Welcome to
the
Baptist
Experience
Student Orientation Module
WELCOME!
Welcome to Baptist Health System student
orientation page. We are excited that you will
be learning at Baptist.
In order to prepare you for your clinical experience, you are required to
complete the orientation module, sign the confidentiality form and take the
test prior to your first student visit at the hospital. You will also be required
to attend a computer class at the hospital prior to your first clinical visit.
This will be set up by your instructor. The completed test and signed
confidentiality form should be submitted via email to the address located on
the bottom of each form.
Again, welcome to Baptist; we wish you a meaningful learning experience
on campus!
Our History
Almost 100 years of service in Alabama
Faith-based committed to physical,
mental and spiritual care
4 hospitals
Approximately 45 Baptist Health Centers
Technology, resources and the experience
for most medical conditions
“High Touch” meeting “High Tech”
Our Mission Statement
As a witness to the love of God,
revealed through Jesus Christ, the
Baptist Health System is
committed to ministries that
enhance the health, dignity and
wholeness of those we serve
through Integrity, Compassion,
Advocacy, Resourcefulness, and
Excellence.
Our Commitment And Purpose
Our Commitment
Better Health; More People
Our Purpose
To Honor God and Others
Baptist Experience
We care about delivering the best patient
and customer experience through a culture
that consistently demonstrates we care.
Our Values
Integrity
Constantly sticking to a strict moral or ethical code in public and in private. It presents the
idea of wholeness. This means that there is no compromise for integrity.
Compassion
The deep awareness of the suffering of other people along with the desire and attempt to
relieve it. It is ministering to the body, mind and spirit of those entrusted to our care, and
treating others as we would want to be treated.
Advocacy
Taking action for, defending or recommending an idea. Advocacy is an ongoing process that
tries to change attitudes or actions. We continuously search for ways to improve the wellbeing of the communities God has given us the privilege of serving….always striving to do
more and better.
Resourcefulness
The ability to take what is given to you and use it effectively or imaginatively. We are
challenged to be careful and responsible stewards of the God-given resources that have
been entrusted to us. We are taught that to those who wisely used what they had, more was
given.
Excellence
The commitment to reach higher and exceed expectations at every level of the organization
through cooperation, sharing of new ideas and an obsession for quality. Scriptures teach us
“whatever we do, we are to do it with excellence and enthusiasm, as unto the Lord.”
The Patient Promise
Our Promise to You
Because it is our sacred privilege to serve you, our goal is to ensure that you receive the
best care in a manner that exhibits the love of Christ.
We promise to deliver an experience that ensures you feel confident in recommending
Baptist Health System as the best place for all health-related needs.
We promise to:
always provide attentive and personalized care that is sensitive to your physical,
emotional and spiritual well being;
always be compassionate and responsive to your needs;
always listen to understand your needs and coordinate your care with our expert
physicians and medical team;
always provide you with open and honest communication, and the information you
need – every step of the way;
always provide a safe and clean environment for you, your family and friends;
always value your time while keeping focused on the importance of your health.
The Culture of Our Organization:
 Shaped by our values
 Guides our behaviors to deliver the best patient and
customer experience
 Assures we meet behavioral expectations of our ICARE
values
 Helps us live our mission and demonstrate faith-based
values
 Recognize, Respect, and work with people with different
beliefs, practices, cultures and rituals to promote and
improve the health of our customers
 Population groups and/or age groups must also be
considered when addressing the patient’s plan of care
Behavioral Standards
Behavioral standards that are used to meet the promise are:
1. Gracious greeting
2. Informative interaction
3. Establish expectations
4. Appealing appearance
A gracious greeting is important to continue with our strong reputation for
caring and compassion. It includes three parts:
•
Smile, make eye contact within 5 seconds
Immediate acknowledgement of someone makes them feel valued and
cared for. It sets the tone for the rest of the interaction and can help
diffuse any anxiety or discomfort the patient may be having. Smiling is
appropriate in most situations. However, there are a few times it is not.
•
Introduce self and facility by introducing yourself, you put the patient at
ease and create a more emotional and personal connection. By stating the
name of the facility, you are helping to tie the patient emotionally to
Baptist. This creates loyalty in the future.
•
Welcome, thank you, good morning starting a greeting with a salutation
helps make the patient feel welcomed. It also shows respect.
Informative interaction is making sure that every patient interaction is
meaningful for the patient. It is comprised of three things:
1.
