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  • In order to keep patients safe while in our care, each caregiver, including physicians, must communicate patient information clearly and completely. CMC staff receiving a verbal order should write down the complete order, then read it back, and receive confirmation from the individual who gave the order.

2011+mandatory+education 2011+mandatory+education Presentation Transcript

  • 2011 Mandatory Education
  • Instructions for completion of Mandatory Education
    • Read each slide
    • Complete the post test; place your answers on the answer sheet provided.
    • Please PRINT your name & department CLEARLY on the answer sheet
    • Return your completed post test to the Organizational Development Dept.
    • If you have any questions, please call:
    • Organizational Development @ 969-8001
  • Contents:
    • Organizational/ Employee Information
    • Environment of Care
    • Risk Management
    • Patient Care Information
    • Infection Control
    • Preventing Back Injuries
  • Organizational /Employee Information
    • CMC Mission, Vision, Values
    • Population-Specific Competencies
    • Professional Behavior
    • Corporate Compliance
    • Performance Improvement
    • Sentinel Events
    • Mission:
    • CMC’s mission is to be the leading provider of quality health care.
    • Vision Statement:
    • We are the friendly Community Hospital dedicated to exceeding expectations in the delivery of care and comfort for the health and well-being for you and your family, in an environment of utmost respect and integrity.
  • Values At CMC
    • Safety – Always first for the welfare and peace of mind of our staff, our patients and their families
    • Respect – Seeing value in everyone and treating them with dignity and kindness
    • Teamwork – Helping each other to help our patients first
    • Integrity – Conducting ourselves in an ethical, confidential and honest manner
    • Leadership – Guiding one another toward achieving our vision and values
    • Balance – Taking care of yourself in both your professional and personal life
    • Customer Satisfaction – Exceeding expectations of those we serve, so they will make us their hospital of choice
    • Recognition – Acknowledging and celebrating our efforts and accomplishments
    • Accountability – Accepting responsibility to exceed expectations
    • Quality – Being the best!
  • Population specific competencies
    • The patient population at CMC represents the diversity of the local community and surrounding areas.
    • Community Medical Center serves a patient population that includes all ages from the neonate to the geriatric patient.
      • It is important to understand the developmental and healthcare needs of each age group
    • Each of us must respect a person’s beliefs & consider their spiritual needs
      • The Chaplain and the Social Service Department may be of assistance with questions about spiritual/ religious matters.
    • It is important to respect cultural differences
      • There may be different views about health and healers.
      • It is important to understand relationships, and who may play a role in the patient’s care
      • Be aware of language and communication issues
  • Diversity
    • Community Medical Center supports the development of an inclusive and multicultural environment.
    • We value diversity as a source of opportunity, both in employees and patients.
    • CMC is committed to promoting diversity in the workforce, as well as respect for the individuality and dignity of others and valuing each employee’s unique talents, cultural perspectives and life experiences to create an environment of excellence.
    • Community Medical Center will not discriminate against any person with respect to age, sex, race, color, marital status, religious affiliation, national origin, ancestry, physical/mental disability, veteran status, sexual orientation, gender-identity or on any basis that would be in violation of any applicable Federal, State or local law .
  • Culture
    • Culture includes patterns of learned behavior, values, beliefs and world view exhibited by groups that may share history and/or geographic proximity
    • May be transmitted through institutions of society (family, religion, educational systems, political systems, media)
    • Beliefs about the cause, prevention and treatment of illness vary among cultures
    • Culture or religion may dictate dietary habits, mode of dress and manner of interaction.
    • Due to perceived bias or cultural norms, some patients & families may feel disenfranchised or suspicious of the healthcare team.
  • Cultural competence
    • Self awareness is important. Be conscious of your own bias or prejudice.
    • Being aware of your own bias helps to open your communication up for receiving more accurate information
    • Listen and try understanding the other person’s perception of the situation or problem
    • Listen carefully, be receptive to non verbal clues and body language
    • Demonstrate respect for other’s values & beliefs.
    • BE COMPASSIONATE, DON’T JUDGE, BE AN ADVOCATE
  • Cultural competence
    • Avoid stereotyping- It creates a barrier to effective communication and finding common ground
    • Applying the “golden rule” may not be effective- determine how others wish to be treated and act accordingly.
    • When in doubt-ASK
    • Never presume anything
    • BE COMPASSIONATE, DON’T JUDGE, BE AN ADVOCATE
  • Culturally Sensitive Care
    • Become familiar with socioeconomic & demographic characteristics, belief systems & health behaviors of other cultures
    • Learn about the person’s specific views on health
    • Understand relationships- the roles that others play in the person’s life
    • Assess for language barriers and communication issues
    • Communicate clearly
    • Be respectful
  • CULTURAL ASSESSMENT
    • L isten with sympathy & understanding to the patient’s perception of the problem
    • E xplain your perceptions of the problem & your strategy for treatment
    • A cknowledge & discuss the differences & similarities between these perceptions
    • R ecommend treatment while remembering the patient’s cultural parameters
    • N egotiate agreement
  • Gender Specific issues
    • Women: Stress can make women more prone to several physical & mental health problems
    • Men: less likely to seek routine care; may ignore symptoms until crisis.
    • Patients with same-sex partners often face prejudice and may delay seeking care or keep silent about certain health problems.
  • Patients with disabilities
    • Accommodate physical disabilities-become familiar with modalities available for these patients.
    • Ask the patient or caregiver about specific type of developmental disability; gain an understanding of the person’s life situation.
  • Limited literacy
    • Ensure understanding when talking with patient; use simple language, avoid using medical jargon, use visual aids
    • Assess any written instructions for readability.
    • Review all information with your patient. e.g. consent forms
  • Low income
    • Persons who have low income or are homeless may not receive regular or any medical care due to inability to pay.
    • May have nutritional deficiencies
    • May need extra discharge support
  • Language
    • Language is often cited as a barrier to adequate care.
    • The law requires that health care providers make their best attempt at communicating.
    • Make use of non-biased certified translators.
  • Communication Barriers
    • All patients at CMC who are deaf or hard of hearing will have the opportunity to complete a “Selection Form for Interpretative Services and TTYs” in order to indicate preference for services to facilitate communication.
    • The person may choose an interpreter on site, Deaf Talk, TTY, or paper & pen for writing notes
    • A Telecommunication Telephone Device (TTD or TTY) is available for hearing impaired patients and can be obtained from Central Supply for use in patient care areas.
  • Communication Barriers
    • Hearing impaired patients who do not sign or lip read, may have a family member or caregiver present whenever possible to assist with communication if it is necessary to start treatment before the arrival of an on site interpreter. The patient will indicate their consent on the back of the “Selection for Interpretive Services “ form.
    • Audiotapes and/or brailed information are available for visually impaired patients.
    • Television is close captioned for the deaf: All TVs have the ability to provide captions. Using the patient call light/TV control can activate this service
    • Where can I find information & help?
    • DEAF TALK
      • A VIDEO CONFERENCING SYSTEM FOR THE HEARING IMPAIRED AS WELL AS AN INTERPRETER SERVICE FOR SPANISH LANGUAGE .
    Meeting the diverse needs of our patients.
  • DEAF TALK On-Demand American Sign Language (ASL) Video Interpreting
    • IF A PATIENT/FAMILY MEMBER IS IN NEED OF AND/OR REQUESTS AN INTERPRETER:
    • CONTACT COMMUNICATIONS. (CMC has 4 units available for use)
    • THE INSTRUCTIONS FOR CONTACTING THE INTERPRETER IS ATTACHED TO THE CART.
    • PLUG THE UNIT INTO AN ELECTRICAL OUTLET AND PLACE IT IN AN AREA WHERE TELEPHONE ACCESS IS AVAILABLE
    • MAKE SURE THAT THE IMAGE ON THE SCREEN IS CLEAR . YOU MAY NEED TO REPOSITION THE UNIT TO GET A CLEARER PICTURE.
    • CALL THE NUMBER LISTED ON THE INFORMATION CARD
    • AND FOLLOW THE PROMPTS.
    • RETURN THE DEAF TALK EQUIPMENT WHEN FINISHED.
    • THIS SERVICE IS AVAILABLE 24 HOURS A DAY.
  • Where can I find information & help?
    • LLE LINK : An interpreter service for non- English speaking people.
    • (This service is available 24 hrs/day. )
    • Obtain a speaker phone.
