SECTION 1 - INTRODUCTION AND PURPOSE
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SECTION 1 - INTRODUCTION AND PURPOSE
We are pleased to welcome new medical
staff and affiliated allied health staff to our
facility. In order to assist your transition to
Capital Regional Medical Center, we have
developed this manual. The content to be
addressed will include, but not be limited
to the following areas: the mission and
values of Capital Regional Medical Center
and the role employees and medical staff
share in achieving the goals set forth in
the mission; patient rights and
confidentiality; the quality improvement
program and each individual’s role and
responsibility; general and specific safety/EOC and health information; risk management and
organizational ethics; infection control protocols; specific OSHA, AHCA and State of Florida
requirements; and important policies.
After completion of this education, you should be able to:
Identify the policies and procedures that ensure the safety of our patients
Describe or demonstrate your role and responsibility in performing your job safely
Understand the everyday precautions used to minimize risk to your health and safety
Practice, and be aware of, the CRMC organizational values, standards, and traditions
Comply with the laws and regulations governing the health care regulatory environment
in which we work
Promote workplace behaviors that fit CRMC expectations
The Joint Commission is a national organization that surveys and accredits health care
organizations using set standards and participation requirements regarding hospital practices
and processes to improve the safety and quality of care provided to the public. The Joint
Commission Human Resource Standard on Orientation, Training, and Education and
Environment of Care Standard on Safety require staff members, students, medical staff and
volunteers to be appropriately oriented to the facility.
OSHA (Occupational Safety and Health Administration) is the Federal agency that assures the
safety and health by setting and enforcing standards. At CRMC we are required through OSHA
Standard 1910.1030 to provide training, outreach, and education regarding bloodborne
pathogens and other potentially infectious materials, exposure incidents, personal protective
equipment, sharps handling, Hepatitis B vaccination protection, and ergonomics guidelines as
outlined in this study module.
AHCA (Agency for Health Care Administration) is an agency of the Florida Department of
Health and Human Services. AHCA oversees the regulation of hospitals, ambulatory surgical
centers, home health agencies, clinical laboratories and other providers. They oversee the
processes relating to Health Care Risk Management and monitor the risk management patient
injury reporting processes, as outlined in this study module, and risk management inspections
and surveys. AHCA also assures that each facility is Life Safety compliant, by performing an
on-site annual Life Safety facility evaluation as well as EOC Program document review.
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SECTION 2 - CRMC ORGANIZATIONAL CULTURE
The VISION and MISSION of Capital Regional Medical Center is:
“Above all else, we are committed to the care and improvement of human life. In recognition of
this commitment, we will strive to improve the quality of healthcare in the communities we
serve.”
In pursuit of our mission, we believe the following value statements are essential and timeless.
We will recognize and affirm the unique and intrinsic worth of each individual.
We will treat all those we serve with compassion and kindness.
We will act with absolute integrity and fairness in the way we conduct our business and
the way we live our lives.
We will trust our colleagues as valuable members of our health care team and pledge to
treat one another with loyalty, respect, and dignity.
CUSTOMER SERVICE PHILOSOPHY
We view the way we treat our customers as the most important part of our jobs, and because of
that we are committed to providing excellent service at all times. We provide new employees
with Customer Service training in orientation. All other employees are required to review
Customer Service training once a year as one of their tenure requirements.
• We handle sensitive situations with our customers quickly and effectively by using the
Service Recovery method A-L-E-R-T to resolve customer complaints.
….Apologize. “I’m sorry this happened…”
….Listen with understanding. “Help me understand your problem.”
….Empathize. Put myself in the customer’s shoes. How would I feel in
this situation?
….Respond to resolve the customer’s problem. Use my empowerment.
….Tell Someone to make sure the problem doesn’t happen again.
CUSTOMER SERVICE STANDARDS OF BEHAVIOR
The Customer Service Standards of Behavior, developed by hospital staff members, are a
measure of overall work performance. All staff members are expected to adhere to and practice
the standards of behavior developed by staff members. There are a total of seven standards.
High importance is placed on each standard, beginning with the first standard that addresses
our primary customer, the patient. Look for the Customer Service hallway on the first floor
across from the Pharmacy Department for more information about our seven standards.
DIVERSITY COMMITMENTS and EXPECTATIONS
“At HCA, we will provide cross cultural competent care to all patients we serve. We will foster a
culture of inclusion across all areas of our company that embraces and enriches the diversity of
our workforce, physicians, patients, partners, and communities.”
