Student Packet 2008 During the time you are completing this module, you may call 802-3382 for any questions. Also the Infection Control nurse is here.

Student Packet 2008

During the time you are completing this module, you may call 802-3382 for any questions. Also the Infection Control nurse is here Monday through Friday 8-4:30 at ext. 4969. During other times, the nursing supervisor is available for questions.

ABOVE ALL ELSE, WE ARE COMMITTED TO THE CARE AND IMPROVEMENT OF HUMAN LIFE. IN RECOGNITION OF THIS COMMITMENT, WE STRIVE TO DELIVER HIGH QUALITY, COST EFFECTIVE HEALTHCARE TO THE Communities WE SERVE.

A TRADITION OF CARINGWe believe the following value statements are essential and timeless: We recognize and affirm the unique and

intrinsic worth of each individual. We treat all those we serve with

compassion and kindness. We act with absolute honesty, integrity

and fairness in the way we conduct our business and the way we live our lives.

We trust our colleagues as valuable members or our healthcare team and pledge to treat one another with loyalty, respect, and dignity.

Care Values Redmond Regional Medical Center has a set of

organizational values that express to everyone who enters our facility what we stand for as a leading health care provider.

These values are: Customer …………………….... Always First Actions ….. Speak Louder Than Words Respect ……………...…. The Golden Rule Excellence ……………... Is Our Standard

These values are basic elements of our strategy to “exceed customer expectations” in providing service to our patients and other guests.

Ethics and Compliance Redmond and HCA have a comprehensive, values-based

Ethics and Compliance Program, which is a vital part of the way we conduct ourselves. Because the Program rests on our Mission and Values, it has easily become incorporated into our daily activities and supports our tradition of caring – for our patients, our communities, and our colleagues. We strive to deliver healthcare compassionately and to act with absolute integrity in the way we do our work and the way we live our lives. All work must be done in an ethical and legal manner. It is your responsibility and your obligation to follow the code of conduct and maintain the highest standards of ethics and compliance.

Ethics and Compliance If you have questions or encounter any situation which you

believe violates the provisions of the code of conduct or the corporate integrity agreement, you should immediately consult your supervisor, another member of the management team, the Human Resources Director (Patsy Adams ext 3023), the Ethics and Compliance Officer (Deborah Branton ext 3036), or the HCA Ethics Line (1-800-455-1996).

Each employee and volunteer is required to attend two hours of initial code of conduct training and a one hour annual refresher training session. Leaders and individuals in key jobs have additional annual education requirements.

Georgia False Claims Laws There is a federal False Claims Act, and there are also Georgia

laws that address fraud and abuse in the Georgia Medicaid program.

Any person or entity that knowingly submits a false or fraudulent claim for payment of funds is liable for significant penalties and fines.

The False Claims Act has a “qui tam” or “whistleblower” provision. This allows a private person with knowledge of a false claim to bring a civil action on behalf of the US Government. If the claim is successful, the whistleblower may be awarded a percentage of the funds recovered.

For additional information please see the Georgia False Claims Statutes Policy.

EMTALA The Emergency Medical Treatment and

Active Labor Act is commonly known as the Patient Anti-Dumping Statute.

This statute requires Medicare hospitals to provide emergency services to all patients, whether or not the patient can pay.

EMTALA When a patient comes to the emergency

department, the hospital must screen for a medical emergency.

If an emergency medical condition is found, the hospital must provide stabilizing treatment.

Patients with emergency medical conditions may not be transferred out of the hospital for economic reasons.

Medical Ethics: End of Life Care Palliative Care

The goal of palliative care is not to cure the patient. The goal is to provide comfort.

Understand the importance of addressing all of the patient’s comfort needs near the end of life. This includes psychosocial, spiritual, and physical needs.

Stay up-to-date on the legality and ethics of using high-dose opiates for physical pain.

Medical Ethics: End of Life Care End-of-Life Decisions

Patients have the right to refuse life-sustaining treatment.

Respect this right and this decision. Withdrawing Life-Sustaining Treatment

Withdrawing and withholding life-sustaining treatment are ethically and legally equivalent. Both are ethical and legal when the patient has given informed consent.

Sexual Harassment You should promptly report the incident to your

supervisor, who will investigate the matter and take appropriate action, including reporting it to the Human Resources Department.

If you believe it would be inappropriate to discuss the matter with your supervisor, you may bypass your supervisor and report it directly to the Human Resources Department, which will undertake an investigation.

Or you may call the Ethics Line at 1/800-455-1996. The complaint will be kept confidential to the maximum extent possible.

SERVICE EXCELLENCE Redmond’s Service Standards are ways

for you to fulfill the CARE values. By practicing these, you will be better able to meet and exceed the needs of all of our customers. Display a service attitude that is courteous and

caring. Anticipate the wants and needs of the people

we serve. Present a professional image. Maintain a safe and clean environment Use good elevator manners.

SERVICE EXCELLENCE Positively represent Redmond Regional Medical

Center in the workplace and the community. Listen to one another and to the people we

serve, then respond promptly and reliably. Keep the people we serve informed about their

care and treatment. Respect the privacy and confidentiality of the

people we serve. Strive to master the skills needed to do your

best for the people we serve. Utilize communication tools to assist us in

responding to our guests.

What is teamwork? A cooperative effort by

members of a group or team trying to achieve a common goal

The concept of people working together

To make teamwork happen… Communication is a necessity Must have interaction with others

even when things aren’t going as planned

Get Feedback from other associates and managers

Share the responsibility

Skills for teamwork: Listening Questioning Respecting and supporting ideas Helping Sharing Participation

Why will Teamwork work for you? Increases productivity and output.

Boosts morale.

Increases customer satisfaction.

Actively involves everyone.

Benefits of Team Work You have more minds working on a

project You can improve product quality You are able to improve associate

morale You can improve productivity You have more cross functional skills

HCA Mission and Values Statement We trust our colleagues as valuable

members of our healthcare team and pledge to treat one another with loyalty, respect and dignity.

Employee Health ServicesINJURIES AND ILLNESSES

Non-Work Related

EHS will provide care for non-work related injuries and illnesses as an immediate care program. Our goal is for all employees to have their own primary care provider (PCP), however, when an employee is unable to see their PCP and they are ill at work, EHS is available for evaluation and treatment as appropriate. Employees may be referred to their PCP for further evaluation, treatment, and/or follow-up. EHS stocks many over-the-counter medications; these are available for employees as needed.

Employee Health ServicesINJURIES AND ILLNESSES

Work Related

Paula Dunwoody with EHS is Redmond’s Injury Coordinator. This role involves employee safety and prevention of work injuries as well as follow-up of all work related injuries. All work related injuries must be evaluated in EHS as soon as possible after the injury.

What To Do If You Are Injured On The Job

If you are injured on the job, report the injury to your supervisor, no matter how minor. Your supervisor should be notified prior to the end of your shift.

Redmond policy requires a notification (incident) report for an injury no later than 24 hours after the incident occurs. This report is completed in our Meditech computer system. If you do not have access to Meditech, your supervisor or Employee Health Services can assist you with this report.

What To Do If You Are Injured On The Job (continued)

All employee on-the-job injuries must be evaluated in Employee Health Services.

Management and/or treatment of the injury may be completed in Employee Health Services. If the extent of the injury warrants a physical evaluation, the employee must choose a panel physician. The physicians panel is updated periodically and is posted on the HR bulletin board, across from the time clock on the first floor, and in Employee Health Services.

What To Do If You Are Injured On The Job (continued)

In an emergency situation, employees may go directly to Redmond’s Emergency Room. Please discuss this with your supervisor.

