ANNUAL SAFETY EDUCATION 2015

Transcription

A U LT M A N H E A LT H F O U N D AT I O N
A U LT M A N H O S P I TA L
Thank you for participating in the 2015 Annual Safety
Education Program. This program will help you to meet
your mandatory safety education requirements, as required
by The Joint Commission, hospital administration, the
Occupational Safety and Health Administration (OSHA)
and various other regulatory agencies.
Additional educational subjects are included at the conclusion
of the newsletter. It is your responsibility as an employee to
read and understand these topics and apply them as needed.
In order to meet your requirements, you must read this
newsletter, follow the directions based on your role in
the organization and complete the post-test through the
organization's Learning Management System. You must
score 80% or greater to successfully pass the post-test. If you
have any questions while reading this newsletter or taking
the post-test, please contact your supervisor or the Safety
Department at ext. 34293.
TABLE OF CONTENTS
ENVIRONMENT OF CARE
Ohio Emergency Codes..........................................................1
Emergency Preparedness Plan for Utilities.........................2
Security Services...................................................................2
Fire Safety..............................................................................3
Incident Reporting and Root Cause Analysis......................3
Tobacco-free Policy ...............................................................4
Safety Counts Every Time ...................................................4
Hospital Incident Command System....................................5
MRI Safety and You..............................................................5
Mass Notification System......................................................5
Needlestick/Significant Exposure Safety.............................5
Back Injury Prevention and Lifting Techniques..................6
Forensic Education................................................................6
Workplace Violence...............................................................6
Hazardous Communications.................................................7
Concealed Weapons...............................................................8
Seasonal Safety .....................................................................8
Negative Air Flow Rooms......................................................9
Electrical Safety.....................................................................9
Patient Owned Equipment....................................................9
Cellular Phones......................................................................9
INFECTION CONTROL
Tuberculosis Control.............................................................9
Bloodborne Pathogens .........................................................9
Infection Prevention and Control.......................................10
PATIENT CARE
HRO......................................................................................11
2014 National Patient Safety Goals...................................12
Right to Meaningful Knowledge.........................................17
Patient Rights......................................................................17
Alarm Safety........................................................................17
Medical Devices and Patient Safety...................................17
Falls Assessment.................................................................17
Pain......................................................................................18
Restraints.............................................................................18
Stroke Safety........................................................................19
Early Heart Attack Care.....................................................19
Abuse/Neglect......................................................................20
COMPLIANCE
Accrediting Bodies...............................................................16
Corporate Compliance.........................................................20
Privacy and Confidentiality................................................20
OHIO EMERGENCY CODES
Aultman Hospital adopted the Ohio Emergency Codes in 2003. They continue to be the standard that all Ohio
hospitals use for notification of emergencies. Community first responders dedicated to public safety (police, fire,
EMS) have also adopted these codes.
CODE RED
Fire (Paged Overhead)
Fire alarm pull stations are located near exits and
stairwells. Please locate the one closest to your unit.
In the event of a Code Red, please follow the fire safety
recommendations as instructed on page 3 of this
newsletter. Remember RACE and PASS!
CODE ADAM
Infant/Child Abduction (Paged Overhead)
Dial ext. 36777 if an infant or child is missing or
known to be kidnapped. Upon hearing Code Adam
paged overhead, employees should secure all halls,
stairwells, elevators, exits and bridges leading
to and from the hospital. Any person carrying an
infant or child, or object large enough to conceal a
newborn infant should be stopped, and the object
should be checked. If the person does not consent to
an inspection, do not allow him or her to leave the
property. Call Security Services immediately at ext.
36777. Refer to the Emergency Management Quick
Reference Guide for additional information. Satellite
facilities should call 911 in the event of a Code Adam.
CODE BLACK
Bomb/Bomb Threat
In the event of a bomb
threat, keep the caller
on the line, and signal
to another employee to
call Security Services
immediately at ext.
36777. Begin asking the
caller the questions from
the back of the green Bomb Placard sign posted on your
unit. Remember to write down the caller’s responses!
Things to remember during a call:
1.Remain calm.
2.Keep the caller on the line as long as possible.
3.Ask and write down as much information as you can.
Be aware of the sound of the caller’s voice, accents,
background noise, etc.
If a suspicious item is found, DO NOT TOUCH IT.
Call Security immediately.
Refer to the Emergency Management Quick Reference
Guide for additional information. Satellite facilities
should call 911 in the event of a Code Black.
CODE YELLOW
Disaster (Paged Overhead)
An internal/external disaster has occurred. Each
department or unit has a specific plan. Send
additional staff to the labor pool in the Morrow House
Auditorium. DO NOT REPORT DIRECTLY TO
THE EMERGENCY DEPARTMENT. Refer to the
Emergency Management Quick Reference Guide for
additional information.
CODE GRAY
Tornado/Severe Weather (Paged Overhead)
Code Gray is implemented during periods of severe
weather, based on alerts from weather services – or
in response to municipal tornado siren activations.
This process was revised in 2012 and eliminated
the practice of using multiple phases. Staff
will be notified of Code Gray implementation and
conclusion through a series of overhead pages. For
staff responsibilities and additional information, please
refer to the Code Gray policy and the Emergency
Management Quick Reference Guide.
CODE ORANGE
Hazardous Material Spill/Release
Contain the hazardous material, and refer to the
additional information. Notify the Spill Consulting
Team at ext. 36888.
CODE BLUE
Adult/Pediatric Medical Emergency –
Cardiopulmonary or Respiratory Arrest (Paged
Overhead)
Dial 35222 to activate. Refer to hospital policy for
CODE PINK
Infant Medical Distress (Paged Overhead)
Newborn in distress in Labor and Delivery, NICU
or the Emergency Department. Dial 35222. Refer to
hospital policy for additional information.
CODE VIOLET
Violent/Combative Patient
Immediately call Security at ext. 36777. Satellite
facilities should immediately call 911 for assistance.
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Ohio Emergency Codes continued
CODE SILVER
Person with Weapon/Hostage Situation/Active
Shooter Incident (Paged Overhead)
Dial 36777 for Security. Isolate patients, visitors
and staff, if possible. Security will reroute all
operational traffic away from areas above, below or
adjacent to the incident. Work cooperatively with the
responding police jurisdiction and Aultman Security
Services. Refer to the Emergency Management Quick
Reference Guide and educational resources on the
employee portal for additional information.
CODE BROWN
Missing Adult Patient (Paged Overhead,
Mr. or Mrs.)
Immediately notify security by dialing 36777. Staff
should monitor all entrances/exits to floor. Security
will monitor remainder of hospital. Code Brown
will be paged overhead and prefaced with a “Mr. or
Mrs.” depending on the patient’s gender. Refer to the
CODE WHITE
Severe or Inclement Winter Weather
Code White refers to extended periods of severe
or inclement winter weather conditions that may
adversely impact staffing levels and the facility’s
ability to provide patient care. Code White
operations include the identification of critical
employees and units, appropriate staffing levels,
lodging arrangements and transportation resources.
Please refer to the Code White Policy and the
CODE GREEN
Class A Reportable Infectious Disease
Code Green indicates the presence of a patient
suspected to have a Class A Reportable Infectious
Disease, as defined by the Ohio Department of
Health. The activation of Code Green is intended to
streamline the notification of key departments and
leadership. Code Green is activated by contacting the
hospital operator at extension 36888 (330.363.6888).
For additional information, please reference the
“Suspected Category A Pathogen Notification Plan
(Code Green)” on PolicyTech.”
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EMERGENCY PREPAREDNESS
PLAN FOR UTILITIES
MEDICAL GASES
In the event of a fire, the unit manager or charge
person makes the determination as to whether to
shut off the medical gases.
Call the following departments if
the oxygen is shut off: Respiratory
Therapy, Maintenance, Safety and
your administrator. Know where your
medical gas shut-off is located and how
to operate it.
COMMUNICATIONS
In the event of telephone failure, use the greenlabeled telephones located in selected areas
throughout the hospital. Please locate the greenlabeled phone closest to your unit. This phone will
have a large green sticker on the top, and emergency
use instructions. Two-way radios have also been
placed in all departments where green telephones
are located as well as in the NICU, CVSICU, CVOR,
CCU, Pediatrics and Psychiatry.
ELECTRIC
In the event of a power failure, the red, orange and
brown outlets will be powered by generators or
uninterruptable power supply (UPS) and can
be used for life-saving equipment. Only lifesaving
equipment is to be plugged into the red outlets. Coffee
pots, microwaves, toasters, etc. are not to be plugged
into these outlets at any time.
SECURITY SERVICES
Security officers help provide a safe and secure
environment for all employees, patients and visitors.
Aultman Security Services offers escorts to/from
vehicles, tire changes, securing of valuables and
response to emergency situations. Offices are located
in the registration area of the Emergency Department
and the ground level of the main hospital next to the
stockroom. Employees are responsible for reporting any
suspicious activities or persons to Security immediately
at ext. 36268.
MEDICAL ASSISTANCE
Person Appearing to Require Medical Aid
Dial 36777 if a visitor or employee needs medical
assistance. Satellite facilities should call 911 for
emergency medical assistance.
