Hospital Emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1234 • Code Blue • Code Red • Rapid Response Team • Campus Assessment TeamMedication Error Hotline . . . . . . . . . . . . . . . . . . . . . . . . . 3-4567Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1111Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-6672Fall Hotline . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-OOPS (8-6677)Poison Control . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-222-1222Exposure Hotline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366-5251Employee Health Service . . . . . . . . . . . . . . . . . . . . . . . . 3-6353Return to Work Hotline . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1333Compliance/HIPAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-6714Administrator on Call . . . . . . . . . . . . . . . . . . . . . . . . . 366-5877Nursing Director on Call . . . . . . . . . . . . . . . . . . . . . . . 359-7873docZ Downtime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-7990

POLICY/PROCEDURE SAFETY REFERENCE

200-11400-0002 Rev. 5/09

Safety Kardex

Building: _______________________________

Department: ____________________________

RAPID RESPONSE TEAM

Rapid Response TeamSOPs R-001– Adult, R-006 - Pediatric, and R-004 - Neonate

PROCEDURE1. To activate, please call 3-1234. 2. This is used at the patient’s bedside anytime you have a concern about the patient’s status, significant change in patient’s condition, or a second opinion is needed. 3. Family’s expressed concern could also warrant a Rapid Response Team (Condition Help).4. Text pagers of the Team are activated and it is not paged overhead.

CAMPUS ASSESSMENT TEAM

• To activate, please call 3-1234. • AED and Medical Backpack Locations: – Locken Lobby – MB1/MB2 Corridor – MB3 Lobby – Outpatient Rehab – VanDemark Building – Surgical Towers – 1000 Elevator Lobby – Wegner Health Service Library – Physician Center – Sanford Children’s Hospital Great Hall – Cancer Center Lobby• This provides a mechanism to respond to non-patient medical emergencies that may occur on the main campus of Sanford

USD Medical Center. This is activated for an individual who has a sudden illness or injury preventing them from seeking medical assistance under their own power (fall, anything less than a Code Blue are examples).

• Team consists of a representative from Maintenance, Security, and Clinical Care Coordinator from Trauma 5 Emergency Department. Security will respond with an AED. Text pagers of the Team are activated and it is not paged overhead.

Campus Assessment TeamSOP C-183

Extension Cords/Space Heaters/Holiday LightsSOP E-290

ExTENSION CORDS/SPACE HEATERS/HOLIDAY LIgHTS

POLICYExtension cords are for temporary use only.Maintenance will evaluate need for extension cords.

PROCEDURE1. Maintenance will issue extension cords for the use of audiovisual equipment when needed.2. Extension cords will not be used in an unsafe manner. - do not leave plugged in when not in use - do not string cords across path of travel3. Departments requesting extension cords will be responsible for returning them.

Electric space heaters may be used only when there is a verified problem with the building heating system and only with permission from the Director of Facilities.

Artificial Christmas trees and artificial decorations are the only acceptable holiday decorations allowed within the Sanford USD Medical Center complex. Nothing electrical, except approved fiber optical lighted trees are allowed and approved by the maintenance department. Candles of any type are specifically banned.

Any questions should be directed to the Director of Facilities.

WATER OUTAgESOP W-030

CODE WATER

Power Plant personnel will notify the switchboard, who will then announce "Code Water Reduced Water Pressure."

Personnel should conserve water by: • not flushing toilet stools unnecessarily • not using water to scrub floors • not giving any baths

Hand hygiene should be performed using waterless antiseptic, visibly soiled hands should be cleaned with a hand wipe first, followed by waterless antiseptic. Disposable hand wipes alone are not adequate hand hygiene.

Once water is restored the Switchboard personnel will announce "Code Water-Cancelled"

CODE ExITSOP C-537

CODE ExIT

POLICYAll hospital personnel will be notified of any missing person via overhead page.

PROCEDURE1. Dial 3-1234 to initiate Code Exit. Notify operator of missing person's age and gender. (see

example below)2. Identify yourself and your call back phone number.3. Give your exact location including building, floor and room number.4. Contact security at 3-1111 or page #1111. Security will respond to your location.5. Search immediate area.6. All employees will monitor the nearest exit until an "All Clear" is paged overhead.7. If a suspicious person is noticed, notify security and note person’s direction of travel.8. When the missing person is found, notify Security or Administrator on Call. They will call the “All Clear.”

