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STUDENT ORIENTATION
HANDBOOK
May 2016
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Table of Contents Page
General Hospital Orientation information………………………………………………………………………….…..3
Hospital Identification, Parking, Lockers………………………………………………………………....................3, 4
Room Bookings……………………….……………………………………………………………………………………………4
IT Access, Confidentiality Agreement, Electronic Documentation…………………………….……………….5
Electronic Medication Administration Record (eMAR/BMV)……………………………….…………………….6
Automatic Dispensing Unit for medications………………………………………………………………….…………6
Scope of Practice for Students………………………………………………………………………………………….….. 6
Medication Cart……………………………………………………………………………………………………………..….... 7
Health and Safety Training…………………………………………………………………………………….…………….. 8
Required Learning Modules/Information for Students…………………………........................................ 8
Accessibility------------------------------------------------------------------------------------------------------------------------------- 8
Asbestos Awareness----------------------------------------------------------------------------------------------------------------- 8
Compressed Gas---------------------------------------------------------------------------------------------------------------------- 9
Electrical Appliances----------------------------------------------------------------------------------------------------------------- 9
Electrical Cords-------------------------------------------------------------------------------------------------------------------------10
Emergency Codes
Emergency Surge Response Plan
Expect Respect
Food, Beverages, Cosmetics
Footwear
Hand Hygiene
Mask Fit Testing
Musculoskeletal Disorder Prevention-Safe Patient Handling
Occupational Health and Safety Handbook
Privacy and Security of Personal Health Information
Safer Engineered Medical Sharps
Smoke-Free Environment
WHMIS
Reporting Health and Safety Concerns
Radiation Safety
Required Learning Module for Preceptors
Information Security Acknowledgement Form………………………………………………………………………..19,20
Confidentiality Agreement Form………………………………………………………………………………………………21
Application of Observational Experience in Operating Room……………………………………………………..22
Acknowledgement of Health and Safety Training for Students………………………………………………….23
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Purpose of this Handbook This resource document is designed to provide orientation and Information Technology, computer (IT) access
support for faculty instructors and students anticipating a clinical placement at Markham Stouffville Hospital (MSH).
We have included important resources and contacts available to support the transition into our facility.
The Professional Practice department organizes and supports student placements at MSH. It is located on the 3rd
floor of Building B room B3516E.
Student placement email:
Faculty Instructors and Preceptors – all forms at the end of this handbook may also be found at the reception desk
in Professional Practice (room B3516E).
Faculty Instructors- please contact the unit Facilitating Nurse or Patient Care Manager to determine unit-specific
orientation needs.
Students – in addition to the information contained in this document, please contact the school to find out details
related to your clinical placement and orientation.
Orientation Faculty Instructors– There is a Faculty Instructor Orientation Day booked at the beginning of each semester. The
first part of the orientation day is mandatory for all new and returning instructors to the hospital. Content covered
will include details about many aspects of transitioning faculty and students to their placements at MSH. Date, time
and location of the orientation day is posted on HSPnet and also sent to the school student coordinators ahead of
the start of the semester.
Faculty Instructor-Led Student Groups – Nursing students at MSH in instructor-led groups are oriented by their
instructors. Orientation will also include sessions led by MSH staff and online learning modules as described below.
Precepted Students – There are Student Orientation Days booked at the beginning of each semester for MSH-
precepted students during their clinical placement. Date, time and location of the orientation day is posted on
HSPnet and also sent to the school student coordinators and hospital preceptors ahead of the start of the semester.
Obtaining Hospital Identification, Parking and Lockers Precepted students will obtain their hospital ID Card, parking and lockers either at the Student Orientation Day OR
on their first day of clinical placement with their preceptors.
Students in a faculty instructor-led group will obtain their ID card with their instructors on their first day of clinical.
Obtaining a Hospital ID Card Students and faculty instructors are required to wear both a school identification badge and a Markham Stouffville
Hospital identification card at all times while in the hospital. The school badge must clearly identify their student
status, and include at least their first name and the name of the school.
To obtain a hospital ID card, complete a Student ID Badge Deposit Form (located at the cashier’s office A1754
or at the reception desk in Professional Practice) and present this form to the cashier with $20.00 cash deposit.
Take the carbon copy of the completed form to the Parking Office located in the north visitor parking lot to obtain
the hospital ID card. Once activated, the card allows you access to locker rooms, appropriate unit/departments
and after-hour door entrances.
At the end of clinical placement, return the ID badge AND the carbon copy receipt to the cashier’s office, at
which time your $20.00 deposit will be returned.
Please note that if the ID badge is not returned within 10 business days of your placement completion, the
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deposit will not be refunded.
If you are a returning student or faculty instructor for another semester, a new card will be issued for each
semester using the same process each time.
Student Parking Markham Site: Students may purchase parking at MSH at the staff rate. To activate the Hospital ID card for parking privileges,
check the appropriate box on the Student ID Card Deposit form. Alternatively you may choose to pay the daily rate
and park in the visitors’ parking lot. Payment will be remitted to the Cashier’s office (Room A1754, Building A) at the
current staff rate on the first day of clinical and at this time students may purchase as many days of parking as
required. The Cashier’s office accepts cash, debit or credit card payment.
On the last day of clinical placement, return the hospital ID card AND the carbon copy of the receipt to the cashier’s
office –$20.00 will be returned at that time.
There is free street parking in the neighboring streets around the hospital, but those streets closest to the hospital
have parking restrictions posted. Also, please do not park in the parking garage associated with the Cornell
Community Centre as you may be subject to a fine.