Aultman Security Services also provides 24 hour
coverage at Aultman Woodlawn and Aultman Orrville
and can be reached at the following numbers:
Aultman Woodlawn: 330-323-8252
Aultman Orrville: 330-466-6483
SATELLITE FACILITIES
Contact 911 directly in the event of an emergency,
then follow building-specific procedures.
Security is also available during business hours at the
following locations:
Aultman North Canton Medical Group: 330-495-8059
Aultman Pain Management: 330-454-7237
FIRE SAFETY
Fires are a threat in hospitals. According to the
National Fire Protection Association, thousands
of fires in hospitals are reported every year. Many
patients are helpless during a fire emergency due
to illness and special needs, increasing their risk of
injury or death.
There are four classes of fires:
CLASS A fires involve the burning of ordinary
combustibles like wood, paper, clothes, rubber or certain
plastics.
CLASS B fires involve the burning of gases and liquids.
CLASS C fires involve the burning of electrical
equipment such as appliances, air conditioning and
heating units, motors and generators that are plugged in.
CLASS D fires involve the burning of certain metals.
TYPES OF FIRE EXTINGUISHERS
Fire extinguishers are an important defense for
putting out fires and can save lives. Make sure you
know where the fire extinguishers are kept and how to
operate them.
In health care facilities, fire extinguishers are
designed to put out Class A, Class B and Class C fires.
ABC extinguishers can be used to fight any type of
hospital fires and are marked with an ABC.
If a fire starts, think and act quickly and safely.
Remember the steps associated with RACE and
PASS:
R - Rescue (anyone in harm’s way)
A - Alarm (by activating a pull station)
C - Contain (the fire)
E - Extinguish (using a fire extinguisher)
To use the extinguisher:
P- Pull the pin
A - Aim the nozzle at the base
of the fire
S - Squeeze the handle together
S - Sweep the extinguisher from
side to side
Be prepared before a fire occurs:
1. Review how to move patients to another unit on
your floor and how to move patients to a unit on a floor above or below your own.
2. Review exit routes.
3. Be familiar with pull station locations.
4. Keep the hallways of your work area free from obstructions.
5. Be familiar with smoke and fire walls.
6. Never block smoke doors, fire doors or exits.
7. Keep calm.
8. If evacuation is necessary, first evacuate horizontally past a fire seperation, then vertically if necessary.
I N C I D E N T R E P O R T I N G A N D R O O T C A U S E A N A LY S I S
Safety Values: At Aultman, safety is our top priority.
As Aultman team members, we are expected to:
•Work to provide a safe environment.
•Always communicate safety concerns.
•Participate in safety education.
•Recognize safety excellence.
•Contribute ideas to improve safety.
•Immediately stop any process if a safety concern is
present.
Sentinel Event: Unexpected occurrence involving
death or serious physical or psychological injury or
the risk thereof.
Serious Safety Event (SSE): A deviation in
generally accepted performance standards that
causes moderate to severe harm or death to a patient.
Precursor Safety Event (PSE): Errors that reach
the patient, but cause minimal, temporary, harm or
no detectable harm.
Near Miss: Any process variation that did not affect
the outcome, but for which a recurrence carries a
significant chance of serious, adverse outcome.
Serious safety events and/or sentinel events should
be reported immediately to your supervisor and
to Patient Safety Officer Laurie Clark, RN, at ext.
33923 in addition to entering a variance.
Root Cause Analysis (RCA): Process improvement
tool that focuses primarily on systems and processes
in order to identify potential improvements, and
decrease the likelihood of future adverse events.
Incident (Variance) Reporting: All quality and
patient safety concerns should be reported through
the electronic variance reporting system. Contact
Patient Safety Officer Laurie Clark, RN, at ext.
33923 if you need assistance with entering a report.
A variance report may be completed through the
safety tab on the employee portal.
Variance reporting is nonpunitive. However,
performance issues and certain actions may warrant
disciplinary action if an individual knew of or
intended to violate a policy, procedure or duty in the
course of performing a task.
Safety Concerns: General safety concerns can be
reported by selecting “Safety Suggestions” under the
“Safety” tab on the employee portal. Concerns may be
reported anonymously, or follow-up may be received
by selecting "yes" and entering current contact
information.
For more information, please review the sentinel event
and variance reporting policies on the employee portal.
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TOBACCO-FREE POLICY
As we continue to lead our community to improved health, Aultman Hospital and all of its other
buildings are tobacco-free. Employees, patients, visitors, physicians, students and contractors are not
permitted to use tobacco products in the building or anywhere on the premises, including parking lots,
sidewalks, streets and vehicles. The use of electronic cigarettes is also prohibited on Aultman grounds.
Please contact Human Resources for information on tobacco cessation assistance for interested employees.
SAFETY COUNTS EVERY TIME
At Aultman, safety is our top priority. As an Aultman team member, safety counts every time. Employees are
expected to work to provide a safe environment, communicate safety concerns, recognize safety excellence,
contribute ideas to improve safety, and immediately stop any process if a safety concern is present. The process
identified below outlines the steps that will occur if an employee experiences an injury on the job.
EMPLOYEE OCCUPATIONAL INJURY/ILLNESS:
An Employee injury/illness is any event or exposure occurring in the work environment that results in an injury or
illness. A near miss is an unplanned event that did not result in an injury or illness, but had the potential to do so.
EMPLOYEE OCCUPATIONAL INJURY/ILLNESS REPORT:
In the event of a work-related injury/illness, all employees are required to immediately notify their supervisor and
complete an “Employee Occupational Injury/Illness Report,” even if medical treatment is not required. This report
titled “Injury Report/Exposure,” is accessible under the “Safety” tab on the employee portal.
PURPOSE OF TIMELY REPORTING:
An “Employee Occupational Injury/Illness Report” serves as the official documentation of a work-related incident
and initiates the workers’ compensation process in determining if the incident was within the course and scope of
employment. Reporting also assists in notifying key personnel who identify and remove safety hazards, identify
trends, implement preventative measures and initiates revisions of policies/procedures to prevent the incident
from happening in the future.
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HOSPITAL INCIDENT COMMAND SYSTEM (HICS)
HICS is a nationwide system created to coordinate disaster responses among government agencies, hospitals, police, fire
and EMS. HICS can join hospitals and other response agencies together in a crisis. Everyone can communicate quickly
and effectively when using the structure of the incident command system, which is a flexible system designed around
standardized positions, rather than specific people.
Aultman’s Incident Command Center is located in the Heart Center Classroom on the third floor of the Bedford Building.
When a CODE YELLOW (disaster) is called, each unit should send a representative to the Labor Pool with the number
and type of staff members in their units. The Labor Pool meets in the Morrow House Auditorium. DO NOT
REPORT DIRECTLY TO THE EMERGENCY DEPARTMENT. Please refer to your Emergency Management
Quick Reference Guide for additional information.
Satellite facilities should follow policy and procedures directly relating to their specific building.
MASS NOTIFICATION SYSTEM
Aultman’s mass notification system is an Internet-based tool capable of
efficiently communicating emergent information to employees via phone,
text, email and pager. The mass notification system will only be used during
times of emergency or disaster. The mass notification system uses contact
information stored in the HR database to communicate. For the system
to accurately communicate, all employees must maintain current contact
information with Human Resources on an ongoing basis. Please refer to the
Mass Notification Policy for additional information.
MRI SAFETY AND YOU
There are general safety tips that
can keep you and your patient safe
when entering the MRI scanning
area:
•Remember the MRI is always ON.
•The magnet is very strong.
NEEDLESTICK/SIGNIFICANT EXPOSURE SAFETY
Standard universal precautions should be observed to prevent contact with
blood or other body fluids. All body fluids shall be considered potentially
infectious materials.
Sharps devices and changes in work practices are used to lower exposure
to blood or other potentially infectious material. Examples of sharps
devices include safety lancets, shielded needle devices, and retractable
angiocatheters. Examples of changes in work practices include not recapping
needles and the use of surgical blade removers. If these devices and changes
in work practice do not eliminate exposure, the use of Personal Protective
Equipment (PPE) is required (i.e., masks, gloves, goggles, gown, head and
foot coverings).
In the event of an exposure, the following steps should be taken:
1.For punctures, cuts, or abrasions: wash the affected area with soap and
water, make the wound bleed. For splashes to mucous membranes (eye,
nose, mouth): flush the affected area with tap water.
2.Call your supervisor immediately.
3.Fill out an Employee Occupational Injury/Illness Report and a
Communication Form for Significant Exposure. These forms should be
completed through the "Safety" tab on the employee portal.
•The closer you get, the
STRONGER the pull.
•Beware of all items that can
become projectiles – such as
oxygen canisters, keys, floor
scrubbers, hand tools, IP phones,
Caremobile units, etc.
•Medical implants such as
pacemakers, aneurysm clips
and TENS units can also pose
hazards. Injuries related to
dislodged implants can occur.
•Only use equipment that has
been tested and approved for use
within the MRI scan room.