If you have a work-related injury and your condition changes (for example: new onset of difficulty walking or worsening pain), report to Employee Health Services immediately. If this office is closed, then contact your immediate supervisor and notify EHS when the office opens.

For any questions or concerns about a work-related injury, contact Employee Health Services 706-236-4968.

What Can You Do To Prevent Sharps Injuries?Be Prepared Complete your Hepatitis B vaccine series and

titer in Employee Health Services free of charge. Organize your work area with appropriate sharps

disposal containers within reach. Receive training on how to use sharps safety

devices. Wear gloves if you expect to come in contact with

blood or body fluids.

What Can You Do To Prevent Sharps Injuries?Be Aware Keep the exposed sharp in view. Be aware of people around you. Stop if you feel

rushed or distracted. Focus on your task. Avoid hand-passing sharps and use verbal alerts

when moving sharps. Watch for sharps in linen, beds, on the floor, or in

waste containers.

What Can You Do To Prevent Sharps Injuries?Follow Policies Don’t recap needles. Never use needles with the needleless IV

system. Be responsible for every device you use. If you identify a sharps without a safety

device, discuss this with your supervisor and/or Employee Health Services.

What Can You Do To Prevent Sharps Injuries?Dispose of Sharps with Care Don’t remove contaminated sharps with your hands

unless medically required (i.e. caps off used needles, scalpel blades). If necessary, use a mechanical device or forceps.

Always activate safety devices immediately after using a sharp. Never remove safety devices. Keep your hands behind the needle at all times.

Disposal of Sharps With Care Place all used sharps in biohazard

containers, see policy IC-45. Securely close biohazard containers when

¾ full and notify Environmental Services to change the sharps container.

Do Not overfill sharps containers. Do Not reach by hand into containers

where sharps are placed.

Additional Sharps Injury Prevention for the OR Use a neutral zone when passing sharps instruments.

Pass sharps on a tray, not directly to another individual. Use verbal alerts when moving sharps.

When suturing, use blunt sutures for muscle and fascia.

Stay focused on your task. Stop if you feel rushed or distracted.

Use mechanical devices such as tongs to handle contaminated reusable sharps. Do Not use your hands.

Prevent Bloodborne Pathogen Exposures Use appropriate barriers such as gloves, eye protection, or

gowns when contact with blood is expected. Wash your hands with soap and warm running water as

quickly as possible after contact with blood or potentially infectious materials.

Don’t eat, drink, smoke, apply cosmetics or lip balm, or handle contact lenses in area with possible exposure to bloodborne pathogens.

Do not store food in refrigerators, freezers, cabinets, shelves, or on countertops where blood or other body fluids are present.

Bloodborne Pathogen Exposure Report to Employee Health Services or the E.R. immediately after a

Bloodborne Pathogen Exposure. If you go the E.R., then follow-up with Employee Health Services as soon as the office opens.

Following a bloodborne pathogen exposure, the risk of infection may vary with factors such as these

the pathogen involved the type of exposure the amount of blood involved in the exposure the amount of virus in the patient’s blood at the time of exposure

The following factors were associated with an increased risk of HIV seroconversion:

deep injury (deep puncture wound) visible blood on source patient device causing injury procedure involving needle placed in a vein or artery of source patient endstage AIDS in source patient

Needle Stick/Sharps Injury What is the risk of infection after exposure?

HBV Healthcare personnel who have received

hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection.

For a susceptible person, the risk from an exposure can range from 6 – 30% and depends on the status of the source individual.


HCV The average risk for infection after a

needlestick exposure to HCV infected blood is approximately 1.8%.

There is a small risk associated with exposure to the eye, mucous membranes, or nonintact skin.


HIV The average risk of infection after a

needlestick exposure is 0.3% (or about 1 in 300).

The risk after exposure of the eye, nose, or mouth is about 0.1% (1 in 1,000).

The risk after exposure to nonintact skin is less than 0.1%.

Needle Stick/Sharps Injury Treatment For The Exposure

HBV Hepatitis B vaccine for all healthcare

personnel who have a reasonable chance of exposure to blood or body fluids.

Hepatitis B immune globulin (HBIG) alone or in combination with vaccine (if not previously vaccinated or no immunity developed after vaccination).


HCV There is no vaccine against hepatitis C and

no treatment after exposure that will prevent infection.

Following recommended control practices to prevent percutaneous injuries is imperative.


HIV There is no vaccine against HIV. Postexposure prophylaxis (PEP) with

retroviral drugs is recommended for certain occupational exposures that pose a risk of transmission of HIV.

PEP is not recommended for exposures with low risk for transmission of HIV.

PEP should be started as soon as possible after exposure, preferably within 2 hours.

Respirator and Respirator Fit Testing to Prevent Transmission of Airborne Illnesses N-95 Respirator

A respirator is designed to provide respiratory protection for the wearer.

An NIOSH approved N-95 mask has a filter efficiency level of 95% or greater against particulate aerosols free of oil.

It is fluid resistant, disposable, and may be worn in surgery.

It can fit a wide variety of face sizes.

Respirator and Respirator Fit Testing Intended Use

RRMC’s N-95 Respirators reduce the wearer’s exposure to certain airborne particles in a size range of 0.1 to 10.0 microns, including those generated by electrocautery, laser surgery, and other powered medical instruments.

The masks are designed to be fluid resistant to splash and splatter of blood and other infectious materials.

These masks are not designed for industrial use.

Respirator and Respirator Fit Testing

Employees Wearing Respirators Any employee with the possibility of

exposure to airborne illness will participate in the respiratory protection program.

This includes all employees who could enter a patient care room when a patient is placed in airborne precautions.

Respirator and Respirator Fit Testing Medical Evaluation

A medical evaluation questionnaire is required for all employees wearing a respirator in the workplace.

This evaluation will determine whether or not an employee is medically able to wear a respirator. All employees may not pass this evaluation.

Employees who do not pass the medical evaluation cannot wear a respirator and should not enter rooms were a patient is on airborne precautions.

Respirator and Respirator Fit Testing Fit Testing

All employees must be fit tested with one of the masks available here at RRMC before they can wear a respirator. 3M 1860 Regular and Small (blue mask) Tecnol Fluidshield Regular and Small (orange duck-bill)

Some employees may not pass fit testing. These employees cannot wear a respirator.

Compliance with OSHA standards requires fit testing completion with hire and repeat fit testing annually thereafter.

Fit testing will be completed in Employee Health Services during month-of-hire annual evaluation.

Respirator and Respirator Fit Testing Mask Size

Every employee fit tested for a respirator is responsible for knowing what size mask they wear.

Employee will have a sticker with mask brand and size placed on the back of their ID badge at the time of fit testing.

Employee Health Services and department supervisors will have documentation of mask size for employees that have been fit tested.

Problems Any employees with medical problems, respirator problems

(such as fit seal difficulty), or any concerns should contact Employee Health Services.

Latex Allergies Latex allergies pose a serious problem for nurses, other

health care workers, and for 1% to 6% of the general population. Anaphylactic reactions to latex can be fatal. Health care workers’ exposure to latex has increased dramatically since universal precautions against blood borne pathogens were mandated in 1987. Latex can trigger three types of reactions: irritant contact dermatitis, allergic contact dermatitis, and immediate hypersensitivity. Many medical devices contain latex that might trigger serious systemic reactions by cutaneous (skin) exposure, (i.e. ECG electrodes, masks, bandages, catheters, gloves, and tape.) There are some diagnostic tests to determine if a person has an allergy to latex. If a patient tells you they are allergic to latex, notify Materials Management and they will provide a cart with latex-free products. Need more information? Contact the Nursing House Supervisor at ext. 3037. For associates with latex allergies, contact Employee Health Services ext. 4968.

