Contributing Departments include: Staff Development, Safety Committee, Safety Officer, Infection Prevention, Risk Management, HIM, Security, IS, HR, RC, Plant Ops, Radiology, and other sources.

Safety & Health Hazards 2018

Resource Guide

1Rev 12/1/17

2

2018 Safety & Health Hazards IndexAbuse & Neglect 98-100 Harassment / Workplace Violence 22-23 RACE 35Active Shooter 55 Hazardous/Cytotoxic Drugs 48 Radiation Safety 40Bioterrorism 54 Hazardous Material 14 & 41-48 Rapid Response Team 56-57Blood Borne Exposure Event 88 HICS 51 Respiratory Viruses – Influenza 91Blood Borne Pathogens 84 HIPAA/Pt Rights/Confidentiality 69-78 Restraints 104-105Bomb Threat 54 HNS 66 Risk Management 61-66CAUTI – Prevention 95 Infant/Pediatric Abduction/Drill 60 Safe Line 2-SAFE (27233) 5C-diff 89 Influenza Vaccine 92 Safety Communication (email) 5Central Line Infection – Prevention 96 Injuries are Preventable 8 SBAR 63Chemical Spill Event 47 Identification Color Alert Bands 101 Security 12 & 21Clean to Dirty Principle 86 Infection Prevention / Exposure 79-96 Sepsis Alert 58Code Blue/Rapid Response 56-57 Introduction-Safety Top Priority 3 thru 4 Service Animals 72Computer Use & Workstation 78 Impaired Provider Recognition 6 Severe Weather Plan 53Cultural Diversity 9 Joint Commission – How to Contact 5 Sharps Safety 46CUS 63 Latex Allergy Management 103 Slips, Trips, & Falls 27De-Escalation 24-26 Lead Apron Safety 108 Smoke Free Environment 30Electrical Safety 38 Medical Emergency 56-57 Standard Precautions 83Emergency Management 17 & 49-57 Medical Gases / Shut Off 36 STEMI Page 58Employee ID / Badge 20 Multi-drug Resistant Organisms (MDRO’s) 90 Stroke Alert 58EMTALA 67-68 Chemical Spills Labels / SDS Sheets 47 Surgical Instrument Pre-Cleaning /Transport 87Environment of Care 10 thru 18 National Patient Safety Goals 107 Surgical Site Infections/Prevention 94Equipment Management 16 & 39 Occurrence/Sentinel Event/Close Call 64-65 System Failures-Basic Staff Response 15 & 52Ergonomics 28-29 Oxygen Safety 37 TeamSTEPPS Tools 63Egress / Exits…Keep Clear 13 & 32 Patient Action Line 59 Team Communication/Work/Training 7Fall Prevention 27 & 102 Patient’s Rights 69-73 Transmission Based Precautions 85Fire Drill 34 Personal Protective Equipment 82-84 Tuberculosis (TB) 93Fire Safety 31-35 Population Appropriate Care 9 Waste Management 41-45Hand Hygiene 81 Protected Health Information-PHI 74-78 Wesley Intranet Polices & Procedures 106

3

Everyone is responsibleto promote a culture of safety!

Culture of Safety

2018

Top PriorityWesley Medical Center considers the practice of safety, infection prevention, emergency & risk management as top priorities for their patients, employees, and customers.

4

Safety Suggestions

5

If you see an opportunity for the hospital to reduce injuries to employees, or a safety concern…don’t keep it to yourself:

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 E-Mail: complaint@jointcommission.org

The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 60181

Safe Line 2-SAFE962-7233

Safety Officer962-2046 or 712-9786

Send e-mail to: Wesley.DL Safety Concerns

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.

?6

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! 7

Injuries are preventable!

8

OUCH!

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.

Celebrating Our Cultures

9

Cultural DiversityPopulation 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

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 appear “strange” to you

Environment of Care (EOC)

10

SafetySecurity

Fire & Life Safety

Utilities Mgmt

Equipment MgmtHazardous Waste

Emergency Mgmt

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 participatein the processes & activities that make the environment safe & effective for all.

