Student Faculty Orientation Packet · 7/19/2019  · Interpretive Services and Linguistic Awareness in Healthcare 10 ... 2019-2021 Strategies to Success Summary Thriving in the Transition

RN Student &

Faculty Orientation Packet

2020-2021

1

2020-2021 RN Student

& Faculty Orientation

Table of Contents

Topic Page

EvergreenHealth 2020-2022 Strategic Plan Summary 3

EvergreenHealth Campus Map 4

Hand Hygiene 5

Personal Protection Equipment 7

Interpretive Services and Linguistic Awareness in Healthcare 9

Pharmaceutical Waste 10

Fall Prevention Fact Sheet 11

Specimen Labeling 13

Scanning Patients and Medications 20

Emergency Codes and Staff Response 21

EvergreenHealth Art of Caring 22

SBAR Communication 23

Patient Bill of Rights 24

EvergreenHealth Policy Review • Code of Conduct

• Exposure to Blood and Body Fluid Management

• Immunity/Vaccination and Tuberculosis Screening Requirements

• Transmission based Isolation Precautions

• Specimen Labeling Flow Chart

• Work Restriction Policy

• Dress Code Policy

• Extended Universal Masking

• Cell Phone Usage and Requirements Policy • Social Media Policy

26

2

2020-2022 System Strategic Plan Summary

Purpose - Our brand promise: Working together to enrich the health and well-being of every life we touch Mission - Why we exist: EvergreenHealth advances the health of the communities it serves through dedication to high quality, safe, compassionate, and cost-effective health care Vision - What we aspire to fully become: EvergreenHealth will create an inclusive community health system that is the most trusted source for health care solutions Values - Shared beliefs that define our culture:

Compassion Excellence Respect Collaboration Accountability

Core Pillars/Goals What we want to achieve

Strategies How we will achieve the pillar/goal

Initiative How we will achieve the strategic imperatives

1. CULTURE & PEOPLE Foster a culture and environment that

enables all employees and medical staff to perform at their best, every day, and fulfill their potential

A set of strategic enablers and strategic imperatives work together to achieve the goals. The strategic enablers are ongoing foundational elements that are fostered continuously and central to the successful execution of the Strategic Plan. Therefore, these are called out in the framework to become embedded in the work of divisions, departments and day-to-day operations. The strategic imperatives, which can change overtime, are overarching pivotal system strategies that create market advantage and distinction. These appear on the Strategic Plan, as well as on department and division plans.

Meaningful & Sustainable Growth 1. Workforce 2. Access to Care 3. Master Facility Planning 4. Geographic Expansion 5. Patient Acquisition 6. Patient Retention 7. Surgical Growth Plans 8. Surgical Capacity & Technology 9. Ambulatory Surgery Model 10. Primary Care 11. Cancer/Seattle Cancer Care Alliance 12. Cardiothoracic/Eastside Health Alliance 13. Neuroscience/ Eastside Health Alliance 14. Orthopedics 15. Women’s & Children’s 16. Partnerships 17. EvergreenHealth Monroe Vision

2. CLINICAL EXCELLENCE Improve and sustain health outcomes by delivering high-quality, safe, value-based care to every patient, every time

3. EXPERIENCE & LOYALTY Deliver exceptional and personalized patient and customer experiences resulting in absolute loyalty Unparalleled Service & Experiences

18. Patient Experience 19. Employee & Provider Engagement 20. Digital Health 21. Digital Patient Experience Platform 22. Virtual Health

4. GROWTH & ACCESS Deliver innovative solutions for the growing and changing needs of the community

5. FINANCIAL STEWARDSHIP Demonstrate strong and sustainable financial performance to ensure affordability and long-term viability

Care Transformation 23. High Reliability Organization 24. Population Health Management 25. Data Analytics 26. Evidence Based Care 27. Patient Flow / Transitions of Care 28. Behavioral Health 29. Eastside Health Network 30. Margin Pressure / Total Cost of Care

3

LEGEND

Building Entrance

Information Desk

Cafeteria/Deli

Restroom

Stairs

Elevator

Escalator

Telephone

Vending Area

ATM

Waiting Area

Red Zone

EMERGENCYENTRANCE

WESTENTRANCE

AmbulanceEntrance

Only

DROP-OFF AREA

WEST PARKINGENTRANCE

(underground)

