Resource Guide
Safety & Health Hazards
2013
Contributing Departments include: Staff Development, Safety Committee, Safety Officer, Infection Control,
Risk Management, HIM, Security, IS, HR, RT, Plant Ops, Radiology, and other sources.
1
2013 Safety & Health Hazards Index
Abuse & Neglect
95-97
Hand Hygiene
77-78
Protected health Information-PHI
69-73
Bioterrorism
53
Harassment / Workplace Violence
22
RACE
35
Blood Borne Exposure Event
84
Hazardous / Cytotoxic Drugs
47
Radiation Safety
39
Blood Borne Pathogens
75
Hazardous Material
15 & 40-47
Rapid Response Team
54-56
Bomb Threat
53
Healthcare-Associated Infection
74
Respirator Mask – Fit
88
CAUTI – Prevention
92
HICS
50
Respiratory Viruses – Influenza
89
C-diff
86
HIPAA/Pt Rights/Confidentiality
66-70
Restraints
101-102
Central Line Infection - Prevention
93
Infant Abduction / Drill
57
Risk Management
58-63
Chemical Spill Event
46
Influenza Vaccine
89
Safe Line 2-SAFE (27233)
5
Clean to Dirty Principle
85
Injuries are Preventable
8
Safety Communication (MOX/email)
5
Close Calls/Occurrences/Sentinel
61-62
Identification Color Alert Bands
98
Security
12 & 21
Code Blue / Medical Emergency
54-56
Infection Prevention / Exposure
74-80
Sentinel Event / Close Call / Occurrence
61-62
Computer Use & Workstation
73
Introduction-Safety Top Priority
3-4
Sharps Safety
45
Cultural Diversity
9
Impaired Provider Recognition
7
Slips, Trips, & Falls
27
De-Escalation
23-26
Joint Commission – How to Contact
5
Smoke Free Environment
30
Electrical Safety
38
Labels
46
Standard Precautions
81
Emergency Management
17 & 48-53
Latex Allergy
100
Surgical Site Infections – Prevention
91
Employee ID / Badge
20
Medical Gases / Shut Off
36
System Failures-Basic Staff Response
15 -16
EMTALA
64-65
Environment of Care
10-18
MRSA
87
Team Communication/Work/Training
6
Equipment Management
16
MSDS Sheets
46
Transmission Based Precautions
82
Ergonomics
28-29
National Patient Safety Goals
104
Tuberculosis (TB)
90
Egress / Exits…Keep Clear
13 & 32
Oxygen Safety
37
VRE
87
Fall Prevention
99
Patient’s Rights
67
Waste Management
40-45
Fire Drill
34
Personal Protective Equipment
79-81
Weather Plan
52
Fire Safety
31-35
Population Appropriate Care
9
Wesley Intranet Policies & Procedures
103
2
Culture of Safety
Everyone is responsible
to promote a culture of safety!
2013
3
Top Priority
Wesley Medical Center considers the
practice for safety, infection control,
emergency & risk management as top
priorities for their patients, employees, and
customers.
4
Safety Suggestions
If you see an opportunity for the hospital to reduce injuries to
employees, or a safety concern…don’t keep it to yourself:
Safety Officer
962-2046(WMC) 858-2935(GHH)
Send a MOX to: WHR.SAFETYCON
Send e-mail to: Wesley.DL Safety Concerns
The Joint Commission –encourages anyone who has concerns or complaints about the safety and quality of
care to bring those concerns or complaints first to the attention of the health care organization’s leaders.
Mail: Office of Quality Monitoring
The Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
E-Mail: complaint@jointcommission.org
Safe Line 2-SAFE
962-7233
5
Work Safe – Wesley Cares
Team Communication / Team Work / Team Training
Every employee is accountable for their own safety
and that of each other, therefore:
• We observe our work place and each other for conditions or behaviors
that affect safety.
• We ask for help when we recognize a risky situation.
• We acknowledge our colleagues when we hear or see them working
safely & thank them for working safely.
• We talk to our co-workers when we think they might be at risk
because we care about them and don’t want to see anyone getting hurt!
6
Recognizing an
Impaired Provider
What is an impaired provider?
Healthcare provider impairment refers to the inability
to practice according to accepted standards as a
result of substance use, abuse, or dependency, as
well as impairment related to mental or physical
illness.
What to do?
Notify your manager and/or house supervisor of your
concerns about the co-worker.
7
OUCH!
Injuries are preventable!
Injuries to employees of
Wesley Medical Center happen.
Most injuries are preventable!!
The injuries we see most often are due to
human behavior…like rushing, taking
shortcuts or not following safety
procedures.
8
Celebrating Our
Cultures
Population Appropriate Care
Refers to our ability to meet the
distinct needs of patients, families,
and co-workers with respect to
cultural, spiritual and developmental
needs.
Knowledge & considerations for each
population includes:
• Communication approaches
• Personal space
• Time orientation
• Social organization
• Safety / environmental interventions
Cultural Diversity
Refers to the differences between
people based on shared ideology and
valued set of beliefs, norms, customs,
and meanings.
Cultural awareness:
• Diversity is an important part of life
• Strive to foster a culture of inclusion
• Be sensitive to distinct needs of
patients, families, and co-workers
with respect to cultural, spiritual and
developmental needs
• Don’t stereotype people…respect
their beliefs, even when they may
9
appear “strange” to you
Environment of Care (EOC)
Each of the 7 plans have components that help identify
risk, plan for education of the risk, teach, monitor results,
and evaluate the outcomes.
EOC standards stress the
need for everyone in the
organization to participate
in the processes &
activities that make the
environment safe &
effective for all.
Safety
Security
Fire & Life Safety
Utilities Mgmt
Hazardous Waste
Equipment Mgmt
Emergency Mgmt
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Environment Of Care
Safety Management Plan
Expectations of Staff:
Components:
• Safety policies
• Hospital Wide Safety
committee
• Education & Training
• Risk Management
• Quality
• Infection Control
• Safety Officer
•962-2046(WMC)
•858-2935 (GHH)
Each person & department
have the responsibility to know
the safety procedures that
pertain to the hospital & their
department
• Responsible for being alert for
& reporting any unsafe acts or
conditions
• Assist in monitoring &
evaluation of current practices
for effectiveness
•
11
Environment Of Care
Security Plan
Components:
• Assesses risk and the
activities to minimize
risk
Expectations of Staff:
Assist security by reporting
suspicious people or
situations
• Abide by the parking, smoking
• Responds to situations
and safe workplace rules
that could be harmful
to our patients, visitors,
and staff
12
Environment Of Care
Fire & Life Safety Plan
Expectations of staff:
Components:
• Oversees the fire
detection &
suppression system in
all our buildings
• System testing &
monitoring
• Fire drills
Comply with fire procedures &
drills
• Keep fire pull stations,
extinguishers, and fire doors
clear for easy access
• Do not go through closed fire
doors during drill/fire
• Keep exits & hallways clear
•
13
Environment Of Care
Hazardous Waste Plan
Expectations of staff:
Always use PROPER
handling and usage
techniques with all
waste materials to
protect ourselves,
patients, and visitors.
