Variance Reporting - Good Shepherd Medical Center

Rev. 7.30.12
Patient Safety
First at GSMC!
Rev. 7.30.12
• Beth Chrismer: Executive Director
National Focus on Patient
• Institute of Medicine report –
“To Err is Human” (Nov. 1999)
• 44,000-98,000 deaths due to medical
• Annual cost $17B-$29B
• Federal Mandate and Regulatory Requirements
-Presidential directive, The Joint Commission,
Centers for Medicare & Medicaid Services,
State regulations
Basics of Patient Safety
Patient Safety:
Actions undertaken by individuals and
organizations to protect health care
recipients from being harmed by the
effects of health care services.
The Case for Patient Safety
• Patient safety is a critical component of quality
• Health care is NOT as safe as it should be
• People do not come to work with the intent to
hurt patients
• We are human therefore mistakes will occur
• When mistakes do occur we want there to be no
• Speak-up for patient safety
Patient Safety System
Patient Safety First at
• Patient safety is a priority at Good Shepherd
Medical Center.
• Our staff and physicians are committed to
improving quality of life and providing safe and
healthy surroundings for patients, visitors, and
• Many procedures are in place to protect the
well-being of our patients and to secure the best
medical outcome possible.
• Everyone has a role in patient safety.
Safety as Our Core Value
The Patient’s Perspective
• Don’t hurt me
• Heal me
• Be nice to me
Culture and Safety
is the shared values and
beliefs of the individuals
in the organization
(the way we act when
no one is looking)
Take Action to Reduce Risk
• Proactive: Monitor patient safety and
redesign high-risk processes to prevent an
event from occurring.
• Reactive: Investigate significant patient
Culture of Safety
Root Cause Analysis
We intensely analyze any error that does occur.
Based on findings we:
Redesign systems
Test new designs
Educate staff on changes
Follow-up to see if new design is effective
• Encourage patients, families, staff and
physicians to report safety concerns on
the hotline
Close calls, near misses, share ideas
Available 24 hours a day, 7 days a week
Leave name and number for follow-up
Ideas of merit qualify for recognition or
Rapid Response Team
Rapid Response Team
• The Five Million Lives Campaign by the Institute
for Healthcare Improvement encourages
healthcare organizations to implement a rapid
response team.
• In 2006 Good Shepherd implemented a rapid
response team.
• The goal is to respond to a “spark” before it
becomes a “forest fire.”
• To prevent deaths in patients who are failing
outside intensive care settings.
Rapid Response Team
– Call Rapid Response anytime you are worried
about the patient!
– Clinical and non-clinical staff, patients and
families can activate the Rapid Response
– The team can respond and assist with
stabilizing the patient before a
cardiopulmonary or respiratory arrest occurs.
Call early, Call often
The Josie King Story
Josie King, an 18 month old little
girl, died from medical errors in
of the best hospitals in our
Josie was the sister of Jack,
and Eva and beloved daughter of
Tony and Sorrel. She died as a
result of a series of hospital errors
and poor communication.
the creation of a patient safety
program, it is the King family’s
hope to prevent this from ever
happening to another patient.
Josie King Foundation - Condition
“H” (Condition Help)
• University of Pittsburgh Medical Center - UPMC Shadyside
and Children’s Hospital of Pittsburgh worked with the King family to
develop the nationally recognized model known as Condition H.
• Condition H was created to address the needs of the patient/family
in case of an emergency or when the patient is unable to get the
attention of a healthcare provider in an emergency situation. The
call provides immediate help when:
– they feel they are not receiving adequate medical attention; or
– if they become concerned with what is happening.
• The program was designed to be a safety net for patients. In many
cases, it is the family who knows the patient better than we do.
• When Condition H is called, a rapid response team arrives
to the patient’s bedside within minutes.
Condition “H” (Condition Help) at
Good Shepherd
Partnering for Safety
When patients partner with the
health care team, it helps us ensure a
safer health care experience for all of
Patients are encouraged to be
actively involved in their own care for
safety reasons.
Involve Patients in Care
Our Patients-Our Partners: One Team, One Goal
A few ways we involve patients in care…
• Educate the patient and/or family about hand hygiene,
respiratory hygiene, contact precautions
• Educate surgical patients about how we prevent adverse
events during surgery
• Inform patients/families how they can report safety
concerns by calling Condition H, Patient Safety Hotline
(BUZZ), Guest Relations or The Joint Commission
2012 National Patient Safety
 The purpose of the Joint Commission’s National Patient
Safety Goals (NPSGs) is to promote specific improvements in
patient safety.
 The goals are revised on an annual basis and highlight
problematic areas in health care and describe evidence and
expert-based solutions to these problems.
 By addressing problems, organizations can promote patient
safety and prevent sentinel events.
 A sentinel event is an unexpected occurrence involving death
or serious physical or psychological injury.
2012 National Patient Safety
Goal 1 Improve the accuracy of patient identification
Goal 2 Improve the effectiveness of communication among caregivers
Goal 3 Improve the safety of using medications
Goal 7 Reduce the risk of healthcare-associated infections
Goal 8 Accurately & completely reconcile medications across the
continuum of care
Goal 15 The hospital identifies safety risks inherent in its patient
UNIVERSAL PROTOCOL: The organization meets the expectations of
the Universal Protocol for Preventing Wrong Site Surgery
Note: Some goals and requirements appear to be misnumbered or missing from the numerical sequence.
This in not a typographical error. Some goals do not or no longer apply to hospitals and therefore have not been included.
Improve the Accuracy of
Patient Identification
To make sure the right person is receiving the
intended care, treatment, and services we must
use at least two patient identifiers.
 Name
 Birthdate
When confirming a patient’s name, staff
members should not state the name and ask
the patient to confirm it. Instead, staff members
should ask the patient to state his or her name
and birthdate.
Reduce the Risk of
CDC Guidelines
Alcohol-Based Hand Sanitizer
 when hands are not visibly soiled
 apply to palm of hand and rub hands together covering all surfaces of
hands and fingers until hands are dry
Soap and Water
 when hands are visibly soiled
 patient has Clostridium Difficile (C-Diff)
 after going to the restroom
 before eating
 at least a 15-second scrub
 the use of gloves does not eliminate the need for hand hygiene
and hand hygiene does not eliminate the need for gloves
Fall Prevention
Patients at risk for falls have a yellow “Fall Risk” armband
applied and a magnet placed outside the patient’s door.
The patient receives a pair of treaded socks.
All efforts are made to move the patient as close as possible to
the nurses desk.
Family or friends are encouraged to stay with patient, if unable
may consider a sitter.
Communicate “at risk” patients during patient report and hand
off between units.