    • Dial the LLE-LINK® phone number (800-234-0780)
    • Enter your access code and the # key
    • Enter language request code and the # key
    • You may enter “0” and # at any time to request a LINK Customer Care Representative
    • You may call the CMC hospital operator and ask for assistance with accessing LLE link
  •  
  • A Typical Call
        • You will be greeted by the interpreter.
        • Identify yourself, the name of your organization and the name of your caller.
        • Allow the interpreter time to introduce themselves to your caller.
        • Briefly let the interpreter know the purpose of your call and any information you need give to or get from your caller.
        • Instruct the interpreter to begin interpreting.
        • Speak in the first person directly to your caller.
        • Let the interpreter know when you are ready to end the call. The interpreter will let your caller know.
  • SOME GUIDELINES FOR HOW TO USE AN INTERPRETER
    • Unless you are thoroughly effective and fluent in the target language, always use an interpreter.
    • Try to use an interpreter of the same sex as the client
    • Avoid using family members as interpreters. This may be a HIPAA violation.
    • If possible, learn basic words and sentences in the target language; emphasize by repetition and speak slowly, not loudly.
    • Be patient. Careful interpretation often requires that long explanatory phrases be used.
    • Address the patient directly: do not direct commentary to or through the interpreter as if the patient did not exist.
  • SOME GUIDELINES FOR HOW TO USE AN INTERPRETER
    • Return to an issue if you suspect a problem and get a negative response. Be sure the interpreter knows what you want.
    • Provide instructions in a simple, clear manner and have patients repeat their understanding
    • Use short questions and comments; avoid technical terminology and professional jargon, like "workup."
    • Use language that the interpreter can handle; avoid abstractions, idiomatic expressions, similes and metaphors.
    • Plan what to say ahead of time. Do not confuse the interpreter by backing up rephrasing or hesitating
  • Meeting the diverse needs of our patients.
    • Where can I find information & help?
    • Religious Beliefs : The hospital computer system contains information regarding various religious beliefs that can be used as a reference.
    • Access the OAS GUI system on your unit.
    • From the main menu choose - Information displays
    • From the Information menu choose – Religious beliefs
    • Choose the desired information to read or print .
  • PROFESSIONAL BEHAVIOR
  • Professional Behavior
    • Disruptive Behavior in Healthcare
    • In July 2008, a Sentinel Event Alert was issued by The Joint Commission on Behaviors that Undermine a Culture of Safety. 
    • The JC has found that intimidating and disruptive behaviors in healthcare environments can:
      • Foster medical errors.
      • Contribute to poor patient satisfaction and preventable adverse outcomes.
      • Increase the cost of healthcare.
      • Cause qualified clinicians, administrators and managers to seek new positions in more professional environments.
    • Professional Behavior
    • What is disruptive behavior?
    • Any behavior that interferes with the orderly conduct of hospital business, from patient care to committee work, can be considered disruptive.
    • This includes behavior that interferes with the ability of others to effectively carry out their duties or that undermines the patient's confidence in the hospital or another member of the healthcare team.
    • Research suggests that nearly 3 in 4 health care providers have experienced some type of disruptive or intimidating behavior in the course of their work.
    • These behaviors include the entire spectrum of workers, clinical and non-clinical, and include all levels of employees and medical staff.
    • Some specific examples of disruptive behavior
    • Profane or disrespectful language
    • Demeaning behavior, such as name-calling
    • Sexual comments or innuendo
    • Inappropriate touching, sexual or otherwise
    • Racial or ethnic jokes
    • Outbursts of anger
    • Throwing instruments, charts, or other objects
    • Criticizing other caregivers in front of patients or other staff
    • Some specific examples of disruptive behavior
    • Comments that undermine a patient's trust in other caregivers or the hospital
    • Comments that undermine a caregiver's self-confidence in caring for patients
    • Failure to adequately address safety concerns or patient care needs expressed by another caregiver
    • Intimidating behavior that has the effect of suppressing input by other members of the healthcare team
    • Deliberate failure to adhere to organizational policies without adequate evidence to support the alternative chosen
    • Retaliation against any member of the healthcare team who has reported an instance of violation of the code of conduct or who has participated in the investigation of such an incident, regardless of the perceived veracity of the report
  • Professional Behavior
    • CMC Code of Conduct
    • It is the policy of Community Medical Center Healthcare System to promote a professional working environment that fosters mutual respect and congenial relationships between and among employees, customers and vendors.
    • As such, any form of harassment, intimidation and/or violence is strictly prohibited and will result in immediate disciplinary action.
    • The Code of Conduct policy establishes guidelines for the acceptable limits of employee conduct and ensures personal responsibility for all verbal and non-verbal behavior.
    • All employees are expected to maintain personal control and refrain from any and all conduct that is harmful, hurtful or that would be viewed unfavorably by a reasonable person.
    • HR Policy501 - Code of Conduct
  • Professional Behavior MEDICAL STAFF PROFESSIONAL BEHAVIOR POLICY
    • Disruptive Practitioners
    • The Medical Staff is committed to providing quality patient care and a work environment that fosters teamwork and respect for the dignity of each patient, visitor, employee, volunteer, student, resident, and member of the medical or allied health staff.
    • Any practitioner, employee or agent of the hospital, or patient who observes behavior by a physician which disrupts the operation of the hospital, or jeopardizes patient care or in any manner violates this policy, shall document the incident on a Behavioral Documentation Form & forward it to the department director & president of the Medical staff
    • This policy is designed to address unacceptable behavior by a practitioner.. If a physician is employed by Community Medical Center, the matter regarding unacceptable behavior shall be brought to the attention of the CEO. The CEO shall have full discretion in consultation with the President of the of the Medical Staff to determine the best manner in which to proceed
  • Professional Behavior
    • Some Guidelines…
      • Perform your job with fairness, integrity, truth and concern for the welfare of our patients
      • Abide by departmental/organizational policies.
      • Report for work on time, as scheduled.
      • Give proper advance notice whenever unable to report for work or report on time.
      • Present a professional appearance at all times by reporting for work appropriately attired and in compliance with hospital policy.
  • Professional Behavior
    • Some Guidelines…
      • Always act in a professional, respectful manner to enhance a spirit of cooperation , mutual respect, and trust among the patient care team.
      • Treat others with courtesy, dignity and respect
      • Be courteous in your communication with others; face-to-face, on the phone and in written communication
      • Address disagreements in a constructive, respectful manner privately and out of earshot of patients or other noninvolved caregivers .
      • Abide by departmental & organizational policies
      • Perform assigned tasks efficiently and in accordance with established quality standards
  • Professional Behavior
    • Name Badge/Appearance
    • Our policy requires that you wear your name badge
    • AT ALL TIMES while you are on duty here at Community Medical Center.
    • The Human Resources Department will issue a photo ID badge to you. This badge will be needed to “swipe” in & out of various areas of the Medical Center.
    • All employees are expected to dress professionally in their approved departmental uniform while on duty.
    • In those situations where a uniform is not required, appropriate business/professional attire is required.
  • Dress Code/ Appearance
    • General Appearance:
    • All clothing worn by employees must be neat, clean, pressed and in good condition.
    • Closed shoes and foot coverings must be worn by uniformed caregivers at all times while engaging in work activities.
    • Special attire or ornamentation worn by staff during holiday seasons or as part of a special hospital event will be allowed upon approval of the department director/manager.
    • CMC logo apparel, as part of the uniform, will be allowed where appropriate and approved by the department director/manager .
    • Hair:
    • Hair shall be neat, clean and present a professional appearance.
    • Employees responsible for providing direct patient care will secure back hair that is shoulder length or longer.
    • Hair coverings such as caps and/or nets will be worn in departments where required by federal/state or hospital regulations.
    • Accessories:
    • Conservative jewelry and other accessories may be worn if they represent a professional image, do not interfere with the performance of duties and comply with standard safety practices. Dangling earrings, long necklaces, or multiple bracelets may not be worn by employees who are direct caregivers.
    • Exposed piercings, to include facial/body rings and/or studs and tongue piercings, are not acceptable and must be removed while on work time. Large, exposed tattoos are to be covered while on work time. Buttons, baseball caps, armbands and/or other similar accessories may not be worn on duty.
    • Nails:
    • Nails should be clean, trimmed and conservative in both length and appearance. In accordance with CDC/APIC/JCAHO recommendations and requirements, any employee with direct patient care responsibilities is prohibited from wearing artificial nails of any type (ie: acrylic, fiberglass, etc).
    • HR Policy605 - Dress Code
  • Sexual harassment
    • It is the intent of the CMCHS to provide an environment that fosters dignity, courtesy and respect for employees, customers, and vendors. All employees are responsible for maintaining professional conduct at all times.
