Centura Health
St. Mary-Corwin Medical Center
Safety Training
Training
Handout
Revised 01/08/2016
Introduction
This handout and presentation are designed to provide an overview of the St. Mary-Corwin Medical
Center (SMC) Safety Program.
Topics include:

Emergency/Disaster Procedures

Fire Safety

Hazardous Materials/Hazard Communication

Infection Control/Bloodborne Pathogens

Electrical Safety

Back Injury Prevention

Reporting Hazards

Occurrence Reporting & Investigation

National Patient Safety Goals
For questions or concerns not addressed here please call the Director of Patient Safety at 557-5917
To Report an emergency within the hospital, dial extension 123, and report it to the communication
center.
Emergency/Disaster Procedures
It is important that all employees understand what to do in the event of an emergency or disaster.
Posted in each department are color-coded Emergency Guides that give concise, step-by-step directions
to follow for each type of emergency.
Note: We recommend that you dial extension 123 and report emergencies to the communication
center. The use of the 911 reporting system is not recommended when the emergency is within
the hospital.
When an emergency is reported to the communication center, they will announce the emergency to the
staff using the Public Address system. To prevent widespread panic within the hospital we use an
Emergency Code system for the announcements.
Overhead Emergency Codes:
Everyone should know that we have two types of overhead codes 1) Medical Codes and 2)
Emergency Preparedness Codes.
1. Medical Codes: Associates who are required to respond to Medical Codes receive specific
training on the appropriate response to the medical code/s they respond to. The rest of the
hospitals associates do not need to take any action at all.
2. Emergency Preparedness Codes: All associates are required to respond to these codes.
The codes are listed on your individual EP Code Cards and in greater detail on DocuShare,
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in the EP Guides posted throughout the facility, and additionally the code information can be
obtained from the Director of Patient Safety.
Here is a simple review of both sets of Codes: Not all are called overhead, some are paged out.
MEDICAL CODES
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Code Blue - A patient in cardiac/respiratory arrest
Code Blue Pedi – A pediatric patient in cardiac/respiratory arrest
Medical Team – A medical emergency in the ED
Trauma 1 – A trauma with significant injury
Trauma 2 – A trauma with substantial injury, less severe that a trauma level 1
Rainbow Team – A newborn in trouble, needing medical assistance
Code Purple – A visitor/employee (non-patient) requires medical assistance
Rapid Response Team- Patient condition rapidly declining
Code Stroke – Stroke team to report to the ED
EMERGENCY CODES

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
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Code Red – A fire or smoke
Code Silver – A lockdown of the facility
Code Mr. Tower – A potential hostage situation
Code Orange – A chemical/hazardous material spill
Code Pink – A missing or abducted child
Code Green (Location) – A potentially violent situation
Code Black – A bomb threat
Code Gray (level) – Disaster …

Alert – To alert and prepare associates that an event in progress will most likely
impact the hospital.

Stand-By – To alert staff the disaster plan maybe activated very soon for an event.

Level 4 – An emergency event exists and can be handled with the current staff.

Level 3 – An emergency event requires existed staff be re-assigned duties

Level 2 – An emergency event requires support that exceeds current staffing and will
require outside agencies to be involved in response.

