MARTIN ARMY
COMMUNITY
HOSPITAL
Hospital Orientation for
Newcomers
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TABLE OF CONTENTS
MEDDAC Command Group
MACH Mission, Vision, and Values
Immunization and Infection Control Requirements
Infection Control Program
MACH Safety Policies and Procedures
Accidental Injury Reporting
Electrical Safety
Fire Emergency Response
Radiation Safety
Electromagnetic Interference (EMI) Awareness
Patient Safety Program
Use of Restraints
Risk Management
Preventive Medicine/Environmental Services
Occupational Health
HAZCOM
HAZMAT
Patient/Staff Rights & Responsibilities
Domestic Violence
HIPAA
Hospital Performance Improvement (PI)
Quick Code/Rapid Response Team
Force Protection and Emergency Management
Hospital Emergency Codes
Prevention of Sexual Harassment
Information Management Division (IMD)
Patient and Family Advocate Office
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MEDDAC Command Group
Colonel Koji D. Nishimura
Hospital Commander
CSM William A. Rost
Hospital CSM
COL Boxmeyer
DCA
LTC John W. Faught
DCCS
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COL Colleen A. Takahashi
DCN
Martin Army Community Hospital:

Mission Statement
Provide quality, safe and appropriate health care using "customer-focused" business
processes to improve the overall health of our community.

Vision Statement
Be the benchmark for quality health care delivery across the Army Medical Department.

Our Values
Our values are the Army Medical Department's values:
a. Absolute Patient Focus - we will be committed to providing exemplary health
services to all entrusted to our care
b. Loyalty - we will bear true faith and allegiance to the United States Constitution, the
Army, the Army Medical Department, soldiers, and their families
c. Duty - we will fulfill our obligations
d. Respect - we will treat people as they should be treated
e. Selfless - Service - we will put the welfare of the Nation, the Army, the Army
Medical Department, patients, and our subordinates before our own
f. Honor - we will live up to all Army Medical Department and Army values
g. Integrity - we will do what is right, legal, and moral at all times. We will hold to the
highest standards of personal and professional ethics
h. Personal Courage - we will face fear, danger, or adversity (physical and moral). We
will be motivated by the moral conviction that what we do is right, worth, and
i. We will take personal responsibility for challenging and correcting what we know to
be wrong
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DEPARTMENT OF THE ARMY
HEADQUARTERS UNITED STATES ARMY MEDICAL DEPARTMENT ACTIVITY
FORT BENNING, GEORGIA 31905-5637
MCXB-PMO (1b)
16 May 2007
MEMORANDUM FOR Staff
SUBJECT: Immunization and Infection Control Requirements
References:
a. The Department of Defense Armed Forces Epidemiological Board Memorandum for the
Assistant Secretary of Defense (Health Affairs), et al, 25 May 1999.
b. The Advisory Committee on Immunizations Practices
c. Occupational Health and Infection Control Policy No. 6-2, “Employee Health”
NOTE: Inactivated vaccines (Td, hepatitis B, influenza, IPV) may be given to pregnant
women if indicated. Pneumococcal vaccine should be administered prior to pregnancy. Live
vaccines (MMR, varicella) should not be given to a pregnant woman or one who is trying to
become pregnant. MMR shots should not be given to personnel who are pregnant or who might
become pregnant within the next three months. A pregnant woman may administer any vaccine
except the Smallpox vaccine.
1. All personnel who can be reasonably expected to be exposed to airborne or bloodborne
infections are required to have the following:
a) Serological evidence of immunity to hepatitis B, measles, mumps, and rubella (MMR),
and varicella, as demonstrated by positive antibody levels to these diseases.
i. If the anti-hBs titer is negative after one series, complete a second three shot series
followed by an anti-hBs titer 1-2 months after the third shot.
ii. If the anti hBs titer is negative after two series the person is considered a non-responder
and will be counseled on what to do in the event of an exposure to a known positive hepatitis-B
source.
iii. Pregnancy and lactation are not contraindications to receiving the hepatitis-B vaccine.
2. Serological evidence of immunity to measles, mumps, rubella, and varicella. If antibody titer
is negative to one part of the MMR titer, after documented proof of two shots, administer another
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MMR and do no titer again. If varicella titer is negative, administer two shots four weeks apart,
need not titer again.
See www.cdc.gov/mmwr/PDF/rr/rr4708.pdf for more information.
a) If a person is found to have a negative serology after two documented doses of MMR, OHS
will refer him/her for one additional dose of MMR. There is no post vaccination serologic
testing if an employee has two documented doses of MMR, which is the ACIP definition of
“immune”. See www.cdc.gov/mmwr/PDF/rr/rr4708.pdf for more information.
3. A baseline negative PPD tuberculin skin test within the past 90 days. Two step testing will be
performed on all new employees who have no documented proof of a TB test within the last
year. Follow-up PPD tests on all health care providers with negative baseline tests will be based
on the hospital’s risk assessment. Individuals with positive PPD tests will be sent to
Community/Public Health for evaluation.
4. Influenza vaccination is strongly recommended annually during the period of mid October
through March of each year. For any questions please contact Charlene Mitchell,
C, Occupational Health, (706) 545-2186 or (706) 545-4041.
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INFECTION CONTROL PROGRAM
EXPOSURE CONTROL PLAN EDUCATION
The Occupational Health and Safety Administration (OSHA)
 published OSHA standard 29 CFR 1910.1030, “Occupational Exposure to Bloodborne
Pathogens”in 1991. This standard requires employers to protect health care workers from
blood and body fluid exposures.
 A copy can be obtained on www.osha.gov.
The EXPOSURE CONTROL PLAN (ECP)
 Located in the Infection Control Manual (ICM) # 3-1 and is designed to eliminate or
minimize occupational exposure to bloodborne pathogens. The ICM is available in all
clinical areas as well as on the LAN under MEDDAC then Infection Control.
An exposure incident
 Any contact with patient’s blood or body fluids to an employee’s non-intact skin, mucous
membranes, or a percutaneous injury to an employee involving a patient’s blood or other
potentially infectious materials (OPIM).
Personnel Protective Equipment (PPE)
 Types of PPE available at MACH include gloves, gowns, masks, face shields, goggles,
glasses, hair covers, shoes covers, and leggings.
 PPE is located on supply carts in all clinical areas
 An employee should select PPE based on their determination of how they may be
exposed during the procedure they are about to perform or assist with.
 Wash hands immediately or as soon as feasible after removal of gloves or other PPE.
 Remove PPE after it becomes contaminated, and before leaving the work area.
 Used disposable PPE will ONLY be disposed of as RMW if it is dripping, saturated,
caked or soaked with blood or body fluids (BBF).
 Reusable PPE will be cleaned in the dirty utility room with STAT 3 or TB Coverage
Spray and allowed to dry.
 Wear appropriate gloves when it can be reasonably anticipated that there may be hand
contact with blood or OPIM, and when handling or touching contaminated items or
surfaces; replace gloves if torn, punctured, contaminated, or if their ability to function as
a barrier is compromised.
 Utility gloves may be decontaminated for reuse if their integrity is not compromised;
discard utility gloves if they show signs of cracking, peeling, tearing, puncturing, or
deterioration.
 Never wash or decontaminate disposable gloves for reuse.
 Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of
blood or OPIM pose a hazard to the eyes, nose, or mouth.
 Remove immediately or as soon as feasible any garment contaminated by blood or
OPIM, in such a way as to avoid contact with the outer surface.
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Hepatitis B vaccine
 Three doses, given in one of the recommended schedules, induces a protective antibody
response in more than 90% of healthy adults and in more than 95% of infants, children,
and adolescents. The vaccine is given intramuscularly at 0, 1 and 6 months after the
primary dose normally in the deltoid muscle.
 The Hepatitis B vaccine is available to all employees free of charge.
In an emergency involving blood or OPIM:
1. Wash the exposed area immediately with soap and water
2. Notify your supervisor
3. Report to the ER within 30 minutes
(bring with you to the ER the source patient’s name, SSN, physician’s name and
diagnosis)
 NOTE: If the exposure qualifies you to take HIV chemoprophylaxis, the
first dose should be administered within two hours of the exposure.
4. Call Occupational Health Service (OHS) at 545-2186/7292
5. Notify the source patient’s primary physician and have the source patient’s blood
work drawn
6. Notify MACH Safety Officer at 544-2224
7. Notify the Infection Control Nurse at 544-3443

A confidential medical evaluation will be conducted by an ER physician.
Following initial first aid the following activities will be performed:
1. Document the routes of exposure and how the exposure occurred.
2. Identify and document the source individuals’: name, SSN, and
name of the treating MD. If the source pt is already known to be
HIV positive new testing need not be performed. Always draw a
HEP B EXP even if the source pt is known to be positive for
hepatitis.
3. Obtain consent (not required for active duty soldiers) and ensure
that these labs are ordered in CHCS:HIV EXPOS,HEP B EXP,&
RPR on the source pt.
4. The exposed employee will be provided with the source pt’s test
results and laws protecting confidentiality.
5. After obtaining consent the exposed employee’s blood will be
tested for RPR, HIV, HAV, HBV, and HCV serological status.
 If the exposed employee does not give consent for HIV testing during
the collection of blood for baseline testing, MACH lab will preserve
the baseline blood sample for at least 90 days.
 The ER MD will then determine the: exposure code, HIV status code,
and PEP recommendations using the flow charts attached to the ECP.
Regulated Medical Waste (RMW)
 All specimens are placed in a biohazard bag
 All RMW is placed in a red bag with a biohazard label
 Any contaminated item may be placed in a red bag
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HIV



Although a serious disease, HIV is very difficult to transmit by needlesticks. Even when
the source of the blood is infected with HIV, the chance of contracting the disease
through a needlestick appears to be approximately 1 in 300. This risk was determined by
careful follow-up of persons exposed by needlesticks to known HIV positive sources.
If the source of your needlestick is unknown or not at risk for HIV, then the chance the
source is positive is very low.
The Licensed Health Care Provider (LHCP) will assess any significant risk to you. The
medical follow-up, which may involve a series of blood tests over the next year, will
determine your infectivity or noninfectivity. If your risk is insignificant you may still
request and receive the tests and undergo medical follow-up by the OHS. Should you
develop fever, chills, and muscle aches and severe headaches during the next 6 months,
schedule a reevaluation since there is a possibility these nonspecific symptoms are related
to HIV (most such illnesses, however, are not related to HIV).
Hepatitis B
 A viral infection involving the liver, and constitutes an important risk associated with
needlestick exposures. Hepatitis B is transmitted much more easily than HIV; infection
occurs within 25% of employees exposed to a known positive source. Fortunately, we
have treatment available that may prevent the development of Hepatitis B, or lessen its
severity if you are infected. There is also a safe and effective vaccine that is advised for
most employees. The LHCP will assess the risk of your exposure and prescribe
appropriate therapy and/or follow-up with OHS. Should you develop a yellow color in
the normally white portion of your eyes, a marked darkening of your urine, or substantial
nausea or abdominal pain during the next six months, schedule a reevaluation.
Hepatitis C (once called non-A, non-B)
 Another type of viral liver infection, and used to be the most common transfusionassociated infection. Fortunately, we now have a screening test for Hepatitis C that
permits the exclusion of most infected blood from use. Even more commonly than with
hepatitis B, hepatitis C can progress to chronic lever disease. The risk of getting hepatitis
C from a known positive source is not well established, but appears to be about 2-4% by
needlestick. If the LHCP finds that your source might represent a significant risk for
hepatitis C, you will be given a treatment that is hoped will help prevent you from
becoming infected.
INFECTION CONTROL NURSE 544-3443, Pager 317-0389
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MACH Safety Policies & Procedures
Accidental Injury Reporting
Military Injuries
All accidental injuries are to be reported, on and off duty Use FB (Med) Form 1529, Record of
Injury (get from Safety Manager) Turn in ASAP, no later than 5 working days after accident
Civilian Job Related Injuries
1. The MEDDAC/DENTAC employee, who has been injured in the performance of duties,
must be escorted to the MACH Emergency Department (ED) by their respective
supervisor or a designated representative as soon as they become aware that an injury has
occurred. It is NOT necessary to bring a form CA-1 to the ED at this time.