    • Harassment based upon race, sex, religion, national origin, age, disability or any status/condition protected by applicable law is strictly prohibited.
    • A zero-tolerance philosophy is being adopted to ensure a workplace free from sexual harassment.
  • Sexual harassment
    • Any CMCHS employee who experiences or witnesses sexual harassment in the workplace must report it immediately.
    • While initial verbal reports of sexual harassment are acceptable, all reports must then be put into writing by the complainant detailing the circumstances of harassment.
    • Reports can be made by:
      • Notifying a department director/manager/supervisor in person, by phone, or via written correspondence. The management staff member must immediately notify Human Resources of the complaint.
      • Notifying Human Resources directly by phone or in person.
      • Completing a Sexual Harassment report form and forwarding to Human Resources.
    • cmcfs1dfsrootIntranetHumanResourcesPolicyHR Policy637 - Sexual Harassment (2) 2010.doc
  • CMCHS COMPLIANCE PROGRAM
    • CMCHS HAS A LONG TRADITION OF ETHICAL AND RESPONSIBLE CONDUCT
    • ALL STAFF MUST ABIDE BY THE LETTER AND SPIRIT OF ALL APPLICABLE LAWS & REGULATIONS
    • AS A MATTER OF EMPLOYMENT ALL STAFF MUST ACCEPT THE REQUIREMENTS OF THE CMCHS COMPLIANCE PROGRAM. SIGN APPENDIX C OF THE PLAN.
  • DEFINITION OF FRAUD, WASTE AND ABUSE
    • HEALTH CARE FRAUD:
      • Intentionally or knowingly and willfully attempting to execute a scheme to falsely obtain money from any health care benefit program. Examples of fraud include purposely billing Medicare for services that were never provided or received; altering claims to obtain higher payments; and soliciting, offering or receiving a kickback, bribe or rebate.
    • HEALTH CARE WASTE:
      • Health care spending that can be eliminated without reducing the quality of care. Examples include the overuse, underuse and/or ineffective use of resources.
    • HEALTH CARE ABUSE:
      • Improper behaviors or billing practices that create unnecessary costs. Examples include billing too much for services/supplies; claims for services that are not medically necessary; and improper billing practices
  • Relevant Laws
    • False Claims Act. The False Claims Act and the Criminal False Claims Statute are federal laws that make it illegal to file a claim with a federal health care program that is not consistent with billing requirements or that contains false or misleading information. This is considered fraud and abuse .
    • Examples of false claims include claims for services :
      • Not rendered
      • Rendered but not appropriately supported by documentation in the patient’s medical record.
      • Not medically necessary
      • Not covered by the government health plan
      • Rendered by one provider and billed by another provider (exceptions exist)
      • Do not meet government program billing guidelines
      • Prepared and sent with the intent of getting payment to which the provider is not entitled .
  • RELEVANT LAWS
    • Whistleblower Protections
      • Whistleblower: An employee, former employee, or member of an organization who reports misconduct to people or entities that have the power to take corrective action.
      • A provision of the False Claims Act allows individuals to:
        • Report fraud anonymously
        • In certain situations, sue an organization on behalf of the government and collect a portion of any settlement that results
      • Any retaliation or retribution against persons who report suspected violations of these laws or file “whistleblower” lawsuits is prohibited.
  • Relevant Laws
    • Anti-kickback Statute . This federal law makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration (e.g. bribes, kickbacks) to induce or reward referrals of items or services reimbursable by a Federal health care program (Medicare, Medicaid, etc.). Remuneration includes anything of value, directly or indirectly, overtly or covertly, in cash or in kind.
    • Examples of illegal activities include:
      • Routine waiver of co-pays and deductibles (except in the case of financial hardship)
      • Accepting payment in exchange for referrals
      • Accepting gifts, such as trips, for prescribing a certain drug or promoting certain equipment
      • Accepting money each time you send a patient to a specific provider
  • Relevant Laws
    • The Physician Self-Referral Prohibition Statute
      • Commonly known as the Stark Law, the Physician Self-Referral Prohibition Statue prohibits physicians from referring patients for a designated health service (DHS) to an entity with which the physician (or a member of the physician’s immediate family) has a financial relationship, unless a statutory or regulatory exception applies. It also prohibits an entity from presenting or causing to be presented a bill or claim for a DHS furnished as a result of the prohibited referral, unless the arrangement falls within an exception
  • Relevant Laws
    • HIPAA PRIVACY RULE.
      • The Health insurance Portability and Accountability Act of 1996 (HIPAA) established standards for privacy of individually identifiable health information. A major purpose of HIPAA is to define and limit the circumstances in which an individual’s protected health information (PHI) may be used or disclosed by covered entities. A covered entity may not use or disclose protected health information, except either: (1) as the Privacy Rule permits or requires; or (2) as the individual who is the subject of the information (or the individual’s personal representative authorizes in writing. Generally, PHI may be used or disclosed for treatment, payment of health care operations without the authorization of the individual.
  • FALSIFICATION OF HOSPITAL RECORDS
    • CMCHS employees will exercise due diligence in preventing the falsification of medical and non-medical records.
    • There are many non-medical records that are kept for inspection purposes, such as various checklists, educational records, evaluations, logs of equipment performance (refrigeration and sterilization records among others), other maintenance logs of electrical and critical equipment function.
    • Both medical and non-medical records are required for verification and review by State, Federal, and Joint Commission inspectors.
    • All personnel are reminded that deliberate falsification of records may be a misdemeanor or a felony offense and is viewed seriously when encountered.
    • Examples of falsifying records include:
      • Creation of a new record when original record cannot be found
      • Back-dating entries
      • Forging other persons initials or names on back-dated entries
      • Post-dating entries
      • Pre-dating entries
      • NOTE: IT IS ABSOLUTELY WRONG TO SIGN ANOTHER INDIVIDUAL’S NAME OR INITIALS TO ANY RECORD, AND NO RECORD MAY BE BACK-DATED.
  • REPORTING
    • SUSPECTION VIOLATIONS SHOULD BE REPORTED TO:
      • SUPERVISOR OR DEPARTMENT MGR.
      • HOT LINE 1-800-345-8382
      • HOT LINE WEB SITE: www.MyComlianceReport.com (access ID to log in are the letters CMC.)
      • DROP BOX OUTSIDE HOSPITAL CAFETERIA.
      • Medicare at 1-800-HHS-TIPS
    • PERFORMANCE IMPROVEMENT
  • Performance Improvement
    • Performance improvement is an ongoing process aimed at
    • improving process and outcomes.
    • Processes are measured and changes are made to
    • improve outcomes
    • Performance will continue to be monitored to make sure
    • that improvements are sustained
    • The Performance Improvement model used at CMC is:
    • Plan, Do, Check, Act
  • Performance Improvement
    • P – PLAN (What areas are targeted for improvement ?)
      • What do we need to accomplish?
    • D – DO (monitor the areas identified for improvement by the using tools for statistical measurement)
      • Collect information /data about the process
    • C – CHECK (analyze the data that was collected to make a determination as to which improvements need to me made)
      • What did we learn?
    • A - ACT (make changes based on the data analysis and re-monitor to identify if improvements have been successful and sustained)
      • What’s next? How do we keep it going?
    • The hospital utilizes a hospital-wide Performance Improvement plan to set the direction for Improvements.
    • Areas identified as high risk, high volume and problem prone, related to safety or quality and are identified by the organization as requiring improvements are areas considered for performance improvements.
    • The Joint Commission and CMS also dictate the collection of certain data that is publically reported (i.e. Core Measures). Hospitals then utilize these results from publically reporting to measure themselves and make improvements .
    • In the very near future hospitals will be paid based on their Quality outcomes.
  • Sentinel Events
    • Community Medical Center is committed to continuous improvement of the quality and safety of patient care.
    • Part of this process is identifying sentinel events, conducting root cause analysis and making any necessary changes to improve the quality and safety of patient care.
    • A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.
    • The phrase “or the risk thereof”( Near Miss) includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
    • Such events are called “sentinel” because they signal the need for immediate investigation and response.
    • The terms “sentinel event” and “medical error” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.
  • Sentinel Events
    • Some examples…
      • Any patient death, paralysis, coma, or other major permanent loss of function associated with a medication error
      • Any event (s) resulting in unanticipated death or major permanent loss of function not related to the natural course of the patient’s illness or underlying condition.
      • Suicide of any patient receiving care, treatment and services in a staffed around-the-clock setting or within 72 hours of discharge.