Identify self, state position, and address the patient by name –
identifying you puts the patient at ease and personalizes the interaction.
Stating your position helps the patient know what to expect and the types
of questions they should ask.
2.
Use the phrase “I’m here for you” with every customer this phrase encompasses what Baptist offers to each patient and to the
community. It is what we want every person to feel and experience when
they interact with us.
3.
Provide instructions verbally- using written format for reinforcement
Customer fact: patients in our community indicate they prefer instructions
verbally, then written. We need to provide verbal instructions, including
asking them if they understood the instructions, checking for their
understanding, and asking them if they have additional questions. In
addition to help with retention of the instructions we ask that you provide
them in written format whenever feasible.
Establishing expectations will help manage and guide patient on what to expect
1.
Review the itinerary and provide an update on timing or any changes as
they occur. Time is an important factor and knowing what patients expect
and then helping them to understand what will be provided is essential to
decreasing anxiety.
2.
Promote the next step. Say something positive about the department or
person they will be interacting with next. We need to take every
opportunity to show our expertise and help patients be less apprehensive of
the next steps. By promoting others, it can show both expertise and how we
work together as a team.
3.
Know top questions patients ask and have answers at your fingertips.
By being ready to answer questions quickly and accurately, it provides the
patient with a sense of confidence that we know what we are doing and that
they are in good hands. Remind them the Patient Information Guide will be
a good source for common patient questions.
Always have an appealing appearance because our appearance is viewed
throughout every step the patient takes.
1.
Your appearance - It is important, it says a lot about the hospital and the
environment. It is important to follow dress code and look professional
every day.
2.
Face Heart to Heart - Your body language sends a loud message even more
than the works you speak- including facing heart to heart with the patient,
making eye contact and smiling when appropriate.
3.
Organized and uncluttered - A neat, organized area sends a clear message
to patients and visitors that the quality of care is high. Avoid or remove
clutter from your workstation in order to promote the perception of
excellence.
If you ever have questions about the Patient Promise or how to fulfill the
standards, please let us know- we are here for you.
GENERAL GUIDELINES FOR STUDENTS
* A student will never assume total responsibility for a patient. The
assigned nurse has responsibility for the patient.
* All planned student activities pertinent to care of a patient will be
shared with the designated Instructor, Staff Nurse, or Preceptor.
* A student who has not attained competency in a skill or procedure is
required to have the Instructor or Preceptor present if the student is to
participate in that procedure.
* A student cannot take a verbal order from a physician or other
discipline.
* A student cannot sign and release physician’s orders.
* A student cannot take a critical lab or critical radiology report.
GENERAL GUIDELINES FOR STUDENTS
* A student must comply with the school dress code. School issued
name badges must be present and visible.
* A student must report any incident/accident to the Instructor,
Preceptor, or Nurse Manager.
* A student cannot cosign as a witness for high-alert medications.
* A student cannot be a witness for written consent.
* All student documentation must be cosigned by the instructor or
preceptor assigned (As prompted in the computer documentation
system).
Sensitivity to Others
No two people are exactly alike. We are all different. These
differences become more important in the health care industry due to
the extremely personal nature of the services provided. We need to
be acutely aware of our differences and create an environment that is
respectful of all people. Be aware of your own feelings regarding
diversity and consistently use behaviors that communicate respect.
We must be able to recognize, respect, and work with people with
different beliefs, practices, cultures, and rituals in order to promote
and improve the health of our customers. Population groups and/or
age groups must also be considered when addressing the patient’s
plan of care. Inform your instructor or preceptor if you have specific
questions regarding sensitivity/ diversity.
Information Management
Information management includes obtaining, managing, and utilizing
information to improve patient outcomes and hospital performances. In
order to maintain confidentiality, access to information is on a need to
know basis. User IDs are issued to students and passwords are
created by the student. The password belongs only to you and it is
extremely important that you do not share it with anyone.
Students may view their assigned patients’ charts in order to prepare
for their clinical experience but should not print or remove any patient
information from the hospital.
To maintain confidentiality of patient information, refrain from having
conversations regarding patients in the hallways, elevators, cafeteria, or