Environment Of Care

Safety Management Plan

11

Expectations of Staff:Components:• Safety policies• Hospital Wide Safety committee

• Education & Training• Risk Management• Quality• Infection Prevention

Safety Officer962-2046

• 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

Environment Of CareSecurity Plan

12

Components:• Assesses risk and the

activities to minimize risk

• Responds to situations that could be harmful to our patients, visitors, and staff

• Assist security by reporting suspicious people or situations

• Abide by the parking, smoking and safe workplace rules

Expectations of Staff:

Environment Of Care

Fire & Life Safety Plan

13

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 doors during drill/fire

• Keep exits & hallways clear

Environment Of Care

Hazardous Waste Plan

14

Expectations of staff:

Components include:• Evaluation• Education• Proper handling• Disposal of chemicals Always use PROPER

handling and usage techniques with all waste

materials to protect ourselves, patients,

and visitors.

Environment Of Care

Utilities Management Plan

15

Expectations of staff:Components include:• Communications systems• Infection Prevention• Negative pressure systems• Environmental support systems• Equipment support systems• Emergency power• Life support systems

• Familiarization of approved alternative procedures when systems are “down”

Environment Of CareEquipment Management Plan

16

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

Environment Of CareEmergency Management Plan

17

Expectations of staff:

www.ready.gov/are-you-ready-guide

Components:• Procedures & preparation for internal & external disasters

• Comply with management for internal disasters

• Participate in community emergency interventions

Environment Of CareLook around your EOC with new critical eyes!

18

• 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?

19

Safety

Employee IdentificationWear your employee ID Badge

20

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 or Wesley Woodlawn 82940

Question those that don’t!

Security 23333 or Wesley Woodlawn Security is 82940

21

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 possible2. Be aware of your environment and who is around you3. Security will escort to your car if you are leaving at a time

that you could be alone

Harassment & Workplace Violence Safety

22

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 medical center premises is strictly prohibited.

Report incident to any of the below:• Management• Human Resources • Ethics Compliance Officer

23

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

24

Escalation of Emotions

Concern

Frustration

Anxious

Anger

Rage

Sick family/self, work schedule, busy/stress

Long wait times, no answers, no one cares, “behind the scenes”, “no one

is listening to me”

Time is ticking, still no answers, what’s going on?!

I’ll yell until they listen! I will be heard!

25

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 non-threatening

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

26

• 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

Things NOT to Do…

WMC covers a lot of ground!Prevent Slips, Trips, & Falls

27

• Watch for water or debris on the floors andhallways or uneven surfaces

• Clean up spills or debris immediately bydoing it yourself or calling the appropriate service

• Watch for dangling cords or cords on the floor

• Pay attention to where you are walking

• Don’t carry loads that obstruct your view

Please help everyone stay safe!

ErgonomicsEducation & Prevention

28

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.

ErgonomicsWork Practice Techniques

29

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

Smoke Free EnvironmentTobacco-Free Campus

30

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 any Wesley property, they should politely inform the individual of the tobacco-free policy.

Cards with policy information are available for distribution from human resources.

Fire Triangle

31

Prevent fires by keeping these sources separate:

Heat – anything that can cause a spark

Fuel – anything that can burn

Oxygen/Air – oxygen or air

Exits / Egress Be Aware Be Responsible

32

• 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, medical gasshutoffs & electrical panels free of equipment & supplies.

• Do not go through closed fire doors during a fire or fire drill.

Alarms / Extinguishers -Be Aware & Be Responsible

33

Fire Extinguisher: PASS

Know the location of:• Fire alarm boxes• Fire extinguishers• Medical Gas shut off

valves• Exit routes

Review procedures to follow in the event of a fire drill or actual fire.

Fire Drill

34

A drill should be responded to as if it were a real fire situation.

• Dial 23131

• Tell operator who you are, where you are, and report a:

“Dr. Red Drill”

• Dial #0 (Wesley Woodlawn)

announce “code red drill and your location” three times

“Dr. Green” or “Code Green” at Wesley

Woodlawnis the all clear signal

announced over the public address system.

Fire Event: RACE

Call 23131 and announce “Dr. Red” or

at Wesley Woodlawn - call #0 and announce overhead

“Code Red” and the location three times very clearly

35

Rescue … remove anyone in immediate danger

Alarm … call 23131 or at Wesley Woodlawn call #0 & 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

36

1. In the event of an emergency, who isauthorized to turn off a “piped in” oxygensupply 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 oxygenzone 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.

Medical Gases / Shut Off Valve

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 Care 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, DO NOT WALK ON BY. Take immediate action. Secure the unsafe tank. Notify the manager!