Uxbridge Site: Students and faculty instructors assigned to the Uxbridge site may park free of charge. The required parking pass is
available at the Uxbridge site from the Manager, Support Services and is to be hung from the rearview mirror for the
duration of your clinical placement. Please return the parking pass to the Manager, Support Services on your final
day of clinical placement.
Lockers We make every effort to assign lockers for students during their placement. Locker assignments are coordinated
through Facilities and Support Services. You may be asked to share lockers due to locker availability. Instructors will
receive their own lockers. Please leave locks on empty lockers at the end of the clinical placement.
Faculty Instructors - please email a list of students and faculty names, as well as gender, to
[email protected]. Locker assignments will be emailed back to the faculty instructor for distribution to
your students. Faculty instructors are asked to send locker requests at least two weeks prior to the start date in
order to receive locker assignments by the date that they are required.
Precepted students - locker assignments will be handed out on the scheduled hospital orientation day or as
arranged through your preceptor. Students may use the locker rooms on the various units as arranged with your
preceptor.
Room Bookings When faculty instructors have received their Meditech username and passwords, they can book a meeting room or
computer training room online via the hospital intranet as follows:
Go to the hospital intranet
Click on “Meeting Room” icon at the bottom of the page
Enter your Meditech username and password
Click on the small calendar icon at the top of the page to find the desired date
Scroll across the page to identify rooms available for booking. Computer training rooms are identified as
such in the booking calendar
On the Add/Edit booking screen, you are required to enter the following information:
Booking Title - the topic of your education session and your name
The start and end date and times of your booking
Your email
The phone extension of the Administrative Assistant in Professional Practice - 7006
Save the changes
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To change or edit any room booking, open the program and click on the booking.
Preceptors are welcome to book and use any of the hospital meeting rooms for student teaching purposes
using the same booking site and process.
Please Note: To have any of the meeting rooms unlocked for you, please dial “0” for Communications and ask to be
connected to Security. Request that Security open the meeting room for you – they will come as soon as they are
free and open the room.
Obtaining IT Access at MSH Requests for IT access for nursing students is obtained by Professional Practice via our electronic database.
Requests for IT access for non-nursing students must be directed to Professional Practice.
Once the placement is confirmed and IT access is approved, it takes approximately one week for IT to provide a
username and password for our electronic documentation system. The IT access information will be given to
precepted students by Professional Practice; instructors will be provided with a list of passwords for their students
prior to the beginning of the placement.
Upon receiving an IT generated password, all students and faculty instructors must enroll in the Password Reset
program. Go to the intranet and do the following:
Click on Password Reset (at the bottom of the intranet page)
Click on “Enroll”
Answer the minimum number of security questions
Click on “Change Password”
Confidentiality Agreements All students are required to sign the following confidentiality agreements prior to beginning their clinical placement:
IT Security Acknowledgement (Page 18, 19 of this booklet) - ONLY if the student is issued network and
Meditech username and password
Confidentiality Agreement (Page 20)
Forms are included at the end of this document and are also available at the reception desk of
Professional Practice; signed forms should be returned to the same location.
Observational Opportunities Professional Practice will arrange all observational or alternative placement experiences that fall outside the
negotiated school placement. Students requesting an observation experience in the Operating Room must
complete the “Application for Observational Experience in the Operating Room” form (included in this document
(page 17) and also at the reception desk in Professional Practice). Priority will be given to students who are
currently placed on a surgical unit and who are in the consolidation phase of their education. These applications are
due within 2 weeks after the start of the clinical placement.
Electronic Documentation Meditech Documentation For a first clinical placement at the hospital, all students and faculty instructors must attend an electronic
documentation training session. Faculty instructors are responsible for training their groups of nursing students.
The hospital will provide training rooms, access to Meditech test environment and lesson plans. Training dates will
be scheduled and communicated via HSPnet and to the school student coordinators prior to the start of the
semester. Schools are responsible for communicating training dates and locations to the students. With the
exception of students at Ryerson University, schools should schedule their precepted students into one of the faculty
instructor-led electronic documentation training sessions.
Exception: Training for specialized modules for the Emergency Department and Operating Room will be scheduled
and provided by MSH Professional Practice.
Electronic Medication Administration Record (eMAR/BMV) Markham Stouffville Hospital utilizes an electronic medication administration record and bedside barcode
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technology for medication administration. For a first clinical placement at the hospital, all nursing,
respiratory and midwife students must complete the eMAR/BMV training tutorial. This can be found on
the hospital Intranet as follows:
Click on Meditech & IT
Click on EMAR/BMV (on left side)
Click on Tutorial video
Faculty instructors will be given additional training and support for eMAR as needed.
Automated Dispensing Unit (ADU) Precepted nursing students, midwife and RRT students have access to the ADU. MSH staff will provide ADU training.
Training dates will be scheduled and schools are responsible for communicating training dates and locations to the
students.
Instructor-led students do not have access to the ADU. However, they do have full access to the medication rooms
and mobile med carts for medications stored in those areas. Faculty instructors will access the ADU as required for
their students.
Faculty instructors who are new to the hospital must attend an ADU orientation session.
Scope of Practice for Students All students are expected to know the limits of their knowledge, skills, abilities, and authority, and to seek
supervision and guidance from their preceptor or faculty instructor as appropriate. In most cases, students should
only perform procedures for which they have had at least theoretical education.
