Required for medical students hoping to complete a rotation at Redmond Regional Medical Center

1. Annual Updates
General Information
• During the time you are completing this module, you may call
802-3379 for any questions. Questions that you have at night
or on the weekends may be directed to the House Supervisor at
3037.
Our Mission Statement
Above all else, we are committed to the care and improvement of
human life. In recognition of this commitment, we will provide
exceptional healthcare to our expanding communities with
compassion and integrity pursuing excellence in all we do.
Helping, Healing, Giving HOPE.
1

2. Vision Statement
As the Nationally recognized tertiary care provider of the
largest healthcare system in NW GA, Redmond will
support and engage our medical staff, expand and
modernize our facilities, grow our Primary Care,
Occupational Health, and EMS networks, and enhance
our community presence. We will promote staff
development and deliver exceptional patient care every
time. Our reputation for success will be recognized
through service line growth, increased market share,
exceptional clinical outcomes, and superior patient,
physician and employee satisfaction.
We are Redmond.
2

3. Values
■ With
■ Excellence
■ Compassion
■ Accountability
■ Respect &
■ Ethics...
■ We are Redmond!
3

4. Ethics and Compliance
■ Redmond and HCA have a comprehensive, values-based
Ethics and Compliance Program, which is a vital part of the
way we conduct ourselves. Because the Program rests on our
Mission and Values, it has easily become incorporated into
our daily activities and supports our tradition of caring – for
our patients, our communities, and our colleagues. We strive
to deliver healthcare compassionately and to act with
absolute integrity in the way we do our work and the way we
live our lives. All work must be done in an ethical and legal
manner. It is your responsibility and your obligation to
follow the code of conduct and maintain the highest
standards of ethics and compliance.
4

5. Ethics and Compliance
■ If you have questions or encounter any situation which you
believe violates the provisions of the code of conduct, you
should immediately consult your supervisor, another
member of the management team, the Human Resources
Director (Patsy Adams ext. 3023), the Ethics and
Compliance Officer (Lori Baker ext. 3015), or the HCA
Ethics Line (1-800-455-1996).
■ Each employee and volunteer is required to attend one hour
of initial code of conduct training and a one hour annual
refresher training session. Leaders and individuals in key
jobs have additional education requirements.
5

6. Georgia False Claims Laws
■ There is a federal False Claims Act, and there are also
Georgia laws that address fraud and abuse in the Georgia
Medicaid program.
■ Any person or entity that knowingly submits a false or
fraudulent claim for payment of funds is liable for
significant penalties and fines.
■ The False Claims Act has a “qui tam” or “whistleblower”
provision. This allows a private person with knowledge of
a false claim to bring a civil action on behalf of the US
Government. If the claim is successful, the whistleblower
may be awarded a percentage of the funds recovered.
■ For additional information, please see the Georgia False
Claims Statutes Policy.
6

7. EMTALA
■ The Emergency Medical Treatment and
Active Labor Act is commonly known as
the Patient Anti-Dumping Statute.
■ This statute requires Medicare hospitals to
provide emergency services to all patients,
whether or not the patient can pay.
7

8. EMTALA
■ When a patient comes to the emergency
department (emergency can be located on any
part of the hospital campus), the hospital must
screen for a medical emergency.
■ If an emergency medical condition is found, the
hospital must provide stabilizing treatment.
■ Patients with emergency medical conditions
may not be transferred out of the hospital for
economic reasons.
8

9. EMTALA
■ If a patient presents on our property or within
250 yards of our property seeking medical care,
we MUST direct them to our ED for a medical
screening, no matter the condition.
■ Patients cannot be asked to leave or be refused
treatment under any circumstance (such as
behavior) prior to a Medical Screening exam
by a Licensed Medical Provider.
9

10. Medical Ethics:
End of Life Care
■ Palliative Care
■ The goal of palliative care is not to cure the
patient. The goal is to provide comfort.
■ Understand the importance of addressing all
of the patient’s comfort needs near the end of
life. This includes psychosocial, spiritual, and
physical needs.
10

11. Medical Ethics:
End of Life Care
■ End-of-Life Decisions
■ Patients have the right to refuse life-sustaining
treatment.
■ Respect this right and this decision.
■ Withdrawing Life-Sustaining Treatment
■ Withdrawing and withholding life-sustaining
treatment are ethically and legally equivalent.
Both are ethical and legal when the patient has
given informed consent.
11

12. Animals in the Hospital
■ There are 2 types of animals that may be
permitted to enter the hospital
■ Service Animals
■ Therapy Animals
12

13. Service Animals
■ Service animals are dogs or miniature horses that
are specifically trained to assist people with
disabilities with the activities of normal living.
■ Staff can ONLY ask:
■ if an animal is required because of a disability
and
■ what work the animal has been trained to
perform, unless it is readily apparent that an
animal is trained to do work or perform tasks
for the individual with a disability.
13

14. Service Animals
■ Requirements of Service Animals and Their Partners/
Handlers
■ The partner/handler must be in full control of the
animal at all times. The care and supervision of a
service animal is solely the responsibility of its partner/
handler.
■ The partner/handler must always carry supplies
sufficient to clean up the animal's feces whenever the
animal and partner are on Hospital property and
properly dispose of the feces in an outdoor trash bin.
■ Provides the service animal with food, water, and other
necessary care or makes arrangements through others
(excluding staff and volunteers) to do the same.
14

15. Therapy Animals
■ Animal visitation is a short term intervention to help improve
the patient’s well being and reduce loneliness. Pets provide
opportunities for patients to display affection and emotion,
practice social skills, and have positive experiences. The visit is
determined by the patient’s needs at a particular time. Pets
used for animal assisted activity are not patient’s pets. The
adult dogs or cats brought to this facility will be certified
through Delta Society (www.deltasociety.org).
■ Animal must be appropriately restrained with identification.
Identification will include a Redmond picture ID Badge
attached to the animal’s vest or collar.
■ Pet Partner Volunteer will contact the charge nurse on the floor
of the patient on the day of the visit.
15

16. Therapy Animals
■ Staff Responsibility
■ Ensures that patient meets criteria for an animal visit.
■ Animals are restricted from food preparation service areas, and
other high risk areas including: any patient with a decubitus,
surgical patients, open wounds or burns, open tracheotomy,
immune-suppression, all isolation precautions rooms, critical
care area patients, patients with tuberculosis, salmonella,
campylobacter, shigella, streptococcus A, MRSA, ringworms,
giardia, and amebiasesis are excluded from this program.
■ In the event that a patient receives a bite or scratch, the
patient’s nurse will complete an occurrence form about the
incident. The nurse will notify the patient’s physician and the
Infection Prevention Director.
16

17. To make teamwork happen…
■Communication is a necessity.
■Must have Interaction with others even when
things are not going as planned.
■Get Feedback from other staff members and
managers.
■Share the responsibility.
17

18. Skills for Teamwork:
■ Listening
■ Questioning
■ Respecting and supporting ideas
■ Helping
■ Sharing
■ Participation
18

19. Teamwork
■ People who work in a hospital situation know how to manage
high-stress situations, but frustrations can build.
■ Working as a team will reduce situations where a staff member
feels overwhelmed by his/her workload or the temperament of an
unpleasant staff member/patient or family member.
■ Compassion and common courtesy are appropriate not only when
communicating with patients; they are also vital in how you treat
your coworkers.
■ If everyone does his/her job in an efficient manner and is aware
of the needs of other staff members, he/she can contribute to the
overall morale.
■ Remember Teamwork is used everyday in healthcare:
■ Rapid Response
■ Code Team Response
■ STEMI or Stroke Alert
■ Patient Hand-Off – SBAR Process
19

20. AIDET
AIDET is a simple acronym that represents five
communication behaviors that can help you build
trust with both patients and colleagues. Executing
these behaviors effectively will help you establish
a positive first impression on others. It allows us to
communicate effectively for patients to become
engaged and to feel confident about what we can
do to help them.
20

21. AIDET
21

22. WHY should we use AIDET with
Patients?
1. Reduces patient and family anxiety by establishing trust
2. Improves compliance for better outcomes because
patients will cooperate more readily with their plan of
care as a result of that trust
3. Clear communication creates a safe environment to
receive care
4. AIDET helps us build customer loyalty; we want to be
their preferred healthcare provider of choice
22

23. Performance Improvement
(PI)
■ Performance Improvement means simply doing
things a little bit better tomorrow than we did
them today.
■ Every Department (clinical and non) must have PI
Projects each year. The Joint Commission
requires all departments to have PI.
■ PDCA or Fast PDCA is used to document our
improvement projects.
23

24. Performance Improvement
■ Recognize opportunities to do things better.
■ Consider putting in an Innovator idea for improvement projects.
■ "Is there a better way to do this?" or "Why are we doing this at
all?”
■ Stay current in your field. Medical knowledge changes all of
the time. Evidence Based Practices and Guidelines are the
cornerstone of our practice.
■ Share your ideas with your supervisor, director, other leader
and/or any teams that you participate on as applicable.
■ We want Redmond to be your hospital of choice. Patient Care
is our focus. Speak up if you see an opportunity.
24

25. Performance Improvement
■ Core Measures, which are a series of evidence-based best practices,
are an integral part of how we deliver patient care at Redmond.
■ They are not optional for a couple of reasons:
■ They represent best care.
■ How well we adhere to Core Measures is compared to every other
hospital in our region and state, as well as across the United States, as an
objective way for consumers to compare how well we deliver care.
■ Medical charts are audited continuously to determine our adherence
to the Core Measures.
■ When we fail to adhere to them, an opportunity exists to improve our
processes. If you were involved in a missed opportunity, the Quality
Department will reach out to you to help determine how to improve
our care delivery.
■ The only Core Measures manually abstracted at this time are STK,
VTE, and Sepsis, but they will begin to electronically pull the other
measures in 4th Quarter 2016. Core Measures are best practice for the
patient.
■ Nurses should commit to memory the next 8 slides on
Core Measures, it’s that important!
25

26. CORE MEASURES:
Myocardial Infarction
• Beta blocker at discharge or document a reason if with-
held
• Document LVSD or Ejection Fraction (EF)
• ACEI or ARB for EF<40% or document a reason if
with-held
• ASA for chest pain/or MI on arrival and discharge or
document reason if with-held
• PCI within 90minutes for STEMI or LBBB
• LDL within 24hrs of admit
• LDL >100 discharged on statin or document a reason if
with-held
26

27. CORE MEASURES:
Congestive Heart Failure
■ Document LVSD or EF
■ ACEI or ARB for EF<40% or document a
reason if with-held
■ Discharge instructions must include:
■ Activity & Diet & Follow-up visit
■ Worsening symptoms
■ Weight monitoring
■ List medications as found on Med Reconciliation
Form
27