Components include:
•
•
•
•
Evaluation
Education
Proper handling
Disposal of chemicals
14
Environment Of Care
Utilities Management Plan
Components include:
•
•
•
•
•
•
•
Expectations of staff:
Communications systems
• Familiarization of approved
Infection Prevention
alternative procedures when
Negative Pressure systems
systems are “down”
Environmental support systems
Equipment support systems
Emergency power
Life support systems
15
Environment Of Care
Equipment Management Plan
Expectations of staff:
Components include:
• Safety, upkeep, and
operation of our patient
care equipment
• Equipment recalls &
alerts
• Clinical Engineering
plays a vital role
• Comply with routine maintenance
schedules; Look for preventive
maintenance sticker with current date
prior to use of equipment
• Take pride in and care of our
equipment
• Monitor equipment cleanliness
to prevent cross-contamination
• Report faulty or mal-functioning
equipment and take out of service
16
Environment Of Care
Emergency Management Plan
Components:
• Procedures &
preparation for internal
& external disasters
Expectations of staff:
• Comply with management for
internal disasters
• Participate in community
emergency interventions
www.fema.gov/areyouready/
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Environment Of Care
Look around your EOC with new critical eyes!
•
How would we “measure up” as of today?
• What could we do “right now” to create a safer EOC?
• What “monitoring systems” can we design to keep our
EOC a safe & cleaner place 24 hours / 7days a week?
18
SAFETY
19
Employee Identification
Wear your employee ID Badge
Question those that don’t!
It is very important for your own protection as well as that of
our patients and guests to be able to identify potential
threats to our security.
YOU have every right to request identification from anyone
in your work area who does not seem to belong there, or
who arouses your suspicions in any way.
If you do not feel comfortable challenging someone…
Call Security #23333 (Main campus)
GHH Security #2940
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Security #23333 (Main Campus)
Galichia Security is #2940
Wesley security staff are
here to provide the best
possible service for a safe
environment.
Security Tips:
When leaving work (especially at night):
1. Walk in groups as much as possible
2. Be aware of your environment and who is around you
3. Security will escort to your car if you are leaving at a
time that you could be alone
21
Harassment &
Workplace Violence Safety
Wesley Medical Center employees
can expect to work in an
environment free of harassment and
disruptive behavior.
As part of our commitment to a safe
workplace, possession of firearms,
other weapons, explosive devices,
or other dangerous materials on the Report incident to any of the below:
medical center premises is strictly
•Management
prohibited.
•Human Resources
•Ethics Compliance Officer
22
Reasons for Aggressive or
Violent Behavior in Hospitals
• Alcohol, drug abuse
• Revenge (for real or imagined slights)
•Stress
•Frustration (long waits, sick child/family)
•Family Problems, financial problems
•Mental illness-paranoia, depression
•Gang or criminal affiliation
•A need for power and control over health
problems
23
Escalation of Emotions
Concern
Sick family/self, work
schedule, busy/stress
Frustration
Long wait times, no answers, no one
cares, “behind the scenes”, “no one
is listening to me”
Anxious
Time is ticking, still no answers, what’s
going on?!
Anger
I’ll yell until they listen! I will be
heard!
Rage
24
6 Steps for De-Escalating Emotions
1.
Remain calm. Breathe – deeply. Keep
your voice low.
2.
Demonstrate respect for yourself and for
the other person. Be gentle, but firm. “I
understand you’ve been waiting. I
will…”
3.
Watch body language, both yours and your
patient’s. Avoid sudden moves. Use slow
and gentle hand movements. Use nonthreatening eye contact.
4.
LISTEN – Pay attention to what the person is telling
you…and what they aren’t
5.
Keep your emotions in check – avoid being pulled in
to the conflict they are experiencing
6.
Know when to say when! Call another Manager
or Security
25
Things NOT to Do…
• Avoid allowing long waits – “check” in when
possible
• Don’t raise your voice
• Don’t take action without explaining what’s
happening
• Don’t engage in power struggles
• Avoid telling the other person that you “know
how he or she feels”
• Do not attempt to intimidate a hostile person
• Crowding someone’s personal space
• Don’t criticize or lecture
• Turing your back on someone during a
conversation
26
WMC covers a lot of ground!
Prevent Slips, Trips, & Falls
• Watch for water or debris on the floors and
hallways or uneven surfaces
• Clean up spills or debris immediately by
doing it yourself or calling the appropriate
service
• Watch for dangling cords or cords on the floor
Please help everyone stay safe!
27
Ergonomics
Education & Prevention
Ergonomics is the science of
working smart & learning to
move and position your body
to reduce stress on muscles,
tendons, and ligaments.
Musculoskeletal Disorders are injuries that
are caused by poor postures, prolonged
position, repetitive movements, and not
using the resources needed to do the job.
28
Ergonomics
Work Practice Techniques
Learn & practice techniques to move & position your body safely.
Never transfer patients when off balance
Lift loads close to the body
Never lift alone, particularly fallen patients, use team lifts or use
mechanical assistance
Avoid heavy lifting especially with your spine (back) rotated
Get training in how & when to use the mechanical assist devices
29
Smoke Free Environment
Tobacco-Free Campus
Wesley Medical Center
It is the responsibility of every employee of WMC to support
and comply with the tobacco-free policy.
If any employee observes anyone using tobacco
products while on Wesley property, they should politely
inform the individual of the tobacco-free policy.
Cards with policy information are available for distribution
from human resources.
30
Fire Triangle
Prevent fires by keeping these sources separate:
Heat – anything that can cause a spark
Fuel – anything that can burn
Oxygen/Air – oxygen or air
31
Exits / Egress
Be Aware Be Responsible
• Always keep one side of hallways clear for a quick and effective
exit if needed. Any hall used for evacuation requires an 8 foot
“coming or going” space AT ALL TIMES.
• Look around & be vigilant about putting items away;
Parking any piece of equipment in the hall greater than 20
minutes is considered an obstruction and is not acceptable.
• Keep EXIT paths, fire alarms, & fire extinguishers free of
equipment & supplies.
• Do not go through closed fire doors during a fire or fire drill.
32
Alarms / Extinguishers Be Aware & Be Responsible
Know the location of:
• Fire alarm boxes
• Fire extinguishers
• Medical Gas Shut off
• Exit routes
Fire Extinguisher: PASS
Review procedures to
follow in the event of a
fire drill or actual fire.
33
Fire Drill
A drill should be responded
to as if it were a real fire
situation.
• Dial #23131 (Main Campus)
• Dial #2940 (Galichia)
• Tell operator who you
are, where your are, and
report a “Dr Red Drill”
Green” is the all
clear signal
announced over the
public address
system.