Unacceptable Practice

37

Electrical Safety

38

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 surrounding electrical equipment dry• Keeping cords from kinking while equipment is in

use

Medical Devices & Equipment Not Working Properly

1. Pull out of service2. Notify manager or ANM3. Input work order to Clinical Engineering with

a detailed description of the problem4. Tag item with work order5. Complete HNS if patient harmed and notify

Clinical Engineering * They are not notified that the HNS has been filled out

Call…• Clinical Engineering 962-2560 or (Wesley Woodlawn) 858-2935 for

medical equipment• Plant Operations 962-2770 or (Wesley Woodlawn) 858-2686 for all other

electrical equipment• After Hours EMERGENCY 962-2712

39

Radiation Safety

40

Contact the Radiation Safety Officer at 962-3030 (page operator).

Radiation producing machines and radioactive materials are operated by specially trained physicians & technologists for diagnosis & treatment of disease.

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 MaterialHigh Radiation Area

Minimizing radiation exposure:• Recognize the hazard signs &

proceed with caution & permission

• Maximize distance between you & the source of radiation

• Wear approved radiation protectiongarments (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

Waste Management Types

41

3 kinds of “waste” found in health facilities:1. General2. Medical3. 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 immunizationof 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

Seek immediate treatment / Notify manager / Complete a HNS reportIf exposed:

Waste ManagementIdentification & Safe Handling

Hazardous Chemical Infectious Cytotoxic Gas

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.

Exposure can occur through inhalation (breathing), ingestion (swallowing), skin contact or absorption, and injection.

42

IT DOES NOT BELONG

IN THE RED BAG…

43

• 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.

Biomedical Waste Bag (Red Bag) Closure Procedure

44

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 containerNO RABBIT EAR TIEING

45

Healthcare Rx Waste Stream ManagementLQ: Generator Status Other waste StreamsLabeled/Identified Hazardous by Pharmacy

Sort Code No Waste Code Dispose of med in black container RCRA Waste: Return to

Rx No Code No Code Empty Items

WasteClass

Non-HazardousRx Waste

HazardousRx Waste

IncompatibleRx Waste

Return to Pharmacy/place in

Aerosol bin

Maintenance

IV Solutions (No Medications)

Sharps/

InfectionsWaste

Empty/Trace vials

and IV bags

Desc

riptio

n an

d ex

ampl

es o

f Was

tes

When medication is left in avial, IV, pill:

All Rx waste without a waste code defaultsto the blue container unless it is in a syringeor ampoule. Any waste with the potentialto leak must be placed in a Ziploc bag. It isnot permitted by the Department ofTransportation (DOT) to transport freefluids.

Examples of Non-HazardousWaste:•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

When medication is left that is hazardous: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

Place wrapper and med in Ziplockthen 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.

Dispose inAerosol Container

Aerosols•HFA Inhalers•Compressed Propellants•NO capsule powder inhalers – place in bluecontainers

Return corrosive andOxidizing meds to

Pharmacy(Send to Pharmacy Code)

Corrosives (Example)•Sporanox•Zinc Sulfate•Unused Ammonia Inhalants

Oxidizers (Examples)•PotassiumPermanganate•Unused Silver Nitrate

Items that can be cut and poured down the drain.

•Maintenance IV Solutions Containing:

-Potassium Chloride-PotassiumPhosphate-SodiumPhosphate -Calcium- SodiumBicarbonate- Dextrose- Saline-Lactated Ringers

No IV’s with medications added.

•Needles•Empty Syringes

•Empty Ampoules

•Saline/Syringe

•Blood/Syringe

No partial medication

bottles, IV’s, or syringes with medications

added

Dispose yourempty/trace

containers per your hospital

policy

•Empty Vials•Empty IV bags•Empty IV Tubing

Empty syringes and ampoules in red sharps container

Cont

aine

r Dispose in baggieand use hospital

approved return topharmacy process.

NO CONTROLLED SUBSTANCES – in any of the above containers. SHARPS – Place in Red Containers.

Blue Container Black

Container

Discard down the drain

Discard in regular trash receptacle

Sharps - Be Aware & Be Responsible

46

Sharps Injury EventSharps ManagementCommunicate with team members& utilize a “safe zone” during procedures.

Use available safety sharp devices.

Needles/sharps shall be disposedof in an approved container tominimize the risk for injury.A Stericycle staff member replaces sharps containers in all patient care areas on a routine basis.

