General Hospital Safety • Fire Safety
(RACE)• Hazard
Communication Plan (HMIS)
. Disaster Plan/ Emergency Codes
• Security Awareness• Workplace Violence• Fall Safety
St. Elizabeth Policies & Procedures• How to Access:
• Open Internet Explorer on your computer
• Type intranet in the address box
• Select St. Elizabeth Policies and Procedures under Quick Links
The information contained in this NetLearning module can be found in further detail in the Disaster Manual, Infection Control Manual,
and the Safety and Health Manual
R Rescue – Rescue/relocate all
people in immediate danger from the fire
A Alert – pull the nearest alarm. Alert all people in the area.
C Contain / the Fire and Smoke – Close all doors and windows to
control air movement. Shut off oxygen (charge nurse).
E Extinguish the fire if possible.
Evacuate the area as instructed.
Any associate who detects smoke and/or flames of any type must take immediate action.
Fire Safety
Evacuation PlanKnow at least two ways to evacuate from
your area.Horizontal (partial)
• moving to the other side of the smoke doors on the same floor
Vertical (general)• When entire floor must be evacuated
Order 1st – Ambulatory note: appoint a helper to go with them
– 2nd – Wheelchair/Ambulatory with assistance
3rd - stretchers/helpless
Fire Safety
There are 3 types of fires:Type A fires might involve wood, paper, clothing, mattresses,
or trash
Type B fires have gasoline, oil, grease, paint, ether or alcohol as the fuel source
Type C fires electricity or electrical equipment.
Red ABC fire extinguishers are used in almost all areas throughout the hospital, on A, B and C type fires. Other fire extinguishers found in specialty areas are Water Mist and Halon.
Should you fight a fire?
Before you consider fighting a fire…• Determine whether fire is small and not
spreading• Confirm you have a safe path to exit• Know how to use a fire extinguisher
P.A.S.S
• P – Pull the pin• A – Aim nozzle of the extinguisher at the base of the fire• S – Squeeze the handle• S – Sweep the extinguisher side
to side. The hospital uses the ABC extinguisher
throughout all facilities. AC or water mist extinguishers are used in surgery and some Radiology areas because of contamination issues.
To Use the Extinguisher
Evacuation Plan
Developed to cover major situations e.g. major hazardous material spills, major structural damage, or disruption of utilities
Follow your department plan for more detailed instructions and assignments. Transfer patients to designated areas only when instructed.
External Disasters
A wide variety of disasters can occur with little or no warning• Examples include chemical spills, earthquakes, fire,
flooding, radiation exposure, severe weather, transportation accidents, terrorist attacks.
These situations can result in multiple injuries/casualties taxing area emergency responders and hospitals.
Further information is available in the Emergency Management Plan
Hazard Communication PlanIn accordance with OSHA, the Hazard
Communication Plan explains :
• Labeling requirements for chemical containers
• MSDS - how to obtain information on hazardous materials
• Proper use and disposal of hazardous materials.
Hazard Communication Plan:
Each chemical or chemical product has a label to identify its common name and a hazard warning. When an original container is not properly labeled, the in-house NFPA 704M system shall be used. This system is a diamond-shaped combination of numbers and colors, which serve as quick index to its general handling methods.
Blue = health hazard
Red = flammability
Yellow = reactivity
White = special precautions
NUMBERING SYSTEM0 = no hazard1 = normally safe, but reactive2 = moderately unhealthy, reactive or flammable3 = very unhealthy, flammable, reactive4 = extremely unhealthy, flammable or reactive
Hazard Communication Plan:
Material Safety Data Sheets
Each product that is classified as hazardous, must have a Material Safety Data Sheets (MSDS) supplied by the manufacturer• No standard format• Available on the Intranet (MSDS ONLINE)
Each MSDS document includes:• Make-up of the product• Precautions taken when handling product• Any protective equipment needed• How to handle spills/exposures
Hazardous Chemical Waste Disposal
Hazard Communication Plan:
• When necessary to dispose of any chemical or chemical container, first review the MSDS for instructions.
• If it is not clearly outlined on the MSDS, contact your supervisor and or Safety Officer to insure proper disposal.
Emergency Codes
Chemical Incident (“Code Orange”)
Implement the “SPIL” plan
S – Secure Area = Patient Safety
P – Protect Person (s) = Isolate Area
I – Inform = Call Security advise of details
L – Leave clean up to trained personnel
Hazard Communication Plan:
Biohazard Waste Biohazard symbol indicates item contains or soiled with blood or body fluids
Also referred to as “Infectious Wastes” If a concern arises regarding exposure to blood or
other potentially infectious materials (OPIM), immediately
contact your supervisor and Employee Health Refer to Infection Control Manual for more informationRed biohazard waste bags are used for infectious waste disposal
Yellow bags are used for CHEMO waste ONLY
Biohazard Waste versus General WasteINFECTIOUS WASTE DISPOSAL
(red biohazard waste bags)
• Items saturated with blood/OPIM that may drip or release contents when held vertical, squeezed, or compacted
• Containers of blood/OPIM body fluids that cannot be safely emptied or are not designed to be emptied (i.e., chest drainage systems)
• Blood bags and tubing• Dialysis waste containing
blood/OPIM• Unfixed human tissue or organs• Laboratory biological waste
GENERAL WASTE DISPOSAL
• Paper, Plastic, Glass• Food• Blue pads• Items such as diapers containing
urine, feces, gastric contents• Sanitary napkins• Emptied urinary drainage bags• IV tubing (sharps end covered or
removed)• Vials of saline/sterile water• Emptied and rinsed containers which
held any body fluids
Infectious Waste disposal costs more than 10 times that of regular trash.