ALWAYS check with an MRI
technologist before entering the
MRI room.
•Call the Employee Health nurse or supervisor immediately if the
exposure involved a known hepatitis or HIV-positive patient.
•Follow-up blood work, hepatitis vaccines, and tetanus vaccines are
available to employees free of charge.
•The patient’s results will be available in Health Services within 48 hours.
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BACK INJURY PREVENTION AND
LIFTING TECHNIQUES
Injury prevention is a major part of our commitment to
providing a safe working environment. Back injuries can result
when using the wrong lifting techniques. To help avoid injury to
your back when lifting and moving objects, three tips on proper
lifting are listed:
TIP 1: Plan Your Lift and Move
Each time you have to move an object or a patient, your first
step must be to plan your move. Planning your move means
making sure you have a clear path to your destination before
attempting to lift and move the load. Make sure the area
through which you are moving the load is clear of obstructions.
If there are obstructions, be sure to clear a path before lifting
and moving the load. Also, check that there are no dangerous
conditions anywhere along the path, such as a wet floor or steps.
TIP 2: Test the Load
Before moving the load, you must make sure you can handle
the weight comfortably. Test the load by gently trying to lift to
see if it’s too heavy or cumbersome to be moved. Either call for
assistance in moving it, or use a device such as a patient lifting
device, cart or dolly to assist you.
TIP 3: Bend the Knees, Keep
Upper Body Straight
You should lift an object by
bending your knees and keeping
your upper body comfortably
straight. Lift the object using
your legs, not your back.
When assisting a patient to transfer take your time and
think BEGINS:
• Belt: Always use a gait belt (Available for order by directors
on BOS). Place the belt around the patient while the
patient is seated and is safe at the edge of the bed. If unable
to safely sit at the edge of bed, consider use of lifting device.
• Edge of bed: Always make sure the patient is positioned
out toward the edge of the bed/chair, but not too far out
that the patient could slide off the edge.
• Get their feet underneath them: As far as they are
comfortably able to.
• Initiate: Let the PATIENT initiate the movement then
standby and assist as necessary.
• Nose over toes: The forward weight shift is essential for
the lift and descent. This is key to reducing the workload on
caregiver and the patient.
• Safety: If you have safety concerns, attain a second person
if you do not already have someone. If you still cannot safely
transfer the patient with a second person, consider a lifting
device. This will be safer for you and the patient.
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F O R E N S I C E D U C AT I O N
Aultman requires that all inpatient
prisoners be guarded continuously by
the custodial agency responsible for the
prisoner. Upon admission, the unit must
notify Aultman Security Services to make
sure that all policies and procedures are
followed. Patient rights will be maintained
with the exception of any legal restrictions
as determined and enforced by forensic
staff, such as limiting visitation or phone
use. Decisions affecting the care of the
forensic patient will not be based on
the criteria set by forensic staff. Upon
discharge, the patient will be returned
to the custody of forensic staff. Refer
to Patient Under Legal or Correctional
Restriction Policy.
WO RKPL ACE VIO LE N C E
Aultman is committed to providing a safe
environment for patients, visitors and staff.
As such, incidents of disruptive behavior
and workplace violence will not be tolerated,
and must be reported as soon as it is safe
to do so. Aultman will not retaliate against
employees making good faith reports
of incidents of disruptive behavior and
workplace violence. Workplace violence is
defined as any physical assault, threatening
behavior, or verbal abuse occurring in the
work setting. Disruptive behavior is defined
as conduct by an individual working in
the organization that intimidates others
to the extent that quality and safety are
compromised. Workplace violence incidents
may involve visitors, co-workers, patients/
customers and personal relationships. If you
experience any type of disruptive behavior
or workplace violence, remove yourself from
the situation, contact Security and/or law
enforcement, and notify your Unit Director/
supervisor. For additional information,
please reference the “ Disruptive Behavior
and Workplace Violence Prevention
Program” on PolicyTech.
HAZARD COMMUNICATIONS
The Hazard Communication Standard (OSHA 29CFR 1910.1200), known as the “Right to Know” standard,
originated in 1983 in the manufacturing industry and was adopted by the healthcare industry in 1987. The Hazard
Communication Standard was significantly updated in 2012, to include the adoption of the Globally Harmonized
System of Classification and Labeling of Chemicals (otherwise known as GHS).
Aultman’s “Hazard Communication Program” is available for reference through PolicyTech on the Employee
Portal. The Hazard Communication Program serves as Aultman’s blueprint for the 5 requirements of the standard,
which include a written program, the use of Safety Data Sheets (SDS), labeling, inventory, and training.
1. Written Program: Hazardous Communication
Program is located on the Employee Portal
under the Tools tab under Policies and
Procedures. It is designed to provide employees
with education to protect employees from contact
with hazardous chemicals at work.
2.
Safety Data Sheets (SDS): Safety Data Sheets
(formally known as Material Safety Data Sheets,
or MSDS) are technical bulletins that provide
information on a product’s chemical hazards.
With the adoption of GHS in 2012, Safety
Data Sheets now use a specific 16 section format,
providing consistency in the information
provided. Safety Data
Sheets can be accessed
through Aultman’s
MSDSonline® program,
available through the
“Safety” tab on the
Employee Portal.
The “Emergency Management Quick Reference
Guide” also has the SDS search instructions
under the Code Orange Section. In the event you
cannot find the SDS or your computer is not
working, call Security (ext.36268). For assistance
during business hours, questions can be
addressed to the Safety Department at
ext.34293.
3.
Labeling – chemical manufacturers are required
to have the new GHS label format implemented
by June 2015. Labels are required to have the 6
elements listed below with a GHS label example.
a.
b.
c.
d.
e.
f.
Product Identifier (on top of the label)
Signal Word (1)
Pictogram (2)
Hazard Statement (3)
Precautionary Statements (4)
Manufacturer Contact Information (5)
GHS Label Example:
If you have a concern about a label, contact the
Safety Department at ext.34293.
4.
Inventory: The hazardous material inventory
is maintained by the Hazmat Coordinator. It is
reviewed and revised annually, or as needed.
Each department is responsible for maintaining
their own hazardous material inventory. The
hazardous material inventory for each
department is reviewed during the
environmental tour process. Chemicals or
products not on the list should be reported to the
Hazmat Coordinator.
5.
Training: Employees receive training on the
Hazard Communication Standard through the
new hire orientation process. Additional training
occurs at the department level, as appropriate.
Toxicologists test materials and report the
level of materials of which we can work with
safely. This amount is called a permissible
exposure limit. Although we can work safely
with hazardous materials below this limit, the
best way to minimize risk is to keep our
exposure as low as possible. To do this, use the
lowest amount of a product necessary for the job,
use good ventilation, wear the appropriate
personal protective equipment (PPE), and avoid
contact with your skin or eyes.
Chemicals can enter the body through four
common ways:
1. Ingesting or eating the material: Eating or
ingesting chemicals usually occurs when food
and hazardous chemicals are used or stored
in the same vicinity.
2. Through the skin: Absorption through the
skin usually requires significant contact time
and can be minimized by preventing
exposure, wearing protective clothing, and
using good hygiene practices.
3. Breathing or Inhaling: Inhaling chemicals is
usually the most significant route of entry.
Using only the amount of chemical or product
necessary for the job, keeping containers
closed and maintaining good ventilation can reduce the risk of breathing or inhaling
the chemical.
4. Punctures, Cuts, Open Wounds: Chemicals
can enter the body through punctures, cuts
and open wounds. If you have any of these
injuries present, make sure they are
adequately covered and you are using
personal protective equipment.
7
ADDITIONAL HAZARD COMMUNICATION INFORMATION
1. Code Orange (Chemical Spill): Orange-colored Spill Management
Placards are posted in areas where spills can occur. Copies of the
placard are available thru the Safety Department upon request. The
Emergency Management Quick Reference Guide contains the Code
Orange procedure. It should be posted in your department. It is also
available on the Employee Portal under the “Safety” tab.
2. Blood Spill Safety: Blood spills must be cleaned using a solution
of 1:10 bleach to water, Red Z or an appropriate spill kit. Additional
supplies are available for order through Purchasing.
3. Hazardous or Unknown Substances Policy – This is located
on the Employee Portal, under the “Tools” tab under “Policies and
Procedures.” Aultman does not accept, for testing or storage, any
materials that are not used in routine business operations. Any
person who has such material will be referred to the appropriate
health department or county HAZMAT team. The procedure for
treatment of contaminated individuals is located in the “Care of the
Contaminated Patient with Hazardous Substances” policy, located
on the Employee Portal, under the “Tools” tab, under “Policies and
Procedures.” Any employee coming across situations as described
above must call Security at ext. 36777, who will then call the Safety
Director.
CONCEALED WEAPONS
Ohio’s concealed carry law allows an individual to obtain a license
to carry a concealed handgun in Ohio, including into private
businesses. Aultman has adopted a policy to restrict the carrying
of handguns or any concealed weapons onto any of its properties,
excluding governmental law-enforcement officers. Employees are
not permitted to carry firearms with them while performing in the
role of their jobs, regardless of location. Signs are posted at all main
entrances of Aultman.
