Mandatory for Your Safety

and theSafety of Patients

and Visitors

2017

• Infection Prevention Hand Hygiene Bloodborne Pathogens Blood Spills and Exposures Personal Protective Equipment(PPE) Sharps Safety Standard Precautions

• TB Symptoms & Precautions

• Emergency Codes

• Medical Gas Shutdown

• Safe Handling of Compressed Gas Cylinders

• Theft Prevention

● Safe Medical Devices Act (SMDA)

● Frequent Safety Rounds Issues

● Cleaning Patient Care Equipment

● Reporting Adverse Events

● BCA (Downtime)

Hand Hygiene Requirements for Cone Health Employees:

• Perform Hand Hygiene:1) Upon entry and exit of a patient room or patient care space,

even if vacant

2) Before & after glove use

3) After contact with patient environment

• Staff with supplies may enter and put the supplies down and then perform Hand Hygiene

• Staff going from one room directly to the next or across the hall without touching anything may perform Hand Hygiene when exiting the first room

• Hand hygiene compliance is required per Cone Health policy

The BBP Exposure Control Plan provides information on:• Hepatitis B Vaccinations

• Jobs and tasks that are risky

• How to choose Personal Protective Equipment (PPE)

If you have questions about BBP:

• Contact Health at Work or Infection Prevention

• After hours, hospital staff contact the Administrative Coordinator

• Refer to the Bloodborne Pathogen: Management Plan

To clean a blood spill:1) Put on gloves and other PPE appropriate to the size of the spill

2) Contain the spill

3) Clean up the blood and dispose of appropriately

4) Spray the surface with an approved disinfectant

5) Wipe clean

If you are exposed to blood or other body fluids:

1) IMMEDIATELY wash the exposed skin with soap and water or hand sanitizer (if soap & water not immediately available). Flush mucous membranes with water or saline

2) Report to your Health at Work nurse or the Administrative Coordinator after hours

3) Complete Report of Injury, Illness, or Exposure through Safety Zone Portal

When handling blood or “Other Potentially Infectious Materials” (OPIM) and anytime there is a risk of a splash you MUST use the following PPE:

• Gloves – when handling blood or OPIM

• Gowns – when there is a risk of splash of blood or OPIM to clothing

• Masks and Goggles (both) or Face Shields –

when blood or OPIM could splash your face

Make sure you know where to find these items and how to use PPE!

Sharps Safety Devices are for your protection and, by law, you MUST use them! Examples of Sharps Safety Devices:• IM/SQ needles and syringes• Needle-less IV tubing sets• Safety lancets• Phlebotomy devices• IV safety catheter

ALWAYS discard sharps, and ONLY sharps, in a sharps disposal container!

Safety Devices MUST be activated before disposal!

Standard Precautions are designed for the care of all patients regardless of their diagnosis or presumed infection status.

These precautions apply to the following: • Blood• All body fluids• Secretions and excretions (except sweat)• Non-intact skin, and • Mucous membranes

Standard Precautions is for ALL Patients in Healthcare

• Care and cleanliness of Cone Health• Cough etiquette and respiratory hygiene• Safe handling of laundry• Patients on precautions and safe transportation• Handling of dirty patient-care equipment,

instruments and devices

In addition to hand hygiene, PPE, and safe injection practices, other elements of standard precautions include:

For more details, see theInfection Prevention Standard andTransmission Based Precautions Policy

• Persistent cough• Bloody sputum• Weight loss• Night sweats

If a patient displays these symptoms, place a surgical/isolation mask on the patient until you can move him/her to a negative pressure room

For more details, refer to the Tuberculosis (TB) Management Plan

To prevent the spread of TB:

Patient• Place on “Airborne Precautions” in a

negative pressure room

• Patient must wear a surgical mask when outside the negative pressure room or when a negative pressure room is not available

Employee• Before entering room, put on N95 mask or

PAPR

• Educate patient/visitors to follow precautions

• Notify Infection Prevention and Facilities Management

Three types of emergency alerts will be used by Cone Health:

(i.e. cardiac arrest)

1. Facility Alerts

2. Security Alerts

3. Medical Events

(i.e. hazardous material spills and fires)

(i.e. active shooters and missing persons)

Some of these emergency alerts are not overhead announced but get sent directly to specialized response teams via pager

Facility AlertsEvent Recommend Plain Language Notes Sample Scripting

Evacuation Facility Alert + Evacuation +Descriptor + Location

Overhead: Your attention please, Facility Alert, Immediate Evacuation, Unit 5Central.