Is Everybody’s
Medical Error Reporting
The Medical Error Hotline is a voicemail line
available 24 hours a day providing complete
anonymity. Employees may use this line to
report concerns regarding a medical error was
not documented, reported or addressed
Rev. 7.30.12
Variance Reporting
Hospital employees and medical staff members
participate in a hospital wide variance reporting
Types of Variance Reports:
• Falls – Fall Safety Report
• Medication Errors – Medication Safety Report
• Other occurrences not in the above categories –
Variance Report
Variance Reporting
 Variance Reports are to be initiated by
hospital staff members or employees involved
in or identifying occurrence.
 All questions or sections of the report must be
 Descriptions should be brief, factual and
 Patients, visitors and employees who sustain
injuries will receive medical attention.
 On-line system allows anonymous
Variance Reporting
• Variances are reported directly from the occurrence area to the
supervisor, manager or director.
•Managers should investigate pertinent issues reported with a brief
summary in the online-system
•Variances are routed to Risk Management within 96 hours of the
•Variance Reports will be trended and reviewed by Risk Management.
•Variance Report Forms are found on GSnet
•To Access for – GSnet – Var Rpts
• Variance Reports are never to be duplicated.
Variance Reporting
Examples of occurrences that should be
reported on the Variance Report:
– Mishaps due to faulty/defective equipment
– Unexpected adverse results of professional care or
treatment – death, brain damage, physical loss or
impairment, etc.
– Unprofessional, threatening or inappropriate conduct of
health professionals or employees
– Patients leaving against medical advice
– Thefts, burglaries and vandalism on hospital premises
Rev. 7.30.12
Impaired Provider
• What is impairment?
– The inability to “practice with reasonable skill
and safety” because of:
Physical illness or condition
Mental disorder
Alcohol or drug abuse
Disruptive behavior
Sexual misconduct/boundary violations
Impaired Provider
• Examples of disruptive behavior:
– Bullying or demeaning behavior
– Sexual harassment
– Abusive treatment of patients or staff
– Profanity or disrespectful language
– Repeated violations of rules and policies
– Physical attacks, hitting, pinching
– Improper comments/illustrations in medical
– Threatening to get someone fired
Impaired Provider
• Healthcare Practitioner Code of Conduct
– Provides guidance to ensure work is done in
ethical manner
– Also referred to as Code of Ethics
Impaired Provider
• Reporting impaired practitioners and disruptive
– Document specific examples and patterns of
disruptive behavior
– Anyone may report an impaired provider or disruptive
behavior to Executive Management
– Complaints are investigated by Human Resources
– Executive Management may identify involved
practitioners to the Committee on Physician Health
– Identity of reporting individual kept anonymous unless
individual gives permission to disclose
– Retaliation against reporting individuals is
grounds for immediate referral to the
Executive Committee for corrective
Safety Sense:
Injury Benefit Plan
Rev. 7.30.12
• Good Shepherd Health System (GSHS) DOES
NOT have workers’ compensation insurance
coverage for work-related injuries
• GSHS is a “non-subscriber” to workers
compensation, and does provide medical, death,
dismemberment and wage replacement benefits
to employees who sustain injuries or
occupational diseases in the course and scope
of their employment.
• The GSHS plan is called SAFETY SENSE
New Plan Effective Aug. 17,
• Our new plan was effective 8/17/09 and provides
similar benefits to workers
– Medical care for injured employees will be provided at
the GSMC Occupational Medicine Clinic. GSMC
Emergency Dept. is for true emergencies.
– Injuries must be reported within 24 hours of
occurrence using the Accident Investigation Report
– A urine drug screen is required for injuries that need
medical treatment.
Benefits Available
• Medical care at Occupational Medicine, specialty
referrals, therapy, and diagnostic testing, as
needed, through Occ Med provider.
• Light duty accommodations for employees
placed on restricted duty
• Wage replacement at 75% of salary for
employees taken off of work after 32 hours of
lost time.
Acknowledgement of SPD
• A Summary Plan Description (SPD) of the SAFETY SENSE
Occupational Injury Benefit Plan is provided to you by clicking the
link on GSNet under “Work-Related Injury” in the Policies section.
Spanish and English versions of the SPD are available on GSNet.
• Please review the plan, print a copy, if you like.
• If you are unable to print a copy and desire a copy, one can be
provided to you by calling the phone numbers given below.
• You have been provided with information about the GSHS SAFETY
SENSE plan and agree to comply with the Plan.
• Please contact Beth Chrismer - (903) 315-1298 for questions.
Patient Rights
Rev. 7.30.12
Patient Rights
 When and where are patients informed of
their rights? At the time of Registration
 Rights include:
– Considerate and Respectful Care
– Advance Directives
– Confidentiality
– Hospital Policy & Procedures
– Patient Complaint Process
Patient Rights
 Notice of Patient Rights posted in Registration area
and available on
 Ethics Committee – Good Shepherd Medical Center
Ethics Committee’s goal is to facilitate ethical
reflection and decision making by persons involved in
the case, focusing on the patient’s values and wishes
versus imposing a decision. Their role is consultative
in nature rather than decision making.
(consent/refusal to treatment, withholding life support,
Chaplain, nurse, physician and others convene to
render decision.
– Decision can be accepted or denied
– Contact your Supervisor to convene the Ethics
of Care and
Rev. 7.30.12
• Tina Collins: Medication Safety (3612)
• Chris Bland: Safety Manager (5163)
Environment of Care
• Disciplines of the Environment of Care
Hazardous materials
Emergency Management
Fire Safety
Medical Equipment
Environment of Care
The Safety Management Plan
at Good Shepherd Medical
Center provides a process to
effectively manage and reduce
safety-related risks to patients,
staff, and visitors.
Environment of Care
Safety Management Goals
•Comply with all safety-related regulatory
•Provide a safe, secure, and therapeutic
environment for patients, staff, and visitors.
•Integrate safety practices into daily operations.
•Identify opportunities to improve performances
in the safety management program.
Environment of Care
This facility has an
Environment of Care Committee (EOCC)
that monitors training and competence of
staff and assesses physical and
operational conditions of the infrastructure
and grounds and equipment through
building inspections, environmental
rounds, safety inspections, and various
performance improvement initiatives.
Healthcare Security
Functions of security include the following:
– To protect staff, patients, visitors, and property.
– To investigate and record incidents, thefts,
disturbances, vandalism, accidents, and traffic
– To provide special services including escorts,
battery boosts, and lock and unlock doors.
– To respond to emergencies such as fire, disaster,
and bomb threat.
Healthcare Security
Phone numbers for Security
– Security: ext. 3376/2196
– FAX: ext. 1153
– If you are inside the hospital, you may dial
“0” and ask the operator to call Security
on the radio. (Preferred method)
Healthcare Security
Secure your valuables
• Lock valuables in work areas.
• Keep valuables out of sight in your car or
• Weapons – No weapons (firearms, clubs,
knives with long blades) may be carried on
• Escorts and Parking Lot Safety– always try to
walk with a group, rather than alone, to your
vehicle. Use the “Buddy System.”
Healthcare Security
• Badges – always wear your ID badge.
