Community Hospital of San Bernardino is a non-profit, full service, acute care hospital in business to provide acute inpatient care, long term care and a wide range of outpatient, ancillary, and therapeutic services.
• We feel a deep responsibility to our patients, to our physicians, to our employees, and to the community we serve.
• We are committed to provide caring, efficient, quality professional services to our patients.
• We are committed to provide out physicians with an appropriate environment in which to treat their patients, including clean and modern facilities, equipment and optimally trained staff.
• We seek to attract capable, highly motivated employees who are oriented and foster an environment that encourages employees’ development to their full potential.
Dignity Health Core Values
Dignity Collaboration Justice Stewardship Excellence
LIVING A CULTURE OF PATIENT SAFETY
As many as 180,000 deaths occur in the United States each year due to errors in medical care. Many of these errors are preventable. An Institute of Medicine report in 1999 called for “a bold overhaul of the U.S. healthcare system – and a strategy to address serious shortcomings in the quality of health care available to all Americans.”
When we talk about patient safety concerns, we mean anything that might impact the wellbeing of a patient. Patient safety concerns include, but are not limited to:
• Hazards that could lead to falls
• Dangerous use of materials, equipment, supplies or waste
• Fire hazards
• Security issues
• Medication events.
Improving patient safety is about changing the culture in health care from one of blame to one where we examine our systems, from beginning to end, to reduce the opportunities for mistakes.
ENVIRONMENT OF CARE STANDARDS
• DWIGHT MARTIN (Director of Facility Management) – is CHSB’s Safety Officer
Working safely in a hospital is more than a matter of watching out for back injuries, needle sticks, and spread of infection or exposure to hazardous materials. It’s a matter of overall ATTITUDE, an awareness of safe and unsafe conditions and behavior. This means WATCHING OUT FOR ACCIDENTS ABOUT TO HAPPEN and doing something to prevent it. This means – follow safety guidelines, because most accidents are the result of not following these guidelines.
Environment of Care Chapters:
1. Safety Management
2. Hazardous Materials Management
3. Life Safety Management
4. Medical Equipment Management
5. Utility Systems Management
6. Security Management
7. Emergency Preparedness Management
Safety Management
All employees are expected to participate in maintaining a safe environment for patients, visitors, physicians, co-workers and you. This means taking an ACTIVE ROLE in reporting any UNSAFE CONDITION OR WORK PRACTICE IMMEDIATELY.
Examples of Unsafe Condition:
• Environmental hazards: such as slippery or uneven floor surfaces, cluttered work area, cabinets or furniture with sharp areas or areas that stick out. Broken hand rails, etc
• Fire Hazards: such as obstructed corridors and fire exits, missing fire extinguishers, accumulated trash and storing items too close to the ceiling.
• Electrical Hazards: such as frayed cords, exposed wires, ungrounded plugs, extension cords, or electrical appliances from the home being used in patient care areas. That means no popcorn poppers, heaters, portable fans, etc... Be aware of cords that get hot when equipment is in use.
• Equipment Hazards: such as unsafe, damaged or defective equipment, overdue electrical safety inspection &/or prevention maintenance and using equipment for other than what it is designed to do.
• Hazardous Substances: such as the generation of strong unpleasant fumes or improper handling and disposal of toxic substances
• Unsafe acts or procedures: such as improper use of equipment or instruments, failure to wear appropriate protective apparel, or attempts to bypass mechanical safety switches, or other equipment safety guards, attempting to repair broken equipment when not authorized, using a chair instead of a ladder.
Reporting of UNSAFE ACTS or PROCEDURES
Complete the Unsafe Condition Reporting form to report any unsafe acts or procedures. Notify your supervisor or manager of any unsafe acts or procedures.
Hazardous Materials Management
Chemicals enter the body in three ways:
1. Skin - skin or eye contact can cause burns, rashes, allergies, vision problems or blindness. Some chemicals may be injected or pass through skin into the bloodstream and poison you.
2. Inhalation - inhaling vapors or fumes could cause dizziness, headaches, or nausea.
Other risks are lung, throat, respiratory damage, unconsciousness, asphyxiation, or even death.