2. It is the responsibility of the injured employee to obtain the form CA-1 and complete
their portion of the form ASAP. The form CA-1 is available for download from AMEDD
Form Flow.
3. Once the injured employee has completed their portion of the form CA-1, they should
then submit it with any supporting medical documentation to their supervisor or
designated representative for review and completion.
4. The supervisor or designated representative will complete their portion on the form CA-1
(hardcopy) and transcribe all information from the hardcopy CA-1 to the electronic CA1. The electronic CA-1 can be accessed via the internet at the following web address:
https://hamlet.cpms.osd.mil/static_java_edi_sup.html. Once both forms are completely
filled out the electronic copy is printed and then submitted.
5. The MEDDAC Safety Manager must be notified immediately of the injury by calling
(706) 544-2224 or pager (706) 317-0332.
6. All medical documentation, the completed hardcopy and the copy of the electronic CA-1
forms which have been signed by the employee, supervisor, and any witnesses, are to be
hand carried to the FECA Administrator, Ms. Felecia Griffin, for authentication. This
process should be completed the day of the injury or NLT noon the day after the date of
notice. The date of notice is the date the employee provided the supervisor with the
hardcopy CA-1 properly filled out and is not necessarily the date of the injury. Ms.
Griffin is located in Bldg #6 Room 134, (706) 545-2777.
7. Civilian employees may be seen in the MACH ED for their initial evaluation and
treatment, but follow-up care may be provided either by MACH or other healthcare
facilities.
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8. For questions, concerns, or additional guidance contact Mrs. Gloria Irizarry, FECA Nurse
(706) 545-2186 or (p) (706) 327-0324.
Patient/Visitor Accidental Injuries
Non-treatment related accidental patient injuries reported to Safety Manager ASAP
Visitor accidents reported to Safety Manager immediately
Property Damage
Report any accidental damage to government property in excess of $1000 by providing a memo
giving details to the Safety Manager.
Any damage by an on-duty staff member to non-government property reported to Safety
Manager as soon as possible.
Reporting Accidents/Injuries within MEDDAC/DENTAC
1. The following summary is a compilation of the requirements in AR 385-40, Accident
Reporting and Records, 1 November 1994, with changes; DA Pam 385-40. Army Accident
Investigation and Reporting, with changes; and Appendix F to MEDDAC Regulation 385-10,
MEDDAC/DENTAC Safety and Fire Prevention Program. All assigned personnel, military and
civilian, should be generally aware of these reporting requirements.
2. All accidents must be reported to the concerned supervisor.
3: Accidents resulting in the below listed consequences must be reported to the Safety
Manager, or to the AOD during other than standard duty hours, as soon as possible.
a. Any accidental death or injury which might result in lost duty time to military (on or
off duty) or civilian (on duty only) staff members.
b. Any accidental death or injury to patients (non-treatment related) or visitors.
c. Any significant ($1,000 or more) damage to government property (this includes
such things as the cost of cleaning up a hazardous material spill), or any damage to nongovernment property which is caused by MEDDAC/DENTAC staff members (such as hitting a
civilian vehicle). For damage to non-government property to be reportable, the staff member
responsible must have been on duty when the accident occurred.
4. Written reports required, and the reporting of less serious accidents. are as follows:
a. Military Personnel: A report must be submitted for all assigned military personnel
injured in accidents on or off duty, where the injury requires treatment, regardless of its severity.
One copy of FB (MED) Form 1529, Record of Injury, will be prepared by the activity to which
assigned and forwarded to the Safety Manager within five (5) working days of the incident. FB
(MED) Forms 1529 may be obtained from any activity Safety Officer or from the Safety
Manager.
b. DA Civilian Personnel: Any DA civilian employee of the MEDDAC or DENTAC
who is injured in an on-the-Job accident must be processed through the MACH Emergency
Room (ER). The employee's supervisor (or a designated representative) must accompany the
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injured employee to the ER. This should be done as soon as the injury is noted. The supervisor
will furnish the injured employee a Form CA-1 to properly report the injury, this form can be
found at http://www.dol.gov/esa/regs/compliance/owcp/forms.htm . Taking the injured employee
to the ER WILL NOT be delayed while waiting to obtain forms. The forms must be completed
electronically by the injured employee, the supervisor, and any witnesses to the injury. A card
copy of the CA-1s will be completed by all and hand-carried to CPAC, FECA Liaison, Bldg 6,
Room 134, the same day as the accident/injury occurs.
c. Property Damage: Activity chiefs and commanders will forward to the Safety
Manager a memorandum concerning all accidental damage to government property which
exceeds $1,000 in repair or replacement cost, and all on-duty accidental damage to nongovernment property caused by assigned personnel. The memorandum will detail what was
damaged, how the damage occurred, estimated repair or replacement cost, and all persons
involved in the incident. The requirement to submit the memorandum does not negate the
requirement to quickly notify the Safety Manager or AOD at the time the accidental damage
occurs.
5. When in doubt on reporting requirements, call the Safety Manager, Ms Lorraine Thomley, at
(706) 544-2224, by pager number 317-0332, or at home through the Information Desk/AOD.
Detailed information on the reporting of serious accidents involving MEDCOM personnel are in
the AOD/SDNCO instructions.
Note: MACH FECA Nurse is Gloria Irizarry, RN, (706) 545-2186 or
pager (706) 317-0324.
ELECTRICAL SAFETY
The Electrical Safety Program for the MEDDAC and DENTAC is detailed in Appendix C
of MEDDAC/DENTAC Regulation 385-10.
1. Patient-Care-Related Electrical Equipment: (equipment intended for diagnostic, therapeutic,
or monitoring purposes in patient care vicinity). Medical Equipment Maintenance Branch of the
Logistic Division closely controls and maintains these. Each major activity ensures the training
for all staff members utilizing such equipment in the care and use.
2. This safety program covers All other electrically powered items, from computers to pencil
sharpeners. Whenever such equipment is brought into the work area for the first time, your
activity safety officer or someone they designate (possibly each supervisor) conducts a visual
inspection for safety to ensure the UL label or marking, the condition of plugs and cords, and the
absence of any obvious defects that could cause an injury or fire.
a. Coffee makers/hot water pots are the only non-job related heat-producing appliances
allowed in MEDDAC facilities. They must be used on a noncombustible surface, and be at least
16 inches from other combustible items (wooden cabinets, bulletin boards, misc. "stuff', etc).
Once in place, and if relocated, they must be inspected by the Safety Manager and an appliance
"Approval Card" issued. Toasters and toaster ovens, hot plates, etc. are not allowed. Microwave
ovens are not "heat-producing", and ALLOWED under the same rules as in paragraph 2 above.
b. MEDDAC does not allow most space heaters in any MEDDAC facilities. They are a
serious fire hazard by the Life Safety Code. A low-powered/low-heat type of space heater is
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allowed in staff non-sleeping areas. The Safety Manager must approve any being considered for
purchase as meeting Life Safety Code requirements. Safety Office can provide sources to
purchase the acceptable type of heater that can be used in the facility.
c. Use no Extension cords in the hospital, except those assembled by the Facilities
Management Branch for temporary or emergency use and their use (or planned use) approved in
advance by the Safety Manager. Fused "power strips", primarily designed to protect electronic
equipment, ARE allowed for use. Normal "store bought" extension cords are forbidden. During
construction and maintenance activities, use extension cords which are in good condition and
tested for grounding and continuity by the Facilities Management Branch.
d.. Do not use "Gang Plugs", any devices that allow more items to be plugged into a
receptacle than it was designed to accommodate. Never use "Cheaters", which allow a grounding
type plug to be plugged into a non-grounded type receptacle. Never overload circuits or bypass
the grounding system.
3. Whenever we plug in any item of electrical equipment for use in a MEDDAC or DENTAC
facility, it is the direct and individual responsibility of each of us to conduct a visual inspection
of the receptacle and the equipment for any obvious defects. Cracked receptacles, broken cord
insulation, missing grounding prongs, cracked or broken cases, etc. will be cause to not use that
receptacle or equipment. Do this quick and simple pre-inspection every time you use a piece of
electrical equipment.
4. Patient owned electrical equipment (such as radios/TVs, electronic games, hair dryers,
curling irons, etc.). The patient cannot use their equipment until the MEDDAC Safety
Manager (If absent, by the Activity Safety Officer or Evening/Night Supervisor) inspects and
tags it as acceptable. Battery powered items do not require such an inspection. If there is any
doubt as to the safety of an item, it will not be allowed. No patient-owned electrical equipment
will be allowed in the Psychiatric Ward, Newborn Nursery, or Recovery Room. Remember, we
are responsible for patient safety while they are with us, even if they are injured by their own
property.
5. Emergency generators provide the primary Emergency Power System for the hospital. The
emergency generators start up and provide power automatically if the "city" power fails. Not
everything connects to the emergency system, only what is necessary for in-patient care and the
safety of all staff and patients. The ER, OR, ICU, and L&D are almost totally covered by
emergency power. Otherwise only partial lighting, selected equipment, some elevators, and
specifically marked electrical receptacles are connected. We do not expect to be able to continue
to "function as normal" under emergency power. Emergency Power electrical receptacles are
identified in three ways:
a. By a yellow cover plate with "EMERGENCY" printed across the top, or,
b. In the patient consoles by a red receptacle, or,
c. In a few instances where an installed white "tamper-proof” receptacle in a patient
console, by a yellow label saying "EMERGENCY". Learn where the emergency receptacles are
in your area. [And yes, they work just fine when normal power is on].
6. Do not use Cell phones and radio transmitters in certain parts of the hospital. They interfere
with some patient care equipment, with the potential to cause harm to patients. For that reason do
not use hand held radios to transmit (listening only is OK) and turn cellphones completely OFF
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(they transmit even when not in use) when in those areas. This ban includes remote-station
telephones and any other devices that transmit. Areas where such action is prohibited are the ER,
OR Wing, ICU Wing, L&D Wing, and the Medical Equipment Maintenance Branch workshop in
the basement.
Fire Emergency Response
(What to Do If the Fire Is In Your Area)
1. Take the following general steps when confronting a fire in the hospital. They could occur in a
different sequence than that given below, depending upon the specific situation. It is very
important that you remember the code word “R*A*C*E”, and know what the letters stand for
and remind you to do. Also remember that your actions will be as part of a team. No one person
can do all the actions, but you need to ensure that they are done.
Rescue patients (persons) in immediate danger
Alarm - Report the fire.
Confine - Isolate the fire.
Extinguish the fire.
Evacuate to another zone
Evacuate the floor or building. (Only Upon Direction From The Fire Department)
a. RESCUE PERSONS IN IMMEDIATE DANGER: Remove any person in immediate danger
to a safe area. If the person discovering the fire must aid another person in immediate danger,
he/she will first call for assistance by calling aloud the phrase, "Page Doctor Red," and repeating
the phrase until personnel in the area respond by coming to assist. Anyone in the area, upon
hearing the code called aloud, will immediately go to assist and start accomplishing the rest of
the fire action steps. Remember, a team effort.
b. ALARM - REPORT THE FIRE. The senior person in the area will take charge and ensure that
the fire is reported by ALL of the means listed below. There is no special order to do them in, do
what’s most practical, but accomplish them all! Remember - teamwork.
(1) Pull the nearest fire alarm.
(2) Call 911 on the nearest telephone. When the 911 operator answers, report the fire in a
calm, clear manner. Give your name and the exact location of the fire, (i. e., Martin Army
Community Hospital, Building 9200, Ward 5B, Room 553). Stay on the phone until you are sure
the Fire Department has all the correct information, but no longer.
