY”
NEVER carry an O2 tank in your arms
ALWAYS place O2 tanks in approved carriers and
holder
11
MRI (Magnetic Resonance Imaging) SAFETY
The magnet is ALWAYS ON, even when not in use
∞
∞
∞
∞
Things that contain metal may be pulled into the scanner, like: scissors, tools, IV poles, oxygen
tanks, wheelchairs, floor buffers, even jewelry
Patients are screened before they enter the scanner, especially for pacemakers,
neurostimulators, aneurysm clips, cochlear implants, & some orthopedic hardware
NEVER enter the scanner room until cleared by the MRI technician
No “Codes” or resuscitative efforts are attempted in the scanner room. The MRI tech will
immediately move
the patient to the holding area, if necessary
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Risk Management
Patient Rights
PATIENTS HAVE THE RIGHT TO:
1. Have their Advance Directives honored
An ADVANCE DIRECTIVE is a document in which an individual either states choices for medical
treatment or designates who should make treatment decisions when they no longer can. Examples of
an advance directive are organ donation, Illinois Department of Public Health (IDPH) Uniform Do-NotResuscitate (DNR) Order Form, livings wills and/or durable power of attorney for health care.
2. Privacy
Patient privacy is a right afforded to patients upon admission, during treatment and upon discharge
from the hospital. It is everyone's duty to protect patient privacy.
3. Appropriate assessment and management of pain
Our PAIN MANAGEMENT POLICY requires health care workers to assess pain and implement
interventions according to patient’s needs and as ordered by the physician.
4. Receive information about the outcomes of their treatment
This right is addressed in the Regional UNANTICIPATED OUTCOME policy and states that patients
and families are entitled to information about the outcomes of diagnostic tests, medical treatments, and
surgical interventions whether those outcomes are anticipated or not.
5. Have their ethical issues addressed
The ETHICS COMMITTEE works to help support patients rights throughout the hospital and assist with
any physician, staff, patient or family member who may have a disagreement or need concerning
treatment that may be controversial or confusing. Every campus has its own ethics committee. You can
contact pastoral care, risk management, or social services/discharge planning in order to access the
ethics committee.
6. Have their rights and welfare protected if they decide to participate in research
The IRB (Institutional Review Board) follows established protocol in accordance with current
Department of Health and Human Services and Food and Drug Administration regulations. The IRB
assures that risks to research subjects are minimized; that subjects are selected fairly and equitably,
and participation is voluntary, and informed consent is obtained from each subject.
It takes a Village when it comes to Victims
We have a community responsibility to protect those who may be victims of abuse and neglect. Victims
can be young or old and may be members of the same household. Abuse can be physical, sexual or
psychological.
Reporting abuse and neglect allows an investigation to be conducted.
13
Illinois law provides immunity for reporting suspected abuse and/or neglect which means there must
only be a reasonable basis for suspicion. For some patient care providers reporting suspected abuse
and neglect is not an option – it is mandatory. However, many times victims and their abusers go to
great lengths to cover abuse when they know someone is watching. That is why housekeepers,
mechanics, food service workers, and volunteers are equally and vitally important in protecting our
patients from abuse and neglect. Refer to your hospital’s policy for phone numbers to report and
resources for victims.
What do you do if you observe something suspicious or a patient shares information with you that
would indicate that the patient may have been abused or neglected prior to hospitalization but you are
not sure if it is abuse or neglect? You should immediately contact your manager and/or social
services.
Patient Safety
Patient safety initiatives provide information to help prevent and reduce potential
future harm to patients from the delivery of medical services. This knowledge is
gained by identifying, reporting, and analyzing problems. Adventist Midwest Health
supports a non-punitive environment that encourages employees to report potential
and actual events. This environment will help us improve all processes and services for the safety of
our patients.
The three processes used to promote patient safety in the Midwest Region are:
∞
∞
∞
Sentinel Event Management
Unanticipated Outcomes
Incident and Medication Variance Reporting
Sentinel Event Management
A Sentinel Event is an event resulting in an unanticipated death or “major permanent loss of function”
not related to the natural course of a patient’s illness or underlying condition. Not every bad outcome is
a sentinel event. The decision to call something a sentinel event is made after a thorough investigation.