Ergonomic Safety Ergonomic Safety is adapting the equipment, procedures

and work areas to fit the person in order to help prevent injuries and improve efficiency. Musculoskeletal disorders (MSDs) affect muscles, nerves, tendons, ligaments, joints or spinal discs. Injuries can include strains, sprains, and repetitive motion injuries.

Signs and symptoms: pain, tingling, numbness, swelling, stiffness, burning sensation, etc. May experience decreased gripping strength, range of motion, muscle function, or inability to do everyday tasks. Risk factors: repetition, forceful exertions, awkward postures, contact stress, and vibration. Common MSDs: Carpal tunnel syndrome, rotator cuff syndrome, trigger finger, tendonitis, herniated spinal disc, and back pain.

Ergonomic Safety Apply these tips to your job: Adjust chair height and

backrest (feet should be flat on the floor, knees level with hips, and lower back supported). Sit an arm's length away from the computer screen. Keep wrists straight and elbows at right angles. Alternate tasks. Use proper body mechanics when lifting, transferring, etc. Avoid reaching and stretching overhead.

You may recommend ways to reduce the chance of developing musculoskeletal disorders to your supervisor. Your work space may be evaluated for ergonomic safety by notifying Paula Dunwoody at ext. 4968. Your departmental safety representative may assist with body mechanic in-services. Report signs, symptoms, illnesses ,and injuries to your supervisor, complete an occurrence report, and obtain medical treatment in Employee Health Services.

12 Principles of Ergonomics Keep everything in easy reach Work at proper heights Reduce excessive forces Work in good postures Reduce excessive repetition Minimize fatigue Minimize direct pressure Provide adjustability and change of position Provide clearance and access Maintain a comfortable environment Enhance clarity and understanding Improve work organization

ErgonomicsThe “Do Nots” Upper Extremity

Shoulder Reaching over 90 degrees (vertical flexion) External rotation of greater than 45 degrees

Elbow Avoid static hold time of flexion

Lower Extremity Sitting position

The hip, knee, and ankle should be placed at 90 degrees

Body positions to avoid Deep knee bends Constant standing in hip and knee extension Walking with feet externally rotated

Ergonomics Self Care

Ice THEN heat Stretch regularly Use good posture Exercise!!!!! Work smart Play smart

Ergonomic Tips The best way to avoid the discomfort of MSDs

is: Change body positions frequently/Set up work stations

to fit your body/Stretch every 45 minutes to an hour/Perform stretches that are designed to decrease discomfort for job specific tasks

Decrease FatigueWarm-up exercisesInterrupt sustained posturesProper ergonomicsAppropriate work methodsLimited overtime

Increase RecoveryPhysical fitnessProper nutritionGood sleeping posturesIce after activitiesAvoid smokingAlternative job placement

Performance Improvement Continual Quality Improvement

What is PI? PI is a work philosophy that encourages

every employee to find new and better ways of doing things. All accredited healthcare organizations are required to have an improvement program. Redmond is accredited by The Joint Commission.


Excellent organizations make sustained and continuous efforts to improve their care and services. Healthcare, our business, is constantly changing; what made us successful last year may no longer be appropriate. Even if we think today's solution is perfect, tomorrow will teach us that it wasn't perfect; it was just the best that we could do at the time

Even though a process may appear to work most of the time, we are challenged to look at the process and ask ourselves, "Is there a better way to do this?" or "Why are we doing this?” Because we live in a rapidly changing environment that is fast-paced and stressful, change brings many opportunities to improve our care and services.


Key Points to Remember Customers come first. Every employee is important. Communication is essential. Tasks (processes) are streamlined whenever

possible. Ongoing improvement is crucial. Improvement should be maintained.

We want to improve everything we do! We owe this to our ultimate customer ~ the patient.

Performance Improvement Continual Quality Improvement What does this mean to me?

Management provides support and guidance, and they bear ultimate responsibility, but the best improvement ideas come from people who work providing care and services for our customers. Continually improving one’s own performance and their own job processes are essential for producing great patient outcomes. Within your department, you have the responsibility to think about your “daily work life” to determine if there are processes that can be improved. At the department level, the organization has determined that the Pillars of Excellence should be continually improved. There are five pillars: Service, Quality, People, Growth, and Finance.

Performance Improvement Continual Quality Improvement What does this mean to me? You can make suggestions for improvement to your

supervisor by expressing the idea and asking if an improvement team could be organized to work on the project. There is also an “Improvement Suggestion Form” in your department’s PI Manual (or posted on your department’s Communication Center); you can fill out the form and turn in to your supervisor. If the idea only relates to your job, your supervisor may ask you to “just do it.” You may be asked to serve on an improvement team or lead an improvement project; you should accept this as an honor.

Risk Management/Patient Safety

2008 National Patient Safety Goals for Hospitals (new items indicated in red)

Improve the accuracy of patient identification. Use at least two patient identifiers when

providing care, treatments, or services.



Improve the effectiveness of communication among caregivers. For verbal or telephone orders or for telephonic reporting of

critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result.

Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.

Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions.



Improve the safety of using medications. Identify and, at a minimum, annually review a list

of look-alike/sound-alike drugs used in the organization and take action to prevent errors involving the interchange of these drugs.

Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field.

Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.



Reduce the risk of health care-associated infections. Comply with current World Health

Organization (WHO) Hand Hygiene Guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with health-care associated infection.



Accurately and completely reconcile medications across the continuum of care. There is a process for comparing the patient’s current

medications with those ordered for the patient while under the care of the organization.

A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.



Reduce the risk of patient harm resulting from falls. Implement a fall reduction program and

evaluate the effectiveness of the program.



Encourage patients’ active involvement in their own care as a patient safety strategy. Define and communicate the means

for patients and their families to report concerns about safety and encourage them to do so.



The organization identifies safety risks inherent in its patient population. The organization identifies patients at risk

for suicide. [Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals – NOT APPLICABLE TO CRITICAL ACCESS HOSPITALS).]



Improve recognition and response to changes in a patient’s condition. The organization selects a suitable method

that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening. [Critical Access Hospital, Hospital]

Patient rights We believe that most patients want to understand and

participate in their care. Therefore, it is important that each patient understand his or her rights and responsibilities while at Redmond. It is also necessary as healthcare workers that we understand patient rights and responsibilities to ensure that quality care is provided.

How are patients informed of their rights? Upon admission, each patient is given a

handbook, which includes a list of patient rights and responsibilities. This patient bill of rights tells a patient and his or her family what they can expect of caregivers and what caregivers expect of them.

Patient rights What is your role in patient rights?

Everyone is involved in protecting the rights of patients, not just those involved in direct patient care. For example, the right to confidentiality means not telling your friends and/or relatives when someone you know has been a patient. Also, you provide privacy for patients by making sure you always knock before entering a patient’s room or any room where a patient might be having a procedure.

Patients have a right to a secure environment, which means you should know how to respond during a disaster or fire in the building.Patients are informed of their right to establish advance directives.

Patients also have a right to file a grievance. You can assist with the investigation and response by contacting Risk Management at ext. 3950 or Administration at ext. 4100 should you have a question.

Patient rights Where can you find a list of

patient rights? In facility Policy RI-04 Rights and

Responsibilities of Patients, the Patient Handbook , posted beside the elevator in the front lobby and at outpatient services and on Redmond’s Intranet site.

Patient rights Access the Ethics Committee and the Ethic Resolution Process.