other public places. Never discuss, disclose or review any information
about a patient’s medical conditions with any other person unless they
have proper authorization.
HIPAA
HIPAA is a federal law that requires all health care facilities to provide to patients
the Notice of Privacy Practices. This notice explains the patient’s rights and when
and to whom an agency will be giving any protected health information (PHI).
PHI includes information related to any health care provided to a person. The
patient’s medical record, as well as name, address, employer, birth date,
telephone/fax number, email address, occupation, account number, social
security number, certificate number, voice prints, finger prints, photos, relatives’
names, and other personal information are also included.
As a student, you should: not share any PHI with anyone who does not have a
need to know it; only seek the information you need to complete your patient care
assignment; not discuss any patient information in hallways, cafeteria, and other
public places; dispose of any PHI material you have in a designated manner; use
PHI materials in a secure area.
In order to gain access to PHI, each student will be required to sign a
confidentiality agreement.
Environment of Care
Environment of Care (EOC)
We are committed to meeting certain performance standards
under EOC. We have also been entrusted to keep our facilities a
safe, functional physical environment for patients, visitors and
staff.
The “environment of care” (EOC) is
made up of 3 basic components:
Buildings
Equipment
People
7 Specific Functions of EOC
1. Safety
2. Security
3. Hazardous Materials & Waste
4. Fire Safety
5. Medical Equipment
6. Utility Systems
7. Emergency Management
Security Management
Everyone is responsible for the Safety and Security of patients,
staff, and visitors while on hospital Campus
Report concerns quickly
Protective Services is available 24/7
Security
FACILITY
Citizen’s
Princeton
Shelby
Walker
EMERGENCY NUMBER
4030
3090
5555
2633
**Be sure you know the emergency number for the facility where you are
assigned!!
The Security Department monitors the hospital and surrounding grounds. There is
a security officer posted in the employee parking areas at shift change. If you leave
the hospital after dark and at a time different than shift change, contact Security.
There will be a security officer to observe/escort you to your vehicle.
YOU can help make our hospital a safer place by taking steps to protect yourself.
Do NOT leave your purse, wallet, or valuables unattended. Keep them out of view.
Report any suspicious person or unauthorized persons to Security immediately.
Fire Safety:
Remember to Race & Pass
R - Remove/Rescue
A - Activate fire alarm
C - Contain fire &
clear hallways
E - Extinguish the fire
P - Pull pin of fire extinguisher
A - Aim at base of fire
S - Squeeze trigger
S - Sweep extinguisher
side to side
 Become familiar with the location of fire alarms & fire extinguishers
in each department.
 Evacuation of patients is first horizontal and then vertical.
 BHS hospitals are smoke free. Smoking is not allowed in patient
rooms.
 Code RED – initiates fire response
 Code CLEAR – indicates fire emergency is all clear
Fire Drill Process
Code RED Paged
Act Fast
• Clear Hallways
• Close Doors
• Prepare to evacuate
Fire Extinguisher
• Locate / Respond
Pull Nearest Pull Station
Keep Fire doors unobstructed
Know Horizontal and Vertical Evacuation
Emergency Codes
BHS Standardized Emergency Codes
Code
Description
Code Blue + Location
Code Blue Pediatric + Location
Code Red + Location
Code Gray + Location
Code Amber + Location & Description
Code Active Shooter
Code Purple
Code Internal Disaster + Location
Code External Disaster
Tornado Watch
Tornado Warning
All Clear 3 Times
Adult cardiac emergency
Pediatric cardiac emergency
Fire
Unruly patient or visitor
Missing adult, child, or infant
Active shooter on campus
No beds available within the hospital
Disaster within the hospital
Disaster outside of the hospital
Tornado watch within geographic area
Tornado warning within geographic area
Situation resolved
Security Sensitive Areas
Area
Risk
Mother Baby areas
Infant abduction/ domestic violence
Pharmacy
Internal theft of drugs/ robbery due to
storage of drugs
Psychiatric areas
Patient violence/ domestic violence
Emergency Department
Robbery due to storage of drugs/
domestic violence/ gang violence/
patient violence
Medical Records
Theft of sensitive patient information
Each of these areas may have special security devices, policies or
procedures related to the security.
SDS Global Harmonizing
The hazard communication tool gives details on chemical and physical dangers,
safety procedures, and emergency response procedures. Your employer
must have one for every chemical and hazardous product in your workplace.
The SDS (Safety Data Sheets) Covers:
1.
Identity – manufacturer name, and address and/or suppliers
information, emergency phone number and date prepared
2.
Hazardous ingredients – worker exposure limits to the chemical are
included
3.
Physical and chemical characteristics – boiling point, vapor pressure,
vapor density, melting point, evaporation rate, water solubility, and
appearance and odor under normal conditions.
4.
Physical hazard such as fire and explosion – and ways to handle those
hazards, such as firefighting equipment and procedure
GHS (Global Harmonizing System) Pictograms and Hazard Classes