• Examples: 4 year old boy “Code Exit, 4, male” Infant girl “Code Exit, O, female”

CODE MAN SOP C-540

CODE MAN

POLICYThis policy describes the procedure to summon additional staff immediately to assist in controlling a situation or combative person that could cause harm to patients and employees or that would result in damage to Sanford property. Designated personnel (Security, Maintenance, Lift Team, and Administrative Representative) are assigned to respond during the day and all male personnel during evening or night shifts.

PROCEDURE1. Dial 3-1234 to initiate Code Man.2. Give your exact location including (building name, floor, wing, room number, etc.).3. Identify yourself and your call back phone number.

OCCUPATIONAL ExPOSURE TO BLOOD/BODY SUBSTANCES

ICM 4-4

OCCUPATIONAL ExPOSURE TO BLOOD/BODY SUBSTANCES

Employee Health Services: (605) 333-6353 (Monday – Friday 0630 – 1500)Exposure Hotline: (605) 366-5251 (24/7)

Promptly report occupational blood or body substance exposure incidents to Employee Health Services or the Exposure Hotline. Notification will result in an immediate evaluation, counseling, and post-exposure treatment as appropriate.

If there are any questions about whether or not the incident constitutes a significant exposure, contact Employee Health Services or the Exposure Hotline. A nurse will assist you in determining whether an exposure to potentially infectious body substances has occurred.

Exposurse that require immediate action: • An injury with a contaminated sharp that punctures the skin • Splash, spray or other contact with blood or other potentially infectious materials that comes in contact with a

worker’s non-intact skin, eye, nose, mouth or other mucous membrane• Mouth to mouth resuscitation without a resuscitation device or ambu bag • Human bite that punctures the skin

Immediately:• Wash thoroughly with soap and water. Do NOT apply caustic agents such as bleach.• Flush mucous membrane with water. Eye flush available in EHS or the ED.• Get treatment in ED for lacerations needing attention

Body Substance definition: Occupational exposure to the following body substances need to be reported and evaluated: Blood; bloody fluid or tissue; semen; vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial or amniotic fluid.

Ambulatory Patients: Report exposure incidents involving ambulatory patients prior to patient discharge. If discharge has already occurred, report as soon as possible.

REMEMBER: Prompt action is indicated to provide the most benefit from post-exposure preventive treatment. Delay in reporting could result in infection transmission from the source.

EMPLOYEE HEALTH SERVICE

EMPLOYEE HEALTH SERVICE

Hospital employees returning to work after an illness must receive the OK to return PRIOR to reporting for work.

How do I get an ill slip? • Call 605-333-1333 – 24 hrs/day, 7 days/wk OR • Come to Employee Health Services between 0630 – 1500 M – F The phone line is accessible 24 hours a day - the phone rings to EHS during regular

business hours and to the Clinical Call Center after hours. Employees will hear the Clinical Call Center message (Healthformation) when the calls are being forwarded to this area.

Reminders: This process is NOT for returning from a Leave of Absence - this must be completed with EHS during regular business hours.

When calls come via the phone, an "OK to work" slip will be faxed to the department to let the department know that the employee is cleared for work (this clearance slip has no confidential information - simply the demographic information and if it is ok to work or not).

Note: This number is NOT the Exposure Hotline used to report bloodborne pathogen exposures (i.e. needlesticks or splashes of blood of bloody body fluids to mucous membranes or open skin). Please do NOT use the hotline to receive clearance for returning to work.

PERSONAL PROTECTIVE EQUIPMENTSOP E-196

PERSONAL PROTECTIVE EQUIPMENT

Some job tasks are performed more safely with the use of additional protective equipment. Such personal protective equipment (PPE) is used to protect eyes, face/head, extremities, clothing, skin, or respiratory tract from a hazard. The hazard may be biological, chemical, radiological or mechanical. Adequate supplies of properly fitting PPE are provided by Sanford USD Medical Center. Be familiar with the proper use of PPE required in your work area. Communicate with your supervisor if additional sizes are needed. Expect your supervisor to include your familiarity with and use of PPE in the monitoring of work practices and your job evaluations.

Information on PPE use with department specific hazards is available in departmental policy manuals. Additional information for protection from biological hazards associated with patient care is included in the Administrative SOP ICM 1-1, the Administrative SOP for Standard Body Substance Isolation.

Personal protective equipment (PPE), including protective equipment for eyes, face, head and extremities, protective clothing, respiratory devices, and protective shields and barriers will be available in applicable departments.