28. CORE MEASURES:
Pneumonia
■ Blood cultures before antibiotics
■ 1st antibiotic in ED within 6 hours of arrival
■ Flu vaccine given – October–March (Must be
current season – Remember to document)
■ Appropriate antibiotic selection
28

29. CORE MEASURES:
Surgical Care (SCIP)
■ Prophylactic antibiotic 1 hour prior to incision (2 hours for
vancomycin)
■ Appropriate antibiotic
■ D/C antibiotic within 24hr (48 for CABG) after surgery end
time or document reason for continuing antibiotic
■ Clip hair only/never shave
(continued)
29

30. CORE MEASURES
Surgical Care (SCIP) (continued)
■ Continue beta blockers (never stop abruptly and document
received the day before surgery and/or the day of surgery as
well as POD 1 or POD2!)
■ VTE (clot) prevention within 24 hours before surgery to 24
hours after surgery
■ Cardiac surgery (CABG, Valve, most CT pts) patients with
controlled postoperative blood glucose (less than or equal to 180
mg/dl) in the timeframe of 18 – 24 hours after Anesthesia End
Time.
■ D/C foley by POD#2 or document reason
30

31. CORE MEASURES
Venous Thromboembolism (VTE)
■ Documentation required for:
■ VTE prophylaxis for ALL inpatients OR
■ “Patient at low risk for VTE, no prophylaxis
needed”
■ If VTE prophylaxis is not built in to an order set,
there is a new universal order set for VTE
prophylaxis
31

32. CORE MEASURES
Immunization Measure
■ UNIVERSAL MEASURE for all patients
■ Pneumonia vaccine status:
■ vaccines must be given, refused, or medically
contraindicated due to allergy or current active
chemotherapy
■ Influenza vaccine status:
■ Oct 1-March 31 – If received prior to admission, it
must have been for the current flu season
32

33. CORE MEASURE
Stroke Core Measure
■ Venous Thromboembolism Prophylaxis
■ by the end of hospital Day 2
■ Antithrombotic Therapy:
■ for ischemic stroke patients by end of hospital
Day 2
■ Discharged on statin medication
■ Assessment for Rehabilitation
■ Stroke Education
33

34. Opportunities for Improvement
■ If you want to learn more about Performance
Improvement or feel you have a better way of
doing things at Redmond, please see your
manager or Shelley Proctor, Risk Manager
(located in the Lower Level at extension 3950.
34

35. National Patient Safety Goals
■ The purpose of the National Patient
Safety Goals is to improve patient safety.
35

36. Identify Patients Correctly
■ Use at least two ways to identify patients.
■ Use the patient’s name and date of birth.
■ Ask the patient who they are and their date of
birth. Verify with the arm band before any
medication administration or treatment.
■ Make sure that the correct patient gets the
correct blood type when they get a blood
transfusion.
■ Follow BCTA process exactly.
■ Match the identifiers on the armband.
36

37. Labeling Specimens
■ Label containers and specimens in the
presence of the patient
■ Perform the Final Check by saying out
loud the last 3 digits from the specimen
label account number and the last three
digits of the patient’s account number on
the patient’s arm band
■ Example – “789” from armband – “789” on
specimen label
37

38. Label Medications
■ Syringes must be labeled when prepared for
the patient and not immediately used
■ Label to include drug name, dose, amount if
not apparent from container, date prepared,
expiration date, use and diluent for
compounded IVs. If patient specific must
have patient name.
38

39. Communication – Critical Results
■ Get important test results to the right staff person and
physician in time to act for patient safety.
■ Critical results from lab, radiology, or cardiology must
be reported quickly, a maximum of 30 – 45 minutes to
physicians. Time can be a factor when addressing these
issues for patient health.
■ Document in Standardized Meditech Screen
39

40. Use Medicines Safely
■ Take extra care with patients who take medicines to
thin their blood. Educate the family and the patient.
■ Record and pass along correct information about a
patient’s medicines. Find out what medicines the
patient is taking currently. Compare those medicines
to new medicines given to the patient.
■ Make sure the patient knows which medicines to
take when they are at home. Tell the patient it is
important to bring their up-to-date list of medicines
every time they visit a doctor.
40

41. Prevent Infection
■ Use the hand cleaning guidelines from the Centers
for Disease Control and Prevention or the World
Health Organization.
■ Use proven guidelines to prevent infections that are
difficult to treat.
■ Use proven guidelines to prevent infection of the
blood from central lines.
■ Use proven guidelines to prevent infection after
surgery.
■ Use proven guidelines to prevent infections of the
urinary tract that are caused by catheters.
41

42. Universal Protocol
■ Use Pre-Procedure Verification Process
■ Proceduralist Marks the Site
■ Time Out – Everyone Stops – and focuses to
ensure that it is the right patient, right
procedure, right side / site and all x-rays,
implants, equipment is available for the
procedure before the start.
42

43. Prevent Mistakes in Surgery
■ Make sure that the correct surgery is done on the
correct patient and at the correct place on the
patient’s body.
■ The physician mark’s the correct place on the
patient’s body where the surgery is to be done.
■ Time out performed with the team before the surgery
to make sure that a mistake is not being made.
■ Nurses complete the pre-surgery checklist prior to
surgery to make sure the patient is ready to go.
43

44. Critical Alarms, Patients at Risk for
Self Harm
■ Identify and keep patients at risk from
suicide safe.
■ Critical Alarms – Alarm fatigue is real.
Critical Equipment may not have the alarm
turned off.
44

45. Identify Patient Safety Risks
■ Find out which patients are at risk for
committing suicide, or are abused or
neglected.
■ Keep the patient safe and notify the
physician.
■ Make sure these patients are referred for
appropriate care and are kept safe in our
hospital.
45

46. I-Privilege
■ If you are un-sure if a physician is
credentialed to perform a service here at
RRMC you can use I-Privilege to look
up his/her credentials.
■ From our home page click on the I-
Privilege link in the right hand column
■ Then on the left of the screen that is
pulled up click on I-Privilege again
■ Then use our COID - 31052 for your
User ID and Password
46

47.
Guidance Document: Tubing and Line Safety using I-
TRACE
47
Behavioral expectations
I: Illuminate the patient care area whenever invasive medical lines and tubes are
manipulated (initiated, accessed, maintained, or discontinued).
T: Perform hand hygiene. Touch the line or tube and trace it from the insertion point on
the patient back to the point of origin.
R: Perform a cognitive review.
• What is the purpose/expected outcome of the line/tube intervention about to
occur? Visualize the actions planned; take time to ensure the planned actions will
deliver the expected outcome.
• Has a 2 point patient identification been carried out?
• Has BCMA been utilized to the fullest extent possible for the intervention about to
occur (e.g. medications; TPN)?
A: Act if any mismatch between the planned activity and desired outcome is discovered,
either through BCMA alerts, independent double checks, or a cognitive review.
C: Clarify and correct. Concerns expressed by primary caregivers, colleagues, patients, or
family member are valid and sufficient reasons to seek clarification before proceeding with
a task involving lines and tubes. Correct any discrepancies before proceeding with the
intervention.
E: Expect to use the ITRACE process: each time a line or tube is accessed, manipulated, or
discontinued and when care is handed-off to another clinician or care team.

48. Do Not Use
Abbreviations, Acronyms, and Symbols
Abbreviation Preferred Term
U Unit
IU International Unit
Q.D. & Q.O.D. daily & every other day
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
X mg
0.X mg
MS, MS04, & MgSO4 morphine sulfate or
magnesium sulfate
µg Mcg
T.I.W. 3 times weekly
c.c. Ml
ii, etc. (apothecary symbols) 2 or two
48

49. Rapid Response Team
■ The purpose of the Rapid Response Team is to
provide critical decision making and intervention at
the first sign of patient decline; to prevent arrest
situations, and save patient lives. The utilization of a
Rapid Response Team will bring critical care
expertise to the patient bedside before a crisis
situation results in a cardiac/pulmonary arrest.
■ The call is initiated by dialing (706) 233-5625 and
entering the patient’s three digit room number.
■ Hospital staff or patient's family/visitors may initiate.
49

50. Rapid Response Team
■ The role of the Rapid Response Team (RRT)
will be to:
■ Assess the patient and the situation.
■ Assist with stabilizing and transporting, if needed, to a
higher level of care.
■ Assist with organizing information to be communicated
to the patient’s physician using the SBAR tool.
■ Educate and support the nursing staff.
■ The RRT does not “replace” calling the primary
physician – but supplements, organizes, and expedites
information to the physician.
■ Family members and visitors may also call the RRT.
50

51. Code Blue & Code Blue PALS
■ Code Blue
■ Adult cardiac or respiratory event.
■ Don’t forget the Rapid Response Team (Call for the
Rapid Response Team when you feel a patient’s
clinical status is in decline and you may prevent a
Code Blue).
■ Know how to call a code and where your supplies are
located.
■ Code Blue PALS
■ Pediatric cardiac or respiratory event.
■ ED Nurse will respond to assist with running the
code.
51

52. FALL RISK
Nursing staff will assess the patient for safety/fall risk at the time of
admission, and as indicated by the unit assessment/ reassessment policy
and with each change in condition: Identify problem as potential for
injury related to fall risk on the care plan/problem list.
Safety rounds (with a purpose) are completed and documented Q 1
hour until 10 pm, then Q 2 hours through 7 am and also PRN.
PLEASE EXPLAIN that we want the patients to call for assistance
and that the hospital environment can be high risk for fall due to
medications. Educate the patient and the family.
52

53. FALL RISK
Fall Reduction Activities
■ Place a yellow sign at the head of the bed.
■ Place a yellow bracelet on the patient.
■ Place yellow socks on the patient.
■ Place fall risk magnetic stickers on the patient’s doorframe.
■ Educate the patient and family about the risk of falling and to call
for help. Show them where the call light is located.
■ See if family members can stay when patients do not follow
instructions. If they are not able, outside resources may be hired
by the family.
■ Frequently round for pain, potty, proximity of patient needs, and
position.
■ Use a low bed if you feel it would be a good tool to avoid a fall.
53

54. Hand-off Communication Process
■ The hand-off communication process for
Redmond is based on the SBAR
communication format.
■ SBAR stands for
■ S – Situation
■ B – Background
■ A – Assessment
■ R – Recommendation
54

55. Hand-off Communication Process
■ The tools used in the hand-off process include:
■ Direct face-to-face communication.
■ Phone report.
■ Reports printed from Meditech - SBARD.
■ Communication is a factor in more than 90% of
Sentinel Events reported to the Joint Commission.
■ Focus on the Patient and the Process. Warm Hand
Off (healthcare worker to healthcare worker) for
patient is best.
55