      • Any procedure on a wrong patient, or wrong side of the body or wrong body part
      • A patient fall that results in death or major permanent loss of function such as a direct result of the injuries sustained in the fall.
    • A Sentinel Event can be identified by any of the following:
      • Department Heads, Nurse Managers, Unit Managers
      • Any Hospital Committee
      • Risk/Quality Worksheets
      • Any Staff Member
    • Whenever a significant variation in patient care is suspected, it is the responsibility of the individual(s) identifying the variance to report the event via the hospital chain of command process. (i.e., staff to immediate supervisor to charge nurse, nurse manager to department manager).
    • Whenever the variation in patient care is an obvious sentinel event , the Director of Nursing (DON) and Clinical Risk/ Regulatory Specialist will be immediately notified. A Root Cause Analysis will be scheduled.
    • Whenever the variation in patient care is a questionable sentinel event , the Sentinel Event Committee will meet within 24 hours of discovery of the event to determine if variation falls within definition of a sentinel event and the level of investigation to be conducted
    • A follow-up report from the Root Cause Analysis (RCA) will be submitted to the Sentinel Event Committee. .
  • ENVIRONMENT OF CARE
    • Safety codes
    • CMC Fire policy
    • Electrical safety
    • MRI safety
    • Safety & Security
    • Staff & patient safety
    • Emergency Preparedness
  • Medical Center Command Center is established. Prepare for Media. Initiate Incident Command System. Dial #55. Secure exterior exits to the building. Look for person(s) carrying anything that could conceal an infant/child. Notify Security and Scranton Police Department. Perform facility search, concentrating on all interior stairwells, closets, bathrooms, and other rooms. Initiate Incident Command System and integrate with law enforcement. Attempted or actual infant/child abduction CODE ADAM Medical Center Command Center is established. Notify Security (8037) and Facilities. Active Shooter CODE SILVER Medical Center Command Center may be established. “ RACE”: RESCUE those in immediate danger if safe to do so; ACTIVATE the Fire Alarm or Notify the Operator (dial #55); CONTAIN the fire by closing all doors; EXTINGUISH the fire if safe to do so. EVACUATE. Fire, smoke, or the odor of something burning 1-2-3 RED Medical Center Command Center may be established. Isolate patient in any room or area. Notify Security (8037) and Facilities. Prepare for decontamination procedures. Hazardous exposure arrival CODE NBC Medical Center Command Center may be established. Access communicable disease kit located in nurses’ station and utilize appropriate protection. Identify area of admission and secure necessary personal protective equipment and carts. Prepare for admission of infected patient and cohort all suspected infected patients in specific area (unit). Admission of or potential arrival of infected patient. INFECTIOUS DISEASE Specific Information General Response Situation or Condition Code Announcement Table 2-1.2 Community Medical Center Emergency Codes
  • Medical Center Command Center may be established. Incident Command System is initiated. Prepare for Media. Evacuate surrounding area. Control access to area; prepare for law enforcement arrival. Hostage Situation CODE ORANGE Medical Center Command Center may be established. Initiate Incident Command System Dial #55 with location of incident. One person from each department responds as assigned by nursing administrative manager. Assess staffing, equipment, supplies, prepare to evacuate or assist as needed. Internal Emergency Incident (requires evacuation of facility) CODE E Initiated by staff discovering patient deterioration. Dial #55. All available male employees respond. Control access to the area. Diffuse the situation or prepare for law enforcement arrival. Contact Mental Health if necessary. Security incident, aggressive/violent patient, visitor or intruder DR. QUICK Initiate Incident Command System. Medical Center Command Center is established. Dial #55. Emergency Department establishes Triage Area. Initiate Department Disaster Plan. Clinical Staff prepare for incoming victim arrivals. (One person from each department to ED as assigned.) Review current resources (manpower and materials). Assess need to implement staff call roster. Mass casualty incident CODE YELLOW Minor/Major Notification by the Incident Commander Prepare for Media. Initiate Incident Command System. Discontinue use of cell phones, pagers, and all electronic devices. Dial #55. Return to department and search all possible areas. Look for suspicious or out-of-place packages, boxes or containers. DO NOT TOUCH IF FOUND! If item is found, move people out of the immediate area and secure until law enforcement arrive. Possible bomb threat BOMB THREAT (No overhead announcement) Specific Information General Response Situation or Condition Code Announcement Table 2-1.2 Community Medical Center Emergency Codes
  • S A F E T Y CODES ….
    • Dial “55” to report emergencies
    • “ CODE BLUE ” indicates an unexpected cardiac or respiratory arrest of an adult patient.
    • “ PEDIATRIC CODE BLUE ” indicates an unexpected cardiac or respiratory arrest of an infant or child
    • “ Rapid Response Team” This indicates a need for the rapid response team (a team of expert care providers including ICU RN & respiratory therapist) to assist the staff with the care of a patient who has had an acute change in condition.
  • S A F E T Y CODES ….
    • Dial “55” to report emergencies
    • “ TRAUMA ALERT” indicates the arrival of multiple trauma patient (s) in the Emergency Department.
    • “ TRAUMA ALERT PINK ” indicates the arrival of multiple trauma patient (s) 14 years of age or under.
    • “ CODE SILVER (__________) DEPARTMENT” indicates an active shooter or person with a weapon on the department announced.
      • Staff should not attempt to intervene or negotiate.
      • Employees will “shelter in place”.
      • DO NOT go to the area specified.
      • When the situation has been diffused and safety is no longer threatened, “ALL CLEAR, CODE SILVER” will be announced.
  • “ 1-2-3 RED ” is the Code for Fire or Smoke.
    • Use R-A-C-E if you discover a fire or smoke condition
    • R escue- Remove persons from area of danger
    • A larm- Sound the alarm. To report a fire, dial 55
    • C onfine- Confine the fire by closing doors
    • E xtinguish - Select the appropriate extinguisher and extinguish the fire after patients/others have been removed .
    • Prevent a Fire!- Report any fire & safety hazards that you observe
    • Know the location of all fire exits, pull stations, fire extinguishers and hoses.
      • Know the location of all medical gas valves and how to shut them off.
  • Fire Extinguisher Use : P.A.S.S .
    • P ull the pin.
    • A im at the base of the fire.
    • S queeze the handle.
    • S weep at the base of the fire,
    • move the fire extinguisher back and forth until the fire is out.
  • FIRE SAFETY
    • Never use a water extinguisher on an electrical or flammable liquid fire. The ABC Extinguisher located on each floor is appropriate in this instance
    • If you have the slightest doubt about your ability to fight a fire....EVACUATE IMMEDIATELY
    • Compartmentalization: Keep the fire & smoke contained. Once all of the patients have been rescued, DO NOT OPEN any fire or smoke doors
    • Evacuation : If further evacuation is necessary, first evacuate patients HORIZONTALLY on the same floor, from the danger area to a safe compartment on a safe side of the floor.
    • If the patients have to be moved off the floor, move VERTICALLY, DOWN to a safe floor below .
    • Remain calm ! Fear & panic easily spread.
    • Never use elevators in a fire emergency!!!
  • Electrical Safety
    • TO REDUCE THE POTENTIAL DANGER….
    • AVOID PLUGGING IN OR UNPLUGGING EQUIPMENT OR TURNING ON A LIGHT WHEN YOUR OTHER HAND OR BODY IS TOUCHING SURFACES SUCH AS BEDS, OTHER ELECTRICAL EQUIPMENT OR PLUMBING FIXTURES
    • DO NOT DRAPE POWER CORDS ON PIPES, IN SINKS, OR OTHER WET SURFACES
    • DO NOT UNPLUG A CORD BY PULLING ON THE CORD
    • "TINGLING" SENSATIONS WHEN YOU BRUSH AGAINST ELECTRICAL EQUIPMENT INDICATE POTENTIAL MALFUNCTION….REPORT IMMEDIATELY!!!
    • DO NOT STAND ON WET SURFACES WHILE OPERATING ELECTRICAL EQUIPMENT
  • Electrical Safety
    • MEDICAL EQUIPMENT…
    • NOTIFY CLINICAL ENGINEERING ( BIOMED.) IF MEDICAL EQUIPMENT DOES NOT SEEM TO BE WORKING CORRECTLY.