Oxidizers

Flammables

Self Reactives

Pyrophorics

Self-Heating


Emits Flammable Gas
Organic Peroxides

Corrosives

Explosives


Self Reactives
Organic Peroxides

Gases Under Pressure

Acute toxicity (severe)

Carcinogen

Irritant

Respiratory Sensitizer

Dermal Sensitizer

Reproductive Toxicity

Acute toxicity (harmful)

Target Organ Toxicity

Narcotic Effects


Mutagenicity
Aspiration Toxicity


Respiratory Tract
Irritation

Environmental Toxicity
Infection Control
General infection control policies are in the “Policies and Procedures” on the Baptist
Intranet. Refer to these policies for specific questions regarding infection control or
consult your instructor or preceptor. Student nurses should use the following guidelines
while in the hospital:
1. Comply with the school of nursing/hospital dress code regulations.
2. Long hair should be pulled away from face to reduce the risk of contamination of
patient food, supplies, etc. and to reduce the risk of personnel hair contamination
from splashes or contact with soiled hands.
3. Avoid touching eyes or mouth during patient contact activities.
4. No eating or drinking in patient care areas.
5. Follow hand washing guidelines.
6. Comply with hospital guidelines for universal precautions.
7. Follow isolation precautions as indicated.
Handwashing
Proper hand care is the single most important way to prevent and reduce
infections. Washing hands with hospital approved soap and water should
be performed if hands are visibly soiled. If hands are not visibly soiled, the
use of the hospital approved alcohol based hand cleaner is the preferred
method of hand care. The alcohol based hand cleaner kills more bacteria
and viruses and has a build up effect to keep killing organisms on the hands
after several uses.
• Wash your hands before and after entering any patient room
• Before putting on gloves and after taking them off
• After touching blood or other body substances (or patient care
equipment contaminated with these), broken skin or mucous membranes
– even if you wear gloves
• Between different procedures on the same patient
If a patient is on contact precautions for Clostridium Difficile, you must
wash your hands with soap and water. Alcohol based hand cleaner is not
effective against this microorganism
Hand Hygiene
Use of Lotions
Lotions are recommended to ease the dryness resulting from frequent
handwashing and to prevent dermatitis resulting from glove use. Use only
hospital approved/supplied lotion.
Nails
Baptist Health System is committed to ensuring a safe and healthy work
environment for patients and staff. We require our direct patient care
givers to have short, clean, natural nails. Artificial nails and nail tips for all
direct and indirect caregivers are prohibited.
Personal Protective Equipment (PPE)
PPE is worn to protect against blood/body fluid exposures.
Know the location of the PPE in the patient care area and be
familiar with them when barriers are indicated and use as
required.
Biohazardous Waste
Biohazardous waste is any type of waste that is contaminated by
blood or other body fluids contaminated with blood. It includes: liquid
or semi-liquid blood or other potentially infectious materials;
contaminated items that would release blood or other potentially
infectious materials in a liquid or semi-liquid state if compressed;
items that are caked with dried blood or other potentially infectious
materials and are capable of releasing these materials during
handling; contaminated sharps; and pathological and microbiological
waste containing blood or other potentially infectious material. These
materials should be discarded in red containers. These containers
have the Biohazard symbol indicating their contamination. The
containers are to be closable, constructed to contain all contents and
prevent leakage during handling, storing, transporting, or shipping.
Always wear PPE when handling Biohazardous Waste.
Bloodborne Pathogen Exposure Protocol
 If you are exposed to blood or body fluids:
 Immediate First Aid
Wash site with soap and water.
Irrigate eyes 15 minutes at nearest eye wash station.
 Notify your instructor or preceptor immediately to
ensure proper treatment, management and follow up.
Preventive Measures
 Create organized work area
 Use standard precautions on every patient,
every time
 Use appropriate precautions when you
anticipate splashes or sprays of blood or
body fluids
 Always use safety designed devices and follow
safe injection practices
 Activate safety device as soon as possible
 Provide adequate lighting
Preventive Measures