EvergreenHealth Human Resources & Technology Center

EvergreenHealthAdministrative

Services Building

BUS STOP WAITING AREA

DeYOUNG PARKING ENTRANCE

Silver Zone

PurpleZone

Green Zone

Blue Zone

Coral Zone

Patient Registration

Breast HealthCenter Registration

Evergreen Professional

Center

NE 130th Lane

120th Avenue NE

124th Avenue NE

Parking LotParking Lot

NE 128th Street

ParkingLot

ParkingLot

Parking Lot

Parking Lot

Parking Lot

Parking Lot

TanZone

Education Center

EAST PARKING ENTRANCE

Deli on Two

CENTRAL ENTRANCE

DRO

P-OFF AREAUnderground W

alkway

DRO

P-OFF AREAGift ShopCourtyard Deli

and Espresso

Chapel

EMERGENCY PARKINGENTRANCE

(Underground)

DROP-OFF AREA

Auditorium

Green Registration

Gift Shop

Café 128

EASTENTRANCE

EMERGENCY Department

Silver Espresso

CENTRAL PARKINGENTRANCEGalleria

EvergreenHealth Medical Center CampusGeneral Information: 425.899.1000

Nurse Navigator & Healthline: 425.899.3000www.evergreenhealth.com

Pharmacy

Baby & Family Boutique

Gene and Irene Wockner Hospice Center

Inpatient Units

Halvorson Cancer Center

DeYoung Pavilion &Sound Transit Center

EvergreenHealth Surgery & Physicians Pavilion

Family Maternity

Center

CentralParking

(lower levels)

EastParking (top deck)

CentralParking

(lower levels)

DEYOUNG PAVILION ENTRANCE

CENTRAL PARKING ENTRANCE

FlatVisitor Guide Map FINAL_2018.indd 1 1/18/2018 12:30:43 PM

4

Absolute SafetyEvery Moment, Every Time.

Everyone has an important role in Hand Hygiene, whether you provide direct patient care or support those who do. At EvergreenHealth, we expect that you practice the five key moments of hand hygiene. These guidelines must be followed at Every Moment, Every Time to ensure the Absolute Safety of our patients.

Five Moments of Hand Hygiene

1. Before touching a patient - before shaking hands, before assisting a patient in personal care activities, such as to move, to take a bath, to eat or to get dressed.

2. Before clean/aseptic procedure - before dressing a wound, applying ointment, making a percutaneous injection / puncture, or before preparing food, medications, or sterile material.

3. After body fluid exposure risk - after removing an invasive medical device, removing any form of material offering protection (such as a napkin, dressing, gauze, or sanitary towel) or after cleaning any contaminated surface and soiled material (soiled bed linen, dentures, instruments, urinal, bedpan, lavatories, etc).

4. After touching a patient - after shaking hands, changing bed linen as the patient is in the bed, applying an oxygen mask, giving a massage or performing a physical non-invasive examination: taking pulse, blood pressure, chest auscultation, recording ECG.

5. After touching the patient’s environment - after an activity involving physical contact with the patient’s immediate environment (such as using a computer, changing bed linen with the patient out of the bed, holding a bedrail, clearing a bedside table), after a care activity (such as touching IV pump, clearing a monitoring alarm) or after other contacts with surfaces or inanimate objects (such as leaning against a bed, leaning against a night table / bedside table).

5. after touching patient environment

3. after body fluid exposure risk

4. after touching a patient

2. before clean/aseptic procedure

1. before touching a patient

5MOMENTS OFHAND HYGIENE

5

How to handrub? WITH ALCOHOL-BASED FORMULATION

How to handwash? WITH SOAP AND WATER

11

10

Apply a palmful of the product in a cupped hand and cover all surfaces.

Rub hands palm to palm right palm over left dorsum with interlaced fi ngers and vice versa

palm to palm with fi ngers interlaced

backs of fi ngers to opposing palms with fi ngers interlocked

rotational rubbing of left thumb clasped in right palm and vice versa

rotational rubbing, backwards and forwards with clasped fi ngers of right

hand in left palm and vice versa

…and your hands are safe.

Wet hands with waterapply enough soap to

cover all hand surfaces.

rinse hands with water dry thoroughly with a single use towel

use towel to turn off faucet

…once dry, your hands are safe.

40-60 sec20-30 sec

Des

ign:

mon

dofr

agili

s ne

twor

k

WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.

October 2006, version 1.

6

Absolute Safety Every Moment, Every Time.

Procedure for Donning (Putting on) PPE Clean PPE can be put on in any order However you must sanitize your hands prior to putting on gloves

1) START WITH CLEAN HANDS

2) PUT ON GOWNa. Left arm first (like a jacket)

b. Right arm second

c. Left arm through hole

d. Velcro shoulder

3) PUT ON MASK

4) SANITIZE HANDS (GEL OR WASH HANDS)

5) PUT ON GLOVES

Left arm first (like a jacket)

Right arm second

Left arm through hole

Velcro shoulder

7

Procedure for Doffing (Removing) PPE Remove PPE at doorway before leaving patient room or in anteroom; If your hands become contaminated during PPE removal, use hand sanitizer before moving to the next step in the process.