Phone: 802-3037. Access the grievance process. Express complaints or concerns

regarding care or services, including discharge. Facility contact: 706-802-3950

Independent Agency:Office of Regulatory Health2 Peachtree Street N.W., Suite 200Atlanta, Georgia 30329 Telephone: 1-404- 657-5726 Peer Review Organizations:Georgia Medical Foundation [Medicare]57 Executive Park South, Suite 200Atlanta, Georgia 30329Telephones: 1-800-282-26141-404-982-0411

Humana Military Healthcare

Services, Inc [Champus]

931 South Semoran Blvd.

Suite 218

Winter Park, Florida 32702

Telephone: 1-800-658-1405

Pain Management Four major goals of pain management

Reduce the incidence and severity of patients' acute postoperative or posttraumatic pain.

Educate patients about the need to communicate unrelieved pain so they can receive prompt evaluation and effective treatment.

Enhance patient comfort and satisfaction. Contribute to fewer postoperative complications and, in

some cases, shorter stays after surgical procedures.

The importance of effective pain management increases beyond patient satisfaction when additional benefits for the patient are realized, e.g., earlier mobilization, shortened hospital stay, and reduced costs.

Sentinel events A sentinel event is an event which results in

unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition. Also, suicide; infant abduction or discharge to the wrong family; rape; hemolytic transfusion reaction involving administration of blood or blood products having a major blood group incompatibility; a health-care associated infection; and surgery on the wrong patient or wrong body part are all sentinel events. Please secure all information and items related to the event. If you have any questions, contact Risk Management at ext. 3950.

Occurrence Reporting An occurrence is an event that is unusual,

significant or notable. Categories include: Patient, Non-Patient (visitor,

MD, volunteer, student, facility, equipment) or Employee Examples include: Near Miss, Fall, Medication, Treatment and/or Testing, Adverse Effect, Equipment, Property, Assault (abuse or harassment), Error, Failure to follow policies & procedures, Failure to follow MD’s orders, User/Operator error, Defective or malfunctioning products, Incorrect action/activity, Inappropriate action/activity, Omission, Delay, Complications, Loss or theft of personal belongings or Auto events with facility vehicles.

Occurrences should be documented in Meditech during the working shift or definitely within 24 hours. The department manager or house supervisor should be notified at the time of the event. Please notify the Risk Manager of all serious and potentially legal situations.

Occurrence Reporting Meditech Reporting

Log onto Meditech - Select 500 Occurrence Reporting - Select Facility - Select Category - (If patient) At prompt type A# then the account number - (If Non-Patient or Employee) Type N into the first field to create a new report (For employee type in last name and press the look-up key) - If no previous Occurrence report exists for this patient you will receive a message “No available notifications for this patient. Create a new one? Answer Y (Yes) - Answer all questions in field - Input will be by free text or pull down menu selection - Enter all the information you know or can obtain.

Occurrence Reporting Look-up key (F9 or F17) displays a pull down menu Previous field key (F6 or F 14) allows you to backup

The enter key allows you to move forward one field. Magic or file key (F12 or F20)

This key will provide the menu for selection. You MUST FILE to save your work.

Exit key (F11 or F 19) Caution exit does not save your work.

Text fields require typing from keyboard. An occurrence report is a confidential

facility report that should not be referenced in documentation on the patient’s record.

Reportable Events State (Georgia) Reportable Events:

The following type events should be reported to the State of Georgia Office of Regulatory Services:

1. Any unanticipated patient death not related to the natural course of the patient’s illness or underlying condition;

2. Any surgery on the wrong patient or the wrong body part of the patient;

3. Any rape of a patient which occurs in the hospital. Redmond Regional Medical Center’s employees and the

medical staff should report to the appropriate department leader and Risk Management at 3950or Regulatroy Compliance at 3038 in the event that any of the above situations occur to a patient at Redmond. A multidisciplinary group will review the situation, complete the State forms, and provide them to the Office of Regulatory Services within 24 hours of knowledge that the event meets one of the State definitions.

Suspected Impairment of Licensed Independent Practitioner Redmond Regional Medical Center makes every

effort to ensure that licensed independent practitioners providing care to our patients are competent and able to carry out their patient care responsibilities free of any impairment(s) that adversely affect their judgment or clinical performance. A licensed independent practitioner (LIP) is defined as any individual permitted by law and the hospital to provide care, treatment, and services without direction or supervision.

Identification of an Impaired LIP An impaired LIP is defined as one who is

unable to provide care, treatment, or services with reasonable skill and safety to patients because of a physical or mental illness, including deterioration through the aging process or loss of motor skill or excessive use or abuse of drugs including alcohol.

Signs and Symptoms of Impairment Signs and symptoms of potential impairment include, but

are not limited to: Personality changes/mood swings Loss of efficiency and reliability Increasing personal and professional isolation Inappropriate anger, resentments Abusive language, demeaning others Physical deterioration Memory loss Increase in tardiness, absenteeism, illness Lack of empathy towards others

Reporting a LIP Suspected of Impairment If any individual in the hospital has a

reasonable suspicion that a LIP may be impaired and this impairment may adversely affect patient care and safety, take immediate action by notifying your supervisor and following the appropriate Chain of Command listed in policy LD 05.

ADVANCED DIRECTIVES Advance Directives include Living Will and Durable Power of

Attorney (DPOA) for Health Care. Living Will only applies to terminal conditions. DPOA for Health Care allows a person to name an agent to speak on

the person’s behalf, when the person cannot speak for their self. Inside the hospital, the attending physician must be present when the

patient names an agent. An agent can speak for the patient concerning any condition.

Patients should be asked at the time of admission if they have an advance directive.

Patients should initial and date a copy of the directive(s) and the hospital staff should place it inside the current medical record.

Social Services can assist by answering general questions and provide blank forms.

Environment of care EMERGENCY PREPAREDNESS CODES

Code Red—Fire RACE Rescue/Activate/Contain/Extinguish

Code Gray—Bomb Threat—Notify Switchboard Code Blue—Adult Cardiopulmonary Arrest Code Blue PEDS — Pediatric Cardiopulmonary Arrest Code Pink – Pediatirc Abduction Code White – Adult Patient Elopement Code Yellow—Trauma—Emergency Room

Support—Do not call ER Code Green— Hostage Situation Code Orange—Hazardous Material Event

Environment of care EMERGENCY PREPAREDNESS CODES

Code Triage—Community Disaster Standby: An event has occurred in the

community Activate: Begin Disaster Plan Stand-down: Return to normal

operations Code 900—Show of Force—All Males

Respond Code 1000—Visitor Needs Assistance—

Stay with person — Notify switchboard

Environment of care Tornado Warning

Tornado warnings will no longer be announced as a Code Black. Instead a more recognizable announcement will be made so that both staff and visitors will be aware of the severe weather potential.

The announcement will be, “Attention, attention, attention. Floyd County is currently under a tornado warning”.

Environment of care CONTACTS

Extension 4000— Emergency line to Operator/PBX Labor Pool Location—Classroom C (Ext. 2273) Facility Privacy Officer — Pam Watkins Facility Information Systems Officer — Brad Treglow Quality Director — Barbara Garner Risk Management – Marisa Pins Patient Safety Officer – Debbie Smith Facility Safety Officer — Clay Callaway Infection Control Director — Terri Aaron Ethics and Compliance Officer — Deborah Branton Service Excellence Administrator — Missy Ragland

Emergency Preparedness

Designed to provide a safe environment for all Drills are used to improve effectiveness Resource guides and manuals are available to assist

you Don’t wait for an emergency to learn what you

should to RRMC utilizes an all hazards approach

When you hear a code-- Do not call PBX!

They do not know what you are supposed to do – they know what they are to do!

Call your supervisor or leader

Mass Casualty Event Code Triage

Standby: An event has occurred – facility must decide if we can meet demands or utilize extra resources Develop a plan with the department Call your immediate family

Activate: Initiate the disaster plan – activate your department response

Stand-down: Begin recovery and return to normal operations

Know your role!