(3) Dial 544-1685 (Information Desk Fire Phone) or 544-2041/2042 (Information Desk)
and report the exact location of the fire.
c. CONFINE -ISOLATE THE FIRE. Confine the fire to the smallest area possible by closing
doors. Doors within MACH will contain a fire for certain periods of time, so this is a very critical
step. If no personnel are at risk, this may be the first step taken upon discovering a fire, followed
by reporting the fire. This step also may include shutting off piped-in oxygen, but only on the
orders of the senior ward person present. Make sure all doors on the unit (ward, clinic, and wing)
are closed to prevent smoke from getting into the corridor and other rooms. (This is also why you
must keep ceiling tiles in place - smoke control).
d. EXTINGUISH THE FIRE. Most hospital fires can be extinguished by such simple actions as
pouring a pitcher of water on it, smothering it with a blanket, unplugging equipment, or turning
off an electrical circuit. Immediate, aggressive action using simple
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methods, progressing to use of the dry chemical fire extinguishers, will eliminate all but the most
serious fires. The sprinkler system will activate if the fire gets too big for you to handle. If there
is any doubt of you being able to put it out, isolate it and let the sprinklers handle it. Quick and
early actions to extinguish the fire are always the first choice.
e. EVACUATE:
(1) Clinics and Administrative Areas, including outlying buildings: If you are in an
administrative area or a clinic, you will immediately evacuate to another zone if the fire is in
your area. (If you are in a building other than the hospital, you will immediately evacuate the
building to the designated assembly area outside). Staff will collect the patients and visitors and
all will move horizontally through smoke doors to another zone. Stop and remain in that zone
unless directed to move elsewhere. Don't move down stairways unless absolutely necessary (due
to the danger of falls during the excitement, and to help you maintain control). Within the
hospital, selected staff members will remain in the fire area and attempt to extinguish the fire -If
the fire is small and they can do so safely. Otherwise they will leave the area and allow the
sprinkler system to activate and extinguish the fire.
(2) Wards: If you are in a unit that has bed patients, you do not evacuate until directed to
do so. Search for the fire, isolate it, and extinguish it if possible. Only when it is clear that the
fire cannot be quickly extinguished, and/or that smoke will make the unit untenable, do you
move patients through fire doors (again horizontally) to the next zone.
(3) Floors/Hospital: Evacuation of a floor or the hospital will only be done upon orders
from the hospital command group or representative.
2. To react properly in the event to a fire, you need to KNOW to following:
a. The meaning of the word RACE. - Rescue, Alarm, Confine, Extinguish/Evacuate.
b. The code word for "Fire" in the hospital. - "Page Code Red". Do not call "Fire!" in
the hospital - use the code word. Use "Fire" in outlying buildings where non-staff may not know
our procedures, and the possibility of panic is not as great.
c. The three steps to report a fire. -- Pull Alarm. Call 911. Call the Information Desk.
d. Evacuation of a unit/area in the hospital should be horizontal if possible (stay on the
same floor), down stairways only if necessary.
e. Who can authorize shutting off oxygen on a unit, and where are the shutoff valves?
Only the senior person present assigned to the unit can order the oxygen shut off.
f. Where is the nearest fire alarm and fire extinguisher to your area? Where is the
nearest fire exit and where does it go?
g. Who evacuates during a fire and when? - Clinics, Admin Areas, and outlying buildings
evacuate immediately upon a fire being reported in their area/building. Wards with bed patients
do not evacuate until they have determined it is necessary.
h. What class of extinguisher is used on what types of fires?
(1) Class A - Use on wood, paper, cloth, and other ordinary combustibles.
(2) Class B - Use on flammable liquids such as alcohol, oil, gasoline.
(3) Class C - Use on electrical equipment still drawing power (plugged in, circuit
breaker not off, etc.).
(4) Class ABC - Use on any of the above. Most extinguishers in the
hospital are ABC, that being the most versatile. It is not as effective on Class A fires as
Class A extinguishers.
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i. How do you use a fire extinguisher? Remember "PASS".
(1) Pull the pin, or (for most of ours), Press the lever to puncture the CO2
cartridge.
(2) Aim at the base of the fire from about 9 feet away
(3) Squeeze the lever
(4) Sweep slowly from side to side, evenly coating the area of the fire,
continuing even after you think the fire is out. Always stay with the
"extinguished"
(It may not be) fire until the fire department arrives, and have
someone go and get another
extinguisher (Just in case).
Fire Emergency Response
(What To Do If the Fire Is NOT in Your Area)
I. Most of us now know that when we see a fire in our area of the hospital we RACE (Rescue,
Alarm, Confine, Extinguish or Evacuate). But what do we do if we are an "innocent bystander" if while we are going about our own business the fire alarm or pager says "Code Red?" Some
activities, such as the Pharmacy, Information Desk. and housekeeping staff, have specific actions
to take. Their supervisors will explain this to them. But what do the rest of us do?
2. When the alarm goes off, all staff members who are not in the area where the fire is reported
will follow these steps:
a. Listen to the voice pager to determine in which area of the hospital initiated the alarm.
Continue your normal duties, but remain aware that the alarm sounded and further instructions
may be given over the pager which will affect you.
b. Reduce your travel within the hospital to a minimum, staying in your duty section as much
as possible consistent with your duties, until the "All Clear" has been given. You may be needed,
quickly! Do not go to the area which initiated the alarm, unless directed to do so.
c. Assist in explaining to patients and visitors what is happening. Just tell them that the fire
alarm sounded, it is being checked out, and there is no danger.
d. Follow the directions of supervisors and Fire Department personnel regarding evacuating
an area or providing assistance to move patients.
3. Treat all alarms as actual fire emergencies (they may be) and follow instructions of senior
personnel. If you don't know what to do, ask another staff member - don't guess.
16
Radiation Safety Training
Regulations that govern the use of ionizing radiation at Martin Army Community Hospital:
a. Title 10 Code of Federal Regulations (CFR), Part 20 and 35
b. AR 11-9 The Army Radiation Safety Program 28 May 1999
c. AR 40-5 Preventive Medicine, 15 October 1990
d. AR 40–14 Occupational Ionizing Radiation Personnel Directory, 30 June 95.
e. MEDCOM Regulation 40-42 U.S. Army Command Radiation Safety Program, 13
AUG 04
f. Army Pamphlet 40-18 Personnel Dosimetry Guidance and Dose Recording Procedures
for Personnel Occupationally Exposed to Ionizing Radiation, 30 JUN 95.
g. TB MED 521 Occupational and Environmental Health. Management and Control of
Diagnostic and Therapeutic X-Rays, 26 FEB 02.
h. TB MED 525 Control of Hazards to Health from Ionizing Radiation used by the Army
Medical Department.
i. MEDDAC Reg 40-8 Radiation Protection Program
What is Radiation?
a. Radiation is defined as energy in transit in the form of high-speed particles and
electromagnetic waves.
b. There are two main categories of radiation, ionizing and non-ionizing. Examples of
ionizing radiation are alpha particles, beta particles, gamma and x-rays, and neutrons. Examples
of non-ionizing radiation are electromagnetic waves produced by radio broadcasts and cellular
phones, microwaves, and laser radiation.
Hazards of the different types of ionizing radiation:
a. Alpha particles travel only 1-2 inches in air, they are an internal radiation hazard and
materials as thin as the outer layer of your skin or latex gloves can stop them.
b. Beta particles can penetrate the skin only a few millimeters, they are both an internal
an external radiation hazard, and can be stopped with aluminum or plastic.
c. Gamma and X-rays are the most penetrating types of radiation, they are an external
radiation hazard, and you need a dense material such as lead to shield against this type of
radiation.
17
(1) a large dose of radiation in a short time can cause Acute Radiation Syndrome
(ARS). A classic symptom of ARS is nausea and vomiting. It would take a dose of about 100
rem before these symptoms would start appearing. As you can see, this is significantly greater
than the yearly limit of 5 rem for a radiation worker.
(2) Prolonged exposure to lower levels of ionizing radiation can produce delayed
effects such as cancer, cataracts, and effects on a developing fetus.
(3) We are exposed to ionizing radiation at all times. An average member of the
U.S. Population gets exposed to ~0.360 rem per year. The largest contribution to this exposure
is Radon. In contrast, the smallest source of exposure is from nuclear power.
Locations of sources with ionizing radiation:
a.
b.
c.
d.
e.
f.
g.
Nuclear Medicine
Waste Storage Area
DENTAC
ER
OR
Oral Surgery
Radiology
Location of sources with non-ionizing radiation:
a.
b.
c.
d.
Oral Surgery
EENT
Dermatology
Occupational/Physical Therapy
Radiation workers and their allowed exposure:
a. Radiation workers are allowed to receive a dose of 5 rem/year. They can receive up to
15 rem/year to the lens of the eye and 50 rem/year to any extremity. Radiation workers who
have declared their pregnancy are limited to 10% of the aforementioned limits. Members of the
general public can only receive a dose of 0.1 rem/year.
b. It is each individual’s OBLIGATION to report unsafe conditions to the Radiation
Safety Officer.
c. You have the RIGHT to be informed of your occupational exposure levels and
bioassay results. Radiation workers will receive an exposure report annually.
d. If you are a radiation worker and you become pregnant, you must declare your
pregnancy in writing. Contact the Health Physics Office for assistance in this matter.
18
Documents posted or located in Nuclear Medicine and/or the Health Physics Office:
a.
b.
c.
d.
e.
10 CFR 19 and 20
NRC License # 10-06493-02
Standard Operating Procedures
Any Notice of Violation
NRC form 3
POC:
Health Physics Office: 544-1513/2458
Nuclear Medicine:
544-2313
Electromagnetic Interference (EMI) Awareness
Regulations that govern the use of non-ionizing radiation at Martin Army Community Hospital:
a. TB Med 523 Control of hazards to health from microwave and radiofrequency
radiation and ultrasound, 15 July 1980.
b. TB MED 524 Occupational and Environmental Health, Control of Hazards to Health
from Laser Radiation, June 1985.
c. MEDDAC Regulation 385-10, MEDDAC/DENTAC Safety and Fire Prevention
Program.
d. MEDCOM Regulation 40-42, U.S. Army Command Radiation Safety Program, 13
AUG 2004.
What is EMI?
Electromagnetic Interference can occur when wireless devices interfere with electronic medical
devices.
What wireless devices?
Wireless devices commonly used in the hospital include:
Cellular Phones
Bi-directional Pagers
Some Personal digital Assistants (PDA’s)
Walkie-Talkies
In what locations are the uses of wireless device prohibited?
19
Radio transmissions are not allowed in areas that are designated as Patient Dependent Equipment
Locations (PDEL’s). Wireless devices MUST be turned OFF when in these locations.
Never use transmitting devices within 1 meter of electronic medical equipment!
These locations include but are not limited to:
Emergency Room
Intensive Care Unit
Operating Room/Recovery Room suite
Newborn Nursery
Labor and Delivery Suites
Medical Equipment Maintenance Shop
* Exceptions can be made by the Safety Manger for maintenance activities and emergency
operations.
It is the responsibility of the staff to actively enforce these standards with visitors, patients, and
other staff. Report cases of non-compliance to the supervisors, Safety Manager, or Radiation
Safety Officer.
POC:
MEDDAC Safety Manger:
Radiation Safety Manager:
544-2224
544-1513/2458
20
PATIENT SAFETY
Joint Commission has mandated that there be a Patient Safety Program in every hospital in
America to reduce and some day completely eliminate all medical errors. In order to
achieve a culture of safety, awareness of potential problems must be a part of daily
operations, 24 hours a day, 7 days a week.
You can contact the Safety Program Manager at 544-4224.
What is the Purpose of a Patient Safety Program?
To prevent or minimize the occurrence of untoward outcomes consequent to medical care
and ultimately improve patient safety and healthcare quality.
To provide a safe environment for patients, visitors and staff.
To prevent injuries and manage injuries that do occur to minimize negative consequences.
To establish a “culture of safety” throughout the Medical Center.
The 2006 Hospital National Patient Safety Goals are:
Patient Safety Goal #1
Improve the accuracy of patient identification.
a. Use at least two patient identifiers (neither to be the patient’s room number)
whenever administering medications or blood products; taking blood samples and
other specimens for clinical testing, or providing any other treatments or procedures.
b. Not applicable.