ü Wash site with soap & waterü Notify manager & Employee Healthü Report to Employee Health (or ED when Employee Health is closed) promptly after any sharps injury. It is recommended that treatment for an exposure to HIV be started within 2 hours of the incidentü Complete HNS report as soon as possible

Chemical Spills .. Labels … SDS

47

LABELS…all substances will be identifiedin original or approved labeled containers.

Chemical SpillIf chemical spills are too large to handle safely, • report immediately to emergency

operator at: 23131 or dial #0 (Wesley Woodlawn) and announce “Code Orange” and the location three times

• Evacuate and secure the area

Check with your manager concerning assigned chemicals on your unit.

The most detailed and comprehensiveinformation about substances are found on the MSDS or SDS sheets.

Safety Data Sheets available 24/7 by calling

Security at 23333and 82940 (Wesley Woodlawn)

Hazardous Drugs/Cytotoxic Drugs (HDCDs)

48

• Patients receiving hazardous and/or cytotoxic drugs in the past 48 hours are identified with an orange identification band.

• Double glove using light blue nitrile 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 bodyfluids, use standard precautions.

• ALL healthcare workers need to follow hazardous waste disposal policieslocated on Wesley’s Intranet under Policy Tech.

Chemo Spill Kit

49

Emergency Management

Emergency Management Plan

50

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. Mitigation2. Preparedness3. Response4. Recovery

There are six critical areas of emergency management:1. Communications2. Resource and Asset Management3. Safety and Security4. Staff Responsibilities5. Utilities Management6. Patient Clinical and Support Activities

Details of the Emergency Preparedness Plan are located on the Wesley Intranet under Department .

HICSHospital Incident Command System

51

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, responsibility-

oriented chain of command– Provides a common mission & language– Provides a method for prioritizing duties

52

Examples:

• Electrical Power but the Emergency Generators Work

• Electrical Power – Total Failure including emergency generators

• Telephones

• 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.

• 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.

• Use cellular phones & overhead paging; Use runners as needed.

Systems Failure Basic Staff Responses

The 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 WARNINGStaff 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

53

Bomb Threat / Bioterrorism

54

Bomb Threat

If you receive a phone call -

or….

See a suspicious package -

Take it seriously!

Bioterrorism• 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/

Call 23131 or 82940 (Wesley Woodlawn)for any threat!

Active Shooter

55

Run – Get to safety first and then call 23333 or #0 (Wesley Woodlawn) to announce – if you cannot speak just leave the line open for dispatch or announcement to be heard.

Hide – If running away is not possible, find a place to hide from the shooter!

Fight – As a last resort, use anything for a weapon and fight.

If you are hiding, do not expose yourself just because someone heard but unseen says they are Security or Police. Wait to be found by a standard room to room clearing search or come out only when absolutely sure that the threat is past and officers are present.

Emergency TeamsC

ode

Blue • Purpose…

to initiate emergency care and resuscitative action.

Rap

id R

espo

nse • Purpose…

to bring critical care expertise and support to the patient outside of the Emergency Department and to reduce the number of Code Blues and lower morbidity.

Med

ical

Em

erge

ncy • Purpose…

to initiate emergency care for any non-patient. This includes visitors and employees.

To Activate an Emergency Team…C

ode

Blue

• Wesley• Dial 2-3131

(specify Adult/Pediatric)

• Dial 2-8848 (Neonatal & BCC)

• Dial 2-8540 (Neonatal, BR, 3 & 4 Women’s Hospital)

• Wesley Woodlawn• Dial #0;

announce “Code Blue” with specific location; repeat three times

Rap

id R

espo

nse • Wesley

• Dial 2-3131 & announce “Rapid Response” and location

• Wesley Woodlawn• Dial #0;

announce “Rapid Response” with specific location; repeat three times

Med

ical

Em

erge

ncy • Wesley

• Dial 2-3131 & announce “Medical Emergency” and location

• Wesley Woodlawn• Dial #0;

announce “Medical Emergency” with specific location; repeat three times

Other Alerts… to bring immediate expert care to the bedside for various conditions

Stroke Alert

Sepsis Alert

STEMI Page

To activate the above alerts…• Wesley Main – Dial 2-3131• Wesley Woodlawn #0 and announce alert with specific location; repeat three

times

Patient Action Line

Purpose – to allow patients/family/direct contact for voicing concerns and/or emergency help not being addressed

Activated by family or patient by dialing 962-7377 (for all campuses)

Infant and Pediatric Abduction

60

• Maternal Child, Pediatric or ED staff will determine possible abduction and Call #23131or #0 and make verbal announcement (Wesley Woodlawn)

• Public Address System enacts announcement

• Security will respond & assist staff in securing all exits of Women’s Hospital, BirthCare Center, Pediatric Depts., and ED.