• Badges must be either worn on the upper left chest by
being attached to a collar, lapel or shirt pocket or
attached to a GSHS approved lanyard.
• Badges are that are damaged due to misuse, wear and
tear or are lost will be replaced at a charge of $5.00 to
the employee.
• Badges are also to be used as access cards for the
employee parking lots.
• Suspicious persons or activities – Report
any suspicious persons or activities
immediately by calling “0” and alerting
the operator or call security at x3376.
Fire Safety
General Guidelines
• To report a fire, call 3000 and report CODE
• Enforce “no smoking” rules.
• Use only approved extension cords.
• Keep flammable materials away from
ignition sources.
• Enforce policies about unauthorized
appliances and equipment.
• Keep general housekeeping in order.
• Report or correct any fire hazards.
Fire Safety
Extension Cords
• Use only approved
extension cords.
• Cords must have a
grounded plug.
• Use the correct cord for
the load and protect the
cord from traffic.
• Be sure extension cords
are in good working
• Do not overload electric
sockets or extension
Fire Safety
Flammable Materials
Keep flammable materials away from
ignition sources.
• Class A fires involve normal
combustibles such as wood, cloth,
paper, rubber, upholstery, and
• Class B fires are related to flammable
liquids, gases and greases, such as
oils, paints, and gasoline.
• Class C fires are related to electrical
equipment such as fuse boxes,
circuit breakers, machinery, and
appliances… computers, televisions
and mechanical equipment.
Fire Safety
Fire Extinguishers
All extinguishers in this hospital are
rated for
Class A, Class B, or Class C fires.
Good Shepherd uses the PASS method of
operating a fire extinguisher:
Pull the pin
Aim at the base of the flame
Squeeze the handle
Sweep from side to side
Fire Safety
Good Shepherd uses the RACE method of
dealing with a fire:
Rescue (Move Patients past 1 Fire Door)
Alarm (Pull Station or Call Operator)
Contain Fire
Emergency Preparedness
Code Words
Emergency number 3000 use for all emergencies
Operation Baker – Emergency Evacuation
Code Gray – Bomb Threat
Code Adam – Abduction in the hospital
Code Yellow – Bioterrorism event
Code Black – Tornado
Code Red – Fire
Code Blue – Cardiac Arrest
Code Pink – Neonatal Resuscitation
Code Stroke – Reponse to Stroke Patient
Operation Able – Mass Casualty
Charlie Brown – Combative individual
Duress Word – ADVICE
Operation Baker Evacuation
Operation Baker is the implementation of
strategic or urgent evacuation of
patients and other persons from the
Medical Center or grounds. Assist all
patients and visitors out of the
building. Be aware of all evacuation
routes in your area.
Bomb Threat
Code Gray
Bomb Threat – Code Gray
Employees in the immediate area of the
bomb should remember:
– Search for and report any suspicious
objects. DO NOT move, jar, or touch the
object or anything attached to it.
– Check public access areas, such as
restrooms, telephone booths, ER, lobby,
and patient rooms first.
– DO NOT turn lights on or off.
– Turn off all two-way radios, cell phones
and pagers.
Abduction in the Hospital Code Adam
• Denotes an abduction from the hospital
• If an employee suspects an abduction, they should
call 3000 and report Code Adam with a description of
the person who was abducted (age, sex, race, etc.)
• All employees should search the area and detain
visitors until an all clear is announced.
“Prevention is the best defense against infant abductions”
HUGS Infant Security System
Bioterrorism - Code Yellow
A substantial influx of patients with illnesses
that are uncommon in nature should be
suspect. Code Yellow will be called when it is
determined these illnesses are a result of a
bioterrorist event (such as anthrax, etc.).
Infection control should be notified
immediately, and all personnel in areas that
provide initial treatment to patients should
be aware of department specific treatment
Tornado - Code Black
A tornado has been spotted within a five mile
radius of the Medical Center. Patients should
be moved to inside corridors and away from
windows until an all clear is announced.
Code Black can be proceeded by :
Operation Weather Watch
move to state of readiness
alert visitors to weather conditions
review Code Black procedures
Fire - Code Red
Fire or smoke situation which requires
activation of the fire response plan.
Respond to a fire by calling the
emergency number 3000 or activate the
fire pull in your area. Locate all exits
and evacuation plans for your work
area to be prepared for an emergency.
Cardiac Arrest - Code Blue
Code Blue is called when a patient
suffers cardiac arrest. This code is
called by calling 3000 and stating Code
Blue and the location or patient room.
The Code Blue team reports to the
location announced and starts
resuscitation efforts.
Mass Casualty – Incident
Operation Able
Hospital expects large number of
patients to be treated due to the
incident. Major Disaster Response Plan
will be implemented upon
announcement of “Operation Able”. All
departments should implement their
department-specific response plans for
appropriate action.
Combative Individual –
Code Charlie Brown
• Charlie Brown alert is issued for a combative
individual with security responding to
subdue the individual. Employees should
balance or offset the person’s behavior with
a helpful, calming response.
• If the behavior becomes violent, call the
emergency response team by contacting
3000, stating “Charlie Brown” and giving
them the location of the event.
Emergency Response Team
• The staff member initially involved with the
combative person and the Charge Nurse
become team leaders. Uses the least force
necessary to physically quiet or restrain
combative individual. Notify treating
physician or ER physician to secure order for
restraint and/or medication.
• The team leader or their designated staff
notifies the hospital operator of the situation
and location by calling “Charlie Brown” to
Duress Word – “Advice”
• Hostage situation – The duress word to alert
the operator of a hostage situation is
ADVICE. All calls should include the word
ADVICE and the CEO’s name with as many
details possible – number of people,
weapons, number of attackers, etc.
• (Example: This is Mr. Williams. I am in the
Personnel Office with four people. Please
contact Mr. Banos. I need his Advice. Have
Mr. Banos contact me at this phone number,
2130, with the advice.)
Hostage Situations
• Immediately notify appropriate department to report
situation and its location.
• Remove people from the area if it can be done in a
safe manner without drawing attention to the
hostage taker.
• Assist in preventing other staff, visitors, and/or
patients from entering the area.
• Identify number of hostages and any suspects.
• DO NOT call out the emergency code. Call Executive
Management and use code word ADVICE.
Electrical Safety
When normal power is interrupted, and
emergency power system takes over.
– The system is powered by diesel-fueled
– The emergency power system comes online
within 10 seconds when normal power is
– Plugs for emergency power are to be easily
seen. (red-outlets)
– Ivory outlets: Normal power-general
Utilities Management
Utilities at Good Shepherd are protected by
back up provisions in case they fail.
• Emergency Power System – takes over
when normal power is interrupted.
Emergency system is powered by seven
generators – four in the hospital and two
in the Medical Plaza and one in the
Customer Service Center. Plugs for
emergency power are either red or labeled
Utilities Management
• Water Outage – follow the Emergency
Water Supply Plan in your Safety
Manual to minimize the impact on
Utilities Management
Fire Detection System
The Plant Operations Department has a fire
detection system that is computerized and
monitored 24 hours a day. These systems are
routinely inspected and tested annually.