    • ANY MALFUNCTIONING EQUIPMENT MUST BE TAGGED, REMOVED FROM SERVICE & SENT TO CLINICAL ENGINEERING FOR REPAIR
    • ALL ELECTRICAL PATIENT EQUIPMENT MUST HAVE A THREE PRONG PLUG AND AN UP TO DATE SAFETY INSPECTION STICKER
  • MRI safety
    • Before anyone may enter the magnet room, a screening form must be completed and reviewed. The nurse on the patient unit will have the patient complete a screening questionnaire before the MRI is done.
    • IF A PATIENT CIRCLES “YES” TO ANY BELOW QUESTIONS,
    • THEY MAY NOT UNDERGO AN MRI:
    • DO YOU HAVE:
    • A Pacemaker?
    • A Cardiac Defibrillator?
    • A Neurostimulator (tens unit, bone stimulator)?
    • A Cochlear Implant? (ear)
    • IF A PATIENT CIRCLES “ YES ” TO ANY OF THE FOLLOWING QUESTIONS, PLEASE NOTIFY THE MRI DEPARTMENT. THE INTEGRITY OF THE IMPLANT MUST BE RESEARCHED.
    • 1. Brain Aneurysm Clips?
    • 2. A Heart Valve Replacement?
    • 3. Any ear surgery with WIRES? (Ex:stapes implants)
    • 5. Any type of Metal Injury to eye (metal fragments)?
    • 6. A Vena Cava Filter? (some must be in at least 6 wks prior to MRI)
    • 7. A Heart Stent? (Must be implanted 6-8 weeks prior to MRI)
    • 8. Any Implanted mechanical/infusion pumps?
    • 9. Any type of vascular clip?
    • 10. Recent surgery (within the last 6 weeks)?
  • MRI safety
    • There are hundreds of metallic implants that can be surgically placed into a person's body for various reasons. 
      • Some of these implants are may be attracted to the magnetic field and can be harmful (even cause death) to the patient if they are subjected to the Magnetic Field.
      • Some may be electronic in nature, in which case, the magnetic field can interrupt the device's normal operations causing injury or death.
      • Metal Injuries can also cause harm to patients. Injuries such as bullet fragments or orbital metal can become dislodged if exposed to the MRI environment.
    • Before entering the MRI Room, ALL individuals (including healthcare workers accompanying a patient) are required to undergo a screening process that will be completed by an MRI Technologist. There will be NO EXCEPTIONS!!!
  • THE MAGNET IS ALWAYS ON!!
    • Keep in mind that ANYTHING that is metal or contains metal components will become a MISSLE in an MRI Room!! People have died in MRI Machines because wrong equipment such as Oxygen Tanks have entered the Room.
    • Anyone entering the room will be asked to remove all belongings that have metal such as jewelry, watches, keys, cell phones, beepers, and wallets (the Magnetic field erases magnetic swipes on credit/MAC cards).
  • Safety & Security
    • Community Medical Center maintains a full-time security force.
    • Security is everyone’s responsibility. Be alert for the entry of unauthorized persons.
    • While on duty, CMC employees must wear their employee ID badge so that it is visible.
    • Access is limited to restricted areas by access code keypad or “swiping” of employee badge
    • If you notice any suspicious behavior or activity Please report to security @ X8030 ( Dial X8037 in an emergency)
  • Safety & Security
    • PARKING:
    • Employees should park in designated areas. Employees should NOT park in the Emergency Dept. parking lot.
    • It is much safer to park in a well lit area and to enter & leave the building with a group when possible.
    • For your safety, there are security alarms located in the lobby areas & center area of the public parking garage.
    • You can take the shuttle if you are parked in the Nay Aug lot or request an escort to your vehicle by security
  • Theft prevention& reporting
    • Keep yourself safe from theft- Avoid bringing cash & valuables with you. Make sure that your property is stored securely.
    • Do not leave valuables in your car and be sure to keep your vehicle locked.
    • Patient valuables should be sent home whenever possible.
    • Keep an accurate valuables list of any items that the patient brings to the hospital including money, jewelry, clothing items hearing aid, dentures, glasses etc.
    • If a theft occurs, report it immediately.
    • Avoid disturbing the scene if at all possible
    • Try to recall as much information as possible regarding the incident and physical description of anyone seen near the area of the incident
  • Staff & Patient safety
    • CMC prohibits unauthorized persons from carrying any weapon on CMC property.
    • Individuals must turn over a weapon to the CMC security staff for secure storage in the security office.
    • If you are aware of any unauthorized individual who is carrying a weapon, notify security at once.
    • If there is a situation where anyone at CMC feels that their safety is at risk, they should call security immediately.
    • 8037 is the number to dial in an emergency or dial “0” for the operator
  • Hazardous Materials
    • As a CMC employee, we want you to be familiar with the potential hazards in your workplace, the personal protective equipment available and how to use it.
    • Know the location of and how to use Personal Protective Equipment (gloves, eye protection etc.) in your area.
    • Be familiar with precautions necessary when handling any substance
    • Report all Chemical Spills to your Charge person.
    • Ask questions about anything that you don’t understand.
    • Safety is also your responsibility.
  • Material Safety Data Sheets MSDS
    • prepared by the manufacturer of a product for the purpose of providing information on the safe use, handling and potential hazards of a product
    • The MSDS describes the physical and chemical properties, physical & health hazards, routes of exposure, how to handle the product safely, and emergency first aide.
    • CMC employee may access MSDS online at:
    • http:// hq.msdsonline.com/cmcscranton/Search/Default.aspx
  • Utilities Management
    • Utility Systems include Elevators, Water, Electricity, Heating,Ventilation and Air Conditioning, Oxygen shut off.
    • Report any problems with Utility Systems to the Plant Services/ Maintenance Dept.
    • Plans for emergency or other utility interruption can be found in Environment of Care Manual located on each unit and online.
    • Emergency power is available throughout the hospital in the event of a power failure. Emergency power receptacles are indicated by their red color.
  • CMC Emergency Preparedness
    • CMC is a participant in the federal Hospital Preparedness Program (HPP).
    • This program enhances the ability of hospitals and health care systems to prepare for and respond to bioterrorism and other public health emergencies. 
    • Current program priority areas include:
      • Interoperable communication systems
      • bed tracking and personnel management and surge capacity
      • fatality management planning
      • hospital evacuation planning
      • decontamination capabilities
      • isolation capacity
      • pharmaceutical supplies
      • training and education
      • drills and exercises
  • CMC Emergency Preparedness
    • The ability of CMC to respond to an emergency depends upon having staff who know what to do, and have the needed skills.
    • As a CMC employee, you should be able to:
      • LOCATE and USE the Emergency Operations Plan (EOP) located in each department in the hospital ( RED Binders) and on the CMC Intranet .
        • http://cmcfs1.cmchs.cmchealthsys.org/policiesandprocedures/EmergencyPlan/home.htm
      • DESCRIBE your emergency response role and be able to DEMONSTRATE it during drills or actual emergencies
      • DEMONSTRATE use of any equipment (such as personal protective equipment or special communication equipment) required by your emergency response role.
      • DEMONSTRATE the ability to seek assistance through the chain of command during emergency situations or drills.
      • DEMONSTRATE the ability to solve problems that arise carrying out your role during emergency situations or drills.
    • The ability of CMC to respond to an emergency depends upon having staff who know what to do, and have the needed skills.
    • As a CMC employee, you should be able to:
      • LOCATE and USE the Emergency Operations Plan (EOP) located in each department in the hospital ( RED Binders) and on the CMC Intranet .
        • http://cmcfs1.cmchs.cmchealthsys.org/policiesandprocedures/EmergencyPlan/home.htm
      • DESCRIBE your emergency response role and be able to DEMONSTRATE it during drills or actual emergencies
      • DEMONSTRATE use of any equipment (such as personal protective equipment or special communication equipment) required by your emergency response role.
      • DEMONSTRATE the ability to seek assistance through the chain of command during emergency situations or drills.
      • DEMONSTRATE the ability to solve problems that arise carrying out your role during emergency situations or drills.
  • CMC Emergency Preparedness
    • Importance:
      • All hospitals must develop written plans and exercise them twice a year.
      • Emergency Operations Plans must cover every employee and every department in the institution.
      • Hospitals must coordinate with Regional Emergency Planning Committees.
      • Know where your department’s
      • Emergency Operations Plan RED Binder is!
  • Risk Management
    • Incident Reporting
    • Documentation
  • REPORTING ADVERSE EVENTS / INCIDENTS
    • In your everyday contact with patients, you are in the best position to identify patient safety issues, unusual outcomes or injuries.
    • Community Medical Center defines an incident as “any unusual happening, which is not consistent with the routine operation of the hospital.”
