Community Hospital of San Bernardino

2015 Annual Update

and EOC Standards

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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

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LIVING A CULTURE OF PATIENT SAFETYAs 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.

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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 Management2. Hazardous Materials Management3. Life Safety Management4. Medical Equipment Management5. Utility Systems Management6. Security Management7. 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.

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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 PROCEDURESComplete 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.

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Hazardous chemicals can create two types of hazards:

1. Physical and Chemical Hazard

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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 Hazard4 = Extreme Highly toxic 4 = Extreme Extremely

flammable4 = Extreme Explosive at

room temperature

3 = 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

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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 entry3. 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 notified3. 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 Streamo 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 1000A “Code RED” is paged over the intercom system to indicate a fire within theHospital

Important Reminders:• Keep emergency exits, corridors and exits c l ear at a ll t im es • 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

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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 ALARMPull the nearest FIRE ALARM BOX and then Dial “1000” to announce a CodeRed

C CONTAINClose the door to the fire area to isolate fire and close the door to all other patients to prevent the spread of smoke

E EXTINGUISHWith 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

CONTAINC Close the patient doors/work area doors to prevent spread of smoke

Stay alert to possible Triage Internal Disaster page.

OPERATION OF FIRE EXTINGUISHERSP 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 SAFETYRegulations 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, anddo 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.

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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. Th ese m ac hin es only gi v e o f f r a di a t ion w h e n ac t u a lly m ak ing a n im a g e . 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 EQUIPMENTPrior 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.

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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.

N EVE R TURN DO W N OR TURN OFF M E DIC A L E QUI P M E NT A L A R M S

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.

IF medical device have caused harm, death or serious illness to a patient or employee, do the following:

1. Attend immediately to the medical needs of the patient2. Report the incident to the attending physician and immediate supervisor3. Report the incident to the Risk Manager4. Remove the device from service and the patient’s room if directed5. Label the device as broken and save all equipment and packaging, do not

disassemble until directed to do so6. Submit an occurrence report7. Report to FDA, employee may file a report to FDA

All health care professionals are expected to report adverse events, even if they are uncertain that the product caused the event and even though they do have all the details. You may also report to the FDA yourself.

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Utility System Management

The Utility Systems are designed to keep our Hospital comfortable for employees and patients. However, these systems may experience problems. When a disruption in utility occurs, each employee must be familiar with procedures for maintaining a safe environment.

EMERGENCY POWERIn the event of Utility Failure (except for telephone), employees are to immediately notify their Supervisor and the PBX Operator. The PBX operator will notify the appropriate departments.For the telephone system, notify Information Technology.

In the event of a loss of electricity, emergency generators become operational in 10 seconds or less. Essential patient care equipment like ventilators should be plugged into outlets that are red.

If the emergency generators should fail:• Obtain an emergency flashlight• Respond to the most immediate patients needs• Make plans to obtain medical air and vacuum• Patients on ventilators may require manual assistance• Communicate: Hand-held radios will be delivered to patient care areas.

Examples of utility systems are:- Nurse Call System - Steam- Telephone - Pneumatic Tube System- Paging System - Natural Gas- Beeper System - Air Conditioning- Medical Gas System - Heating and Ventilation System- Vacuum System - Electricity with/without Emergency Power- Domestic Water - Elevators

EMERGENCY SUPPLIESEmergency supplies are stored in the departmental disaster kits. Know where your emergency supplies are located.The Kit Contains:

Flashlights Water for patient use (oral medication) Waterless hand-washing product for infection control purposes

MEDICAL GAS SHUT-OFFIn the event of a failure of the medical gas systems the following individuals have been authorized to shut off the equipment. (Cardiopulmonary is responsible for providing back up oxygen)

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• Isolated Unit or Floor:The charge nurse, shift lead or manager will order the shut off of medical gas equipment and ensure the safety of the patients.

• Facility-WideAfter Nursing Administration and Cardiopulmonary have ensured the safety of the patients, they will notify Engineering to shut off the main medical gas equipment.