Examples of possible sentinel events:
1. Suicide of any patient receiving care, treatment, and services in a staffed around-the-clock
setting or within 72 hours of discharge
2. Discharge of an infant to the wrong family
3. Rape (defined according to law/regulation)
4. Hemolytic transfusion reaction involving administration of blood or blood products having major
blood group incompatibilities
5. Surgery on the wrong patient or wrong body part
6. Unanticipated death of a full term infant defined as any perinatal death unrelated to a
congenital condition in an infant having a birth weight greater than 2500 grams
7. Abduction of any individual receiving care
8. Unintended retention of a foreign object in a patient after surgery or other procedure
9. Severe neonatal hyperbilirubinemia (bilirubin greater than 30 milligrams/deciliter)
10. Prolonged fluoroscopy with cumulative dose greater than 1500 rads to a single field, or any
delivery of radiotherapy to the wrong body region or greater than 25 percent above the planned
radiotherapy dose
11. All identified cases associated with a health care associated infection including the
management of patient before and after the identification of infection
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Procedure if you are involved with a Sentinel Event:
1. Ensure appropriate care of the patient
2. Secure and sequester any physical evidence/devices involved in the event
3. Notify Risk Management (RM) immediately. RM, with the “screening” team, will review the
scope and impact of the event.
Unanticipated Outcomes
An Unanticipated Outcome requires disclosure to patients and/or families. An example of an
unanticipated outcome - during abdominal surgery a bowel is perforated requiring further surgical
repair.
Procedure:
1. Notify Risk Management.
Incident and Medication Variance Reports
The online Risk Management Event Report Form is a mechanism for reporting quality issues, improper
performance of patient care duties, injuries, property damage, accidents, medication variances, or other
events not anticipated. In order to provide safe care, all of us need to report potential (what could have
gone wrong) as well as actual (what did go wrong) events. Potential events/variances are recognized,
corrected and reported before they reach the patient. Actual events/variances are reported because
they reach or impact the patient.
As an example, a medication variance is an event in which a medication is dispensed and/or
administered in a manner that varies from what was prescribed. Medication variance could also include
prescribing variances by the physician (potential variance), omission of dispensing (potential variance)
and/or administration (actual variance) of a prescribed medication.
Reports need to be completed by the end of the shift in which the incident/variance/concern was
identified. Reports that have complete and accurate information filled out help us understand the
variance and its potential or actual impact on safe patient care. Completed online reports are emailed
to the Manager/Assistant Director/Director and Risk Management.
15
National Patient Safety Goals from The
Joint Commission
Patient Safety is our #1 Priority
It’s everyone’s job to make it safer for patients in our hospitals
The purpose of the NATIONAL PATIENT SAFETY GOALS is to prevent patient harm
The goals are reviewed and revised every year based on recommendations from experts on how to
prevent the problems reported by hospitals across the country
Our Patient Safety Programs are evaluated during visits by Accrediting Agencies such as the Joint
Commission.
We are continuously evaluating & refining our Patient Safety Programs by doing EOC/Safety Rounds,
Tracers and education at all of the AMH facilities.
We look for:
∞ Safe practices in action
∞ Adherence to the patient safety goals
GOAL: ACCURATE PATIENT IDENTIFICATION
Always use at least two patient identifiers (FOUND ON THE WRISTBAND) when drawing blood,
collecting specimens for clinical testing, providing other treatments or procedures or administering
medications. Acceptable identifiers are:
∞ PATIENT NAME
∞ DATE OF BIRTH
∞ MEDICAL RECORD NUMBER
Note: NEVER use the room
number as an identifier!
∞ Be sure to compare the two patient
identifiers from the wristband with
the patient information on
requisitions, medications, and
patient stickers.
And
∞ Always
label specimens at the bedside point
of collection in the presence of the patient. Doing these two things will
help to prevent mislabeled specimens.