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The above diversity statement is a reflection of our appreciation for the people who work here
and the customers we serve. The leadership of the organization has recognized diversity as a
rich component of organizational culture.
Our Commitment to Diversity, Inclusion and Cross Cultural
Competence
We are committed to an inclusive environment which embraces and
enriches our patients, workforce, physicians, communities and business
partners.
What do we mean by Diversity, Inclusion and Cross Cultural
Competence?
Diversity is the collective mixture of differences and similarities. It is inherent in any group even
when the group may not be visibly diverse. Diversity includes but is not necessarily limited to
race, ethnicity, nationality, gender, age, sexual orientation, physical abilities, communication
style, problem solving styles, personality, conflict resolution styles, occupation, education level,
socio-economic status, marital status, geography, etc.
Inclusion
Creating an environment where all talent is engaged and fully utilized.
Cross Cultural Competence
A continuous learning process to develop knowledge, appreciation, acceptance and
skills to be able to discern cultural patterns in your own and other cultures and be
able to effectively incorporate several different perspectives into problem solving,
decision making and conflict resolution
HCA has a website that will provide you with information on different cultures. CultureVision -
general information as well as specific information related to health care beliefs and practices
www.crculturevision.com
Go to client log-in
username: hcadiversity
password: respect
The diversity commitments and expectations go hand in hand with the Customer Service
Standards of Behavior and Employee Standards.
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SECTION 3 - ENVIRONMENT OF CARE SAFETY STANDARDS
CRMC strives to be in compliance with the Joint Commission Environment of Care Standards.
These standards contain recommendations for health care organizations to provide a safe,
secure, functional, supportive, effective and efficient environment for patients, staff members
and other individuals in the hospital. This is crucial to providing quality patient care and
achieving good outcomes.
To achieve this goal, the following education about your role in the environment and the
processes for monitoring, maintaining and reporting on it are listed.
SAFETY MANAGEMENT
All hospital and medical staff are required to act in a safe and
responsible manner that does not place themselves or others at risk.
Safety Risks in the hospital environment include:
Risk of exposure to infectious disease.
Risk of other accidental injury, i.e., back sprain, slips, falls.
Risk of chemical, gas or radiation exposure.
Risk of injury through direct patient contact.
Medical staff must take the following actions to eliminate, minimize or report safety risks, as
follows:
Identify potential physical or procedural safety hazards or risks and promptly
recommend preventive safety measures.
Correctly follow CRMC policies and procedures.
Use Standard Precautions & special Transmission Prevention Precautions
All medical staff have a duty to report unsafe conditions or acts so that they may be addressed.
The Environment of Care Team monitors the Safety Management Program. It promotes a safe,
secure, functional, supportive, effective and efficient environment. Medical staff may report
concerns to any director or to Administration.
Areas monitored in the safety program include:
Internal/External departmental safety plans,
policies, procedures and drills.
Employee safety knowledge.
Risk to customers and property.
Hazard surveillances.
Fire Prevention.
Utility / Equipment Management.
Emergency Preparedness.
Hazardous Materials.
Security Management.
Product safety recalls.
Maintaining a smoke-free environment.
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Everyone has a duty to report unsafe conditions or acts to assist in correcting safety
violations. Our Hazard Surveillance Program assists in determining any safety violations
before any adverse event may occur. Inspections conducted by external officials may include,
but are not limited to:
Florida Department of Health
Agency for Health Care Administration
Department of Environmental Protection
The Joint Commission
OSHA
SECURITY MANAGEMENT
There are three major areas of concern in security management:
1. Minimizing security risks in CRMC facilities, parking lots and high-risk areas of the
hospital.
2. Handling security incidents involving patients, families, visitors, physicians, employees
and property.
3. Coordinating emergency security procedures and involving the appropriate staff related
to emergency security codes.
Reporting Security-Related Incidents
Medical staff should report security-related incidents to any director or to Administration as soon
as possible.
Security-related incidents include but are not limited to:
Theft (larceny and felony)
Lost and Found
Vehicle Accident
Personal Threatening Situation/ Hostile Environment
Safety or Hazardous Conditions Reports
General Information Reports
Call 2121 and report Code Grey for security emergencies
CRMC Security will notify proper authorities, depending on the severity of the incident. Hospital
or medical staff should not risk harm or injury to themselves if there is a security incident or
failure.