Nursing students may perform controlled acts authorized to nursing with appropriate supervision and guidance from
their preceptor. The following activities are outside the scope of practice for nursing students at MSH:
Implementing medical directives
Accepting delegation of a controlled act not authorized to nursing
Checking and hanging blood or blood products (students may regulate IV transfusion rates, and monitor
patients receiving blood or blood products)
Independently caring for patients receiving epidural (students may participate in caring for these patients
under the supervision of their preceptor)
Being left “in charge” on a unit (students may work with the Facilitating Nurse to develop understanding of
the role, and of the complexities of coordinating the care provided at the unit level)
Performing point of care glucose testing (restricted due to process for quality control maintenance and
workload)
Accepting verbal or telephone orders from physicians
Completing independent double checking of high risk medications (must be completed by two registered
staff members or one staff member and the faculty instructor – the student may be the 3rd checker in this
interaction)
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Health and Safety Training Markham Stouffville Hospital is committed to preventing occupational illness and injury in the workplace and
establishing a safe and healthy workplace environment for all, as per the Occupational Health and Safety Act
(OHSA). Under the Occupational Health and Safety Act, the hospital has the responsibility to provide health and
safety training for all persons who work in the hospital.
The Ministry of Labour mandates that students working in a healthcare facility must comply with the facility’s
workplace health and safety policies, procedures and measures.
This package provides the basic health and safety training for students at the hospital. Each section provides details
of where students can obtain further information.
Internal Hospital Resources
The hospital Intranet links to a wide variety of clinical and non-clinical resources. You are encouraged to visit the
Student Placement page under “Professional Practice”. The “Home” page of every computer screen in the hospital
defaults to the Intranet and there are also computers that access the Intranet at the Cornell Community Centre &
Library in the Markham Stouffville Hospital section of the library on the 2nd floor. The hallway link between the
hospital and the Community Centre is on the 2nd floor of the hospital.
Online Learning Modules
The hospital has an online learning management system called LiMe that facilitates completion of many online
learning modules. LiMe may be accessed both at the hospital on the Intranet and also from home. Once you receive
your network username and password, you can access the LiMe learning modules from home by following the steps
below:
Go to the hospital website at www.msh.on.ca
Click on the tab “Staff & Physician Portal” on the top right of the screen
Click on the tab “Learn.msh.ca”
Sign in using username and password
Click on the “Course Registration” tab on the left side of the screen to either search for a course or to view
all of the currently offered courses listed there
Enroll for a course using the “Enroll” button on the right side of the screen
Click on “Learning Home” tab on the left side of the screen to see all courses you have registered for and to
begin completing the courses.
Required Learning Modules for Students at MSH For those modules indicated below, complete the training on LiMe; for others read the information provided below
and note the listed resources for obtaining further information.
Upon completion of this section of the handbook and the required LiMe modules, you are required to sign the
“Acknowledgement of Health & Safety Training for Students” and “Statement of Commitment” document (Page 21
of this booklet) and return to Professional Practice.
1. Accessibility – LiMe module
2. Asbestos Awareness For years asbestos was known as the material of 1000 uses. It was used for many industrial applications such pipe
and wall insulation, fireproofing and soundproofing. In recent years, asbestos has been found to cause chronic,
often fatal lung diseases. To help protect us, asbestos is regulated under the Occupational Health and Safety Act of
Ontario. This regulation is referred to as the Regulation respecting Asbestos on Construction Projects and in
Buildings and Repair Operations (O. Reg. 278/05). The mere presence of asbestos in a building does NOT
constitute a hazard or unacceptable risk of health. Asbestos fibers become a concern when they become airborne
as a result of a disturbance or deterioration. Our policy establishes a prevention program which outlines precautions,
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practices and procedures to prevent the exposure of individuals to airborne asbestos fibers and abatement/
removal procedures.
General Precautions:
Be aware of materials in your workplace that may contain asbestos. Consult the Master Asbestos Location
List in Plant Maintenance and Biomedical Service (Markham) and Support Services (Uxbridge)
Do not damage or remove asbestos-containing materials.
Promptly report damaged asbestos-containing materials (e.g. pipe insulation) to the Manager/Director of the
department to have it properly inspected and repaired.
Do not sweep, dust or vacuum debris that may contain asbestos. This must only be carried out by properly
trained staff.
Leave the area if the amount of damage is significant. Restrict access to others.
Do not enter ceiling space in which there is sprayed fireproofing unless you have been specifically trained to
do so.
Where asbestos is known to exist:
Markham site: On gaskets in the Mechanical rooms in Building A
Uxbridge site: flooring in Health Records Department
For more Information:
o An Asbestos Education Brochure is available. To obtain the brochure, please contact Safety Advisor,
Occupational Health and Safety Department, ext. 6231.
Policy 080.901.005: Asbestos Management: Administration Manual: Health and Safety
3. Compressed Gas Under the Occupational Health and Safety Act, a storage cylinder for compressed gas shall be secured in position
during transportation, storage or use. It is important that compressed gas, whether empty or full be in a secured
upright position to prevent the risk of injury from vessels bursting, falling, causing a trip hazard, creating leaks in
equipment or hoses and possibly producing runaway reactions. Please remember to:
Always handle compressed gases with extreme caution
Never tamper with safety devices in cylinders, valves or equipment
Only competent authorized workers are to handle compressed gas cylinders
Check the label, not the cylinder colour, to identify the gas and know the hazards associated with the
cylinder prior to use
Carefully check all cylinders to equipment connections prior to use and periodically during use, to be sure
they are compatible, tight, clean, in good condition and not leaking
Securely fasten (e.g. gas cylinder rack/holder, chained) and store all compressed gas cylinders in an upright
position to prevent them from falling over or becoming a trip hazard
After using a compressed gas cylinder, ensure the valve has been closed.