Patient Safety Goal #2
Improve the effectiveness of communication among caregivers.
a. 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 “read back” the complete order or test result
b. Standardize a list of abbreviations, acronyms and symbols that are not to be used
throughout the organization.
c. Measure, assess, and if appropriate, take action to improve the timeliness of
reporting, and the timeliness of receipt by the responsible licensed caregiver, of
critical test results and values.
d. Not applicable.
e. Implement a standardized approach to “hand off” communications, including an
opportunity to ask and respond to questions.
Patient Safety Goal #3
Improve the safety of using medications.
a. Retired in 2006.
b. Standardize and limit the number of drug concentrations available in the
organization.
c. 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.
d. Label all medications, medication containers (e.g., syringes, medicine cups,
21
basins), or other solutions on and off the sterile field in perioperative and other
procedural settings.
Patient Safety Goal #4
Not applicable.
Patient Safety Goal #5
Retired in 2006.
Patient Safety Goal #6
Not applicable.
Patient Safety Goal #7
Reduce the risk of hospital acquired associated infections.
a. Comply with current Centers for Disease Control and Prevention (CDC) hand
hygiene guidelines.
b. Manage as sentinel events all identified cases of unanticipated death or major
permanent loss of function associated with a health care associated infection.
Patient Safety Goal #8
Accurately and completely reconcile medications across the continuum of care.
a. Develop a process for obtaining and documenting a complete list of the patient’s
current medications upon the patient’s admission to the organization and with the
involvement of the patient. This process includes a comparison of the medications
the organization provides to those on the list.
b. A complete list of the patient’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.
Patient Safety Goal #9
Implement a fall reduction program and evaluate the effectiveness of the program.
Patient Safety Goal #13
Encourage patients active involvement in their own care as a patient safety strategy.
a. Define and communicate the means for patients and their families to report concerns
about safety and encourage them to do so.
Patient Safety Goal #15
The organization identifies safety risks inherent in its patient population.
a. The organization identifies patients at risk for suicide.
Universal Protocol (UP)
Wrong site, wrong procedure, and wrong person surgery can be prevented.
a. Conduct a preoperative verification process as described in the Universal
Protocol.
b. Mark the operative site as described in the Universal Protocol.
c. Conduct a “time out” immediately before starting the procedure as described in
the Universal Protocol.
22
What Can We Do?
Focus your attention on high-risk processes. Incident reports & other information
are used to identify risk-prone
patient care issues. Fill out incident reports as needed.
USE OF RESTRAINT
Philosophy
Restraint has the potential to produce serious consequences, such as physical or
psychological harm, loss of dignity, violation of an individual’s rights and even death.
Because of the associated risks and consequences of use, BMACH is increasingly
exploring ways to decrease restraint use through effective preventive strategies or the use
of alternatives.
Policy
MEDDAC Reg 40-57 “Use of Restraints and Protective Devices” apply to each episode of
restraint. Restraint will only be used when less restrictive methods are not sufficient to
protect the patient or others from injury. The decision to restrain requires adequate and
appropriate clinical justification. Restraint is to be applied for no longer than is clearly
needed, and any doubts about the need for restraint should be resolved in favor of an
alternative to restraint. BMACH does not permit the use of restraints for punishment or staff
convenience.
Definitions
Restraint. Any involuntary method of physically restricting a person’s freedom of
movement, physical activity or normal access to his or her body.
Restraint may be applied as either part of a protocol approved by the medical staff or as
directed by doctor’s orders.
Therapeutic Holding. The temporary emergency means of providing safety and
preventing injury by holding a patient physically without the use of mechanical restraining
device.
Soft Mechanical Restraints. Soft but durable material to involuntarily restrain the
movement of the whole or a portion of a patient’s body as a means of controlling his/her
physical activities in order to protect him/her or others from injury or to provide needed
medical care (i.e. IV lines, tubes, etc.)
Mechanical Restraints. The use of equipment such as locked Velcro or soft restraints to
involuntarily restrain the movement of the whole or portion of a patient’s body as a means of
controlling his/her physical activities in order to protect him/her of others from injury.
Locked Velcro restraints are to be used only when soft mechanical restraints are not
clinically adequate.
23
These standards do not apply to the following:
Medical Immobilization Devices. Restrictions that are inherent and customary parts of
medical, dental, diagnostic, or surgical procedures – i.e. surgical positioning, intravenous
(IV) arm boards, radiotherapy.
Adaptive-Supportive Devices. Restrictive devices used to meet the assessed needs of a
patient who requires adaptive support (postural) – i.e. orthopedic appliances, braces, to
maintain sitting position.
Medical Protective Devices. Restrictive devices used to avoid direct, accidental injuries
such as helmets, bedrails, safety straps on litters and wheelchairs.
Legally Mandated Devices. Restrictive devices used as law enforcement devices – i.e.
handcuffs used for patients in police custody.
Competent Trained Staff. Direct Care staff members, who have completed hospital restraint
training and have passed both a written and practical examination on the safe application of
restraint, release from restraint, monitoring procedures and alternative to restraint. Training
is conducted annually and documented in the staff member’s Competency Assessment File.
Nursing personnel who are qualified through competency-based training coordinated by
Hospital Education Division (HED) are responsible for initiating and terminating restraint as
guided by MEDDAC Reg 40-57 or by physician order.
Both LIPs and RNs can initiate restraints. If initiated by the RN, a verbal or telephone order
must be obtained from an LIP within the time constraints IAW MEDDAC Reg 40-57. There
must be clear clinical justification, i.e., an individual assessment with a conclusion that the
patient’s behavior poses a risk of injury to self or others prior to exercising an individual
order for restraint. Such assessment will be clearly documented in the progress notes
within the patient’s chart.
All staff are responsible for ensuring that:
 Less restrictive alternatives are considered prior to the use of restraint
 The patient’s rights, well-being, and dignity are protected and preserved
 Restraint is safely applied and removed by competent staff
 The patient is assessed and monitored appropriately
 The patient’s needs are met during the restraint episode
 The restraint episode is properly documented

The patient and family are educated and included/involved in the decision process
for the use of restraint
Choice of Restraint Device
The least restrictive type of restraint will be used first. Only equipment specifically designed
for restraint will be used. Only locked Velcro and soft restraints are used at Martin Army
Community Hospital (MACH).
Education
Advising and educating the patient and/or the patient’s legal representative for the use of
restraint is required. It is sufficient to advise and educate once per hospitalization providing
the behavior leading to the application of restraint remain consistent (i.e., pulling of tubes).
If a new behavior is encountered (i.e., attempt at self-harm in a patient who previously
received advice and education for restraint to prevent the pulling of tubes), restraint should
24
be discussed for the new behavior.
The use of “prn” or “as-needed” restraint order is PROHIBITED.
MACH does not use seclusion for behavioral patients.
Allowable Duration of Restraints
Single-episode duration cannot exceed 24 hours in patients with other than primary
behavioral health needs.
Single-episode duration cannot exceed four hours for adults with primary behavioral health
needs.
Single-episode duration cannot exceed two hours for children and adolescents age 9 to 17
with primary behavioral health needs.
A doctor’s order is needed when continued restraint is required in excess of the times listed
above. When a patient is placed in restraints for primary behavioral health needs
physicians must do a face-to-face initial assessment of the patient within four hours, then
every eight hours for adult patients.
If restraint is terminated early and the same behavior reoccurs, the original doctor’s order
for restraint can be used if the prescribed time frame has not elapsed and alternatives to
restraints have not been effective. Patients in restraints for other than primary behavioral
health needs require a physician note each calendar day. Nursing staff must monitor the
patient and document every two hours. Patients in restraints for primary behavioral health
needs require continuous 1:1 monitoring and documentation on the Restraint Flowsheet,
and a Nursing Restraint note must be documented every four hours in CIS.
Reporting. The use of restraint will be identified on the Nursing 24-hour report.
Documentation
Documentation by both the LIP and the RN must address that less restrictive means of
control were attempted.
Documentation must include the following:
 Clear clinical justification for use of restraint
 Less restrictive measures that were attempted but unsuccessful
 Type of restraint employed
 Extent of patient and family education annotated on the progress note
 Patient care issues, to include efforts taken to preserve patient’s rights, dignity, and
privacy
 A time limited order
RISK MANAGEMENT & PEER REVIEW
The focus of Risk Management is to identify opportunities to improve care in an
interdisciplinary, comprehensive, ongoing manner. Risk Management is a systematic
process of identifying, evaluating and correcting problems to minimize or eliminate the
threat of injury/risk to patients, family members, visitors and Medical Treatment Facility
(MTF) personnel, as well as financial or other loss to the government.
25
The components of the Risk Management Program are:
a. To identify and evaluate individual cases of alleged undesirable, adverse or
substandard patient care.
b. To identify general clinical areas of risk that represent actual or potential sources
of patient injury.
c. To resolve identified clinical problems disclosed through the Risk Management
process.
d. To provide staff education/training opportunities related to the prevention,
reduction, or elimination of clinical sources of patient injury.
Three major areas of Risk Management are:
Sentinel Event – A sentinel event is an unexpected occurrence involving death or
serious physical or psychological injury, or the risk thereof. Serious injury specifically
includes loss of limb or function. The phrase “or the risk thereof” includes any
process variation for which a recurrence would carry a significant chance of a
serious adverse outcome.
Good Catch – Used to describe any process variation which did not affect the
outcome, but for which a recurrence carries a significant chance of a serious
adverse outcome. Such a near miss falls within the scope of the definition of a
sentinel event, but outside the scope of these sentinel events that are subject to
review by the Joint Commission under its Sentinel Event Policy.
Standard of Care (SOC) – Identified, documented, and generally accepted levels of
care that serve as clinical guidelines for the delivery of safe and effective patient
care and patient response to that care with a variety of clinical situations
The Risk Management Officer: 544-1536
PUBLIC NOTICE
The Joint Commission deals with organization quality, safety of care issues, and the
safety of the environment in which care is provided. Anyone believing that he or she
has pertinent and valid information or concerns about such matters is encouraged to
contact the Chief of Quality Management in order to allow them to deal with the issue
quickly and efficiently, or Joint Commission directly at:
Division of Accreditation Operations
Office of Quality Monitoring Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Faxed to (630) 792-5636 or E-mailed to complaint@jcaho.org
All reports will be kept in the strictest confidence. No retaliatory, disciplinary action
will be taken against employees when they report safety or quality of care concerns.
This notice is posted in accordance with the Joint Commission’s requirements and
may not be removed.
26
PREVENTIVE MEDICINE/ENVIRONMENTAL
SERVICES
Occupational Health Service
Occupational Health Service is located in Soldier's Plaza, Bldg #2630 (last row of Bldgs.)
Business hours: Monday through Thursday: 0700 -1700
Friday: 0730 - 1630
Phone: 545-2186
FAX: 545-1386
Occupational Health Services provides Job Related Medical Surveillance Screenings to both
civilian employees and soldiers to monitor job related health and safety issues. This includes but
is not limited to, hearing and vision conservation, reproductive hazards, blood and body fluid
exposures, radiation protection, FECA program provides support to civilian employees with
work related injuries, specialized group education and worksite surveys.
All New civilian employees and soldiers are processed through Occupational Health at the time
of arrival to and departure from duty at Fort Benning, GA. For arriving personnel, this ensures
fitness for duty and continuity of care started at the last duty station. For departing personnel, it
helps ensure continuity of care and referral to the appropriate providers at the next duty station.