On the individual unit or floor, you have a:
Pull station
Smoke detector
Fire extinguisher
Chiming light or horn and light
Fire doors
Other Utilities-Elevators
• 30 Elevators in use in the facility
• Elevators are a very safe mode of
• Always practice proper elevator
Medical Equipment
• Know where the shut-off valves and
zone valves are located when working
with oxygen, vacuum, and medical air.
• Be prepared to shut off
valves as instructed
during a fire.
Medical Equipment
Safe Medical Device Act
A means for reporting equipment that could or has
caused or contributed to the death or permanent
injury to a patient.
When discovered, immediately notify supervisor
and/or the Risk Manager.
The equipment must be reported to the FDA within
10 days.
Medical Equipment
If there is any chance the equipment has harmed a
patient in any way
– remove the item from service immediately, with
– label it as defective
– complete an incident report.
DO NOT try to repair it yourself, and do not allow it to be
worked on or examined by someone else.
Immediately report malfunctioning equipment to
BioMed at x4532.
Medical Equipment
All equipment is inspected periodically
by Bio-Medical Services.
The Biomed Shop contains a library of operator
and service manuals for equipment and spare
parts for critical life support equipment
CALL x4532
7:00 a.m. to 4:30 p.m. M-F
After hours, On-Call BMET is available by calling the operator
Life Safety
When are Interim Life Safety Measures
• Construction areas
• Locations near construction
• All buildings that do not meet current life
safety codes
• Implemented if construction restricts,
impedes or changes personnel emergency
exit routes or affects fire
detection/suppression systems.
Hazard Communication
• All hazardous materials have a Material
Safety Data Sheet (MSDS) available
through your department, your supervisor
or on GSnet
• Right to Know assures employees are
aware of possible exposures in their work
• All hazardous materials must have a label
naming the chemical and have adequate
hazard warning. Report any unlabelled
containers to your supervisor.
Hazard Communication
The National Fire
Protection Association’s
placard system provides a simple
system of hazard identification.
The placard is diamond in
(blue, red, white, yellow)
Color coded for type of hazard.
Number coded for severity of
the hazard.
Hazard Communication
• Keep disposable empty compressed
gas cylinders separate from other trash
and secured in the proper location for
your area.
• Cylinders should be chained or secured
when not in use
• Dispose of cylinders as directed at your
Hazard Materials
Spills or Leaks of Known Hazardous
Take the following actions for spills or leaks
of a known substance:
– Immediately secure the area
– Request assistance from Environmental
• Environmental Services has trained personnel to
clean spills – hazardous and unknown.
• They will obtain special equipment (spillkits, mops,
towels, etc.
Hazard Materials
Spills or Leaks of Unknown Substances
For spills or leaks of an unknown
substance, you should:
– Isolate the area from public and all nonessential persons.
– Secure the area
– Request assistance
– Determine the nature of the material
– Contain the spill or leak
Hazardous Material
Response Team
The team is responsible for responding to all
spills housewide 24 hours a day.
The team is comprised of:
EVS Personnel
Safety Manager
Plant Operations (if spill is on grounds)
Other Personnel as needed
Hazardous Material
Response Team
• Good Shepherd has policies on GSNet
in the HazMat Manual on hazardous
materials and spills.
• Nursing has policies on GSNet
regarding chemotherapy safe handling
and usage.
• Environmental Services -Cleans spills
greater than 5cc
• Nursing - Cleans spills less than or equal
to 5 cc & reports spills greater than 5cc by
calling 3000.
Hazard Materials
Blood or Body Fluid Spills
• Minimize your risk of exposure by containing,
removing, and disinfecting all blood or body fluid
spills as quickly and effectively as possible.
• Wear gloves and other appropriate Personal
Protective Equipment (PPE).
• Use a dry absorbent material to
– Solidify larger fluid volumes
– Transform them into an easily handled semi-solid
Hazard Materials
Eyewash Station
• Employees who may be exposed to
hazardous corrosive chemicals
should know how to use emergency
eyewash equipment.
• If the spill is on protective equipment,
remove the equipment (gloves,
glasses, goggles, clothing) after the
eyewash is activated.
• Rinse away chemicals remaining on
the equipment.
Radiation Safety
Distance and Shielding
Two techniques for reducing dose rate are
– Distance
– Shielding
– Mobile units - six feet
Maximizing the distance between
the source and the worker
decreases exposure significantly.
Radiation Safety
Leave the badge at work in a specified
location at the end of each day. (one
month wear)
Use dosimeters only for measuring an
occupational dose.
Do not wear the dosimeter if you are
receiving medical or dental exposures
as a patient.
Protect from extreme temperature
changes, humidity and chemicals
Do not expose to water or liquid
Body Mechanics
Injuries on the job can be prevented by using the Five
Principles of Body Mechanics.
1. Posture – keep your chin level and slightly tucked, keep
chest up but not out, stomach muscles tight, knees not locked
2. Keep objects close to your body
3. Face the object
4. Symmetry – use both sides of your body equally, use both
hands whenever possible
5. Wide base of support
– Standing – Legs should be at least shoulder-width apart.
They can be either side to side or one in front of the other.
– Sitting – Keep weight evenly distributed.
Rev. 7.30.12
• Joey Sutton: Care Direct Coordinator
• Jeanie McKay: Director of
Organizational Development (5276)
Cultural Diversity
Good Shepherd Medical Center represents a
diverse population of people from our staff to
our patients.
You will be asked to take a new look at the
population served by learning about cultural
values, beliefs, norms, and practices of
particular cultural groups.
Cultural Diversity
Keys to Success:
• Communication Styles – be sensitive to body language when addressing
– Facial expressions – frowning, smiling, etc.
– Gestures – pointing, hand signals, etc.
Example: American people widen their eyes to show anger, Chinese
people narrow theirs. Some cultures view making eye contact as rude
versus being polite.
• Personal Space – be aware of the dynamics of your impact on:
– Distance - backs a way
– Touch – May want or not want to be touched
Example: American culture expects people to stand about an arm’s
length apart when talking, Hispanics favor being closer and moving
away might be perceived as being “cold.”
• Relevance of Time
– Immediate versus later
Recognize that differences in time consciousness may be cultural and
not a sign of laziness or resistance.
Cultural Diversity
GSMC supports Cultural Diversity by:
Religion -Chaplaincy services available for all
Language – Cyracom telecommunication for
over 300 languages, ASL, interpreters.
Food Requests – Special diets available on
Cultural Diversity
All people are NOT alike
regardless if they are of
the same culture.