Upon discovery of a compressed gas leak from a cylinder, hose, valve or other connection, discontinue use
until the leak is rectified. Under NO circumstances, is a leaking compressed gas cylinder to be used!
When not in use, the valves on the cylinders must be covered with their appropriate caps.
For more Information:
o Policy 080.901.155 Compressed Gas: Safe Use and Storage, Administration Manual: Health and Safety
4. Electrical Appliances All medical and non-medical equipment coming into the hospital both new and repaired whether purchased by the
hospital, or on loan, under evaluation or staff/ personally owned will meet the CSA Z32.2-M89 “Electrical safety in
Patient Care Areas; CSA C22.1 Canadian Electrical Code and CSA C22.2 “Electrical Medical Equipment” standards
and be subject to an electrical safety inspection by Plant Maintenance/Support Services. Three to two wire adaptors
(cheater plugs) and extension cords are prohibited from use on all equipment. Temporary emergency extension
cords must be supplied or inspected by the Plant Maintenance/Support Services and never to be smaller than 16
gauge. Excessively long line emergency extension cords are to be avoided. Coffee makers and kettles must be used
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We need
help!
in a location approved for use as per the Fire Code and Building Code. Standardized Kettles and Coffee makers
must shut off automatically. The use of portable heating devices, such as open electric heaters/ceramic heaters are
prohibited anywhere in the facility.
For more information
o 080.901.150 Electrical Appliances/Equipment Inspection, Labeling, Usage and Safety
5. Electrical Cords The hospital requires that all electrical cords are secured to prevent the cords from creating a trip hazard. Students
have the responsibility to:
Inspect work area on a daily basis to ensure that it is safe and that cords are neatly secured and do not pose
a tripping hazard
Adhere to the recommended housekeeping practices & other safe work practices to prevent trip-related
incidents.
Be aware of work environment surroundings and what temporary hazards that may be created during the
course of daily duties
Position equipment to avoid cables crossing pedestrian routes; use cable covers securely fix to surfaces, or
consider use of cordless tools
Notify your supervisor, at the Markham site, to submit an IMaint report and at the Uxbridge site to submit a
Meditech requisition for any cords creating a trip hazard
Report to your supervisor any health and safety concerns related to electrical cords
For any employee incidents related to trip hazards by electrical cords, contact your supervisor to complete an
online IReport and follow the hospital policy Reporting and Investigation of Employee Accidents and
Incidents (Policy # 080.901.030; Health & Safety, Administrative Manual)
Not tamper with any secured electrical cords
6. Emergency Codes Emergency Codes are in place to protect personnel, patients, visitors and property of the hospital during an
emergency situation. Codes are initiated by
Markham site: Dialing 555
Uxbridge site: Dialing 58 and announcing code over Public Address System
All codes are announced over the Public Address System and are in effect until an “All Clear”, “End” or “Cancel”
announcement is made
For more Information on any of the codes:
o Access your Emergency and Disaster Manual, available in each department
o The hospital has developed A Colour of an Emergency Orientation booklet that has information on
our Emergency Code policies. This is available by contacting the hospital’s Safety Advisor at ext. 6231.
Code 111
Code 111 is announced when there is a request for immediate short-term assistance for a
critical situation anywhere in the hospital and additional staff is required for a short period of
time. Code 111 can be activated independently or in conjunction with other Emergency Codes (for example,
a Code 111 may be needed to assist in a Code Green).
Code Black
Code Black is the coordinated hospital-wide search for a bomb with provisions to ensure staff, patient and
public safety. Threats MUST be taken seriously. Code Black is in place to provide information and an
organized plan of action to ensure the safety of staff, medical/dental/midwifery staff, patients, the public
and the hospital in the event of a bomb threat. All bomb threats will be considered genuine until proven
otherwise. Any employee and students can initiate a Code Black. A bomb threat can come in the form of a telephone
call, written note, e-mail or suspicious package. Staff will conduct a search of their departments. All staff and
students should remain in the hospital until the “All Clear” is announced.
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Code Blue
A Code Blue is called when an adult collapses and does not respond to stimuli such as calling out the
person’s name. A Code Blue can be initiated by pressing the Code Blue button in the patient’s room, if
available or call 555 (Markham site); 58 (Uxbridge site). When you call a Code Blue, a team arrives to take over
using advanced life support techniques. Every second counts for the victim of an respiratory or cardiac arrest. The
sooner resuscitation is started, the better the outcome.
Code Brown
Code Brown is the procedure that allows staff to respond to an uncontrolled or unplanned release of a
potential hazardous material in any quantity, reducing any potential for adverse effects on human health
and the environment. Chemical specific spill kits are found in specific departments (e.g. formalin, chemotherapy
drugs). A general spill kit is found
Markham site: outside Receiving (Building A), or behind SPD (Building B).
Uxbridge site: main floor, under the stairwell by Materials Management
Please ensure you are aware of where the department spill kits are located. The hospital has specific staff trained in
spill response procedures.