1) REMOVE GOWNa. Undo velcro to remove front flap

b. Peel gown down arms and roll gown inside out, with the contaminated side turned in on itself

c. Hold removed gown away from body, roll into a bundle and place in hamper

2) REMOVE GLOVES

3) REMOVE MASK

4) SANITIZE HANDS (GEL OR WASH HANDS)

Absolute Safety Every Moment, Every Time.

Undo velcro

Remove gown

Remove front flap

8

Interpreter Services – Linguistic Awareness

EvergreenHealth serves Limited English Proficient individuals (LEP), deaf, hard of hearing, and disabled

patients/surrogate decision-makers. These individuals must be able to effectively communicate their medical

condition and history with hospital staff.

It is illegal to ask patients to bring or pay for their own interpreters. Friends, family members or staff may not

interpret during any clinical communication. Patients and family members insisting on using their own interpreter

or not wishing to have an interpreter, will be advised the following: we must ensure an accurate exchange of

information, patients do not pay for the use of interpreters, and interpreters are also for the providers; therefore,

we will use an unbiased and trained professional interpreter during any clinical communication. Only DSHS certified

interpreters from one of EvergreenHealth contracted agencies may interpret for providers/patients.

Remember: interpreters help not only patients but also healthcare providers.

Federal Legislation & Policies

2001 - CLAS Standards - They aim to improve health care quality and advance health equity by establishing a framework for organizations to serve diverse communities.

2000 - Executive Order 13166 – Requires all federal financial assistance recipients to uphold Title VI. 1990 - American with Disabilities Act – First civil rights law addressing the needs of people with disabilities, prohibiting

discrimination in employment, public services, public accommodations, and telecommunications. 1964 - Civil Rights Act -Title VI – Prohibits discrimination on the basis of race, color, and national origin in programs and

activities receiving federal financial assistance. It is the legal foundation for language access services. 1946 - Bill-Burton Act – It was designed to provide federal grants to improve the physical plant of the nation’s hospital

system.

EvergreenHealth Interpreter Services Guidelines

For American Sign Language hospital emergencies and unplanned visits ONLY: Utilize the Video Remote Interpreter (VRI) located in

the Switchboard (Purple Basement B377). Please return immediately after use and email Grp Interpreters indicating time checked out

and time returned. For scheduled appointments: opportunely requests an interpreter ONLY from our contracted agency.

For more information about Interpreter Services please email [email protected] and/or go to

EverLink>Departments>Interpreter Services; under FACTS you will find too the Interpreter Request Form.

USE

Telephonic Interpreting

ALL CASES except for those listed in

Face-to-Face Interpreting

Immediate access in

over 180 languages

Pacific Interpreters

Hospital ONLY: 1.888.869.7344 Clinics: 1.800.264.1552

THE RIGHT SERVICE AT THE RIGHT TIME

24 HOURS A DAY, 7 DAYS A WEEK,

365 DAYS A YEAR

WHEN IT IS APPROPRIATE TO USE

Face-to-Face Interpreting

CT & MRI with a contrast agent

Combative patients

Deaf patients (sign language)

Mental Health (patient is aggressive/agitated)

Speech or hearing problems

Sexual Assault

Women & Children Services for the following conditions

∙ Fetal Demise ∙ Terminations

∙ Twin to Twin Transfusion Cases

Interpreters (including Sign Language) Call: 425.899.2585 (24/7)

Call: 425.899.2585

Do not use Hopelink Interpreter Services

EH Interpreter Services

Joy Hanson, Director

Ana Balducci-Curtis, Coordinator

06/2020

9

Standard RCRA Black Box – Black and White Label Epinephrine/Physostigmine – Purple Container Aerosol Black Box – Black and Green Label

Empty, partial or full vials and syringes without needles:

Epinephrine

Physostigmine Partial or full:

Chemotherapy

Dehydrated alcohol

Insulins

Nicotine

OnabotulinumtoxinA (Botox)

Phenol

Silver Sulfadiazine Cream/Ointment

Warfarin

Empty, partial or full syringes with needles attached:

Epinephrine

Physostigmine

What to put into bin:

All metered dose inhalers (MDIs)

Benzocaine sprays (Hurricane, Cetacaine)

Pentafluoropropane and tetrafluoroethane spray (Gebauer’s, Pain Ease)

Nitroglycerin Spray

Sevoflurane

Desflurane

Where bin is located:

Dirty utility rooms on each patient unit

Inpatient Pharmacy

Where bin is located:

Dirty utility rooms in Emergency and ICU

Inpatient Pharmacy

Where bin is located:

Dirty utility rooms on each patient unit

Inpatient Pharmacy

Blue Sharps AND Pharmaceutical Container

Yellow Trace Chemo Waste Container

Red Biohazard Bags Sink Controlled Substance Destroyer Container

General Trash

What to put into bin:

All medications NOT on any other list (Includes all non-chemotherapy hazardous drugs)

All sharps, needles, empty glass ampules that do/did not contain epinephrine or physostigmine or chemotherapy

What to put into bin or bag:

EMPTY chemo syringes, bags, tubing

All garb (gloves, gowns, etc.) used for compounding or administering chemo

What to put into bag:

Disposable, non-sharp supplies containing blood and/or body fluids, including soaked/saturated items

What to put into sink:

Plain IV solutions without additives (normal saline, dextrose, lactated ringers, D5NS, D5LR, D5½NS)

Fluids with electrolytes such as magnesium or potassium, etc.

What to put into container:

All controlled substances (note: empty controlled substance into container, then throw empty IV bag, vial or syringe into regular trash)

What to put into bag:

Empty IV bags or IVs with less than 3% remaining

IV tubing

Empty syringes

Empty vials

Where bin is located:

Every patient room

Every med room

Dirty Utility Rooms

Inpatient pharmacy

Where bin or bag is located:

Inpatient pharmacy

Mobile cart used for chemo administration, stored in dirty utility room (6 Silver)

Where bag is located:

Dirty utility room

Where sink is located:

Patient rooms

Inpatient pharmacy

Where container is located:

Med rooms

Inpatient pharmacy

Where bag is located:

Patient rooms

Utility rooms

Med rooms

Inpatient pharmacy

Guide to Pharmaceutical Waste—October 2017

10

Minimize delays in results: label your specimen properly.

6.22.20

A properly labeled specimen has:

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Minimize delays in results: label your specimen properly.

6.22.20

The collector’s

initials

The patient’s name toward

the top of the tube

Orient the label so the color

strip on the tube shows: this is

the only way to know what tube

it is when the top is removed.

Don’t write anything in

the space behind the

bar code: the lab’s

scanner cannot read the

bar code and rejects the

tube!

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6/22/2020

Fall Prevention

A fall is defined as an unplanned descent to the floor with or without injury. Patient falls contribute to mortality and increased morbidity in the general patient population. Implementation of a falls/injury risk assessment and prevention program targets those at risk due to such factors as environmental challenges, functional limitations, and patient and family educational deficits. However, all patients may be at risk for falls.

General precautions that are in place for all patients include:

Orientation to surroundings and use of call light

Keeping bed in low, locked position

Keeping floors obstacle free

Keeping personal belongings and call light within patient's reach at all times

Intentional rounding

Use of non-skid footwear

Adequate lighting

Encouraging patient and families to call for assistance when needed

Yellow bracelet with the words “FALL RISK”

Safety huddles are held at the beginning of each shift with all staff for the purpose of going over recent falls and current fall risks on unit. Because of increased risk of injury with a fall, information about fall risk will include the "ABCS" - Age 85 or greater, Bones (Osteoporosis, recent fracture or other bone disorder), Coagulopathy (on anticoagulants or with a bleeding disorder) and Surgery (during current admission). This information will be passed on in shift report and documented on whiteboard along with patient's fall risk assessment.

Acute Care Inpatient (ONC, OSN, MED/SURG, CCU, PCU, CNV and ARU)

The following list of equipment may be used to prevent patient falls:

1. Call light within reach for patient and/or family 2. Alarm systems for doors, chairs, toilets, or beds as appropriate 3. Lift equipment to provide safe patient movement and prevention of falls 4. Gait belt or appropriate assistive devices (walker, cane, etc.) 5. Yellow arm band with the words “FALL RISK” 6. Visual doorway identifier 7. In-room patient white boards designating fall risk assessment as Low, Mod, or High 8. Fall risk alert on Medical Record or bed board 9. Omnibelt as a reminder for patients with impulsive behavior

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6/22/2020

Frequency of Fall Assessment:

Assess patient fall risk using the Modified Morse Fall Scale

Assess patient risk of injury with fall using the ABCS Risk Assessment

1. Upon admission 2. Upon transfer from one unit to another 3. Following any change of patient status that may affect fall risk 4. Following a fall 5. Every shift

a. Document the assessment in the medical record b. Document on patient white board as LOW, MOD, or HIGH risk c. In addition to the risk assessment tool, the nurse is expected to apply her/his

clinical judgment about the patient's risk for falls

Fall Risk Interventions:

Implement basic fall prevention interventions as listed in supportive data for ALL patients.