Code Orange Hazardous Material Event Haz Mat Team will respond If they walk in – don’t touch them – take

them back out the way they came in Stay uphill and upwind! Decon is in ED or outside Don’t forget your PPE’s

Code Blue & Code Blue PALS Code Blue

Adult cardiac or respiratory event Don’t forget the Rapid Response Team (Call for the

Rapid Response team when you feel a patient’s clinical status is in decline.)

Know how to call a code and where your supplies are

Code Blue PALS Pediatric cardiac or respiratory event ED Nurse will respond to assist with running the

code

Code 900 You are in a situation in which you are

threatened verbally or physically All males respond Crisis Prevention Intervention (CPI)

training is available DO NOT USE THIS CODE FOR

LIFTING HELP!!

Code 1000 Visitor or family member is ill or injured

Stay with person and have someone call ext. 4000 to report the incident

ED Nurse and House Supervisor will respond

Call 4911 ONLY if “packaging” is required

Tornado Warning A Tornado has been reported in our area

Close patient doors Get everyone out of halls and away from glass Discourage visitors from leaving

Turn beds to inside walls Clear area of anything that can become a projectile Instruct family members & ambulatory patients to

go into the bathrooms and cover themselves

Code Green Hostage situation is occurring

Lock down your area Do not try to negotiate Police should be alerted to enter in an area

distant from the hostage situation

Code Grey There has been a bomb threat

If you get it, notify the switchboard Look for packages or people that should not be in

your area Only if there is a legitimate reason would we

evacuate Take direction from Incident Command or law

enforcement Leave lights alone!

Code Pink Pediatric Abduction

Can be a patient or visitor Patient Care Coordinator

Call ext. 4000 Give gender and age Building must be locked down Each department has a response

PBX will announce -Code Pink b or g and age Try to detain but do not put yourself in harm’s way

Get a good description of person, vehicle, tag, etc. Make sure unoccupied rooms and areas are checked.

Code White Patient Elopement Patient Care Coordinator

Call ext. 4000 Give gender and age and clothing description Building must be locked down Each department has a response

PBX will announce -Code White m or f and age Make sure unoccupied rooms and areas are checked

Code Yellow - Trauma Trauma patient is coming or has arrived ED needs:

Lab Radiology General notice for House Supervisor

Don’t go unless you are assigned Don’t call the ED to find out what it is!

Severe Weather Each leader will review staffing and

supplies for the anticipated period. It is your responsibility to get here! We will provide housing We can provide child care

If you have a special needs situation, we need to know before hand

Transportation may be provided

Evacuation Move from unsafe to safe area

Ambulatory first Sickest last

Horizontal Evacuation Room to Room, Wing to Wing

Vertical Evacuation Floor to floor

Full Scale Triage and transport area will be established

Make sure you account for all patients

Pandemic Influenza A pandemic is an infectious event that has a global

impact (such as those in 1918, 1958 & 1968) The impact on society will be huge! Respiratory Hygiene/Cough Etiquette

Learn it, live it, teach it! Annual flu shots are recommended to decrease the

risk of a pan flu event For more information, visit www.pandemicflu.gov

Prepare Your Family Have a plan for your family Rewiew your Personal Preparedness Planning Kit Make sure you have a plan for pets You will be required to work If you have special needs, let us know

Special needs adult or children and no other adult to care for them

Military obligations DMAT, other volunteer organization

Do Not UseAbbreviations, Acronyms, and Symbols

Abbreviation Preferred Term

U Unit

IU International Unit

Q.D. & Q.O.D. daily & every other day

Trailing zero (X.0 mg)

Lack of leading zero (.X mg)

X mg

0.X mg

MS, MS04, & MgSO4 morphine sulfate or

magnesium sulfate

µg Mcg

T.I.W. 3 times weekly

c.c. Ml

ii, etc. (apothecary symbols) 2 or two

Environment of Care Defective Equipment

Defective equipment should be reported to BIOMEDICAL Services via Meditech or at Ext. 4962 if equipment removal constitutes an emergency. Equipment will be tagged. Tag will say “danger defective equipment”.

Security Related Incidents Any incident requiring Security assistance (i.e.

theft or suspicious activity), contact security by dialing 0 and asking PBX to page a member of Security.

Please refer to the Environment of Care section of the policy manual for in-depth information on these topics.

Bio-terrorism Update Healthcare facilities may be the initial site of

recognition and response to bio-terrorism events. All patients in healthcare facilities, including symptomatic patients with suspected or confirmed bio-terrorism-related illnesses should be managed utilizing Standard Precautions. For certain diseases or syndromes (smallpox and pneumonic plague), additional precautions may be needed to reduce the likelihood for transmission. For more in-depth information on this topic, please refer to the

Bio-Terrorism Readiness Plan policy. A quick reference guide is posted in the Emergency

Department For further information visit www.ready.gov

What is HIPAA? The Health Insurance Portability and Accountability Act

deals with patient privacy and security of information and systems. HIPAA was developed to protect health insurance coverage, improve access to healthcare, reduce fraud and abuse, and in general improve the quality of healthcare. The privacy section will govern the use and disclosure of individually identifiable health information and patient rights in regard to their protected health information (PHI). The security section will ensure that we protect confidentiality, availability, and integrity of individually identifiable information. HIPAA is a federally mandated law. Compliance is mandatory. The law has both civil and criminal penalties for non-compliance.

HIPAA’s TOP TEN Properly dispose of PHI (Privileged Health

Information) in shred boxes, not trash cans.

Access, use or disclose only the minimum necessary amount of PHI to accomplish a task.

Take reasonable measures to prevent unauthorized access to PHI - conceal, turn over, or secure PHI that is not needed for immediate use — turn off computer screens or use screen savers when you leave your work area — NEVER share computer passwords with others.

Close patient doors and pull curtains when discussing and administering procedures.

Immediately report improper disclosures of PHI, whether accidental or otherwise, to your Facility Privacy Official — Pam Watkins — 3095.

When PHI is discussed within the workplace, lower your voice or move to a private area if others might overhear you.

NEVER discuss any information relating to any patient outside of the workplace, including elevators and hallways, for any reason.

Respond to patient questions, concerns and complaints about privacy and security of their PHI respectfully and as quickly as possible. All concerns and complaints should be reported to the Facility Privacy Official immediately.

If you have any questions or are ever in doubt about what to do, ask your Facility Privacy Official.

But in emergencies, always put patient care ahead of all else — even HIPAA.

Protecting Patient Privacy All health care personnel must obtain

permission from the patient prior to discussing any health care issues in front of a patient’s visitors.

Organ Donation Timely referrals of potential organ donors

Healthcare professionals are required to identify and refer all deaths and imminent deaths (brain deaths) to the Donation Referral Line at (800) 882-7177. Timely referrals preserve the option of donation for families of medically suitable patients.

INFECTION PREVENTION Each year, it is estimated that millions of infections occur in the

United States as a result of hospitalizations. The cost to treat these infections is enormous.

Our goal is to identify and reduce risks of healthcare associated infections in patients, visitors, and healthcare workers.

Hand washing is the single most effective way to prevent the spread of infection. Routine hand washing involves a rigorous rubbing together of well lathered hands for 15-20 seconds followed by a thorough rinsing under running water. Must use soap and water if hands are visibly soiled.

Hand hygiene with an alcohol based product is acceptable as long as the hands are not visibly soiled. (Always wash hands with soap and water if the patient you are caring for has C. Difficile).

IC Champions monitor handwashing in our facility. The use of gloves does not eliminate the need for good hand washing.