Biomedical Waste, General Waste, and Hazardous Materials Management - (Chemo)
Biomedical waste must be segregated, handled, labeled,
transported, stored and treated in a manner that protects
the health, safety and welfare of our patients, staff and
environment in accordance with Chapter 64E-16 of the
Florida Administrative Code and OSHA Standard
1910.1030.Biomedical Waste is: Any item for disposal that
is contaminated with any of the following body fluids:
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Any item contaminated with any of the body fluids listed below needs to be disposed of directly
into a red Biomedical Waste Bag at the point of origin. These red-bagged items are incinerated
at a location away from the hospital.
Blood Semen Vaginal Secretions
Cerebral Spinal Fluid Joint Fluid Pleural Fluid
Peritoneal Fluid Pericardial Fluid Amniotic Fluid
General waste is disposed of in clear bags and is transported to a local landfill for final disposal.
General waste is defined of as any type of waste that is NOT contaminated with blood, semen,
vaginal secretions, spinal fluid, synovial fluid, pleural fluid, pericardial fluid, amniotic fluid or
lymph. Examples of general waste are:
Disposable plastics and unbroken glass
Body excretions or secretions, e.g., feces, urine, sputum, vomitus, not
contaminated with visible blood
Paper products
Under the OSHA Right To Know Act, you have a right to
know about:
1. Hazards of specific chemicals used in your work
setting.
2. Personal Protective Equipment (PPE) needed to
prevent injury.
3. How to handle hazardous chemicals properly to
protect yourself and others.
Material Safety Data Sheets (MSDS) provide specific
information about hazardous chemicals such as:
Chemical manufacturer’s name
What actions to take if exposed to a hazardous chemical
The content of the chemicals used in your area
MSDS master files are located in Materiels Mgmt. and the Emergency Room.
The MSDS book specific to your job function should be easily located in your
department.
MSDS can also be located on the CRMC website – Haz Soft link
Chemicals should be stored in the original
container or a new container must be relabeled
with exactly the same information as the original
label.
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EMERGENCY MANAGEMENT PLANS
Your role and responsibilities for responding to emergencies are based on the Incident
Command System and the medical needs of the situation. The Emergency Color Codes used
during overhead announcements indicate the type of emergency or exercise being conducted.
You may expect to participate in Emergency Color Code exercises at any time. There are
specific policies that reference each Color Code. A Safety Kardex is available in the
Physician’s Lounge. The kardex explains the type of code and general responsibilities.
Emergency Preparedness
The CRMC Emergency Preparedness Management Plan provides guidance on organizational
and community-wide emergencies affecting the CRMC.
Emergency Phone Numbers
Report Emergencies – 2121 (within the facility)
Safety Officer – 5095
Security – 4141
Risk Mgmt – 5056
Administrative Supervisor – 5014, 8282 and 8283
Administration – 5015
Definitions of Emergency Color Codes
Code Black – Bomb Threat
Code Blue – Cardiac / Respiratory Arrest
Code Grey – Security Emergency
Code Green – Disaster Plan
Code Orange – Hazardous Material/Bio Terrorism
Code Brown – Extreme Weather
Code White – Hostage/Weapon Situation
Code 500 – Sudden influx of unanticipated patients in the ED/Staffing Need
Code Red – Fire
Code Pink – Infant/Child Abduction
Bomb Threats/Suspicious Package Plan (Code Black)
Bomb threats should ever be taken lightly. Even a false threat is a
serious crime. All threats are treated as actual situations.
Do not touch anything suspicious. Instead, look at any unusual
package in your areas from a reasonable distance.
Use precaution in identifying suspicious packages or written letters
that may contain inappropriate labeling, strange return addresses, an
obvious presence of powder, or excessive packaging material.
Upon being informed of the receipt of a bomb threat, PBX will
implement the response by notifying all departments using the
overhead paging system announcing “Code Black” 3 times.
PBX will also announce “We are maintaining radio silence. Please refrain from using cellular
phones until further notice”. This will be repeated every ten minutes until the all clear has
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been given. If the location of the bomb is given, PBX will not announce “Code Black” but
will announce the radio silence message
PBX will notify the CEO/Administrator on Call/designee of the bomb threat.
Local law enforcement and fire departments will be notified. The news media will not be
notified.
Cardiac / Respiratory Team (Code Blue)
Dial 2121 and request the Code Blue Team..
Security Emergency / Violent Situation (Code Grey)
This can be any situation in which you feel your safety or the safety of a patient, family member,
visitor or anyone in the area is threatened.
Disaster Plan / Multiple Casualty (Code Green)
The general Disaster Response Plan or Code Green is used when a disaster involves multiple
victims at one time. Examples would include a plane crash, or multiple car accident.