Security Management

SERVICES: The following are examples of services provided by the Public SafetyDepartment:

• Investigations• Patrol and Monitoring activities• Escorts• General Information• Emergency Response• Violence in Workplace Program• Building Watch Program• Liaison with Law Enforcement

Identification Badges:When you are in the Hospital, it is required that you wear the identification badge that was issued by the Hospital. The badge is to be worn above the waist and the picture must be visible. If you lose your badge, report it and have it replaced immediately.

• DISTRESS CALL: Inside the hospitalIf you are involved in a threatening situation, DIAL “2000” on any phone (except pay phones). The operator will dispatch Public Safety immediately to the location.

• DURESS ALARM: Outside the hospitalDuress alarm buttons are located in the employee parking lots. The alarms are located on what appears to be a light post. It is always better to besafe than sorry, so use the alarms when you think something is going on and you need security immediately. When the Duress Alarm is activated, the system:• Sounds an audible alarm• Light goes on• Alerts PBX operators who will notify Public Safety by radio

VIOLENCE in the WORKPLACE PREVENTION PLANViolence can happen anywhere. It can come from patients, families or co-workers. Acts or threats of physical violence, including intimidation, harassment, or coercion, which in your judgment affects the patient, Hospital staff or property will not be tolerated.We must be alert to changes in a person’s behavior and alert those in authority. Below are some factors that are known to cause an individual to become irritated and possibly assaultive.

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• Demands for compliance/regimentation• Recent changes in medication• Encroachment on personal “space”• Visits/changes in relationships/death• Environmental factors: Sudden change/ crowding/ noise/ chaotic activity/ weather /

scheduling of activity/neglect.• Loss or destruction of: -Property -Ego/ self-esteem -Relationships -Territory• Staff attitudes: -Authoritarian -Hostile/uncaring -Inconsistent/ “too busy” -Neglectful

- Unsupportive/unsympathetic -Rude/ sarcastic

Warning Signs of Possible Violence Slight changes in usual baseline activity level or behavior Requesting more staff attention Slight to obvious increase muscle tension and activity associate with the same: finger-

tapping, pacing, rocking, hand-wringing, etc. Sudden, sullen withdrawal; increased intensity of psychotic symptoms.

If you come in contact with a violent person• Stay calm• Do not approach alone• Dial “2000” to notify PBX or use a duress alarm• Inform your supervisor

Employees responsibilities for safety in the workplace: Report immediately to Public Safety any incident that threatens the safety of

employees, patients, and visitors. Be alert to overemotional patients and visitors who make threats or show extreme

anger, especially if they appear to be using alcohol or drugs Get help if you feel unsafe while dealing with anyone. Be alert to potential for violence in a co-worker who is often threatening, angry,

defensive, or blames others for problems. Report any concerns about danger from a co-worker for confidential investigation and,

if necessary, counseling or discipline.

INFANT/CHILD ABDUCTION “CODE PINK” – Call 1000Policy:

• Whenever it is noted that an infant or child is missing, the staff is to DIAL “1000” to notify PBX, even with the Infant alert system.

• The operator will announce “CODE PINK” over the hospital PA system

• Department staff directly involved in perinatal/pediatric care is responsible for maintaining the integrity of the security of the unit.

• Infants shall be transported in bassinets/isolettes between Hospital Units.

• Staff in departments located adjacent to perinatal/pediatric care shall close their unit; place someone at the door to question anyone carrying an infant, large bag or bundle.

• Notify Public Safety through PBX of anyone suspicious.

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Emergency Preparedness Management

Triage Internal: an incident that happens on campus and results in damage to property and/or employees that are beyond our normal capacity to handle.

Triage External: an incident that happens outside hospital and requires us to be prepared to treat more emergency patients than we can normal handle.