“Dr
34
Fire Event: RACE
Call 23131(Main Campus)
Call 2940(Galichia)
Rescue … remove anyone in immediate danger
Alarm … call #23131(Main Campus) or #2940(GHH) state who you are,
your location, & what the situation is; If no phone is available … pull
the nearest fire alarm
Contain … the fire if possible / close doors and windows
Extinguish / Exit … use PASS if you can safely do so
Pull pin Aim Squeeze Sweep
35
Medical Gases / Shut Off Valve
1.
In the event of an emergency, who is authorized to
turn off a “piped in” oxygen supply to an identified
medical gas zone area?
Answer: A shared decision between respiratory care
and nursing will be made to authorize the actual shut
off of any piped in oxygen zone valves in the
identified area.
2. What action needs to be taken if an oxygen zone
valve is to be closed?
Answer: Locate patients who are currently on oxygen
in the identified zone and provide an oxygen cylinder
and/or arrange transfer to another area.
All zone valves are identified with the rooms/areas that are controlled by that valve.
36
Oxygen
Cylinder Safety
Secure and safely store all oxygen
cylinders (full or empty) by placing
inside the rack or a 2-wheeled
carrier in your unit’s cylinder
storage area. If rack is full, call
Respiratory Therapy to pick up.
When transporting a patient, secure
the oxygen tank i.e. in provided
hollow storage area of the transport
cart, or in the wheelchair
mounted carrier.
Laying on floor in patient room or hallway
Standing alone without being secured in an
approved carrier
In the cylinder storage area but NOT
placed in the rack
Standing in a wheelchair/cart carrier
(ones without wheels)
Laying on patient bed
Stacked on other equipment
If you see an oxygen cylinder that is not secure or
contained, DON”T WALK ON BY take immediate action.
Secure the unsafe tank. Notify the manager!
37
Electrical Safety
Minimize electrical hazards by:
• Checking electrical equipment before each use
• Checking plugs and cords for exposed wire or damage
• Disconnecting cords by pulling on the plug not the cord
• Using only 3-prong plugs when possible
• Water and electricity do not mix! Keep hands dry &
keep areas surrounding electrical equipment dry
• Keeping cords from kinking while equipment is in use
Call Clinical Engineering #22560 for medical equipment
Call Plant Operations #22770 for all other electrical equipment
Call for After Hours EMERGENCY #22712
38
Radiation Safety
Contact the Radiation Safety Officer at 962-3030 (operator page).
Radiation producing machines and
radioactive materials are operated by
specially trained physicians &
technologists for diagnosis &
treatment of disease.
Minimizing radiation exposure:
• Recognize the hazard signs &
proceed with caution & permission
• Maximize distance between you &
the source of radiation
• Wear approved radiation protection
Signage, indicating type & level of
hazard, is posted where radiation is
being used; these rooms are
shielded with lead or concrete to
minimize radiation levels to meet
regulatory standards.
Caution: X-rays
Radioactive Material
High Radiation Area
garments (i.e. lead apron) when
assisting with diagnostic studies
• Step back a few feet from the
radiation machine or patient during
the actual exposure
• Limit your time/exposure around
radiation equipment & materials
• Staff who could be exposed to greater
then 10% of annual exposure limits
are assigned personnel radiation
monitors to assess their level of
exposure
39
Waste Management Types
3 kinds of “waste” found in health facilities:
1. General
2. Medical
3. Hazardous chemical
General waste – non-hazardous waste that poses no risk of injury or infections.
This is similar
in nature to household trash. Examples include paper, boxes, packaging materials, bottles, plastic
containers, and food-related trash.
Medical waste – material generated in the diagnosis, treatment, or immunization
of patients including:
• Blood, blood products, and other body fluids (fresh or dried blood or body fluids such as
bandages & surgical sponges)
• Organic waste such as human tissue, body parts, the placenta, and the products of conception
• Sharps (used or unused), including hypodermic and suture needles, scalpel blades, blood
tubes, pipettes, and other glass items that have been in contact with potentially infectious
materials
Hazardous chemical waste – is potentially toxic or poisonous and includes cleaning
products, disinfectants, cytotoxic drugs, pharmaceutical waste (drugs/wrappers) and
radioactive compounds
40
Waste Management
Identification & Safe Handling
Think safety – Use appropriate PPE - gloves, facemasks, protective face
shields, and protective clothing.
Utilize appropriate waste management containers for sharps, biohazard
substances, solid waste, etc.
Hazardous
Chemical
Infectious
Cytotoxic
Gas
Exposure can occur through inhalation (breathing), ingestion (swallowing),
skin contact or absorption, and injection.
If exposed:
Seek immediate treatment / Notify manager / Complete a HNS report
41
IT DOES NOT BELONG
IN THE RED BAG…
• It does not belong in a red bag,
if the item would NOT release
infectious fluid (blood or other
potentially infectious material)
when compressing the bag
• It does not belong in the red bag,
if the item has the potential to
“poke” through the bag
When removing waste from a
patient’s room, ALWAYS
separate the biohazard
waste from the regular waste.
42
Biomedical Waste Bag (Red Bag) Closure
Procedure
Step 1:
Place all biomedical waste into appropriately
marked bag. Do not fill bag more than ¾ full.
Step 2:
Gather and twist the top of the red bag.
Step 3:
Twist bag closed with tie or single hand knot.
Step 4:
Place properly closed bag into
biomedical waste container located in
the soiled utility room.
THINGS TO REMEMBER:
Always close bags properly before placing in
biomedical waste container
NO RABBIT EAR TIEING
43
Healthcare Rx Waste Stream Management
LQ: Generator Status
Sort
Code
Description and examples of Wastes
Waste
Class
No Waste Code
Dispose of med in black container
Non-Hazardous
Rx Waste
Hazardous
Rx Waste
When medication is left in
a vial, IV, pill:
When medication is left that is
hazardous:
All Rx waste without a waste code
defaults to the blue container unless it
is in a syringe or ampoule. Any waste
with the potential to leak must be
placed in a Ziploc bag. It is not
permitted by the Department of
Transportation (DOT) to transport free
fluids.
Examples of Hazardous Waste:
•Vaccines
•Bulk (more than 3%) Chemo
•Nicotine Gums & Lozenges (+wrappers)
•Toradol, Digoxin (liquid)
•Nasal Spray, Sore Throat Sprays,Lozenges
•Unused Multi-Vitamins (no wrappers)
•Insulin and Insulin Drips
Examples of Non-Hazardous
Waste:
•I.V. Antibiotics
•Tylenol, Aspirin
•Lidocaine,Bupivacaine,Xylocaine
•Dobutamine, Dopamine, Pitocin
•Nitro drips/tablets
•Injectable Contrast, Barium
•Solu-Medrol,Solu-Cortef,
Diphenhydramine
•TPN’s
•Heparin
•Approximately 95% of all medications
Not permitted:
Blood Products or infections
waste
Syringes or ampoules
Container
Labeled/Identified Hazardous by Pharmacy
Blue
Container
Place wrapper and med in
Ziplock then black
container waste code
Capture Full, partial plus empty
packaging for:
•Nicotine/Nicotrol
•Coumadin/Warfarin
Partial syringes/sharps
acceptable in small 2 gallon
black container.