Add the following interventions when designated Moderate Risk: 1. Provide assistance with toileting during rounds 2. When assisting patient to bathroom, stay nearby 3. Evaluate effects of medications that increase the individual’s risk of falling with

assistance from pharmacy, as appropriate 4. Determine if appropriate to move patient closer to nurse’s station or constant care room 5. Partner with patient to determine which side of the bed they usually get out of-

consider placing tethers (IV pump, Foley bag, etc.) on that side of the bed 6. Consider implementing use of appropriate equipment as in equipment list above

Add the following interventions when designated High Risk: 1. Implement yellow identifier at patient room entrance 2. Place yellow socks and/or yellow bracelet on high fall risk patient 3. Assure patient is able to be visualized from hallway if staff not present 4. When assisting patient to the bathroom, stay in the bathroom, within arm's

reach, to monitor and assist patient 5. Use of chair, toilet and bed alarms are highly recommended 6. Consider use of constant observer 7. Implement "no-passing" zone on high fall risk patients: After reviewing high risk patients

at safety huddle, all staff on unit are aware that these patient's call lights are highest priority. All staff will accept responsibility to assure call light is answered immediately.

EMERGENCY DEPARTMENT

The following list of equipment may be used to prevent patient falls: 1. Light within reach for patient and/or family 2. Lift equipment to provide safe patient movement and prevention of falls 3. Gait belt or appropriate assistive devices (walker, cane, etc.) 4. Yellow socks or yellow arm band

14

6/22/2020

5. Yellow/visual doorway identifier 6. Room curtains to remain open if patient is alone 7. In-room patient white boards designating fall risk assessment as Low, Mod, or High 8. Fall precaution icon added to ED tracking board 9. Additional interventions as ordered by MD

WOMENS AND CHILDREN'S

Moderate and High Risk Nursing Interventions (over the age of 8 yrs): 1. Provide distraction to the patient as appropriate 2. Assist moderate risk fall patients to the bathroom, staying close to the bathroom door

to listen to patient activity 3. Determine if appropriate to move patient closer to nurse’s station

Moderate and High Risk Nursing Interventions (under the age of 8 yrs): 1. All Infants and children up to the age of 8 years are considered at minimum a Moderate

Risk 2. Side rails, crib rails, and side walls are always in the ’up’ position unless care is provided 3. Families are educated on proper fall prevention techniques when holding,

feeding, snuggling, bathing, carrying, and other activities that take place when the infant or child is not in their bed

EDUCATION OF PATIENT AND FAMILY

Using Teach Back method, educate the patient/family about fall prevention to include: 1. Reasons for precautions (i.e. recent fall, impaired mobility, medications, recent

surgery, use of anticoagulants) 2. Assistive devices (i.e. walkers, gait belts, lift equipment) 3. Fall prevention precautions (i.e. yellow bracelet, yellow flag, bed or chair alarm) 4. How to request assistance

POST FALL PROCEDURE

Fill out fall event/post fall assessment in ad hoc charting

Document fall in the Progress Notes

Assure SafelinQ report is completely filled out by person witnessing fall

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6/22/2020

FALL PRECAUTIONS

Patients with a high fall risk (Morse score > 45) need to have fall

precautions in place at all times.

Bed or chair alarm on: Make sure the Posey alarm is

used (not the in-bed alarm,) and that the pad that is

under the patient (in the bed or the chair) is the one

plugged in to the sensor! You can label the bed and

chair cords with labels near the top to make it easier to

quickly identify which one is which. When a green light

shines from the top of the alarm – it is armed and

functioning.

o Standard work: before you move a patient from

bed to chair & before getting the patient out of

bed, unplug the bed strip and plug in the chair

strip. When the patient sits in the chair, it will

automatically be set, and the bed alarm won’t sound while you are moving the patient.

Documenting Morse Fall Scale in Cerner:

Found in Care Compass

Or in AdHoc

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6/22/2020

Morse Fall Scale in QS: Maternal Chart:

Maternal falls usually occur post-delivery, first or second time getting out of bed.

Assess vital signs, sensory/motor of legs prior to getting out of bed.

Assist out of bed first and second time out of bed post-delivery.

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6/22/2020

Newborn Chart:

Newborns at risk for falling out of adults arms and off day bed or patient bed

Recommend adults don’t hold baby when they are at risk of falling asleep

Recommend baby doesn’t lay on day bed or patient bed without being held.