IF YOU ARE PERSON DETECTING THE SPILL (BEYOND DEPARTMENT CAPABILITIES):
S – SAFELY evacuate area and SECURE the scene
P – PREVENT spread of vapours/gases/fumes – close doors
I – INFORM Telecommunications (Markham - Dial 555; Uxbridge - Dial 58 and announce, Uxbridge) – provide
details (location, size, source, chemicals involved and code level)
L – LEAVE all electrical equipment alone
L – LOCATE Material Safety Data Sheets (MSDS) and available spill kit
Code Green
Code Green is intended to facilitate the evacuation when a crisis poses a threat to safety. It refers to the
evacuation of a specific area or of the entire building. The CEO, a member of the Senior Management
team, or Fire/Police personnel on site can initiate a Code Green. A Code Green is announced over the
Public Address System and the second stage of the fire alarm system (120 strokes/min) and strobe lights will be
activated for 20 minutes. It is important that you know where you would evacuate to in event of a Code Green.
Code Green Classifications
Code Green: Hospital wide evacuation – no immediate danger
Code Green Stat: Hospital wide evacuation – immediate danger
Code Green (Area Specific): Area evacuation – no immediate danger
Code Green (Area Specific) Stat: Area evacuation – immediate danger
Code Grey
Code Grey is to alert the hospital of an unplanned interruption/loss of essential
service/infrastructure failure or an external air contamination entering the building. Its purpose
is to provide an immediate plan of action to ensure the safety of everyone within the building
and allow the hospital to continue its operations. Some examples of interruption/loss of essential services may
include but not limited to, electricity/power, medical gas, water, telecommunications, fire panel, air handling units,
mag-locks in Mental Health and elevator system. There are 3 stages to Code Grey and they are:
Code Grey – Stage 1 Infrastructure Failure
Unplanned interruption of essential services in a single department - Minor incident, managed within the
department with internal resources
Code Grey – Stage 2 Infrastructure Failure
Unplanned interruption of essential services in multiple departments - Major incident, managed within the hospital
site.
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Code Grey – Stage 3 Infrastructure Failure - Unplanned interruption of essential services hospital wide. Critical
Incident, usually impacting the community
Code Grey - Stage 3 External Air Exclusion - External air is contaminated with potentially dangerous emissions (i.e.
chemical, smoke from fire). Critical Incident, usually impacting the community
Code Orange
Code Orange is a plan to help mobilize the hospital's resources in the event of an external disaster.
The size of the disaster will determine the response at that point in time due to the number and
severity of casualties and based on the resources currently available in the hospital. Code Orange can be initiated by
Senior Management, Emergency Physician or the Emergency Facilitating Nurse. Staff and students are notified of a
Code Orange via the following methods:
On-Call Staff: Paged
On-Site Staff: Overhead page
Off-duty Staff: Called back through the use of the "Call and Go, Fan Out Procedure". Call and Go Fan-out is a
recall of multiple employees to the hospital for an unexpected emergency. Students are not a part of the fan
out.process.
Code Orange, CBRN
Code Orange – CBRN is intended to mobilize hospital resources in the event of a major external
Chemical Biological Radiological and Nuclear (CBRN) disaster that exceeds the hospital’s ability to
provide services due to the number and severity of the casualties requiring mass decontamination. It
is an expectation that all staff and students will respond to both a real and/or a Mock Code Orange – CBRN
according to the plan. Code Orange – CBRN is activated by the Emergency Facilitating Nurse or the Emergency
Physician and is authorized by the hospital Incident Manager (Executive On-call). A Code Orange – CBRN has 4
Stages, each of which can be activated independently or progressively depending on the needs of the situation.
Stage 1: Pre-alert and Preparation: Hospital is informed of an external disaster and alerted of potential involvement.
Stage 2: Decontamination: Hospital is involved and resources and abilities may be exceeded. (Activity typically
involves Emergency & Supplementary Staff.) Preparation for decontamination will take place at this time. Call back
of off-duty staff may be limited to Nursing, Medical and those required to meet the current needs.
Stage 3: Disaster: Hospital is involved and resources and abilities are exceeded. (The whole organization will be
mobilized). During day shift Monday to Friday, sufficient resources may exist within the hospital and may only require
activation of Code 111.
Stage 4: Debriefing, Evaluation and Assessment: At this stage, the emergency is ending and key staff is debriefed to
identify the effectiveness of the response and where improvements can be made.
Code Pink
Code Pink is intended to inform staff and students that a child between 0 months to 18 years of age is
having a cardiac or respiratory arrest. A cardiac arrest team including a paediatrician (Markham site) will
be responding to the code. A Broselow/Neonatal crash cart is also brought to the location.
Code Purple
Code Purple is when there is an incident of hostage-taking. A hostage-taking incident can occur when: any
person(s) is confined, imprisoned, forcibly seized or detained against their will by a person without the
authority to do so; the hostage taker(s) causes any person(s) to receive a threat of death or bodily harm or
induce any person or organization to commit an act or mission for releasing the hostage(s); or any
person(s) have confined or barricaded themselves in a room and threaten violence and/or have weapons. Code
Purple is a silent code and will not be announced over the Public Address System.
Code Red
The Code Red policy contains procedures used to respond to a fire emergency, while ensuring everyone’s
safety and minimizing the potential for injury or damage.
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Do you know what do if fire is in your area…..R.E.A.C.T.
Remove anyone in the room. Call out “Code Red, location” & close door
Ensure all doors are closed, activate evacucheck markers if no persons(s) is in the room
Activate the fire alarm (pull station)
Call (Markham - Dial 555; Uxbridge - Dial 58 & announce). Give exact location and nature of fire.