GOAL: IMPROVE COMMUNICATION BETWEEN CAREGIVERS
Certain Lab test results, Cardiology, Respiratory, and Radiology test findings are Critical Values. Critical
values could have a significant impact for the patient. Critical Values must be communicated to a
physician who can act on the results.
16
Reading back verbal & telephone orders and Critical Test Results means you are validating the
information.
Timeliness & documentation of critical test results are being tracked to evaluate need for improvement.
Critical TESTS have also been identified in the same areas. Time of the order for a Critical TEST until
the results are available for the physician will be monitored.
Avoid the Use of Unapproved Abbreviations.
Follow the Guidelines Printed On All Physician Order Forms
Legibility and readability improve patient safety! Write and Print Clearly~
Poor communication is the #1 cause of medical errors.
GOAL: IMPROVE RECOGNITION AND RESPONSE TO CHANGES IN A PATIENT’S CONDITION
Adventist Midwest Health facilities have Rapid Response Teams which provide early response by
specially trained individuals to changes in a patient’s condition.
During 2008, Teams have:
∞
∞
∞
∞
∞
∞
Identified ways in which the patient, family or others can call a Rapid Response
Developed and tested models for use in some specialty areas (Obstetrics, Pediatrics)
Educated doctors and clinical staff about new changes
Developed patient/family education and appropriate signage for patient rooms
Piloted the processes
Prepared to be fully implemented with this program by January 1, 2009
17
Infection Control
Precautions / Education
Standard Precautions
∞ Applies to all patients, all the time
∞ Requires health care workers to wear gowns, gloves, masks & eye protection when contact
with body fluids or blood is possible
∞ Are always in effect even when utilizing additional transmission precautions
Transmission Precautions
Contact Precautions
∞ Wear gown and gloves every
time you enter the room
∞ Change gloves after contact
with infective material
∞ Remove gown and gloves
upon leaving room
∞ Perform hand hygiene after
gloves and gown are
removed.
∞ Use soap and water for
patients with diarrhea
Droplet Precautions
∞ Wear simple mask when
entering the room
Airborne Precautions
∞ N-95 mask required when
entering room
∞ Visitors wear a simple mask
Isolation Education
Patient Education
∞
∞
∞
Family and Visitor Personal Protection
∞
∞
Explain to patients/visitors/family the
reason for isolation
Review with patients the personal
protective equipment that staff, family
and visitors must wear to safely care for
them
Document in the medical record that this
education took place on the
interdisciplinary Education form; check
off isolation type and write in the
diagnostic results.
∞
∞
Family and visitors of a patient requiring:
Contact Precautions – must wear same
personal protective equipment staff wear
Airborne Precautions – must wear a simple
mask
Droplet Precautions – must wear a simple
mask
Personal Protective Equipment (PPE)
18
Gloves
∞ Worn as part of Standard Precautions when handling all body fluids and broken skin
∞ Worn upon entry to a patient’s room for Contact Precautions
∞ Hands must be washed before putting on gloves and immediately after removing
gloves
∞ Always inspect gloves for holes before wearing them
∞ Replace worn out or torn gloves
Gowns
∞ Worn as part of Standard Precautions
if clothing may come in contact with
body fluids or broken skin
∞ Required to be worn upon entering a
patient’s room requiring Contact
Precautions
Masks with Eye Protection
∞ Worn when splashing is possible, as
part of Standard Precautions
∞ Simple masks are required of staff
caring for a patient requiring Droplet
precaution
N-95 Respirator
∞ Health care workers must be fittested to wear an N-95 Respirator
∞ Health care workers must fit-check
the N-95 Respirator each time they
enter the room of a patient on
∞
Airborne Precautions
N-95 Respirators are required to care
for patients suspected or known to
have TB, SARS, Monkey pox,
Chicken pox and Measles.
Influenza
The Joint Commission (JCAHO) requires all health care workers to
receive influenza education. All health care workers are
encouraged to receive an annual seasonal influenza vaccination
because unvaccinated health care workers can transmit influenza
to patients.