56. Patient rights
■ Patients and healthcare workers need to understand patient rights and responsibilities to
ensure that quality care is provided and that the patient can participate fully in their
treatment and care.
■ How are patients informed of their rights?
■ Patient Hand Book
■ Patient Bill of Rights
■ Signage in all areas of the hospital.
■ Patients have a right to an advocate to stay with them during their hospitalization as long
as it does not infringe upon other patient’s rights or interfere with clinical care or pose risk.
■ Patients must be asked about what language they prefer to receive their healthcare
information. The hospital is responsible to provide information in the requested language.
■ A patient or an advocate who is participating in their care must have the opportunity to
use a competent translator in the preferred language. If a patient or family member
refuses to utilize the provided interpreter, a waiver must be signed.
56

57. Patient rights
■ What is your role in patient rights?
■ Every patient who does not speak English as their
primary language, is deaf, hard of hearing, and/or blind,
is entitled to an interpreter free of charge.
■ There are forms in “Forms on Line” that are REQUIRED
to be completed for each patient whether or not they
chose to use the interpreter. Please see policies RI-05,
RI-06 and RI-07.
■ This form should be placed on the patient chart after it
has been signed and has a date and time.
Our patients will be thankful that they are able to
understand what is happening to them while they are in
our care.
57

58. Patient rights
Please also remember
All patients also have the right to:
-Refuse or accept treatment
-Formulate Advance Directives
-Informed participation in decisions involving their health care
-The right to know who is responsible for authorizing and
performing procedures or treatment
-The right to have his/her own physician notified
promptly of his/her admission to the hospital
58

59. Patient rights
■ Everyone is involved in protecting the rights of patients.
For example, the right to confidentiality means not
telling your friends or relatives when someone you
know has been a patient.
■ We provide privacy for patients by always knocking
before entering a patient or procedure room.
■ Patients have a right to a secure environment. Know
how to respond during a disaster or fire.
■ Patients are informed of their right to establish advance
directives or to change their current advance directive
status.
■ Patients also have a right to file a grievance. You can
assist with the investigation and response by contacting
Risk Management at ext. 3950 or Administration at ext.
4100 should you have a question.
59

60. Patient rights
■ Where can you find a list of patient
rights?
■ In facility Policy RI-04 Rights and
Responsibilities of Patients, the Patient
Handbook, posted beside the elevator in the
front lobby and at outpatient services, and
on Redmond’s Intranet site.
60

61. Patient rights
■ Access the Ethics Committee and the Ethic Resolution Process.
Phone: 706-802-3037.
■ Any concerns over patient safety may be reported to the Joint
Commission. Phone: 800-994-6610.
■ Access the grievance process. Express complaints or concerns
regarding care or services, including discharge.
■ Facility contact: 706-802-3950
Independent Agency:
Office of Regulatory Health
2 Peachtree Street N.W., Suite 200
Atlanta, Georgia 30329
Telephone: 1-404- 657-5726
Peer Review Organizations:
Georgia Medical Foundation [Medicare]
57 Executive Park South, Suite 200
Atlanta, Georgia 30329
Telephones: 1-800-282-2614
1-404-982-0411
Humana Military Healthcare
Services, Inc. [Champus]
931 South Semoran Blvd., Suite 218
Winter Park, Florida 32702
Telephone: 1-800-658-1405
61

62. When information involving healthcare is discussed
with a patient, the patient is entitled to be able to
speak and hear in a language they consider their
primary language.
Language Services Associates will provide
interpretation services for all patients or their
family members or those assisting with making
medical decisions with or for the patient in most
any language.
.
Translation Services

63. ■ The process is simple – no matter what
language is required. Just contact:
LANGUAGE SERVICES ASSOCIATES
Dial: 1.877.274.9745
Access Code 1808319#
(have the special telephones available when
you call)

64. ■ Please explain to the patient and
family that this service is FREE of
charge!
■ Document the use of service or the
denial of service.

65. ■ If you are in an area where you are not able to
use the telephone or the laptop, we do have
Interpreters available.
■ Please check with your Director for additional
information. (This information should also be
available on a pink sign located in your area).

66. We also have Hearing Impaired translation
available from the Georgia Relay Center
for Speech and Hearing Impaired.
This agency provides a conference-type
telephone call for interpretation. It requires
a special telephone located at the
Switchboard.

67. There are forms that should be signed and placed in the
chart if the patient wants to use or refuses our
interpreting services and/or if they want to use a
family member instead of an interpreter.
These are located in the Accommodation policies under
RI-05 (Limited English), RI-06 (Deaf) and RI-07
(Blind).
If you are unable to locate these, check with your Director or call EXT. 3950.

68. ADVANCED DIRECTIVES
■ Advance Directives include Living Will and Durable Power of
Attorney (DPOA) for Health Care.
■ Living Will only applies to terminal conditions.
■ DPOA for Health Care allows a person to name an agent to
speak on the person’s behalf, when the person cannot speak for
their self.
■ Inside the hospital, the attending physician must be present
when the patient names an agent. An agent can speak for the
patient concerning any condition.
■ Patients should be asked at the time of admission if they
have an advance directive. If the patient has a copy, obtain
a copy for the chart BY CONTACTING HIM.
■ Patients should initial and date a copy of the directive(s)
and the hospital staff should place it inside the current
medical record.
■ Social Services can assist by answering general questions and
providing blank forms.
68

69. Pain Management
■ Four major goals of pain management
■ Reduce the incidence and severity of patients' acute
postoperative or posttraumatic pain.
■ Educate patients about the need to communicate unrelieved
pain, so they can receive prompt evaluation and effective
treatment.
■ Enhance patient comfort and satisfaction.
■ Contribute to fewer postoperative complications and in
some cases, shorter stays after surgical procedures.
■ Effective pain management has additional benefits for the
patient ,e.g., earlier mobilization, shortened hospital stay,
and reduced costs.
69

70. Unanticipated Adverse Events and How to
Report
Occurrence Reporting
■ An occurrence is an event that is unusual, significant or notable.
■ Categories include: Patient, Non-Patient (visitor, MD, volunteer,
student, facility, equipment) or Employee Examples include:
Near Miss, Fall, Medication, Treatment and/or Testing, Adverse
Effect, Equipment, Property, Assault (abuse or harassment),
Error, Failure to follow policies & procedures, Failure to follow
MD’s orders, User/Operator error, Defective or malfunctioning
products, Incorrect action/activity, Inappropriate action/activity,
Omission, Delay, Complications, Loss or theft of personal
belongings, or Auto events with facility vehicles.
■ Occurrences should be documented in Meditech during the
working shift or definitely within 24 hours. The department
manager or house supervisor should be notified at the time of
the event. Please notify the Risk Manager of all serious and
potentially legal situations.
70

71. Occurrence Reporting
■ Meditech Reporting
■ Log onto Meditech - Select 500 Occurrence
Reporting - Select Facility - Select Category - (If
patient) At prompt type A# then the account number
- (If Non-Patient or Employee) Type N into the first
field to create a new report (For employee type in
last name and press the look-up key) - If no
previous Occurrence report exists for this patient ,
you will receive a message “No available
notifications for this patient. Create a new one? “
Answer Y (Yes) - Answer all questions in field -
Input will be by free text or pull down menu
selection - Enter all the information you know or
can obtain.
71

72. Occurrence Reporting
■ Look-up key (F9 ) displays a pull down menu.
■ Previous field key (F6) allows you to backup.
■ The enter key allows you to move forward one field.
■ Magic or file key (F12):
This key will provide the menu for selection.
You MUST FILE to save your work.
■ Exit key (F11):
Caution exit does not save your work.
■ Text fields require typing from keyboard.
■ An occurrence report is a confidential facility report that
should not be referenced in documentation on the patient’s
record.
■ If you have any difficulties, please don’t hesitate to contact RISK
MANAGEMENT at 3950.
72

73. Sentinel events
■ A sentinel event is an event which results in
unanticipated death or major permanent loss of
function, not related to the natural course of the
patient’s illness or underlying condition. Also,
suicide; infant abduction or discharge to the wrong
family; rape; hemolytic transfusion reaction
involving administration of blood or blood products
having a major blood group incompatibility; a
health-care associated infection; and surgery on
the wrong patient or wrong body part are all
sentinel events. Please secure all information and
items related to the event. If you have any
questions, contact Risk Management at ext. 3950.
73

74. Reportable Events
■ State (Georgia) Reportable Events:
■ The following type events should be reported to the
State of Georgia Office of Regulatory Services:
■ 1. Any unanticipated patient death not related to the natural
course of the patient’s illness or underlying condition;
■ 2. Any surgery on the wrong patient or the wrong body part
of the patient;
■ 3. Any rape of a patient which occurs in the hospital.
■ We report all deaths where the patient has been in
restraints within the previous 24 hours to CMS or if a
restraint was implicated in the cause of death
■ Report to the appropriate department leader and Risk
Management at 3950 or Regulatory Compliance at 3038
in the event that any of the above situations occur . The
situation is reviewed and reported to the Office of
Regulatory Services within 24 hours of knowledge that
the event meets one of the State definitions.
74

75. Suspected Impairment of Licensed
Independent Practitioner
■ All healthcare workers including physicians and
nurses should be competent and able to carry out
their patient care responsibilities free of any
impairment(s) that adversely affect their judgment or
clinical performance.
■ A licensed independent practitioner (LIP) is defined
as any individual permitted by law and the hospital
to provide care, treatment, and services without
direction or supervision (e.g., doctor).
75

76. Identification of an Impaired LIP
■ An impaired LIP is defined as one who is
unable to provide care, treatment, or
services with reasonable skill and safety to
patients because of a physical or mental
illness, including deterioration through the
aging process, loss of motor skill, excessive
use or abuse of drugs including alcohol.
76

77. Signs and Symptoms of Impairment
■ Signs and symptoms of potential impairment
include, but are not limited to:
■ Personality changes/mood swings
■ Loss of efficiency and reliability
■ Increasing personal and professional isolation
■ Inappropriate anger, resentments
■ Abusive language, demeaning others
■ Physical deterioration
■ Memory loss
■ Increase in tardiness, absenteeism, illness
■ Lack of empathy towards others
77

78. Reporting a LIP Suspected of
Impairment
■ If any individual in the hospital has a
reasonable suspicion that a LIP (or any
other healthcare workers) may be impaired
and this impairment may adversely affect
patient care and safety, take immediate
action by notifying your supervisor, and
following the appropriate Chain of
Command listed in policy LD 05.
78

