Dear Employee,
Congratulations on your upcoming anniversary with ColquittRegional Medical Center. The attached workbook has been designedto keep you current on general safety procedures at the hospital. Some of the sections will serve as a refresher, while otherportions will bring you up-to-date on recent changes. Yoursafety and the safety of those around you depends on yourknowledge of how to properly handle emergency situations.
After reviewing the contents of this workbook, please log into the web site and complete the annual safety test. If you have any special needs, please call
us at (229) 890-3548.
Remember, safety is everybody's business.
COLQUITT REGIONAL MEDICAL CENTER
GENERAL SAFETY STUDY GUIDE
2017
TABLE OF CONTENTS
INTRODUCTION ...... 1
EMERGENCY CODES...... 4-6
FIRE SAFETY ...... 6-8
HAZARDOUS MATERIALS ...... 8-9
PATIENT RIGHTS ...... 9-11
GENERAL UTILITIES MANAGEMENT PLAN ...... 12-14
PERFORMANCE IMPROVEMENT UPDATE ...... 14-15
BACK CARE AND SAFETY ...... 15-20
CUSTOMER SERVICE ...... 20-23
MRI (Magnetic Resonance Imaging) SAFETY...... 24
INFECTION PREVENTION AND CONTROL ...... 25-50
COLQUITT REGIONAL MEDICAL CENTER
EMERGENCY CODES
All employees are expected to be familiar with the overallhospital plan for emergencies. You should know what yourspecific duties are within your department. If you are unsureabout any of the following information, ask your department headto clarify it for you.
*MAKE SURE YOU KNOW WHERE OUR DEPARTMENT'S SAFETY MANAGEMENTPLAN IS LOCATED****MAKE SURE YOU KNOW YOUR RESPONSIBILITY IN ANYOF THESE EMERGENCIES**
Dial "5300" to page overhead.
Code Red - Initiates Fire
You may have a specific role such as: Removing patients/visitorsto safe areas behind fire doors, closing doors, or taking a fireextinguisher to the site of the fire.
Code Red Clear - Clears Fire
Code Triage - Disaster Plan Activation
A crisis that overloads the present staff in the EmergencyDepartment (i.e. automobile accidents, excessive injuries from atornado, etc.) You may be called back to the hospital to assistwith such items as: Calling in staff to assist, controllingupset visitors, or tagging incoming patients.
Code Triage Clear - Clears the Disaster
Code Orange - Hazardous Materials Release
Code Pink - Infant/Child Abduction
You will need to be sure all exits are monitored. Do not let people with children or large boxes, bags, etc. leave thehospital until they have been cleared or the infant/child hasbeen located.
Code Gray - Indicates a Security Problem
Alerts security of the potential/existing problem. Only designated personnel should respond to the area requestingassistance. All other staff should temporarily avoid this area.
Code Silver - Security Duress Code
Any staff member who encounters or suspects a person isbrandishing a weapon, an act of violence, or a hostage (orpotential hostage) should not attempt to intervene or negotiatebut dial 0 and report to the switchboard operator providing asmuch information as possible:
a. Location of incident (building, floor and room)
b. The number of armed persons and their behavior
c. The number of hostages, if applicable
d. Type of weapon(s) involved (handgun, long gun, knife,
bomb, etc.)
e. Injuries sustained (if any)
Employees may also dial 67 and page Code Silver.
Code Blue - Patient in Respiratory/Cardiac Arrest
Paging Number for Code Blue is (4444). This will automaticallylet the switchboard operator know the location of the code.
Bomb Threat: No Paging Code.
Departments will quietly be notified by phone.
If you should receive the phone call:
a. Keep individual talking as long as possible.
b. Get someone's attention and alert them to thethreat (write message
while you continue talkingwith the caller).
c. Listen to the callers voice. This may help youidentify the caller.
d. Listen for background noises that may tell youwhere the caller is
located.
e. Ask the caller where the bomb can be located andwhat time it is
expected to blow up. (Try todetermine if the caller knows the lay-out
of the hospital without directly asking them.)
f. Once the caller has hung up, notify yourDepartment Head, Nursing
Supervisor, orAdministration if this has not already been done.