• Unaffected departments will assign an employee to the closest exit to monitor and detain suspicious persons if possible or to track and identify them if not.

• Drills will be conducted; respond appropriately

Risk Management

61

Your Responsibility within theRisk Management Program

62

• Be constantly alert for occurrences that might cause undesirable effects

• Communicate the positive and/or negative aspects of the occurrence

• Document the occurrence in an HNS for further tracking and monitoring• An HNS is a Hospital Notification System used within the hospital for

reporting incidents. Risk management law requires all employees and healthcare providers to report occurrences, sentinel events, and close calls.

• HNS’s should be completed on an incident within 24 hours of the occurrence.

• 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)

TeamSTEPPS Tools

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SBAR CUS• Structured Communication technique• Conveys a great deal of information in

a succinct and brief manner

• Patient advocacy tool• Catches team members attention• Provides opportunity to prevent error

S = Situation • Identify yourself, patient by name, age, gender

and reason for admission. What is going on with the patient.

B = Background• Review recent relevant history. Provide a brief

summary of clinical background/context. What actions have already been taken.

A = Assessment• Give your clinical impression. What do you think

the problem is.R = Recommendations• Suggestions for actions to be taken.

C = State your Concern•“I’m concerned about . . .”

U = State why you are Uncomfortable•“I’m uncomfortable with . . .”

S = State that there is a Safety issue•“This may be a safety issue.”

Not resolved? Use your chain of

command

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An unusual event, situation, incident or unexpected outcome

Examples:• 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

What is an “Occurrence”?

Sentinel Event is defined as “an unexpected occurrenceinvolving 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 (RCA) or Serious Event Analysis (SEA) of the event to develop a corrective action plan that would preventrecurrence.

– 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.”

– Close call events need to be investigated and an action plandeveloped to ensure everyone’s safety & to prevent recurrence

Sentinel Event / Close Call

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Hospital Notification System

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OccurrencesSentinel Events

Close Calls

Document ALL within 24 hours

with an HNS

Risk management law requires all employees and healthcare providers to report occurrences, sentinel events, and close calls.

EMTALA(Emergency Medical Treatment and Active Labor Act)

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EMTALA States:

The Emergency Department must provide to any individual that comes to the emergency department :

(includes: Main ED, West ED, Birth Care Center, Birthrooms, Wesley Woodlawn ED, and Wesley Derby 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.

EMTALA

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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, WesleyWoodlawn and Derby ED, or within 250 yards of the main buildings, but does not include Wesley Care Clinics.

EMTALA policies are found on the intranet under policies and procedures.

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HIPAA / Patient Rights / Confidentiality

HIPAA – Privacy Rule and HITECH ActHealth Insurance Portability & Accountability Act of 1996

Health Information Technology for Economic and Clinical Health Act

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– Patient’s Rights – listed in Notice of Privacy Practices

– Federal Regulation with provider and individual fines for violation

– Protected Health Informationusing & disclosing any form of PHI via any type of media (oral, written, electronic)

ALL healthcare employees are obligated to protect patient privacy rights! (patient & non-patient care areas, physicians, residents, volunteers, & students)

If there is a HIPAA concern: Notify your manager or the facility privacy official

“FPO” & complete a HNS report. Our FPO is Julie Hertzler 962-2041

Patient Rights• Respected without regard to age, gender,

disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender, identity or expression, national origin, medical condition, marital status, veteran status, payment source or ability.

• Right to choose a person to be the healthcare representative and/or decision maker.