Avoid stereotyping
Rev. 7.30.12
Population Specific
– Neonates - birth – 6 months
– Infants – 6 months – 12 months
– Toddlers – 1 year – 4 years
– Preschooler – 4 years – 6 years
– School age – 6 years – 12 years
– Adolescent – 13 years – 18 years
– Adult - 19 years – 65 years
– Geriatric – 65 years old and beyond
Population Specific
Neonates: birth – 6 months
– Smile
– Follow objects with eyes
– Maintain head control
Population Specific
Infants: 6 months – 12 months
– Increased development of the arms and
– Babies become familiar with their bodies by
putting hands and feet in mouth
Population Specific
Toddlers: 1 year – 4 years
– Significant people are parents
– May appear afraid of strangers
– Very active
– Use play to learn
Population Specific
Preschooler: 4 years – 6 years
– Short attention spans and a lot of energy
– Curious and imaginative
– Afraid of being in hospital, the dark, and
Population Specific
School age: 6 years – 12 years
– Knows the difference between fantasy and
– Have a strong need to follow rules
– Act younger than they are
Population Specific
Adolescent: 13 years – 18 years
• Do not like to ask questions for fear of
appearing “stupid”
• Can react with anger when frustrated
• Peer identity is very important
Population Specific
Adult: 19 years – 65 years
– Early Adulthood – Manages a household,
rears children, develops career
– Middle Adulthood – Accepts physical
changes, maintains a healthy lifestyle,
plans for retirement
Population Specific
Geriatric: 65 years old and beyond
– Bones become more fragile and fracture
more easily
– May have decreased vision and hearing
– May be depressed related to a decrease in
their physical abilities
Population Specific
Population specific skills are the skills used to
give the care and attention that meets an
individual’s needs.
• Each individual has his or her own likes and
dislikes, feelings, thoughts, beliefs, life
experiences and abilities.
• Experts have determined that these qualities
are similar according to a person’s age or stage
of life.
• When we understand these stages of life, we
improve the care and attention given to
patients, families, and visitors.
Spiritual Care
Rev. 7.30.12
Spiritual Care
Offered to all patients, families, staff and volunteers:
• Non-denominational spiritual counselor providing spiritual
support and counseling
• Bereavement support
• Sacraments
• On-call clergy available for pastoral care
• Stress management
• Services for special occasions
• Chapel – First floor, across from Waiting area
Spiritual Care
Offered to all patients, families, staff and volunteers:
• Pre-operative patients and family members
• Patients who have religious/spiritual requests
• Patients, families and/or staff experiencing
emotional/spiritual distress
Spiritual Care
A spiritual care consult can be obtained by:
• Physician Order
• Employee/Volunteer request
• Patient/Significant other request
Consult the Chaplain
through phone extension 2636,
Pager # 903-232-5588
Through the hospital operator
Death and
Rev. 7.30.12
Palliative Care
Starts in the initial phase of the disease
process, and continues through this process
until cure, remission, or death occurs. In
palliative care, no specific treatment is
excluded, from curative treatments to
resuscitation; however, emphasis remains on
comfort care of the patient and the needs of the
family dealing with a life-altering disease
Hospice Care
Hospice is primarily a concept of care, not
specific place of care. Hospice emphasizes
palliative rather than curative treatment;
quality rather than quantity of life.
Professional medical care is given, and
sophisticated symptom relief provided. The
patient and family are both included in the
care plan and emotional, spiritual and
practical support is given based on
the patient’s wishes and family’s
Abuse and
Rev. 7.30.12
Abuse, Neglect & Exploitation
• As a skilled caregiver your responsibility includes:
– To know when you see a victim of abuse
– To offer the care needed
– To report:
• Social Services
• Nursing Supervisor
• Texas Department of Protective Services
Abuse, Neglect & Exploitation
Forms of Abuse
– Self – does not care for basic needs , unfilled
prescriptions, does not eat properly or has poor
grooming habits
– Caretaker – Neglect or dependent child/adult
– Emotional –Spoken threats, aggressive behavior
– Physical- Hitting, kicking, throwing
– Sexual – Sexual harassment, sexual assault
– Exploitation – Taking advantage of or misuse of
patients personal belongings, including finances
Abuse, Neglect & Exploitation
Signs of Neglect
Poor hygiene
Body lice
Unfilled prescriptions
Failure to thrive
Basics – necessities of life, housing, clothing,
nutrition, medical care, needs supervision
– Munchausen Syndrome by proxy
in the
Rev. 7.30.12
Domestic Violence
A Healthcare Issue
• 25-30% of women presenting to the ER are current
or formerly battered women
• 2.2 – 3.1% of patients (700,000 – 1.1 million)
in the ER present with abuse related trauma
• Abused woman account for 64% of all female
psychiatric inpatients
• 18 – 32% of pregnant women are abused
All adult patients in the ED and
in the Inpatient Units are
screened for domestic
Victims are offered the
resources of the Women’s
Center and Shelter or the
Texas Department of
Protective Services.
Violence in the Workplace
Health care and social service workers face an
increased risk of work-related assaults stemming
from several factors, including:
•The prevalence of handguns and other weapons among patients,
their families or friends.
•The increasing number of acute and chronically mentally ill patients
now being released from hospitals without follow-up care, who now
have the right to refuse medicine and who can no longer be
hospitalized involuntarily unless they pose an immediate threat to
themselves or others.
Violence in the Workplace
Additional risk factors of work-related assaults,
•The availability of drugs or money at hospitals, clinics, and
pharmacies, making them likely robbery targets.
•Situational or circumstantial factors; the increasing presence of gang
members, drug or alcohol abusers, trauma patients, or distraught
family members, long waits in the ED, all leading to client frustration.
Violence in the Workplace
Why is workplace violence prevalent in
•Healthcare workers deal with people on a daily basis who:
•Are scared – they do not know what is happening or they know
that what may happen will be unpleasant
•Are feeling loss of personal power – they need to show that they
are still in control and can act as an individual
•Are angry – they are angry at the situation which has placed them
in the healthcare workers’ care; they are angry that their loved
ones are hurting or are ill or dying
•Are in pain or are sick
Violence in the Workplace
Workplace Violence Prevention
GSMC is committed to the prevention of all forms
of violence in the workplace, and to providing a
safe and secure work environment for all
Report warning signs of potential violence as
soon as possible to a security officer or
Violence in the Workplace
Workplace Violence Prevention
Practice Non-Violent Crisis Intervention
•Recognize the signs of someone in an agitated
•Stay in control of your own behavior
•Do not handle crisis alone
•Practice tension reduction and therapeutic
Rules &
Rev. 7.30.12
• Deb Stewart: Mgr. Privacy Officer
(2684) [email protected]
• Compliance Hotline: 903-315-5053
Background: Federal
Privacy Protections
• Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
• Applies to:
– Hospitals, physician practices, and other providers
– Health insurance companies
• Protects the confidentiality of health
• Gives patients certain rights with respect to
their health information
Background: State Privacy
• State laws and regulations also protect
patient privacy
• State laws may apply to information
about sexually transmitted diseases,
HIV, genetic testing, or other conditions
• Providers must comply with both federal
and state laws
Background: Protected
Health Information (PHI)
• HIPAA is designed to protect information that:
– Identifies individual patients, including
demographic information
– Relates to the past, present, or future physical or
mental health of a patient
– Relates to the past, present, or future payment for
a patient’s healthcare services
How the HIPAA
Impact Our Daily
Rev. 7.30.12
Dr. Jones’ office contacts the hospital to
schedule an admission for Mr. Smith. He will
be admitted for surgery to repair a fractured
• The Hospital Must:
– Provide a notice of Privacy Practices if this is the
patient’s first admission.