Often there is only minimal time to prepare for a multiple casualty situation.
Hazardous Material / Bio Terrorism (Code Orange)
In the event of an external situation involving contamination of victims with hazardous materials
such as biological agents, chemicals, radioactive material or toxic waste, Capital Regional
Medical Center will prepare to receive victims and set up a
decontamination area.
Extreme Weather (Code Brown)
This code includes a tornado, hurricane and severe thunderstorm
warnings in our immediate area. Hospital staff will secure the facility and
implement actions to protect patients.
Hostage / Weapon Situation (Code White)
Any situation where an individual is being held against his/her will by an armed perpetrator.
Call the PBX operator – 2121 and state your name, location and as much information as
possible.
Code 500 – A sudden influx of unanticipated patients in the Emergency Dept. / Staffing Need.
This emergency code will be used to provide the emergency department with additional
personnel in the event of an unanticipated emergency situation, such as several critical patients
arriving at the same time.
Life Safety Management (Fire) – (Code Red)
Life safety management means that specific preventative safety measures should be used to
avoid or respond to life threatening situations involving fire or other disasters.
Do not cross fire zones during a fire or fire drill except in a patient emergency.
The hospital’s assembly point in the event of total evacuation. (parking lot of 2626 Care
Drive Office bldg.)
All corridors should have an 8 ft. clearance at all times.
In the event of a CODE RED, stay within a Smoke / Fire Compartment and wait for
further instructions. NEVER BREAK THROUGH A FIRE BARRIER (self closing doors).
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The Plant Operations Director / Manager and the Tallahassee Fire Department are
the only people authorized to order evacuation procedures.
Fire drills and fire safety procedures are unannounced, conducted and monitored on a regular
basis. Know what the acronym “RACE” stands for in case of a fire:
R = Rescue persons in immediate danger. (only if safe to do so)
A = Activate alarm. Pull the nearest station and call 2121 and report Code Red.
C = Contain the fire by closing all doors and windows.
E = Extinguish the fire with the use of a fire extinguisher. (only if safe to do so)
Signs are mounted near doorways, elevators throughout the facility to
indicate your position and evacuation route if needed due to a fire in
your area.
To safely extinguish a manageable fire, remember the key word
“PASS” for the correct steps in operating an extinguisher:
P = Pull the pin from extinguisher handle.
A = Aim at base of fire.
S = Squeeze handle to spray chemical / discharge extinguisher.
S = Sweep across (side to side) at the base of the fire to completely
cover and extinguish. Once the chemical settles, watch for a re-flash.
Fire or fire drill key actions are:
1. Know locations of fire pull stations and fire extinguishers.
2. Close doors in corridor areas.
3. Know how to activate the fire alarm in your area.
4. When calling the operator, correctly identify fire location.
Medical Gases will be shut off by Respiratory Personnel by order of the Fire
Marshall or Senior Administrative Representative on-site.
Risk of Infant or Child Abduction (CODE PINK)
Infants and children are at risk of abduction while they are patients at the hospital.
If a “code pink” overhead announcement is made, staff is required to take immediate
action:
Go to the nearest stairwell, doorway, or hallway while a room-by-room search of the unit
takes place.
Be observant of any suspicious person who may or
may not appear to be carrying something.
Watch for individuals carrying gym bags, shopping
bags, backpacks, etc. Babies are rarely carried in
an abductor’s arms.
You may ask someone to wait until the “all clear” is
announced if you suspect that person, or you
should walk with or follow him or her and ask a co-
worker to call X2121 for you. A word of precaution
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– do not try to take a baby or child away from an adult or physically block a person’s
progress. It is against the law to detain someone against his or her wishes.
SAFE HAVEN FOR NEWBORNS
A safe haven is a safe place where newborns may be left by a
parent who wishes to terminate their parental rights. They are
created to protect newborns from harm and injury. Florida
statute designates 1) hospitals, 2) emergency care centers,
and 3) fire departments as safe havens.
The CRMC staff is expected to follow procedures for
newborns that are left by their parent at a safe haven if they
become aware of this act:
If a newborn is left within the CRMC campus the infant must be taken to the Emergency
Room. If the newborn is left anywhere other than the CRMC campus, the infant must be
transported to the ER via Emergency Medical Services (EMS). Health care professionals
can consider the act of a parent leaving a newborn as implied consent for treatment.
The act of a parent leaving a newborn in a safe haven is not to be considered child abuse or
neglect unless signs of abuse are noted. The law presumes the parent who leaves a newborn
does not intend to return for the infant and consents to termination of parental rights.