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Patient Visitation RightsFamily, spouses, partners, friends and other visitors are important in the care process of patients. We affirm the following visitation rights of patients.Patients shall:• Be informed of their visitation rights• Designate healthcare representative/decision maker• Be able to receive visits from their attorney, physician or

clergyman at any reasonable time• Be able to speak privately with anyone they wish unless

not medically advised• Be accompanied by ADA approved service animals

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Patient Privacy Rights

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The right to access their PHI (Protected Heath Information)

The right to request amendment of PHIThe right to an accounting of disclosuresThe right to opt out of the patient directoryThe right to confidential, alternate communicationThe right to restrict accessThe right to receive the notice of privacy practices

Protected Health Information (PHI)

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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)

Electronic health information:• Log off the computer when finished or when walking

away from the computer to care for a patient. • 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 by putting [encrypt] in the

subject line of emails

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, volunteers, 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,

all PHI must be placed in a secure shred bin at the end of each shift.– 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

Tips to Safeguard Patient’s PHI

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Tips to Safeguard Patient’s PHI

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Oral/Verbal/Written health information:

• 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 co-

workers 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 prior to 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 962-7800 within 24 hours

Potential ViolationsRequire reporting Manager, HNS or FPO

What are the most commonly reported HIPAA Privacy Concerns in the Wesley family of providers?

Failure to Safeguard PHI: • Issuing discharge instructions or prescriptions to the wrong patient• Errors in faxing reports, assigning the wrong physician mnemonic causing results to be sent to the

wrong physician, e-mailing PHI without encryption• Placing patient information in trash bins• Taking photos with cell phone or personal recording device• Placing patient information on Facebook, Twitter, or other social media sites

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, or co-workers• Access of Meditech to view your own PHI without proper documentation

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)

Remember:Each employee must access and share only the minimum information necessary to

perform their job regardless of the extent of access provided to them. 77

Computer Use & Workstation

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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.

An employee accessing the computer system is responsible for any activity performed under his/her USER ID.

Never share your passwordEach user’s computer activity is audited at least once a year.

BEFORE LEAVING A COMPUTER or PYXIS:SIGN OFF & SECURE any information.

Log off or use “Ctrl/Alt/Delete”

This action helps to ensure the protection of the information as well as prevent any activity occurring under your user ID in your absence.

Infection Prevention - HAI

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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

Infection Prevention

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Healthcare-Associated Infection (HAI)An infection that develops in a health care setting that is related to

receiving care in that setting.

Single Most Effective Way to prevent the spread of communicable diseases!

Foam• Before donning gloves• Immediately after removing

PPE (includes gloves)• Before and after each

patient contact• Before you eat

Hand Washing• Before donning gloves• Immediately after removing

PPE (including gloves)• Before and after each

patient contact• After you use the restroom• When caring for a patient

with diarrhea (enteric precautions)

• When hands are visibly soiled

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Personal Protective EquipmentPPE

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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.”

How to Use PPE:• Ensure your gown is tied to prevent your clothes from becoming

contaminated.• 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 & discard in waste container (never leave around your neck or in a pocket for re-use!).

Standard Precautions

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Standard Precautions is 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 to PROTECT YOU!

Use Barrier Devices

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If you think “it” will:

Burp or Squirt or Splash

Protect yourself!Be prepared… treat all blood/body fluids as potentially infectious (eye goggles or a mask with a face shield…gown or apron…and gloves)

Expanded Precautions-Transmission BasedContact Precautions• Always wear gloves and gown when entering the room• Strict hand hygiene compliance• Clean gown and sheet should be placed on the patient prior to

transport outside their hospital room.

Droplet Precautions• Always wear a procedure mask whenever entering the room,

eye protection while providing direct patient care and gloves and gowns if they will come in contact with surfaces contaminated by respiratory secretions

• Procedure mask is to be worn by the patient any time they leave their hospital room.

Airborne Precautions• Negative pressure room: Keep the door closed!• Staff wear N95 respirator mask or PAPR while in the room.• Patient’s are to wear procedure mask when they leave their

room.• Visitors wear a procedure mask while in the room.

Enteric Precautions• Always wear gloves & gown when entering the room• Strict handwashing with soap & water• Use bleach wipes on all equipment exiting the room

Recognize the alertsObserve signage on doors defining type of precaution;Rose identification band on patient

Standard Precautions always apply

DO NOT RE-USE or SAVE disposable PPE

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SAFE WORK PRACTICES“CLEAN to DIRTY Principle”

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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: • High Touch Surfaces such as light switches, door handles, and curtains can

become contaminated if touched by soiled gloves/hands.

• 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”?