Outbreaks of influenza have been documented in hospitals and
long term care facilities. Getting an influenza vaccination reduces
the transmission of influenza in health care setting as well as
reducing staff illness and absenteeism.
Influenza vaccine is free, available through Employee Health. Influenza is a viral disease that occurs in
annual epidemics in the U. S. It is a serious disease - each year 200,000 people are hospitalized with
influenza – about 36,000 die because of it.
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The flu shot works to prevent influenza. You can get the flu shot at any time during the flu season –
usually October through March. You can not get influenza from the flu shot.
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Tuberculosis & Bloodborne Pathogens
Tuberculosis
∞
∞
∞
TB is a communicable disease caused by the Mycobacterium Tuberculosis or the Tubercle
Bacillus
Infectious droplets are spread in air when an infectious person sings, coughs, sneezes, or
speaks
Common symptoms of TB include:
1. Cough lasting more than 3 weeks in duration
2. Chest pain and bloody sputum
3. Fever, chills and night sweats
4. Weight loss
5. Increasing fatigue
Employee TB Skin Testing
∞
Employees must have annual skin testing which is required by IDPH (Illinois Department of
Public Health) and EHS (Employee Health Services) of Adventist Health System
Annual N-95 Fit Testing
∞
Annual fit testing is required for all staff who must wear the N-95 respirator when caring for a
known or suspected TB patient
Bloodborne Pathogen Control
Route of Transmission
Work Related:
∞
∞
Accidental needle stick
Unprotected splash to the face
Bloodborne Pathogens
∞
∞
Human Immune Deficiency Virus
(HIV)
Hepatitis B (HBV)
∞
Hepatitis C (HCV)
Others:
∞
∞
∞
∞
Unprotected sex with an infected
person
Tattoos
Body piercing
Sharing toothbrushes and razor
Prevention of Exposure at Work
Engineering Practices
Work Practices
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EQUIPMENT WHICH REMOVES
INFECTIOUS AGENTS IN A SAFE MANNER
∞
∞
∞
∞
∞
o
o
o
SHARPS CONTAINER – All sharps
must be placed in a securely
mounted, puncture proof container
Discard when 3/4 full.
SELF SHEATHING NEEDLES
NEEDLELESS SYSTEM
ISOLATION TRASH BINS – Red bins
that prevent leaking
BIOHAZARD LABELS – Should be
placed on any blood or body fluid
o
o
o
o
No eating, drinking and
smoking in Patient Care
Areas
Hand Washing
No Recapping of needles/use
safety needles
No mouth pipetting/use
automatic pipettes
Remove clothing
contaminated with blood or
body fluids immediately
Use Personal Protective
Equipment
Use hospital approved
disinfectants to clean. Pay
attention to disinfectant
contact time.
Warning Labels
Warnings labels are affixed to the following:
∞
∞
∞
Containers of regulated waste
Refrigerators and freezers containing
blood or other potentially infectious
materials
Other containers used to store,
transport, or ship blood or other
potentially infectious material.
Blood and Body Fluid Exposure Follow-Up
After treating the exposure site and receiving appropriate treatment, document the exposure using the
Employee Injury Report which can be found on the INTRANET.
∞ Make sure to include the following information:
1. Route of exposure (Where were you splashed, stuck, etc…)
2. Describe the circumstances of exposure (Type of needle, etc…)
∞ Notify your supervisor and contact Employee Health. After hours go directly to Emergency
Department.
∞ You can expect:
1. To have appropriate testing of yourself and the source individual (if identified)
2. To be provided with your test results and those of the source individual through
Employee Health.
3. Post exposure counseling and medical evaluation as needed
∞ POST EXPOSURE PROPHYLAXIS WHEN MEDICALLY INDICATED
Hand Hygiene
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New Information: Hand Hygiene Alert!!!
CDC Hand Hygiene Guidelines and The Adventist Midwest Health Hand Hygiene Policies state:
∞ No artificial nails or nail extenders on any clinical staff who directly or indirectly touch patients
such as: nursing, dietary, central sterile processing, pharmacy,
respiratory therapy, phlebotomy and neurophysiology
∞ Short natural nails are recommended for clinical staff
∞ Clear nail polish may be worn if it is not chipped
∞ Studies have shown that artificial nails have been associated
with infection transmission in hospitals.