Hazard Communications Program (HAZCOM)
1. “HAZCOM” is the "Hazard Communications Program, it has three major parts:
a. Labels. The manufacturer initially labels all hazardous products. The purpose of the label is
to provide you important information about the container's contents. The user (that's you) must
supply a label, for a damaged or lost or label, or if you put the product into a new container (such
as a spray bottle, bucket, soaking basin, etc.). Numerous types of labels are available for use If
they provide the required information. Any type of label, even a piece of tape, is acceptable for
short-term use. Labels must provide a lot of basic information, such as the chemical's name, its
flammability, the name/address/phone number of the manufacturer/distributor, a list of its
chemical ingredients, target organs in danger from exposure, etc. The most important
information, however, is just one word either DANGER. WARNING or CAUTION. Always
read the label before using a product. It's the first defense against injury from hazardous
products, materials, and substances.
b. Hazardous Material List (HML). There must be a HML in all work areas where workers
are using or exposed to hazardous materials, and it must list all (with some exceptions)
hazardous products in that work area. The "work area" may be as large as the entire hospital if
workers from a specific department are scattered throughout it, the size of a clinic or ward, or as
small as a single room. For al1 workers using or exposed to the hazardous products, the HML
must always be available. That means no locking it up in a room or filing cabinet. It's OK to have
27
it in the notebook with the MSDSs, as long as the notebook is readily available. All workers
must know of the HML, and where they can find it. They also must know that they have the right
to check the HML before being required to use a new product to learn if it is hazardous.
c. Material Safety Data Sheets (MSDS). The manufacturer or importer of hazardous
substances provides the MSDSs. They provide very detailed information on the product such
facts as manufactures name, address, and emergency phone number, substances' common and
chemical name, and it's hazardous, ingredients, physical characteristics (looks, smell,
evaporation rate, boiling/melting temperature, etc.), fire, explosive and reactivity data, health
hazards and first aid measures, including safe exposure levels, symptoms of overexposure, and if
it's a carcinogen, storage, handling, spill cleanup and disposal data, special protection and
precautions required, and preparation date of the MSDS. MSDSs for the hazardous substances
staff members work with or around must be reasonably available to them whenever the facility is
operational. Although it is OK to take up to 20 minutes to provide a MSDS to a worker, we
prefer that they be readily available to everyone at all times. In a rack on the wall or in easily
identifiable notebooks prominently displayed at a nurse's station or behind a reception desk are
the best locations. Do not hide them out of sight in a supervisor's office. All outlying clinics or
other work areas must have their own book of MSDSs. All workers must know where to obtain
the MSDSs for products in their area. That is another reason to have the MSDS books in plain
sight.
2. All workers have the right, under Public Law, to request and examine the MSDS for any
hazardous product that they work with or around (provided the substance is covered by the
HAZCOM program all are not).
3. The HAZCOM program includes drugs unless they are in solid, final form for administration
to a patient, Or are prepackaged and sealed for delivery to a patient. The hospital pharmacy
maintains the MSDSs for all relevant drugs in the hospital pharmacy. Request them from the Inpatient Pharmacy during non-duty hours.
4. Handle spills of hazardous substances, to include body fluids and substances not technically
under the HAZCOM Program, as follows:
a. Confine to prevent spreading, using whatever is available.
b. Notify persons in the area, the Environmental Science Officer (or Industrial
Hygienist), the Information Desk, and the Safety Manager.
c. If the spill is of a Small amount, use the proper spill kit (and protective equipment)
and clean up the spilled substance. Put all the absorbed substance in a plastic bag, label it, and
turn it in to Logistics Division for proper disposal. Never treat a spill by pouring other substances
on it.
d. If a Large amount (over 1-gallon), await the arrival of trained personnel.
5. HAZCOM - Communicating hazards, and protective measures, to you.
Read the labels!!!!
28
HAZARDOUS MATERIALS AND WASTE MANAGEMENT PROGRAM
(HAZMAT)
}> The policy and guidance for safe management of hazardous materials and waste, which
includes acquisition, storage, use, disposal and documentation is found in MEDDAC Regulation
40-37 Hazardous Materials and Waste Management Program.
» If you work with or are potentially exposed to hazardous materials or waste, you must
receive training in Hazardous Communication (HAZCOM), under 29 Code of Federal
Regulations 1910.1200. This includes understanding the hazards of chemicals and the
appropriate protective measures necessary to ensure health and safety.
}> Hazardous materials are chemicals or mixtures of chemicals or natural products whose
presence or use is a health or physical hazard.
}> This information about a particular chemical may be found in the Material Safety Data
Sheet (MSDS) provided by the manufacturer.
}>When working with chemicals, by law, you must already know the proper procedures for
the clean up and proper disposal of hazardous materials or waste spills. You are responsible for
the clean up and disposal when spills involve chemicals you work with. To obtain an initial spill
kit, contact the Environmental Health Section at 545-1445/1446.
}> If you do not normally work with chemicals, i.e. administrative staff, and you come across
what looks like a chemical spill or unknown spill, it is your responsibility to perform the
following steps:
(1) If you can do so safely, STOP THE SPILL.
(2) If not, block the area to prevent persons from stepping on the spill and direct persons
around the spill while you solicit assistance from a nearby staff member.
(3) Once another staff member arrives to assist you, call the Environmental Science
Officer at 545-1446 (pager 317-0465), or the Industrial Hygiene Manager at 545-1428. If the
spill is greater than five gallons immediately notify the hospital information desk 544-1685 to
notify the fire department.
(4) If less than five gallons, obtain your area's spill kit.
(5) Don personal protective equipment (goggles, gloves, etc.).
(6) Contain the spill.
(7) Clean up the spill, DO NOT TREAT THE SPILL WITH ANY OTHER
CHEMICALS,
place in bag, label with hazardous waste or chemical name.
(8) Turn in labeled bag to the Hazardous Waste Manager (544-4977/2230).
(9) Decontaminate yourself, most importantly, wash your hands and any other area that
may
(10)Report to your immediate supervisor and Safety Manger that a spill occurred and it
was properly cleaned up and disposed.
29
PATIENT/STAFF
RIGHTS & RESPONSIBILITIES
PATIENT/STAFF RIGHTS AND RESPONSIBILITIES
(Excerpt from MEDDAC REG 40-98 dtd 25 FEB 03
PATIENT/STAFF RIGHTS AND ORGANIZATIONAL ETHICS
Patient Rights:
(1) Consideration and respect of patient rights is a standard of practice that will be
provided by all hospital staff. Meeting this standard requires collaboration between the patient
and the staff to meet the patient's needs. A booklet, which explains patient rights, is available on
each inpatient unit and outpatient clinic for the patient, family, and staff to review. Information
related to patient rights is prominently displayed throughout the facility in commonly accessed
areas.
(2) The provision of patient care services includes recognition/consideration of the
psychosocial, spiritual, and cultural values that effect the patient’s/family’s responses. MACH
policies and procedures are designed to allow integration of the patient’s spiritual beliefs and
cultural practices into the plan of care given that they are not harmful to others or interfere with
the patient’s medical therapy.
(3) Depending on the nature and extent of the patient's needs, protective services are
available and may range from counseling to child or adult protective services, and/or full
guardianship.
(4) Mechanisms such as the PAL system and the Ethics Committee exist to address
conflict(s) which may arise in the clinical and administrative provision of patient care, to include
disagreements between patients and family members, patient and staff conflicts, and/or staff
member disagreements.
(5) Specific Patient Rights:
(a) Medical Care: The patient has the right to quality care and treatment consistent
within accepted standards of practice based on our available resources. Patients have the right to
be involved in the development of their plans of care. Patients have the right to refuse treatment
to the extent permitted by law and government regulations, and to be informed of the
consequences of their refusal.
(b) Respectful Treatment: The patient has the right to considerate and respectful care,
with recognition of personal dignity, cultural and spiritual needs.
(c) Effective Pain Management: The patient has the right to appropriate pain assessment
and pain management. It is the responsibility of the staff to communicate to patients and
families that pain management is an important part of care.
(d) Privacy and Confidentiality: The patient has the right, within legal and military
regulations, to privacy and confidentiality concerning medical care. Privacy may not be a right
where issues of public health are concerned.
30
(e) Identity of Care Providers: The patient has the right to know, at all times, the
identity and practice level of healthcare personnel, as well as the name of the healthcare provider
primarily responsible for their care.
(f ) Explanation of Care: The patient has the right to an explanation concerning their
diagnosis, plan of care, procedures, and prognosis in terms that the patient/family can be
expected to understand. In the event that patients have a communication barrier (i.e. foreign
language, hearing impaired, etc.), appropriate measures will be taken to ensure that effective
information exchange occurs between patients and healthcare providers.
(g) Informed Consent: The patient has the right to be provided information in nonclinical terms so they can make knowledgeable decisions regarding consent for, or refusal of,
treatments. Such information will be provided in writing and include significant complications,
risks, benefits, and available alternative treatments.
(h) Research Projects: The patient has the right to be advised if the facility proposes to
engage in or perform research associated with their treatment. Patients have the right to refuse to
participate in any research projects. A patient’s refusal will not compromise their access to care.
(i ) Safe Environment: The patient has the right to care and treatment in a safe
environment.
(j ) Rules and Regulations: The patient has the right to be informed of the facility's rules
and regulations relating to patient and/or visitor conduct. Patients will be informed about
smoking rules and can expect compliance with those rules from other individuals.
(k) Patient Complaints: Patients are entitled to information about the mechanism for the
initiation, review, and resolution of patient complaints. Hospital staff members will contact the
PAL Office for assistance in managing patient concerns or complaints.
(l ) Conflict Resolution: All consumers have the right to a fair and efficient process for
resolving differences with their healthcare providers and the institutions that serve them.
Conflicts most commonly encountered involve patient complaints related to the provision of
services by care providers. The PAL Office is charged with the responsibility of facilitating
resolution of conflicts using every resource available including the chain of command or the
deputy commanders, if indicated. Patients have the right to be informed of the results of conflict
resolutions.
b. Patient Responsibilities.
(1) Providing Information: Patients are responsible for providing accurate and
complete information regarding past illnesses, hospitalizations, medications, pain management,
and other matters relating to their health. Patients have the responsibility to participate fully in
all decisions related to the provision of their medical care within their capability. Implicit in this
responsibility is the requirement to inform hospital staff if elements of the treatment plan and the
patient’s role in it are unclear.
(2) Respect and Consideration: Patients/family members are responsible for
considering the rights of other patients and healthcare personnel, and for assisting in the control
of noise, smoking, and the number of visitors. Patients are responsible for being respectful of the
property of other persons and of the facility.
(3) Compliance with Medical Care: Patients are responsible for compliance with the
healthcare (medical, nursing, dietary, OT/PT, etc.) treatment plans, including follow-up care as
recommended by healthcare providers. This includes keeping appointments on time, notifying
the facility in a timely manner when appointments cannot be kept, and adhering to
prescribed/recommended treatment plans.
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(4) Medical Records: In the event that records are transported by the patients for the
purpose of medical appointment, consultation, etc., patients are responsible for ensuring that
their records are promptly returned to the medical facility for appropriate maintenance. All
health and medical records documenting care provided by any military facility are property of
the government. Documents may not be removed from the record and the records may not be
taken from the facility, the exception being the transportation to another medical facility in
keeping with Department of the Army policy (i.e., incident to permanent change of station
moves).
(5) Rules and Regulations: Patient/visitors are responsible for following the rules and
regulations regarding patient/visitor conduct.
(6) Reporting of Patient Complaints: Patients share responsibility for assisting the
Commander in providing the best possible care for all beneficiaries by reporting any violations
of rights. Patient's recommendations, questions, or complaints should be reported to the PAL
Office.
c. Patients with special needs:
(1) Care of the Dying Patient:
(a) A dying patient is defined as a patient with an incurable or irreversible condition
leading to immediate or impending death.
(b) Staff providing care for the dying patient will be aware of any unique or special
psychological, social, emotional, and spiritual needs of the patient/family.
(c) Various disciplines will be consulted to plan care based on the patient/family needs.
The multidisciplinary care plan will insure uninterrupted care when the patient desires outpatient
palliative care or home management. Pain management is implicit in palliative care.
(2) Do Not Resuscitate (DNR) Orders.
(a) A DNR order suspends the automatic initiation of cardiopulmonary resuscitation and
may only be written by a privileged member of the medical staff. Provisions for the
implementation of DNR orders are specified in MEDDAC Regulation 40-96.