Black
Container
Other waste Streams
RCRA Waste:
Return to Rx
No Code
No Code
Incompatible
Rx Waste
Maintenance
Sharps/
IV Solutions
Infections
Waste
Return to
Pharmacy/place in
Aerosol bin
Dispose in
Aerosol Container
Aerosols
•HFA Inhalers
•Compressed
Propellants
•NO capsule powder
inhalers – place in blue
containers
Return corrosive and
Oxidizing meds to
Pharmacy
(Send to Pharmacy
Code)
Corrosives (Example)
•Sporanox
•Zinc Sulfate
•Unused Ammonia
Inhalants
Oxidizers (Examples)
•Potassium
Permanganate
•Unused Silver Nitrate
Dispose in baggie
and use hospital
approved return to
pharmacy process.
NO CONTROLLED SUBSTANCES – in any of the above containers.
(No Medications)
Items that
can be cut
and poured
down the
drain.
•Maintenance
IV Solutions
Containing:
-Potassium
Chloride
-Potassium
Phosphate
-Sodium
Phosphate
-Calcium
- Sodium
Bicarbonate
- Dextrose
- Saline
-Lactated
Ringers
No IV’s with
medications
added.
Discard
down
the
drain
•Needles
•Empty
Syringes
•Empty
Ampoules
•Saline/
Syringe
•Blood/
Syringe
No partial
medication
bottles, IV’s,
or syringes
with
medications
added
Empty Items
Empty/Trace
vials and IV bags
Dispose your
empty/trace
containers per
your hospital
policy
•Empty Vials
•Empty IV bags
•Empty IV
Tubing
Empty syringes
and ampoules in
red sharps
container
Discard in
regular
trash
receptacle
SHARPS – Place in Red Containers.
44
44
Sharps - Be Aware &
Be Responsible
Sharps Management
Communicate with team members
& utilize a “safe zone” during
procedures.
Use available safety sharp devices.
Sharps Injury Event
 Wash site with soap & water
 Notify manager & Employee Health
 There is a 2 hour window for treatment of
potential HIV / AIDS exposure
 Complete HNS report
Needles/sharps shall be disposed
of in an approved container to
minimize the risk for injury.
A Bio-System staff member replaces
sharps containers in all patient care
areas on a routine basis.
45
Chemical Spills .. Labels .. MSDS
LABELS…all substances will be identified
In original or approved labeled containers.
Chemical Spill
If chemical spills are too large
to handle safely, report immediately
to emergency operator at
23131(Main Campus)
And 2940 (GHH)
Check with your manager
concerning assigned chemicals on
your unit.
Material Safety Data Sheets
available 24/7 by calling
Security at 23333 (Main Campus)
And 2940(Galichia)
The most detailed and comprehensive
information about substances are found on
the MSDS sheets .
46
Hazardous Drugs/Cytotoxic Drugs
(HDCDs)
•
Patients receiving hazardous and/or cytotoxic drugs in the past 48 hours are identified with
an orange identification band.
•
Use the long cuffed light blue gloves when administering chemo and other hazardous
drugs.
•
A Hazardous/Cytotoxic Precautions sign will be posted in the patient’s room.
•
To reduce exposure to hazardous/cytotoxic drugs found in body fluids,
use standard precautions.
•
ALL healthcare workers need to follow hazardous waste disposal policies
located on Wesley’s Intranet (General Policies – Hazardous Waste).
47
Emergency Management
48
Emergency Management Plan
Wesley Medical Center under The Joint Commission (TJC) facilitates a
flexible “All Hazards” approach to emergency management that can be
adapted to a variety of catastrophic emergencies.
The Emergency Management Plan (EMP) applies to any internal or external
disaster. All employees have a role in the EMP.
Emergency Management (EM) addresses the four phases of disaster response:
1. Mitigation
2. Preparedness
3. Response
4. Recovery
There are six critical areas of emergency management:
1. Communications
2. Resource and Asset Management
Details of the Emergency
3. Safety and Security
Preparedness Plan are located
4. Staff Responsibilities
on the Wesley Intranet under
5. Utilities Management
Department .
6. Patient Clinical and Support Activities
49
HICS
Hospital Incident Command System
HICS is a program developed to assist in the
operation of hospitals during times of a planned
drill or an unplanned event (internal or external).
– Provides an identifiable, responsibilityoriented chain of command
– Provides a common mission & language
– Provides a method for prioritizing duties
50
Systems Failure
Basic Staff Responses
Examples:
•
Electrical Power but the
Emergency Generators Work
•
Ensure that life support systems
are on emergency power (RED
Outlets). Ventilate patients by
hand as necessary. Complete
cases in progress ASAP. Use
flashlights. Monitor patients
according to severity.
•
Electrical Power – Total Failure
including emergency generators
•
Utilize any battery operated lights
available, hand ventilate patients,
manually regulate IV’s as needed.
Don’t start new cases. Monitor
patients. Provide for visitor safety.
•
Telephones
•
Use cellular phones & overhead
paging; Use runners as needed.
51
The NEW Wesley Severe Weather Plan has 3 Levels of activation
Level I Severe Thunderstorm/Tornado WATCH
Staff Responsibilities:
-Locate and place patient’s shoes at bedside
-Explain to patient and/or family actions being taken are precautionary only.
-Ensure visitors in waiting rooms are aware of alter and of safe locations
Level II Severe Thunderstorm/Tornado WARNING
Staff Responsibilities
-If equipped, window shades or blinds are to be pulled over windows
-Ensure patient and/or family members are informed and reassured
-Place an extra blanket on each patient’s bed
Level III Severe Thunderstorm/Tornado WARNING of Immediate Danger
(Wesley is in the path of danger)
Staff Responsibilities
-Immediately move all patients to the inside hallway
-If patient absolutely cannot be moved to hallway, move as far away from
windows as possible and cover with blankets
-Close all doors
-As is possible, ensure waiting rooms are alerted to danger
-Do not leave the building
An “ALL CLEAR” will be announced when conditions are not longer a danger
52
Bomb Threat / Bioterrorism
Bomb Threat
If you receive a phone call -
Bioterrorism
•
or….
•
See a suspicious package •
Environmental contamination
includes chemical, biological, or
radiological events that put
visitors, patients, customers and
employees in danger.
For questions, operator page
our regional bioterrorism
coordinator.
An excellent resource is
http://www.cdc.gov/
Take it seriously!
Call 23131 (WMC) or #2940 (GHH)
for any threat!