Severe Weather "Watch" - Conditions are Favorable
Severe Weather "Warning" - Conditions are Present
These codes indicate hazardous weather in our area. You may beassigned to shut doors, close blinds, take any objects away fromwindows that could pose a potential hazard. Always know inadvance the safest areas that yoiu could go to if the weathershould get too severe. NEVER LEAVE YOUR PATIENT UNATTENDED.
FIRE SAFETY
If a fire starts in your area, follow the RACE procedure.
In fire safety RACE stands for:
Rescue - Rescue patients who are in immediate danger ofsmoke and flames.
Alarm - Alarm other staff to fire's location by pulling the fire alarm and
paging "Code Red" and giving location.
Confine - Confine the fire and smoke by closing the doorto the room that
has the fire.
Evacuate - Evacuate the area horizontally behind thenearest fire door.
*Fight the fire only if it is small and contained(like in a wastebasket), and
if you know how tooperate a portable fire extinguisher. Beforefighting
even a small fire, be sure that the areahas been evacuated and the fire
has been reported.
Class of fire Type extinguisher to use
Class "A" Wood, paper, cloth Water
Class "B" Flammable liquids Dry Chemical-Halon
(oil,grease,gas)
Class "C" Electrical Dry Chemical-Halon
NEVER USE WATER TO EXTINGUISH A CLASS "B" OR CLASS "C" FIRE! TO
DO SO COULD RESULT IN ELECTROCUTION AND DEATH.
An "ABC" fire extinguisher can be used for wood, paper, cloth,flammable liquid and electrical fires.
IMPORTANT: Depending on the type and size of extinguisher youare using, you may have only 8 to 60 seconds before yourextinguisher is empty.
MAKE THEM COUNT!
To operate a fire extinguisher, think PASS:
Pull - Pull the pin out of the extinguisher.
Aim - Aim the hose at the base of the fire.
Squeeze - Squeeze the handle of the extinguisher.
Sweep - Sweep the hose back and forth to put out the fire.
TOENTER A ROOM IN WHICH A FIRE IS SUSPECTED:
1. Feel the door carefully to determine if the door is HOT. Ifthe door is too hot
to maintain contact with - DO NOT ATTEMPTTO OPEN IT. Obviously, if the
door is that hot, whatever isinside the room has already been destroyed. To
open the doorwould create a "flashover" and the result would be injury toyou.
2. If the door is NOT HOT, stand to the side of the door andgently push it open.
NEVER STAND DIRECTLY IN FRONT OF THEDOOR.
3. Count to 15 before entering the room. You have introducedfresh air into the
room and a flash up or explosion ispossible.
4. Go in low and stay below level of smoke when attemptingrescues.
When attempting to rescue a victim, follow these guidelines:
If the victim's clothing or bedding is on fire SMOTHER THEFIRE:
- Cover the patient/victim from the side with a blanket,mattress pad, etc.
placing the covering directly on topof the victim will trap air and allow the
fire to continue burning).
- Smooth away air trapped beneath the covering. Air isoften trapped
between the arms and the body and betweenthe legs.
c. Remove the patient from the bed to an area of safety.
d. Be sure to close the door behind you when you exit theroom. This will keep
the fire from spreading to otherareas.
Remember to NEVER use an elevator during a fire emergency. Theelevator shafts act like a chimney and draw smoke in. There isalso the danger of the fire causing a mechanical failure andgetting trapped in the elevator.
Familiarize yourself with the location of the fire alarm pullstations and fire extinguishers in your area. Also note the location of smoke compartments.
HAZARDOUS MATERIALS
Information concerning the chemicals used in your areacan be found in the Material Safety Data Sheets (MSDS) notebooklocated in your department. Please ask your supervisor for thelocation. If you are not familiar with its contents, becomeaware of the information in this notebook. DO NOT WAIT FOR ANACCIDENT TO OCCUR! It may be too late to protect yourself.
Labeling: the higher the number, the greater the risk.