79. Environment of Care
■ Defective Equipment
■ Defective equipment should be reported to
BIOMEDICAL Services via Meditech or at Ext. 4962 if
equipment removal constitutes an emergency.
Equipment will be tagged. Tag will say “danger
defective equipment”.
■ Security Related Incidents
■ Any incident requiring Security assistance (i.e. theft or
suspicious activity), contact security by dialing 0 and
asking PBX to page a member of Security.
■ Please refer to the Environment of Care section of the
policy manual for in-depth information on these topics.
79

80. Eye Wash Stations
■ Know where they are located
■ Do not block access to the station
■ Flush eyes for 15 minutes unless MSDS indicates
different flush time for the substance involved in the
exposure
■ Water should be temperate (not too hot or cold)
■ Weekly checks and flushes must be performed for each
eye wash station
■ Eye wash stations must be available everywhere corrosive
materials are used or stored
80

81. Eye Wash Station Locations
■ Employee Heath
■ Outpatient
■ Emergency Department
■ Outpatient Oncology
■ Lab
■ Pharmacy
■ Radiology
■ Cardiology
■ BioMed
■ Maintenance – Boiler Room
■ Environmental Services –
Equipment Room
81

82. O2 Tank Storage
■ Cylinders are designated as full or empty by the description
below:
■ Unopened or Unused Cylinders = Full
■ Used Cylinders = Empty
■ Cylinders that are unopened/Unused or Full should be properly
secured in the green racks/Full
■ Cylinders that have been used or have been opened should be
properly secured in the red racks/Empty. Even if gas remains in
the cylinder. Cylinders of compressed gas should be stored in
designated areas.
■ All freestanding cylinders, whether empty or full should be properly
secured.
■ Freestanding cylinders should never be secured to portable or
moveable equipment that is not designed for their use.
■ Cylinders should never be placed on a stretcher.
■ A patient should never be asked to hold an e-cylinder for transport.
82

83. Hazardous Material and Waste
Read Container Labels—Before handling any chemical container, always read the label.
Warnings may be in words, pictures, or symbols.
Consult the Material Safety Data Sheet (MSDS)– A MSDS gives more detailed
information on a chemical and its hazards. It also gives you specific precautions for
protecting yourself from dangerous exposure. Your department should have a
notebook with a list of the chemicals used in your area.
Use Proper Handling Techniques– Always wear proper personal protective equipment.
Dispose of Chemicals Properly– Carry and store chemicals only in approved, properly
labeled, safety containers. Never dispose of chemicals in containers used for ordinary
waste. Never pour them down sewers or drains. Always consult the MSDS sheet for
approved method of disposal.
Contact the Lab at ext. 3117 or 4050
if you have questions.
83

84. FIRE SAFETY
■ Make good housekeeping part of your work routine.
■ Keep passageways and exits clear.
■ Don’t let furniture or equipment block stairways, halls,
or exits.
■ Keep floors clear of waste and spills.
■ Make sure exit paths and doors are well-lit and clearly
marked.
■ Know your area.
■ Where are the fire pull stations and extinguishers
■ Know how to extinguish
■ Cover and smother
■ Be careful to not fan the flames
84

85. FIRE SAFETY
■ Check fire doors.
■ Make sure nothing is blocking them.
■ Never wedge or prop them open.
■ Dispose of trash safely.
■ Put waste in approved containers.
Keep these away from heat sources.
■ Put flammable substances in approved
metal cans or containers.
85

86. FIRE SAFETY
■ Prevention is the best defense against
fires.
■ To prevent fires related to electrical
malfunction remove damaged or faulty
equipment from service and submit
malfunctioning equipment for repair.
■ To prevent fires related to equipment
misuse do not use any piece of
equipment you have not been trained to
use.
86

87. FIRE SAFETY
It's easy to use a fire extinguisher if you can remember the acronym
PASS, which stands for Pull, Aim, Squeeze, and Sweep.
■ Pull the pin.
This will allow you to discharge the extinguisher.
■ Aim at the base of the fire.
If you aim at the flames (which is frequently the
temptation), the extinguishing agent will fly
right through and do no good. You want to hit
the fuel.
■ Squeeze the top handle or lever.
This depresses a button that releases the
pressurized extinguishing agent in the
extinguisher.
■ Sweep from side to side
until the fire is completely out. Start using the
extinguisher from a safe distance away, then
move forward. Once the fire is out, keep an eye
on the area in case it re-ignites.
87

88. IF YOU DISCOVER A FIRE –
REMEMBER:
■ RACE
■ R - RESCUE anyone in
immediate danger
■ A - Activate the
ALARM
■ C – CONFINE or
CONTAIN the fire
(close the door)
■ E - EXTINGUISH
small controllable fires/
or EVACUATE
88

89. All Foam and Gel Hand Cleaners
■ Foam and gel hand cleaners are becoming very popular for hand
cleaning in the healthcare environment. For them to be effective,
they must contain more than 60% alcohol. That makes the hand
cleaners FLAMMABLE. It is not unsafe to use the hand cleaners,
but you should be aware of the following information each time the
hand cleaner is being used:
■ After applying the gel or foam, the alcohol on the hands should be
allowed to evaporate for 30 seconds.
■ The solution on your hands is flammable until the alcohol evaporates.
■ If a flame or spark is near your hands before the alcohol evaporates, a
fire could occur. There have been reports of healthcare workers whose
hands caught on fire from a spark or from static electricity after using
an alcohol based hand cleaner.
■ Alcohol burns very clean and the flame is almost clear.
89

90. Prepare Your Family
■ Visit www.ready.gov to find resources to prepare your family:
■ Prepare yourself by building an emergency preparedness kit
■ Made sure your family is educated on where to find information regarding the kit and what to do
■ Make sure your preparations and supplies will cover your family for 72-96 hours
■ Make sure you think about the following when preparing your kit
■ Pets
■ Special needs children or adults
■ Seniors
■ Infants & young children
■ Teach your family you may be required to work
■ Have a safe place for them to stay
■ If you have needs for child care in order to work, let us know
■ If you have other obligations which may prevent you from reporting to work, make
sure you manage is aware ahead of time so they won’t surprised. These include:
■ Military obligations
■ DMAT, other volunteer organizations
75

91. How would Redmond handle an emergency event?
■ Redmond utilizes the Hospital Emergency Incident Command System
(HEICS)which provides us with proven and predictable command structure
designed to handle any event.
■ HEICS provides us with:
■ Proven Incident Command System structure (ICS) for healthcare use
■ Predictable chain of management
■ Flexible organizational chart which allows for scalable responses
■ Prioritized response checklists
■ Defines position responsibilities
■ Improves documentation for improved accountability and cost recovery
■ This Incident Command structure can be utilized for any event allowing
Redmond to be prepared to manage “all hazards”.
■ Redmond has policies in place and uses drills to help improve our response.
■ When you hear a code announced do not call PBX to get details or find out what
you should do (they are only responsible for knowing their role).
■ Don’t wait for an event to learn your role! Speak with your manager during
orientation to find out what the response is specific to your department.
76

92. Emergency, someone call FOR HELP!!!
■ Question: What do you do in the hospital when you need
help in a hurry?
■ Answer: Call extension 4000. The switchboard will answer
your call immediately.
■ This extension should be used the same as if you needed
“911”. It is designed for emergency situations, not just to
get through to the switchboard in a hurry. For example,
this line could be used for a Code Blue or if a visitor was
seriously hurt.
■ NEVER use this phone line for anything other than
emergencies!
92

93. EMERGENCY PREPAREDNESS CODES
■ Code Triage - Provides guidelines for
operations in the event of an emergency - this is
a multi-step code which will be shown on
separate slide
■ Code 900 - Show of force
■ Code 1000 - Visitor, associate, family member
needs assistance
■ Code Manpower – Lifting assistance
■ Tornado Watch or Warning – has been issued
for Floyd County
93

94. EMERGENCY PREPAREDNESS CODES
(cont’d)
■ Code Red—Fire
■ Code Gray—Bomb Threat
■ Code Blue—Adult Cardiopulmonary Arrest
■ Code Blue PEDS — Pediatric Cardiopulmonary Arrest
■ Code Pink – Pediatric Abduction
■ Code White – Adult Patient Elopement
■ Code Green— Hostage Situation
■ Code Orange—Hazardous Material Event
■ Code Silver —Active Shooter
■ Code Black - Structural damage to facility
94

95. Inclement Weather
When the facility is made aware of a potential for weather that
makes travel difficult or unsafe, plans will be made to have
appropriate coverage to continue essential operations.
■Each leader will review staffing and supplies for the anticipated
period
■Employees are expected to report to duty. Administration or
Managers will notify staff if there is a need to come in early to
arrive before weather system hits
■Make sure to pack clothing, medicines, personal items, foods,
etc. for 24-72 hours
■We will provide housing either on campus or with a local vendor
to allow staff to be available as needed
■Make sure to have plans for family, family members with special
needs and pets for 96 hrs.
■If you drive make sure you have supplies and a way to
communicate if stranded
95

96. Organ Donation
■ Timely referrals of potential organ donors is
critical.
■ Healthcare professionals are required to identify
and refer patients who meet clinical triggers to
the Donation Referral Line at (800) 882-7177.
■ Timely referrals preserve the option of donation
for families of medically suitable patients.
■ A representative from LifeLink our organ
procurement agency is the only one who can
approach a family about donations.
96

97. Heart Disease Remains #1 Cause of Death in the U.S.
97

98. It’s a Fact!!
Each year, approximately 1.2 million Americans suffer a
heart attack, and nearly one-third of these individuals
die…many before they reach the hospital.
About every 26 seconds an American will suffer from a
coronary event. Almost every minute, someone will die
from one.
Hundreds of thousands of Heart Attack victims survive,
but are left with a damaged heart.
Why??????
98

99. People often dismiss heart attack warning signs. Many
people wait too long before getting help. It is just not
the heart attack itself that kills, but time wasted trying
to decide whether or not to go to the hospital.
More than 50% of all patients experiencing chest
pain walk into the ED rather than calling 911.
It is critical for those who experience any chest
discomfort or heart attack symptoms to call 911
and quickly get to the Emergency Department.
Heart Attack Facts

100. Time wasted = muscle lost
TIME IS TISSUE!!
85% of muscle damage takes place within the first one to two
hours. It is within this timeframe that the blocked heart vessel
needs to be opened to avoid permanent muscle damage.
The best way to stop the heart attack process is to detect the
symptoms early and act before damage to the heart muscle
occurs.
100
Heart Attack
Facts

101. A heart attack occurs, in most cases, when a
blood vessel supplying heart muscle becomes
completely blocked. The vessel has become
narrowed by a slow buildup of cholesterol
deposits which may crack open, forming a clot.
101
When a clot occurs, it completely blocks
the supply of blood to the heart muscle.
That part of the muscle will begin to die
if the individual does not seek immediate
medical attention.
Blocked artery
(before
treatment)
Same blocked artery
(with restored flow after
treatment)
Heart Attack Facts

102. What You Need to Know
Know the frequent signs of a heart attack:
Chest discomfort: Most heart attacks involve discomfort in the center of the
chest. It may feel like pressure, squeezing, fullness, or pain, and may be
steady or come and go.
Discomfort in other areas of the upper body: This may include pain or
discomfort in one or both arms, the back, neck, jaw, or stomach.
Shortness of breath often accompanies other symptoms.
Other symptoms may include breaking out in a cold sweat, nausea, or light-
headedness.
102

103. What You Need to Know
Heart Attack Signs/Symptoms in Women include:
■ Unusual fatigue
■ Upper abdominal pressure or discomfort
■ Nausea or Vomiting
■ Lower chest, neck, shoulder, jaw or arm
discomfort
■ Dizziness
■ Unusual shortness of breath
■ Back pain
■ Light-headedness, fainting, sweating,
103
More women in the US die of heart disease each year than
men. Women often experience signs and symptoms that are
different from men, or may go unnoticed altogether.