– Make a “good faith” effort to obtain a written
acknowledgment from the patient that he has
received the Notice of Privacy Practices
– Tell him that information will be put in the facility
directory and allow him an opportunity to object.
A few weeks after his discharge, Mr.
Smith returns to the hospital and
requests a copy of his records.
Under HIPAA, patients have the right to access their
records in designated record sets and obtain copies
of them. This right extends for as long as the hospital
keeps the records.
Designated record set for providers includes:
-Medical Records
-Billing Records
-Diagnostic images such as X-Rays, EKGs and
A few weeks after his discharge, Mr.
Smith returns to the hospital and
requests a copy of his records.
May charge a reasonable cost-based fee for
making copies and for postage. May not
charge a fee for retrieving records for review.
Most providers do not charge for copies sent
to other providers or given to the patient for
continued care.
Mr. Smith wants to know to
whom the hospital has released
information from his records.
• Individuals have the right to request an
“accounting of disclosures” of PHI for six
years prior to the request.
• Exceptions:
Payment, treatment, or operations
To the patient or someone authorized by the patient
To those involved in the patient’s care
For national security or intelligence purposes
To correctional institutions and law enforcement
Before April 2003
After reviewing his records, Mr. Smith finds
information he believes is incorrect. He asks
to have the record amended.
• Patients have the right to request an amendment:
– In a designated record set
– For as long as the hospital maintains the records
• Most providers require a written request with
• Providers have 60 days to act (with a possible 30-day
• If the request is granted, the hospital must:
– Notify patient that amendment was accepted
– Inform relevant persons identified by patient.
• Amendment requests in our facility must be
referred to the privacy officer.
After reviewing Mr. Smith’s
request, Dr. Goodcare denies the
• Many deny request if PHI:
– Was not created by the hospital (unless the
originator is no longer available)
– Is not part of the designated record set
– Was not available for inspection
– Is accurate and complete
If the request for amendment
is denied:
• The hospital must give written notice to
the patient, explaining:
– Reason for denial
– Right to submit written statement of
disagreement or have request included
with future disclosures
– Individual’s right to complain to the privacy
officer or HHS
Mr. Smith’s wife requests a copy of his
recors. She says Mr. Smith wants to send it
to another doctor who is treating him.
• The patient’s written authorization is
necessary to give his wife a copy
• The records could be sent to another
healthcare provider upon request, because
this is covered as part of treatment, payment,
and healthcare operations.
A few months later, Mr. Smith comes back for a
follow-up visit. As he’s leaving, he overhears two staff
members discussing his case in the hallway. Visibly
upset, he returns to the information desk and says he
wants to file a complaint.
• Patient discussions should never occur in a
public area, where they may be overheard by
• Patients have the right to file complaints if
they believe their privacy has been violated,
and we take these complaints very seriously
• The privacy officer should speak privately
with the patient to better understand the
situation and express concern
Penalties for Violations
• We will take corrective action up to and
including discharge of an employee
• Individuals may also be subject to
criminal and prison time, for intentional
Guarding Ethics:
False Claims
and Corporate
Rev. 7.30.12
• Ken Cunningham, Executive VicePresident (903)315-2656
Federal and State False
Claims Laws
• Laws to prevent and detect fraud, waste
and abuse in federal and state health
programs, such as Medicare and
• Civil lawsuits may be filed to recover
damages and penalties from healthcare
providers who submit false claims
• Any person may file a lawsuit who has
knowledge of false claims
Federal and State False
Claims Laws
• Healthcare provider that commits fraud
and abuse against Medicare/Medicaid
may be fined $5000 - $11,000 for each
false claim
• May be liable for payment up to three
times the government’s damages
• May be liable for payment of costs of civil
action against the healthcare provider
Federal and State False
Claims Laws
• Individuals are encouraged to report misconduct
under the “whistleblower” provision
• Individuals may bring a civil lawsuit on behalf of
the US Government to recover funds paid by
Medicare/Medicaid false claims
• Government may determine if the lawsuit has
merit and may or may not join the lawsuit
• “Whistleblower” may receive reasonable
expenses for attorney’s fees and percentage of
amount recovered
Federal and False Claims
• “Whistleblower” discovered to be involved in false
claims, the share of the recovered amount may be
• “Whistleblower” convicted of criminal conduct related to
the submission of the false claim will be dismissed from
the lawsuit with no compensation
• “Whistleblowers” are protected from employer retaliation
• “Whistleblowers” subjected to retaliation may bring civil
lawsuit in federal court and will be entitled to:
– Reinstatement of job with same seniority
– Two times the amount of back pay with interest
– Additional damages such as attorney’s fees
Federal and State False
Claims Laws
• What is Fraud?
– Fraud is knowingly and willfully executing, or
attempting to execute, a scheme to defraud
any federal or state health care program or
obtain by false means or fraudulent pretenses
any money or property owned by or under
control of federal or state health care
What is Abuse?
• Abuse may directly or indirectly result in
unnecessary costs to Medicare/Medicaid,
improper payments, or payments for services
which fail to meet professional standards or care
or that are medically unnecessary.
• Abuse involves payment for items or services
when there is not legal entitlement payment,
although the provider not knowingly or
intentionally misrepresented facts to obtain
Examples of Health Care
• Collecting more than the coinsurance or
deductible allowed by Medicare/Medicaid.
• Using procedure or revenue codes that describe
more extensive services than those provided
• Requiring a deposit or other payment from a
Medicare beneficiary as a condition for
admission, continued care, or provision of
• Billing for services grossly in excess of those
needed or required by the patient (EX: Billing for
complete lab profiles when only a single
diagnostic test is necessary)
Reporting Compliance
• Good Shepherd asks and encourages
anyone to report suspected problems or
issues dealing with fraud, waste and
abuse in federal and state health care
• Good Shepherd Compliance policy has
detailed information for your use regarding
these circumstances available on
Reporting Compliance
• Call the Compliance Officer: Ken Cunningham
• Place an anonymous call to the GSHS
Compliance Hot Line 903-315-5053 (24/7)
• Send a letter to:
– Compliance Officer, Good Shepherd Health System
700 East Marshall
Longview, Texas 75601
Reporting Concerns Through
Joint Commission
• The Joint Commission on Accreditation of Healthcare
Organizations (Joint Commission) is an independent,
not-for-profit, national body that oversees the safety and
quality of healthcare and other services provided in
accredited organizations.