Hand Hygiene: Wash hands at least in the following situations:

Before donning sterile gloves when inserting a central intravascular catheter

Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure

After contact with a patient’s intact skin (e.g. when taking a pulse or blood pressure, and lifting a patient)

After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings

If moving from a contaminated body site to a clean body site during patient care

After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient

After removing gloves Before eating and after using the restroom

Partners in Your Care A comprehensive hand hygiene program

involving the patient. Signs have been placed in patient rooms

“It’s OK to Ask”. Patients have a right to ask if you washed your hands before you take care of them

Goal for Hand Hygiene is 100%

sm

Artificial Nails: Direct patient care givers can not wear

artificial nails. Also some departments such as OR, can not wear them.

Nail polish may be worn in most departments as long as it is not chipped. Check with IC or your leader if you have questions about whether you can wear polish in your department.

Personal Protective Equipment Personal Protective Equipment (PPE) is provided at no cost

to the associate Worn when there is a chance of contact with blood or other

potentially infectious body material (OPIM). PPEs include, but are not limited to: gloves, gowns, goggles,

pocket masks, and shoe coverings. PPEs are available in each department.

Wear gloves when it can be reasonably anticipated that there may be hand contact with blood or OPIM and when handling and touching contaminated items or surfaces. Replace them if torn or punctured or if their ability to function as a barrier is compromised.

Gloves must be removed before leaving the room. Hands must be washed after glove removal.

Personal Protective Equipment Wear appropriate face and eye protection when

splashes, sprays, splatters, or droplets of blood or OPIM may pose a hazard to the eye, nose, or mouth.

Remove immediately, or as soon as feasible, any garment contaminated by blood or OPIM.

PPEs may be disposed of in the regular trash unless contaminated with blood or other OPIM, if contaminated they must be disposed of in red biohazard bags.

Each department has a list of tasks and what PPE is recommended or mandatory to wear while performing those tasks. Ask your leader about this list.

Standard Precautions Standard Precautions apply to all blood or body fluid

which is considered potentially infectious. Very important to wear appropriate PPE when dealing with blood or body fluids.

By using standard precautions you will substantially reduce your risk of infection with a blood borne pathogen.

In addition to standard precautions, there are three types of transmission based precautions (isolation precautions) used for patients with documented or suspected transmissible pathogens that require more than standard precautions.

Isolation Precautions: Contact (wear gown, gloves,

sometimes mask) Airborne (wear N 95 mask) Droplet (wear regular mask)

Contact Precautions Used in addition to standard precautions Bacteria transmitted by direct patient

contact or by indirect contact by touching environmental surfaces.

Isolation gowns and gloves must be worn and sometimes a mask.

Private room for patient or placed with patient with the same bacteria.

Patients should wear an isolation gown and wash hands before leaving the room.

Environmental services should be notified on patient discharge to terminal clean room.

Airborne Precautions Used in addition to standard precautions for

illnesses transmitted by airborne droplets. Patient is placed in a negative air flow room. If patient must leave room, they are given a mask

to wear. Staff must be fit tested for an N 95 mask before

entering this type of isolation room. Staff members who have not been fit tested may not go in this room.

Visitors are taught by the nurse how to wear the mask.

Persons not immune to measles or varicella (chicken pox or disseminated varicella) should not enter the room of patients with these illnesses.

Droplet Precautions Used in addition to standard

precautions for illnesses transmitted by large droplets.

A regular mask is worn in this room.

Patient must be placed in a private room.

If the patient needs to leave the room, they are given a mask to wear.

Methicillin-Resistant Staphylococcus Aureus (MRSA)

Staph aureus are bacteria commonly found on the skin of healthy people.

MRSA can be present without causing disease. When there is no associated disease, we call their presence colonization. If MRSA is causing disease such as fever or pneumonia, we call it infection.

MRSA is spread by contact thus contact precautions are implemented (gown and gloves)

Good hand washing is the best prevention for the spread of MRSA.

MRSA: Use disposable equipment, such a B/P cuffs

as much as possible. Any equipment taken in to the room must be

cleaned/disinfected prior to removing it from the room.

Education is given to patient/visitors by the nurse. The visitor may decide for themselves whether or not to wear a gown or gloves.

If the visitor will be visiting other patients during this visit, they must wear a gown and gloves in the patient’s room who has MRSA, just like our associates.

MRSA: Notify receiving department that the patient

is on contact precautions . If possible, schedule procedures when there

are fewer patients in the area. The patient should wear an isolation gown

and wash hands prior to transport. Have the area where the patient has been

terminally cleaned by Environmental Services.

Screening for MRSA Certain high risk populations are screened

for MRSA on admission by having a nasal swab screening completed.

If they have MRSA in their nose, they are placed on contact precautions to reduce the risk of MRSA to others.

You may have noticed more patients on isolation precautions because of this process.

Community MRSA Patients who already have MRSA on

admission to our facility have Community Acquired MRSA. This is different from MRSA acquired in a healthcare setting.

Usually it is a skin infection or MRSA colonization in the nose.

Community MRSA is increasing throughout the US.

Tuberculosis (TB) Update Spread from person-to-person through the air when a person

who has an active case of the disease coughs, sneezes, laughs or sings and the bacteria is inhaled by a person close by. Infection is usually detected by a positive PPD skin test and an abnormal chest x-ray.

A person can also have the TB germ which is dormant (not active TB). This person has a positive skin test but they are not ill. They cannot spread the bacteria to others, however they do have an increased risk of eventually acquiring active TB during their lifetime and may be asked to take medications to prevent the development of active tuberculosis.

Upon hire, associates are required to have a PPD skin test to detect possible TB unless they have ever had a positive skin test. RRMC is a low risk facility for TB. This means we do not have to have annual skin testing except in certain areas.

Tuberculosis (TB) Update Symptoms of TB include: greater than three weeks of

cough, unexplained fever, weight loss, and night sweats.

Persons who have active TB are capable of spreading the infection to others.

Associates with active tuberculosis will be placed on a work furlough until cleared by the health department as no longer being a risk of transmission to others and healthy enough themselves to perform the tasks of their occupation.

Patients suspected of having active tuberculosis are placed on airborne precautions in a private room with negative air flow. The door must remain closed at all times except when entering and exiting the room.

Special masks (N 95) are worn by healthcare personnel when entering the room .

N 95 Masks

Notify Employee Health Services if your facial structure changes. This change can be due to weight loss or gain, dental work which changes your facial structure, or other changes.

If your mask does not fit for any reason, or you have a problem with wearing the mask, contact Employee Health Services.

Personnel should fit check the mask before entering the patient’s room. The mask must be discarded if it becomes soiled or at the end of your shift. Masks are stored in the ante room.

How would the hospital handle an influx of infectious patients? If a large number of infectious

patients suddenly presented to the hospital, we would activate our emergency preparedness plan.

This plan addresses staffing, supplies, and other issues that might occur as a result of the increased patient load.

Blood Borne Pathogens A copy of our plan is available to any associate. The plan explains the processes we have in place to minimize

exposures, and what we do if there is an exposure to a blood borne pathogen.

The following fluids are considered to be potentially infectious: blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, or any other fluid that is visibly contaminated with blood and all body fluid where it is difficult or impossible to differentiate, saliva in dental settings, tissue and organs that are not fixed other than intact skin (from any human living or dead), HIV containing cell or tissue cultures or organs, and tissue from experimental animals infected with blood borne pathogens.

What is Hepatitis B (HBV)?

Hepatitis B is a serious liver disease. Symptoms include jaundice, fatigue, fever, nausea and

abdominal pain. It can be transmitted by contact with infected blood and body

fluids. HBV is much easier to transmit than HIV and lives on

surfaces for longer periods of time. You can help protect yourself from acquiring Hepatitis B if

you practice infection control guidelines and get vaccinated. The Hepatitis B vaccination is given free of charge to

associates. Generally people have few side effects from the vaccine. If you previously declined the vaccination, you may notify Employee Health Services if you choose to begin this series.