53
Emergency Teams
RAPID RESPONSE
(ADULT & PEDIATRIC)
The purpose of the team is to bring critical care expertise and support to the patient outside of the
Emergency Department or Intensive Care Units
Main campus team:
 Consist of:

•


MICU (senior RN)
Resident; if requested by team
Respiratory Therapist
Primary RN caring for patient
 Can be activated by calling 2-3131
Galichia team:
 Consist of:
 House Supervisor
 Respiratory Therapist
 Primary RN caring for patient
 Can be activated by calling 695-9999
 No pediatric team available
Patient Action Line (PAL):
 allows patients/family direct contact for voicing concerns and/or emergency help
 Can be utilized when medical attention/concerns are not being addressed
 Activated by family or patient by calling:
 962-7377 (WMC Main Campus)
 858-2965 (Galichia)
• Director on call will respond and activate a team if necessary at either location
Any employee can call that is concerned about a patient!
54
Emergency Teams (Continued)
Code Blue
(Adult , Pediatric or neonatal)
The purpose of the team is to initiate emergency care and resuscitative action
 Main campus activation:
 2-8540 (Neonatal, BR, 3 & 4 WH)
 2-8848 (Neonatal BCC)
 2-3131 (Specify Adult/Pediatric )

Main campus team consists of:
 Critical care RN & Respiratory Therapist
 Resident & Pharmacist (Adult/Peds)
 EKG Technician & Chaplain
 Galichia activation:
 Dial #0
 Announce “Code Blue “w/ specific location, repeat once
Medical Emergency
(Adult or Pediatric)
The purpose of the team is to initiate emergency care for any non-patient
 Main campus will call 2-3131 and announce “Medical Emergency”
 Galichia will call house supervisor 858-2965 or activate EMS
 WMC Team consists of:



ECT or RN from ED or Trauma
Security
Chaplain
55
56
56
Infant and Pediatric Abduction
• Maternal Child staff will determine possible
abduction and Call #23131
• Public Address System enacts announcement
• Security will respond & assist staff in securing all
exits of Women’s Hospital & BirthCare Center
• Unaffected departments will assign an employee
to their closest exit to monitor & detain
suspicious persons if needed
• Drills will be conducted; respond appropriately 57
Risk Management
58
Ask: What / Why / How
We as an organization must establish and maintain a
culture by asking….
- What happened?
- Why did it happen?
- How can we prevent it from
happening again?
59
Your Responsibility with the
Risk Management Program
• Be constantly alert for occurrences that might cause undesirable
effects
• Communicate the positive and/or negative aspects of the
occurrence
• Document the occurrence on HNS for further tracking and
monitoring
• Report unsafe conditions/situations to your manager, risk
management at 962-7274, or to the SAFE line (2-SAFE, 962-7233)
• If the unsafe condition/situation poses an IMMEDIATE threat or
harm, consider what immediate actions you can take
(Note: use your chain of command to assist with actions needed to provide a safe
environment)
60
What is an “Occurrence”?
-an unusual event, situation, incident or unexpected outcomeExamples:
• Medication or other treatment errors
• Patient, visitor, or employee injuries
• Patient or family dissatisfaction
• Malfunctioning equipment
• Unintentional lacerations or perforation of an organ or body part
• Unexpected death
61
Sentinel Event / Close Call
Sentinel event is defined as “an unexpected occurrence involving
death or serious physical or psychological injury or
the risk thereof”
– Notify Risk Management ASAP 962-7274
– You may be asked to participate in a Joint Commission required Root
Cause Analysis of the event to develop a corrective action plan that
would prevent recurrence
– The Joint Commission periodically releases “Sentinel Event Alerts” with
recommended practices
Close call is defined as “an unplanned incident that does not cause
injury, but under different circumstances could have;” it
was prevented due to insight of a healthcare provider
who acted to prevent it
– Close call events need to be investigated and an action plan developed
to ensure everyone’s safety & to prevent recurrence
62
Hospital Notification System
Risk management law
requires all employees
and healthcare providers
to report occurrences,
sentinel events, and
close calls.
Report immediately
to manager:
Occurrences
Sentinel Events
Close Calls
Document ALL
within 24 hours
with an HNS
63
EMTALA
(Emergency Medical Treatment and Active Labor Act)
EMTALA States:
The Emergency Department must provide to any individual that comes to
the emergency department :
(includes Main ED, West ED, Birth Care Center, Birth rooms, GHH ED)
•Appropriate medical screening exam and stabilization within the capability and
capacity of the facility, regardless of the ability to pay.
•Stabilizing treatment prior to an appropriate transfer to another medical facility.
•Appropriate transfer requires the completion of the EMTALA Memorandum of
Transfer form.
64
EMTALA
When is an EMTALA obligation triggered?
•When an individual or a representative acting on the individual’s behalf requests
an examination or treatment for a medical condition.
•A prudent layperson observer would conclude from the individual’s appearance or
behavior that the individual needs an examination or treatment of a medical
condition.
•The individual can request emergency medical care ANYWHERE ON HOSPITAL
PROPERTY which includes : Main Campus, West ED, GHH, or within 250
yards of the main buildings, but does not include Wesley Care Clinics.
•EMTALA policies are found on the intranet under polices and
procedures.
65
HIPAA / Patient Rights / Confidentiality
66
HIPAA – Privacy Rule
Health Insurance Portability & Accountability Act of 1996
ALL healthcare employees are obligated to protect patient privacy rights!
(patient & non-patient care areas, physicians, residents, volunteers, & students)
– Patient’s Rights
– Federal Regulation
– Protected Health Information
-using & disclosing any form of PHI via any
type of media.
If there is a HIPAA concern:
Notify your manager or the facility
privacy official & complete a HNS
report.
67
Patient Privacy Rights
•
•
•
•
•
•
•
The right to access their PHI (Protected Heath Information)
The right to request amendment of PHI
The right to an accounting of disclosures
The right to opt out of the patient directory
The right to confidential, alternate communication
The right to restrict access
The right to receive the notice of privacy practices
68
Protected Health Information (PHI)
What is PHI?
It is ANY health-related information that can be directly
linked to the patient…such as name, address, any
number identification (i.e. medical record, x-ray, driver’s
license), etc
• Relates to the physical or mental condition of individuals
(past, present or future); and the treatment or payment of
their care
• Transmitted or maintained in any form
(electronic, paper or verbal representation)
69
Tips to Safeguard Patient’s PHI
Electronic health information:
•
Log off the computer when finished
•
Do not share computer passwords
•
Do not text or post PHI to social media.
•
Do not access PHI without a need to know to perform the job (i.e. Meditech information)
•
Password protect personal recording devices with patient’s PHI (i.e. PDA, laptop, flash drive)
•
•
•
If lost or stolen, report immediately to manager and security. Call 27800
Do not leave printed or electronic patient information exposed where visitors or unauthorized
individuals can view it
Encrypt emails contain PHI, confidential or sensitive information.
Use of personal recording devices (i.e. cell phones, digital camera, PDA, etc) –
personal photograph or recording devices are prohibited from use to protect privacy
of Wesley Medical Center physicians, employees, patients, and visitors
Written health information: (patient work lists, medical record & billing records)
–
–
–
–
–
Do not discard PHI in trash can (PHI no longer needed MUST be disposed of by shredding!)