Level 1 – An emergency event results in Federal Disaster declaration.
Fire Safety
It is important to understand that hospital fire safety requirements differ dramatically from home fire
safety. A hospital’s fire fighting and evacuation strategies are complicated by the fact that many patients
cannot be moved without assistance and/or life-supporting machinery.
Because of this we make every effort to move staff, visitors, and patients to places of safety
within the facility before evacuation.
Should the need to evacuate the hospital arise, SMC will activate its “Disaster Plan” and the
Emergency Operations Center will direct the evacuation.
Evacuation may be partial or complete and is accomplished in one of two ways.
1. Horizontally: This involves moving patients to a safe area on the same floor.
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2. Vertically: This involves moving patients downward to other floors or to the outside. Patients should
be evacuated to higher floors only under extreme emergency conditions.
SMC uses the R.A.C.E. and P.A.S.S. acronyms:
R.A.C.E. stands for the four basic steps you should follow during a fire:
•
R: Rescue or remove everyone from immediate danger
•
A: Activate the alarm or turn in an alert followed by a phone call. Turning
in the
alarm is a priority because the fire department can be on its way while other activities are being
performed. Thus, while one employee is turning in the alarm, another can be removing a patient,
employee, or visitor from danger.
•
C: Contain or control the fire. All doors and windows should be closed to prevent the spread of
smoke and flames.
•
E: Extinguish the fire or evacuate the area. This should only be done in the case of a manageable
fire, such as a fire in a wastebasket. Immediately available equipment such as a blanket, sheet, or
bedside water pitcher should be utilized to extinguish the fire. If possible, two employees should fight
the fire together using two fire extinguishers.
P.A.S.S. stands for the four basic steps for using a fire extinguisher.
1. Pull the pin.
2. Aim the nozzle
3. Squeeze the handle
4. Sweep back and forth
Hazardous Materials & Hazard Communication
In the 1970s the Occupational Health and Safety Administration (OSHA) enacted a law that requires
employers to provide information and training to employees on the hazards of the chemicals they work
with. It’s called the “HAZCOM” or “Right-to-Know” standard and it’s designed with your health & safety in
mind.
Key elements of the HAZCOM standard:
You must receive adequate training before working with hazardous chemicals. (This training plus training
from your supervisor)
Material Safety Data Sheets (MSDS) must be made available to you. (Some units retain
hard copies, but the best source is our online MSDS service at www.3eonline.com)
You must be informed of hazardous chemicals present in your work area and of
operations in which they are involved.
You should know how to detect the presence or release of a hazardous chemical.
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You must be provided personal protective equipment and engineering controls.
You must know the proper procedures for responding to emergencies.
[If you have questions at any time about chemicals, hazardous materials, and our Hazard
Communication program, please contact your supervisor, and/or the Director of EVS services.]
Material Safety Data Sheets:
Manufacturers prepare Material Safety Data Sheets for each chemical they produce. It describes the
physical and chemical properties of the product, the health hazards, and appropriate emergency
response procedures. And, it can tell you of acute and chronic effects that can be caused by exposure to
hazardous chemicals.
Each work section that uses or stores hazardous chemicals will have a listing of the chemicals they use
and copies of each chemicals MSDS. Copies of all MSDS’s applicable to SMC are available on-line at:
www.3eonline.com
To log into the system the Username is: SMCMC1 and the Password is SMCMC99.
If you cannot access the site please contact the Director of Environmental Services
at ext 885369
Infection Control & Bloodborne Pathogens
Infection Control:
The goal of surveillance, prevention, and control of infection is to identify and reduce the risk of acquiring
and transmitting infections among patients and others.
STANDARD PRECAUTIONS
FOR EVERY PATIENT
Hand washing! Hand washing!
Foam in and foam out in every room!
ALWAYS USE UNIVERSAL PRECAUTIONS
Blood/Body Fluids: Use Universal Body Substance Precautions.
Regular Waste: Place items with non-infectious waste, contaminated with little or no
blood or body fluids into white/clear trash bags.
Infectious Waste: Red bag only items that contain 1cc or more of blood/body fluids.
Needles-No Recapping: If necessary, use one hand
technique. Change sharps containers when filled to the
designated line on the container.
Personal Protective Equipment: Gloves, gowns, masks, goggles/face shields.
Know Location of: Bloodborne Pathogen Exposure Control Plan, and Infection
Control Plan
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The Exposure Control Plan Covers:

Universal Precautions

Isolation Precautions

Hand washing

Housekeeping

Sharps

Infectious Waste


Infectious Waste Management
Contaminated Sharps Discarding

Eating, Drinking and Smoking

Specimen Containers and Storage

Linen/Laundry

Personal Protective Equipment

Hepatitis B Vaccination/Post-Exposure and
Follow-Up

Gloves

Gowns & Aprons

Masks

Goggles

Caps/Goods/Shoe Covers

Waste Handling Procedures

Hepatitis B Vaccination

Post-Exposure and Follow-up

HIV Virus Post-Exposure management

Documentation of Exposure and Reporting

Management of HIV Infected Associates
20-Second Health Care Hand wash:
The objective of the 20 Second Health Care Hand Wash is the simple removal of soil and potential crosscontaminants acquired in the course of daily living or patient care. It is indicated in the following
situations:

Before and after routine patient contact

Before/after routine patient bathing

Before handling food

For personal hygiene
The procedure for the 20-Second Health Care Hand Wash is as follows:
1. Evaluate the availability of clean towels. If the towel dispenser has a “common” turn handle, crank,
push-button or other contaminated access knob, obtain towel first. Until ready for drying, place the
towel in a clean area—for example, between the elbow and clothing.
2. Turn on the water.
3. Wet hands.
4. Obtain soap and spread it around to all areas of the hands.
5. Rub the hands together with vigorous friction and cleanse all areas of the hands and wrists. Keep the
hands lower than the elbows so that dripping occurs from the fingertips. Do not touch the faucet,
handles, or sink itself. Avoid wetting of clothing by standing back slightly from the sink.
6. Rinse the hands thoroughly with running water, if available, or use other means to remove soap.
Allow excess drips to go into the sink. Do not flip water off the hands.
7. Dry the hands thoroughly with a clean towel or by air.
8. Turn off the water without contaminating clean hands.
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9. Discard the used towel in an appropriate container.
For questions please contact the Infection Control Nurse at extension 5719 or pager 586-1623.
Electrical Safety
Zzzzztttttt. POP! That’s the last sound you want to hear when dealing with electricity, and
unfortunately, many people each year are injured or killed when working on or around
electrical devices. This often happens because they lacked the proper training or tools to
work safely when dealing with hazardous electrical energy.
According to OSHA "Electrical equipment or electrical system design, installation,
modification, testing, repair, and maintenance shall be done by QUALIFIED AND
AUTHORIZED electrical personnel." At SMC, only qualified technicians will perform all work on electrical
equipment.
SMC Policy on Extension Cord Use Includes:

The use of extension cords will be limited to temporary use only.

Only facility owned UL approved cords will be used within the hospital (they are issued by the
Maintenance Department).

All extension cords will be 3-wire, #16 gauge or better and grounded.

Two or Three prong plug adapters are strictly prohibited.

The use of multiple circuit adapters must be approved by the Maintenance Department.

Cords requiring repair, inspection, or replacement should be submitted to the Maintenance
Department.
Note: Personal electrical equipment brought into the facility will be approved for use by the supervisor or
safety monitor. Personal electrical equipment must be in good operating condition at all times.
Equipment may be non-grounded (2-wire type) however; it must have UL approval markings on the case.
Safe electrical work practices:

Avoid wet working conditions and other dangers

Use Ground Fault Circuit Interrupters. GFCI's are electrical devices that are designed to detect
ground faults (when current is "leaking" somewhere outside its intended pathway). If your body
provides the path to ground for the leaking current, you could receive a shock or be electrocuted.
GFCI's should be used in all wet locations and on outside outlets.

Use proper wiring and connectors

Use extension cords properly and temporarily:

Cords must be UL listed and have 3 prongs

Power bars must have a fuse or breaker

Do not use 2-prong, ungrounded cords in a lab

Do not run cords through walls, doors, under rugs, or across aisles

Do not repair cords--buy new ones
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
Make sure the total number of watts connected to the cord does not exceed the rating of the cord.
Before working on electrical equipment, maintenance will follow proper the appropriate Lockout/Tagout
procedures. Lockout/Tagout (LO/TO) is a process that ensures that energy sources are controlled in the
off position so a worker is not exposed to that energy source. Please contact the Safety Officer for any
questions regarding LO/TO procedures.
Biomedical Equipment:
BIOMEDICAL ENGINEERING
The Clinical Engineering Department
manages an aggressive Preventative
Maintenance program with an emphasis
electrical safety inspection, verification of
operation, and calibration. Clinical
Equipment included in the Preventative
Maintenance Program can be identified by
Inspection/PM sticker that shows the
following:
BY
2
on
proper
DUE
an
DATE
 Date: The date when the PM was
completed.
 By:
The initials of the technician performing the test.
 Due: The large number in the center is the month due. The Due line shows the last two digits of the
year due.
Back Injury Prevention
Body Mechanics & Safe Lifting:
Body mechanics refers to the application of principles of human anatomy and lever
systems in a manner that improves ease, efficiency and safety in activity.
Basic Principles:
1. Use stronger muscles over weaker muscles (i.e. lifting with your LEGS and NOT YOUR BACK).
2. Maintain the natural curves in your back during activity and lifting.
3. Pushing weight is safer than pulling weight.
4. Keep the weight of the object close to your body when lifting.
5. Maintain a wide base of support with your feet.
6. Stabilize muscles of the back during lifting or other activity (i.e. contract abdominal muscles).
7. PLAN your movements, especially when lifting with another person.
8. GET HELP when needed.
9. If lifting a person, tell them how to help you when able.
10. Do not combine twisting or bending with lifting:
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
Use legs, shift weight, pivot turn feet and body toward the direction you are going to substitute for
bending and twisting when you lift.
Rules of Body Mechanics
When Lifting:

Check footing: Keep feet shoulder-width apart for:

A wide base of support

Better balance

Stability
Move close to person / object:

Hold person / object close to the body.

