Internal Disaster Situations:
Radiation Safety
The following code names will be announced over the
page system if an internal disaster situation occurs:
1. Dr. Black – bomb threat
2. Dr. Comfort – heating or air-conditioning
failure
3. Dr. Data – Computer system is down
4. Dr. Gas – loss of medical gas and/or
suctioning function
5. Dr. Green – hazardous material emergency
6. Dr. Hold – hostage situation
7. Dr. Lift – elevator emergency
8. Dr. Orange – internal infectious disease crisis
9. Dr. Pink – pediatric abduction
10. Dr. Power – utility failure
11. Dr. Red – fire emergency
12. Dr. Wet – flood emergency
13. Communication Disaster – Failure of
telecommunication equipment
If you hear one of the above announcements remain
with the patient and follow instructions of staff. During
an emergency or unusual situation, follow VCUHS staff
instructions.
At VCUHS, the main sources of radiation exposure
include laboratories, patients, and X-ray producing
machines. Rooms with radiation sources are labeled
with a Radiation symbol and say “Caution-Radioactive
Materials” or “Radioisotopes Used in this Room.” Do
not enter these rooms without first talking to VCUHS
staff about protective equipment and exposure
precautions. If you are in a room when an X-ray is to be
performed, either leave the room or put on the personal
protective equipment specified by the X-ray technician.
MRI Safety
Magnetic Resonance Imaging (MRI) uses a large and
powerful magnet to produce images of the body. The
magnets are on 24 hours a day. Do not enter a MRI
scan room without first completing a MRI Safety
Checklist to screen for metal objects (e.g.,
pacemakers, surgical clips, metal fragments) and
other risk factors. Always be cleared by a MRI
technologist before entering the MRI scan room to
ensure your personal safety and the safety of others. For
MRI Safety questions call MRI at 828-4494, or 8280953.
Fire Safety:
“Dr. Red” announced by over-head paging, indicates a
fire or fire drill is in progress. If the location of the Dr
Red announced is in your area, you are to:
 Close door to the patient room/exam area.
 Remain with the patient.
 Follow instructions from a VCUHS staff
member or the fire department.
Emergency Relocation & Evacuation


When the audible fire alarm and strobe lights
activate in the Nelson Clinic, Ambulatory Care
Clinic, Gateway and A.D. Williams – Evacuate the
building immediately when directed to do so by the
Unit Management.
When the audible fire alarm and strobe lights
activate in the Main Hospital, North Hospital and
Clinical Care Hospital –be prepared to relocate to
the area designated by the Unit Plan. Relocate
immediately when and where directed to do so by
the Unit Management.
VCUHS Vendor Orientation Brochure
Smoke Free Environment
VCUHS is a smoke free environment. No smoking is
allowed in or around any of our facilities.
Virginia Commonwealth University
ORIENTATION
for
VENDORS
providing
care, treatment, or services
to patients
Drug Free Workplace
VCUHS expects all individuals providing care or
customer services in our environment to be able to do so
competently and unimpaired by chemical substances. If
you suspect an individual of being impaired in the
performance of their duties, please report your concern
to the department manager of that area. If a vendor is
suspected of being impaired, they will be reported to
their agency and removed from their assignment.
Reporting Suspected Abuse
All patients must be assessed for potential risk of child
or adult abuse, neglect, sexual assault or domestic
violence. If you suspect child or adult abuse, neglect,
sexual assault or domestic violence contact the
Department of Care Coordination/Social Work at 8280242.
Patient Care Concerns
If you need assistance in resolving patient care
concerns, other VCUHS resources available to help you
include: Patient/Guest Relations 804-628-0400; Clinical
Administrator 804-628-0034: or Corporate Compliance
804-828-0500. Externally you may contact, Virginia
Department of Health’s Center for Quality Health Care
Services and Consumer Protection at 804-367-2104 or
The Joint Commission at 1-800-994-6610.
May 2011
Introduction
Confidentiality
Welcome to VCU Health System. Though you are
employed by someone else, you are here at this time to
provide care, treatment, or services to one of our
patients. While you are here, there are practices that you
need to know to support your own safety as well as the
safety of our patients. This brochure is designed to
explain our expectations for you while you are here and
to identify resources that may be of assistance.