Morse Fall Scale Reference Text

https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:29072

Initial Assessment or Re-assessment: 1. Initial: admission, first scale done in hospital

2. Re-assessment: any thereafter

History of Falling: 1. If the patient has a history of falls within 3 months of admission – this value may change if they fall

while they are here, YES = 25 points

2. If no falls w/in last 3 months, and no fall during hospitalization, NO = 0 points

Secondary Diagnosis: 1. If only one diagnosis is listed on the patient’s chart, score as NO = 0 points

2. If more than one medical diagnosis is listed on the patient’s chart, score as YES = 15 points

18

6/22/2020

Mobility Aid: 1. If a patient walks independently with no assistance of any kind, score 0

2. If a patient walks without a walking aid (even if does walk with a nurse assist), or is on bedrest and

does not get out of bed at all, score 0

3. If the patient uses crutches, a cane, walker, or wheelchair, score 15

4. If the patient ambulates clutching onto furniture for support, score 30

IVF Infusion/Narcotics/Diuretics: 1. If no infusing IV, no narcotics, no diuretics, score NO = 0 points

2. If patient has an infusing IV or is taking any narcotics or diuretics, by any route, score YES = 20

points

Gait/Transferring: 1. Normal gait = walking with head erect, arms swinging freely at the side, striding without hesitation,

score 0

2. Bedrest/immobile = patient does not ever get out of bed and walk at all (by MD order or unable),

score 0

3. Weak gait = May be stooped in walking, but able to lift the head and walk without losing balance,

steps are short and may be shuffling, score 10

4. Impaired = May have difficulty getting out of a chair, head down, watches the ground, poor

balance, cannot walk without assistance or a walking aid, score 20

Mental Status:

This is based on patient’s self-assessment of their ability to walk. Ask the patient, “Are you able to walk to the bathroom alone, or do you need help?”

1. If the patient’s reply judging their ability is consistent with their true ability and the MD activity

orders, the patient is scored 0 (oriented to own ability.)

2. If the patient’s response is not consistent with their actual capability and MD orders for activity,

then they are judged to be overestimating their abilities or forgetful of limitations = 15 points

19

7/25/19

Scanning Percentages: What’s the Big Deal?

Evergreen has a lot of systems in place to minimize the risk of medication errors, which can be

devastating for patients.

Beyond our “5+ rights” of medication administration, we have computer order entry (to minimize

transcription errors – remember trying to read handwriting in years past?), guardrails in our IV pumps to

catch dosages outside the expected range, pharmacy review of all new drug orders, a medication error

committee that reviews all med errors that cause harm to a patient, and bar code scanners to be the

final double check of “right patient” and “right medication.”

Organizations that rate the quality of health care facilities (like Leapfrog, Center for Medicare/Medicaid

Services (CMS) and The Joint Commission (TJC) look at what safety systems hospitals have in place as an

indicator of quality care – which they report back out to the public. Bar code scanning of patient and

medication at least 95% of the time is one of the metrics they follow.

Organization bar code scanning of both patients and their medications must be maintained above 95%.

Because of this please make sure of the following:

Scanners are programed for the one PC they are connected to. They cannot be taken room to room

The scanners must be charged to work please make sure to keep them in the charging dock

Please scan your patient every time, if their arm band does not scan have an new one printed

Please do not override medications unless it is a true emergency,

If you have a medication that is not scanning make sure to notify pharmacy and your manager

If there is a problem with your scanner please make sure to call the help desk, they know that these issues should take a priority (ask your CN, HUC, or Manager to help you with this if you are too busy)

Please remember that while we need to be diligent with this scanning please read and complete your 5 rights of medication administration!

o Right drug o Right dose o Right time o Right person o Right route

Although scanning won’t protect against every error, it is just one of the systems our policy

states we will follow. If there are barriers to scanning, please bring them forward so the

process can be improved to assure the highest level of safety for patients and staff.

DID YOU KNOW??? If your keyboard has “caps lock” activated, your med scanner won’t

recognize your patient’s armband barcode? If your scanner fails to read the armband, check to

make sure caps lock is off!

20

SILVER

EMERGENCY CODES & STAFF RESPONSE

HOW TO CALL A CODE Dial x1199 (Inside Hospital) Dial 9-911 (Outside Hospital)

State the Code, Location, Color Zone and Name

CODE BLUE

ADULT

NEONATES

PEDIATRIC

Arrest or Medical Emergency

An adult, child, or infant’s heart has stopped or they are

not breathing.

• Initiate Basic Life Support.

• Hospital: Dial x1199 or press Code button

CODE BLUE Adult arrest or medical emergency

CODE BLUE NEO Neonates arrest or medical emergency

CODE BLUE PALS Pediatric arrest or medical

emergency

CODE RED

Fire or Smoke In Case of Fire Perform R.A.C.E:

R-Rescue anyone in immediate danger

A-Activate alarm and call x1199

C-Contain fire and smoke by closing doors

E-Extinguish the fire if possible

Emergency Number: Hospital Dial x1199

Emergency Number: Other Dial 9-911

To Utilize a Fire Extinguisher (P.A.S.S.)