4 - Extreme
3 - Serious
2 - Moderate
1 - Slight
0 - Minimal
The alphabet letter on the label indicates the proper safetyequipment to be worn when cleaning up the hazardous chemicals.
Each department should have a Hazardous Materials Poster locatedin that department. This poster indicates which equipment is tobe worn with which alphabet letter. If you don't know thelocation of your poster, please ask your supervisor.
Every employee has the "Right To Know" what hazards areassociated with their job. If you have any doubts concerningyour safety and well-being, always ask your Department Head toexplain.
INFORMATION SYSTEMS
All information accessed in the Meditech system must be treatedas confidential. An employee may only access patient informationwhen needed to continue the treatment of the patient and/or forbilling/chart auditing information. Computer system passwordsare used to protect the confidentiality of patients and employeesand an employee's password should never be given to another
individual to use. Computer passwords expire every 90 days. Computer passwords leave an electronic audit trail and everyoneaccessing patient information will be held accountable for allinformation accessed with that password.
PATIENT RIGHTS
1. The patient has the right to considerate and respectfulcare.
2. The patient has the right to obtain from his physiciancomplete current
information concerning his diagnosis,treatment, and prognosis in terms the
patient can bereasonably expected to understand. When it is not medically
advisable to give such information to the patient, theinformation should be
made available to an appropriateperson on his behalf. He has the right to
know, by name,the physician responsible for coordinating his care.
3. The patient has the right to receive from his physicianinformation necessary
to be informed consent prior to thestart of any procedure and/or treatment.
Except in emergencies, such information for informed consent shouldinclude
but not necessarily be limited to specific procedureand/or treatment, the
medically significant risks involved,and the probable duration of
incapacitation. Wheremedically significant alternatives for care or treatment
exist, or when the patient request information concerningmedical alternative,
the patient has the right to suchinformation. The patient also has the right
to know thename of the person responsible for the procedure and/or
treatment.
4. The patient has the right to refuse treatment to the extentpermitted by law
and to be informed of the medicalconsequences of his actions.
5. The patient has the right to every consideration of hisprivacy concerning his
own medical care program. Casediscussion, consultation, examinations, and
treatment areconfidential and should be conducted discreetly. Those not
directly involved in his care must have permission of thepatient to be
present.
6. The patient has the right to expect that all communicationsand records
pertaining to his care should be treated asconfidential.
7. The patient has the right to expect that, within itscapacity, a hospital must
make responses to the request ofa patient for services. The hospital must
provideevaluations, service and/or referral as indicated by theurgency of
the case. When medically permissible, a patientmay be transferred to
another facility only after he hasreceived complete information and
explanation concerning theneeds for the alternative to such a transfer. The
institution to which the patient is to be transferred mustfirst have accepted
the patient for transfer.
8. The patient has the right to obtain information as to anyrelationship of his
hospital to other health care andeducational institutions insofar as his care is
concerned. The patient has the right to obtain information as to the
existence of any professional relationships amongindividuals, by name, who
are treating him.
9. The patient has the right to be advised if the hospitalproposed to engage in
or perform human experimentationaffecting his care or treatment. The
patient has the rightto refuse participation in such research projects.
10. The patient has the right to expect reasonable continuity ofcare. He has the
right to know, in advance, whatappointment times and physicians are available
and where. The patient has the right to expect that the hospital willprovide
a mechanism whereby he is informed by his physicianor a delegate of the
physician of the patient's continuinghealth care requirements following
discharge.
11. The patient has the right to examine and receive anexplanation of his bill,
regardless of source of payment.
12. The patient has the right to know what hospital rules andregulations apply to
his conduct as a patient.
Patient Responsibilities
13. The patient is responsible for providing, to the best oftheir knowledge,
accurate and complete information aboutpresent complaints, past illnesses,
hospitalizations,medications, and other matters relating to the patient's
health.
14. The patient is responsible for asking questions when they donot understand
what they have been told about the patient'scare or what he/she is
expected to do.