Security and the unit supervisor should be notified immediately
if anyone is believed to be carrying a weapon. At no time should
employees put their safety at risk.
8
SEASON SAFETY
CAUTION ICE!
W AT C H Y O U R S T E P
The winter season can create
numerous hazards for Aultman
team members, visitors, and
patients. Weather related
conditions may cause an increase
in slip, trip and fall accidents
in parking lots, sidewalks and
building entrances. Employees
can keep themselves safe and
off the ground with these tips to
preventing slips, trips, and falls on
snow and ice.
Tips to Preventing Slips and Trips
on Snow and Ice
•Wear appropriate footwear
to increase traction. Smooth
leather soles and high heels offer
little traction on ice and snow.
•Use caution when entering
or exiting your vehicle and
pay attention to the surface
condition.
•Walk on surfaces that have been
cleared or treated when possible.
Avoid taking shortcuts.
•Avoid carrying large or heavy
loads that can throw off your
balance when walking.
•Avoid stepping on uneven
surfaces.
•Avoid walking with your hands
in your pockets, as this reduces
your ability to use your arms for
balance if you do slip.
•Slow down and take shorter
steps so you can react to a
change in traction more easily.
•Pay attention to detail when
walking on winter surfaces;
minimize distractions by
avoiding the use of cell phones
and other electronic devices
when walking.
•Report any unsafe conditions
immediately.
N E G AT I V E A I R F L O W R O O M S
ELECTRICAL SAFETY
All hospital-owned medical
equipment that is on a preventive
maintenance schedule should
have a white sticker listing the
inspection date and the followup inspection date. It is your
responsibility to look for that
sticker and make sure the date
for reinspection has not passed.
All non-medical equipment that
is on a preventive maintenance
schedule should have an asset
tag on it showing the equipment
number, model and serial number.
All negative pressure isolation rooms are tested for proper airflow on a
quarterly basis. When a negative pressure room is needed, nursing is to call
the Help Desk at ext. 36226 to have the negative pressure room tested. This
should occur prior to admitting a patient to the room. Once the room has
passed inspection, Maintenance will tell the charge nurse to document room
compliance and instruct the nurses to use their keys to turn on pressure
monitoring alarms (where applicable) outside the room. Nursing is required
to notify the Help Desk at ext. 36226 on a daily basis to ensure the room is
then checked daily until the patient is released. When the patient is released,
nursing should use their keys to turn off the pressure monitoring alarms
outside the room.
CELLULAR PHONES
The use of cellular phones is not allowed inside the hospital and in other
buildings where patient care is performed. Cellular phones are permitted for
usage by the public in all waiting areas, lobbies and cafeterias. Cellular phones
may interfere with medical equipment when used in patient care areas.
A N N U A L S A F E T Y E D U C AT I O N 2 0 15
B L O O D B O R N E PAT H O G E N S
Dealing with the possible contact of bloodborne pathogens is a usual
part of the day for many staff. By using standard precautions, we treat
everyone as if they have potentially infectious blood, body fluids and
moist body substances. It is important that all staff members take a
moment to protect themselves by first putting on appropriate personal
protective equipment (PPE) such as gloves, gowns, masks, eye covers/
goggles or additional coverings. Transmission can occur when body fluids
or moist body substances of a source patient have contact with a portal of
entry in the health care worker. In the health care setting, transmission
usually occurs through needlesticks, sharps injuries, or splashes to the
eyes, nose, mouth or open areas of skin. Our Exposure Control Plan helps
to educate staff to decrease the risk of transmission and is to be used
when caring for all patients. The standard precautions are a combination
of universal precautions and body substance isolation that focuses on
the isolation of all moist body substances including blood, feces, urine,
sputum, saliva, wound drainage and other body fluids.
Personal equipment such as
radios only need to be inspected
and stickered upon being
introduced into the facility.
Maintenance no longer requires
annual reinspection of these
devices. The owner of the
equipment will be responsible for
completing a daily inspection to
ensure electrical safety.
Call the Help Desk at ext.
36226 if you find any past-due
inspection dates or have any
equipment issues.
PAT I E N T- O W N E D
EQUIPMENT
All patient-owned electrical
appliances and medical
equipment must be checked prior
to use. Call the Help Desk at ext.
36226 to have an item inspected.
If the item is approved for use, it
will receive a dated white or green
sticker. All patient-owned electric
blankets, heating pads, etc. are
strictly prohibited.
TUBERCULOSIS CONTROL
Staff members are required to submit to TB testing upon hire and following an exposure to TB. Exposed staff will have TB
testing at the time of the exposure and at 10 weeks following the initial test. Staff who work in specified areas considered
medium risk, high risk, or areas indicated by our annual TB Risk Assessment, will be required to submit to annual or
more frequent testing as necessary. Staff having signs or symptoms of this contagious, airborne disease are strongly
encouraged to notify Employee Health Services and should contact their private physician for evaluation/treatment.
Patients suspect for, or diagnosed with TB are placed in Airborne Isolation until TB is ruled out.
9
INFECTION PREVENTION AND CONTROL
Infection control means reducing the spread of
infections to patients, families, and co-workers. The
prevention of infection is everyone’s responsibility.
Hand hygiene is the single most important
technique to prevent the spread of infection! Please be
aware of the following hand hygiene information:
THE 5 MOMENTS OF HAND HYGIENE ARE:
1. Before touching a patient
2. Before clean/aseptic procedures
3. After body fluid exposure/risk
4. After touching a patient
5. After touching a patient surrounding
SOAP AND WATER HAND WASH IS REQUIRED:
•When hands are visibly or physically soiled.
•After any contact with a patient/environment
suspected or known to have spores (i.e.,
Clostridium difficile or Bacillus anthracus).
•After any contact with a patient/environment
suspected or diagnosed with Norovirus.
PATIENT PERCEPTION OF HAND HYGIENE
Multiple types of hand hygiene education have been
presented to staff including ongoing competencies
and even a video presentation about the World Health
Organization’s 5 Moments for Hand Hygiene. Despite our
efforts to increase staff compliance, patient perception of
hand hygiene among caregivers has been noted to be less
than desirable. Recent National Research Corporation
patient satisfaction survey results indicated Aultman
health care personnel (HCP), specifically nurses and
physicians, are not performing hand hygiene as often as
necessary.
HAND-WASHING STEPS:
1. Wet hands under water.
2. Apply soap, being sure to lather ALL
surfaces for 15 seconds.
3. Rinse thoroughly.
4. Dry thoroughly with paper towel.
5. Use towel to turn faucet off.
6. May follow with alcohol-based hand sanitizer
to reduce bacterial counts.
ALCOHOL-BASED HAND SANITIZER
•Alcohol-based hand sanitizer is readily available
throughout the organization. Hands may be
decontaminated by using alcohol-based hand
sanitizer when:
•Hands are not visibly/physically soiled.
•Situations have not occurred requiring a soap
and water hand wash.
WORLD HEALTH ORGANIZATION
“MY 5 MOMENTS FOR HAND HYGIENE”
The World Health Organization has established
guidelines indicating 5 specific moments in which health
care workers should perform hand hygiene “at the point
of care.” This approach will be used to monitor our hand
hygiene compliance within the hospital. Be reminded of
Your 5 Moments of Hand Hygiene:
Your 5 Moments
E
OR ASEP
TIC
EF EAN/
EDUR
L
E
C ROC
2
P
B
for Hand Hygiene
4
10
1
BEFORE TOUCHING
A PATIENT
Y
E
3
AFTER
TOUCHING
A PATIENT
D
AF
T E R BO U
FLU
OS
P
I
D
X
E
RIS
K
R
1
BEFORE
TOUCHING
A PATIENT
5
WHEN?
Clean your hands before touching a patient when approaching him/her.
WHY?
To protect the patient against harmful germs carried on your hands.
AFTER
TOUCHING PATIENT
SURROUNDINGS
Opportunities in which hands are cleansed and are
not observable by a patient are often perceived as
not completed by the HCP. As a result of the timing
of hand hygiene, patients may not know if HCP have
cleansed their hands. For example, hand hygiene may be
performed upon exiting one patient’s room immediately
prior to entering another patient’s room. Additionally,
the location of sinks and Purell dispensers may be in
areas that are out of the patient’s sight; contributing to
the patient’s perception of the absence of hand hygiene.
Patients have been encouraged to remind HCP to
cleanse their hands in the event they have not observed
this action. Studies have shown patient are often
uncomfortable confronting HCP, as they felt embarrassed
or awkward and did not want to seem disrespectful.
The following strategies have been identified as ways to
provide a heightened awareness to both patients and HCPs.
• Cleanse hands in the patient’s sight. This allows
them to recognize that this important piece of their
care has been completed.
• Discuss hand hygiene while cleansing hands.
This increases patient awareness and perception,
encourages patient recognition of the importance
of cleansing their own hands, and imbeds the
action of hand hygiene deeper into HCP’s everyday
practice.
• Openly discuss hand hygiene and invite the patient
to become more active in speaking up when they
see that HCP have not taken the appropriate
opportunity to cleanse their hands.