DESIGNATED AREAS FOR DISASTER MANAGEMENT FUNCTIONS(Areas may change depending on type of disaster)

• Ambulance Patient Drop Point - Emergency department Triage area.• Communications Command Post – Rushmore Room• Dependent Care/Overnight stay - PHP• Discharge Area – By MRI pad behind kitchen• Delayed Care (holding) Area – Couplet Care East• Incident Command Post – Rushmore Room• Information Center (patient/family) - Cafeteria• Labor Pool – Medical Library• Media Center, Press information – Solarium• Worried Well/Minor treatment – East Campus Lobby/Fischer Room

Your ROLE in a disaster:If you are ON-DUTY when a disaster strikes

• Patient Care Providers: Remain in your work area and continue duties until you receive further directions from your supervisors. Charge personnel are to make a list of patients, indicting who can be sent home or transferred to a lower level of care. Gather all transporting devices, wheelchairs and gurneys, and hold them until called for.

• Non-Patient Care Providers: Report to the labor pool Big Bear Wear your photo identification badge at all times Stay at your assigned post at the end of your shift until released or reassigned by

your supervisor.

If you are OFF-DUTY when a disaster strikes• Keep your telephone free in case you are needed to be called in for duty. Do not call

the hospital, unless you have been told to do so.• Listen to your radio and/or television news broadcast• Report for duty when you are next scheduled to work, unless you are notified

otherwise.

CommunicationThe back up communication system includes: a red telephone system which will automatically activate if the Hospital phone system fails; distribution of 2-way radios and cell phones to all patient care areas in a disaster; ham radios, and the use of runners between departments.

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Supplies and EquipmentBackup supplies and equipment are available for disaster. Nursing Units have standardized kits which include water (for patient medications), flashlights, waterless hand cleanser, and disaster instructions with the location of disaster centers.

Hospital Emergency Codes

The following are the color codes used at Community Hospital of San Bernardino:1. Code Gray – this is called when there is a violent or agitated person. To activate Code Gray dial,

ext 1000

2. Code Pink – this is called for infant abduction. To activate Code Pink dial ext. 1000

3. Code Purple – this is called for child abduction. To activate Code Purple, dial ext. 1000

4. Code Yellow – this is called for bomb threat. To activate Code Yellow,dial ext . 1000

5. Code Silver – this is called for person with a weapon or hostage situation. To activate Code Silver, dial ext 1000

6. Code Green – this is called for patient elopement. To activate Code Green, dial ext. 1000

7. Code Red – this is called for fire emergency. To activate Code Red, dial ext 1000

8. Code Orange – this is called for hazmat emergency. To activate Code Orange, dial ext 1000

9. Code Crimson – this is called for need for massive blood transfusion.

10. Code Bio – this is called for bioterrorism. To activate Code Bio, dial ext . 1000

11. Triage Internal – this is called for Internal Disaster. To activate, call ext. 1000

12. Triage External – this is called for External Disaster. To activate, call ext. 1000

13. Distress – this is called for Silent Call for Security. To activate, call ext 2000

14. Code Blue – this is called for medical emergency. To activate Code Blue, dial ext 3000

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PREVENTION of SLIPS and FALLSCommon causes of falls

• Toileting (to or from bathroom or commode)• “Didn’t want to bother the nurse”• Reaching for item on tray table/bedside table/floor• Unsafe environment

Identifying patients at risk for fall:• Use of YELLOW armband• Use of YELLOW magnet by patient’s board

Practice good housekeeping, keep slip, rip and fall hazards from occurring. Beds and medical equipment in the hallway causes tripping. Clear the hallway and find storage for the equipment. Pay attention to what’s in your path when walking. Use WET FLOOR signage and pay attention to the signage. Avoid calling or texting on the cell phone or the Spectra phone while walking.

Safety FIRST, what to do: If you see a wet spot on the floor, warn others about the spill and get a WET FLOOR

signage. Then clean with paper towels if they are available near you, otherwise, call EVS or

PBX. Let them know of the wet area for EVS to clean. Never carry a load that blocks your vision. Shorten your stride on damp surfaces.