• Employees and the public may report concerns about
safety or the quality of healthcare being provided at
GSHS to the Joint Commission at 800-994-6610.
• Concerns regarding accreditation and the accreditation
performance on individual organizations can be obtained
through the Joint Commission website at
Rev. 7.30.12
Corporate Compliance
• Ensures that Good Shepherd operations are
conducted in compliance with its’ policies and
procedures in an ethical manner
• Employees are expected to conduct themselves
in accordance with the highest ethical standard
and avoid wrong doing
Corporate Compliance
Compliance is everyone’s job!
Examples of compliance policies are
explained in your handbook, such as:
– Do not discuss cost of services with other
– Do not use GSHS tax-exempt status to
purchase or for personal benefit
– Do not take equipment or supplies without
Corporate Compliance
Employees should:
– Receive a copy of the Compliance Handbook
(yellow) upon hire
– Read, sign and acknowledge compliance with
– Report any compliance issues
Hotline: (903)315-5053
Corporate Compliance
Employees should:
– Complete the 2010 Compliance Handbook
CBL and acknowledgement test on GSLS
– Report any compliance issues
Hotline: (903)315-5053
and Control
Rev. 7.30.12
• Terry Smith: Infection Control Nurse
• Cheryl Herbert, Infection Prevention
Director (2662)
Goal of Infection Prevention
• Prevent healthcare associated infections (HAI)
through education, surveillance, observation and
monitoring of infections/communicable diseases.
• Infection prevention applies to everyone,
including patients, visitors, healthcare workers,
volunteers, contract employees, physicians and
others as needed.
• Infection prevention extends from inpatient care
to outpatient, rehab, skilled care, home
care…anywhere a patient receives care.
Basic Principles of Infection
• Infections cause by bacteria and viruses can be
transmitted between patients & healthcare workers. To
avoid infection comply with these practices:
Hand hygiene – no artificial nails
Care & cleaning of equipment
Standard precautions and use of PPE
Transmission based precautions (isolation)
Reporting needle sticks or blood/body fluid exposures
Prevention is the key!!
Basic Principles of Infection
• Infection can be spread in the following ways:
– Direct contact: spread of infection or germs is
person-to-person by direct touch or contact.
– Indirect contact: Spread of disease or germs is
cause by the environment, or by equipment and
medical devices that are not cleaned properly or
become contaminated by improper handling.
– Airborne Route: Spread of disease by germs in the
Standard Precautions
• Are intended to reinforce well established infection
prevention principles such as hand hygiene
• Reduce the risk of spreading or acquiring bloodborne
diseases such as HIV or Hepatitis B
• Apply to all patients and healthcare workers
• Food and drink should be in appropriate areas
• Use barriers to prevent transmission of germs
(pathogens) from:
– Excretions (like stool)
– All body fluids
– Secretions (except sweat
-- Blood
--nonintact skin
--mucous membranes (mouth, eyes)
Standard Precautions
• Gloves
– Wear prior to touching blood, body fluids, secretions,
excretions, contaminated items, and when performing
vascular access procedures (IV catheters)
– Use clean gloves to touch mucous membranes and
non-intact skin
– Change gloves between tasks and remove promptly
after procedures to prevent environmental
– Always perform hand hygiene before and after glove
Standard Precautions
• Environmental Control:
– Clean and disinfect environmental surfaces, beds, bed rails, bedside
equipment, bathrooms and other frequently touched surfaces daily and
when soiling occurs
– Clean all blood spills with an appropriate disinfectant per the Exposure
Control Plan
• Linen:
Contain and transport all linen in water-proof bags
A second bag is required if outside contamination of the first bag occurs
Soiled linen must never be placed on the floor
Do not overfill the bag (more than 2/3 full for convenience of handling
and proper closure
– Bags must be securely closed
– Bagged linen should be placed in specially designated areas
for pick up. Environmental services will remove linen per
Standard Precautions
• Trash
– Contain regular trash in a clear plastic bag
– Use the red biohazard bag or other designated biohazard
container for items that are soiled with blood, that cannot be
emptied of blood (e.g. chest tube bottles or blood transfusion
bags), or that are caked with blood that could flake off. When in
doubt, use a red bag
– A second bag/container is required if outside contamination of
the first bag/container occurs
– Trash is placed in special containers in designated soiled
– Environmental Services will remove trash per procedure.
Standard Precautions
• Sharps
– Disposal containers are designated for proper disposal of needles,
syringes, and scalpels. Never dispose of sharps in the regular trash
– Do not bend, recap, resheath, shear, or break used needles or other
sharps; activate safety mechanism where applicable
– Do not overfill sharps container
– Safety devices (resheathing IVs, safety syringes and scalpels, etc) must
be discarded in sharps containers! Safety mechanism must be activated
prior to disposal
• Laboratory Specimens:
– All specimens are to be considered infectious at all times
– Transport in a clear plastic bag labeled with the biohazard symbol
– A second bag/container is required if outside contamination of the first
bag/container occurs
– Secure specimens appropriately for Pneumatic Tube
OSHA Standard on
Bloodborne Pathogens
• Bloodborne diseases like HIV or Hepatitis can be spread
when infected fluids enter the body through:
Needle stick or sharps injury
Cuts, scrapes or other breaks in the skin
Splashes of blood or body fluid in the mouth, nose or eyes
Oral, vaginal or anal sex
Sharing used needles
Baby through birth process
• HIV (Human Immunodeficiency Virus)
– May start with mild flu-like symptoms and progress; will then weaken the
immune system which increases the risk of infections or cancer and
may eventually cause death
– Can lead to AIDS (Acquired Immunodeficiency Syndrome)
– Can be carried in the blood stream without symptoms –
the person doesn’t know that they are infected
Bloodborne Diseases
• HBV (Hepatitis B Virus) can cause:
HCV (Hepatitis C Virus):
Active Hepatitis B: a flu like illness that can last for many months
A chronic carrier state: the person may have no symptoms, but can pass HBV to others
Cirrhosis, liver cancer and death
Consider the HBV vaccine. It is your best protection against Hepatitis B and is provided free
of charge in Employee Health
The HCV also attacks the liver and is similar to HBV. There is currently no vaccine available
to protect you
Patients may not have symptoms of the disease, but can still transmit the
infection. The only way to consistently protect yourself is to follow Standard
precautions (face protection, gloves, gowns, mouth-to-mouth resuscitation
device) every time you expect to have exposure to blood or body fluids
A copy of the OSHA Standard on Bloodborne Pathogens is available on
request by calling Infection Prevention at x2662
Isolation Precautions
• Transmission-Based Isolation Precautions are used for patients who
have highly contagious diseases/conditions. In addition, these
precautions can be used “empirically” based on signs/symptoms of
disease before a firm diagnosis is made
– It is very important to be consistent with hand hygiene, use of gloves,
care of the environment, and cleaning of equipment.