(Infection Prevention and Control continued)
As a High Reliability Organization, the ultimate goal
is to provide the safest experience for our patients.
Please begin having conversations with your patients
about hand hygiene. Invite patients to discuss any
missed opportunities with you. Opening the lines
of communication will often decrease the patient’s
anxiety with an uncomfortable conversation and may
improve their confidence in the care provided. Perform
hand hygiene in the view of the patient. This is your
opportunity to show patients the importance of hand
hygiene in their safe care.
Another important component of infection prevention
and control is the practice of transmission-driven
isolation precautions. These precautions are used in
addition to standard precautions and are for patients
who are known or suspected to be infected or colonized
with certain infectious agents. All health care workers
are required to adhere to isolation practices as per the
Infection Control Policies and Procedures.
Medical or infectious waste is anything disposable that
is contaminated with blood or body fluids. Only throw
away medical or infectious waste in red trash bags
with a biohazard symbol. DO NOT place red bags
in a regular trash bag or send red bags down the
trash/laundry chutes. Place all red bags in the large,
red trash barrel located in the dirty utility room on
each unit.
HIGH RELIABILITY ORGANIZATION
Did you know your chance of dying in a plane crash are 1 in 10 million departures, but your chance of dying due to
a medical error in a U.S. hospital is 1 in every 382 admissions? Hospitals do things right much of the time. But even
very infrequent failures in critical processes can have terrible consequences for a patient, family and even an employee. This is why Aultman has embarked on a journey toward becoming a highly reliable organization. Employees have
been trained on five tools for reliability and five tones to promote teamwork. These tools and tones are human error
prevention strategies that help us to perform our tasks as intended consistently over time. By practicing what we
have learned and ingraining it into our daily routines, we become highly reliable and achieve our desired outcomes.
Can we count on you every time to use the tools and tones below?
• Self-check using STAR: Stop-Think-Act-Review.
2. Communicate Clearly
• Repeat back and read back to verify.
• Use phonetic and numeric clarifications.
• Ask clarifying questions.
• When communicating about a problem, use
SBAR – Situation, Background, Assessment, Recommendation.
3. Think Critically
• Use a questioning attitude to validate and verify the information.
4. Cross Monitor
YT
E.
IM
• Use ARCC – Ask Questions, Make Requests,
Voice Concerns, Use Chain of Command.
R
VE
5. Speak Up
E
ME
• Peer-checking and Peer-coaching: Be willing to
check others and have others check you.
• 5:1 Feedback - Encourage safe and productive
behaviors.
• Give advice when others use unsafe and unproductive behaviors.
6. Smile and say hello.
7. Introduce yourself and your role.
8. Listen with empathy and intent to understand.
9. Communicate positive intent of your actions.
10. Provide opportunities for others to ask questions.
ON
1. Pay Attention to Detail
TONES for Teamwork
YO
UC
AN
CO
UN
T
TOOLS for HRO
11
2015 NATIONAL PATIENT SAFETY GOALS
National Patient Safety Goals are established by The
Joint Commission and are used to assist organizations in
addressing identified concerns for patient safety.
Goal 1: Improve the accuracy of patient
identification.
Use at least two patient identifiers when providing
care, treatment and services.
Aultman requires proper identification of patients
by using two patient identifiers before administering
medications or blood products; taking blood samples
and other specimens for clinical testing or providing any
other treatment or procedure. When administering blood
or blood products, two qualified individuals must use
two patient identifiers to verify transfusion information.
Aultman accurately identifies patients by name, as well
as date of birth or medical record number. Trauma
patients are assigned a trauma number for identification.
Misidentification of specimens can lead to significant
harm to patients. Please make sure to follow the below
steps for appropriate specimen collection:
1. Verify patient identity using the appropriate
identifiers listed above.
REMINDER: It is NEVER acceptable to use the
patient’s room number or physical location as an
identifier.
2. Obtain specimen.
3. Label specimen container in the presence of the
patient.
REMINDER: Blood Bank specimens must have
a handwritten label with the patient’s full name,
medical record number, date and time of collection
and collector’s initials.
4. Once the specimen is labeled, compare to the patient
identification band to check for discrepancies.
5. Prior to sending specimen to lab, the label on the
specimen must be compared to the requisition to
check for discrepancies.
Eliminate transfusion errors related to patient
misidentification.
Match blood products to the order and the patient by
using a two-person verification process.
Goal 2: Improve the effectiveness of communication
among caregivers.
Report critical results of tests and diagnostic
procedures on a timely basis.
Critical results of tests and diagnostic procedures are
reported to the licensed independent practitioner within 60
minutes of the result, even if the result is unchanged,
improving or expected for a patient’s clinical
diagnosis. Any result designated in the Critical Results
12
Reporting Policy may be life threatening and require
immediate attention. The Critical Results policy, including
the list of Critical Results, is available on the Policy &
Procedure system (PolicyTech) on the employee portal.
ALWAYS remember:
The licensed caregiver must be notified within 60
minutes of the completion of the results.
60 minutes: A shared time between Lab or Radiology
and Nursing to Provider Notification.
•Results available → Results reported to
Nursing → Results reported to provider
Document the receipt of results, communication
of the results, and any action in PROVIDER
NOTIFICATION.
Goal 3: Improve the safety of using medications.
Label all medications, medication containers
and other solutions on and off the sterile field in
perioperative and other procedural settings. Note:
Medication containers include syringes, medicine cups
and basins.
Medications and solutions MUST be labeled when…
99The medication or solution is not IMMEDIATELY
administered by the person who has prepared the
medication or solution.
99When any medication or solution has been
transferred from the original packaging to another
container.
99The person preparing the medication or solution
does not administer it. Identification is done both
visually and verbally by two individuals qualified to
participate in the procedure.
99Multiple medications are being administered.
Immediately discard any medication or solution found
unlabeled.
Remove all labeled containers on the sterile field
and discard their contents at the conclusion of the
procedure.
All medications and solutions and their labels both on
and off the sterile field MUST be reviewed by entering
and exiting staff responsible for the management of
medications.
The LABEL must include the following
information:
99Medication name
99Strength
99Quantity
99Diluent and volume (if not apparent from the
container)
99Expiration date when not used within 24 hours
99Expiration time when expiration occurs in less than
24 hours
Note: The date and time are not necessary for short
procedures, as defined by the hospital.
Reduce the likelihood of patient harm associated
with the use of anticoagulant therapy.
One of our most important goals is to reduce the
likelihood of patient harm associated with the use of
anticoagulant therapy. Comprehensive education is
provided to our patients with standardized educational
pathways for Warfarin, Heparin, Plavix and Lovenox.
Video education materials for Lovenox and Warfarin are
also available. For the safety of our patients, INRs should
be done daily on all patients receiving Warfarin. Even
patients stabilized on their dose for a long period of time
may be at risk when they are admitted to the hospital.
Many medications given in the hospital may affect the
way patients react to Warfarin. Review of current INR
results is required prior to administration of Warfarin.
Cerner now requires that an INR value in an acceptable
range be entered in the system prior to administration
as an additional safety check. Standardized orders
for Warfarin and heparin are available for use. Our
pharmacists review the use of anticoagulant medications.
Maintain and communicate accurate patient
medication information.
Medication discrepancies can significantly impact the
safety of our patients. Medication reconciliation is
intended to identify and resolve discrepancies—it is a
process of comparing the medications a patient is taking
(and should be taking) with newly ordered medications.
•A list of the patient’s current medication information
should be obtained when admitted to the hospital or is
seen in an outpatient setting
•The list should be documented in the medical record.
•Home medication information is compared to
the medications provided while in the care of the
organization.
•Any discrepancy should be resolved.
•The patient (or family as needed) should be provided
with written information about medications which
should be taken upon discharge from the facility or at
the end of an outpatient encounter.
•Patients are encouraged to maintain an accurate
medication list and to communicate any changes to all
providers of care.
Goal 6: Reduce the harm associated with clinical
alarm systems.
Improve the safety of clinical alarm systems.
Medical equipment and devices require the use of
alarms to alert staff in a healthcare setting of potential
issues occurring with patients and equipment. These
alarms are necessary and assist staff in providing safe
care for patients. Alarm fatigue has become one of the
most difficult issues to manage in a healthcare setting.
Finding the perfect balance of alarms requiring clinical
intervention (actionable alarms), while minimizing
the alarms which do not require clinical intervention
(non-actionable alarms), is key to providing appropriate
care for patients. Over time, clinicians may become
desensitized, overwhelmed, and even immune to the
sound of an alarm. When certain medical devices
constantly alert staff, they may react to the alarms
by turning down the volume, turning off the alarm, or
adjusting the alarm settings. Actions such as these may
have very serious or even fatal consequences. Hospitals
are placing heightened awareness on the management
of clinical alarms. The Alarm Management Committee
is making strides to appropriately minimize the nonactionable alarms. The Committee reviews and assess
the alarm data and begin the task of determining which
alarms may be safely eliminated or adjusted. The goal
is to decrease the number of non-actionable alarms and
to improve the quality of actionable alarms, making the
alarms more meaningful.