Hand Hygiene
Prevent the transmission of health care associated
infections by proper hand washing and the use of
gloves.
Soap and Water Hand Wash
∞
∞
When to wash your hands
∞
∞
∞
∞
∞
∞
∞
∞
∞
∞
∞
∞
∞
∞
∞
Wet hands
Keeping hands lower than elbows, apply
soap
Wash for at least 15 seconds, working up
a lather
Cover all surfaces of hand, pay close
attention to under and around fingernails
and the webbing in between the fingers
Rinse well under running water
Pat dry hands with a paper towel. Don’t
rub!
Turn faucet off with paper towel
Before starting work
∞
Before and after touching a patient
Before and after handling a patient’s
equipment
∞
Whenever hands are visibly soiled
∞
Between handling patients
Before performing any invasive procedures
∞
Before giving medications
Before and after wearing gloves
Alcohol hand wash
After personal use of the toilet
After blowing or wiping nose
∞ Preferred method of hand hygiene.
Before and after eating
∞ Apply alcohol based hand rinse
Before preparing food
∞ Rub vigorously, covering all parts of hand
Before going home
– in and around the fingernails and the
AND when in doubt
webbing in between fingers
∞ Allow to air dry. Do not towel or dry off
∞ DO NOT USE WHEN HANDLING STOOL
SPECIMENS OR CARING FOR
PATIENTS WITH DIARRHEA, especially
C. Difficile
Hand Care
∞
∞
Sharps Safety
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Hand lotion provided by the hospital may
be used.
DO NOT USE HAND LOTION FROM
HOME; IT IS NOT COMPATIBLE WITH
GLOVES AND ANTIMICROBIAL SOAP.
Did you know?
AMH hospitals provide a wide variety of sharps safety devices to protect employees from accidental
needle sticks and other sharps injuries
Employees who use sharps are instructed about the safety features and are expected to use
them properly
Safety features must be activated after every use and before disposal
Activated sharps safety devices must be disposed of by placing into rigid sharps
containers
Each facility has an Exposure Control Plan that explains how we plan and implement for prevention of
exposure to blood and bloody body fluids. See the policy on the Intranet
Sharps users are involved in evaluating and selecting safety engineered devices
Sharps containers must be changed when ¾ full. Don’t wait!
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Fit For Duty?
Every hospital is a drug-free workplace. All employees must be free from
the influence of drugs & alcohol at work. Employees who engage in the
sale, use, possession, manufacturing, diversion, or transferring of illegal
drugs or controlled substances will be subject to disciplinary action or
termination. Employees who use alcohol during work hours, or who abuse
prescription drugs, will also be subject to disciplinary action or termination,
per our “Fitness for Duty” Policy.
You must NOT drink alcohol or use drugs before coming to work.
You must NOT be under the influence of drugs or alcohol while at work.
TAKE CARE OF YOURSELF SO THAT YOU ARE FIT FOR DUTY AT ALL TIMES
1.
2.
3.
4.
Get help with your personal problems
Don’t drink alcohol frequently or in excess
Don’t use illegal drugs
Get enough food and sleep
Call the Employee Assistance Program (EAP) for professional, confidential help
1-888-327-4827
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Ergonomics
Office Ergonomics
Slouching, slumping or bending forward at the waist in a chair can lead to
discomfort, fatigue and backache. Follow these guidelines to help prevent
problems from occurring when sitting at your workstation.
∞ Monitor placed for eyes facing forward
Top 1/3 of the screen at eye level with the
Neck in neutral position.
∞
∞
∞
∞
∞
∞
Wrists should be a natural extension of the forearm, not angled up or down
Elbow relaxed, lower arm at approximately 90 degrees to upper arm
Sit all the way back in the chair with your shoulders & back relaxed
Hips, knees should be bent to 90 degrees
Feet resting firmly on the floor
Take mini-breaks every 30 to 60 minutes and frequently change position. Mini-breaks
from 15 seconds to 3 minutes include alternating tasks such as a trip to the copier
or standing and stretching or rolling head & shoulders.