3. Ingestion - swallowing chemicals can poison you or damage internal organs. This usually results from eating or smoking after handling chemicals without washing first.
Hazardous chemicals can create two types of hazards:
1. Physical and Chemical Hazard
Flammable chemicals catch on fire easily.
• Some chemicals explode under certain conditions.
• Reactive chemicals may burn, explode, or release toxic vapors if exposed to certain other chemicals, heat, air or water.
2. Health Hazard
• Corrosive chemicals burn the skin or eyes.
• Toxic chemicals cause illness or even death.
• Acute health problems show up right after exposure (ex: burns or rashes).
• Chronic health problems develop over time after repeated exposure (ex: cancer, allergies, damage to lungs or other organs).
SDS (Safety Data Sheet)
Know where your SDS binder is located in your department
• Safety Data Sheets are kept in each department for the chemicals used in that department
• On- Line access.
• SDS describes safe use, precautions, and actions to be taken if exposure occurs
• SDS describes what safety equipment you need to wear when using the chemical
• SDS describes the health hazard, fire hazard, reactivity hazards of the chemicals used in your department.
HMIG (Hazardous Materials Identification Guide)
CHSB has selected the HMIG to standardize secondary labeling throughout the facility. Through the use of this program, employees will be able to recognize potential hazards and utilize necessary protective equipment, simply by reading the label.
Either the original manufacture’s label or an HMIG label is affixed to the outside of the container. A container without a label MUST be treated as hazardous.
The HMIG systems hazard rating index is used to describe the degree of hazards using a 0 -
4 scale, 4 being the most hazardous.
Health Rating Index Flammability Hazard Reactivity Hazard
4 = Extreme / Highly toxic / 4 = Extreme / Extremely flammable / 4 = Extreme / Explosive at room temperature3 = Serious / Toxic / 3 = Serious / Flammable / 3 = Serious / May explode if shocked
2 = Moderate / Moderately toxic / 2 = Moderate / Combustible / 2 = Moderate / Unstable, may react with water
1 = Slight / Slightly Toxic / 1 = Slight / Slightly combustible / 1 = Slight / May react if heated or mixed with water
0 = Minimal / All chemicals have some toxicity / 0 = Minimal / Will not burn under normal conditions / 0 = Minimal / Normally stable
HAZARDOUS SUBSTANCE SPILL CODE ORANGE – Call 1000
• In the event of a hazardous substance spill or spill of unknown substance no matter the amount.
1. Remove anyone near the spill (including yourself)
2. Isolate (close doors) and deny entry
3. Notify the PBX operator of the spill by dialing 1000
• A “CODE ORANGE” will be called for hazardous spills. Code Orange will be announced over PA system when multiple departments are involved.
1. DO NOT attempt to clean up a hazardous spill.
2. The house supervisor must be notified
3. Our Hazardous Waste Company will be contacted to clean up all spills including chemotherapy spills in all areas.
4. Responders include engineering, public safety and house supervisor
• Waste Stream
o Normal Waste
◦ Regular Trash – Gray or Flesh Bin
◦ Paper - Blue Bin
◦ Protected Health Information - Shredder
o Biohazard Waste
◦ Regulated Waste/Body Fluid – Red Bin
o Pharmaceutical Waste
◦ Blue and white Bin
Life Safety Management
CODE RED – Call 1000
A “Code RED” is paged over the intercom system to indicate a fire within the
Hospital
Important Reminders:
• Keep emergency exits, corridors and exits clear at all times
• Never put door wedges, that prevent doors from closing, under door
• Never stack items closer than 18” from the ceiling.
• Keep doors closed unless they are controlled by an electromagnetic system
• Never block access to pull stations and fire equipment
• Do not use or allow visitors to use the elevator in the event of fire.
• Keep telephone lines clear for fire control.