Do not post PHI on bulletin boards or leave exposed in public areas
Be sure to blacken out patient names on “Thank You” cards posted in public areas
Do not label patient’s full name on tracker boards and chart backs
Do not leave medical records open or unsecured
70
Tips to Safeguard Patient’s PHI
Oral/Verbal/Written health information:
•
Use patient curtains
• Lower your voice
• Black out patient names on “Thank You” cards posted on public
bulletin boards
• Do not speak of patient information in public areas with coworkers or non-authorized persons
• Limit voice mail to name, facility, call back number & brief
purpose for call unless quality or safety of care will be
impacted
• Obtain patient’s pass code when discussing results on the
telephone
• Ask visitors to leave patient room when health information
is being discussed
• Obtain patient’s permission to discuss health information
in front of visitors and/or family members present
• Report HIPPA violations through Hospital Notification System,
Facility Privacy Officer or the Ethics and Compliance Officer.
• Report the loss of any portable electronic device to the IT
director, Facility Privacy Officer, or by calling 27800 within 24
hours.
71
Violations
All violations are reported to HCA Corporate & to the Office of Inspector General (OIG)
What are the most commonly reported HIPAA Privacy Violations at Wesley?
Not Safeguarding PHI:
_
Placing patient information on Facebook, Twitter, or other social media sites.
–
Errors in faxing reports, assigning the wrong physician mnemonic therefore results are
sent to the wrong physician, e-mailing PHI without encryption, placing patient information
in trash bins and taking photos with cell phone or personal recording device
Inappropriate Access to information:
–
–
Use and disclosure of patient PHI without a need to know (i.e. patients not in your care)
Access of Meditech to view PHI of newsworthy patients, friends, family members, coworkers
Care & Notification:
–
Inappropriate verbal disclosures without patient permission (i.e. sensitive diagnosis
shared with family without patient permission / calling report over cell phone in public
area / social media / cell phone photos)
Remember:
Only those employees with a legitimate “need to know” may access, use or
disclose PHI.
Each employee must access only the minimum information necessary to perform
their job regardless of the extent of access provided to them.
72
Computer Use & Workstation
An employee accessing the computer system is responsible for
any activity performed under his/her USER ID.
Never share your password
Each user’s computer activity is audited at least once a year.
BEFORE LEAVING A COMPUTER or PYXIS:
SIGN OFF & SECURE any information
This action helps to ensure the protection of the
information as well as prevent any activity occurring
under your user ID in your absence.
Open computer screens and charts sitting in public places should not
be left unattended. This is not only a quality concern, but carries the
potential of fines should protected health information fall into the
wrong hands. Protect your patient and yourself by securing charts
and turning off computer screens promptly.
73
Infection Prevention - HAI
Healthcare-Associated Infection (HAI)
An infection that develops in a health care setting that is related to
receiving care in that setting.
Infection Prevention is everyone’s business
74
Infection Prevention
STOP GERMS!
• Attention to hand hygiene, use of PPE (personal protective equipment),
use of standard & transmission-based precautions are all essential!
• Prevention of infection is an important part of what you do everyday!
Bloodborne Pathogens
It is critical for healthcare workers to
consider & treat all blood/body fluids
as potentially infectious.
75
Single Most Effective Way to prevent
the spread of communicable diseases!
Hand Hygiene:
Just DO IT!
Every Patient / Every Time
Perform…
•
•
•
•
•
•
Prior to donning gloves
Immediately after removing PPE (includes gloves)
Before & after each patient contact
Before you eat
After you use the restroom
Any other time you think of it!
76
Hand Hygiene - Wash
•
First, wet your hands with warm
running water and then add soap.
•
Use friction by rubbing your hands
together, making a soapy lather. Do
this away from the running water for at
least 15 seconds. Wash the front and
back of your hands, wrists, as well as
between your fingers and under your
nails.
•
For rinsing, position hands/fingers
down towards sink. Rinse your hands
well under warm running water.
What is good hand washing technique?
By rubbing your hands vigorously with
soapy water, you pull the dirt and the oily
soils free from your skin.
The soap lather suspends both the dirt and •
germs trapped inside and they are then
quickly washed away.
•
Dry hands thoroughly with a clean
paper towel.
Turn off the water with a dry paper
towel and dispose in a proper
receptacle.
77
Hand Hygiene - Foam
Waterless Hand Antiseptic
Hand De-Germing
•
Place adequate amount
of foam/gel in one palm
to cover all surfaces of
both hands and wrists;
then rub the hands
together until the
hands/wrists are dry.
•
These products are only
intended to kill germs,
not to remove visible
dirt.
FOAM IN
AND
FOAM OUT
78
Personal Protective Equipment
PPE
Personal protective equipment (PPE) is defined by the Occupational Safety
and Health Administration (OSHA) as “specialized clothing or equipment,
worn by or used by an employee for protection against infectious materials.”
EACH OF YOU…locate & use the PPE & bio-hazard disposal containers in
your work area…understand the type of PPE required for protection from
the activities you will be performing. Know how to put PPE on and take it off
correctly for your protection.
– Gloves protect the hands
– Gowns or aprons protect the skin and/or clothing
– Masks and respirators protect the mouth and nose
The respirator has been designed to also protect the respiratory
tract from airborne transmission of infectious agents
– Goggles/special eyewear protect the eyes
– Face shields protect the entire face
79
Personal Protective Equipment
How to Use … Respirator Mask
How to Use PPE:
•
•
•
•
•
Keep gloved hands away from face;
Avoid touching or adjusting other PPE;
Limit surfaces and items touched
Remove gloves if they become torn;
perform hand hygiene before putting on
new gloves
Discard gloves near the exit inside the
room; “foam out”
Discard disposable gown & mask after
each use–DO NOT REUSE OR SAVE!
When wearing a disposable mask,
make
sure it is secured properly on your face.
When finished, remove mask by
touching only the ties or the elastic
bands and discard in waste container
(never leave around your neck or in a
pocket for re-use!)
How to Use Respirator Mask:
•
•
•
Place over nose, mouth and chin; fit
flexible nose piece over nose bridge
Secure on head with elastic bands;
adjust to fit
Perform a fit check
– Inhale (mask should collapse);
– Exhale (check for leakage around face)
Removing respirator mask:
•
•
•
•
•
Front of mask/respirator is contaminated –
DO NOT TOUCH!
Grasp elastics and remove
Discard in waste container
Perform hand hygiene
80
Standard Precautions
A group of infection prevention practices that apply to all patients, regardless
of suspected or confirmed diagnosis or presumed infection status.
Standard precautions require putting a barrier between you & the source of infection.
When there is a risk of exposure to blood borne infections, work safely by applying
the Principle of Standard Precautions!