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Safe Patient Handling
THINK IT THROUGH
∞
∞
∞
USE GOOD FORM
Assess the patient’s ability to
participate
Clear away obstacles
o Get help as needed:
o slide boards
o draw sheet
o trapeze
o CO-WORKER
Use good form
∞
∞
∞
DON'T
Push a carrier, cart or
wheelchair. You can push
twice as much without back
strain as you can pull
Stay close to the cart or
wheelchair
Use both arms and tighten
your stomach muscles
DO
DON’T
***********************
USE GOOD FORM
∞
∞
∞
∞
∞
∞
Always lock wheelchairs, carriers and beds
Position height of bed at elbow level of caregivers or same height as the carrier
Ask the patient to assist if possible
Use both arms and tighten your stomach muscles
Keep your head up and back aligned. A forward bend to lift can put 1000 pounds of pressure on your lumbar
(lower) spine
Tighten your stomach muscles and pull on the draw sheet to move the patient to a carrier
27
DON'T STRAIN
DO GET HELP
Safe Lifting Basics
USE GOOD FORM
∞
∞
∞
∞
∞
∞
∞
DO
Keep back straight
Bend your legs at hips & knees
Tighten stomach muscles
Keep object closer to body
Use smooth, controlled movements
Avoid twisting & jerking
Avoid overhead lifting. Use approved stool or
ladder
DO
DON’T
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DON'T
DO
DON'T
29
DO
Corporate Compliance
Tips for Protecting Patient Privacy
As healthcare workers we are stewards of PHI. PHI is “Protected Health Information”. PHI is any
information that we receive or create about our patients that could (alone or in combination) identify
who the patient is. You may access PHI only as you needed to do your job. You may disclose PHI
only as needed to support the patient’s treatment or payment for services.
1. Know your Minimum Necessary Standard. This describes what PHI you may access, use
and disclose as you do your job. If you don’t know your Minimum Necessary Standard, ask
your manager or contact the Privacy Officer, Anne Herman at (630) 856.4572.
2. Monitor your Conversations. Patient
information may only be discussed with those who have a need to know. If you are having a
discussion about a patient with others who have a need to know, make sure it is in a private
area, where it will not be overheard.
3. Manage Your Password: If you have access to PHI that is in computer systems, make sure
you have your own unique password. Never, never, never share your password!
4. Manage Your Work Documents: PHI is everywhere; in medical records, on surgery
schedules, on lab reports and “to do” lists. Take perfect care of any PHI in your possession;
making sure it is secured and available only to those who have a need to know.
5. Manage Your Workstation: If you have a computer to do your job, make sure you complete:
1. Log off whenever you leave your workstation
2. Have operational screensavers that work.
3. Face monitors away from public traffic
6. Dispose of PHI in shredding bins: Located throughout your facility. Please make sure to use
these bins to dispose of all confidential information.
Respect your Coworkers’ Privacy: Employees have the same right to patient privacy as any patient
who receives care. If you see a coworker receiving care, you can acknowledge that employee with a
nod or a “hello”. Please remember that, unless you are supporting the care for that patient, you have
no right to access or disclose ANY information about their visit.
30
Language Interpretation
Language and Culture impact the health care experience. Our “duty to serve” crosses all cultures,
religions, and languages. If you encounter a patient who does not reliably speak or understand
English, you have a duty to offer the patient free interpreter services during critical
communications. This includes individuals who are hearing impaired or who have a primary language
other than English. Work with your manager to arrange for an interpreter, as needed. We have
employees who are trained interpreters in addition to having contracted interpreter, and telephone
interpretation via use of the Language Line. Below are tips for effective use of an interpreter for patients
who do not speak or understand English reliably:
TIPS For Effective Use of An Interpreter
Brief the Interpreter: Identify who you are
and the objective of the interpretation
session.
Speak Directly to the Patient: All
communication should be directed to the
patient, not the interpreter.
Segments: Speak in one or two short
sentences at a time. Pause to allow the
interpreter to deliver the message.