104. What You Need to Do
■ Be able to recognize the early symptoms of a heart attack.
■ Educate others in early heart attack care. Inform them about the
importance of early recognition, quick action, and calling 9-1-1!
■ Be an advocate for Redmond EMS and Redmond Regional Medical
Center.
104

105. Accreditations and Awards
Redmond is an accredited Chest Pain Center by the Society of
Cardiovascular Patient Care.
Redmond also has a Disease-Specific Certification and from
The Joint Commission for AMI (Heart Attack) care.
Redmond has received the Gold Performance Achievement Award
by The American Heart Association for Cardiovascular and
Heart Attack care.
105
We work hard to make sure that we follow national clinical guidelines, provide
outstanding quality, and provide education to our staff and the population we
serve about Early Heart Attack Care.

106. Heart Failure Facts
■ Heart failure is the leading cause of morbidity (ill
health) and mortality (death) in the U.S.
■ The most common reason for admission to the
hospital in the age group 65 years and older!
■ 1 in 5 people diagnosed with Heart failure die
within 5 years of diagnosis.
■ Many people can lead full and enjoyable lives if
Heart Failure is managed with lifestyle changes,
education, diet, and medications.
106

107. What is Heart Failure?
■ A condition resulting from the heart’s inability to
pump an adequate amount of blood to meet the
body’s needs.
■ It can be sudden, but usually develops over time.
■ Basically the heart can’t keep up with the body’s
workload.
It Does Not mean your heart is going to STOP beating
It Does mean the heart pump is weak.
107

108. What Causes Heart Failure?
Anything that can damage the heart can cause Heart Failure:
■ High blood pressure.. Common cause
■ CAD and Heart attack….Most common cause
■ High cholesterol and arrhythmias
■ Damage to heart valves
■ Viruses, drugs, excessive alcohol
■ Advancing age or congenital heart defects
■ Heart muscle disease
■ Etc.
108

109. When your heart is damaged
■ At first the weakened heart tries to make up for it’s
inability to meet the needs of the body by:
■ Enlarging to contract more strongly
■ Beating faster (got to get that oxygen to the cells!)
■ Blood pressure increasing to perfuse the organs
These temporary measures mask the problem of
heart failure, but they don’t solve it. Heart failure
continues and worsens until these substitute processes
no longer work, and you start seeing signs of heart
failure.
109

110. Warning signs of Heart Failure
■ Shortness of breath
■ Swelling in feet,
ankles, stomach
■ Weight gain from
FLUID (not fat weight)
■ Fatigue, tiredness
■ Increased heart rate
■ Coughing when lying
down
110

111. Prevention of Heart Failure
■ Lose weight (weight causes increased work)
■ Stay active (exercise helps everything)
■ Quit smoking (and avoid second hand smoke)
■ Keep your BP under control
■ Eat healthy (low fat …low SALT)…lower your Cholesterol
■ Limit alcohol (If you drink alcohol, do so in moderation.
This means no more than one or two drinks per day for
men and one drink per day for women)
■ Control your Diabetes
■ Routine MD checkups and immunizations
■ If you have chest pain…get to the ER!!!
111

112. Treatment of Heart Failure
■ Treat the underlying Cause (BP, CAD, etc.).
■ Weigh daily… looking for fluid build up.
■ Heart healthy 2 GM Sodium diet …no added salt.
■ Limit fluid intake (less than 2 liters).
■ Medications for heart failure and BP control….Be
compliant!
■ Lifestyle changes…(weight loss, exercise, smoking,
etc.).
■ Limit Stress.
■ Know the signs of heart failure!
112

113. Redmond Regional
Medical Center
■ Maintains Advanced Certification for the treatment of
Heart Failure with The Joint Commission.
■ Has Gold Plus Achievement with American Heart
Association in the treatment of Heart Failure.
■ We strive everyday to provide evidence based care for
our patients with heart failure.
113

114. Facts About Stroke
3rd leading cause of death in the United States.
Risk increases with age, but people of any age
can have a stroke.
Leading cause of adult disability in the U.S.:
■ Without treatment, 62% of people who have
a stroke will have moderate to severe
impairment.
114

115. What is a stroke?
Old Term: CVA or
Cerebrovascular
accident.
Bad term because stroke
is preventable and
treatable.
New Terms: Stroke, TIA
It’s not an “accident.”
A stroke occurs when
something happens to
interrupt the steady
flow of blood to the
brain.
115

116. Three Types of Strokes
■ Mini-Stroke or Transient Ischemic Attacks
(TIA) – brief episodes of stroke symptoms.
■ Ischemic Stroke is caused by blood clot. The
clot blocks flow of blood to brain.
■ Hemorrhagic Stroke is caused by bleeding.
Results from burst or leaking blood vessels in
the brain.
116

117. Stroke Symptoms: Remember “FAST”
Only one
symptom is
necessary to
indicate
stroke
117

118. F = Face • Droops on left
or right side
• Sudden
drooling
• Numbness
Ask person
to smile
• Look for difficulty
holding things or
putting on clothing
• Numbness
• One arm drifts down
or won’t go up
• May have trouble
walking
A = Arms
Ask person to raise
both arms
118

119. S = Speech • Slurred speech
• Doesn’t make sense
• May not understand
what other people
are saying
• Forgets how to
read or write
Ask to
repeat
phrase
or name
object
• Time lost is
brain lost
• Save time
and brain
cells
• Go in an
ambulance
T = Time
At any sign,
Call 9-1-1
119

120.
Stroke Prevention: Know your Risk Factors and develop a
lifestyle to decrease you risk
■ High Blood pressure
■ Tobacco use
■ Diabetes
■ TIAs
■ Carotid or other artery
disease
■ Atrial Fibrillation or
other heart disease
■ Certain blood disorders
■ High blood cholesterol
■ Physical inactivity and
obesity
■ Excessive alcohol
intake
■ Illegal drug use
■ Increasing age
■ Gender
■ Heredity and Race
■ Prior stroke
120

121. “Stroke Alert”■ EMS and Emergency Department play key role
in coordinating care of stroke patients admitted to
our hospital
■ What if the patient is already here and starts
having signs and symptoms of a stroke????
Call our Rapid Response Team at:
706-233-5625
Redmond Regional Medical Center
is certified by The Joint Commission
as a Primary Stroke Center.
121

122. Sexual Harassment
■ The following is prohibited:
■ Unwelcome sexual advances, requests for sexual favors,
and all other verbal or physical conduct of a sexual or
otherwise offensive nature.
■ Behavior that engenders a hostile or offensive work
environment will not be tolerated. These behaviors may
include but are not limited to: offensive comments, jokes,
innuendoes and other sexually-oriented or culturally
insensitive/inappropriate statements, printed material,
material distributed through electronic media or items
posted on walls or bulletin boards.
122

123. Sexual Harassment
■ You should promptly report the incident to your
supervisor, who will investigate the matter and take
appropriate action, including reporting it to the Human
Resources Department.
■ If you believe it would be inappropriate to discuss the
matter with your supervisor, you may bypass your
supervisor and report it directly to the Human Resources
Department which will undertake an investigation.
■ Or you may call our Ethics and Compliance Officer, Lori
Baker, at 3015 or the Ethics Line at 1/800-455-1996. The
complaint will be kept confidential to the maximum extent
possible.
123

124. VIOLENCE PREVENTION
■ Violence can happen in any department or area.
■ Before violence strikes, there are usually warning
signs.
■ These include:
■ Making threats, talking about or carrying weapons
■ Screaming, cursing, challenging authority
■ Restlessness, pacing
■ Violent gestures, such as pounding on a desk
■ A loner, someone angry and depressed
124

125. VIOLENCE PREVENTION
■ You can help prevent violence by:
■ Treating everyone with respect
■ Checking the patient charts for history of
violence or aggression, alcohol or other drug
abuse
■ Trusting your gut feelings
■ Watch for warning signs
■ Try to spot—and head off—trouble before it
turns to violence
■ Staying calm if someone starts to lose control
■ Don’t let your escape path get blocked
125

126. VIOLENCE PREVENTION
■ To reduce your risk for potential injury use the
following guidelines:
■ Notify security at the first sign of a potentially violent
situation
■ Communicate in a low, calm tone of voice
■ Allow the person to voice their feelings
■ It’s important to stay calm and maintain self-control
■ Avoid defensive words or angry gestures
■ Do not argue
■ Do not turn your back on the person
■ If possible, give the person what they demand
126

127. RECOGNIZING ABUSE, NEGLECT
And Exploitation
■ Signs of Abuse
■ History inconsistent with nature and extent
of injury
■ Delay in seeking medical treatment
■ Frequent Emergency Room visits
■ Accident prone
■ Discrepancy in patient’s and family’s story
■ Bruises in various stages of healing
■ History of previous trauma in patient or
sibling
127

128. The Definitions
■ Abuse
■ To treat in a harmful, injurious or offensive way
■ Neglect
■ To omit through indifference or carelessness
■ Signs and symptoms include;
■ Failure to thrive
■ Poor hygiene
■ Dehydration
■ Malnutrition
■ Poor social skills
■ Exploitation
■ To use for profit, to ask for money or materials
128