Fire / Smoke Alarm Facility Alert + Fire/Smoke Alarm + Descriptor + Location Overhead: Your attention please, Facility Alert, Fire Alarm activation Unit 5North.

Hazardous / Materials Spill Facility Alert + Chemical Spill + Descriptor +Location

Overhead: Your attention please, Facility Alert, Chemical Spill, 1st

Floor Laboratory.

Mass Casualty Facility Alert + Mass Casualty + Descriptor (may have levels) + Location

Overhead: Your Attention Please, Facility Alert, External Mass Casualty Incident, Emergency Department.

Medical Decontamination Facility Alert + Medical Decontamination +Descriptor (biological, chemical, radiological, or unknown) + Location

Overhead: Your Attention Please, Facility Alert, Medical Decontamination event, Emergency Department. Decontamination Team please report to the Emergency Department.

Surge Capacity/Mass Casualty Facility Alert + Surge Capacity/Mass Casualty + Descriptor (may have levels) + Location

Overhead: Your Attention Please, Facility Alert, Mass Casualty Incident, Emergency Department.

Utility / Technology Interruption Facility Alert + Type of Service Interruption +Descriptor + Location

May not overhead page but may be sent as an

Email message

Overhead: Your Attention please, Facility Alert IT Network Downtime, Implement downtime procedures for (patient charting, VoIP phones, and paging systems)

Weather Facility Alert + (Instruction) + Weather +Descriptor (National Weather Service Statement)+ Location

Also sent via email and text messages

Overhead: Attention, Facility Alert Tornado Warning. Move away from windows to interior portions of the building. The National Weather Service has issued a Tornado Warning for the local area in effect until (time).

Security AlertsEvent Recommend Plain Language Notes Sample Scripting

Missing Infant / Child <18 yrs.

Security Alert + Infant/Child Abduction + Descriptor (gender) + Last Seen Location

Overhead Page: Security Alert Infant Abduction, male infant, last seen in room 322.

Decisionally-Impaired Missing Person >18 yrs.

Security Alert + Missing Person + Descriptor(Age, gender) + Last Seen Location

Overhead: Security Alert Missing Person 65 year old female wearing a hospital gown last seen 4th Floor West Wing.

Armed Intruder / Shooter/ Hostage Situation / Threat of Violence

Security Alert + (Instruction) + Descriptor + (Type of Threat) + Location Not Overhead Paged. Use Emergency Lockdown

Announcement

Radio Communications to Officers:

Bomb Threat / Suspicious Package

Security Alert + (Type of Threat) + Descriptor + Location Not Overhead Paged. Sent via email and phone

notification to identified areas.

Phone or text notification to Officers:

Emergency lockdown Security Alert + Controlled Access + Descriptor +Location Overhead: Attention, Security Alert, Emergency Lockdown Emergency Department. (Radio Communications to Officers with details)

Medical AlertsEvent Recommend Plain Language Notes Sample Scripting

Medical Emergency or Incident Medical Alert + (Type of Emergency-Incident if available) + Descriptor + Location

Not Overhead paged. Send via Emergency response Team, Pagers and phones

Phone or text notification to Emergency Team Members

To Report a MEDICAL EMERGENCYCall the emergency number for your facility and state the:

1. Specific request

2. Location, and

3. Patient age (adult vs pediatric).

Example: Code Blue, 1st floor radiology MRI room, adult

escue anyone in immediate danger!

ctivate the Alarm & Call the Emergency Number!

lose Doors & Windows!

xtinguish the Fire if Possible, Evacuate if Necessary!