What is Hepatitis C (HCT)?

Hepatitis C is a disease that attacks the liver. It is transmitted by contact with an infected

person’s blood or blood products which enters the body of a person who is not infected.

HCV infection often occurs without symptoms or with mild symptoms. The symptoms are very similar to those of Hepatitis B.

There is no vaccine that offers protection from Hepatitis C.

What is HIV? Human Immunodeficiency Virus (HIV) is the virus that

causes the disease Acquired Immune Deficiency Syndrome (AIDS).

HIV damages the immune system and makes a person with AIDS more likely to get serious infections and other diseases.

To become infected with HIV, the virus must get into your body and enter your bloodstream.

Many people who are infected with HIV do not have symptoms for years. Persons who are HIV infected (with or without symptoms, diagnosed with AIDS, or recently exposed with a negative HIV antibody test) can spread HIV to others.

It may be transmitted by contact with an infected person’s blood or body fluids which enter the body of a person that is not infected.

How to Reduce Transmission of Blood Borne Pathogens? Observe engineering controls; needle-less

systems, safety devices, sharps disposal containers, biohazard waste containers, needle boxes at appropriate height.

Observe work practices; never recap needles, perform hand hugiene, use appropriate PPEs, do not bend or break needles, do not eat or drink in areas where there is potential for exposure, do not store food or drinks in a refrigerator that is used to store blood or other potentially infectious material (OPIM), use red biohazard bags for disposal of infectious wastes.

Know the job tasks in your department that may involve exposure to blood or OPIM and wear appropriate PPEs.

What is an Exposure? Contact with another person’s blood or OPIM such as in needle

sticks/sharps exposures, mucus membrane exposure, or exposure to non intact skin.

If you are exposed to blood or OPIM, you should clean the skin injury site with soap and water. If it is a mucous membrane exposure, flush the area with water.

Inform your supervisor or the designated charge person and go to Employee Health Services (may go to the Emergency Room during other hours) to be evaluated.

Complete occurrence form. You will receive risk information, be evaluated by the ER physician

or the Nurse Practitioner in Employee Health Services, be informed of recommendations of treatment, and receive care.

You should follow up after your initial evaluation the next day with Employee Health Services.

You will receive a written opinion for any future recommended follow up in approximately 15 days.

Five Questions OSHA might ask about Blood Borne pathogens: What is standard precautions? All blood and body fluids

are treated as if potentially infectious by wearing appropriate PPE when dealing with them.

What do you do when there is a blood spill? Wear PPE, locate spill kit, follow directions, dispose of properly in red bag and disinfect area where spill occurred.

What do you do with contaminated sharps and laundry? Used sharps go in designated sharps containers made of hard plastic that are puncture resistant, linen goes in the dirty linen hamper or is taken to linen chute.

Questions continued Have you been offered the hepatitis B vaccination

free of charge? Yes by employee health services (all employees have opportunity to receive the vaccine)

Where is the Blood borne pathogen plan? On the intranet under IC policies, in the nursing office or can be obtained through employee health services

If you have any questions about Infection Prevention or Blood Borne Pathogens, you may contact Infection Control ext 4969 or ext 3394 (8:00 – 4:30 pm Monday through Friday)

By beeper: Terri Aaron 770-553-0430 or Rebecca Alexander 770-553-0970. If Infection Control is not available contact your Department Leader or the Nursing House Supervisor

Biohazards Biohazard Labels

These labels are warnings that the contents of the container are possibly infectious materials.

Linens Use standard precautions when

handling linens. Linens are treated as if potentially infectious. Linens removed from isolation rooms should be taken to the laundry chute.

Hazardous Material and WasteRead Container Labels—Before handling any chemical container, always read the label.

Warnings may be in words, pictures, or symbols.

Consult the Material Safety Data Sheet (MSDS)– A MSDS gives more detailed information on a chemical and its hazards. It also gives you specific precautions for protecting yourself from dangerous exposure. Your department should have a notebook with a list of the chemicals used in your area.

Use Proper Handling Techniques– Always wear proper personal protective equipment.

Dispose of Chemicals Properly– Carry and store chemicals only in approved, properly labeled, safety containers. Never dispose of chemicals in containers used for ordinary waste. Never pour them down sewers or drains. Always consult the MSDS sheet for approved method of disposal.

Contact Steve Wilson in the Lab at ext. 3116 or 4050

if you have questions.

Biohazardous Waste Management It is VERY important that hazardous medical waste be

placed in the appropriate disposal system. The following are considered hazardous waste and must be disposed of properly. Chest tubes — Place in red bags Anything “wet” with blood or body fluid (gauze,

disposable towels, etc.) — Place in red bags Suction canisters — Use isolyzer and place in red bags Blood bags after infusion completed — Place in red bags All used syringes with needles — Sharps containers

(needle boxes) All sharps (needles, scalpels, suture needles, etc.) —

Sharps containers (needle boxes) *Always activate the safety device

VIOLENCE PREVENTION Violence can happen in any department

or area. Before violence strikes, there are

usually warning signs. These include:

Making threats, talking about or carrying weapons

Screaming, cursing, challenging authority Restlessness, pacing Violent gestures, such as pounding on a desk A loner, someone angry and depressed

VIOLENCE PREVENTION You can help prevent violence by:

Treating everyone with respect Checking the patient charts for history of

violence or aggression, alcohol or other drug abuse

Trusting your gut feelings Watch for warning signs Try to spot—and head off—trouble before it

turns to violence Staying calm if someone starts to lose

control Don’t let your escape path get blocked

VIOLENCE PREVENTION To reduce your risk for potential injury

use the following guidelines: Notify security at the first sign of a potentially

violent situation Communicate in a low, calm tone of voice Allow the person to voice their feelings It’s important to stay calm and maintain self-

control Avoid defensive words or angry gestures Do not argue Do not turn your back on the person If possible, give the person what they demand

Emergency, someone call FOR HELP!!! Question: What do you do in the hospital

when you need help in a hurry? Answer: Call extension 4000 or 4060. The

switchboard will answer your call immediately. This extension should be used the same as if you needed “911”. It is designed for emergency situations, not just to get through to the switchboard in a hurry. For example, this line could be used for a Code Blue or if a visitor was seriously hurt.

NEVER use this phone line for anything other than emergencies!

RECOGNIZING ABUSE & NEGLECT Signs of Abuse

History inconsistent with nature and extent of injury

Delay in seeking medical treatment Frequent Emergency Room visits Accident prone Discrepancy in patient’s and family’s story Bruises in various stages of healing History of previous trauma in patient or

sibling

Reporting Abuse Nursing Interventions:

Routinely screen during each patient encounter. Screen one-on-one in a private environment. Assess patient’s immediate safety. Listen with a non-judgmental attitude. Document in the medical record the following: abuse history

(subjective and objective), results of safety assessment, authorities notified, family notified, treatment given, and any safety instructions provided.

The person suspecting the abuse should notify Social Services during weekday hours and the House Supervisor at night and on weekends to inform them of the situation. These resource persons will assist with the notification of the authorities.

Reporting Abuse Reporting Responsibilities:

Notify the MD. Notify DFACS or Adult Protective Services (APS) of the

possibility and the appropriate authorities. GA has general mandatory reporting laws. MUST report to

law enforcement the following: injuries resulting from general violence and injuries inflicted by gun, firearm, knife, or other sharp object.

Resources: Department of Family and Children Services (DFACS): 706-294-6500 / Police Dept: 911 / Battered Woman/Domestic Violence Hotline: 1-800-334-2836 / Prevent Child Abuse GA: 1-800-532-3208

Adult Protective Services: 1-888-774-0152

RECOGNIZING ABUSE & NEGLECT Signs and Symptoms of

Neglect Failure to thrive Poor hygiene Dehydration Malnutrition Poor social skills

CULTURAL COMPETENCY Cultural competence means

providing medical care in a way that takes into account each patient’s values, beliefs, and practices.