129. Reporting Abuse, Neglect or
Exploitation
■ Nursing Interventions:
■ Routinely screen during each patient encounter.
■ Screen one-on-one in a private environment.
■ Assess patient’s immediate safety.
■ Listen with a non-judgmental attitude.
■ Document in the medical record the following: abuse history (subjective
and objective), results of safety assessment, authorities notified, family
notified, treatment given, and any safety instructions provided.
■ The person suspecting the abuse should notify Social Services
during weekday hours and the House Supervisor at night and on
weekends to inform them of the situation. These resource persons
will assist with the notification of the authorities.
129

130. Reporting Abuse
■ Reporting Responsibilities:
■ Notify the MD.
■ Notify DFACS or Adult Protective Services (APS) of the
possibility and the appropriate authorities.
■ GA has general mandatory reporting laws. MUST report to
law enforcement the following: injuries resulting from general
violence and injuries inflicted by gun, firearm, knife, or other
sharp object.
■ Resources: Department of Family and Children Services
(DFACS): 706-294-6500 / Police Dept.: 911 / Battered
Woman/Domestic Violence Hotline: 1-800-334-2836 /
Prevent Child Abuse GA: 1-800-532-3208 /
Adult Protective Services: 1-888-774-0152
130

131. Population Served at RRMC
Demographic RRMC Population Served
White 87.66%
Asian 0.23%
African American 9.63%
Hispanic 2%
Multi-Racial 1.14%
Other Race 1.34%
131

132. Population Served at RRMC
Most Common Principal Diagnosis
■ Coronary Artery
Disease
■ Septicemia
■ Acute Myocardial
Infarction
■ Osteoarthritis
■ Chest Pain
■ Atrial Fibrillation
■ Renal Failure
■ Pneumonia
■ Congestive Heart
Failure
■ Stroke
■ Respiratory Failure
132

133. CULTURAL COMPETENCY
■ Cultural competence means
providing medical care in a way that
takes into account each patient’s
values, beliefs, and practices.
■ Culturally competent care promotes
health and healing.
133

134. CULTURAL COMPETENCY
■ The healthcare provider must have an
understanding of the predominant cultures
that exist in the geographic area in which s/
he provides patient care. Because the U.S. is
so diverse, certain cultures may not be seen
in all areas of the country.
134

135. CULTURAL COMPETENCY
■ A very important aspect of cultural
competency is the avoidance of
stereotyping.
■ We must not presume that all people of a
certain culture adhere to all aspects of their
culture. The healthcare provider must
identify which aspects are appropriate for
each patient during the admission process.
135

136. CULTURAL COMPETENCY
■ Communication begins with identifying the
patient’s primary language.
■ Patient must be offered an interpreter in their
preferred language free of charge. If family
interprets, a waiver must be signed.
■ As a staff member, if you have any cultural
or religious preferences that might impact
on your delivery of patient care please
let your supervisor know.
136

137. Federal Privacy Rules
• HIPAA: Health Insurance Portability &
Accountability Act – Protected Health
Information (PHI) – established federal rules for
healthcare organizations & staff to protect
patient privacy
• HITECH: Health Information Technology for
Economic and Clinical Health Act – expanded
rules regarding breach notification to patients
and government
137

138. Patient Rights Regarding
Protected Health Information
• Right to Privacy
• Right to Access/Review
• Right to Opt Out of Directory (Census listing)
• Right to Request an Amendment
• Right to Request Privacy Restrictions
• Right to Confidential Communications
• Request an Accounting of Disclosures (who received information)
• HIPAA privacy standards require that facilities use and disclose only the
minimum amount of protected health information (PHI) necessary to accomplish
the intended purpose.
• Authorization for uses and disclosures of protected health information (PHI) must
be obtained for uses and disclosures outside of treatment, payment and health
care operations, unless otherwise permitted by law
• HITECH require Breach Notification to the patient and the Department of Health
and Human Services. The media must also be notified when breaches involving
more than 500 individuals in the same state or jurisdiction occur.
138

139. Protected Health Information
■ Once patient information is given as
identification, it is protected;
■ Name, DOB, SSN, insurance # ID, address,
telephone number, etc.
■ Diagnosis, treatment, personal information
■ Paper/electronic medical record, images,
photographs, voice recordings, spoken word
139

140. Staff Responsibility
• Protect health information
– Don’t leave PHI in plain site (counters/monitors)
– Discard paper in shredding bin
– Ask patient permission before discussing PHI in front of
visitors
– Validate requestors authorization to information BEFORE
discussing or releasing
– Share only what is minimally necessary
– Refer privacy complaints/restriction requests to Facility
Privacy Officer
– Document /log disclosures to others outside organization
– Secure electronic media
– Encrypt confidential emails
140

141. Violations/Breaches
■ Facility Privacy Officer to investigate
■ (Extension - 3095)
■ Substantiated Breach Notification to:
■ Patient
■ Department of Health & Human Services
■ Media, if more than 500 patients impacted
(example: loss of laptop with PHI on it)
141

142. Examples of Breaches
• Fax information to wrong number
• Discuss PHI with unauthorized person
• Throw PHI in the regular trash
• Leave PHI unattended in public area
• Write PHI on white board with patient ID in public
area
• Take a photo of a patient without permission
• Post PHI on Facebook or Twitter
• Access electronic medical record on family member
• Give patient another patient’s paperwork by mistake
142

143. Violations/Sanctions
Types of Violations:
■ Negligent: Accidental, oversight, lack of
education or failure to follow acceptable
protocols
■ Intentional: Deliberate action/inaction
Employee Sanctions:
■ Re-education
■ Disciplinary action up to termination
143

144. Civil & Criminal Penalties
• Facility AND/OR the staff member who breaches
PHI may face:
– Civil Penalties
– Criminal Penalties
IT ISN’T WORTH IT TO LOSE:
– Lose your job
– Lose your credibility
– Lose professional license
– Pay a financial fine
– Go to jail
144

145.
Information Security
The Who, What, Where,
When, Why, and How of
protecting sensitive
information.
145

146. Session Goals
■ Review Common Information Security Terminology
■ Provide Key Contact Information - Who
■ Explain Types of Information - What
■ Provide Key Resources Information - Where
■ Share When to Report Concerns or Incidents - When
■ Describe Why You Should Care about Information Protection - Why
■ Give Specific Tips on What You Can Do to Protect Information - How
146

147. Common Terminology
■ Privacy - addresses the use and disclosure of individuals’ health
information as well as individuals‘ rights to understand and control how
their health information is used.
■ Information Security – assures patients that the integrity, confidentiality,
and availability of their electronic protected health information (ePHI) is
protected as we collect, maintain, use, or transmit it.
■ PHI – Protected Health Information
■ ePHI – electronic Protected Health Information
■ PII – Personal Identifiable Information
Look for the blue bubble for more definitions through out the presentation.
147

148. Contacts
■ Service Desk
■ 888-821-1065
■ Division and Facility Information Security Contacts:
o Director of Information Security Assurance (DISA)-Monica Smith
o Facility Information Security Official (FISO)-Brad Treglown
o Zone FISO (ZFISO) – Angie Turner
■ Atlas keyword DISO or FISO
■ Division and Facility Privacy Contacts:
o Ethics and Compliance Officer (ECO)-Lori Baker
o Facility Privacy Officer (FPO)
■ Atlas Keyword ECO or FPO
148

149. Types of Information
Information Security standards define sensitive data as data that includes one
or more of the following types of information:
■Social Security numbers
■Any government issued identification number
■Account number in combination with any required security code, access code,
or password (e.g., a PIN) that would permit access to an individual's financial
account
■Electronic Protected Health Information as defined by the HIPAA Security
Rule
■Human Resources employee files
149

150. Challenge!
Which of the following is not PHI?
A. Medical record number
B. Finger prints
C. Shoe size
D. Photographic images
E. Fax number
150

151. Examples of Protected Health Information (PHI)
■ Name.
■ Address including street, city,
county, zip code and equivalent
geocodes.
■ Names of relatives.
■ Name of employers.
■ All elements of dates except
year (i.e. DOB, Admission,
Discharge, Expiration, etc.).
■ Telephone numbers.
■ Fax Numbers.
■ Electronic e-mail addresses.
■ Social Security Number.
■ Medical record number.
■ Health plan beneficiary
number.
■ Account number.
■ Certificate/license number.
■ Any vehicle or other device serial
number.
■ Web Universal Resource
Locator (URL).
■ Internet Protocol (IP) address
number.
■ Finger or voice prints.
■ Photographic images.
■ Any other unique identifying
number, characteristic, code.
151

152. Resources
152

153. Am I in Compliance?
■ What happens if I violate an IS policy or standard? See WS.SWB.03 - Sanctions Process
■ Am I using email appropriately? See IS.SEC.002 Information Security - Electronic
Communications
■ What did I agree to when I signed a Confidentiality & Security Agreement? See
Confidentiality & Security Agreement (Atlas Keyword: CSA)
■ Do I use USB drives appropriately? See COM.MH.02 - Information Handling Procedures
■ Do I encrypt emails containing sensitive data? See COM.EI.01 - Electronic Transmissions
■ Do I lock my workstation when I leave it unattended? See AC.UR.02 - Session Security
■ If my laptop or mobile phone was stolen, how quickly must I report it? See IR.RISE.01 -
Incident Reporting
■ Do I know how to sanitize electronic media correctly? See COM.MH.01 - Media Sanitization
■ What is a business owner or CFO responsible for? See IS.SEC.009 Information Security -
Risk Acceptance and Accountability
■ What are managers required to do? See WS.SWB.01 - Management Responsibilities
153

154. Report Concerns or Incidents
To one of the following within 24 hours:
■FISO
■FPO
■Service Desk
■ 888-821-1065, choose the Security option
■An incident could include:
■ Stolen/lost computer or portable device (phone)
■ Misdirected fax or email
■ Virus alert on your computer
■ Posting of PHI on a social media site
WHY?
Reporting incidents or
concerns promptly allow
the appropriate personnel
to respond in a timely
manner in order to
manage risks to the
enterprise - even if the
incident is accidental.
154

155. It’s Part of the Job
■ It is the right thing to do.
■ HCA’s mission says we are “committed to the care and improvement
of human life”. This includes taking care of our patient’s
information.
■ We are legally bound to protect the confidentiality of our patients,
the company and its employees' information.
■ At HCA, we take privacy and information security seriously.
• HIPAA - Health Insurance Portability and Accountability Act
• HITECH - Health Information Technology for Economic and Clinical Health Act
155

156. To Reduce the Risks
■ Identity Theft
■ Loss of Privacy
■ Loss of Trust
■ Costly Breach Notifications
■ Malware like Viruses, Worms, Trojans, Spyware
■ Cyberbullying
■ Online Predators
• Breach Notification – Usually in the form of letters sent out to individuals whose
protected health information has been disclosed or compromised.
• Malware – malicious software
156