Each employee will be required to utilize personal protective equipment if the job function requires doing so. Personal protective equipment will be accessible via Supply Chain Management.

Please contact the Safety Director at #3-6672 or pager #1071 if you have questions regarding PPE.

Risk Management and Patient Relations

RISK MANAgEMENT AND PATIENT RELATIONS

PATIENT COMPLAINTFor assistance with patient/family complaints that cannot be handled at the bedside, contact Patient Relations at 3-6546, or pagers 1496, 1296, or 2210.

RISK MANAgEMENTFor questions regarding legal issues or potential liability concerns, contact the Risk Manager at 3-3234 or pager 2080.

COMPLIANCE WITH THE SAFE MEDICAL DEVICE ACT OF 1990 (SOP S-015)The Safe Medical Device Act (SMDA) has multiple aspects. One aspect includes the “purchase to disposal” tracking requirements for implantable patient items and life-sustaining devices. If an incident with a device occurs, report it to Risk Management Department immediately. Collect and preserve any and all materials that were in use when the event occurred, including all disposable and reusable items associated with each device or piece of equipment.

To minimize the impact of regulations on Sanford USD Medical Center operations, the Risk manager will determine the need for and appropriateness of reporting per the Medical Device Safety Act. Risk Management will be in charge of all investigations. Reports of events will be submitted internally, to manufacturers and to the FDA as required by law. Contact Risk Management at the number noted below to report an occurrence involving a medical device.

TO REPORT AN EVENT INVOLVINg A MEDICAL DEVICE CONTACT:Risk Management Coordinator: 3-3234, pager 2080Biomedical Engineering: 3-6365

After-hour resource: Contact the Administrator on Call by calling 366-5877 (cell)

HAZARD COMMUNICATION

HAZARD COMMUNICATIONSOP H-035

POLICY1. Material Safety Data Sheets (MSDS) are maintained for all chemicals at Sanford USD Medical Center.2. Characteristics of hazardous chemicals include: • Toxic (mercury, cadmium, lead) • Flammable (paint, degreasers) • Reactive (cyanide, bleach) • Corrosive (rust removers, battery acid)3. Anything containing blood or other potentially infectious material will be labeled or red-bagged as a potential biological hazard.

PROCEDURE1. Copies of the Hazard Communication Program are located in each department’s Safety Manual, Section 11.2. All hazardous chemicals will be labeled: • In English • Even if transferred to a secondary container unless it will be used immediately by you.3. Material Safety Data Sheets (MSDS) • MSDS sheets contain the identity of the chemical, chemical characteristics, physical hazards, health hazards, exposure limits, precautions, personal protective equipment, emergency first-aid procedures, and the name and phone number of person responsible for MSDS. • Each department keeps department specific MSDS’s. • The Master of all MSDS sheets is located in the Safety office and on Sanford Connect (MSDS online).4. Each department keeps an inventory list of chemicals used/stored in department.5. Utilize personal protective equipment according to the MSDS.6. Protection of human life is the main priority if a hazardous chemical spill occurs. See Adm. SOP H-036.7. Hazards associated with blood and other potentially infectious materials will be communicated as follows: • Refrigerators/freezers containing blood of lab specimens will have biohazard label. • All specimen containers will be handled according to standard BSI. No label is required unless

transported off site. • Soiled linen hampers are handled according to standard BSI. • Equipment that cannot be decontaminated will be labeled with a biohazard symbol indicating which part of the equipment remains contaminated. • Containers which store and transport reusable sharps will be labeled with a biohazard symbol.8. Medical waste will be handled according to Adm. SOP ICM 5-22.

Hazardous Chemical SpillContaminated Patient Response

SOP H-036 & SOP D-035

HAZARDOUS CHEMICAL SPILL/CONTAMINATED PATIENT RESPONSE

POLICY:Any employee aware of a chemical spill which may be potentially harmful, will notify the Maintenance Department immediately (3-6667). If it is a chemotherapy spill, call Oncology (8-6190) and refer to Adm SOP A-210.

PROCEDURE:1. Based on incoming information, The Sanford Command Center will determine the

need for lockdown.2. Once a decontamination event is announced, staff should remain aware that the

areas outside the facility could be contaminated.3. The decon team will be activated via overhead page or other means and will report

to the staging area in the Trauma 5 ambulance garage.4. Decon team members will be briefed on the incident specifics.5. All decon team members will be given pre-entry evaluations to determine fitness for

duty.6. The decon team leader will assign roles as appropriate.7. The decontamination operation will not begin until all team members and equipment

are in place.8. Once decontaminated, patients may be released to Trauma 5 for treatment.9. No contaminated patients will be allowed into Trauma 5 without decontamination,

there will be no exceptions.10. The safety officer will be immediately notified of the operation and will have ultimate

authority over the decon operation.