81
Expanded Precautions-Transmission Based
Contact Precautions• All staff to always wear gloves when entering a
contact precautions room
•
•
Strict hand washing compliance
Gowns are needed when you want to prevent
contamination of your clothing from contact with the
patient or the patient’s environment
• Patient has an open or draining wound
• Dressing changes / bathing or repositioning of
patient
Droplet Precautions• All staff to always wear a surgical mask whenever
they enter the room, and eye protection while providing
direct patient care and gloves and gowns if they will
come in contact with surfaces contaminated by
respiratory secretions
Recognize the alerts
Observe signage on doors
defining type of precaution;
Rose Pink identification
band on patient
Follow the evidence-based
practice - Use appropriate
PPE (personal protective
equipment)
“Monitor & Correct”
those who don’t follow
acceptable practice
• Surgical mask to be worn by the patient if patient
leaves room or is transported outside of patient’s
hospital room
Airborne Precautions• Negative pressure room
• Staff to wear N95 respirator mask for TB or if
DO NOT RE-USE/SAVE
disposable PPE
susceptible to other disease indications
• Surgical mask for patient during transportation
outside of patient room
82
Use Barrier Devices
If you think “it” will:
– Burp
or
-Squirt
or
-Splash
Be prepared…
PRIOR to dealing with “it”, put on protective equipment!
(eye goggles or a mask with a face shield…gown or apron…and gloves)
83
Event of an Exposure
If you are exposed through splashes, needle stick
puncture wounds, or other sharps injury from any
potentially infectious material:
– immediately locate a hand-washing facility & wash your skin
with soap & water
– if eyes, mouth or nose, flush with lots of water
• Notify your manager & seek immediate treatment & evaluation!
-(WMC)Employee Health #22656 or Emergency Department
-(GHH) Employee Health # 2610 or Emergency Department.
– if treatment is necessary for HIV, the medication should be
started within 2 hours of exposure
– document event with an HNS by the end of the work shift
84
SAFE WORK PRACTICES
“CLEAN to DIRTY Principle”
Touch clean body sites or surfaces before you touch dirty or heavily
contaminated areas.
Be aware of environmental surfaces and avoid touching them unnecessarily
with contaminated gloves.
These examples of “touch contamination” can potentially expose you to
infectious agents:
Surfaces such as light switches, door handles, and cabinet knobs can become
contaminated if touched by soiled gloves.
Don’t drag dirty linen/trash on the floor or down the hallways. The chance of
contamination of the environment is very high. Use roller devices for moving.
How many times do you see someone adjust their glasses, rub their nose, or
touch their face with gloves that have been in contact with a patient or
something on your unit considered “dirty”?
85
C-Diff
BE INFORMED
•
•
•
•
C-Diff is spread between patients by health-care workers and others on
hands, clothes and shared equipment.
Barrier Precautions are required to control C-Diff – wear gloves and gown
EVERY TIME YOU ENTER A C-DIFF PRECAUTION ROOM
Cleaning of shared equipment (e.g. stethoscope, glucometer, BP machine)
between patients or using dedicated equipment in CONTACT precaution
rooms is required to control C-Diff. Wipe equipment with disinfectant wipe
per manufacturers directions
Vigilant environmental cleaning by environmental services as well as by all
patient care providers is required to control C-Diff.
– *Decrease clutter–only keep supplies at the bedside you currently need
– *Wipe surfaces with disinfectant wipe each shift
– Terminal Clean upon dismissal
•
We must all speak up when we see other’s not following vigilant hand
washing, barrier precautions (Gown & Gloves) in CONTACT precaution
rooms or lack of cleaning of shared equipment. We will not win the fight
against C-Diff unless every one who comes in contact with our patients
follows and practices the same guidelines.
86
VRE / MRSA
Be Aware & Practice Infection Prevention
Vancomycin-Resistant Enterococci
VRE
Transmission:
• VRE is usually passed to others
by direct contact with stool, urine or
blood containing VRE
• It can also be spread indirectly
via the hands of healthcare providers
or on contaminated environmental
surfaces
Infection Prevention Practices:
• Contact precautions
• Dedicated equipment; Disinfect ALL
Equipment before it leaves patient room
• Terminal Clean upon dismissal
(TEAL Alert on door)
Methicillin Resistant Staph Aureus
MRSA
Transmission:
• MRAS is spread by hands – direct or
indirect contact with contaminated surfaces
Infection Prevention Practices:
• Contact precautions
• Disinfect ALL Equipment before it leaves
the patient room; MRSA can live for hours
on environmental surfaces
• Perform hand hygiene
• Screening for MRSA-nasal swab on high
risk patients
• Identified with pop-up box on
admission
87
Respiratory Viruses
A regular procedure mask is what is needed
to protect you from all respiratory viruses,
including Influenza.
Health Care Workers and visitors should wear
a mask when in the patient’s room.
The patient should wear a mask when they
are in the hallway or in waiting areas.
An N-95 respirator or PAPR should be worn
by the healthcare worker when they are
involved in aerosol generating activities such as
CPR, sputum induction, bronchoscopy, or open
88
suctioning.
Influenza Vaccine
• Vaccination is the best protection against contracting the flu.
Yearly influenza vaccination generally begins in September and
continues throughout the influenza season which generally peaks in
January or later.
• Healthcare personnel are among the priority groups that the CDC
recommends be the first to receive influenza vaccines each year.
Infections among healthcare workers can be a potential source of
infection for vulnerable patients. Also, increased absenteeism among
healthcare professionals could reduce healthcare system capacity.
• Vaccines change each year based on which types and strains of
viruses may circulate.
About 2 weeks after vaccination, antibodies that provide
protection against influenza virus infection develop in the body.
89
Tuberculosis (TB)
When a person with active TB of
the lungs shouts, coughs or
sneezes, the TB germs may
spread into the air. Anyone
nearby can breathe the germ
into his or her lungs.
A TB patient should be in a
negative pressure room.
When not in this room, they
should be wearing a surgical
mask.
Healthcare workers & visitors
should wear a N-95 respiration
mask when caring for or
visiting the patient.
Employees are required
to complete TB skin
testing every year.
90
Surgical Site Infections: Prevention is the Key!
SURGICAL-SITE INFECTION (SSI)
An infection that occurs after surgery in the part of the body where the surgery
took place. Redness and pain around the surgical site; drainage of cloudy fluid
from the surgery site; fever.
Nurses must be aware of guidelines and practice evidence-based care.
By working together with the patient and the other healthcare professionals, you
can take specific steps to help decrease SSIs.
Do your part by becoming educated and remaining alert as new information for
treatment and care become available.
PREVENTION STRATEGIES:
•Aseptic technique helps decrease infection incidence
•Infection prevention practices including sterilization methods,
operating room ventilation, surgical technique, and antibiotic
availability
91
CAUTI Prevention
Cath only when necessary
Avoid routine irrigation
Technique is always sterile
Height of the catheter bag-always below waist
Education for staff
Tubing and bag off floor and free of kinks
Education to patients
Remember to maintain a closed system
Secure properly
92
Central Line Care Bundle
• Perform hand hygiene prior to touching line.