Culturally competent care promotes health and healing.

CULTURAL COMPETENCY The healthcare provider must have an

understanding of the predominant cultures that exist in the geographic area in which s/he provides patient care. Because the U.S. is so diverse, certain cultures may not be seen in all areas of the country.

Cultural reference materials are available in each of the patient care areas. These reference materials cover various cultures and religions.

CULTURAL COMPETENCY Some of the major cultural domains that need to be addressed in

the delivery of transculturally-competent patient care include: Communication (language) Family roles and family organization High-risk health behaviors Nutritional habits and preferences Pregnancy and childbearing practices Death rituals Spirituality/religion Healthcare practices Alternative healthcare providers (folk

practitioners)

CULTURAL COMPETENCY A very important aspect of cultural

competency is the avoidance of stereotyping.

We must not presume that all people of a certain culture adhere to all aspects of their culture. The healthcare provider must identify which aspects are appropriate for each patient during the admission process.

CULTURAL COMPETENCY Communication begins with identifying the

patient’s primary language. Family members, friends, and other Healthcare providers can assist with interpretation of the patient’s history, chief complaints, needs, etc.

As a staff member, if you have any cultural or religious preferences that might impact on your delivery of patient care please let your supervisor know.

Cultural Competency To achieve the important goal of preventing, identifying and resolving

barriers maintain the following principles :

Inclusiveness. Strive to prevent exclusion any of patient or staff member. Respect is showing appreciation and regard for the rights, values and

beliefs of others. Respect. Foster an environment that maintains respect for cultural

differences between patients and staff members. Value. Appreciate and value cultural differences. Diversity is a state of being diverse; difference; unlikeness; variety;

multiformity. Service. Strive to provide accessible services to every patient. Understanding. Try to assess and identify the needs of the culturally

evolving patient population and incorporate those needs into your programs and practices.

Compliance. Adhere to all applicable federal and state laws and regulations addressing limited English proficiency and cultural competency.

FIRE SAFETY Make good housekeeping part of your work

routine. Keep passageways and exits clear.

Don’t let furniture or equipment block stairways, halls, or exits.

Keep floors clear of waste and spills. Make sure exit paths and doors are well-lit and

clearly marked. Know your area.

Where are the fire pull stations and extinguishers Know how to extinguish

Cover and smother Be careful to not fan the flames

FIRE SAFETY Check fire doors.

Make sure nothing is blocking them. Never wedge or prop them open.

Dispose of trash safely. Put waste in approved containers.

Keep these away from heat sources. Put flammable substances in

approved metal cans or containers.

FIRE SAFETY Prevention is the best defense

against fires. To prevent fires related to

electrical malfunction remove damaged or faulty equipment from service and submit malfunctioning equipment for repair.

To prevent fires related to equipment misuse do not use any piece of equipment you have not been trained to use.

All Foam and Gel Hand Cleaners Foam and gel hand cleaners are becoming very popular for hand cleaning in the

healthcare environment. For them to be effective they must contain more than 60% alcohol. That makes the hand cleaners FLAMMABLE. It is not unsafe to use the hand cleaners, but you should be aware of the following information each time the hand cleaner is being used:

After applying the gel or foam, the alcohol on the hands should be allowed to evaporate for 30 seconds. You could wave your hands in the air to accelerate the evaporation.

The solution on your hands is flammable until the alcohol evaporates. If a flame or spark is near your hands before the alcohol evaporates, a fire could

occur. There have been reports of healthcare workers whose hands caught on fire from a spark or from static electricity after using an alcohol based hand cleaner.

Alcohol burns very clean and the flame is almost clear.

Information Security Redmond Regional Medical Center relies heavily on computers to meet its

operational, financial, and informational requirements. The computer systems, related data files, and the derived information are important assets of the company. Redmond has established a system of internal controls to safeguard these valuable assets by processing information in a secure environment. As a Redmond employee, you are expected to share the responsibility for the security, integrity, and confidentiality of this information.

Policy EnforcementAny employee who has knowledge of a violation of the IT & S

Security policy must immediately report the violation to his/her supervisor. Anyone who violates the policy is subject to:

Suspension Termination Civil and/or criminal prosecution Other Disciplinary action

Secure your workstation at all times!

Information Security RRMC standards and policies include

information about: Individual accountability for the use of any

computing and network resources The authentication process to allow access to, and

use of, systems and networks Audit trails of sensitive security events A means to ensure the integrity of systems,

networks, and processes The design and implementation of security controls

with adequately met identified risks The controls necessary to interface Redmond

computer systems/networks with foreign computer systems/networks

Please refer to policies IS.SEC.001 – 005 for additional information.

Information Security Appropriate Access

Access is based on your job function and your “Need to Know”.

User ID and Password Your assigned 3-4 ID and password

identifies and authenticates you as a valid user of an electronic system or application. In order to insure proper documentation, you should never write down or give your User ID or Password to anyone else. You should never use anyone else’s User ID and Password.

Information Security Guidelines for creating a good quality password

Eight characters or more Uppercase and lowercase letters Combinations of letters and numbers Easy to type Made up of a “pass phrase”. Think of a phrase that is unique

and familiar to you, easy to remember, but not easy to guess. Inferior passwords

Your User ID or Account Number Your Social Security Number Birth, death, or anniversary dates Family members names (including pets) Your name (forward or backwards) Your favorite song, artist, author, etc A word or name found in any dictionary

Information Security Workstation Security

Protection of the workstation and its equipment is each employee’s responsibility. Control your work area fully so that ALL your equipment and information is kept secure.

Secure Workstations When not in use, hard copy information is kept in a secure

place Information on any screen or paper is shielded from casual

public view Terminals are not left active or unlocked and unattended Short (5-20 minutes) Screensaver “time-out” settings Company approved anti-virus software actively checks files

and documents Only company approved, licensed, and properly installed

software is used “Shareware” or downloaded Internet programs are not

permitted User ID and Passwords are not written down and physically

displayed “Log Off” and “Shut Down” your PC before leaving work

each day

Information Security Electronic Communications Promote effective and efficient

business communication Use e-mail and the Internet in a

productive manner Transmit information only to

individuals that are authorized to see it

Do not bypass system security mechanisms

Do not automaticaly forward messages using mailbox

Do not access or distribute obscene, abusive, libelous, or confidential information

Do not conduct any type of personal solicitation

Send only relevant information to people who need it

Do not use publicly accessible areas of the Internet to transmit or display info

Use e-mail and the Internet for highly limited personal use

Do not distribute chain letters rules to e-mail addresses outside hospital

Do not address another persons e-mail Do not transmit unsecured patient

identifiable or other sensitive and offensive material

Maintain and enhance the hospital’s public image

*Do not use electronic communication for any purpose which is illegal, against company policy, or contrary to the company’s best interest

Information Security Social Engineering “Social Engineers” are individuals who attempt to

gain access to systems of confidential information through the manipulation of others. Using a combination of basic knowledge about a given business with some personal information or details that the “victim” will recognize, the Social Engineer converses with, wins the trust of, and extracts information from an employee.

To combat social engineering: Limit your conversations in public areas Be aware of your surroundings and who listens to

your conversations Identify as fully as possible anyone asking you for

information

Student Packet 2008 During the time you are completing this module, you may call 802-3382 for any questions. Also the Infection Control nurse is here.

Documents

valuesbased ethics

compliance program

compliance redmond

georgia false claims

federal false claims

hca ethics line

set of organizational

highest standards of