Remember: Fire needs FUEL, HEAT and OXYGEN to exist
What to do if the fire is in your immediate area (above, below or next) REMEMBER---R.A.C.E
R / RESCUERemove anyone in immediate danger of the fire area
A / ALARM
Pull the nearest FIRE ALARM BOX and then Dial “1000” to announce a Code
Red
C / CONTAIN
Close the door to the fire area to isolate fire and close the door to all other patients to prevent the spread of smoke
E / EXTINGUISH
With proper extinguisher, fight fire without endangering yourself EVACUATE If necessary, move the patients to the next fire zone (smoke compartment).
What to do if the fire is NOT within your immediate area
CONTAIN
C Close the patient doors/work area doors to prevent spread of smoke
Stay alert to possible Triage Internal Disaster page.
OPERATION OF FIRE EXTINGUISHERS
P / Pull out the safety pin.A / AIM the nozzle at the BASE of the fire (stand about 10 feet away from the fire)
S / SQUEEZE the handle
S / SWEEP the nozzle from side to side
CODE RED DRILLS (Fire Drills) are to be treated as a real fire.
RADIATION SAFETY
Regulations place a strict limit on the amount of radiation that you can receive at work. The maximum allowed for most employees each year is about the same as from a CT scan. Most nurses, housekeepers and other employees only occasionally work around radiation sources, and
do not receive any significant exposure. Still, it is important for you to recognize radiation sources and know what rules to follow when you are near them.
There are TWO primary sources of radiation you may encounter; Mobile X-Ray machine and radionuclide used in test and therapy. Mobile X-Ray machines include the regular X-Ray machines and the mobile fluoroscopy; often called the C-arm. These machines only give off radiation when actually making an image. The X-Ray beam is highly directional and only small amounts of radiation scatter in other directions. At other times, there is NO radiation.
PRECAUTIONS
• Move away from X-Ray machines when they are making an image
• Wear a leaded apron if you are helping during the procedure
• Always wear a lead apron when working near the C-Arm that is in use.
The other source of radiation is radionuclide given for tests. These may be given by mouth or through the intravenous line. Usually the half-life is short and no special precautions are needed. However, when larger doses are given, the half-life is longer. In that event you need to take special precautions. The radioactive sign is placed outside the door of patients that are radioactive. When you see the caution sign, follow these precautions:
• Check with the person in charge before entering, so you’ll know if there are any special precautions
• Tell your supervisor if you are or may be pregnant
• Wear gloves when caring for the patient because their body fluids are temporarily radioactive. No special precautions are required if you will not be touching the patient.
• Put contaminated items in a separate, labeled container.
Medical Equipment Management
The objective of the Medical Equipment Management Program is to ensure that medical equipment is safe and effective for use by patients and staff. You must be sure that equipment has been inspected prior to use. Also, you must be trained to operate the equipment.
EMPLOYEE RESPONSIBILITY FOR EQUIPMENT
Prior to use of any equipment:
Do a visual inspection of the equipment
Cords and plugs have no exposed wires and are not frayed. Plugs fit tightly into sockets.
Tags are current
Functional checks or self check occurs when applicable
Report to Bio-Medical (ext 1545) any equipment that does not have a current inspection tag.
PRACTICE COMMON SENSE SAFETY
• Don’t overload outlets
• Don’t run cords along the floor
• Don’t touch anything electric with wet hands.
• Never use anything that is damaged or does not work properly.
Report any problems to the appropriate department or your supervisor. Do not use defective equipment. Tag it and put it out of service.
Equipment training is required when:
• There is an employee(s) new to a work area or assignment
• There is any new equipment introduced to your area
• A change or update occurs with current equipment.
NEVER TURN DOWN OR TURN OFF MEDICAL EQUIPMENT ALARMS
SAFE MEDICAL DEVICE ACT (SMDA)
Purpose: The SMDA legislation was designed so that the FDA could quickly be informed of any medical product that has caused or suspected to have caused a serious illness, injury or death. The FDA will take action to track and/or recall the product for further action.
Reporting must be completed within ten working days after an event is determined to be reportable.
A Medical Device is defined as any instrument, apparatus, or other article that is used to prevent, diagnose, mitigate or treat a disease or to affect the structure or function of the body with the exception of drugs. Medical devices include but are not limited to the following: ventilators, patient restraints, monitors, defibrillators, laboratory equipment, and hospital beds.