Surgical Instrument Pre-Cleaning and Transporting

All non-disposable surgical instruments must be cleaned to

prevent biofilm adherence and

transported safely to prevent exposure

Event of an Exposure

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If you are exposed through splashes, needle stick puncture wounds, or other sharps injury from any potentially infectious material:• Immediately wash your skin with soap & water or if eyes, mouth

or nose, flush with lots of water

• Notify your manager• Seek immediate treatment & evaluation! Employee Health:

22618 or 82049 (Wesley Woodlawn)(If Employee Health is closed, report to the Emergency Department)

• If treatment is necessary for HIV, the medication should be started as soon as possible after the exposure

• Document as an “employee incident” with an HNS by the end of the work shift

C-DiffBE INFORMED

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• C-Diff is a spore forming bacteria that is resistant to most

cleaning solutions and can be transported on healthcare

workers hands.

• Enteric 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

ENTERIC precaution rooms is required to control C-Diff. Wipe

equipment with bleach 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 bleach wipe each shift

– Special Clean upon dismissal

Multi-drug Resistant Organisms (MDRO’s)Special Clean

• Carbapenem Resistant • Contact Precautions

• Enterobacteriaceae (CRE)• Contact Precautions

• Vancomycin Resistant Enteroccocus(VRE)

• Clostridium difficile (C-diff) • Enteric Precautions• Wash hands with soap and water

Infection Prevention Practices:• Dedicated or disposable equipment ;

Disinfect ALL Equipment before it leaves patient room

• Special Clean upon dismissal (Rose“C” Alert on door)

• Perform hand hygiene

Routine Clean• Methicillin Resistant Staphylococcus

Aureus (MRSA)

• Extended-Spectrum Beta Lactamase (ESBL)

• MDRO Proteus mirabilis

Infection Prevention Practices:• Contact precautions

• Dedicated or disposable equipment

• Disinfect ALL Equipment before it leaves the patient room; MDRO’s can live for hours on environmental surfaces

• Perform hand hygiene

Respiratory Viruses

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A regular procedure mask is what is needed to protect you from all respiratory viruses, including Influenza.

Healthcare 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 suctioning.

Influenza Vaccine

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• Vaccination is the best protection against contracting the flu. Annual Influenza vaccines are offered to all employees at no cost. Any employee declining to receive a flu vaccine will be required to wear a procedure mask while at work during Influenza season (generally November through March).

• Healthcare personnel are among the priority groups that the CDC recommends 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.

Tuberculosis (TB)

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When a person with active TB of the lungs talks, 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 procedure mask.

Visitors should wear a procedure mask for their protection when visiting the patient.

Healthcare workers should wear an N-95respirator or PAPR when caring for the patient.

Latent TB: Persons with latent TB are not infectious and cannot spread TB infection to others.

TB skin testing is available through Employee Health for exposure follow-up.

Surgical Site Infections: Prevention is the Key!

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SURGICAL-SITE INFECTION (SSI)

PREVENTION STRATEGIES:

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 purulent fluid from the surgery site, abscess or fever.

• Hand hygiene every patient every time• Excellent technique with dressing changes or manipulation – always wear

gloves• Good surgical skin prep with Duraprep or Chloraprep and allow to dry

completely• Limiting traffic in the operating room• Patient education (preoperative, operative and postoperative)• Patient’s can:

– Stop smoking at least 2 weeks prior to surgery– Good glucose control– Loose weight prior to surgery– Shower with Chlorhexidine prior to surgery

Catheter Associated Urinary Tract Infection (CAUTI)

Signs and SymptomsØ Dysuria – painful burning

urination. (i.e. The patient complains of a burning sensation when passing urine)

Ø Urinary Frequency – frequent urination without an increase in the total daily volume of urine

Ø Urinary Urgency – a feeling of the need to void urine immediately (not do to acute retention)

Ø Fever >100.4Ø Suprapubic tendernessØ Costovertebral angle pain or

tenderness

Bundle PreventionØ Hand hygiene prior to any

catheter insertion or manipulation

Ø Only use a catheter when indicated

Ø Sterile technique when inserting the catheter

Ø Use one catheter for each attempt

Ø Do not disconnect catheter from collection bag

Ø Keep collection bag belowthe level of the bladder

Ø Apply securement device

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**Don’t forget to write the insertion date on the bag**Change securement device and date it every 7 days