      • These are recorded on risk quality work sheets (incident reports) and must be completed within 24 hrs. of the occurrence and given to the department manager
      • Department manager will follow up on the incident & then forward the report to the Clinical Risk/Regulatory Specialist and then to Risk Management.
        • Occurrence form is not to assign blame but to evaluate process involved; this is a non-punitive reporting environment
        • An opportunity to improve practice & quality of care
  • Safety/Risk Occurrence Reports
    • Factual statement
    • Gives account of what actually happened to a particular patient in a particular situation
      • Does not give opinions of what happened or why it happened
      • Does not point fingers or assign blame
      • Is not part of Medical Record
      • Does not take the place of documentation in the Medical Record
      • These reports are used for risk, quality issue tracking and trending and loss prevention
  • Documentation Tips
    • Documentation should always be complete, accurate and recorded in a timely fashion
    • Use only abbreviations approved by CMC. Do not use abbreviations are listed in the Administrative Policy & Procedure manual, located on the CMC intranet at: http://cmcfs1.cmchs.cmchealthsys.org/policiesandprocedures/administrativepolicies/policies/
    • If an Error Occurs in documentation – DO NOT USE WHITE OUT!!! Place a single line through the error (so that it is still legible) then initial and date the error.
    • Do not criticize or argue with the other providers, the patient or the family in the medical record
    • Document the effects of medication AND what was done if the medication was not effective.
    • Document all assessments of patient, changes in condition and reflect those changes in the plan of care.
  • Patient Care
    • Patient Safety
    • National Patient Safety Goals
    • Identifying & Reporting Abuse
    • Patient Rights & Responsibilities
    • Confidentiality
    • Safe Haven/ Newborn Protection Act
  • Patient Safety
    • The goal of the patient safety programs is to is to maintain and improve patient safety
    • Safety can be improved through staff education & involvement in the process.
    • CMC’s administration, medical staff, managers and employees are all integral to creating & maintaining a safe environment.
    • CMC utilizes a systematic, coordinated and continuous approach to the maintenance of patient safety
      • Sharing of information about optimal patient safety practices
      • Identification of causes and systems change to prevent further incidents such as medication errors or patient falls
  • Patient Safety
    • CMC has a dedicated patient safety officer as well as a patient safety committee.
    • There is a system in place (accessible 24/7) that allows for staff reporting of safety concerns
    • Employees who report a serious event or cannot be subject to any retaliatory action for reporting the serious event or incident and have protections afforded under Pennsylvania’s Whistleblower Law.
    • TO REPORT A SAFETY CONCERN:
      • Call the Patient safety Officer ( Gina McCabe) at X8810
      • Call the Patient Safety Hotline @ X7000
      • Complete a form and place it in the drop box outside the Atrium Cafeteria in the basement
  • A little info about fall prevention …
    • All hospital staff are responsible for preventing falls.
    • Patients and family members should be educated about the dangers of falls and how to prevent them.
    • Patients are assessed for risk of falling-
      • Does he/she have difficulty walking?
      • Is the patient confused?
      • Have problems with memory, sleeping, pain?
    • Anticipate situations that may increase the risk of falling
      • Anticipate the patient’s needs for assistance.
    • Make the environment safe
      • Keep furniture out of the patient’s way
      • Be cautious with equipment cords etc
      • Make sure that lighting is adequate
      • Provide supervision as needed
    YELLOW PATIENT ARM BAND = IDENTIFIED FALL RISK
  • PATIENT SAFETY GOALS
    • The purpose of the
    • National Patient Safety Goals
    • is to improve patient safety.
    • The goals focus on safety issues in the healthcare environment and how to prevent problems.
  • Identify patients correctly
    • Two patient identifiers required
    • CMC utilizes: Patient Name & Date of Birth
    • When?
      • Administering Medications / Blood Products
      • Taking Blood Samples/Specimens
      • Providing Treatment / Procedures
      • Therapeutic Trays
  • Eliminate Transfusion Errors Related to Patient Misidentification
    • Before initiating a blood or blood component transfusion:
    • Match blood component to physician order
    • Match the patient to the blood component
    • Use a two-person verification process: At CMC this process requires 2 RNs
  • IMPROVE STAFF COMMUNICATION
    • When reporting of critical test results by telephone, verify the completeness and correctness of the order or result by having the person receiving the information record and read back the complete order or result.
    • Communication is the number one root cause of ALL sentinel events combined!
    • Assure critical results of tests and diagnostic procedures are provided to the patient’s licensed caregiver within an established timeframe so that the patient can be promptly treated.
    • At CMC, the timeframe is within 60 minutes of obtaining results
  • Use medicines safely
    • All medicines must be labeled. Medicines removed from the original package and placed in a syringe, cup or basin must be labeled.
    • The label must include:
    • Drug name Drug Strength
      • Amount
    • Expiration Date
    • Extra care must be taken with patient who take medications to thin their blood (anti-coagulants).
  • Prevent Infection
    • CMC complies with WHO Hand Hygiene Guidelines:
        • When to wash with soap and water :
            • Visibly dirty
            • Contaminated or soiled
        • What to wash :
            • All surfaces of your hands and up to wrists
        • How Long :
            • A minimum of 15 seconds or as long as it takes to sing “Happy Birthday” at a normal pace.
    • CMC investigates and reports any injuries or deaths of patients from infections that occur in the hospital
    • Proven guidelines are followed to treat infections
  • Implement Evidence-Based Practice to prevent………
    • Healthcare-associated infections due to multi drug-resistant organisms (MDRO)
    • Central line-associated bloodstream infections (CLA-BSIs)
    • Surgical Site infections
  • Targeted Surveillance for Methicillin-Resistant Staph Aureus (MRSA) at CMC includes
    • PCR screening via nasal swab on all Nursing Home admissions, acute care transfers in AND to all ICU / CTICU admissions.
    • Positive MRSA PCR screened patients are placed in contact isolation for their entire admission.
    • Patient positive results are entered into computerized patient care systems for all disciplines to be aware.
  • Protocols to avoid central line-associated bloodstream infections include………
    • Education to CMC staff, patients, families and licensed independent practitioners
    • Data & outcomes presented to key CMC stakeholders regularly
    • Utilize a central line insertion checklist
    • Use a standard kit that contains all components needed, which includes a full sterile barrier
    • Use an evidence-based antiseptic for skin preparation
    • Disinfection protocols and processes in place to remove immediately once unnecessary.
  • Check patient medicines
    • Find out what medicines each patient is taking. Make sure that it is OK for the patient to take any new medicines with their current medicines
    • CMC will accurately and completely reconcile Medications Across the Continuum of Care.
      • Utilizes the:
        • Nursing Admission Assessment
        • Home Medication Reconciliation Order Sheet
        • MAR
      • Medications will be reconciled throughout the course of hospital treatment.
  • Check patient medicines
    • When a patient leaves the hospital, the primary care provider is informed of what medications the patient is taking upon discharge.
    • When a patient leaves the hospital, a list of their medications is given to the patient and the list is explained to them.
  • Identify patient safety risks
    • Identify which patients are most likely to try to harm themselves.
    • One of the first steps in preventing suicide is identifying and understanding the risk factors. These may include, but are not limited to:
      • previous attempt at suicide
      • history of mental illness
      • alcohol / substance abuse
      • physical illness
      • loss
      • child/physical abuse
      • Isolation
      • Access to lethal methods
      • barrier to treatment
  • Recognize/Respond to Changes in a Patient’s Condition
    • There must be a way to get help from specially trained staff when a patient’s condition appears to get worse.
    • We have a successful
    • Rapid Response Team in place!
    • The purpose of the Rapid Response Team is to prevent codes outside of the Intensive Care Unit (ICU) by having the medical surgical staff nurses recognize a potential problem and use a proactive nursing assessment approach to obtain clinical data and communicate with the physician to determine ongoing treatment
  • Prevent errors in surgery
    • The “Universal Time Out” applies to ALL Surgical Procedures (including procedures in settings OUTSIDE of the Operating Room)
      • If a consent is required for the procedure, a time –out must be completed!
    • The pre-procedure verification process should include ALL relevant documents.
      • Team members should check for consistency with each other, patient’s expectations, and the team’s understanding of the intended patient, procedure, site and implants if applicable.
  • Prevent errors in surgery
    • The patient should be involved & active in the process, to the extent that it is possible
    • The surgeon is responsible to mark the part of the body where surgery will be done.
      • The patient should be actively involved in doing this.
      • This is REQUIRED especially when sites are “paired” sites
      • e.g. left vs. right
  • Identifying & Reporting Abuse
  • Identifying & Reporting Abuse
    • What is abuse?