• Scrub the hub for 15 seconds prior to every access.
 Friction is necessary to remove germs.
• Dressing changes every 7 days or if dressing is loose or
soiled.
Apply Bio-patch for anyone over the age of 2 months.
• Change caps every 7 days
• Assess necessity of lines daily-discuss with physician
for removal.
• Assess every shift for signs of infection:
Fever, redness at insertion site, drainage.
93
Clinical Topics
94
Abuse and Neglect - Identifying Victims
• Abuse:
evidence of bruising, bleeding, malnutrition, burns, bone
fractures, subdural hematomas, soft tissue swelling or death (and the
condition is not justifiably explained or the history given does not fit with
the degree or type of injury/condition)
See WMC Clinical Practice policy D-90 and D-91 for more info
• Neglect:
caregiver fails to take the same actions to provide
adequate food, clothing, shelter, medical care or supervision that a
prudent caregiver would give.
95
Abuse & Neglect..Adults & Children!
Kansas Law requires that all health professionals report suspected
abuse or neglect in adults and children
Hospital policy requires that
suspected abuse or neglect be
reported immediately.
Initial interventions must include the collection of and safeguarding of any
evidentiary material.
(use WMC Security 23333 as resource as well as GHH Security at 2940).
96
Abuse & Neglect - Reporting
• Report any suspected or alleged abuse/neglect to Case Management
(seven days a week, 8 a.m. – 5 p.m.). The Case Manager may assist
you in reporting to the appropriate agency.
•
At all other times, the House Supervisor is notified and they will
contact Wesley Security as necessary. Security will contact law
enforcement as appropriate.
For more information on signs, symptoms, and follow-up for victims of
abuse and neglect:
Go to the WMC Intranet,
choose “Departments”,
choose “Case Management”,
look for “Adult Abuse” and “Child Abuse” information
97
Color Coded Patient ID bands
The Kansas Hospital Association (KHA)
uses 5 standardized alert colors
• Purple for do not resuscitate
• Red for allergies
• Yellow for fall risk
• Green for latex allergy
• Pink for limb alert
Know Your Wristband Alert Colors!
Wesley Inpatient Wristband
(Always use 2 identifiers prior to placing on patient)
Kansas Standardized Wristband Alert Colors
Do Not Resuscitate
Allergy
Fall Risk
Latex Allergy
Limb Alert (place band on limited extremity)
Wesley Specific Wristband Alerts
Wesley identifies 3 additional alert
colors:
• Bright lime green for pacemakers or
internal defibrillators
• Orange for hazardous drugs
• Rose pink for infection prevention
Pacemaker or ICD
Patient Receiving Cytotoxic or Hazardous Drugs
Infection Prevention (rose color insert into clear band)
Paper Armband -
Emergency Department
Paper Armband -
Outpatient
98
Falls
How do I know if a patient is at risk for falls?
• A magnetic star is placed on the patient’s doorway
• A yellow armband is placed on the patient’s wrist
You are walking by a room with a “Falling Star” magnet on the doorway and see the patient up out of bed and
no one is assisting them. What should you do?
Immediately enter the room and assist the patient. After the patient is back in bed safely, contact the primary RN and
make them aware of the situation.
You are on your way to lunch and hear an alarm sound (i.e. bed alarm).
What should you do?
Immediately enter the room and assist the patient. After the patient is back in bed safely, contact the primary RN
and make them aware of the situation.
If a patient falls….Complete the following:
•Post Fall Debriefing form - #NS611 (Any staff member)
 Stabilize then complete immediately
•RN will also need to complete/document:




Post Fall Assessment
Patient Assessment
Re-evaluation of fall risk
Fall in medical record
 Notification of patient’s attending physician
 Notification of patient’s family
 Hospital Notification System (HNS)
99
Latex Management
• Latex allergy develops from exposure to natural rubber
latex & is a serious medical problem for a growing
number of patients and healthcare workers
• Reactions may include: sore, red, itchy, cracked or
irritated skin; runny nose, sneezing, cough, rash or hives
that happen after exposure to latex
• There is no treatment for a latex allergy except
avoidance
• Patients are identified with a “dark green” identification
bracelet & signage on door
• Providing a latex-safe environment is our responsibility!
100
Restraints

Patients have been seriously hurt and even died trying to escape from
restraints.

Restraints should be tied to parts of adjustable beds that will move with the
patient, and not the frame of the bed.
Never tie a restraint to the side rail of the bed.

Restraints can restrict circulation and injure skin at the application site.

Restraints may cause pressure ulcers by limiting patient mobility.
 The lack of mobility also makes the patient more vulnerable to hospital acquired infection and
increased patient falls.

Patients are rendered helpless to protect themselves from fires and other
environmental hazards.

The loss of control patients feel may aggravate disorientation or confusion.

Alert patients find the experience humiliating and demoralizing, and
restraints may cause embarrassment when seen by visiting
relatives and friends.

If you ever see a patient in restraints that appears to be
in trouble, immediately assist the patient then notify the
nurse about the situation.
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Restraint Alternatives
Alternatives to restraint use can include the following…
Monitoring
Environmental Measures
Comfort Measures
Interpersonal Skills
Staffing
Education
Diversion Activities
Medication/Nutrition
Occupational Therapy/Activities
Regular Toileting
When restraints are necessary, it is everyone’s
responsibility to:
•Ensure their safe use
•Use alternatives whenever possible
•Use restraints ONLY as a last resort
•Always respect the patient’s rights and autonomy
•Prevent the patient fromPhysical harm
Psychological harm
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Wesley’s Intranet
Get detailed information
Policies & Procedures
Infection Prevention Practices
Management of Waste Materials
Safety PowerPoint Presentation
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The Joint Commission
National Patient Safety Goals
1
Improve the accuracy of patient identification
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2
Improve the effectiveness of communication among caregivers
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3
Report critical results of tests and diagnostic procedures on a timely basis
Improve the safety of using medications
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7
Use two patient identifiers (patient name and birth date) when providing care, treatment, and services
Eliminate transfusion errors related to patient misidentification
Label all medications, med containers, (syringes, medicine cups, and basins), and other solutions on & off the
sterile field in perioperative and other procedural settings
Reduce the likelihood of patient harm associated with use of anticoagulation therapy
Reconcile patient medications on Admission, Transfer and Discharge
Reduce the risk of health care associated infections
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Current hand hygiene guidelines from Centers for Disease Control & Prevention or World Health Organization
Prevent health care-associated infections due to multidrug-resistant organisms
Prevent central line-associated bloodstream infections
Prevent surgical site infections
Prevent catheter associated urinary tract infections.
15 The organization identifies safety risks inherent in its patient population
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Risk for suicide
Universal Protocol - The organization meets the expectations of:
Pre-procedure Verification, Mark Procedure Site, and Time Out immediately before procedure or incision
December 2012
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The End!
Thank you for your participation and
cooperation in completing the
2013 Safety Program.
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