Try to extinguish the fire if safe to do so and you are trained
Refer to the hospital’s Code Red policy for department specific information.
Code White
Code White is intended to provide a timely, efficient and effective response when a person is behaving
aggressively and poses a threat to self, others or the hospital. The Code White Team serves as a
resource to departments to assist in de-escalation and, where necessary, control of violent, disruptive
behaviour. The Team uses Crisis Prevention Intervention Techniques, a safe, non-harmful behaviour management
system designed to help healthcare workers provide the best possible care of disruptive or out-of-control persons
even during their most aggressive moments.
Code Yellow
In the event a patient is deemed as missing, the Code Yellow search procedure will be initiated. A
patient’s level of risk will be assessed to assist in determining the appropriate stage of the Code Yellow search plan
to be implemented. The Patient Care Manager, Facilitating Nurse or delegate is responsible to initiate the Code if a
patient is discovered missing. This person assumes the role and responsibilities of the Incident Manager. All
students are expected to participate and follow the policy.
S – SEARCH own department/unit using your search maps. For a Code Yellow Amber SECURE designated exits.
Advise Security immediately if you are unable to secure an exit.
E – ENGAGE Evacucheck markers and close all doors after each room is searched.
A – Be on ALERT for missing patient in a Code Yellow. For a Code Yellow Amber be ALERT for suspicious persons (e.g.
Persons wearing bulky clothing, carrying bags, appearing pregnant). In a Code Yellow Amber, all bags are
searched at the secured exits.
R – RECORD on Search Map. For a Code Yellow Amber, REMAIN at exits until clearance.
C – CALL Incident Manager with results.
H– HAND over Search Map to Incident Manager at end of Code.
Code Yellow Amber
Code Yellow Amber is a hospital wide search for an infant or child (patient or visitor) who is missing. The
Incident Manager for Code Yellow Amber is the Patient Care Coordinator or the Facilitating Nurse in the
Care Area from which the child has gone missing. In non-patient situations, the Incident Manager may be
Security if this is most appropriate. Initiation of Code Yellow Amber presumes that reasonable preliminary
steps have already been taken to find the child. Code Yellow Amber search defines a method of securing the exits
and conducting a hospital-wide search to a) prevent the abduction of an infant or small child; and/or b) a child is
missing from an area where he/she is expected to be. This procedure is used when there is reason to believe that
the infant/child could be hidden from view and carried out of the hospital or the child has left without authorization.
Code Yellow Amber uses the same search procedures as a Code Yellow
There are two outcomes of a Code Yellow or a Code Yellow Amber:
1) ALL CLEAR when the patient or child is found; or
2) END when the patient or child is not found. The next shift must be informed that the code is still in effect and the
patient or child is still missing. Description must be retained for 48 hours.
The hospital has a Newborn Infant/Paediatric Security Program that integrates physical boundaries, surveillance
technology and reporting mechanisms to safeguard against infant abduction and patient wandering.
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As per the Newborn Security program, all newborn infants are restricted to the Childbirth and Children’s
Centre except for diagnostic tests or at time of discharge. At time of discharge, the parent(s) and significant
other will be given a green envelope labelled “Infant Discharge”. As a member of the hospital you should
approach the new mother described above, and explain the Newborn Infant Security policy. You should then
verify that she and the infant are wearing corresponding ID bands. If they match, redirect the mother back to
Building B, 4th floor and observe to see that she does return to the area. If the mother does not cooperate or
you feel the infant is in danger at anytime, contact Security immediately.
The Infant/Pediatric Security System is an electronic monitoring system that consists of a computer
program, door/elevator alarms, locked exterior doors and security tags. The infant’s/child’s whereabouts is
monitored in real-time and an alert is generated when an attempt is made to tamper with a security tag, an
infant/child is moved through an exit, or into an elevator without an authorized escort, when an infant/child
is lingering in the vicinity of an exit or when an infant/child tag is undetected.
Severe Weather:
The severe weather policy is in place to help the hospital prepare for severe weather by listing steps
which can be taken to protect the staff, volunteers, students, patients and visitors during these
unusual times. Examples of severe weather include tornadoes, severe thunderstorm, blizzard, high
winds, heavy snow, snow squall, heavy rain and significant freezing rain. During a severe weather
announcement staff should:
• Move everyone to inner hallway or room, away from windows, outside walls and doors if required and if
possible
• Close windows, curtains and blinds
• Close door, activate evacucheck if patient moved from room
• Not use elevators
• Use telephone only for emergencies only.
• Report building damages to Facilities/Support Services
• Be prepared for Code Green
7. Emergency Surge Response Plan The hospital has enhanced and expanded its Pandemic Plan so that it can be applied more broadly to different
emergency situations. The plan has been renamed the Emergency Surge Response Plan. The Emergency Surge
Response Plan provides guidance for decision making to best utilize scarce resources, both human and physical,
during a critical event. It is based on the assumption that there will be an increased demand for health services. As
demands for these services increase other less essential services will be assessed and deferred as appropriate.
Clinical and support services at both sites have developed plans to respond to the changes as required. The Plan is
based on the Incident Management System, an international emergency protocol that provides an operational
framework for emergency management. Our framework outlines a command structure which identifies leadership
roles and responsibilities, as well as clinical and support decision-making teams. In a critical event response
coordinated decision making and communication will be vital.
8. Expect Respect – LiMe module
9. Food, Beverages and Cosmetics The Occupational Health and Safety Act states:
No food, drink, tobacco or cosmetics shall be consumed, applied or kept in areas where infectious
materials, hazardous chemicals or hazardous drugs are used, handled or stored. O. Reg. 67/93, s.