Utility Failure - ElectricityHow do I identify
what is on Emergency Power?
Red receptacles are automatically connected to emergency power
Red switches control lights on emergency power
When in doubt, ask Plant Engineering
Keep in mind: All equipment on
emergency power will have a 10 second interruption from a utility outage
You can lose Emergency Power• Breakers can trip• Wires can fail• Human error can
take placeYou must be prepared to
deliver critical patient care
Oxygen/Other Medical Gases• Supplied from central locations/Warehouse• Contact Plant Engineering if failure occurs• Know where shutoffs are in your area
• Must be accessible and not blocked by equipment, supplies, etc.
• Usually near nurse’s station• The charge nurse is responsible to see
that oxygen is turned off in a fire situation.
Oxygen Cylinder Safety• All should be safely stored, with valves closed,
in a carrier, stand or rack (in case of damage, the tank can act like a rocket or missile, causing injury) No more than 12 Full cylinders In a room.
• Note: O2 cylinders stored on wheelchairs and stretchers are considered working stock unless they sit longer than 30 minutes.
• Full tanks should be in a separate rack from the Empty cylinders.
• 02 cylinders must be in a rack not lying on the floor or hanging from a hook.
Service Label ProgramClinical Engineering Department
QA/PM Inspection Completed
Expires: _________________
If expired, contact Clinical Engineering
Scheduled QA/PM not required
For service, contact Clinical Engineering
Electrical Safety Testing Passed
If the date on the label is expired, please discontinue use and contact Clinical Engineering.
Clinical Engineering maintains an inventory of all medical equipment. Items that are not inspected on a regular basis will have this label.
Clinical Engineering confirms the operational & electrical safety of all medical equipment (demo, loaner, rental) brought into the medical center. This label indicates that the confirmation has been performed. The label should not be removed until the equipment has left the medical center.
Safe Medical Devices• Medical device malfunction
which results (or could have resulted) in patient death, serious illness or injury should be immediately reported to supervision, risk management and clinical engineering for investigation.
• For more information, see “Investigation and Reporting of Incidents Involving Medical Devices” Risk Management Policy
Contact Security EXT 12270
Call immediately to report• Theft/missing property• Vandalism• Assaults• Disturbances• Suspicious people• Fire/smoke (after activating fire alarm)• Any other event you consider security-related
When reporting incidents to Security, write down what you see. It is essential that accurate information is given.
The #1 security problem is unattended/unsecured property like purses!
Sensitive Areas
• Know who you are granting access• Identify people before opening door• Secure areas are equipped with panic
alarms• Know how to use panic alarms• Some areas have closed circuit cameras
which are monitored by Security and other areas
• After accessing a secure area, make sure the door closes securely behind you without allowing access to someone following you
Workplace Violence• The Health System is committed to providing a
work environment free from threat or harm
• We have a policy of zero-tolerance for workplace violence
• Employees are to immediately report any incidents of workplace violence to their supervisor and the Security Department
Employee Fall Safety
Fall Safety is the responsibility of ALL Associates
• Pay attention to all fall signage when on patient units and throughout the facility.
• Assure that walkways and hallways are clear of all obstacles
• Respond to call lights quickly • When transporting patients who may be
ambulating, apply non-skid footwear.• Always be aware of patients or visitors who
may need assistance• Employee’s need to be aware of their
surroundings and watch where they are walking.
The U.S. Department of Health and Human Services has devised a list of cultural standards that healthcare organizations are expected to meet. They are: “Standards for Culturally & Linguistically Appropriate Services in Healthcare” (CLAS).
Patient Safety – Interpretive Services
The requirements of the standards span the organization. These are examples of the requirements
related to safe patient care provided by healthcare organizations (HCO):
• HCO must offer and provide language assistive services….
• HCO must provide to patients/consumers in their preferred language both verbal and written notices informing them of their right to receive language assistive services at no cost to them
• HCO must assure the competence of the language assistive service. Families & friends should not be used to provide interpretive services.
SEH provides interpreters for our patients
Language ServicesTelephone or in-person interpreters services available at no cost to the patient.
Sign Language Interpreter Services are available for the deaf and hard-of-hearing.
Contact information is available in every department and through HR.
SEH provides written resources for our patients
• Translations of written documents into languages other than English
• Mosby Consult provides patient education sheets with many translated into Spanish
Staff Resources related to cultural care can be found:
• Culture and Clinical Care - This textbook available in all clinical departments.
• NetLearning Modules
• Delmar Thomson (Cengage) CBL Modules – accessible on NetLearning
Emergency Codes
CODE BLUE
CODE RED
A cardiac or respiratory arrest has occurred somewhere in the hospital. The code and location will be announced and only designated personnel respond to the emergency site.
A fire alarm has been received for one of the Healthcare Facilities. This code and location will be announced three times over the public address system.
Emergency Codes
ALL CLEAR
Represents theconclusion of any of the
emergencysituations Except Code
Blue
Emergency Codes
Tornado has been sighted in Boone, Campbell, Kenton or Grant Counties
Move to area of safety as designated in your Disaster Manual.
In patient care areas, ambulatory patients should be moved to patient bathroom or corridor, closing all fire doors. Instruct visitors to take shelter.
Non-ambulatory patients should have head of bed raised and the back of head of bed facing the window.
TORNADO WARNING
Emergency Codes
TORNAD
O
The US Weather Service has issued a
Conditions are favorable for a tornado or
Severe weather.
Tornado watchTORNADO
WATCH
Emergency codesNew code
CODE ORANGE
S Secure the area
P Protect any people
I Inform ,Call Security at 12270
L Leave cleanup to trained personnel.
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