– Germicidal wipes are available for use on surfaces such as keyboards,
stethoscopes, and electronic thermometers
• These additional precautions are necessary to interrupt the chain of
Isolation Precautions
• Airborne Isolation Precautions
– Used for diseases that are transmitted through the air by tiny particles
that can travel long distances on normal air currents.
– Examples of airborne disease include tuberculosis (TB), rubella
(measles), and varicella (chickenpox)
– Patients who are suspected of or are diagnosed with these diseases are
placed in a private, separately ventilated, negative pressure room
Isolation Precautions
• Airborne Isolation Precautions (cont’d):
– The door must be kept closed to maintain negative pressure (air
in the room won’t flow out)
– Anyone entering the room must wear a N-95 respirator as
respiratory protection. These are not regular surgical masks, but
rather a fit-checked respirator required by CDC – annual fit
testing and medical evaluation required
– If the patient must be transported, place a surgical mask on the
patient or provide tissues to cover cough
– Supplies outside the room would include a posted Airborne
Isolation sign, a box of small and regular sized N-95 respirator
masks and germicidal wipes to disinfect small pieces of
equipment coming out of the room
Isolation Precautions
• Droplet Isolation Precautions:
– Used for diseases which are transmitted by large respiratory droplets
– Coughing, talking and suctioning create these droplets. They are so
large, they “rain down” (fall out of the air) within 2-3 feet of the patient
– Examples of droplet spread diseases include the flu, meningitis caused
by Neisseria meningitis, pertussis (whooping cough) and streptococcal
respiratory disease
– A private room is necessary
– A negative pressure room is not indicated
– Wear an isolation mask(ear loop) when entering the room
– The patient should wear a surgical mask during transport and cover
– Supplies outside the room would include a posted Droplet Isolation
Precaution sign, a box of isolation masks (yellow ear loop
masks) and germicidal wipes to be used to disinfect small
pieces of equipment coming out of the room
Isolation Precautions
• Contact Isolation Precautions
– Used for diseases/conditions which are transmitted by physical
contact with the patient or the patient’s environment
– Examples of contact spread diseases or conditions include
– A private room is necessary
– Wear gloves when entering the room
– Wear a gown when entering the room for contact with the patient
or environmental surfaces/patient care equipment
– Remove the gown and gloves before leaving the room and
perform hand hygiene
– Supplies outside the room would include a posted Contact
Isolation Precaution sign, a cart to store the gowns,
gloves and germicidal wipes to disinfect small pieces
of equipment coming out of the room
Isolation Precautions
• Contact Special Isolation Precautions
– Used with patients known or suspected to have Clostridium
difficle (C. diff)
– This organism is spread through contamination of the
environment by C. diff spores or by unwashed hands of
healthcare workers
– A private room is necessary
– Wear gloves when entering the room
– Wear a gown when entering the room for contact with the patient
or environmental surfaces/patient care equipment
– Remove the gown and gloves before leaving the room and wash
your hands with soap and water. Hand sanitizer does not kill C.
diff spores
Isolation Precautions
• Contact Special Isolation Precautions (cont’d):
– Environmental Services will clean these rooms with a special
cleaning solution to help kill the spores
– Supplies outside the room would include a posted Contact
Special Isolation Precaution sign, a cart to store the gowns,
gloves and germicidal wipes to disinfect small pieces of
equipment coming out of the room
– A reminder sign will be posted in the room at the door, to remind
you to wash your hands with soap and water before you leave
the room
Isolation Precautions
• Multi Drug Resistant Organisms (MDRO):
– Several common germs or bacteria like Methicillin Resistant
Staphylococcus Aureus (MRSA) and Vancomycin Resistant
Enterococcus (VRE) have become resistant to many antibiotics.
This means the usual antibiotics prescribed will not kill these
germs and so they are called Multi-Drug Resistant Organisms
(MDRO). While these germs should not cause an illness in
healthcare workers, if a patient gets an infection from one of
these resistant organisms, the doctor may not be able to cure the
– MDRO can be spread by direct contact from the hands of a
healthcare worker to a patient. Contact Isolation precautions,
when used correctly, will prevent the patient-to-patient spread of
A Healthy Workplace
Cover Your Cough
– Cover your mouth and nose with a tissue when you cough or
sneeze OR
– Cough or sneeze into your upper sleeve, not your hands
– Put your used tissue into the trash
– Clean your hands by washing with soap and water or by using hand
– Get a flu shot every year
– Protect yourself and our patients!
Notify your supervisor prior to beginning
work shift of any potentially infectious
Non-intact skin / skin infections
GI illness
Respiratory illness
Influenza: Protect Your
Patients. Protect Yourself.
Common Flu Symptoms:
• Fever (usually high)
• Headache
• Tiredness
• Cough
• Sore throat
• Runny or stuffy nose
• Body aches
Influenza Transmission:
• Flu spreads person to
person in respiratory
droplets when people
who are infected cough or
• Healthy adults may be
able to infect others 1 day
before getting symptoms
and up to 5 days after
getting sick.
Influenza: Protect Your
Patients. Protect Yourself.
Healthy Tips to Prevent the Flu:
Wash your hands
Don’t cover sneezes and coughs with your hands
Don’t touch your face
Clean your ‘shared spaces’
Get enough sleep
Drink more water
Continue a moderate exercise program
Eat healthy
Limit alcohol intake
Listen to your body
• Tuberculosis (TB) is a serious lung infection caused by a
tiny germ called a mycobacterium. When an infected
person sneezes, coughs or speaks, the germs are
expelled into the air and can be inhaled by another
• Symptoms:
Severe, prolonged cough (may cough up blood)
Fever and night sweats
Weight loss
• TB can be easily controlled by following these
– Initiate Airborne isolation Precautions as described earlier under
Transmission-Based isolation Precautions
– Use caution when doing cough inducing procedures, like suctioning or
– A portable air treatment machine is available for use in areas without a
separately ventilated, negative pressure room. Refer to the Infection
Prevention Manual for directions in obtaining the unit, if needed.
– New employees receive a skin test called a TST (Tuberculin Skin Test).
A small amount of fluid (PPD) is injected under the skin on the forearm.
A raised, red area on the forearm where the test is placed means the
test is positive and you may have been exposed to TB. A thorough
physical examination including a chest x-ray would be done to check for
Infection Prevention and
Patient Safety Initiatives
• Hand Hygiene
• Reducing drug resistant organisms
• Eliminating bloodstream infections caused by central
lines (large catheters inserted close to the heart)
• Eliminating urinary bladder infections caused by
• Reduce and eliminate infections from surgery
• Infection prevention is important for you and particularly
for our patients. Everyone is responsible for following the
basic principles for hand hygiene, cover your cough,
standard precautions and transmission-based isolation
• Report any exposure concerns and Infection Prevention
will communicate any exposure issues.
• If you need more information, please refer to the
Infection Prevention Manual (available online on GSnet)
or contact the Department of Infection Prevention at
Set, Go!
Rev. 7.30.12

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