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• Perform hand hygiene prior to touching line• Always wear gloves prior to accessing line including during flushing or

medication administration• Apply alcohol cap on every hub or scrub the hub for 15 seconds prior

every access • Change the dressing every 7 days or if dressing is loose, wet or

bloody• Apply securement device (change with dressing change)• Apply antimicrobial patch for anyone over the age of 2 months• Change caps every 7 days • Assess necessity of lines daily-discuss with physician for removal• Daily CHG bathing for all adult ICU patients and pediatric and adult

neutropenic patients.• Assess every shift for signs of infection:

• Fever >100.4• Redness at insertion site• Drainage

• Label dressing with date and time applied

Central Line Care Bundle

Clinical Topics

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Abuse and Neglect - Identifying Victims

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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)

Neglect: caregiver fails to take the same actions to provide adequate food, clothing, shelter, medical care or supervision that a prudent caregiver would give

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

Wesley Woodlawn Security at 82940)

Abuse & Neglect..Adults & Children!

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Abuse & Neglect - Reporting

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• Report any suspected or alleged abuse/neglect to Case Management (seven days a week, 8 am – 5 pm). 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”• Choose “Abuse”• Look for “Adult Abuse” and “Child Abuse” information

Color Coded Patient ID bands

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Know Your Wristband Alert Colors!Wesley Inpatient Wristband

(Always use 2 identifiers prior to placing on patient)

Allergy

Latex Allergy

Fall Risk

Limb Alert (place band on limited extremity)

Pacemaker or ICD

Do Not Resuscitate

Paper Armband - Emergency Department

Paper Armband - Outpatient

Patient Receiving Cytotoxic or Hazardous Drugs

Infection Prevention (rose color insert into clear band)

Wesley Specific Wristband Alerts

Kansas Standardized Wristband Alert Colors

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

Wesley identifies 3 additional alert colors:• Bright lime green for pacemakers or

internal defibrillators• Orange for hazardous drugs• Rose for infection prevention

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Falls How do I know if a patient is at high risk for falls?•A yellow armband with FALL RISK in black lettering is placed on patient.•Yellow star is placed on their door OR the yellow light outside the door is activated

You are walking by a room with a “yellow star” magnet on the doorway or yellow light activated outside the door 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.

RN will need to complete/document:Ø Post Fall Assessment Ø Patient Assessment Ø Re-evaluation of fall riskØ Post fall debriefing

Ø Fall in medical record (patient note)Ø A Hospital Notification System (HNS)Ø Notification of patient’s attending

physicianØ Notification of patient’s family

Latex Management

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• Latex allergy develops from exposure to natural rubber latex & is recognized as a serious medical problem for 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!

Restraints

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• 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.

Restraint Alternatives

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Alternatives to restraint use can include the following…

Monitoring EducationEnvironmental Measures Diversion ActivitiesComfort Measures Medication/NutritionInterpersonal Skills Occupational Therapy/ActivitiesStaffing 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-

üPhysical harmüPsychological harm

Wesley’s Intranet

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Get detailed informationPolicies & Procedures

Infection Prevention PracticesManagement of Waste MaterialsSafety PowerPoint Presentation

Locate this Icon on a work computer desktop!

The Joint Commission National Patient Safety Goals

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1. Improve the accuracy of patient identification• Use two patient identifiers (patient name and birth date) when providing care, treatment, and services• Eliminate transfusion errors related to patient misidentification

2. Improve the effectiveness of communication among caregivers• Report critical results of tests and diagnostic procedures on a timely basis

3. Improve the safety of using medications• 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

7. Reduce the risk of health care associated infections• 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

6. Improve the safety of clinical alarm systems• Establish alarm safety as a hospital priority• Identify the most important alarm signals to be managed.• Establish policies and procedures for managing the alarm identified above

15. The organization identifies safety risks inherent in its patient population• 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

Joint Commission mandates that all lead accessories be inspected each year.

• Tape should not be used on aprons to tighten the fit. Removing the tape can destroy the integrity of the cover.

• Lead should not be folded. Folding can cause the lead to crack. Damaged lead will not provide the same protection from radiation exposure.

Lead aprons & shields are labeled with a colored sticker depicting the year of inspection. The color will change annually.

If you find lead without a white date sticker, please notify the Imaging

Department at 22955 or CVL at 82959 (Wesley Woodlawn).

The label color for 2018 is White.

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The End!

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Thank you for your participation and cooperation in completing the

2018 Safety Program.