TELEPHONE SERVICE: LOSS OF NORMAL(Code Telephone)

SOP T-021

TELEPHONE SERVICE: LOSS OF NORMAL (Code Telephone)

POLICY: In the event that telephone service is lost to the main Sanford telephone system, independent lines that dial directly into the public calling network, have been installed to accommodate telephone traffic. These phones are strategically placed through the facility and are identified by their red color. Please see Telephone Directory for Power Failure Phone locations.

- The switchboard operator will announce two times “LOSS OF NORMAL TELEPHONE SERVICE. PLEASE REFER TO SOP T-021 FOR DOWNTIME PROCEDURE”.

- Sanford USD Medical Center has 46 commercial power failure phones in the facility.- Do not dial 9 when making an external call on the power failure phones.- To reach the hospital operator during a telephone outage, please dial 334-

3122. The operator may use the backup overhead paging system to announce appropriate overhead pages (emergency pages).

- There are 3 two-way radio base stations and 20 portable two-way radios available for use in the event of loss of normal telephone service. The 20 portable two-way radios are located in the Ambulance Garage. The radio base station locations are:

• Maintenance Department • Disaster Control Desk • Power Plant

- Other means of communication should be determined by the appropriateness for each department and their workload (pneumatic tube system, e-mail correspondence, runners, etc…).

Note: For complete listing of Power Failure Phones, refer to SOP T-021.

CODE ELECTRICAL POWER

• The Total Energy Plant Operator will inform the Switchboard of the problem. • The Switchboard Operator will announce overhead two times: “CODE ELECTRICAL POWER REDUCED ELECTRICAL POWER CONDITION” • Each individual in charge of an area or department will shut off all nonessential

electrical devices immediately (i.e. lighting reduced to a minimum, fans, refrigerators, heaters, or any and all equipment that is not considered critical should be shut off).

• When all electrical power capabilities have been returned to their normal conditions,

the Switchboard Operator will announce overhead: “ELECTRICAL POWER HAS BEEN RESTORED.”

Code Electrical PowerReduced Electrical Power

SOP E-060

PHI-HIPAA/PRIVACY

PHI-HIPAA/PRIVACY

The following Sanford USD Medical Center Administrative SOPs address the issue of information security:

C-625: Confidentiality. The “Need to Know” principle is the guiding concept in determining what information can be shared or accessed. This includes patient information from charts, records and the computer as well as certain non-patient information. Patient discussions are clearly off limits in elevators, cafeteria, stairwells, waiting rooms, meeting rooms, auditorium and other public areas. Telephone conversations will be conducted with confidentiality in mind.

O-087: Obtaining/Canceling Computer Security Codes. Computer access codes are confidential. Sharing your own or using another’s security code is subject to disciplinary action, including termination. Computer access codes are provided only upon the request of the department director. Departments with free standing computer systems are responsible for developing security policies for their area.

S-101: Security and Safeguarding of Health and Hospital Information. Every attempt is made to safeguard medical records, hospital information, documents and other storage from unauthorized users. This includes handling and security by staff as well as providing structurally safe, fire-resistant and water-resistant storage environments for permanent record storage. Hospital computer systems are protected by backup tapes in a secured environment. Sharing of information with other facilities and organizations must have department director approval. Storage is secured during off business hours or when staff not present in areas such as medical records and information systems. The medical record is a legal document. All entries to it are considered final and not to be altered or removed. Corrections to medical record entries are only allowed by the individual making the original entry. Suspected security breaches will be reported to the employee’s department director.

I-087: Information, Release of Non-Patient. To safeguard strategic information from competitors and protect procedures, protocols and policies developed in the course of doing business. Affiliate facilities are assisted with such information after consultation with the department head and/or the appropriate Vice President wherein the information/document resides.