15. The patient is responsible for following the treatment plandeveloped with
the practioner. He/she should express anyconcerns he/she has about
his/her ability to follow theproposed course of treatment; the hospital, in
turn, willmake every effort to adapt the treatment plan to thepatient's
specific needs and limitations. Where suchadaptations are not
recommended, the patient shouldunderstand the consequences of failing to
follow therecommended course of treatment, or of using othertreatments.
16. The patient is responsible for the outcomes if he/sherefused treatment or
fails to follow the practitioner'sinstructions.
17. The patient is responsible for following the hospital'srules and regulations
concerning patient care and conduct.
18. The patient is responsible for being considerate for otherpatients and
hospital personnel by not making unnecessarynoise, smoking, or causing
distractions.
19. The patient is responsible for respecting the property ofother persons and
that of the hospital.
GENERAL UTILITIES MANAGEMENT PLAN
The General Utilities Management Plan is designed to providehospital personnel guidance in the response to failures ofutility systems that support the patient care environment. Utilities within the hospital setting include systems for
medicalgases, medical/surgical vacuum, communication systems, and data
exchange systems. Each staff member should be knowledgeable inthe appropriate action if an essential utility system fails. Employees should refer to the departments policies and proceduresfor more specific instructions in the area of utility failures asit relates to their respective departmental functions.
1. Loss of Electrical Power:
If normal electrical power is disrupted, the emergencygenerator should
provide electricity to the emergency(Red) outlets. All life support
equipment should beplugged into emergency outlets. Should emergency
power belost, appropriate clinical measures should be implementedby the
staff to effectively monitor patients status andall disturbances in electrical
power. This shall not belimited to total electrical failure.
2. Loss of Water Pressure:
In the event of water loss the Facility Operationsshould be notified to
initiate the emergency water supply.
3. Medical Gases:
Leaking Medical Gases can pose a serious hazard. Ifleaking medical gases
are encountered, the FacilityOperations, Respiratory Therapy Department,
and person incharge of the respective area should be immediatelynotified.
Measures should be taken to ensure that no electrical sparks or open flames
exist in that area. Thetype and quantity of leaking gas will dictate the
appropriate actions.
4. Loss of Central Medical Gas System:
In the event the Central Medical Gas System (oxygen, air,nitrous oxide) fails
to operate, the Facility Operationsand Respiratory Therapy should be
UTILITIES MANAGEMENT (Cont...)
immediately notified. All patient carriers should identify patients who
requirethe administration of oxygen and notify the RespiratoryTherapy
Department, so that a portable gas supply can besupplied to those patients
and/or areas. The OperatingRoom must maintain an appropriate level of
portablemedical gas tanks at all times.
5. Elevator Failure:
The Facility Operations should be notified in the eventan elevator ceases to
function properly. If an employeeis in the elevator and it ceases to function,
the employeeshould notify the switchboard by using the phone locatedin the
elevator. If a patient is on board thedysfunctional elevator, the operator
should be informedand asked to call the patients respective nursing station.
6. Communication Failure:
The Tele-Communications Department (Information Systems)should be
notified if the phone, paging system, nursescall system, two way radio
system, or computer system arenot functioning properly. If one
communication system isnot operational, another system may be utilized to
continue normal operations of the department. Example: If the beeper
system becomes inoperative, the phone systemmay be used to orally page
individuals, or should thetelephone system cease to operate, the EMT
service may usethe radio system to contact the police, sheriff’sdepartment,
or surrounding EMT Services who can thenappropriately divert calls. There
are also cellularphones in place with the operator and the nursing
supervisors.
In the event of total communications failure eachdepartment should
designate individuals to hand carrymessages. Communications outside the
hospital can beconducted through the EMT Radio Service and the cellular
phones. The EMT service can transmit radio messages viatheir hospital base
unit, mobile units, or portable unitsto the police department, fire
department, sheriff’sdepartment, or surrounding EMT services.
UTILITIES MANAGEMENT (Cont...)
7. Medical/Surgical Vacuum Failure:
If the Central Vacuum System becomes dysfunctional theportable suction
unit should be utilized. These units maybe obtained from the Central Sterile