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NATIONAL PATIENT SAFETY GOALS

Goal #1 improving the accuracy of patient identification. Use two identifiers – Name and Medical record number.

Whenever possible the patient should be an active participant. Have them state their name.

Color bands –o White is patient IDo Red is allergieso Yellow – risk for fallo Purple – DNR

Goal #2 Improve effectiveness of communications among caregivers Quickly get important test results to the right staff person Provide report or HAND-OFF among care providers using the SBAR process

Goal #3 Improving the safety of using medications Label all medicines that are not already labeled

o For peri-operative and other procedural settings: LABEL all syringes, medicine cups. Label AFTER medication is transferred

to the syringe or other container. Do not pre-label empty syringes or basins. Label to include:

o Medication Nameo Strengtho Quantityo Diluent & Volumeo Preparation Date

Visual and Verbal verification is required if the container is handed off toanother person to administer and at break/shift relief.

Discard any unlabeled containers immediately. To reduce compounding errors, use only oral unit dose products, prefilled syringes,

or premixed infusion bags & premixed infusion bags. Take extra care with patients who take medicines to thin their blood (anticoagulant)

o Pharmacy provides unit-dose warfarin, prefilled Fragmin syringes, and premixed heparin drips.

o Follow CHSB approved protocols for heparin drips and warfrain.o A baseline INR is required before the first does of warfarin.o Programmable infusion pump is required for all heparin drips.o NEVER bolus heparin from bag!o Educate patient/family:o The importance of follow-up monitoring, compliance, Food-Drug Interactions

and adverse drug reactions & interactions

Accurately and completely reconcile medications across the continuum of care. Ensure a process exists for comparing the patient’s current medication with those

ordered for the patient while under the care of the hospital.

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Goal # 6 Reduce Harm Associated with Clinical Alarms. Improve the safety of clinical alarm system

Goal # 7 Reduce the Risk of Health Care Associated Infections. Comply with CDC guidelines for hand hygiene Prevention of:

o Multi-drug resistant organisms (MDRO)o Central Line Associated Blood Stream Infections (CLABSI)o Catheter Associated Urinary Tract Infections (CAUTI)o Surgical Site Infections (SSI)o Ventilator Associated Event (VAE)

Manage any Healthcare acquired infection causing death or permanent loss of function as a sentinel event

Goal #15 The Organization identifies safety risks inherent in its patient population. Identify individuals at risk for suicide.

S Sex

A Age

D Depression or Hopelessness

P Previous attempts or psychiatric care

E Excessive alcohol or drug use

R Rational thinking loss

S Support System Loss

O Organized plan or serious attempt

N No significant other

S Sickness

Universal Protocol Always verify that you have the right patient for the right procedure and the site is

correct. Important ways to meet our goal:

o Use the Pre-procedural check listo Ensure correct identification of the patiento Make sure site is marked by practitioner doing procedureo Alternate site marking process – pink armband on the ankle or wrist of the

specific side and marked by the practitioner with name of procedure and theirinitials.

o The patient validates the site of surgeryo “Time Out” performed immediately prior to procedure.o Additional “time Out’ conducted for 2 or more procedures

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REPORTING SAFETY CONCERNS

Because patient safety is everyone’s responsibility, everyone has a duty to report his or her concerns. This also means everyone shares in the responsibility of improving safety.

By reporting our concerns, we are helping each other achieve this goal together. Remember, reporting is about improving processes, procedures and systems, not about blaming individuals.

For an urgent safety or security issue at Community Hospital of San Bernardino, including urgent patient safety concerns, call the operator.

Otherwise, your first resource should be your manager or supervisor. If you have a patient safety concern, talk with him or her about it.

Other resources available to you are your area’s safety manual, Risk Management ext. 1258, Quality Management ext 1518, and the Patient Safety Officer (Caroline Swinton) ext. 1256.

REPORTING

You have the right to report your concerns for patient safety or hospital performance to The Joint Commission.