 No hand-to-hand passage of sharps.
 Do not attempt to catch a falling sharp.
 Never leave sharps unattended or
place them in an inappropriate place.
 Monitor gloves for holes and
punctures.
 Dispose of ALL sharps immediately in the
sharps container.
 Do not overfill or use over filled sharps container - (3/4
rule)
 No recapping
Not Regulated Medical Waste
Disposable paper drapes, lab
Lab coats, paper towels, band aids
Disposable basins, bedpans, urinals
Bonnet caps with no blood
Empty urine cups, stool containers, Foley
Bags/tubing, diapers, chux
Exam & cleaning gloves
Empty collection bottles & bags
Sanitary napkins & tampons (personal)
Paper & plastic wrappers, packaging,
boxes, computer paper, office waste
Unused medical products & supplies
PPE (worn but not soiled)
Food products & waste (soda cans, paper
cups, plastic utensils)
Empty IV bags, bottles & tubing without
needles
Blue Wrap
Regulated Medical Waste
Saturated or grossly soiled disposables, i.e.,
bloody gauze,
dressings, lap pads, OB and surgical peripads & gloves
Containers, catheters, or tubes with fluid
blood or blood products not discarded or
flushed i.e., blood sets, suction canisters &
drainage sets (Need adequate absorbent
material in container)
 Dialyzers & tubing
Microbiology specimens, used culture plates,
tubes, bottles & devices
Placentas & surgical specimens
Blood spill clean-up materials
Sharps Containers RMW Material
Needles & syringes, Scalpel blades, lancets
Glass pipettes, slides, and tubes
Broken contaminated glass
Staples & wires (Cardio-catheter wires)
Disposable suture sets & biopsy forceps
Transport bag system
Small, Red Bio bags will be placed inside the patient rooms or
centrally located on the floor.
Nurses will attain a bag when needed in order to dispose of REAL
medical waste (soaked or saturated with blood).
Once medical waste is disposed, Nurses will tie up the bag in a
balloon knot fashion and place into the proper designated
biohazard container, located in the soiled utility closet.
the red bag is tied Just like a balloon
Recyclable items
The following items CAN be thrown
into the BLUE Containers:
Metals – aluminum cans, tin cans,
paper clips
Plastic – bottles, shrink wrap, plastic
bags
Paper – magazines, newspapers, NONHIPAA documents, used folders,
junk mail, phone books
Cardboard Boxes – glove boxes,
medicine boxes, medical supply
packaging, tissue boxes
Confidential documents
Put all patient information
into shred bins.
Anything that can identify a
person is considered
patient information.
• Even sign in sheets.
Disposal of pharmaceutical waste
Cut and drain all maintenance
solutions.
• Witness waste all narcotics.
Sharps management service – empty
sharps only disposal
• No meds in the reds.
• Unbroken empty vials go in trash, not in a Sharp box.
Pharmaceutical waste disposal
Place Nicotine and Coumadin wrappers and not fully used
patches back into small bio bags and send back to the
pharmacy .
Pharmaceutical waste disposal – left
over medication
• Half full medical
vials
• Dropped Pills
• Expired/Old Pills
• Left over IV’s
containing medication
Pharmaceutical waste disposal – left
over medication in a sharp – behind
pyxis – rarely used
ALL OF THESE ITEMS ARE TRASH
Electrical Safety
Electrical safety is needed to prevent fires and shock.
1. Inspect all equipment prior to use, check for cracks in glass or plastic and
sharp or rough edges.
2. Do not use if cords are frayed.
3. Use only equipment with a 3-pronged plug.
4. Do not use unfamiliar equipment.
5. Use equipment only for what is intended.
6. Report all broken equipment immediately; label broken equipment “DO
NOT USE”.
7. Do not try to repair broken equipment.
8. Do not use any device that blows a fuse or gives a shock. Report all
shocks immediately, even small ones.
Patient incidents involving medical equipment or products must be reported
immediately to your instructor/preceptor. This must be reported to Risk
Management according to the Safe Medical Devices Act (SMDA).
Emergency Management Quick
Reference
Tornado Precautions
1. Move all non-secured objects away from the windows, such as books, flowers, personal
belongings, etc.
2. Close the curtains or blinds.
3. Close doors.
4. If instructed, evacuate patients and visitors to areas without windows (halls, etc.).
5. If unable to move patients from rooms with windows, cover patient with blankets.
Fire Precautions – Code Red
1.
2.
3.
4.
5.
Remove the patient and visitors.
Activate the fire alarm and call to report.
Contain the fire by use of fire extinguishers and closing doors.
Clear the hallways.