Ask Patient if they Understand: Inquire
periodically to assure the patient has
understood the message.
Do Not Ask the Interpreter’s Opinion: The
interpreter’s job is to relay meaning without
a personal opinion.
Reading Script: When reading prepared
text or documents, slow down to give the
interpreter time to keep up.
Everything You Say will be Interpreted:
The interpreter’s job is to relay your entire
message to the patient. Do not relay
information unless it is intended for
interpretation.
Avoid Jargon or Technical Terms: Clarify
any potentially confusing technical terms as
you speak. There is often not a 1:1
correlation between technical terms in English
and in another language.
Avoid Interrupting the Interpreter: The
interpretation may be of greater length (more
words) than your English message. Many
concepts have no equivalent in another
language. Give the interpreter time to provide
the message to the patient.
Culture: The interpreter may point out a
cultural issue and ask you to rephrase if they
believe a particular question is culturally
inappropriate.
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Celebrating Cultural Diversity
DuPage and Cook County are home to a rapidly growing number of immigrants. There are many
cultures represented in our workplace. The identity, values, and beliefs of both your coworkers and
patients may differ from your own because of their cultural background. Culture shapes the way we
think about illness and death, parenting, religion, pain, authority and work.
We need to be more aware of our coworkers’ and patients’ cultural codes.
We need to be more sensitive to our coworkers’ and patients’ cultural codes.
Here are some best first steps:
∞ Establish and build relationships with your patients and coworkers
∞ Work to understand your own cultural code (what beliefs and values do you hold close)?
∞ Be respectful of cultural differences.
∞ Respect the appropriate level of formality in other cultures.
∞ Speak at a comfortable pace for your coworkers and patients who have a different primary
language. Seek the assistance of an interpreter for those patients in need.
∞ Check yourself constantly for cultural assumptions.
Reference books are available in many departments and in the library on various cultural differences
and practices.
Celebrate, respect, and integrate this knowledge into your interactions with them!
32
S.H.A.R.E.
SHARE is an acronym representing the five points of our Adventist Health System customer service
initiative. SHARE is deeply rooted in our organization's mission and vision. At the corporate level, our
mission is "To extend the healing ministry of Christ." Within Adventist Midwest Health we have defined
our Mission as:
"Adventist Midwest Health is a Christian Healthcare leader committed to partnering with physicians and
our community to provide whole person care and to promote wellness."
Adventist Midwest Health's core values are: excellence, Christian service motivation, stewardship,
integrity, and acceptance.
SHARE is:
SENSE people's needs before they ask
HELP each other out
ACKNOWLEDGE people's feelings
RESPECT the dignity and privacy of others
EXPLAIN what's happening
SENSE: Sensing people's needs is about understanding the dynamics of where we work - in a hospital
setting - and using what we already know about our patient's situation to take action to seek to meet
their needs before they have to ask us. This SHARE behavior is about taking the initiative and about
taking action.
HELP: Helping each other out is about team. It is about being a team where anyone can feel free to
stop any process at any time if they think something is unsafe or not in the patient's best interest. It is
also about helping my co-workers. We all need a little help at times and it is always a boost to know
there are people you can count on to help us when we need it. We (the staff) are many people (along
with the patient and their loved ones) who make up the interdisciplinary team bringing our best to the
table to help make our patients well, to bring about healing experiences.
ACKNOWLEDGE: Acknowledging others is about empathy. Walk a mile in their shoes. We may not
have experienced exactly what our patient is going through, but it will help us understand why they are
having such a difficult time if we can empathize with them and where they are at in their journey.
RESPECT: Respecting the dignity and privacy of others is about courtesy. It is about treating others the
way we would want to be treated - regardless of how different they might be from us. It is about
protecting their rights to privacy as they come to us in their time of greatest need.
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EXPLAIN: Explaining what's happening is all about communication. This is the toughest job. We are all
so different and it is so critical that we understand each other. So much of communication is non-verbal.
Many times our actions speak louder than words. Do your part to make sure communications are
appropriate and correct.
34