You can contact TJC at 1-630-792-5800 push #6 or i-800-994-6610. Website: www.jointcommission.org

You also have the right to report any potential Medical Device problems to the FDA.

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False Claims Act

Federal and State Laws Protects Whistleblowers

The law. The federal False Claims Act makes it a crime for any person or organization to knowingly make a false record or file a false claim with the government for payment.

Under certain circumstances, an inaccurate Medicare, MediCal, Medicaid, VA, Federal Employee Health Plan or Workers’ Compensation claim could become a false claim. Examples of possible false claims include someone knowingly billing Medicare for services that were not provided, or for services that were not ordered by a physician, or for services that were provided at a sub-standard quality where the government would not pay.

A person who knows a false claim was filed for payment can file a lawsuit in Federal Court on behalf of the government and, in some cases, receive a reward for bringing original information about a violation to the government’s attention.

Whistleblower Protection. The federal False Claims Act protects anyone who files a false claim lawsuit from being fired, demoted, threatened or harassed by their employer for filing the suit. An employee who was harmed by their employer for filing a false claims lawsuit may file a lawsuit against their employer in Federal Court.

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PATIENT RIGHTSThe patient has the right to considerate and respectful care, and to be made comfortable. They have the right to respect for cultural, psychosocial, and spiritual and person values, beliefs and preferences.

Reasonable responses to any reasonable request made for service

Receive care in a safe setting, free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment.

Formulate advance directives. This includes designating a decision maker if patient become incapable of understanding a proposed treatment or become unable to communicate their wishes regarding care. Hospital staff and practitioners who provide care in the hospital shall comply with these directives. All patient rights apply to the person who has legal responsibility to make decisions regarding medical care on patient behalf.

Have personal privacy respected. They have the right to be told the reason for the presence of any individual. They have the right to have visitors leave prior to any examination and when treatment issues are being discussed. Privacy curtains will be used in semi-private rooms.

Refer to the Administrative Manual for a complete list of patient rights.

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INFECTION CONTROL

Every employee is responsible for the prevention of infection. Protect yourself and others by practicing these basic hygienic measures.

Wash hands often and appropriately Cover coughs and sneezes with disposable tissue or at least, your

hands. Wash your hands afterwards. You may also cough into yoursleeve.

Do not touch your own eyes, nose, or mouth except with freshly washed hands Wash hands after performing any personal care for yourself, such as

blowing your nose or using the restroom. Stay home from work if you have a contagious illness such as the flu or the start of a cold.

THE SINGLE MOST EFFECTIVE WAY OF PREVENTING THE SPREAD OF INFECTOINS IS PROPER HAND HYGIENE

When to wash your hands: Before starting work When hands look or feel soiled After handling blood and body fluids, even when gloves are worn Between patients Before and after eating Before and after smoking Before putting on and after removing gloves - remember, gloves are just another layer

of skin and some have microscopic holes.

When to wash with soap and water: Visibly soiled Come in contact with blood or body fluid When caring for a patient with C.difficile

How to wash with soap and water: Warm water. Water that is too hot or too cold irritates the skin Antimicrobial Soap. Enough to work up a good lather Friction: at least 15 seconds of friction is needed to remove dead skin scales and other

debris. Free-flowing water. Let it flow freely enough to adequately rinse off soap and soil Paper towel. Thoroughly pat hands dry with paper towel Use paper towel to turn off water and open door.

When to use alcohol hand gel: When you have NOT come in contact with blood, body fluids, or C.difficile. Gel in and gel out of every patient room

Hand Hygiene

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How to use alcohol hand gel:Rub into hands thoroughly until dry, paying close attention to the palms, between fingers and around any rings.

Gloves are not a substitute for hand washing.

Gloves can keep contamination in just as effectively as they keep it out. Once they are contaminated inside, they act as a reservoir for bacteria

When unwashed hands are placed inside gloves, perspiration can lead to proliferation of any infectious organisms already present on the hands.