      • Abuse is the mistreatment of one human being by another. Domestic violence is a term used to describe abuse of men, women or children, and elder abuse.
      • Abuse is intentionally hurting another person and can include physical, sexual, and emotional abuse.
  • Identifying & Reporting Abuse
    • Some Facts About Abuse :
    • Abuse is present in all cultures, in every social class, and in all ethnic groups.
    • One in three women worldwide is a victim of domestic abuse at some time in her life.
    • Men may also be victims of abuse.
    • Individuals in same-sex relationships experience abuse at the hands of their partners at about the same rate as heterosexual couples.
    • More than 15 million children are exposed to domestic violence nationally, and approximately 1 million additional children experience some type of abuse from family members.
    • Elderly people are also victims of abuse. There are 2 million or more cases of elder abuse in the US annually.
    • A person's level of education, age, financial status, and religious or other institutional affiliations don't preclude the chance that abuse may take place.
    • Nursing made Incredibly Easy! July/August 2010
  • Identifying & Reporting Abuse
    • Types of Abuse:
    • Physical The individual presents with current or past skeletal injuries or injuries to internal organs. Damage to external parts of the body such as bruising and abrasions may be visible.
    • Sexual This includes sexual assault, Incest, and rape.
    • Sexual assault is inappropriate and/or aggressive contact with the victim's or perpetrator's genitalia or other "private" areas.
    • Rape is sexual intercourse by force or compulsion. This includes statutory rape: sexual intercourse with a child who is less than 14 years of age by a person 18 years of age or older.
    • (Any person < age 13 cannot legally give consent for sexual activity. It is considered a felony and reportable to law enforcement)
    • .
  • Identifying & Reporting Abuse
    • Types of Abuse:
    • Emotional abuse includes belittling, name calling, verbal attacks, and other aggressive demoralizing behavior, which can injure the person psychologically and lead to long-term consequences that diminish quality of life
    • Neglect and deprivation are also types of abuse. Whether the perpetrator withholds financial resources, education, food, clothes, shelter, or medical attention, neglect can cause irrevocable injuries, with serious consequences to the patient's physical and emotional well-being.
  • Identifying & Reporting Abuse
    • In addition to your ethical and moral responsibility, you have a legal obligation to report abuse, especially mistreatment of children and other vulnerable groups. Federal and state laws require healthcare professionals to report suspected abuse of children, the elderly, and physically or mentally compromised individuals.
  • Identifying & Reporting Abuse
    • A standard set forth by The Joint Commission requires that healthcare institutions have in place criteria to identify, assess, and provide appropriate treatment for victims of abuse, neglect, or deprivation.
    • CMC ADMINISTRATIVE POLICY :
    • It is the policy of the Community Medical Center to identify, assess, and report any suspected abuse / neglect and refer cases to the appropriate agency.
    • PROCEDURE :
    • All patients entering CMC will have an initial assessment for potential abuse/neglect.
    • The following questions will be asked during the Admission Assessment and documented on the Nursing Admission Assessment Form:
    • Has anyone ever failed to take care of you when you needed help? If YES , automatic Social Service consult.
    • Do you feel safe at home? If NO , automatic Social Service consult.
    • Are you afraid to go home? If YES , automatic Social Service consult.
    • Social Service will conduct the formal screening.
    • For more information, see the CMC Administrative policy & Procedure manual.
  • Identifying & Reporting Abuse
    • A list of private and public community agencies that provide for assessment and care of abuse victims is maintained in Social Services.
    • * National Domestic Violence Hotline: 1-800-799-SAFE (7233); TTY: 1-800-787-3224
    • * ChildHelp USA National Child Abuse Hotline: 1-800-4-A-CHILD (422–4453); TDD: 1-800-2-A-CHILD (222–4453)
    • * National Youth Crisis Hotline: 1-800-442-HOPE (4673)
    • * Elder Abuse Hotline: 1-800-252-8966
    • * Parent Hotline: 1-800-840-6537.
  • Patient Rights & Responsibilities
  • Patient Rights & Responsibilities
    • Patients have the right to privacy, confidentiality, ethics consultation, refusal of treatment, safety, special accommodations when needed, assessment & management of pain and more.
    • Patients have the right to speak to a Patient Representative to have complaints and/or suggestions for improvement heard, and the right for assistance with special needs, including interpretation services.
    • Patient responsibilities include asking questions, providing accurate information, acting in accordance with hospital rules, being considerate of other patients, following treatment plans and more.
    • Community Medical Center encourages patients and families to be active members of their healthcare team in order to provide the highest quality of care.
    • Every patient that is admitted to CMC
    • receives a written copy of their rights and responsibilities along with information about ways to help prevent medical errors.
  • Confidentiality
    • All information regarding patients and their families is strictly confidential.
    • The right to privacy is to be preserved at all times and in all locations, both in and out of the hospital.
    • Information, whether made available verbally, in written documentation or accessed via computer or other means should be carefully guarded and communicated only as needed for patient care purposes or hospital business.
    • Employees MAY NOT print or photocopy information from the patient’s medical record and remove it from Community Medical Center’s premises at any time.
  • Confidentiality
    • Do not discuss sensitive patient information in public areas: elevators, halls, cafeteria
    • Speak at a low volume when talking with patients & families to keep the conversation private
    • Access and use only the information necessary to perform your job.
    • Patient information & medical records may only be released with the patient’s authorization. Release forms are available from the medical records department.
    • Log off the computer when you have completed your tasks. Do not share your sign-on & password with anyone.
    • Protect patient information. Be aware of others who may be able to view protected information while you are accessing the computer or patient chart.
  • What is a “Safe Haven”?
    • Hospitals are required to be a “safe haven” to help parents of unwanted newborns find a safe alternative to abandoning the baby.
    • CMC is a safe haven for these babies.
    • The Newborn Protection Act in PA is a law to protect newborns (up to 28 days old) that might otherwise be abandoned or harmed by permitting a parent to leave the newborn at a hospital without fear of prosecution. Newborns can be brought to the Emergency Department and be given up by a parent who may remain anonymous and without fear of legal repercussions.
  • What is a “Safe Haven”?
    • What should I do?
    • Any hospital staff member may receive a baby from a parent.
    • You should take the baby to a treatment area of the Emergency Department.
    • You may only ask about medical history or problems, and whether the parent needs care themselves.
    • The parent is NOT REQUIRED to give any information.
    • Non-licensed staff should hand the baby to the first available doctor or nurse for medical evaluation. Social Services and Security will be notified by the E.D. staff.
    • What happens to the baby?
    • The baby will be examined by a doctor and provided any medical care needed.
    • Children & Youth Agency will take custody and find a family for the baby.
  • Infection control
    • Safety
    • Hand Hygiene
    • Personal Protective Equipment (PPE)
    • Handling Sharps
    • Handling blood spills/Other Potentially Infectious Material
  • How Infection Spreads:
    • Source
      • The place where the infectious microorganism (germ) originates (people, the environment, objects)
    • Host
      • Someone who is susceptible to infection
      • (some people such as very young, old, hospitalized or ill are more susceptible)
    • Mode of transmission
      • A route for the infectious agent (germ) to get from source to host (this can be by direct contact, droplets traveling through the air, or airborne on dust particles)
  • Protecting Yourself & Others From Infection Standard Precautions: Barriers
    • Hand Hygiene
    • Gloves
    • Gowns/Aprons
    • Masks
    • Goggles
    • Sharps containers
    • Ventilation Devices
  • Hand Hygiene (The Most important prevention)
    • When?
      • Consider waterless when no sinks; wash with soap & water ASAP
      • before patient care
      • after removing Personal Protective Equipment, gloves
      • after task is completed
      • between tasks
      • After personal hygiene
    • How?
      • Remove rings, bracelets & watches
      • Wet hands with warm water and apply soap, rubbing briskly for 15 seconds
      • Scrub between fingers, under nails, up wrists and forearm
      • Rinse under warm running water
      • Dry thoroughly with paper towel, use same towel to turn off faucets, then discard
  • Personal Protective Equipment (PPE)
    • Gloves
      • Use when touching potentially contaminated items /material or to prevent contaminating an item or when handling chemicals
      • There are many different types of gloves available with different thickness or content ( latex, vinyl, polyurethane)
      • Change gloves often (gloves are for single use only)
    • Gowns/ Aprons
      • Wear to prevent soiling of clothing and skin contamination when job duties require contact with blood, body fluids or non-intact skin
  • Personal Protective Equipment (PPE)
    • Mask & Goggles
      • to protect mucous membranes of the eyes, nose and mouth from droplets of blood or body fluids
      • use anytime there is a potential risk ( e.g. suctioning)
    • Masks or respirators
      • surgical mask is used to prevent exposure to air borne microbes such as chickenpox and rubella
      • Duckbill mask is used to prevent exposure to smallpox, TB or SARS. This mask must be fitted properly.