Evacuate patients as directed- horizontally first, the down- using stairs.
Emergency Management Quick
Reference
Bomb Threat – Code Internal Disaster
1. Stay on the phone as long as possible. Notice accent, background noise, etc. Ask
where the bomb is, what kind of bomb, when it will go off, why, etc. Do not notify
other staff or patients and families.
2. While on the phone, get another staff to call Security.
3. If a suspicious item is found, immediately clear the area of patients.
Infant Abduction – Code Amber
1. Immediately lock down unit and keep locked down until all clear is announced.
2. Search all areas of unit and waiting room and restrooms. Look in hampers, etc.
3. Call Security for any suspicious activity and to report area clear.
Clinical Care Measures
Clinical care measures are quality initiatives that are prompted by the federal
government. The initiatives empower consumers to make more informed decisions
and encourage providers to improve quality of healthcare. Our core measures are:
•
•
•
•
•
Acute Myocardial Infarction
Congestive Heart Failure
Stroke
VTE Prophylaxis
Immunizations
Best practices are defined for each of the measures. The following tables list the
core measures, best practices, and our plan for implementing the best practices.
ACUTE MYOCARDIAL INFARCTION
Best Practices
1. Aspirin on arrival
2. Beta Blocker at discharge (ex: Coreg, Lopressor, Toprol, Zebeta)
3. EKG less than 10 minutes from arrival
4. Door to Drug (TNK) less than 30 minutes
5. Door to PCI less than 90 minutes
CONGESTIVE HEART FAILURE
Best Practices
1. Evaluation of left ventricular function (ECHO, Cardiac Cath)
2. ACE Inhibitor or ARB/and Beta Blocker for Left Ventricular Systolic
Dysfunction (EF less than or equal to 40%.)
ACEIs (ex: Benazepril, Lisinopril, Lotensin, Lotrel, Quinapril)
ARBs (ex: Benicar, Hyzaar, Losartan)
Beta Blockers (ex: Coreg, Lopressor, Toprol, Zebeta)
3. Discharge Instructions – include appointment with date and time
STROKE
Best Practices
1. VTE Prophylaxis
2. Thrombolytic Therapy by day 2
3. Lipid profile within 48 hours
4. Discharge on Thrombolytic Therapy, Statin if greater than 100, assessed for
rehab, and stroke education
VTE PROPHYLAXIS
Best Practices
1. Anyone 18 years or older should have VTE prophylaxis or documented reason
why none. Ambulatory patients must be documented by physician.
May include: Anti-embolism stockings, Xarelto, Heparin, SCD’s, AE pumps
2. Patients discharged home on Coumadin must have Coumadin Therapy
Discharge Instructions.
IMMUNIZATIONS – FLU SEASON – OCTOBER THROUGH MARCH
Best Practices
1. All patients 6 months and older must be reassessed for flu vaccine status.
2. Have had prior to arrival during current flu season
OR
Refused
OR
Receive during current visit
The facility has defined other outcomes measures and
continuously implements plans and actions to improve
performance in the following areas:
•
•
•
National Patient Safety Goals
Patient Satisfaction
Patient Falls
National Patient Safety Goals
Goal 1: Improve the accuracy of patient identification
Always use 2 appropriate patient identifiers: verbally match name and DOB on
armband with patient record.
Label containers used for blood other specimens in the presence of the
patient.
National Patient Safety Goals
Goal 1C: Eliminate transfusion errors
A qualified transfusionist and a second individual qualified to
transfuse objectively match patient and blood or blood
component
National Patient Safety Goals
Goal 2: Improve the effectiveness of communication
among caregivers
 Report critical results of tests and diagnostic procedures on a
timely basis
 When nurses receive a critical test result, record results in Epic
and record the time the results are called to the physician
 Call critical test results to physicians within ONE hour
National Patient Safety Goals
Goal 3: Improve the safety of using medications
Label all medication containers or other solutions on and off
the sterile field in the OR and other procedural areas
Keys to compliance:
• Standardized protocols
• Integrated dietary component
• Baseline labs
• Monitoring
• Programmable pumps
• Policy
• Patient education
National Patient Safety Goals
Goal 6: Reduce the harm associated with clinical alarm
systems
Keys to compliance:
• Establish as hospital priority
• Identify most important alarm signals
• Establish policies and procedures for management of alarms
• Medical and hospital staff education
National Patient Safety Goals
Goal 7: Prevent Infection – perform hand hygiene
Hand hygiene
• All employees are to follow the current Centers for Disease Control and