(b) The decision to initiate a DNR order is based on the patient's medical condition and
prognosis and either:
{1} the patient's Advance Medical Directive
{2} a legally-competent patient's decision during the course of the
hospitalization;
{3} by the legal representative of an incompetent patient; or
{4} as the result of a decision of the Ethics Committee.
(3) Organ and Tissue Donors.
(a) During the admission process patients are interviewed by the PAD representative
regarding their interest in participating in the Organ and Tissue Donor Program and/or the desire
for additional information. Patient responses are noted on the FB(MED)FM 1525.
(b) MACH has established a liaison with LifeLink of Georgia for support in the
management of identified donors and staff education. The telephone number for contacting
LifeLink is 1-800-544-6667.
d. Staff Rights and Responsibilities.
(1) Supervisor's Responsibilities.
(a) Supervisors have the responsibility for describing the nature and responsibilities of
the job requirements to staff members. This will allow employees an opportunity to address any
issues that may conflict with their values, ethics, or religious beliefs.
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(2) Staff Rights and Responsibilities:
(a) Staff members have an obligation to inform their supervisors of objections to
involvement in any form of patient care based upon cultural or religious beliefs, values, or ethics,
which arise during their employment. Such examples include: exclusion from participation in
particular elective procedures of patient care; i.e. abortion, birth control, blood transfusions, etc.
These requests will be examined by the chain of command and may or may not be approved.
Staff members are not permitted to decline participation in care delivery during acute or
emergent situations.
(b) Patient care will not be interrupted or adversely affected at any time based upon staff
member’s withdrawal from a particular element of care. The chain of command will insure
uninterrupted care, with competent supplemental staff, until subsequent examination of the staff
declination can be resolved.
(c) The Ethics Committee may be used to review staff rights related to issues involving
requests for exclusions from patient care requirements.
(d) Conflict resolution involving staff members will be managed individually IAW
policies and procedures delineated in Army Regulations and civilian personnel policies. The
chain of command will support resolution achievement involving sanctioned activities to include
union representation, EEO investigations, legal counsel, and so forth.
(e) The right to provide care and treatment in a safe environment.
(f ) Staff members are responsible for supporting the mission and values statements of the
organization.
(g) Staff members are charged with fulfilling job responsibilities in a manner affirming the
organization's statement of patient rights.
d. Ethics Committee. The purpose, functions, and membership of the Ethics Committee are
addressed in Appendix A of this regulation.
e. Organizational Ethics.
(1) The Department of Defense establishes the billing procedures/costs.
(2) Transfers and referrals of patients to civilian providers will be in keeping with
standards of conduct governing actions of DOD civilian and military employees, and will adhere
to all federal statutes. In situations where more than one network facility or provider can
accomplish the same procedure or treatment, and the patient does not express a preference, the
healthcare finder will equitably alternate referrals among the providers.
(3) In cases where contract physicians make referrals for treatments that could potentially
result in business for their private practices or physician group practices, the appropriate
department chief or designated representative will review the consult for appropriateness prior to
the approval of the procedure/visit.
(4) All agreements between MACH and civilian facilities are governed by contracting
directives, (e.g. Federal Acquisition Regulation, congressional entitlement, DOD and DA
directives, and the MCSC TRICARE Contract) and standards of conduct.
For more information or questions regarding this information, please contact the Office of the Quality Management
Office at (706) 544-1548/1536.
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Domestic Violence
Types of Domestic Violence
CHILD ABUSE: Involves physical or mental injury, sexual abuse, and/or neglect of the basic
needs of a child (under 18) by a parent, relative, childcare provider or anyone who is responsible
for the child which may harm or threaten the child’s health and/or well-being.
SPOUSE ABUSE: A pattern of behavior where one person in a relationship tries to gain power
and control over his or her partner through fear and intimidation. This can take the form of
threatening or actually using physical violence; or the abuse can be emotional, economic, or
sexual.
ELDER ABUSE: Evidence of physical/sexual abuse, to include inconsistent explanation or
injuries, frequent injuries, inappropriate administration of medication, depravation of necessities
and other maltreatment of an elderly person by their caretaker.
SIBLING VIOLENCE: Quarrels between siblings culminating in punching, scratching, biting
and kicking power struggles to prove supremacy over territorial rights and ownership (this is the
most commonly recognized, expected and accepted form of family conflict).
General Facts About Domestic Violence

In the United States, it is estimated that a woman is battered every 15 seconds. A rape is
committed every 6 minutes.
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1 out of every 7 married women are the victim of marital rape.
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25% of abused women were battered during pregnancy. While the most commonly
abused parts of a woman’s body are her face and breasts, during pregnancy the focus of
attack shifts to her abdomen.
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55% of all female victims of domestic sexual abuse are children under the age of 11 years
old.
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At current rates, 1 woman in 4 will be sexually assaulted in her lifetime
Indicators of Child Abuse
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Unexplained scars and old wounds are on the body.
Inadequate or inappropriate explanations are given as to how new injuries were sustained.
Multiple fractures are present.
Multiple or recurrent injuries (i.e. burns, subdural hematomas, fractures exist).
A child is dead on arrival at the hospital.
Reports or complaints of sexual abuse are made.
Young child are left unattended for an extended period of time.
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Advanced untreated diseases are diagnosed.
Unsanitary living conditions exist.
Emotional, moral, or social deprivation is indicated.
Unexplained incidents of “failure to thrive” are diagnosed.
Pregnancy under age 16.
Indicators of Spouse Abuse
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Physical Indicators
Emotional Indicators
Verbal Indicators
Spouse abuse may be suspected when an explanation of an accident is inconsistent with
injuries sustained or when there are multiple injuries on the face, neck, chest, abdomen with
no reasonable explanation.
Women are greater risk during pregnancy and evidence of their injuries during pregnancy
are especially suspect.
Males suffer more from verbal and emotional abuse, but can be victims of physical abuse
from beating, biting, scratching, cutting, stabbing and gunshot wounds.
Indicator of Elder Abuse
 Physical Indicators
Any injury incompatible with history
Evidence of inadequate care (i.e. gross decubiti)
Evidence of inadequate or inappropriate administration of medication
Poor skin hygiene
Signs of confinement
Behavioral Indicators
 Fear
 Hesitation to talk openly
 Anger
 Denial
 Indicators for the family/care giver
REPORTING
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AR 608-18, 20 Oct 03, The Army Family Advocacy Program requires all
personnel to report information about spouse abuse
MEDDAC Pamphlet 6080-18, Management and Evaluation of Suspected Child,
Spouse and Elder Abuse cases
Medical personnel should consult with SWS if any indicators of elder abuse are
observed
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AREAS OF CONCERN
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Male victims in suspected abuse cases
Female victims choosing not to have cases reported
Notification by the physician to have a physical exam (per MEDCOM
Reg 608-18)
Requesting SWS on-call on non-child and spouse abuse cases
Completion of PCAN and spouse abuse packets
Consult written for follow-up
Limit number of individuals in exam room?
Immediate notification of SWS on-call to ER of an adult sexual assault
victim
Advise that obtaining as much information as possible over the phone
regarding an on-call case helps to coordinate are and reduce the time
spent and cost of overtime
New Georgia Law regarding Domestic Violence
LOCATION
Soldier’s Plaza/building #2625
MACH 4th floor/room #412
MACH 9th floor/office #903
OFFICE HOURS
CRISIS WORKER
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545-1661
544-4418
544-2052
0700-1630 hrs/Mon-Fri
SWS during duty hrs,
on-call worker after duty.
Hospital Insurance Portability and Accountability Act ~ HIPAA
The HIPAA Privacy Rule protects the confidentiality of patient medical data by
regulating its use and disclosure by all covered entities. Individually identifiable health
information (IIHI), including demographics, is protected under HIPAA. The Privacy Rule
covers Protected Health Information (PHI) stored or transmitted in any form or medium electronic, paper, and oral. The HIPAA Privacy Rule is not limited to documents
contained in the official medical record. The HIPAA Privacy Rule protects the
confidentiality of patient medical data by regulating its use and disclosure by all covered
entities. Individually identifiable health information (IIHI), including demographics, is
protected under HIPAA.
Authorizations are required for use or disclosure of information for non- TPO
purposes such as some types of research and sending marketing materials. The
Privacy Rule also prescribes the elements for a valid authorization and outlines
situations for which a patient's opportunity to agree or object is not required. Some
examples of permitted uses or disclosures include averting serious threats to health,
judicial proceedings, public health activities, and medical facility patient directories. In
addition, the Privacy Rule has a military exemption clause, specific requirements for
research, protection provisions for psychotherapy notes, and de-identification
requirements for PHI prior to its use or disclosure.
HIPAA also increases the patient's control over his/her health information. The patient
has a right to:
. A written Notice of Privacy Practices (NOPP) from health plans and providers.
. Access, inspect, and obtain a copy of PHI.
. Request an accounting of disclosures of PHI.
. Request amendment or correction of their records.
. Request restrictions on uses and disclosures of PHI.
. Receive confidential communications by alternative means/at an alternative location.
. Authorize use or disclosure of PHI for purposes other than TPO.
. Complain to the covered entity and to HHS of any violations of privacy rights.
HIPAA Privacy Officer, Patient Administration Division, (706) 544-2140
37
Hospital Performance Improvement
The Performance Improvement Program at Martin Army Community Hospital is dynamic and continuous. It
employs the FOCUS PDCA cycle as its management model to describe the ongoing nature of continuous
improvement. This corresponds closely to the Design-Measure-Assess-Improve cycle promoted by the Joint
Commission on Accreditation of Healthcare Organizations.
Improving Organizational Performance
Design
F - Find a process to improve
O - Organize an appropriate team
C - Clarify the current knowledge
U - Understand the causes of process variation
S - Select the process to improve
Act
Measure
FOCUS PDCA
Cycle
Do
Improve
Plan
Check
Assess
As the staff reviews the key processes and outcomes we are involved with, by asking the following three questions,
we can determine whether those processes and outcomes are performing to standard:
1) Are we doing a good job in our section? (or is that key process or outcome performing well?)
2) How do we know, based upon what criteria? (What have we measured?)
3) What does the data (facts) show?
This process is aptly captured by the following illustration.
MACH PI Program Concepts
(Deliberately designed to reduce bureaucratic
encumbrances to improvement)
* Write Scope of Care/Services Provided.
* Identify Most Important Process
(Prioritizes Improvement Efforts)
* Develop Performance Measurement Indicators.
Performance Measurement Program
Command Level
Indicators
Department Level Indicators
Service Level Indicators
Individual Level Indicators
( Management By FACT )
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RAPID RESPONSE TEAM (RRT)
1. PURPOSE: To provide guidance and establish protocols for the Rapid Response Team.
2. REFERENCES:
a. Thelan’s Critical care Nursing: Diagnosis and Management, 5th Edition
2006.
b. Brunner & Suddarth’s Text Book of Medical-Surgical Nursing, 10th
Edition, 2004.
c. Prevent avoidable codes with a Medical Emergency Team; Virginia
Mason Medical Center, Seattle Washington; Mar 06.
d. Buist, M.D.; Moore, G.E.; Waxman, B.B.; Effects of a Medical Emergency
Team on reduction of incidence of and mortality from cardiac arrests in
hospital: Preliminary study. British Medical Journal; Feb 16, 2002; 324 (7334):
387-390.
3. SCOPE: The Rapid Response Team brings critical care expertise to the bedside of adult
patients.
4. RESPONSIBILITIES: To prevent codes by using Rapid Response Team (RRT) to
intervene before patients develop cardiopulmonary arrest or other adverse events.