4 Steps to Respond to a Fire:

1)

2)

3)

4)

4 Steps for using an extinguisher - P.A.S.S.1 2 3 4

When using a common/shared computer:

From the SharePoint home

page, look on the list of Applications

and click on MSDS Online.

When using your personal workstation:

From your SharePoint home

page, click first on Resources.

Then scroll down and click on

MSDS Online.

However you get here, then go to

MSDS Search…

And search for the product you

need a safety data sheet for.

Phasing in New Symbols…

Hazard Communication

Standard PictogramAs of June 1, 2015, the Hazard Communication Standard (HCS) will require pictograms on labels to alert users of the chemical hazards to which they may be exposed. Each pictogram consists of a symbol on a while background framed within a red border and represents a distinct hazard(s). The pictogram on the label is determined by the chemical hazard classification.

• The department’s charge nurse (or designee) shall contact Facilities, describe the circumstances and determine if shutdown is necessary.

• Clinical personnel receive authorization from nurse in charge to initiate shutdown.

• Remove the cover on the valve box.

• Grasp the handle on the affected gas line and pull forward, rotating the handle outward until it is fully closed and protruding from the valve box.

• Close all other affected medical gases in like manner.

O2 tanks and other compressed gas cylinders can explode!

They must be handled with extreme care!

• Secure with a chain or in a rack when stored

• Use only an approved carrier during transport – an approved carrier is designed for this purpose

• Store in limited quantities - No more than 12 tanksare allowed in one smoke compartment unless stored in an approved cabinet

• Full, Empty, and Ready to Use tanks must be stored separately and clearly labeled for easy identification

Reduce your risk of becoming the victim of a theft. Your best defense is to limit the opportunity. Here are some basic

security reminders…

Security awareness is everyone’s business

Parking Lots:• Keep valuables out of sight

• Place money, purses/wallets, GPS devices (and holders), packages & shopping bags in your car’s trunk

• Always lock your vehicle

• Park in well-lit areas

• When it’s dark outside, walk to your car with friends & co-workers. You may also request an escort by calling Security Services, if available.

• Secure motorcycles & mopeds; Secure bicycles with a lock in the bicycle rack

• Be aware of your surroundings! Walk with purpose and avoid using your cellphone or texting.

Security awareness is everyone’s business

At Work:• Lock valuables and personal items in a

desk drawer, locker, or enclosed office.

• Always wear your Cone Health ID badge. Notify Security Services immediately if you lose or misplace your badge.

• If an unfamiliar person is in an employee area without an ID badge, do not assume they are supposed to be there. Ask how you can assist and call Security Services immediately if they act suspicious.

• If you misplace or lose your keys, notify Security Services as soon as possible.

• Be aware of your responsibility to protect patient’s property from theft.

Security awareness is everyone’s business

Cone Health Security Services:

Security awareness is everyone’s business

• Moses Cone Hospital• Wesley Long/BHH/LeBauer• Women’s Hospital• Annie Penn Hospital• Alamance Regional • High Point MedCenter• Kernersville MedCenter• Off-site Locations

2-78492-18502-4900(336) 951-4478(336) 586-4297(336) 884-3648(336) 992-5100Call 911

Federal law requires a REPORT of all incidents where there is a reasonable suspicion that a medical

device caused or contributed to a patient’s:

Serious Injury Serious Illness DeathMedical devices include anything, other than drugs, used in a patient care or diagnostic setting. Here are some examples:

• Defibrillators• Monitors• Implants• Lab Devices

• Bandages• Infusion Pumps• Catheters • IV Sets

• Beds• Wheelchairs• Rehab Equipment• Lift Equipment

Incidents are reportable if they: • Require surgery or medical intervention,• Result in permanent impairment of a body function• Permanently damage a body structure

If a patient is injured by a medical device:1.Take care of patient’s immediate needs2.Remove device from use (save all settings and disposables)3.Label device – “Do not use”

with the date & time4.Alert your supervisor5.Go to Cone Connects under

Tools & Resources

6.Choose and Complete a Safety Zone Portal (SZP)

Blocking Vital Safety EquipmentEyewash StationsOxygen Cylinders

•Medical gas panels

• Electrical panels

• Fire extinguishers

• Fire doors

• Fire alarm pull stations

NEVER Block the Following Items

Blocking Vital Safety EquipmentEyewash StationsOxygen Cylinders

Eyewash Stations

• Flush weekly and enter into log

•Must activate with one motion

Blocking Vital Safety EquipmentEyewash StationsOxygen Cylinders

Oxygen Cylinders

• “Full” tanks have NEVER been opened. A good way to remember where to put a tank – Never put a tank back in the full rack once you have taken it out.