157. How Can I Protect Information?
1. Passwords
2. Workstation Security
3. Portable Device
Security
4. Malware Protection
5. Electronic
Communications
6. Phishing
7. Social Engineering
8. Social Media
9. Mobile Devices
10. Awareness
Learn more about ten areas where you can
actively protect information.
157

158. Passwords
■ Your password is your key. Do not give your key to
any one else - ever!
HCA will never ask for your password
■ Use different user names and different passwords for
work use and personal use.
■ Create a strong password. Use a combination of
letters, number, special characters, upper and lower
case.
WHY?
If someone uses your
password to access
unauthorized systems or
information, it is very
difficult to prove that you
were not the one to access
it. You could be held liable.
If someone steals your
network password and it’s
the same as your online
banking password, the bad
guys can get lots of
information.
158

159. How Much Time Would it Take
To crack your
password…
The graph is from inetsolution.com
159

160. Creating Strong Passwords
“I love my dog Spot”
This example uses the first letter of each word
of a sentence. If Spot is 5 years old, it is easy to
remember the number "5" at the end of the
password.
Strong Password = ilmdSx5
or
Strong Password = Il0vemyD0gSp0t5!
Using the same phrase, here are examples of weak passwords:
Weak Password: mydog
or
Weak Password: Spot1
WHY?
STRONG PASSWORDS
•IMPROVE PATIENT
SAFETY
•PROTECT YOU
•ARE UNIQUE
•IMPROVE
CONFIDENTIALITY
160

161. Workstation Security
• Lock or log off when you are done to activate the
screensaver
■ Lock: Press CTRL-ALT-DELETE, select LOCK
■ Lock: Windows logo key and “l”
■ Log off: Select START, and Logoff.
• Log out of applications on shared workstations when done
• To suspend a session in MEDITECH, press Shift F12 to
lock the patient record.
■ Make sure no one is watching over your shoulder when
you enter information, PIN numbers, or passwords.
■ If you feel someone is watching what you’re typing, lock
your screen immediately and ask that person if you can
help them.
WHY?
Prevent
unauthorized
viewing of data on
your unattended
workstation.
161

162. Device Security
■ Always keep portable equipment/devices with you and
in your sight or lock them up when not in use.
■ If using or traveling with a company-owned laptop,
request a cable lock from your IT&S Department.
■ If it is necessary to leave your laptop in your vehicle,
make sure that it is out of sight.
■ If you require the use of a USB drive, ensure it is
encrypted.
■ Don’t store sensitive data on a portable device unless
you need to for your job.
WHY?
One lost or stolen
device could result
in a costly breach
notification. Even
if there isn’t a
breach, there is
also the cost to the
company to replace
the hardware or
device.
162

163. Malware Protection
■ Be aware of phishing.
■ Avoid pop-ups that advertise anti-virus or anti-spyware
programs.
■ Don’t install unapproved software to your device.
■ Do not plug an unknown USB into your computer.
■ Connect back to the HCA network through the VPN gateway if
you use your HCA device away from the office before using the
internet.
■ Avoid using your HCA device to visit internet sites that are
known for malware such as social networking sites (My Space
and Facebook), coupon sites, etc.
WHY?
Malware disrupts or
damages your computer’s
operation, gathers sensitive
or private information, or
gains access to private
computer systems. Malware
is mean.
163

164. Electronic Communications
Before you press the [SEND] button on an email,
Instant Message (IM), or Text, ask yourself
four questions:
1. Does it include sensitive data?
2. Where is it going (internal HCA
recipients or external)?
3. Is the recipient authorized to have that
data?
4. Is the data protected?
❖ Refer to Electronic Communication policy-IS.SEC.
002 for more information.
164

165. Email Encryption
■ Add [Encrypt] anywhere in the Subject line
to encrypt the email and any attachments.
WHY?
Email is like a
postcard. Encryption
is like the envelope.
Unless encrypted,
the contents can be
viewed during transit
which could result in
a costly breach
notification.
HCA requires
encryption of emails
containing sensitive
data.
• Do not include any sensitive information in the
subject line.
• This encryption technique ONLY works if you
are emailing from your HCA supplied email
address. Messages to internal recipients do not
require you to enter [Encrypt].
• Any of the brackets work – [], (), {}, <>.
165

166. Other Email Requirements
■ DON’T use your personal email accounts (e.g.,
Gmail or Yahoo) to conduct Company business
– use your Company email (e.g. Outlook or
MOX).
■ DON’T forward company email to a personal
address.
■ NEVER access another person's e-mail
(unless specifically authorized).
WHY?
If sensitive information
is transmitted using
other email systems,
the data is no longer
protected by the
company’s security
controls and the
information could be
compromised causing
possible damage to the
company reputation,
financial loss, and
liability to you.
166

167. Know How to Catch a PHISH
Phishing - unlawful attempt to obtain personally identifiable information (PII) about you
or others such as Social security numbers, Credit card numbers, Bank account information;
usually occurs via email
WHY?
Your identity
could be stolen.
Your credit could
be ruined. Your
computer could be
infected with a
virus. You could
cause someone
else’s identity to
be stolen.
P Personal Data Reference or Request
H Hyperlinks or Attachments
I Inaccurate Information
S Suspicious Sender
H Hurry Up and Respond
Look for these clues in an email:
167

168. Verify or Report a PHISH
■ Call the sender or the organization represented in the email or visit their
website (not using the link in the email) to see if they have reported any
phishing attempts.
■ Send a separate email (not a reply) to the sender.
■ Contact your local Help Desk, FISO (Atlas Keyword: FISO), or DISO
(Atlas Keyword: DISO).
■ Learn more about Phishing and hyperlinks on Information Security’s Atlas
site. Keyword: Protect
168

169. Social Engineering
■ Don’t share sensitive information with anyone
over the phone or in person even
■ If they appear as “friendly”.
■ If they seem in a hurry to get the
information.
■ If they use an agitated tone or are very
pleasant depending on how you respond.
■ Ask to see a badge.
■ Wear your badge.
Social Engineering - an attempt to gather information
from you in order to gain access to systems and/or gain
confidential information; can occur in person, over the
phone, or electronically
WHY?
Social engineers
intend to get
information from
you without you
knowing or
understanding what
they are doing.
169

170. Social Media
■ DO NOT post sensitive information (including
photos) on the Internet (e.g., discussion groups,
Facebook, LinkedIn, Twitter, MySpace,
YouTube, Flicker, bulletin boards, chat services,
non-secured web sites, etc.)
■ Refer to HCA Social Media Guidelines posted to
Atlas.
■ Report suspected violations of company policy
regarding social media.
WHY?
Posting patient or
company information
to social networking
sites like Facebook
and Twitter could
cause a potential
violation of HIPAA or
could be an action that
could result in
Company fines and
lawsuits. Email
HIPAA
Communication for
clarification on what
information can and
cannot be shared.
170

171. Mobile Devices
■ iPhones, iPads, etc.
■ Susceptible to the same risks as your computer.
■ Same physical security rules apply.
■ Same email rules apply.
■ Per the Confidentiality and Security Agreement (CSA): Personally owned
devices that synchronize company data (email on your phone), must be
encrypted
Mobile Device - Any electronic device that has the potential to store, process, or transmit
Company information wirelessly and is designed for mobility or small enough to be easily
transported or concealed such as smart phones, tablets, and personal digital assistants
(PDA).
171

172. Other Tips
■ Setup a profile to use the Password Reset tool
■ Have you set up your profile yet? Atlas: Password Reset
■ Stay informed
■ At work, use Atlas Keyword: Protect.
■ Read emails sent from Information Security or your FISO/DISO.
■ Spread the word about safe security practices to your colleagues,
family, and friends
■ When you learn something new about security, share with others so
they can stay safe on the Internet
172

173. Awareness: Threats Follow You Home
Your Information Security responsibilities do not stop at the
end of your work day.
Remember the Risks?
■Identity Theft
■Loss of Privacy
■Loss of Trust
■Costly Breach Notifications
■Malware like Viruses, Worms, Trojans, Spyware
■Cyberbullying
■Online Predators
173

174. Review of Session Goals
■ Review Common Information Security Terminology
■ Provide Key Contact Information - Who
■ Explain Types of Information - What
■ Provide Key Resources Information - Where
■ Share When to Report Concerns or Incidents - When
■ Describe Why You Should Care about Information
Protection - Why
■ Give Specific Tips on What You Can Do to Protect
Information - How
174

175. New Hire Orientation:
Infection Prevention and Employee Health
During the time you are completing this module,
you may call 802-3379 for any questions.
If you have questions about Bloodborne
Pathogens, contact Employee Health at ext
4968, or Infection Prevention ext 4969 or 3038
8:00am – 5:00 pm
Monday through Friday
If EH or IP is not available, contact your
Department Leader or the Nursing House
Supervisor.
1

176. Employee Safety and
Workers’ Compensation
■ Our facility’s commitment is to you.
■ We have programs in place to make our facility as
safe as possible for you, our patients, and visitors!
■ We will work in your best interest to ensure
accidents are handled properly and you get the
medical care you need.
■ With your help, our program will be effective!
2

177. Employee Safety Committee
■ Consists of members from key departments
within this facility.
■ Meets bi-monthly to review injury statistics
and address prevention needs.
■ Completes quarterly hazard surveillance
rounds to identify and correct hazards.
■ Progress is monitored by Senior Leadership.
3

178. Area’s of Focus
■ Compliance with all policies & procedures.
■ Timely hazard reporting.
■ Timely accident reporting.
■ Always wear appropriate Personal Protective
Equipment.
■ Slip, trip, & falls prevention.
■ Patient management.
■ Eliminate or decrease sharp injuries and body
fluid exposures.
4

179. Compliance with all Policies and
Procedures
■ Employees are responsible for following current
RRMC policies and procedures and notifying their
supervisor for identified safety hazards.
Wear Personal Protective Equipment
■ Employees are responsible for wearing the
appropriate personal protective equipment for
isolation precautions (see Infection Prevention slides
for details).
5

180. Timely Hazard Reporting
■ Hazards will ultimately injure one of our staff, a
patient, or a visitor.
■ We are all responsible for eliminating all hazards.
■ Report potential hazards to Clay Callaway, Safety
and Security Officer and/or Employee Health
Services.
■ Discuss potential hazards during staff meetings.
6

181. Timely Accident Reporting
■ If you are injured on the job you should report the
accident to your supervisor immediately!
■ The appropriate medical care is coordinated for you
through Employee Health Services. Contact
Employee Health Services for panel physician
authorization.
■ A post-accident investigation will be performed by
your manager to determine what, if anything, can be
done to prevent a similar occurrence from happening
again.
7