H-095 Disclosure of PHI-HIPAA Privacy Policy: Medical Records: Release of Information: Review this policy to become informed about releasing patient information. Learn when an authorization is or is not required prior to releasing patient information. Only Medical Records is authorized to release information following discharge. For continuation of care during hospitalization, information may be released by the nursing unit or Social Services. Privileged and non-privileged information; faxing information; third-party payors; special considerations for release of information in the case of minors, emancipated minors, subpoenas to attorneys, agencies such as the IRS or child protection services through statutory privilege (i.e. Workers' Compensation), mental health records, deceased patients and detoxification services records are all addressed in this policy. Note: Disclosure to Law Enforcement form (#3920-0043).

Fire Plan (Code Red)SOP F-025

FIRE PLAN (CODE RED)

Smell of Smoke: Investigate any smoke smell and call Maintenance at 3-6667 or pager #1307

Sight of Fire/Smoke: Report fire/smoke to all persons within hearing distance using “Code Red”, then follow RACE procedure

R-Rescue • Remove patient(s) from immediate fire area and close doors

A-Activate• Sound Alarm using pull box• Notify Communications at 3-1234 stating location and type of fire

C-Contain • Close all doors and windows

E-Evacuate/Extinguish • Attempt to extinguish fire with available fire equipment (P.A.S.S.) • Prepare for horizontal evacuation should the need develop • Leave On/Off electrical devices as is • Do not use elevators in affected building • Know location of Oxygen shut-off valves

Fire Alarm• Communications will notify personnel via an overhead page: “Attention, Attention

Code Red (and location)”• All personnel will report to their assigned duty station when alarm called• Follow departmental fire plan to specific instructions for your area• When Fire Department authorizes end of alert, Communications will page “CODE

RED ALL CLEAR”

(CODE DISASTER) DISASTER PLAN SUMMARY(Refer to Disaster Plan on Sanford Connect)

DISASTER PLAN (CODE DISASTER)

• The Disaster Plan is implemented for internal, external, or national disasters at the discretion of Administration. It is initiated by the President, Vice-President or Emergency Department Clinical Care Coordinator.

• The Communications department announces overhead “Attention, Attention, Code Disaster (Note: Code Disaster for 15 patients or more; Code Disaster Decon for any incident requiring

decontamination regardless of potential patient count). Code Disaster Decon will require mobilization of the Decontamination Operations Team.

• The Incident Command Center will be located in the Hospital Administration 4000 Board Room

• For incidents resulting in patient decontamination needs, the overhead page will be “Attention, Attention, Code Disaster Decon”. Refer to SOP D-035 for additional information.”

Department Unit Response• All staff return to their departments.• All departments will report available beds and/or available equipment to the

Control Center. (Note: Keep equipment on unit during drill; Bring equipment to Trauma 5 during actual Code

Disaster). • All Departments will report number of staff on duty who are available to help elsewhere (Call numbers/role to Personnel Pool 3-6357). Staff report to Human Resources to wait for assignment• ID badges are to be worn by all employees.• Prepare for possible emergency admissions, discharge of stable patients and/or

transfers/evacuations depending on disaster situation.• Sign onto e-mail for internal emergency communications.• ON DUTY staff must remain in or report to “assigned work area” until released by supervisor.• OFF DUTY staff should report to the hospital when notified of the disaster via phone or news media if help is requested.• Enter through the Locken (Main) Lobby.• Report to Personnel Pool in the concourse area outside Sanford Health Foundation unless

have a specific role in disaster• Telephones will be used for emergency calls only.• Visitors/family members should remain with inhouse patients. Visitors/family

members in the cafeteria or lobby areas should be directed to return to the patient’s room.• Family members of (or calls for) disaster patients should be directed to Meeting Rooms A, B,

and C (8-5085, 8-5087, 8-5088 or, if no answer, 3-1456)• News media personnel (or calls) should be directed to the Van Demark Building (328-1450 or 328-1451)• When the disaster no longer exists, communications will announce overhead

“Attention, Attention, Code Disaster, All Clear”

Incidnet Command Center/Emergency Operations 3-6489 (Fax 3-1531) Personnel Pool 3-6357 Family Center 3-1452 or 3-1454 Physician Resource Pool 8-2928 (Fax 8-2903)

EVACUATION PLAN SUMMARYSOP E-225

EVACUATION PLAN

• Evacuation will be initiated by the President, Administrator on Call or Department Clinical Care Coordinator/supervisor of affected area(s).

• When assistance is requested via overhead page, available personnel should respond to the area with available wheelchairs and carts.

• Patients will be moved internally to alternate buildings before moving to alternate care sites off campus.