Gloves may have very fine holes. The presence of holes can expose the HCW or a patient to an infection.

Degradation of a glove may not be visible, but it can make the glove useless and can increase the risk of bacterial migration through the glove

Perspiration inside the glove provides an optimal environment for microbial growth, which can lead to skin problems

Skin Care and Nails

Fingernails should be no more than ¼ inch in length. No artificial nails, bonding, tips, or wraps Only skin care with lotion that is compatible with hospital approved hand gel is allowed Personal lotions can accelerate the deterioration process in gloves and decrease the

efficacy of hand hygiene products, increasing the penetration of pathogens and therefore, are not allowed.

To ensure patient and healthcare worker safety, Infection Control auditors actively observe healthcare worker hand hygiene practice.

Remember… Infectious pathogens are most often carried on unwashed hands. We are responsible for

minimizing this risk.

CONTACT PRECAUTIONS - for MRSA, C-diff, VRE, RSV, and scabies to name a few Most frequent mode of transmission Required for patient’s known or suspected to be infected or colonized with resistant organisms Designed to reduce the risk of transmission by direct or indirect contact. Place patient in private room (when feasible) Wear gloves and a gown when entering the room. Change gloves after contact

with contaminated items or material. It is likely that you will come in contact with something contaminated.

Limit transporting the patient from the room to essential purposes only. C-Diff identified by black square on patient census board -

Transmission Based Precautions

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MRSA identified by black circle on patient census board.-

DROPLET PRECAUTIONS - Droplets are generated by coughing, sneezing, talking or suctioning. Most common organisms are influenza, pertussis, and meningitis. Place patient in a private room (when feasible) Wear a barrier mask that covers eyes, nose and mouth when working within

3 feet of the patient. Limit transporting the patient from the room to essential purposes only.

Place a barrier mask on the patient if transport is necessary.

AIRBORNE PRECAUTIONS - droplet nuclei remain suspended in the air for long periods of time. Airborne precautions are used for TB, Measles, chickenpox, or SARS.• Place patient in Airborne Isolation room with negative pressure• Place a HEPA filtration unit in room and turn on low• Wear a N95 particulate respirator when entering the room• Do not transport patient from the room unless absolutely necessary.• Place a barrier mask (not a N95) on the patient if transport is necessary.

OSHAAEROSOL TRANSMISSIBLE DISEASE STANDARD

Aerosol Transmissible diseases include pathogens transmitted by droplet or airborne means. Healthcare workers performing high hazard procedures are at risk of exposure to these pathogens. To provide a higher level of protection, the use of Positive Air Purifying Respirators (PAPR) are required during the performance of high hazard procedures such as: open air suctioning extubation bronchoscopy sputum Induction cardiopulmonary resuscitation

PAPRs are NOT needed for routine care of these patients. During routine care, don the appropriate mask or respirator based on the mode of transmission.

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OSHABLOODBORNE PATHOGENS STANDARD

BLOOD AND BODY FLUID EXPOSURE CATEGORIESCATEGORY I: Tasks that involve exposure to blood, body fluids, or tissues. All procedures or other job-related tasks that involve an inherent potential for membrane

or skin contact with blood, body fluids, or tissues, or a potential for spills or splashes of them, are Category I tasks. Use of appropriate protective measures should be required for every employee engaged in Category I tasks.

CATEGORY II: Tasks that involve no exposure to blood, body fluids, or tissues, but

employment may require performing unplanned Category I tasks. The normal work routine involves no exposure to blood, body fluids, or tissues, but

exposure or potential exposure may be required as a condition of employment. Appropriate protective measures should be readily available to every employee engaged in Category II tasks.

CATEGORY III: Tasks that involve no exposure to blood, body fluids, or tissues, and Category I tasks

are not a condition of employment.

METHODS of COMPLIANCECHSB understands that there are number of areas that must be addressed in order to effectively eliminate or minimize exposure to bloodborne pathogens in our facility.