Keep objects low.

Do not reach.
Squat:

Do not use back muscles.

Do bend hips and knees

Do keep back straight.

Do not lift with your arms.
Use legs when lifting:

Squat.

Straighten legs while lifting.
Turn, do not twist:
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Take small steps to turn.

Do not twist the body.
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Do’s and Don’ts of the Workstation
Don’t reach. Don’t work outside of the “ergonomic window” (the natural swing radius of the arms when
the elbows are placed at the sides).
Do keep your work within the “ergonomic window”.
Don’t bend your wrists to type.
Do keep your wrists in a neutral position and take frequent stretch breaks
2016 NATIONAL PATIENT SAFETY GOALS
GOAL #1: IMPROVE THE ACCURACY OF PATIENT IDENTIFICATION
01.Identification starts at the time of registration (this is the first
validation) (Policy: Patient Identification III-A.10.f)
01.Use at least two patient identifiers
03. Providing care, services, nutrition, administering medications or
blood products; collecting blood samples and other specimens for
clinical testing, or providing any other treatments or procedures.
03. Containers use for blood and other specimens are labeled in the
presence of the patient.
03. Eliminate transfusion errors related to patient misidentification by
matching blood or blood component to the order during a two-person
bedside or chair-side verification process, (bar coding).
01. Always use name & Date of birth with all new orders.
SMC’s two patient identifiers are patient NAME AND DATE
OF BIRTH.
GOAL #2: IMPROVE THE EFFECTIVENESS OF COMMUNICATION AMONG CAREGIVERS.
03. Measure, assess and, if appropriate, take action to improve the
timeliness of reporting, and the timeliness of receipt by the responsible
licensed caregiver, of Critical results and Diagnostic procedures and
values.
(Policy: Notification Process of Critical Tests & Critical Values, III-A1.ff)
Critical Values
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03. The organization defines critical results and values, reporting and
receipt by the responsible licensed care giver. Chart it in LIP
notification
We measure the time frames of reporting, receipt by caregiver and
reporting to the physician
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GOAL #3: IMPROVE THE SAFETY OF USING MEDICATIONS.
04. Label all medications, medication containers (e.g., syringes,
medicine cups, basins), or other solutions on and off the sterile field in
Perioperative and /or Other Procedural settings. i.e. Labeling occurs
when any medication or solution is transferred from the original
packaging to another container and includes drug name, strength,
amount, expiration date when not used within 24 hours, and expiration
time when expiration occurs in less than 24 hours. (Policy: Medication
Labeling in Procedural Areas, MM 202)
05. Reduce the likelihood of patient harm associated with the use of
Label all Meds in OR & procedure settings
anticoagulation therapy. We have implemented a hospital-wide
Teach how to prevent Blood Clots
program to individualize the care provided to each patient receiving
anticoagulant therapy. This includes baseline lab, and education on
dietary /medication interactions with patient and families as well as
monitoring the effectiveness of the treatment. (Policy: Anticoagulation
Clinic Services Pharmacy #8.0, Antithrombotic Therapy for Deep Vein
Thrombosis (DVT) Prophylaxis , Clinical #6)
03. Medication Reconciliation; Maintain & communicate accurate
patient medication information.
(Policy: Centura Health P/P Medication Reconciliation,III.B.b)
A. A process exists for comparing the patients current medications
with those ordered for the patient
While under the care of the organization.
B. Complete the list of the patient’s medications is communicated to
the next provider of services and
Communication is documented and the complete list is provided to
the next provider of services. The
complete list of medication is also provided to the patient on
discharge from the Facility.
C. Reconcile Discharge Medication patient list with MD Discharge
Medication orders
Goal #6 Reduce the Harm Associated with Clinical Alarm Systems
Improve the safety of all climical alarm systems.
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A. Policy will be developed identifying safe alarm system practices.
B. Risk Analysis will be conducted to identify high risk alarms on
each unit.
C. Alarms will be set to be patient specific and parameters set to
decrease alarms on the units.
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GOAL #7: REDUCE THE RISK OF HEALTH CARE-ASSOCIATED INFECTIONS