182. Slip, Trip, & Fall Accident Prevention
■ A slip occurs when there is too little traction or friction between the shoe and the
walking surface. Some common causes of slips are wet surfaces, occasional spills,
weather hazards, and loose rugs.
■ A trip occurs when a person’s foot contacts an object in their way or drops to a
lower level unexpectedly, causing them to be thrown off-balance. Common causes
of trips are obstructed view, poor lighting, clutter, wrinkled rugs, uncovered cables
or cords, bottom drawers not being closed, and uneven walking surfaces.
■ A fall occurs when you are too far off balance. This can occur as a same level fall
or a fall to a level below the one you are walking on. Falls from elevations such as
ladders, stairs, and loading docks can be much more severe.
■ There are numerous personal factors that may increase an individual’s risk of a slip,
trip, or fall. These include age, body shape or mass, gait dynamics (the particular
way an individual walks), physical condition, perception (an individual’s ability to
see and their awareness of their surroundings), and psychological and psychosocial
factors (stress and distractions).
8

183. Slip, Trip, & Fall Accident Prevention
Here are some simple ways to alter your behavior and help avoid slips,
trips, or falls:
■ Watch where you are going while walking – pay attention and look for slip,
trip, and fall hazards
■ Walk, don’t run – make sure you give yourself enough time to get where
you are going
■ Don’t engage in activities that may be distracting – for example: reading or
texting while walking
■ Use handrails when climbing or descending stairs
■ Check that your walkway is clear and that your view is not blocked before
you lift anything
9

184. Slip, Trip, & Fall Accident Prevention
Here are more simple ways to alter your behavior and help avoid slips,
trips, or falls:
■ Don’t carry a load that you can’t see over or around while carrying
■ Walk carefully and slowly when transitioning from one walking surface
to another
■ Slow down and take small steps if the walking surface is cluttered,
narrow, uneven, slippery, or at an angle
■ Wear stable proper fitting shoes with non-slip soles – avoid backless
shoes to help decrease your risk for slips, trips, or falls
■ When entering a building on a wet day, remove as much water from
your shoes as possible – walk carefully as the floors may be slippery
10

185. Patient Management Accident Prevention
■ Patient Transfers - Bed to Chair
■ Make sure everyone involved knows their role and expectations for the
transfer
■ Call for assistance if the patient is a mod or max transfer
■ Call for assistance if the patient has required more than one person in
the past
■ Call for assistance if you are unsure how the patient will do
■ Make sure that the surface you are leaving and the surface you are going to
are close and that all brakes are applied
■ If one side is weaker, it is best to transfer to the stronger side
■ Ensure the patient is wearing proper foot wear
■ Transition the patient from supine to sitting edge of bed
■ Give the patient time to adjust to this position to ensure they do not get
dizzy or lightheaded
11

186. Patient Management Accident Prevention
Continued…
■ Help the patient scoot to the edge of the bed so their
feet are resting on the floor for balance and support.
■ Place a gait belt around the patient
■ Position yourself for the transfer
■ Have patient rock with you and stand on the count of
three to ensure everyone is assisting at the same
time
■ Pivot to the chair (Use a Pivot Disk when
appropriate)
■ Have patient reach for the surface/arm rests of the
surface they are transferring to
■ Remove gait belt
12

187. Patient Management Accident Prevention Continued
■ Patient Transfers – Bed to Bed or Bed to Stretcher
■ Make sure everyone involved knows their role and expectations for
the transfer
■ Ensure sheet is adequately under the trunk and buttocks of the
patient
■ Ensure enough people are present for the size of the patient
■ Those on the side being transferred to, kneel on the bed to pull the
patient half-way
■ Make sure patient keeps their arms folded across their chest
■ One person takes charge and counts to three for everyone to go
■ Patient is transferred halfway, then the people receiving the patient
get off the bed onto the floor and the people sending get on the bed
for the remaining half
■ Ensure everyone is ready and the lead counts to three again.
13

188. Patient Management Accident Prevention Continued
■ Patient Transfers – Repositioning in Bed
■ Use gravity to assist if able and place the bed in Trendelenburg
■ Have the patient bend their knees to assist with the push
■ Have them place their arms across their chest
■ Ensure the pad/sheet is adequately under them
■ Ensure everyone knows their role
■ One lead counts to three for patient to push with their legs and
those assisting to pull
■ Make sure you move with the transfer and do not twist or torque
your body, rather move your feet and step
■ For all transfers, know your precautions: Cardiac, Total Hip Precautions,
Lumbar Precautions following surgery, Hemiparesis, etc…
■ Contact our Rehab department as needed for questions.
14

189. Safety: A Shared Responsibility
■ Redmond’s responsibility is to provide a
safe work environment that facilitates safe
work procedures.
■ Each employee’s responsibility is to
practice safe work skills that incorporate
proper body mechanics and work
procedures while keeping their body well
and fit for their work tasks.
15

190. If you are Injured on the Job
■ Report the injury to your supervisor IMMEDIATELY!
■ File and Incident report in Meditech
■ Workers’ Compensation benefits may apply to your
injury, please follow up with Employee Health
Services.
■ Workers’ Compensation provides the following
benefits:
▪ Medical - Follow-up after emergency treatment
and evaluation by authorized providers is
coordinated through Employee Health Services.
▪ Lost Wages – The state has limits on the amount
of lost wages you may receive if you miss time
from work.
16

191. Direct Cost of Injuries
■ Inability to continue working
■ Impact on your wages
■ Disruption of your family life and routines
■ YOUR CAREER
17

192. Set Good Examples
■ Be proactive in the identification of hazards and
prevention of injuries.
■ Report injuries timely and work with Employee Health
Services throughout the rehab process.
You Must Maintain Communication
■ Maintain contact with your department Director weekly.
■ Contact Employee Health Services with any issues
related to your injury!
18

193. Transitional Duty
■ Light-duty or transitional duty may be accommodated if a
department has a need and is able to utilize an employee for job
duties that fall within the employee’s treating physician job
restrictions and charge these hours to their department without
going over productive staffing targets or creating overtime as a
result of accommodating light duty.
■ This will be reviewed and approved on a case by case basis by
the department director, Employee Health Services, and the HR
director as needed.
■ If the department becomes no longer able to provide these job
duties without going over productive staffing targets, then light-
duty work will not be an available option.
19

194. Employee Health Services (EHS)
Non-work Related Illness or Injury
■ EHS stocks many over-the-counter medications; these are
available for employees as needed.
■ EHS also provides free blood pressure checks, weight
checks, and basic first aid.
■ You must report to EHS annually for your required health
update and Respirator Fit test (if appropriate for your job).
■ Employees may be referred to their Primary Care
physician for further evaluation, treatment, and/or follow-
up.
20

195. Blood Borne Pathogen Plan
■ A copy of our plan is available on the RRMC intranet site.
(Policy IC-10)
■ The plan explains the processes we have in place to
minimize exposures, and what to do if there is an exposure
to a blood or body fluids.
■ Potentially infectious fluids: blood, semen, vaginal
secretions, cerebrospinal fluid, synovial fluid, pleural
fluid, peritoneal fluid, pericardial fluid, amniotic fluid, or
any other fluid that is visibly contaminated with blood and
body fluid where it is difficult or impossible to
differentiate, saliva in dental settings, tissue and organs
that are not fixed other than intact skin (from any human
living or dead), HIV containing cell or tissue cultures or
organs, and tissue from experimental animals infected
with blood borne pathogens.
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196. How to Reduce Transmission of Blood
Borne Pathogens?
■ Observe engineering controls; needle-less systems, safety
devices, sharps disposal containers, biohazard waste
containers, needle boxes at appropriate height.
■ Observe work practices; never recap needles, perform hand
hygiene, use appropriate PPEs, do not bend or break needles,
do not eat or drink in areas where there is potential for
exposure, do not store food or drinks in a refrigerator that is
used to store blood or other potentially infectious material, use
red biohazard bags for disposal of infectious wastes.
■ Know the job tasks in your department that may involve
exposure to blood or other potential infectious material and
wear appropriate PPEs. Ask your leader for a list of tasks in
your department and the required PPE.
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197. What Can You Do To Prevent Sharps
Injuries?
Be Aware
■ Keep the exposed sharp in view.
■ Be aware of people around you. Stop if you feel
rushed or distracted.
■ Focus on your task.
■ Avoid hand-passing sharps and use verbal alerts
when moving sharps.
■ Watch for sharps in linen, beds, on the floor, or in
waste containers.
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198. What Can You Do To Prevent Sharps
Injuries?
Be Prepared
■ Complete your Hepatitis B vaccine series and
titer in Employee Health Services free of charge.
■ Organize your work area with appropriate sharps
disposal containers within reach.
■ Receive training on how to use sharps safety
devices.
■ Wear gloves if you expect to come in contact with
blood or body fluids.
24

199. What Can You Do To Prevent Sharps
Injuries?
Follow Policies
■ Don’t recap needles.
■ Never use needles with the needleless IV
system.
■ Be responsible for every device you use.
■ If you identify a sharps without a safety
device, discuss this with your supervisor
and/or Employee Health Services.
25

200. What Can You Do To Prevent Sharps
Injuries?
Dispose of Sharps with Care
■ Don’t remove contaminated sharps with your hands
unless medically required (i.e. caps off used needles,
scalpel blades). If necessary, use a mechanical
device or forceps.
■ Always activate safety devices immediately after
using a sharp. Never remove safety devices. Keep
your hands behind the needle at all times.
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201. Dispose of Sharps With Care
■ Place all used sharps in biohazard
containers, see policy IC-45.
■ Securely close biohazard containers when ¾
full and notify Environmental Services to
change the sharps container.
■ Do Not overfill sharps containers.
■ Do Not reach by hand into containers where
sharps are placed.
27

202. Additional Sharps Injury Prevention for
the OR
■ Use a neutral zone when passing sharps instruments.
Pass sharps on a tray, not directly to another
individual. Use verbal alerts when moving sharps.
■ When suturing, use blunt sutures for muscle and
fascia.
■ Stay focused on your task. Stop if you feel rushed or
distracted.
■ Use mechanical devices such as tongs to handle
contaminated reusable sharps. Do Not use your
hands.
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203. Hepatitis B
■ Hepatitis B is a transmittable blood borne disease
affecting the liver
■ Can be mild lasting a few weeks or a serious lifelong
illness
■ Symptoms may include jaundice, fatigue, fever,
nausea, and abdominal pain
■ Transmitted when infected blood and body fluids
enters the body of a person who is not infected
■ Exposures may occur with needle-sticks/sharps
injuries
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