1. STANDARD PRECAUTIONSTreat the following body fluids as if they are known to be infectious for HBV, HCV, HIV, and other bloodborne pathogens:

• All human blood or body fluids such as: Semen Vaginal secretions Cerebrospinal fluid Synovial fluid Pleural fluid Pericardial fluid Peritoneal fluid Amniotic fluid Saliva Any unfixed cell, tissue, or organ Wound drainage and culture medium or other solutions

• Other Potentially Infectious Materials (OPIM)

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2. PERSONAL PROTECTIVE EQUIPMENT (PPE)Employees are provided with appropriate PPE that they need to protect themselves against exposure. The equipment includes but not limited to: Gloves Gowns APRONS Laboratory coats Face shields/masks Safety glasses Goggles Mouthpieces Resuscitation bags Mouth-to-mask ventilation devices Hoods Shoe covers

Employees must use protective equipment effectively, adhering to the following practices:

• Any garments penetrated by blood, body fluid, or OPIM are removed immediately• Personal protective equipment is removed prior to leaving work area• Gloves are worn in the following circumstances:

-whenever employee anticipate hand contact with potentially infected material-when performing vascular access procedures-when handling or touching contaminated items or surfaces.

• Disposable gloves are replaced as soon as practical after contamination, tearing, punctures, or otherwise losing their ability to functions as an exposure barrier.

• Disposable gloves are to be changed between patients and between tasks on the same patient, never washed (as in hand hygiene.

• Utility gloves are decontaminated for reuse unless they are cracked, peeling, torn or exhibit other signs of deterioration.

• Masks and eye protection are used whenever splashes or sprays may generate droplets of infectious materials

• Protective clothing is worn whenever potential exposure to blood or bloody fluid is anticipated• Surgical caps/hoods and/or shoe covers are used in any instance where

“gross contamination” is expected.

3. ENGINEERING CONTROLSEngineering controls eliminate or minimize employee exposure to bloodborne pathogens. CHSBemploys equipment such as: Sharps disposal containers Devices with engineered sharps injury protection Ventilating laboratory hoods as appropriate

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4. WORK PRACTICE CONTROLS

In addition to engineering controls, our facility uses a number of Work Practice Controls to help eliminate or minimize employee exposure to bloodborne pathogens.• Employees will perform hand hygiene before and after contact with any patient• Employees will perform hand hygiene immediately, or as soon as

feasible, after removal of gloves or other personal protective equipment.• Wash hands following any contact of body areas with blood or any other infectious materials.

Also flush exposed mucous membranes with water.o When appropriate, antiseptic hand cleansers may be used. Handwashing with

soap and water should occur as soon as possible.o Use of the needleless system is preferred for preventing sharps injuries. Non-

needle sharps should include engineered sharps injury protection when available.

o Contaminated needles and contaminated sharps are not to be bent, sheared, broken, recapped, or removed unless: It can be demonstrated that there is no feasible alternative. The action is required by specific medical procedure. Whenever the recapping or needle removal is required, it is accomplished

through the use of a medical device or a one-handed technique.o Contaminated reusable sharps are placed in appropriate containers

immediately, or as soon as possible, after use.o Eating, drinking, smoking, applying cosmetics or lip balm, handling contact

lenses is prohibited in work areas where there is potential for exposure to bloodborne pathogens.

o Food and drink is not to be kept in refrigerators, freezers, on shelves, on counter tops, or in other storage areas where blood or other potentially infectious material are present.

o When a new employee comes to our facility, or an employee changes jobs within the facility, the employee must be trained in the appropriate work practice controls.

5. ENVIRONMENTAL SERVICES (EVS)CHSB set up a written schedule for cleaning and decontamination of the various areas of the facility.• All equipment and surfaces areas are cleaned and decontaminated after contact with

blood or other potentially infectious materials.