32.
What does this all mean?
There are some clear areas in the hospital that staff are not permitted to consume food and drinks as per the
regulations.
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No beverages and food are permitted in/on housekeeping carts, supply carts, patient supply storage areas,
procedure rooms, the Lab, maintenance workshops.
No food to be consumed within the clinical area (i.e. at desks in patient care corridors, communication
desks) Food in sealed containers can be on the unit (for example chocolate bars being sold for funding) but
they cannot be opened and consumed in the area.
The regulations also impose the following restrictions on access to beverages:
Beverage containers with a lid (i.e. individual water bottles, coffee/ tea containers, etc.) can be on a unit
to be consumed provided this consumption/storage is away from:
direct patient care areas (i.e.) patient examination bays, adjacent corridor, procedure areas, and
treatment rooms
contaminated equipment/materials such as utility rooms, areas where specimens are stored.
Private/employee areas of the department (i.e. conference rooms, staff lounges, lunch room, classroom/meeting
room, private office areas) have no restrictions on container types for food or drink although we always recommend
lids on liquids to reduce spills.
For more Information:
o Policy 080.901.145: Staff Food, Beverage and Cosmetics: Administration Manual: Health and Safety
10. Footwear All students must wear footwear appropriate for the potential hazards present in their work environment
and in accordance to Sections 11(c) and (d) of the Health Care and Residential Facilities Regulation
67/93 of the Occupational Health and Safety Act. Supervisors are responsible for advising students of the
appropriate type of footwear they should be wearing while working in their units/departments. The
footwear appropriate for students must have the following characteristics:
o Well-fitting shoe in which the foot is securely placed
o Sole is made of non-slip material
o Heel is low to moderate (2-5 cm in height)
o Toe must be covered (sandals or other open-toed shoes are not allowed)
o Shoe should be enclosed and have no open slits
o In Laboratories, Food Services, SPD/Porters and for activities that involve significant walking, the heel must
also be covered and secure
o Shoe material must be durable and impermeable to protect from chemicals, hot liquids or sharps such as
needles
o Examples of appropriate footwear include running/walking shoes and flat street shoes. Individual
departments may specify additional requirements for footwear
Extremes in footwear (e.g. very high heels or high platform soles) or open (i.e. no protection to the foot such as flip-
flops) are not appropriate. Please remember that the parking lots are considered part of your work environment and
you must wear appropriate footwear walking to and from the parking lots.
For more Information:
o Policy 080.901.095:Footwear Policy: Administration Manual: Health and Safety
o Discuss with Manager/Director of your service
11. Hand Hygiene – LiMe module
12. Latex-Safe Environment Every reasonable effort will be made to create a latex safe environment to all persons at the hospital due to the
potential allergic reaction that may arise from exposure to latex. Students that develop or have potential latex
allergies during the employment at the hospital shall contact Occupational Health and Safety Department and
complete the online IReport. Any serious reactions go to Emergency immediately for medical attention. If known to
have a latex allergy, students will avoid any contact with latex balloons, and other identifiable latex products. Refer
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to Appendix A in Policy 140.914.914.005 Latex Avoidance Protocol (Interdisciplinary Manual, Diagnostic Specific
Protocol) for examples of hospital products that contain latex. It is important that you advise families or visitors that
latex products such as balloons are not permitted at the hospital and should be removed as soon as possible.
For more Information:
o Policy 080.901.047: Latex Safe Environment, Administration Manual: Health and Safety
13. Mask Fit Testing Engineering controls will be considered the primary means of controlling respiratory hazards.
Respiratory protective equipment will be used as a means of supplementing the protection
provided by engineering controls or when engineering controls are: not in existence or not
obtainable; not reasonable or practical due to frequency, duration or nature of the operation or
procedure; rendered ineffective due to a temporary breakdown; or ineffective to control in an emergency situation
such as a spill. The hospital cannot eliminate exposure to airborne contaminants. By providing appropriate Personal
Protective Equipment (PPE), the hospital is dedicated to controlling potential exposure, thereby minimizing the risk
of exposure.
Respirator selection varies widely for individual contaminant protection such as infection control, chemical, welding,
asbestos or painting operations. Airborne and droplet infectious agents require the use of a NIOSH approved N95
respirator mask and face shield. Respirators appropriate for chemical or physical hazards will be selected on the
basis of criteria listed in CSA standard Z94.4-11 and/or NIOSH publications. Fit testing is required for all tight-fitting
respirators, including those selected to protect students from hazards associated with infectious agents and
chemical exposure. Fit testing is required by law every 2 years. Under no circumstances shall a student wear a
respirator for which he/she has not been fit tested to.
Occupational Health and Safety Department is responsible for organizing fit testing. In order to be properly fit tested,
facial hair must be removed. Individuals who, for personal, health or cultural reasons choose not to remove facial
hair will be re-assigned, if possible, in the event that they are required to perform a task with air contaminant
exposure, provide care to a patient on airborne precautions or during an outbreak.
To book your mask fit testing, please contact the Occupational Health and Safety department: Markham - ext 6280;
Uxbridge - ext 5233.