5. POLICY & PROCEDURES:
a. Team Members:
Medical Officer of the Day (MOD)
Nursing Supervisor
ICU Registered Nurse
Respiratory Therapist
b. Condition(s) to activate the Response Team:
1. Acute change in HR <40 or >130
2. Acute change in SBP <90 mm Hg
3. Acute change in Respiratory Rate <8 or>32
4. Acute change in SaO2 < 90%
5. Acute change in conscious state (somnolent)
6. Nurse feels an impending crisis
c. Medication the Team’s Nurse can administer without the MOD present:
1. Lasix 20 mg IV (Pulmonary Edema)
2. NTG tabs (spray) x 3
3. 0.9 Normal saline/Lactated Ringers
4. Oxygen
5. D50W
39
6. Narcan
7. Nebulizer (Albuterol/Atrovent)
d. Procedures the Team’s Nurse can perform without the MOD present:
1. ABG’s
2. Start IV access
3. Nasotracheal Suction
4. Fingerstick Blood Glucose
5. X-ray
6. EKG
7. Initiate transfer to ICU
6. The treatment of the patient is determined by the symptoms presented and past medical
history. The Ward Nurse will provide a brief history of the patient to the Rapid Response
Team.
7. Clinical treatment (indications) for specific symptoms should be considered by the Rapid
Response Team:
a. Heart rate <40 or >130 (symptomatic)
1. Start a peripheral IV or Heplock
2. Administer O2 @ 2 liters per nasal prongs
3. NTG Tabs (spray) x 3 for chest pain/discomfort
4. EKG
5. Initiate Transfer to ICU
b. SaO2 < 90, Respirations<8 or>32
1. ABG’s
2. Start O2 as low as 2 liters per nasal prong up to non-rebreather mask
3. Portable Stat Chest X-ray
4. Assess Pulmonary Status
5. Lasix 20 mg IV (if crackles auscultated throughout lungs)
6. Nebulizer (wheezes)
7. Bag-Valve-Mask
8. Nasotracheal Suction
9. Pulse Oximeter
10. Initiate Transfer to ICU
c. SBP <90mm Hg (symptomatic)
1. Start Peripheral IV
2. Administer 500cc Bolus of 0.9NS/Lactated Ringers (if no history of CHF)
3. Place Patient in a Modified Trendelenburg.
4. O2 (2 liters per Nasal Prongs)
d. Somnolent (difficult to arouse)
1. Fingerstick Blood Glucose
40
2.
3.
4.
5.
6.
7.
8.
O2 (Nasal Prongs, B-V-M, Face mask)
Narcan (1 amp IV)
D50 (1/2 – 1 Bristojet IV)
Start Peripheral IV
EKG
ABG’s
Initiate Transfer to ICU
e. Impending Crisis
1. Start Peripheral IV
2. Administer O2
3. Pulse Oximeter
4. Cardiac Monitor
8. The Rapid Response Team can be activated by:
a. Staff member calls 211 and request the Rapid Response Team to the appropriate
room number
b. The AOD/Front Desk staff announce on overhead page “Rapid Response
Team” room___.
c. The AOD/Front Desk staff activate the paging loop: MOD 576-1130, Nursing
Supervisor 576-1460, ICU Registered Nurse 576-1080, Respiratory Therapy
576-8089 with the text message “Rapid Response Team room__”.
d. The Team responds to appropriate room.
9. The Primary Physician/Attending Physician will be notified about the patient’s condition
as soon as possible.
41
FORCE PROTECTION AND EMERGENCY MANAGEMENT
1. FORCE PROTECTION PROGRAM (AR 525-13): Force Protection is a security program
designed to protect soldiers, civilian employees, family members, facilities, and equipment in all
locations and situations. Force Protection is accomplished through planned and integrated
application of physical security, information operations, protective services, law enforcement,
and combating terrorism. All are supported by intelligence, counterintelligence, and other
security programs. Individual protective measures you can implement consist of securing your
personal belongings and being alert for suspicious objects and personnel around your work area.
If someone is on your floor whom you think should not be there, ask them if they need
assistance. This will clue you in on whether they have a reason to be there or not. MEDDAC
personnel (military, civilian, and contract personnel) will wear their ID badge at all times
when on duty. These ID badges are for our safety and the patient’s protection. They should be
worn above the waist or on a lanyard. If you see a coworker not wearing their ID badge, stress to
them their importance. Report lost or stolen IDs to the Human Resources Division. Read
MEDDAC Regulation 525-13 (MEDDAC Force Protection-Security Management Program) and
the Emergency Management Plan (EMP). Know emergency phone numbers, codes, and
procedures.
2. OPERATIONS SECURITY (OPSEC): OPSEC is the protection of military operations and
activities. By using Information Security, Physical Security, and Counter Intelligence, OPSEC
can eliminate or control intelligence indicators and deny hostile forces information susceptible to
exploitation. OPSEC is becoming more difficult and increasingly important. Practice and live
OPSEC – always!
INFORMATION SECURITY: Practice good radio and telephone procedures. DO NOT
DISCUSS unit plans, strengths, locations, personnel, equipment, and disposition while
transmitting in an unsecured mode. Authenticate questionable information.
PHYSICAL SECURITY: Remain alert and use proper security procedures. Properly safeguard
all items under your control and ensure sensitive items are secure.
3. EMERGENCY MANAGEMENT PROGRAM: The mission of the Emergency
Management Program is to provide the best possible service, care, and safety to all patients,
visitors, and staff in the event of an internal or external disaster situation or disruption in
operation also known as a Mass Casualty (MASCAL). In the event of a mass casualty situation,
the Hospital Commander (or designee) will declare a CODE GRAY. If after duty hours, the
notification/recall roster will be activated and staff, unless engaged in direct emergency care will
report to their designated area. Physicians will report to the Physician Labor Pool (Connelly
Conference Room); nurses report to the Baugh Conference Room, and non clinical staff report to
the Manpower Pool located in the Dining Facility to await further instructions. Unless
previously informed by the Department Chief, staff members will remain in the manpower pool
until released. It is important everyone know what your specific duties are and where to report
when a “CODE GRAY” is announced so we can be best prepared.
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4. EMERGENCY MANAGEMENT RESPONSIBILITIES: Read the Emergency
Management Plan (EMP). Know your Individual and Department roles. KNOW THE
CODES. Have a copy of the notification/recall roster on hand. Ensure it is updated monthly –
call the next person in line or until someone answers. DO NOT use open communication lines
during an emergency. Incoming calls are our primary means of communication.
5. HOSPITAL EMERGENCY CODES:
- CODE GREEN : – COMBATIVE PERSON Indicates an altercation is in progress. Always
protect self, patients, and staff. Use more than one person to subdue individual(s).
- CODE BLACK: – BOMB THREAT: If you receive the threat, utilize the Bomb Threat
Checklist (FB Form 48 - located next to every phone) and obtain as much information as
possible. If you find a suspicious package and you think it is possibly a bomb, notify your
supervisor, information desk, security officer, or Military Police immediately. DO NOT
DISTURB THE PACKAGE! Remove personnel from the area and secure. In the event a
CODE GRAY-BRAVO is announced, try to remain calm. If warranted, EVACUATION WILL
BE ANNOUNCED ON THE OVERHEAD PAGE. Otherwise, DO NOT evacuate. If
instructed, personnel will evacuate and report to the designated evacuation area.
- CODE PINK – INFANT SECURITY: Post a guard at all exits. Inspect ALL bags and
packages leaving the building. DO NOT let any infants/small children depart the hospital until
an “ALL CLEAR” is announced.
- CODE ORANGE – HAZMAT: Notify your hazardous material coordinator.
6. WEATHER WARNING INFORMATION - In the event severe weather is predicted, the
following weather warning codes will be announced on the overhead page and the
telecommunicator system:
- CODE GRAY – Severe Weather Watch: Disseminate to all personnel, safeguard life,
Government, and personal property.
- CODE GRAY – Tornado Watch: Disseminate to all personnel, safeguard life, Government,
and personal property.
- CODE GRAY – Tornado Warning: When instructed, close all doors, moved patients away
from windows, and move to interior of building.
7. PARKING: Parking is only authorized in designated parking spaces. All vehicles shall be
parked well inside marked parking spaces. Parking in areas other than designated parking
spaces, parking in fire lanes, no parking zones, loading docks/zones, yellow curbs, or in such a
manner that blocks or partially blocks traffic, pedestrian lanes or emergency vehicle access is
prohibited. Additionally, vehicles are to occupy only one space - there will be no double
parking (to include parking behind another vehicle). There will be no driving over a curb to
park over sidewalks or under trees. Such behavior damages the landscape and wastes the
43
resources it takes to repair the damage caused and will result in the issuance of a DD Form 1408,
Armed Forces Traffic Ticket. Vehicles will not be parked more than 72 hours in one location
unless prior permission for such extended parking has been obtained from the Company
Commander. Vehicles parked more than 72 hours may be considered abandoned and will be
towed at owner’s expense. No Privately Owned Vehicles or contractor vehicles will be parked
by the Logistics Loading Dock and lot located by Building 9207 without a parking permit from
the Facilities Management Branch.
Handicapped Parking. Handicapped parking at MEDDAC serves a very special need for
some of our customers and staff. A handicapped sticker alone is not grounds for parking
in a handicapped space. Georgia State Traffic Code 40-6-226 provides a fine of not less
than $100.00 and not more than $500.00 for the illegal use of a handicap space. Anyone
found in violation of illegally parking in a handicapped slot will be ticketed. The driver or
passenger must be legitimately recognized as handicapped.
44
PREVENTION OF SEXUAL HARASSMENT IN THE WORKPLACE
1. The Department
of the Army policy regarding the Prevention of Sexual Harassment states
that sexual harassment is unacceptable conduct that will not be tolerated in the workplace. The
Army requires mandatory training in the Prevention of Sexual Harassment (POSH) for all
DA civilian and military personnel to ensure the understanding of the issue as well as the
responsibilities in preventing sexual harassment in the workplace. The mandatory POSH
training will include the following objectives:
a. Define sexual harassment in the workplace.
b. Ensure Army policy is understood and applied.
c. Identify situations that have the potential to be sexually harassing.
d. Identify employer and employee potential liabilities & responsibilities.
e. Identify avenues of redress for victims of sexual harassment.
2. Sexual harassment is defined as a form of sex discrimination that involves unwelcomed sexual
advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature
when:
a. Submission to, or rejection of such conduct is made either explicitly or implicitly a term or
condition of employment:
. b. Submission to, or rejection of such conduct by a person, is used as a basis for career or
employment decisions affecting that person;
c. Such conduct has the purpose or effect of unreasonably interfering with an individual's
work performance or creates an intimidating, hostile, or offensive working environment.
3. Legally, sexual harassment falls into two categories - Quid Pro Quo and Hostile Work
Environment:
a. Quid Pro Quo is a Latin term meaning "this for that." Quid Pro Quo sexual
harassment occurs when employees are required to engage in sexual relations or otherwise
submit to offensive conduct of a sexual nature as a condition of employment. Quid Pro Quo
sexual harassment examples include demands for sexual favors in exchange for promotions;
awards, favorable assignments; or disciplinary actions against subordinates who refuses sexual
advances; and threats of poor performance evaluations because of the refused sexual advances.
b. Hostile Work Environment sexual harassment occurs when workplace conduct is
unbearable to the extent that it causes unreasonable interference with job performance, or
conduct in the workplace that creates an intimidating, hostile, or offensive work environment for
the victim. Examples of a hostile work environment include the use of derogatory gender-biased
terms; comments about body parts: displays of sexually suggestive pictures or computer screensavers; explicit jokes, and unwanted touching of a sexual nature.
4. Acts of sexual harassment can run the gamut from unwanted sexual attention, innuendoes and
verbal comments of a sexual nature, to physical assaults. Incidents of sexual harassment are
45
usually repeated offenses, however, a single act can be considered sexual harassment if it is
violent, such as rape or physical assault, or if there is a demand for a sexual favor that is linked to
an employment benefit or bias. Anyone can be a harasser! A harasser can be male or female,
supervisor or non-supervisor, civilian or military personnel. Although surveys show that a
perpetrator is generally a person in a position of authority over the victim, a perpetrator can also
be a co-worker, or a customer. If tolerated, behaviors of sexual harassment will undermine the
work environment by adversely affecting morale, productivity, and readiness. The Army's policy
on the Prevention of Sexual Harassment provides a commitment to eradicate inappropriate
behavior that could be perceived to be sexual harassment in \he workplace. Therefore, all Army
personnel are expected to ensure that the highest level of professional behavior and courtesy is
extended in the workplace.