• Patients will be moved horizontally first, and if necessary, vertically.• Evacuation will occur in the following order: ambulatory patients and visitors, least

critical and those closest to danger area, and then more critical patients.• At least one staff member will remain with the patients at the receiving area.• The paper medical record should accompany the patient if evacuated to an

on-campus alternative site.• If the patient will be evacuated to an off-site location, copies of the medical record

should be sent with the patient if time allows. See Inter-agency transfer sheet.• Visitors will be directed to leave the facility via identified safe routes of egress.• General department response

• All on-duty personnel will report to their assigned duty area.• Individual in charge of each department/unit will wear a red arm band.• Locate extra carts and wheelchairs in the department/unit and be prepared to

deliver to the area(s) of evacuation.• Have an individual manage the telephone in each department/unit.• All hospital employees will remain on duty until released by their immediate

supervisor.

Tornado WATCH AND WARNINgSOP T-070

TORNADO PLAN

POLICY:Tornado Watch: Weather conditions are ideal for the development of a tornado.Tornado Warning: Tornado has been spotted near Sioux Falls or the surrounding geographical area.

PROCEDURE:

When Tornado Watch announced: • Clinical Call Center will notify the Operator.• After notification by the Operator, the Administrator on Call will make determination

which functions of the SOP will be implemented. Use Schroeder Auditorium and Meeting Rooms for shelter.

• Maintenance staff will be notified to close all outside doors and to notify the Power Plant to place the emergency generators on line.

• When determined, the Administrator On Call will instruct the Operator to page overhead “ATTENTION, ATTENTION, A TORNADO WATCH IS IN EFFECT.”

• Make preparations for moving patients and visitors into hallways.• The Administrator On Call during a Tornado Watch may order some or all of the

following items:• Order that no procedure will be started.• Order that no patient will be anesthetized.• For Tornado Watch…determine the need for services of “call” personnel.• For Tornado Warning…”On Call” staff will be contacted for extreme emergencies.

WHEN TORNADO WARNINg ANNOUNCED:If the Civil Defense sirens are activated, the Switchboard Operator will page “ATTENTION, ATTENTION, TORNADO WARNING-TAKE COVER.”

• Visitors and patients will be moved into the hall closing the doors behind. For patients who can’t be moved, windows will be shut, drapes closed and extra blankets put over the patient. If possible, one person will stay with each of these patients. Patients on the West and South sides of the building will be moved first.

• Security and Nutrition & Food Services personnel will assist visitors located in the cafeteria and lobby to the lower level. No one should remain in the Atrium area.

• When the alert has been canceled, “ATTENTION, ATTENTION, THE WEATHER ALERT HAS BEEN CANCELED.”

SNOW EMERgENCY PLANSOP E-143

SNOW EMERgENCY PLAN

• When snow related weather is severe, the Administrator On Call may declare a “Sanford USD Medical Center Snow Emergency” and open the Snow Desk (3-6489).

• Employees may be reassigned to areas of the hospital to perform duties within their capabilities.

• The policies regarding staffing may be suspended by the Administrator On Call.

• The Admissions Department will implement the snow emergency room assignment procedure.

• The Admissions Department will serve as the coordinating point for persons needing sleeping facilities.

• Employees who are scheduled to work must make every effort within the bounds of safety to be at Sanford USD Medical Center on their own accord and be familiar with emergency pick up points within Sioux Falls.

• Employees who can not get to Sanford USD Medical Center on their own will contact their supervisor who will determine the need for the employee to be picked up.

• Departmental employee needs will be referred to the snow desk and the Administrator On Call.

BOMB THREAT SOP B-070

BOMB THREAT

POLICY: Any bomb threat received by anyone at Sanford USD Medical Center will be assumed to be “Legitimate.”

PROCEDURE: • Under no circumstances will the person receiving the call terminate the call, be abrupt or

speak other than normally. • Attempt to get another staff member on the line TO listen. • Try to get as much information as possible from the caller. • Try to determine sex, age, voice or speech patterns of the caller. Male:____ Female:_____ Tone:________ Age:__________