Sources: Retrieved from the following on 7/22/15
http://www.jointcommission.org/assets/1/18/SEA_50_
alarms_4_5_13_FINAL1.PDF
http://www.jointcommission.org/assets/1/6/medical_
device_alarm_safety_infographic.pdf
Goal 7: Reduce the risk of health care–associated
infections.
Hand Hygiene
Information regarding this NPSG is included in the
“Infection Prevention and Control” section.
Prevent hospital acquired infections related to
Multidrug-resistant Organisms (MDRO)
Multidrug-Resistant Organisms are one of the most
common causes of health care-associated infections.
MDROs are organisms that have become resistant to
many antibiotics commonly used to treat them. Proper
hand hygiene, and standard and transmission-driven
precautions are essential in preventing the transmission
of MDROs. MICU and SICU take special precautions to
prevent the transmission of MDROs. Patients admitted to
MICU and SICU who meet certain criteria are screened
for MRSA and Acinetobacter as applicable. Screening
helps identify patients who may be infected or colonized
with such organisms. The patients who are deemed high
risk are preemptively placed in isolation until culture
results are available. In addition, any patient in the
hospital who is diagnosed with an MDRO will also be
placed in isolation.
Aultman uses a method to alert staff of patients who
culture positive during a current admission or who
re-enter the hospital system with a history of an MDRO.
These patients are identified by a two-letter code. The
following codes may be used alone or in combination for
patients with more than one organism.
•CM: (MRSA) Methicillin-resistant Staphylococcus
aureus
•CV: (VRE) Vancomycin-resistant Enterococcus
13
•CD: (C. diff) Clostridium difficile
•CE: (ESBL) Extended-spectrum beta lactamase
(Enzyme produced by certain bacteria that can break
down several types of antibiotics, rendering them
ineffective)
•CA: Acinetobacter baumannii haemolyticus
•CR: (CRE) Carbapenem-resistant enterobacteriaceae
The below information is used by clinical staff to
determine if a patient is still colonized and/or infected
with the organism:
•Place the patient in preemptive isolation precautions
*See below for the exception for C. diff.
•Attempt to determine when the patient was colonized/
infected with the specific organism. This is done by
reviewing patient lab testing. If you are unable to
determine when the patient had a positive result,
please contact Infection Prevention during normal
weekday business hours. After hours or on weekends
or holidays, you may contact the Microbiology lab to
assist you.
•Once the information regarding the positive result
is known, notify the physician. The physician will
determine if the patient has cleared the organism. This
may be done via clinical correlation and/or testing.
•Each positive result requires a predetermined amount
of testing that should be conducted to determine the
patient no longer has the organism. Please see the
following policy for specific timeframes and testing
that should be conducted. https://policies.aultman.com/
dotNet/documents/?docid=5513&mode=view
•The physician may place an order to discontinue the
isolation once he/she has determined the patient no
longer is infected and/or colonized with the organism.
•Physicians should order the removal of the specific code
that has been ruled out.
•Contact LAB personnel to remove code at extension
33498.
*NOTE: Regarding patients readmitted with codes for C.
diff (CD): Absence of clinical symptoms (diarrhea) is all
that is required to request a code removal order from the
physician. Isolation is not required in this circumstance.
Infection Prevention & Control monitors multidrugresistant organisms (MDROs) and health care-associated
infections throughout the organization. Here are just a
few ways everyone can assist in the prevention of these
types of infections.
•Always follow proper hand hygiene.
•Observe all isolation protocols (standard and
transmission-driven precautions) by using personal
protective equipment (PPE) as indicated.
•Clean and disinfect equipment or items that have
been used.
Isolation Reminders
Another important component of infection prevention and
control is the practice of transmission-driven isolation
precautions. These precautions are used in addition to
14
standard precautions and are for patients who are known
or suspected to be infected or colonized with, certain
infectious agents. All health care workers are required
to adhere to isolation practices as per the Infection
Prevention and Control Policies and Procedures.
Transmission-based isolation categories correspond with
how the specific diseases are transmitted. Aultman uses
3 transmission-based isolation categories. Visual cues at
the bottom of each sign indicate the required PPE prior to
room entry.
REMINDER: Isolation signage is not to be removed upon
discharge or transfer between units.
•Signage must remain on the doorway until the room
has been cleaned and disinfected by Housekeeping.
•Housekeeping will return the signage to the charge
nurse to be discarded.
Special Isolation Signage for C.difficile and
Norovirus
Signage for C.difficile and Norovirus is different than
regular stringent contact signage. These two diseases
require the room to be double cleaned and disinfected
upon discharge. Hand washing must also be performed
with soap and water. Purell is not to be used after
contact with a patient/environment with one of these
diseases.
Please use the alternative signage, and remember to
place the smaller sign on the Purell dispenser in the
patient’s room.
Stringent Contact Signage
C.diff and
Norovirus
Signage
Purell
Dispenser
Signage
Regular
Stringent
Contact Signage
Personal Protective Equipment (PPE)
Proper use of PPE is essential to prevent the
transmission of infections to patients and staff.
•All PPE should be donned prior to entry and
removed prior to leaving an isolation room.
•Visual cues on isolation signage indicate required PPE.
•Additional PPE may be indicated based on Standard
Precautions. (i.e., mask and eye protection may be
necessary in Stringent Contact Precautions if there is
a risk of splash, spray or aerosolization.)
•If you cover your mouth and nose with a mask, YOU
MUST WEAR EYE PROTECTION.
If you have any questions about isolation, please feel
free to contact the Infection Prevention and Control
office at ext. 34815.
Prevent hospital-acquired infections related to
central line-associated bloodstream infections
(CLABSI).
Central lines are intravenous catheters commonly
placed into a large vein, usually in the neck, chest,
arm, or groin, to provide fluids or medications to
patients. Central line-associated blood stream
infections (CLABSI) are infections that can occur from
the placement and use of a central line. CLABSIs are
among the most deadly healthcare acquired infections,
with a reported mortality rate of 12-25%. Consistently
following hospital policy for insertion and maintenance
of central lines can help prevent CLABSI. Clinical staff
must follow the hospital policy for the insertion and
maintenance of central lines which includes some of the
following infection prevention strategies:
Provide EDUCATION to patients, and their families
as needed, their families about ways they can help
prevent line associated bloodstream infections. This
should be done both prior to insertion of a central
line, and as needed, while one is in place.
Promote proper insertion techniques as stated in the
Central Line Insertion Policy and Checklist.
All participants are empowered to IMMEDIATELY
stop the procedure if any of the steps are not followed.
Chlorhexidine-based antiseptic for skin
preparation should be used during insertion and
dressing changes (Use for patients over 2 months of
age, unless contraindicated).
Perform Hand hygiene prior to manipulation of the
catheter.
Disinfect the ports before accessing the line (“Scrub
the Hub”). Alcohol-based port protector caps should
be in place on ALL access ports of a central line.
Change dressing every 7 days, and as needed.
Change NEEDLESS CAPS every 96 hours with
tubing changes, or when blood is visible in the cap.
Evaluate the site for infection frequently.
Review daily (with physician) the necessity of the
line.
Removal of nonessential catheters helps prevent
infection.
The Infection Prevention & Control department reviews
all suspect cases of CLABSI. When cases are identified,
Unit Directors are notified and an additional review of
each case is completed. This information is presented
to the CLABSI Committee to determine if there are
additional opportunities for improvements to our
current practice.
Prevent hospital-acquired infections related to
surgical site infections (SSI)
Aultman follows evidence based practice guidelines
for the prevention of SSIs. Following the appropriate
guidelines decreases the risk of surgical site infections
for patients. Close monitoring of targeted surgical
site infections helps to quickly identify any areas of
concern and assists in identifying opportunities for
improvements. The following are a few strategies to
help prevent surgical site infections:
•Optimization of a patient prior to surgery (healthy
skin condition, no illness, resolution of potential
issues which may impact the outcome of surgery, i.e.
MRSA colonization).
•Proper pre-operative patient and/or family education.
•Patient to shower with antimicrobial soap (i.e.,
chlorhexidine gluconate [CHG] based product) the
night before and the morning of surgery.
•Application of CHG-impregnated cloth to area of
surgical procedure.
•Appropriate hair removal—Clipping instead of
shaving.
•Appropriate skin antisepsis at the time of surgery.
•Appropriate antibiotic selection and timing
(administered within one hour prior to surgical
incision).
•Post-operative education to patient and family
regarding ways to prevent infection such as hand
hygiene, surgical incision/wound care, and dressing
changes.
15
Prevent hospital-acquired infections related
to catheter-associated urinary tract infection
(CAUTI)
A urinary catheter is a tube inserted into the bladder
through the urethra to drain urine. Patients who have
urinary catheters inserted and used for a prolonged
period of time are at in increased risk of developing a
catheter-associated urinary tract infection (CAUTI).
The following are a few of the evidenced-based
guidelines clinical staff members use to decrease the
risk of CAUTI.