Prevention (CDC) hand hygiene guidelines:
• Use friction to wash hands for 15-20 seconds with soap and water. Dry
hands with a paper towel and use the paper towel to turn off the faucet;
OR
• Use alcohol sanitizer when hands are not visibly soiled, rubbing hands
together, until hands are dry.
• All staff are to use alcohol sanitizer upon entering and exiting patient
and treatment/exam rooms.
No artificial nails are allowed in patient care areas.
For Surgical Scrub (See policy and guidelines).
Hand hygiene is monitored to improve results.
National Patient Safety Goals
Goal 7- Prevent infections with Multi-Drug Resistant
Organisms(MDRO)
Place patients with multi-drug resistant organisms (MDRO) in
Contact Precautions (if MDRO respiratory infection-use
Droplet plus Contact Precautions)
Give the patient/family education on infection prevention
strategies, tell the family to take precautions.
National Patient Safety Goals
Environmental Cleaning to prevent
transmission of MDROs
 Clean and disinfect surfaces that are in close proximity to the patient Bed rails, over bed tables and frequently-touched surfaces in the patient
care environment (e.g., keyboards, door knobs, surfaces in and
surrounding toilets in patient’s rooms)
 Dedicate non-critical medical items to use on individual patient known to
be infected with multidrug-resistant organisms.
 Direct patient care staff are responsible for cleaning/disinfecting medical
equipment.
National Patient Safety Goals
Goal 7-Prevent Infection - Catheter Associated Urinary
Tract Infections
Foley catheters should have limited use and duration to situations
medically necessary for patient care.
Use sterile technique for foley catheter insertion, with procedure observed
by a trained buddy.
Manage foley catheters by:
• labeling the foley bag with date of insertion
• secure the catheter
• maintain the sterility of the urine collection system
• maintain the foley bag below the patient’s bladder
• collect urine specimens aseptically from port
National Patient Safety Goals
Goal 7- Prevent Infection-Central Lines
To prevent infection related to central lines implement evidence-based
standards for reducing infections (central line bundle)
 Hand hygiene performed prior to insertion or manipulation
 Maximal Barrier Precautions and sterile technique used during insertion
(inserter wears sterile gloves, gown, mask, and cap.) Draping the patient.
 Chlorhexidine skin prep
 Optimal site selection with avoidance of femoral vein
 Use standardized kit for CVL insertion
 CL insertions observed for adherence to sterile technique
Use standardized protocol to disinfect catheter hubs and injection ports (Scrub
the Hub). Evaluate all lines routinely and remove nonessential catheters.
National Patient Safety Goals
Goal 7- Prevent Infection - Surgical Site
In Surgery Department
 Antibiotics are administered prior to procedure (given within 1 hour)
 Only clippers or depilatories are used to remove hair if necessary
 The patient temperature is monitored to keep the patient warm during
procedure (normothermia)
In Patient Care Unit
 Controlling glucose level below 180 mg/dL after procedure (Cardiac)
 Discontinue Antibiotics within 24 hours after procedure (48 hrs for
Cardiothoracic)
 Discontinue foley by the second post-procedure day - exception is
Urology and GYN patients and when physician documents the medical
necessity to continue
 Strict adherence to aseptic technique when changing dressings
National Patient Safety Goals
Goal 15 – Identify Patient Safety Risks
•
The organization identifies patients at risk for suicide
•
A risk assessment is completed that includes factors that might
increase or decrease suicide risk. The patient’s immediate safety
needs and most appropriate setting for treatment are addressed.
The organization provides information such as crisis hotlines to
individuals and their family members for crisis situations.
National Patient Safety Goals
Universal Protocol – Prevent Mistakes in Surgery
•
UP 1A: Preoperative verification process
•
UP 1B: Mark operative site
•
UP 1C: Active time out immediately before starting the procedure
•
Conduct a “time out” with the entire procedure team confirming:
o
o
o
o
o
Correct patient
Correct procedure
Correct site is marked (if required)
Correct patient position
Special equipment/implants available
Congratulations!
You are now part of
The
Baptist Experience!
This is the completion of the student orientation module. Now
proceed to the post-test and confidentiality statement.
Be sure to email those as instructed on the bottom of each form.