Ask the following questions: • Where is the bomb located?______________________________________________ • In which building, on what floor and in which room?_______________________________ • Is the bomb set for a specific time?____________________________________________ • What kind of bomb is it?___________________________________________________ • How can we identify it? _____________________________________________________ • How large? ___________________________________________________ • In what type of container?____________________________________________ • What color? ________________________________________________ • What is your name?_________________________________________________ • Who would do something like this?_____________________________________________ • Why would someone do something like this?_____________________________________ • When was the bomb placed?________________________________________________ • Listen for special noises or sounds which may give a clue to the location of the caller._____________________________________________________KEEP THE CALLER ON THE LINE AS LONG AS POSSIBLE, obtaining information go over information again, double check information provided, keep talking… • Immediately notify the Switchboard Operator who will notify the appropriate personnel. • The appropriate personnel will authorize putting the Search and Report Plan into Action: • Operator will notify Police Department and announce “ATTENTION, ATTENTION, SEARCH

AND REPORT.” • Call Maintenance and notify them of the threat, #3-6667. • Portable radio systems will not be used during a bomb threat and telephones would be

used for emergency calls only. • After 1700 hours and on weekends and holidays, initiate the Fire and Disaster Call List. • Emergency Operations Center will be activated, #3-6489. • Department Directors will search their own areas and report to the Control Center their

findings. • If a suspicious item is found, do not touch it. Report it to the Control Center and evacuate

the area and stand by to show the police where the suspicious item is. • Leave all electrical devices in their current status. • Have visitors stay with patients. • Secure building as in a fire, close all doors and windows. • During the initial search, do not search locked areas. • Discourage patient and visitor movement within the building. • Maintenance will lock all doors and only emergency patients will be admitted through ED. • Two employees will be assigned to block the ED entrance to allow only identified staff into

the building. • Bomb Squad members from the SF Police Department will be assigned to the Incident

Command Center to investigate all suspicious packages of items found in the search. • When notified of the all clear, “ALL CLEAR” will be announced.

BIOLOgICAL EMERgENCY READINESS AND RESPONSE PLAN

SOP ICM 10-1

BIOLOgICAL EMERgENCY READINESS AND RESPONSE PLAN

Biological emergencies may occur as concealed events, in which persons are unknowingly exposed to an infectious biological agent and the event is suspected only upon recognition of unusual disease clusters or symptoms. It may occur as an announced event, in which persons are warned that a biological agent has been released and exposures have already occurred, or it may include naturally occuring events such as an influenza pandemic.

If any biological emergency is suspected, facility emergency response systems should be activated. Notification should be immediate.

Call Infection Prevention and Control: 3-6478 (After hours 366-5251) Infection Prevention and Control Coordinator, Sharon Rockman . . . . .3-7363 Hospital Epidemiologist: . . . . . . . . . . . . . . . . . . . . . . . . . . pager 331-1821 Infection Prevention and Control Practitioners . . . . . . . . . . . . . . . . . . .3-3134 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-6385 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-7377 Infection Prevention and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-6478

Notification will result in an immediate evaluation to determine reasonable suspicion for a bioterrorism event. A suspected bioterrorism event will result in activation of the Emergency Response Group. This will activate a network of communication that will involve healthcare administration, local and state health departments, the FBI field office, local, state and federal emergency management and CDC.

Activation of the Biological Emergency Response Plan results in a activation of the Emergency Operations Plan (Code Disaster).

The Biological Emergency Readiness and Response Plan, appendices and printed educational information on agents that could be used are found on Sanford connect. Look under Sanford USD Medical Center, Infection Prevention and Control Policies and Procedures, in Chapter X (ten).

CODE gRAYSOP C-532

CODE gRAY

• A, “CODE GRAY” to stay away Overhead Code will be paged overhead campus-wide when one of the two situations listed below occurs. It is common for these types of incidents to move to different locations, the overhead code location will be paged as locations change in an effort to communicate areas of possible danger. This code is a campus wide notification with all reacting to threat in their location. A hostage incident usually results from one of the following three occurrences:Policy: It is the policy of Sanford Health to rely on staff and quick response from law enforcement to resolve any

hostage taking or incident involving an active shooter on campus. Persons at Sanford will need to determine the most reasonable way to protect life.

Do not endanger your safety or the safety of others. • Responsibility for Plan Activation: Any staff member who witnesses a hostage / active shooter situation is responsible for implementing a

“CODE GRAY” code when safe to do so. Overall control of the hostage / active shooter situation and all negotiation is the responsibility of the

most senior ranking employee present until law enforcement are on the scene.

Operator Responsibilities Quickly determine the most reasonable way to protect life. Operator will page overhead 2 times, “CODE GRAY” ,STAY AWAY, AND LOCATION. Operator will contact Law Enforcement, Security, Administrator on Call, Medical Director On Call,

Director of Safety, Facilities Director, and Marketing to have them report to Command Center.