P-Pull the pin twist as you remove it

A-Aim at the base of the fire

S-Squeeze the handle

S-Sweep from side to side

CODE GRAY

Combative or Out of Control Person In the event a person is combative or exhibit out of

control behavior, Dial x1199 and report a Code Gray

with the following information.

Early Identification (Prior to Code Gray)

A person’s aggressive behavior is escalating Dial x1199 and

requests Security STAT. Security staff will initiate a response and

make an effort to de-escalate the situation prior to reaching a

Code Gray status.

CODE Weapon or Hostage Situation

Code Silver Weapon

At risk or confronted by a person with a weapon

Code Silver Hostage situation

To activate the Code Silver Dial x1199

Security and Emergency personnel will respond.

CODE BLACK

(Internal Triage)

Bomb Threat / Suspicious Package

To report a bomb threat or suspicious package Dial

x1199 and request Security to respond “STAT”

providing the following information:

1. Your location and/or the location of the incident

(Your name, floor #, wing color & location).

2. Wait for Security to respond to your location after

Security arrives; provide the officer with the

situational information.

CODE INTERNAL

/ EXTERNAL

TRIAGE

External Event

An event that impacts services

To activate the Event Alert Team Dial x1199

EVENT ALERT, level 1,2,or3

Level 1 = Full Activation, response by all 1-2 staff person to

the Labor Pool.

Level 2 = Partial Activation, 1-2 staff person to

the Labor Pool when requested.

Level 3 = Alert/Standby – Await further instructions from

Management

CODE

ORANGE Hazardous Materials Spill A significant hazardous material spill, release or odor

CODE AMBER ALERT

Infant/Child Missing

An infant or child is missing or abducted.

• If Infant – Code Amber Alert

• If Child – Code Amber Alert + age of child

CODE

ONE Non-Life Threatening Event Response required by clinical and security staff for a non- life threatening event. (example: Slip,Trip, Fall)

RAPID RESPONSE

TEAM Medical Team Required A patient’s medical condition is declining and needs an

emergency medical team at the bedside.

(Prior to heart or respiration stopping)

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Art of Caring

Warm welcome • establishing initial rapport • identifying the reason(s) for the visit • orienting to call light / room

Gathering information • exploration of problems • understanding the patient’s perspective • providing structure to the visit

Building the relationship • developing rapport • involving the patient

Explanation and planning • providing the correct amount and type of information • aiding accurate recall and understanding • achieving a shared understanding that incorporates the patient’s perspective

and shared decision making

Fond Farewell ‐ Closing the session 22

S

B

A

R

SBAR

SBAR is a communication method used to frame any conversation to be used whenever crucial information is transferred between staff, services

or patients and families.

SBAR is the communication standard at EvergreenHealth.

Situation A concise statement of the problem

What is the headline?

Background Pertinent and brief information related to the situation What has happened?

Assessment Analysis of the problem What is going on?

Reco mmendation Requested action, order or change What is needed?

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Methods for Expressing Your Concerns

Patient and Client

Bill of Rights

Patients, clients, families and visitors

are encouraged to express complaints

or concerns about any aspect of their

care or experience with EvergreenHealth

Medical Center. Concerns or complaints may be directed to any

Evergreen staff member or to: Patient Relations

EvergreenHealth Medical Center

12040 NE 128th St., MS #8

Kirkland, WA 98034

Telephone: 425.899.2267 Please be assured that expressing a complaint or

a concern will not compromise your care. We will

promptly investigate all complaints and grievances

and work to resolve them in a timely, reasonable

and consistent manner.

You may also lodge a grievance directly with the

Washington State Department of Health and/or

The Joint Commission.

Department of Health

Health Systems Quality Assurance –

Complaint Intake

1.800.633.6828 (complaints only)

Calls are received from 8 a.m. to 5 p.m.,

Monday through Friday.

Department of Health

P.O. Box 47857

Olympia, WA 98504-7857

[email protected] The Joint Commission

1.800.994.6610

[email protected]

12040 NE 128th Street

Kirkland, WA 98034

www.evergreenhealth.com

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At EvergreenHealth Medical Center,

every effort is made to provide you with the

best possible health care. While we are known

for providing advanced medical solutions, it is

our belief that the power to heal comes from

many places. That knowledge is still the most

powerful tool — yours and ours. That’s why we

have adopted these Patient and Client Rights

and Responsibilities to help guide our actions.

The statement of rights and responsibilities is

for those who receive services from Evergreen.