      • Wear a mask with any patient in airborne/respiratory or droplet precautions
  • Contact precautions
    • When?
    • Drug resistant bacteria e.g. MRSA, VRE
    • C. Difficile
    • Major drainage from wound infections
    • Diarrhea if very frequent, patient has poor hygiene practices and if patient is incontinent
    • Highly contagious skin or parasitic infections (scabies, lice, impetigo)
    • What?
    • Create a barrier ALL THE TIME
    • Transmission is by direct patient contact or contact with items in the environment
    • Wear gloves and gowns when entering the room
    • Remove all PPE and perform hand hygiene before leaving the room
  • Droplet Precautions
    • When?
    • To prevent transmission of germs through contact with respiratory secretions. (Cover your cough!!)
    • What?
    • Wear a Mask
      • Surgical mask is the primary barrier unless patient has large amounts of secretions or drainage
      • Wear mask when working within 3 feet of patient
      • Wear mask when suctioning
      • Mask on patient when transporting
  • Airborne/Respiratory Precautions
    • When?
    • To prevent transmission of germs that remain infectious over long distances when suspended in the air
    • What?
    • Mask
      • use at all times
      • Duck Bill (must be fitted) for TB, SMALLPOX,AVIAN FLU & SARS
      • surgical mask for Chicken Pox & other
    • Isolation room needed
      • negative pressure may be necessary
      • keep door closed
    • Teach patient to cover nose & mouth when coughing
  • Infection Control : Policy & Procedure Manual
    • Available online (Coreport)
    • http://cmcfs1.cmchs.cmchealthsys.org/policiesandprocedures/administrativepolicies/policies/
    • Part of the Administrative Policy & Procedure Manual
    • Includes the Isolation Reference Manual
    • Contains information about the types of isolation, how the disease/organism is transmitted and the PPE to be used with each
    • Contact Infection Control X 7247
    • to inform them about patients with
    • contagious disease or infection
  • Safety Management
    • Report all Needle Stick Injuries to Employee Health immediately. Fill out an employee incident form.
    • All needle stick exposure injuries will be evaluated in the Emergency Dept. Report to the ED as soon as possible.
    • Treat all as potentially infectious. Use Standard Precautions when dealing with any patient.
    • Personal Protective Equipment (PPE) is available on every unit and should be used to prevent exposure.
  • Handling Sharps – Preventing Injury
    • Sharps containers
      • are puncture resistant and leak proof
      • They must be secured in an upright position
      • Do not place any items on top of sharps container
      • should be emptied when 2/3 full
          • Snap lid shut securely before removing
    • Practice safe handling techniques
      • Dispose of all sharps carefully –in designated containers
      • Use one handed recapping when necessary
      • Use safety devices according to mfgr. recommendations
      • Sharps should never be discarded in a bag or carried loose in your pocket
  • In case of exposure…
    • Wash the affected area thoroughly, flush with plenty of water
    • Report to the Emergency Department for evaluation as soon as possible
    • Report the exposure to employee health and complete an employee incident report (white form)
  • Blood spill clean up
    • Soak up as much as possible with a cloth. Cloth should be discarded in red biohazard waste receptacle
    • Use EPA hospital-approved disinfectant for spills (must be tuberculocidal)
    • Use PPE for blood spill cleanup (gloves, gown etc)
    • If spill is large, contact the housekeeping department for a blood spill kit.
    • Contact housekeeping to clean/disinfect area of spill.
  • Preventing Back Injuries
    • Tips
    • Posture
    • Injury Prevention
  • Tips to prevent back injuries
    • A strong back is a healthy back. 
      • Conditioning through regular exercise and stretching keeps your back healthy. It is like doing regular maintenance on your car; if it is never done, the vehicle is likely to breakdown.
    • If it is too much, get help.
      • Many times, back injuries are caused by workers lifting, or attempting to lift an object they knew was too heavy.  Asking for help from another employee or using a mechanical device to lift heavy or bulky objects is not only smart, but it is more efficient.
    • Use proper Body Mechanics
      • Good body mechanics allow an employee to bend, lift or stretch in the most efficient way to reduce the strain on their muscles and joints and prevent injury.
  • PROPER POSTURE:
    • To avoid back injuries, it is important to maintain proper posture throughout the day.
    • To maintain proper posture, the three natural curves must be aligned. Your three curves are correctly aligned when your ears, shoulders, and hips are in a straight line. To maintain this proper alignment, keep your chin tucked back, shoulders down and back, and your stomach and buttocks tucked in.
  • PROPER POSTURE:
    • Some tips for maintaining a good posture includes:
      • Stand up straight.
      • Think of being tall and straight, do not arch your back.
      • Do not lean forward or lean back. Leaning puts strain on the back muscles.
      • Eyes forward, not looking down but rather 20 feet ahead.
      • Chin up (parallel to the ground). This reduces strain on neck and back.
      • Shrug once and let your shoulders fall. Then relax your shoulders slightly back.
      • Suck in your stomach
      • Tuck in your behind - rotate your hips forward slightly. This will keep you from arching your back.
  • Sleeping
    • Make sure you are sleeping on a firm mattress.
    • Avoid sleeping on your stomach or with your head elevated on an oversized pillow. These positions cause the back to arch and places stress on the spine.
    • The side and back are the best positions for maintaining a neutral position and a must for anyone with back or neck problems.
    • Place a pillow between your knees (for side sleeping) or behind your knees (for back sleeping). This will help keep your spine in the right position and help ease stress on the lower back.
    • Use a pillow that allows you to keep your head aligned with the rest of your body. Numerous and/or oversized pillows may look great on a made bed but do not necessarily benefit your back while sleeping .
  • Sitting
    • Place your buttocks at the back of the seat while maintaining a small space between the back of your knees and the seat of the chair.
    • Place your feet flat on the floor with your knees bent at a 90° angle.
    • Pull your shoulders back and lift your chest.
    • Lift your chin until it is level and relax your jaw and mouth.
  • Standing/Walking
    • Avoid standing in one position for prolonged periods of time. Change your position as often as you can. This will not only help relieve stress on your spine, it also helps increase circulation and decrease muscle fatigue. When you can, stretch. Gentle stretching exercises during a break can help ease muscle tightness.
    • Be aware of your posture. Are you standing correctly? Check and double check throughout your day.
    • Make sure the surface you are standing on is firm and level.
    • If possible, lean on a solid support. This can help reduce fatigue during long periods of standing .
  • Body Mechanics & Back Injury Prevention
    • When lifting or moving something: maintain a wide base of support – a wide or staggered base of support will improve your stability and reduce risk of losing your footing
    • Keep objects close to your body – this decreases stress to your back as the load is as close to your body’s center of gravity.
    • Avoid twisting while lifting- pivot your feet or move your entire body to change directions to decrease stress to your back.
    • Use your legs, not your back. (The back muscles are not your strongest muscles.)
  • Body Mechanics & Back Injury Prevention
    • Lift with legs- utilizing legs and large muscles will diminish the workload to the back.
    • Push an object – pushing the object (vs. pulling) increases to the weight advantage and thus is easier on your back.
    • Tighten stomach muscles – reduce strain to the back by using stomach muscles to create your own protective corset as you move objects.
  • You are this Hospital
    • You are what people see when they arrive.
    • You are the eyes they look into when they are frightened and lonely.
    • Yours are the voices people hear when they ride the elevators and when they try to sleep and when they try to forget their problems.
    • You are who they hear on their way to appointments which could affect their destinies, and what they hear after they leave those appointments.
    • Yours are the comments people hear when you think they can’t.
    • Yours is the intelligence and caring that people hope they will find here.
    • If you’re noisy, so is the hospital.
    • If you’re rude, so is the hospital.
    • And if you’re wonderful, so is the hospital.
    • No visitors, no patients can ever know the real you, the you that you know is there – unless you let them see it.
    • All they can know is what they see and hear and experience.
    • And so we have a stake in your attitude and in the collective attitudes of everyone who works at this hospital.
    • We are judged by your performance.
    • We are what you give, the attention you pay, the courtesies you extend.
    • Thank you for all you’re doing .