Medical Personnel Responsibilities Quickly determine the most reasonable way to protect life. Evacuate, have a plan, leave belongs behind, keep hands visible. Hide out, stay out of sight, block entry into your area and lock doors. Take action, last resort, only when your life is in imminent danger If safe to do so, report following information to Administration, Security, and Police: Description of hostage taker or active shooter. Number of hostages or injured, and weapons if known. The number of hostage takers or shooters involved and description(s), if possible. Make specific notes of any threats or demands being made. Media should be directed to Marketing Department for information.

NOTE: All calls will be referred to the Marketing Department (366-2432) representatives, who will be in the designated media coordination area.

PATIENT SAFETY gOALS

PATIENT SAFETY gOALS

Improve the accuracy of patient identification• Use 2 patient identifiers (patient name and date of birth) when administering meds, blood, blood products,

taking blood samples or specimens, or providing treatments or procedures.• Be sure that the 2 identifiers on the order (dietary order, lab requisition, MAR) match the patient’s ID Band.

Improve the effectiveness of communication among caregivers• Read Back telephone and verbal orders and critical test results (TORB and VORB).• DO NOT USE abolished abbreviations, acronyms and symbols.• Report critical test results to a responsible, licensed caregiver in a timely manner. (Admin. SOP C-100)• Implement a standardized approach instead of "handoff" communication, including an opportunity to ask/

answer questions. Use SBAR – Situation, Background, Assessment, and Recommendation.

Improve the safety of using medications• Identify “look alike/sound alike” drugs in the organization and report these to the Medication Safety Officer.• Label ALL medications and containers containing medications or other solutions on or off the sterile field.• Verbally AND visually confirm all medications when the person preparing the medication is not the person

administering it.

Reduce patient harm associated with the use of anticoagulation therapy• Collaborate with the physician, nurse, and pharmacist to ensure that safe care is delivered to all patients on

anticoagulation therapy.• Provide education to all patients/families regarding their anticoagulation therapy; including the importance of

follow-up monitoring, compliance issues, dietary restrictions, and potential drug interactions and reactions.

Reduce the risk of health care associated infections (nosocomial infections)• Comply with CDC hand hygiene, contact precautions, & disinfecting of the environment guidelines.• Educate & implement evidence based guidelines to prevent central-line associated & surgical site infections.• Report all cases of unidentified death or permanent loss of function associated with a nosocomial infection.

Accurately and completely reconcile medications across the continuum of care• Upon admission and with the patient’s involvement, document a complete list of patient’s home medications.• Compare these meds to the meds ordered at the facility.• A complete list of the patient’s medications is received and communicated to the next provider of service each time the patient is transferred (between in-house departments and at discharge).• Document that medication reconciliation has been completed during transitions in care.• The complete list of medications is also provided to the patient on discharge from the facility.

Reduce the risk of patient harm resulting from falls• Assess and periodically reassess each patient’s risk for falling and take action to address any identified risks.• Communicate patient’s risk for falling and safety interventions at every hand-off.• Provide education to patients/families on strategies used to reduce the risk of falls.

Encourage patient’s active involvement in their own care as a patient safety strategy• Define and communicate the means for patients and their families to report concerns about safety and

encourage them to do so (Rapid Response Team & Condition H).• Involve patients in the bedside hand-off report by asking them for their questions and comments.

The organization identifies safety risks inherent in this patient population• Complete the Navigator questions in DocZ to assess suicide risk on all inpatients. • Patients that are identified at risk must be kept in a constant line of sight/supervision until they are assessed

by a Mental Health Counselor.

• Improve recognition and response to changes in a patient’s condition• Call the Rapid Response Team (dial 3-1234 & ask for the RRT/give the patient room number) whenever

criteria is met or you are concerned about the status of a patient.

Universal Protocol for prevention of wrong site, wrong procedure, wrong person surgeries• Verify correct person, procedure and site with patient involved, awake and aware, if possible.• The Proceduralist must mark operative site for procedures involving right/left distinction with a mark that will

be visible after the patient has been prepped and draped. • Procedures without right/left distinction still require site marking by an alternative process, see SOP O-030.• A “Time out” must be done immediately before starting the procedure in the location where the procedure will

be done, just before starting the procedure. The “Time out” must involve the entire operative/procedural team. Everything that can safely stop, must stop during the “Timeout”. The “time out” process must be documented.