5. Individuals who perceive they are victims of sexual harassment should make it clear that such
behavior is offensive to them. If comfortable, victims can tell the harasser that the conduct is not
welcomed, however, informing the alleged harasser is not mandatory prior to filing a complaint.
Reports of sexual harassment can be made through the chain of supervision, the military Equal
Opportunity (EO) Office, the Office of Inspector General (IG), or the civilian Equal Employment
Opportunity (EEO) Office.
6. Questions regarding Martin Army Community Hospital’s on-line raining in the Prevention of
Sexual Harassment, prepared by the servicing Equal Employment Opportunity Office, should
contact the following:
Equal Employment Opportunity Office
USAIC
BLDG 2507 Indianhead Road
Fort Benning, GA 31905
POC: Ellis Dandy, EEO Manager
Winnie Torain, EEO Specialist
(706) 545-1872
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INFORMATION MANAGEMENT DIVISION
Here are a few helpful IMD FAQs that you may find useful:
IT Help Desk
The IT Help Desk can be reached at 544-1758 press 1. When you call you should
have the following:
-
Your username
Your PC’s ECN number (on the white sticker on the CPU/tower)
You should have time on the phone to troubleshoot your problem
You should be at your PC
LAN Passwords
When logging on to a system you will need your username and your
password. Your username should be your last name, first and middle
initials. Your password should be something only you should know. DO NOT
SHARE YOUR PASSWORD. The AR 25-2 password requirements are listed
below:
1. Minimum of 10 characters.
2. Passwords must contain characters from at least three (3) of the following
four (4) classes:
Description
Examples
------------------------------------------------------------------English upper case letters
A, B, C, ... Z
English lower case letters
a, b, c, ... z
Westernized Arabic numerals
0, 1, 2, ... 9
Non-alphanumeric ("special characters") such as punctuation symbols
3. Password expiration will be no less than 90 days and no more than 150
days. (Active Directory requires a 90 day password expiration.)
4. To prevent passwords from being reused, 10 password changes will be
stored in a password history.
5. Passwords may not use any part of the user’s name.
Challenge and Response
If you have forgotten your password or it has expired, then you need to call
the Help Desk. If you have a Challenge and Response in, then the
technician can change your password over the phone. A Challenge and
Response is a question that the technician can ask you over the phone that
can positively identify you (i.e.…mother’s maiden name, dog’s birthday,
SSN, etc.)
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E-mail
You will use Microsoft Outlook to access your e-mail account. Your e-mail
address should be firstname.lastname@amedd.army.mil. To access your
e-mail from home or when on TDY, you should use OWA (see page 3).
OWA is a web site that you can go to and check your e-mail. Everyone
should have an AKO email address and your AKO email address should be
forwarded to your AMED email address.
Other Resources
MACHNET:
https://sermcportal.amedd.army.mil/cops/mtfs/ftb/default.aspx
MACHNET is an internal web site that houses a lot of information, like
the duty rosters, lunch menus, department policies, etc. Click on IMD
Tips for computer tips.
HELP DESK: The Help Desk also checks out copies of FormFlow to
users to take home and load on their PCs. If you are interested in the
any of these tools, simply call 544-1758 and make arrangements to
check them out.
Information Assurance Facts (BMACH 25-2)
c. PHYSICAL/ENVIRONMENT SECURITY.
(1) The computer system has been configured with the proper operating system and
program software. Do not make any changes without consulting with the IAM.
(2) Do not eat, smoke, or drink in the immediate vicinity of the computer system.
(3) Keep terminal areas clean.
(4) Media (diskette, CD-ROM, DVD, zip disk, etc.) are fragile items. Misusing or
mishandling can damage them or cause loss of data. The following procedures will be used
when handling media:
(a) Do not place media on terminals, in books, or under equipment.
(b) Do not touch exposed areas or try to wipe media clean.
(c) Keep media out of direct sunlight and away from extreme heat.
(d) Do not place media near any magnetic source such as telephones, radios, tape
recorders, speakers, and microwave ovens.
(e) Do not bend media or place rubber bands or paper clips on them.
(f) Do not write directly on media with a ball point pen, pencil, or other hard writing
instruments. Use a felt tip pen or write on the label before affixing to media.
(g) Store media in either storage trays or boxes to avoid pressure to the sides.
(5) Turn the system off when not in use or when unattended.
(6) Secure offices (lock doors and windows) during non-duty hours or when unattended
for long periods of time, i.e., lunch.
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b. PERSONNEL SECURITY.
(1) Only government personnel who have a favorable personnel background
investigation, verified by OTD, are authorized to use these systems. Permission must be granted
by the IAM before any other type personnel can operate the system.
(2) Information Management Division personnel will brief each person who operates a
system with an initial briefing by utilizing FB(MED)FM 1556 (see Appendix C). This form
must be completed and submitted to IMD prior to the issuance of passwords for access to any
computer system (e.g. Outlook, CHCS, etc.).
(3) All users are required to complete the TMA web based HIPPA security training to
maintain user level privileges on an annual basis.
(4) The initial security training and awareness briefing for IT will be conducted during
Newcomer’s Orientation.
c. INFORMATION SECURITY.
(1) All magnetic media (to include magnetic tapes, floppy diskettes, zip disks, CDROMS, DVDs, etc.) will be marked with identification information. Identification information
will be at a minimum: disk name, software program, user name, and organization. Standard
Form 711 can be used for this purpose. Media will also be labeled with the appropriate
classification. Standard Forms 706 (TOP SECRET), 707 (SECRET), 708 (CONFIDENTIAL),
and 710 (UNCLASSIFIED) and DA Label 97 (FOUO) will be used.
(2) Backup data, which if lost would impact on operations or require significant effort to
restore, after every update (at a minimum - weekly.)
(3) Privacy Act and For Official Use Only (FOUO) data will be labeled, controlled,
stored, disseminated, and destroyed IAW references c and d.
d. PROCEDURAL SECURITY:
(1) Software.
(a) Only software specifically developed, purchased or leased, and approved for use will
be used on government-owned systems.
(b) User-developed, public domain, shareware, or other privately owned software,
regardless of source must be approved by Information Management Division (IMD).
(c) Copyrighted software may be copied only as explicitly set forth in its contract.
Copyright laws prohibit using the operating disks for any purpose other than installation on the
system for which it was purchased. The operating disks for the system will be used only on this
system and no other system.
(d) Master/original copies of copyrighted software will be stored in locked cabinets,
desks, or within rooms which can be locked to protect against damage, loss, or unauthorized
duplication.
(2) Anti-Virus Protection.
(a) All systems will be protected with Norton Anti-virus to prevent virus infection.
(b) Any diskette received by personnel within this organization from an outside source
will be checked for virus contamination prior to introduction on any government system.
(c) All virus contamination will be reported immediately to the IAM at 544-1557.
(3) Passwords.
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(a) Passwords for access to other systems will be closely guarded by the individual to
whom they are issued. Do not reveal passwords to anyone or store them in plain view. You
are required to memorize and destroy all computer generated passwords. Report compromised
passwords to your IAM immediately for disciplinary actions. Individuals who use other
employees passwords, or individuals who allow others to use their passwords are both in
violation of this security SOP.
(b) Passwords will be changed IAW local and Department of the Army policies and
procedures for unclassified systems. In the event of a compromised password all passwords will
be changed immediately.
(4) Use of Personally-owned IT hardware or software that connects to the network at the
work site is strictly prohibited, per AR 25-1, paragraph 6-1f (5)(i).
(5) Any real or suspected infractions of security will be immediately reported to the
IAM or Information Management Division personnel.
e. PERMISSIBLE USE OF GOVERNMENT COMMUNICATIONS RESOURCES:
(1) Government communication resources (including telephones, facsimile (FAX)
machines, electronic mail (e-mail) and other access to the internet) shall be for official use and
authorized purposes only. In limited circumstances, "authorized purposes" may include personal
use.
(2) Communications which are most reasonably made from your normal work place
(such as checking in with spouse or children, making medical, home and automobile repair and
similar appointments, or making bank transactions), are authorized, subject to the following
conditions:
(a) Whenever possible, personal communications should be accomplished before or after
work hours, during lunch, or other authorized breaks;
(b) If made during normal work hours, the communications will be kept infrequent and
short;
(c) You may not incur any long distance tolls or other usage fees chargeable to the
Government. You must use toll-free numbers or charge the communications or other fees to
your personal credit card.
(d) You may not solicit business, advertise, or engage in other selling activities in
support of private business enterprises; fundraising activities (other than those permitted by JER
3-210); or any other use that may reflect adversely on the Army or which is incompatible with
public service.
(3) You may not send group e-mails to offer items for sale or other personal purposes
(e.g., selling an automobile or renting a private residence). You may not send group e-mails to
announce events sponsored by a non-Federal entity without the prior approval of your
supervisor.
(4) The internet provides a tremendous resource of information interchange and other
communication through such vehicles as mail list servers, databases, files, and web sites.
Subject to the restrictions stated above:
(a) You may use computers to access and use internet resources for professional
development purposes if it does not detract from your primary duties or mission.
(b) You may use computers to access and use these internet resources for any other
personal reason, such as routine e-mail correspondence with your children away at college,
reading a business magazine website or checking stock quotes; but you may do this only before
and after work hours, during your lunch period, or other authorized break during the work day.
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(5) You should be aware that any use of Government communications resources is with
the understanding that such use is generally not secure, not anonymous, and serves as consent to
monitoring.
f. INSPECTIONS: Periodic spot/night checks will be conducted to ensure these procedures
are enforced. Appropriate administrative and/or disciplinary actions in accordance with Chapter
XIV, Army Regulation 380-5, Department of the Army Information Security Program, will be
taken in cases of violations of the procedures provided herein.
g. DISCIPLINARY ACTIONS: Any case involving security violations will result in the
following disciplinary actions:
(1) First violation will result in an official letter routed throughout the chain-ofcommand to the offender.
(2) Second violation will result in temporary removal of all Automated Information
Systems (AIS) access privileges.
(3) Third violation will result in permanent removal of all AIS access privileges.
(4) Habitual violators will be handled on a case-by-case basis at the discretion of the
Commander, IMO (with assistance from the IAM).
Accessing your email from home or while TDY
1. Open Internet Explorer. In the URL location type in:
https://medmail-ne.amedd.army.mil/exchange
or
https://medmail-se.amedd.army.mil/exchange
2. You will receive a pop-up authentication box like the one pictured below. In the box
type in: amed\firstname.lastname and your password you use to log onto your computer
at work. Then click OK.
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3. Your mailbox will come up. Since we have migrated to Active Directory with Server
2003, your mailbox will look very similar to your Office 2003 Outlook desktop. You
will be able to access Public Folders now also.
Patient and Family Advocate Office
The Patient and Family Advocate functions as a liaison between patients, family members, and
staff. If a patient has a compliment for the staff, a concern, questions or a complaint, they can
address those issues with the Patient and Family Advocate. Complaints and concerns are
addressed immediately when possible. If not possible to resolve issue at the time of the patient's
visit, a report is provided to the Chief of the responsible department and the department staff is
responsible for resolving the issue, contacting the patient and providing response to the Patient
and Family Advocate so that the case can be closed.
.
Comment cards are located throughout the hospital and outside the Patient and Family
Advocate office if the patient or family member wants to complete a card and drop it in the box;
we also have voice mail if the patient or family member would like to leave a message.
We have Patient's Rights Pamphlets and a booklet on Advance Directives if the
patient or family has an interest in these subjects.
Monthly reports are provided to all department chiefs so that you can monitor the degree of
satisfaction with the services provided within the department.
Location of office: Room 103, directly across from the Information Desk
Hours of operation: 0800-1630, Monday through Friday
Phone:
544-1817
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