• Ready to use tanks have been opened and are greater than 500 PSI.

Always Wear Gloves When Using These Products

“Purple Top” Super Sani-

Cloth

BleachWipes

• Wet/Contact Time = 2 Minutes

• Cleans BP Cuffs, stethoscopes, bedrails, IV Pumps, Glucometers

• Use for items/surfaces contaminated with blood/body fluids

• Wet/Contact Time = 4 Minutes

• Use for Equipment from rooms where patient is on Enteric Contact Precautions

Three regulatory agencies mandate pharmaceutical waste collection:

EPA

NC Department of Environmental Quality

DOT

Our pharmaceutical waste program will be changing in the near future, so keep an eye out for more information about that. For now, however, let’s review the basics of our current program…

Infectious Medication WasteDiscard in regulated medical

waste sharps container

Human Albumin Thrombin

Fluids with No Added Medications

Discard down the sink drain

• Normal saline• D5W

• Lactated ringers

Solid WasteDiscard in the trash

• Empty vials• Empty IV bags

Discard in sharps container

• Empty syringes, including needleless devices

Hazardous Drug Waste

Place empty packaging in a

plain, clear, plastic bag, seal, and

dispose of in the black bin

• Coumadin (warfarin)• Nicotine gum and patches

Inhalers and Aerosol Sprays

Return to pharmacy for disposal

Corrosive AcidsReturn to Pharmacy for

further segregation

Any partial medications in this categoryPharmaceutical Waste Segregation Chart

(click on the chart to see it in more detail)

What is an Adverse Event/Incident?“Any happening not consistent with the routine operation of Cone Health or the routine care of a particular patient. Such incidents may or may not result in actual injury”.

Examples: Skin tear, pressure ulcer, fall, medication error, needle on a meal tray, skin marker that is not visible, unsuccessful catheter insertion, lab specimen mislabeled

Why report adverse events?When you report incidents and near misses you help make Cone Health a safer place for patients, staff and visitors

How do you report adverse events?Report adverse events/incidents via SafetyZone™ Portal (SZP)

On your personal SharePoint page, find it in the Quick Links, and on a shared computer, scroll down to the bottom of

the Applications list.

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There are two types of downtimes:

• Scheduled DowntimeIntentional downtime planned in order to have various technical updates and/or fixes applied

• Unscheduled DowntimeUnanticipated downtime due to internal or external issues with the system

Downtime is a period of time where access to Cone HealthLink [EPIC] is eliminated or restricted.

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There is a CHL downtime policy and procedure in place that outlines the downtime procedure that should be followed.

This P&P covers:

• using the BCA computers within the department • completing work using paper forms, and• using other electronic platforms for retrieving information.

You should be familiar with your dept-specific procedure!

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Most areas have a BCA Downtime computer that stores reports/forms to use during a scheduled or unscheduled downtime.

You should ALWAYS know where your BCA computer is located and how to access paper forms.

Patient care/daily operations should remain at a high level during downtime, as well as at any other time.

For questions concerning the content of this course or other Safety related questions or concerns, contact:

Cone Health Safety Office

832-4357

Safety@conehealth.com

Follow these links to explore the important policies mentioned earlier in the presentation:• Bloodborne Pathogen Management Plan• Infection Prevention Standard and Transmissions

Based Precautions• TB Management Plan• Medical Gas Shutdown

Now let’s see what you’ve learned!

It’s time to proceed on to take the test.

And remember… the passing score is 100%