•Educate patients about prevention of CAUTI
•Evaluate need for catheter daily.
o Limit catheter use to those necessary for patient care.
o Remove catheter as soon as it is no longer needed.
•Proper hand hygiene performed prior to contact with
catheters.
•Use aseptic technique for site preparation/insertion.
•Maintain sterility of equipment and supplies.
o Use soap and water to cleanse the catheter
insertion area (urethra) prior to antiseptic use and insertion of a catheter.
•Use catheter securement devices to prevent
obstructed urine flow and drainage.
•Maintain a closed urine collection system.
•Replace catheter system as needed.
•Daily Catheter Care done with soap and water and
as needed.
o Proper technique=
SOAP&WATER-WASH-RINSE-DRY.
o Do not use other products for catheter care.
Universal Protocol
Universal Protocol is a process that was established
to assist in the prevention of wrong site surgeries.
Universal Protocol should be used for operative and
other invasive procedures that expose patients to more
than minimal risk. These may include procedures
performed in settings other than the operating room
such as a special procedures unit, endoscopy units, at
the bedside or interventional radiology suites.
A pre-procedure VERIFICATION process should be
done to establish the correct procedure, patient and
surgical site. The procedure site should be MARKED
PRIOR to the procedure by the licensed independent
practitioner who is ultimately accountable for the
procedure and will be present when the procedure
is performed. This should occur with the patient’s
involvement when possible. A “TIME-OUT” is
performed to provide a final verification of the correct
patient, procedure and site. The “TIME-OUT” should
be performed in the room immediately before the start of
the surgery/procedure with all team members actively
involved. All activities should be suspended during the
TIME-OUT, unless doing so will compromise safety.
ALL team members must agree on the correct patient
identity, the correct site and procedure to be done.
Goal 15: The hospital identifies safety risks
inherent in its patient population
Aultman identifies patients at risk for suicide by
completing a brief risk assessment on all patients.
All admitted patients are asked “Do you have
any thoughts of harming yourself or others?”
A more in-depth risk assessment is conducted and
interventions are made if a patient answers yes to this
question. Identified patients are also provided with
follow-up resources upon discharge.
ACCREDITING BODIES
For any patient care or safety issue an employee feels is not being addressed by management, please notify the
Compliance Office at ext. 33380. If an employee feels that the issues are still not being addressed, employees can call
The Joint Commission anonymously at 1-800-994-6610 or email complaint@jointcommision.org. Employees can also
contact the Ohio Department of Health anonymously at 1-800-347-0553.
16
ALARM SAFETY
RIGHT TO MEANINGFUL
KNOWLEDGE
Alarm fatigue is a nationally recognized trend. In addition to issuing a sentinel event
alert on alarm management, The Joint Commission has also established a National
Patient Safety Goal that was effective in 2014.
Aultman believes patients have
the right to receive information
about their care – including test
outcomes, medical treatments
and intervention whether results
are positive, negative, expected or
unexpected. Refer to the Patient’s
Rights and Responsibility Policy.
Many medical devices have alarm systems to alert staff of potential patient safety
issues. These alarm-equipped devices are essential to providing safe care to patients
in many health care settings. Clinicians depend on these devices for information they
need to deliver appropriate care and to guide treatment decisions. However, these
devices present a multitude of challenges for health care organizations.
PATIENT RIGHTS
“Your Rights as a Patient" are
included in the “Guide to Patient
and Visitor Services” and are
available to all patients upon
admission. The Patient’s Rights
Policy states: “No person shall
be denied access to treatment or
accommodations that are available
and medically indicated, on the
basis of such considerations as
race, color, creed, national origin,
diagnosis or the nature of the
source of the payment for his/her
care.” Refer to the Patient’s Rights
and Responsibility Policy.
FALLS ASSESSMENT
It is every employee’s
responsibility to promote patient
safety by identifying patients at
risk for falling. As patients are
identified as high risk for falls,
a yellow magnet is placed on the
door frame of the room and a
yellow wristband is placed on the
patient. Yellow nonskid slippers
are also given to the patient to
wear whenever getting out of
bed. Patients may also have a
chair alarm or bed alarm. These
identifiers are implemented as
a communication tool, so every
employee is able to identify the
patient at risk and intervene to
prevent a potential fall. If you
observe a potential fall situation,
notify a staff member immediately
or pull the emergency cord in the
bathroom if you feel it is unsafe to
leave the patient.
Research shows that the number of alarm signals per patient per day can reach
several hundred, depending on the unit within the hospital, translating to thousands
of alarm signals on every unit and tens of thousands of alarm signals throughout a
hospital every day. It is estimated that between 85 and 99 percent of alarm signals
do not require clinical intervention. As a result, clinicians may become desensitized
or immune to the sounds and are overwhelmed by information – in short, they suffer
from “alarm fatigue.”
Some factors that contribute to alarm-related sentinel events include:
• Improper alarm settings.
• Alarm signals not audible in all areas.
• Alarm signals inappropriately turned off.
• Alarm settings that are not customized to the individual patient or patient
population.
• Alarm conditions and settings that are not integrated with other medical devices.
• Equipment malfunctions and failures (this includes failures due to weak/dead
batteries).
At Aultman, an Alarm Management Team has been developed to assess our
environment. Our brains are wired to listen for red (critical) alarms that typically
require immediate attention. It is important to keep in mind that the blue (noncritical) alarms such as the “leads off” alarm can be equally as critical. These patients
are essentially non-monitored until the leads are addressed. In these cases, a critical
alarm could be missed. Low battery alarms can quickly turn into dead batteries.
Batteries should be changed in a timely manner when low.
Help do your part in keeping our patients safe by remaining attentive to alarms.
MEDICAL DEVICES AND PATIENT SAFETY
Medical device reporting (MDR) is the mechanism for the FDA to
receive significant medical device adverse events or malfunctions from
manufacturers and health care providers – such as hospitals – so
they can be detected and corrected quickly. Risk Management submits these
reports to the FDA on behalf of Aultman.
Aultman is required to report any medical device that contributes to the death
or serious injury or illness of a patient. Additionally, Aultman reports device
malfunctions. A “malfunction” is defined by the FDA as “the failure of device
to meet its performance specifications or otherwise perform as intended.”
If a medical device fails to work before or during use, an employee or the
employee’s manager must report such malfunction to Risk Management.
What should an employee do if an event involving a medical
device occurs?
An employee must document the event of harm or injury involving a
medical device factually in the patient’s medical record and complete a
variance report. The variance report should include the make, model, lot
number, serial number and manufacturer of the medical device, along with
a description of the event. If possible, the employee must not discard the
medical device or return it to the company without approval from Risk
Management. A medical device that is involved in an event will be evaluated
by, and sequestered, in Risk Management.
17
RESTRAINTS
Restraint is any manual method, physical or
mechanical device, or material or equipment, that
immobilizes or reduces the ability of a patient to move
his or her arms, legs, body or head freely. These types
of restraints include bed rails, geriatric chairs, soft
restraints and nylon restraints.
A chemical restraint is a drug or medication when
it is used as a restriction to manage the patient’s
behavior or restrict the patient’s freedom of movement
and is not a standard treatment or dosage for the
patient’s condition.
RESTRAINT ORDERS
A physician must see the person in restraints for violent/
self-destructive behavior within one hour of restraints
being used or within 24 hours for mechanical restraints.
The attending physician performs an in-person
assessment of the restrained patient and reorders or
discontinues restraint once every calendar day.
RESTRAINT ALTERNATIVES
Alternatives include, but are not limited to, the following:
Diversional activity – TV; videos; music
therapy; audio tapes and player; relaxation tapes and techniques; small jobs the patient enjoys and agrees to attempt (i.e., folding washcloths).
Verbal interaction – speak in a clear, calm voice; frequently orient/reorient to person, place and setting; offer support and encouragement; promote interpersonal communication; reinforce safety.
Nonverbal interaction – approach in a calm,
slow, nonthreatening manner; smile; listen attentively allowing time for comments, concerns
or questions (answer any and all questions in a timely manner).
Supervision – move patient close to nurse’s
station; frequent room checks; encourage family to
stay/sit with patient; bed alert, if applicable.
Exercise/ambulation – passive/active ROM; up in chair; ambulate in room or hallway, with assist if necessary. Allow to wander in supervised area.
Comfort measures – frequent position changes; pain management; pillows and other positioning aides; eliminate unnecessary tubes/lines; toileting
schedule; offer snacks and warm beverages; if possible, provide companionship (i.e., a volunteer).
Modify environment – reduce sensory stimulation; provide a structured environment; appropriate lighting; keep free of clutter; encourage family to bring in limited personal possessions such as family photos or items familiar to the patient.
Promote reality – TV or newspaper; open window curtains; leave door to room open; familiarize patient to surroundings.
If options fail and restraints must be used, the leastrestrictive method of restraint should be chosen.
The patient’s rights, privacy and protection, dignity,
autonomy and physical/psychological well-being
are always to be considered. Refer to Restraint and
Seclusion Policy.