For more Information:
o Policy 080.901.110: Respiratory Protection Program – Mask Fit Testing Administration Manual: Health and
Safety
14. Musculoskeletal Disorder Prevention – Safe Patient Handling – LiMe module
15. Occ Health and Safety Handbook – LiMe module
16. Privacy and Security of Personal Health Information – LiMe module
17. Safety Engineered Medical Sharps – LiMe module
18. Smoke-Free Environment The hospital is committed to providing a safe, healthy and vibrant environment for its employees,
medical/dental/midwifery staff, medical trainees, volunteers, students, patients, visitors and any person entering
the hospital’s properties. In order to create this environment, the hospital will lead in safety best practices by
providing a smoke- free hospital environment to ensure that those who work, receive care and/or visit the hospital
are not exposed to the health risks associated with second-hand smoke. The hospital does this by promoting and
enforcing an environment that prohibits smoking including holding of lit tobacco and e-cigarettes on hospital
property including all buildings, grounds and vehicles on the property. Students are to
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Comply with, support, promote and assist in enforcing the Smoke-Free Environment policy
Advise patients at the hospital of the smoke-free environment
Inform patients about available smoking cessation supports
Be good neighbours and refrain from using tobacco products on the property of nearby businesses and residences.
Not smoke in the vehicle when carpooling to attend educational events or work related functions paid for by the hospital
Approach any person who is observed smoking on hospital property and advise him/her that smoking is not permitted on hospital property. Contact Security if assistance is needed. During the day at Uxbridge site contact your manager or director.
Report non-compliance people as outlined in Smoke-free Environment policy
19. WHMIS (completion required due to MSH-specific content) – LiMe module
Reporting Health and Safety Concerns
Injuries/diseases requiring only first aid do not have to be reported to the WSIB but a record of the details should be
kept by the school in the event that a report is required in the future. Injuries/diseases requiring healthcare and/or
lost time incurred are reportable to WSIB
You must report your concern to preceptor. If needed, seek first aid or medical treatment immediately. During
normal business hours (Monday to Friday; 0800 to 1600 hours) you will be assessed in Occupational Health and
Safety. After normal business hours, you should be seen in the Emergency Department. A hospital IReport is to be
completed by you and your preceptor within 24 hours of incident.
Resources The following resources are available to you if you have any health and safety concerns:
Your preceptor
Occupational Health and Safety Department (Markham – ext. 6280; Uxbridge – ext. 5233)
Required Learning Module for Preceptors at MSH
The Ministry of Labour mandates that hospital preceptors working with students are in a supervisory position and as
a requirement of the Occupational Health & Safety Act, must complete the supervisor competency online education.
1. Supervisor Competency Training – LiMe module
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Application for Observational Experience in the Operating Room
Please complete this form and return to Professional Practice Leader, Perioperative, c/o Professional Practice
Department.
Student Name: ____________________________________________ Date:________________________
College/University: _________________________________________Program:____________________________
Current Clinical Area: _______________________________________
Date Range of Placement_______________
Clinical Instructor Name: ______________________________________________________
Clinical Instructor Email: _____________________________________________________
Dates Available:
________________________________________________________________________________
Times Available:
________________________________________________________________________________
(Note: Clinical Instructor must be in the hospital and available during the observational experience)
What procedure would you like to observe?
__________________________________________________________________________________________
Clinical Instructor: Why do you recommend this applicant for an observational experience?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________
Student, please attach a synopsis which includes the following:
Why do you want to observe this surgery?
What learning do you hope to gain from observing this surgery?
What research have you done to prepare yourself to observe this procedure? Please list sources and give
examples of your knowledge gained.
What questions will you ask during the entire observational experience? Be specific and provide examples.
How will you incorporate this experience into your practice?
How will you share this experience with your colleagues?
What are your future goals in the health care field?
All Clinical Instructors will be contacted regarding the status of the request. If the applicant is successful, a date
and time of the procedure will be provided. Additional instructions will be sent to the clinical instructor outlining
expectations for the observational experience.
Surgical Services Management Section
Approved: Y [ ] N [ ] Reason for decline:_____________________
Approved by: ______________________ Date: _________________________________
Date of Observation:__ ______________ OR# _____ Surgeon:_____ ___________
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ACKNOWLEDGEMENT OF HEALTH & SAFETY TRAINING FOR STUDENTS
Under the Occupational Health and Safety Act, Markham Stouffville Hospital Corporation has the responsibility to
provide health and safety training of all persons who work in the Hospital on an annual basis. I understand that as a
student with staff privileges in a health care facility, I must comply with the facility’s workplace health and safety
policies, procedures and measures.
I understand that employment to Markham Stouffville Hospital Corporation requires that I complete the health and
safety training that has been developed for short-term students.
This acknowledges that I have received, read and understood the Markham Stouffville Hospital Corporation’s Health
and Safety Training for short term student’s package. I also acknowledged that the hospital has met its
responsibility under the Occupational Health and Safety Act by providing this health and safety training and ensuring
I understand the training.
I am well aware of the resources available to me in the hospital if I have any health and safety concerns or require
further health and safety training.
Print Name______________________ Signature ______________________Date __________________________
STATEMENT OF COMMITMENT
I, ________________________________________, have been made aware of the policies that relate to workplace
violence prevention and the Expect Respect Program of the Markham Stouffville Hospital Corporation.
I am committed to creating and sustaining safe working environment.
Print Name______________________ Signature ______________________Date __________________________
The Hospital is committed to promoting, providing and maintaining a work
environment where respect and dignity are demonstrated at all times.
The Hospital supports each individual’s right to work in an atmosphere that is safe,
healthy, supportive, secure, and respectful. Markham Stouffville Hospital Corporation
has a zero tolerance for behaviour that is disrespectful or threatening.
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