6. MEDICAL WASTE MANAGEMENTThe California Medical Waste Management Act with CHSB will provide direction on the proper disposal of biohazardous waste to include sharps waste and wastes contaminated with blood or body fluids. The following will be in red plastic bags marked with BIOHAZARD and be disposed utilizing the biohazard waste pathway.• Liquid or semi-liquid blood or OPIM• Items grossly saturated with liquid or semi-liquid blood or OPIM• Pathological and microbiological wastes containing blood or OPIM• Contaminated items containing liquid, semi-liquid, or caked dried blood or body fluids

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7. LINEN• All soiled linen is considered contaminated and is to be handled using Standard Precautions.

Wear gloves whenever handling soiled linen.

• All soiled linen will be placed into a blue bag lined linen hamper.• Do not allow bags to become more than 3/4 full.• Soiled linen is handled as little as possible and is not sorted or rinsed at any time.• If leakage is anticipated, linen shall be double bagged to prevent soak through.• Do not place soiled linen on the floor, table, chairs, etc.

EVS is responsible for the collection and handling of contaminated linen and biohazard waste

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Cleaning Product Guidelines

Sani-Cloth Plus Dispatch with bleach

Surfaces Use on hard, non porous surfaces such asFormica, glass, carts, telephones, etc.

Disinfect hard surfaces or equipment potentially contaminated with C.difficile.

Dilution Pre-mixed Pre-mixed

Efficacy • Wipe and leave on for 5 minutes• Surface must remain visibly wet for 5 minutes• Re-wet if drying occurs sooner than the

required ”wet” contact time

Wipe surfaces and leave wet for at least 5 minutes

FOR HEAVILY SOILED ITEMS:Clean the item first by removing any visible blood/fluid, then disinfect with a wipe (2 steps).

Teach visitors strategies for the prevention of infection. They are part of our safety team.

For further information, please refer to the on line Infection Control Manual or Call Infection Control Office at ext 1515

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WHAT ARE PNEUMOCOCCAL AND INFLUENZA VACCINES:• Pneumovax – Pneumococcal Pneumonia vaccine have been developed to prevent

pneumococcal infections

• Flu vaccine – Influenza vaccine have been developed to prevent influenza infections

Pneumovax Flu Vaccine

Candidates Candidates– All patients 65 years of age or

older who have not been vaccinated or unknown vaccination status

– Patients vaccinated prior to age 65 in whom ≥ 5 years have passed since first dose

– All patients between 18 and 64 years of age with any of the following conditions:

• A non-functioning spleen, splenectomy, asplenia, sickle cell disease

• Immunocompromising conditions: HIV or AIDS, leukemia, Hodgkin’s Disease, lymphoma, multiple myeloma, generalized malignancy or on immunosuppressive chemotherapy, current radiation therapy, currently on long-term steroid treatment, and organ or bone marrow transplantation

• Chronic renal failure or nephrotic syndrome

• Chronic cardiovascular disease (CHF, cardiomyopathies)

• Chronic pulmonary disease, including COPD, emphysema, asthma, and/or cigarette smoker

• Cerebrospinal fluid leak or cochlear implant

• Diabetes mellitus• Alcoholism or cirrhosis

– Inactivated Influenza Vaccine will only be administered October 1st - March 31st

– All persons 6 months of age or older

– All women who will be pregnant during the influenza season

Flu Vaccine

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Who can NOT receive vaccine Who can NOT receive vaccine– Pneumococcal Vaccine is NOT GIVEN

when:• Patient has received the vaccine

within the last 5 years.• Allergy to vaccine in past.• Patient refused vaccination.• Physician order not to give

vaccine.• Patient received or will receive

chemotherapy within 14 days• Patient with moderate or severe

acute illness with or without fever (100.4 F)

• Pregnant/lactating• Previous reaction to vaccine• Received the shingles vaccine

within the last 4 weeks

– Already immunized this flu season

– Severe allergy to eggs– Serious reaction to prior

influenza vaccine– Patient refused (RN should

notify Physician)– Physician order not to give

vaccine– History of Guillain-Barré

syndrome