01. Comply with current Centers for Disease Control and prevention
(CDC) hand hygiene guidelines.(Policy: Hand washing)
Foam in and Foam Out when entering the patient’s room and/or
providing treatments, services or passing Medications.
03. Implement evidence-based practices to prevent health careassociated infections due to multidrug-resistant organisms in acute
care hospitals. (Policy: Isolation Discontinuing contact Precautions for
MDRO’s & C-Difficile & Flagging Multi Drug Resistant Organism IC
001)
This applies to, but it not limited to MDRO’S, MRSA, VRE, C Diff and
Multiple Drug Resistant gram negative bacteria.
04. Implement evidence-based guidelines to prevent central lineassociated infections and surgical site infections. (Policy, Peripherally
Inserted Central Catheters (PICC’s) care, maintenance & Removal,
III A. 26)
The Central Line Bundle is followed Hospital wide and in ICU.
Monitoring for all central-line infections is ongoing. We participate
in the SCIP (Surgical Care Improvement Project) and Central Line
WASH YOUR HANDS: GERMS LIVE
program.
THERE
05. Implement evidence-based practices for preventing for preventing
surgical site infections,(SCIP Core Measure Guidelines)
06. Remove Indwelling Catheter within 24 – 48 hours post operative
when ordered. (Policy; Monitoring use of Indwelling Urinary
/Catheters & Reducing the Risk of CAUTI’s, III-A.13.i)
GOAL #15 THE ORGANIZATION IDENTIFIES SAFETY RISKS INHERENT IN ITS PATIENT POPULATION
A. The organization identifies patients at risk for suicide. General
hospital patients are higher risk for suicides: Factors include Dementia,
Traumatic Brain Injury, Chronic or Intense pain, poor or terminal
prognosis and substance abuse.
All patients are screened for risk factors on admission using the
scripted questions from the Clinical Information System
Ask the questions on the General Admission screen in the Clinical
Support System
Have you had thought of harming yourself or others within the past 6
months?
Have you had any major stressors or changes in the past year?
Have you had any recent losses or Traumatic experiences in the past
year?
Please consult the Psych-liaison staff to help with care
Universal Protocol for Preventing Wrong Site, Wrong Procedures. and Wrong Person Surgery
A. Conduct a Pre procedure verification process
B. Mark the Procedure site
C. A time out is performed before a the procedure
Use the Script Prevent an error
(Policy: Universal Protocol, III-A.10,k)
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Reporting Hazardous Conditions
If you find a hazardous condition within SMC you should immediately report it to the associate or
supervisor responsible for that area.
If it cannot be corrected immediately (on the spot), please contact the Director of Patient Safety.
We will assess the hazard and make recommendations for correcting the condition and determine what
interim measures can be taken to mitigate to possibility of an accident occurring while awaiting long-term
corrective actions.
Occurrence Reporting and Investigation
SMC has developed programs for reporting and investigating accidents and occurrences. Specific
program elements are listed in the Safety Management Plan.
Staff Injury/Exposure Reporting: If an employee is injured on the job, they are to report to the Employee
Health Office, and an Employee Incident Report is completed. The Employee Health Office and the
Director of Patient Safety review employee Incident Reports.
Occurrence Reporting: The Occurrence Report is used to document occurrences that involve patients.
This form is completed via Meditech by the staff member, and is reviewed by the up line supervisor as
appropriate. The completed on-line forms are forwarded to the Director of Patient Safety as well as the
Quality Department for review and assessment/disposition. All occurrence reports are confidential.
Again, for questions or concerns not addressed here please call the Patient
Safety Manager at 557-5916.
And remember to report an emergency within the hospital, dial extension
123, and report it to the communication center.
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Centura Health
St. Mary-Corwin Medical Center
Safety Training Packet Review
DATE:__________________ DEPARTMENT:__________________________
ASSOCIATE/CONTRACTOR NAME
(PRINT):_________________________________________________________
ASSOCIATE/CONTRACTOR
SIGNATURE:_____________________________________________________
SUPERVISOR’S NAME
(PRINT):_________________________________________________________
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