In addition to these rights, we make every effort

to protect your privacy and the privacy of your

health information. For more information about

Evergreen’s privacy practices and your rights

regarding privacy, please read our Notice of

Privacy Practices. If you have questions about

Evergreen’s privacy practices, please contact

our privacy officer at 425.899.5599.

Patient and Client Rights As a patient or client, you have the right to: • Be notified of your rights and exercise your

rights in regard to your care.

• Receive safe, private, high-quality and

respectful care.

• Be provided impartial access to care.

• Receive medical services in a life-threatening

emergency.

• Have a family member or representative of your

choice and your physician notified promptly of

your admission to the hospital.

• Receive visitors designated by you or your support

person; these include, but are not limited to, a

spouse, domestic partner, other family member

or friend. You have the right to withdraw or

deny your consent at any time. Evergreen will

not restrict, limit or deny visitation on the basis

of race, color, national origin, religion, sex,

gender identity, sexual orientation or disability.

Visitors are restricted from most treatment and

procedure areas and may be limited based on

your medical condition.

• Have your comfort needs addressed through

appropriate pain assessment and management.

• Be informed of aspects of your condition to

help you make informed decisions regarding

your care.

• Request medically necessary and appropriate

services or refuse treatment or services to the

extent permitted by law, and be informed of the

potential consequences of such an action.

• Receive detailed information, in terms you

can understand, about your care, your illness,

your treatment or other services that you

may be receiving.

• Know the name of your physician and others

who care for you.

• Effective written and verbal communication that is

appropriate to your age, understanding and language.

• Actively participate in decisions involving your care,

including the consideration of ethical issues, and be

informed in advance of any change in your plan of care.

• Receive care from personnel who are properly trained

to perform assigned tasks and to coordinate services.

• Courteous and respectful treatment of person and

property, privacy, and freedom from abuse and

discrimination.

• Receive spiritual care, if desired.

• Confidential management of your patient records

and information.

• Access information in your own patient record within

a reasonable amount of time following your request.

• Be informed of the process for submitting and

addressing any complaints to the hospital facility

or a state agency.

• Receive an explanation of your bill and our policy con-

cerning billing and payment for services, and the right

to inquire about the possibility of financial assistance.

• Seek a second opinion or choose another caregiver.

• Freedom from the use of seclusion or restraint in of any

form unless medically necessary for your well-being.

• Receive adequate information to help you make an

informed decision whether to participate or refuse

to participate in experimental treatment or research.

• Be informed that refusing to participate in research

will not compromise your access to care, treatment

and services.

• Sign an advance directive such as a living will or

durable power of attorney for health care and have

hospital staff and your providers comply with your

directives to the extent permitted by hospital policy

and state and federal laws.

• Be informed of the reasons for impending discharge,

transfer to another facility and/or level of care,

ongoing care requirements, and other available

services and options as appropriate.

• If you are a Medicare patient, you have the right to

receive a notice of your discharge rights as well as a

notice of your non-coverage rights, and to be notified

of your right to appeal premature discharge.

Patient and Client Responsibilities As a patient or client, you have the responsibility to: • Participate in decisions involving your care.

• Provide a complete and accurate medical history

to the best of your knowledge, and to provide

information about current medications or

treatments.

• Ask questions and seek clarification of your

diagnosis, course of treatment or care plan.

• Provide information about complications or health

symptoms.

• Follow the proposed course of treatment or care,

recommendations and advice upon which you and

your provider have agreed.

• Be considerate of the rights of other patients and

clients, and care personnel, and to be respectful

of property.

• Provide accurate and timely information about

sources of payment and your ability to meet

financial obligations.

• Make it known whether you understand what is

expected of you, and whether you are able and

willing to comply.

Parents and guardians may represent or assist a patient

or client in fulfilling these rights and responsibilities. 25

Last updated: 8/13/2020

EvergreenHealth Policies for Incoming Students

Prior to starting your student placement, review each policy as it pertains to your role at

EvergreenHealth. Your signature on the Code of Conduct and Student Attestation form will

attest to the fact that you have read and reviewed each policy prior to your start date. To

access the policy, please click on the link below each policy title.

Code of Conduct Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:10054

Exposure to Blood and Body Fluid Management Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:12201

Immunity/Vaccination and Tuberculosis Screening Requirements Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:20412.

Transmission based Isolation Precautions Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:15955.

Specimen Labeling Flow Chart Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:29818

Work Restriction Policy Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:12203.

Dress Code Policy Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:29548

Extended Universal Masking for Covid-19 Epidemic

Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:38901

Cell Phones Usage and Requirements Policy Policy Location: https://www.lucidoc.com/cgi/doc-gw.pl?ref=everg5:15833.

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