While here you may become aware of confidential
medical information. Disclosure of confidential health
information to any other person, or allowing any other
person access to, any information related to VCUHS
which is proprietary or confidential and/or pertains to
employees, patients or patient care is strictly prohibited.
Reptrax Participation
As a vendor who provides services that affect patient
care, you are required to participate as a Reptrax
member and to keep your profile active and current.
Obtain a Reptrax ID badge upon arrival in Gateway
lobby and display when providing services at VCUHS.
Competency
Prior to providing direct patient services, VCUHS will
need to confirm through Reptrax that you have the
required credentials to perform the duties expected. In
addition, a representative from VCUHS will observe
your performance to determine if the knowledge, skills,
and abilities you display support that you are competent
to provide patient service. If there is a concern
regarding competency, you will not be allowed to
independently provide patient treatment or care.
Staff Identification Badges
All staff should be wearing a VCUHS issued
identification badge that will assist you in knowing
who they are, their job at VCUHS, and how they might
assist you.
Patient Identification
It is essential that before you provide any patient care or
treatment that you make sure you have the correct
patient. At VCUHS we use two patient identifiers. For
inpatients, we use the patient name and medical record
number. For outpatients, we use the patient name and
date of birth. Always confirm you have the correct
patient before proceeding with any type of service.
Changes in Patient Condition
If you observe what you perceive to be a decline in the
patient's condition, notify nursing staff immediately.
Remain with patient until help arrives and then follow
instructions.
Customer Service Expectations
We expect everyone who represents our organization, to
treat those with whom they interact with respect,
courtesy and caring. VCUHS strives to provide equal
opportunities, services, and access to all persons without
regard to race, color, religion, gender, age, national
origin, disability, or veteran’s status. If you have
difficulty communicating with a patient due to language
differences, contact the Office of Language Services
(628-1116) or ask a staff member for assistance in using
the language interpretative services phone.
Patient Rights and Responsibilities
Patients are entitled to certain rights. We affirm the
Patient Bill of Rights and Responsibilities posted
throughout our organization and all persons serving our
organization are expected to support and respect these
principles.
VCUHS Vendor Orientation Brochure
Patient Falls
VCUHS’ fall precaution program identifies patients
with a high probability of falling by placing an orange
sticker on the patient’s door and giving the patient a
special identification band. If the patient you are seeing
is identified in this way, do not let the patient out of bed
unassisted. Call the nursing staff for assistance.
Precautions for patients who are at risk for falls:
 Upper bed side-rails should remain in an upright
position and the bed should remain at its lowest
height.
 If the patient attempts to climb over side-rails,
notify a staff member immediately, remain with the
patient, and maintain patient safety/security while
waiting for staff.

If you observe a patient fall, do not attempt to move
the patient. Call for help and remain with the
patient.
Infection Control Instructions
To protect yourself and the patient:
 Wash hands for 15 seconds before and after contact
with patient. Foam soap located outside patient
rooms may also be used.
 Wear a gown and gloves with any potential contact
with blood and/or body fluids.
 Gloves do not replace hand washing! Hands should
be washed after removing gloves.
 If further precautions are needed, VCUHS staff will
provide additional instructions.
Respiratory Protection
In some areas, respirators (masks) are necessary to
protect you from harmful dusts, fibers, fumes, mists,
gases, or vapors. Individuals who wear respiratory
protection must be fit-tested to determine if the
respirator is providing an effective barrier. Persons,
who may be exposed to tuberculosis, must be fit-tested
for a specific (N-95) mask prior to entering a room
where possible exposure could occur.
Infectious Waste
Materials contaminated with blood or body fluids must
be discarded properly. Always use standard precautions
when handling infectious or medical waste. Use red or
orange bags to dispose of infectious waste materials.
Place infectious sharps in a red, biohazard labeled,
plastic sharps container that is no more than ¾ full. Do
not mix non-infectious sharps with infectious sharps.
Chemotherapeutic Waste
Chemotherapeutic
sharps
and
items
visibly
contaminated with chemotherapeutic agents are to be
placed in black containers.
Items used with
chemotherapeutic agents but not soiled are to be placed
in yellow bags.
May 2011