18
PA I N
Aultman is committed to the management of the
patient’s pain. Pain is physical: disease, injury
and infection cause much of the tissue and nerve
damage responsible for pain. Pain is also emotional
– and factors such as stress, anxiety, trauma and
depression can play a role in a person’s suffering. The
management of pain involves all caregivers as well as
the patient and his or her family. Proper management
promotes a satisfying treatment experience, speeds a
patient’s recovery and controls health care costs.
Patients view pain differently, and their actions may
not reflect the behavior expected for a certain level of
pain. Two patients with the same injury or surgery
can experience very different levels of pain. Some pain
has no clear cause, but it’s no less real for the person
who is suffering. Pain should be rated by the patient,
not the clinician.
Pain is measured using a rating scale. One of the most
commonly used scales is pictured below. Caregivers
are responsible for using the appropriate scale when
assessing their patients for pain. The patient should
be asked to rate his or her pain during the first exam,
a minimum of once each shift, an hour after any
intervention (medication or other) and after potentially
pain-producing procedures. It is also important to
ask the patient what level of pain he/she is able to
tolerate. Notify the physician if the patient’s pain
rating continues to be above a tolerable level after two
consecutive interventions.
Clinicians should recognize that words such as “ache”
or “sore” may be substituted for the word “pain.”
Children and infants experience pain, too – and
special tools such as face charts and the newborn pain
scale may be needed to help children communicate
their pain. Patients who are unable to think or speak
well may communicate their pain by nonverbal cues
such as grimaces, moaning or restlessness. Pain
may be managed by simply repositioning a patient.
If you are unable to help in a way that relieves pain,
always notify a caregiver who can help. REMEMBER:
Managing pain is everyone’s responsibility!
EARLY HEART ATTACK CARE (EHAC) AND ACUTE CORONARY SYNDROME (ACS)
We as the Aultman Team need to gain knowledge and act when appropriate as soon as we come upon a patient, visitor
or fellow co-worker with complaints of symptoms that may represent a heart attack otherwise known as Acute Coronary
syndrome (ACS). Knowledge of Early Heart Attack Care (EHAC) and Acute Coronary Syndrome (ACS) is key to
improving outcomes for our community.
FACTS
•For 50 percent of people experiencing early symptoms of
a heart attack, the heart attack could be prevented with
early treatment.
•There are 380,000 deaths annually from heart
attacks, and half of these deaths occur before
reaching the hospital.
•Every 34 seconds, an American will have a coronary
event - and someone will die every minute.
The goal of EHAC is to educate everyone on the early
symptoms of a heart attack in order to prevent a heart
attack. It also makes the public responsible to obtain
immediate treatment for themselves or someone
they see experiencing these symptoms. There are
clear benefits of early treatment and activating the
emergency medical service.
Early recognition of ACS symptoms decreases the time to
treatment which is critical in the early stages of a heart
attack. If you are experiencing a heart attack, actual
muscle cells are dying. The sooner treatment is received,
the less damage occurs to your heart. The less damage to
your heart, the better the outcomes. TIME IS MUSCLE!
Heart attack signs include:
•Chest pressure, squeezing or discomfort (heartburn or
indigestion).
•Discomfort down one or both arms, the back, shoulder, jaw.
•Shortness of breath with or without pain.
•Fatigue.
•Lightheaded or dizziness.
•Nausea, vomiting, fullness.
•Ventricular arrhythmias.
•Breaking out in cold sweat.
Atypical symptoms (especially in women):
•Pain in back or shoulder blades.
•Fainting.
•Confusion.
•Sleep problems.
•Unusual feeling of fatigue or weakness.
•Indigestion.
•Feeling of doom.
If you think you or someone you know is experiencing a
heart attack, act immediately!
•Don’t wait! Quick treatment may save a life.
•If at home or off hospital campus, call 911.
•Call the Rapid Response Team for patients at ext. 36888.
•Call a Medical Assist for visitors at ext. 36777.
STROKE SAFETY
Stroke is the No. 5 cause of death, behind heart disease, cancer, and chronic lower respiratory diseases. Stroke is the leading
cause of serious, long-term disability in the United States. Each year, about 795,000 people suffer a stroke. On average,
someone in the United States suffers a stroke every 45 seconds and every three minutes, someone dies of a stroke.
Risk factors for stroke that can be controlled or treated include high blood pressure, carotid artery disease, atrial
fibrillation, high cholesterol, diabetes, smoking, obesity, excessive alcohol use and physical inactivity. Other risk factors
that cannot be changed include family history, gender (strokes are more common in men than women), increasing age,
prior stroke or Transient Ischemic Attack (TIA) and African-American race.
STROKE IS A MEDICAL EMERGENCY
Know these warning signs of stroke and teach them to others:
•Sudden numbness or weakness of the face, arm or leg, especially
on one side of the body.
•Sudden confusion, trouble speaking or understanding.
•Sudden trouble seeing in one or both eyes.
•Sudden trouble walking, dizziness, loss of balance or coordination.
•Sudden, severe headache with no known cause.
Many stroke patients have no idea they are having a stroke because brain cells are dying, which can affect judgment.
Recognizing when stroke is occurring and reacting FAST to get lifesaving treatment can save lives.
FACE – Ask the person to smile. Does one side of the face droop?
ARMS – Ask the person to hold both arms up evenly. Does one arm drift downward?
SPEECH – Ask the person to repeat a simple sentence. Are his or her words slurred or mixed up?
TIME – If the person shows any of these symptoms, seek emergency medical attention. Brain cells are dying.
If a patient is experiencing these acute signs and symptoms, activate the Rapid Response Team by calling ext. 36888.
Call a Medical Assist at ext. 36777 if a visitor or employee is having any of these signs or symptoms. Every second counts!
19
PRIVACY AND CONFIDENTIALITY
C O R P O R AT E C O M P L I A N C E
Aultman has served our community since 1892 with a
reputation for excellence and integrity. The Aultman
Compliance Program was established to support our
commitment to the highest standards of conduct,
honesty, and integrity in our business practices.
Compliance is all about doing the right things for the
right reasons.
Our Corporate Compliance Program is a formal
program that supports Aultman’s commitment to
following policies and standards of conduct so that we
are in compliance with applicable federal, state and
local laws and regulations as well as Aultman’s policies
and ethical standards.
The Corporate Compliance Program:
•Demonstrates our good-faith effort to comply with
federal health care program requirements.
•Establishes procedures to prevent, detect and correct
noncompliance.
•Provides a method for employees to report potential
problems.
•Serves as a resource to resolve compliance issues.
Compliance affects everyone. As an Aultman employee,
you are expected to:
•Carry out your job duties with integrity and honesty.
•Learn and understand what laws and regulations
apply to your specific job function and level of
responsibility.
•Exercise good judgment and do the right thing when
performing your job duties.
•Report suspected compliance concerns or problems.
Employees should report concerns or problems to
their manager, the Compliance Officer or the Aultman
Compliance Line at 1-866-907-6901. Employees
reporting compliance concerns in good faith will not be
subject to retribution or discipline.
Aultman maintains the privacy and confidentiality of
personal and medical information entrusted to us by
patients and others. As an Aultman employee, you are
required to:
•Protect the confidentiality and privacy of patient
information, customer information, employees’
information and other proprietary information
by complying with the federal laws, the HIPAA
Privacy and Security regulations, state laws and
accreditation standards.
•Only access, use or disclose medical, clinical,
employee and business information when such use
or disclosure is supported by a legitimate clinical
or business purpose and is in compliance with
Aultman’s policies and procedures, applicable laws,
rules and regulations.
•Only access your own health care information or the
health care information of your friends and families
through the Medical Records department and with
written authorization.
•Refrain from discussing patient, employee,
customer or business information in any public
area, including elevators, stairwells, restrooms,
lobbies and dining areas.
•Safeguard all confidential and proprietary
information by maintaining documents in secure
areas and not sharing access codes or passwords.
•Protect Electronic Health Information by using a
unique user ID and password to access electronic
devices and systems. User IDs and passwords should
not be shared with anyone.
Employees with privacy questions or concerns may
contact the Compliance Office at ext. 33380 or email
compliance@aultman.com.
ABUSE/NEGLECT
It is the responsibility of all health care workers to recognize, treat and protect any patient who may be the victim of abuse,
neglect or exploitation. Ohio law states that any health care professional – working within the scope of his/her professional
capacity and who has reasonable cause to believe a patient is being abused, neglected or exploited – shall report the
situation immediately to the proper authority. Abuse, neglect or exploitation has been identified by Aultman to include, but
not be limited to, the following:
•Abuse, neglect or exploitation of a child.
•Abuse, neglect or exploitation of a mentally or developmentally disabled person.
•Abuse, neglect or exploitation of a compromised adult age 60 or older.
•Domestic violence.
Health care workers having knowledge or reasonable cause who report abuse/neglect cases in good faith are protected from
civil or criminal liability related to the investigation, report or testimony. Failure to report known or suspected abuse may
result in civil liability.
If any cases of abuse are suspected, notify your supervisor and consult the appropriate abuse/neglect policies for proper
reporting methods.
20

ANNUAL SAFETY EDUCATION 2015

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