UTILITY SYSTEMS SAFETY
Plant Operations is responsible for having the knowledge and skills necessary to perform
maintenance on the utility systems in the organization. All employees have an obligation to
practice safe use of these systems and to know the process for reporting utility system
problems, failures and user errors.
Utilities management provides for the safe and reliable operation of all utility systems to
maintain a safe, comfortable Environment of Care and reduce risk in the event of any utility
disruption. Our utility systems impact a variety of systems such as life support systems, infection
control, environmental support equipment and communication systems throughout the CRMC
organization.
You should know that in the event of power loss, the Hospitals Emergency Generator will
start within 10 seconds. While operating on Emergency Power, only RED OUTLETS will
work.
Electrical Safety is an important responsibility for everyone. Follow these important reminders:
Red Outlets are considered a life safety branch and are only used for critical medical
equipment.
Immediately report faulty, broken or malfunctioning electrical equipment to Plant Operations.
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MEDICAL EQUIPMENT SAFETY
Hospital and medical staff using medical equipment as part of their job responsibilities must use
the specific safety procedures related to the equipment. Training on the capabilities, limitations,
and special applications of equipment must take place in accordance with manufacturer’s
guidelines and with departmental policy.
When an equipment failure or problem is identified, the equipment will be marked with a
red tag that states “DEFECTIVE MAINTENANCE REQUIRED”, removed from service.
The red DEFECTIVE MAINTENANCE REQUIRED tag must be filled out by an
employee with the knowledge of the equipment problem.
If any patient, employee or medical staff is injured due to an equipment failure or
problem, refer to policy 901.191, Safe Medical Device Act (SMDA) Medical Device
Reporting.
The users and maintainers of medical equipment must have the knowledge and skill to
be able to demonstrate or describe these specific safety measures, based on
department policy.
SECTION 4 – INFECTION CONTROL AND BLOODBORNE PATHOGENS
The Centers for Disease Control and Prevention
estimates that, approximately 2 million patients each
year acquire infections not related to their admitting
diagnosis. It is estimated that hospital-acquired
infections result in approximately 90,000 deaths and add
$4.5 to $5.7 billion in health care costs. It is also
estimated that possibly one-third of these hospital-
acquired infections may be prevented if current
guidelines are followed.
Hand Hygiene - Washing your hands is the most
important thing you can do to help prevent the
spread of infection.
Soap and water should be used when hands are visibly
soiled and when C.difficile or Anthrax is known or suspected. It takes only 10-15 seconds to
clean your hands with soap, running water and friction. An alcohol based hand antiseptic may
be used when hands are not visibly soiled. A golf-ball sized amount of alcohol foam is rubbed
into the hands until the hands are dry.
When should you wash your hands?
• When you get to work • When you leave the restroom • When they are dirty
• When you go home • After eating • After coughing
• Before eating • After removing gloves • After blowing your nose or
sneezing
• Before touching your face or eyes • Between patients • Between body sites on the same
patient
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STANDARD PRECAUTIONS and PERSONAL PROTECTIVE EQUIPMENT (PPE)
Standard precautions is a system of barrier precautions used by all personnel when there is a
potential for contact with blood, all body fluids, secretions, excretions, non-intact skin and mucus
membranes of ALL patients. CRMC provides Personal Protective Equipment (PPE) at no cost
to employees. PPE are the barriers that provide protection to hospital and medical staff and
include gloves, masks, goggles, gowns, booties and caps.
Gloves are to be worn if there is a potential for your hands coming
in contact with anyone else’s blood, body fluids, secretions,
excretions and non-intact skin or mucus membranes. Gloves
must be changed between tasks and procedures. Gloves are removed
when they become contaminated, damaged and before leaving the
work area. Gloves should be removed by peeling one off from
top to bottom and holding it in the gloved hand. With the exposed
hand, peel the second glove from the inside, tucking the first glove inside the second. Dispose
of them immediately and then thoroughly wash your hands.
Mask and goggles are worn during procedures and patient care activities that may generate
splashes or sprays of blood, body fluids, excretions or secretions to the employee’s eyes or
face.
Gowns are worn to protect the skin and prevent soiling of clothing when
performing patient care duties likely to produce splashes or sprays of blood
or body fluids or cause soiling of clothing.
Booties and caps are available to protect the shoes from splashes and
contamination. Hair covers (caps) are also available.
Hospital and medical staff must remove all PPE and place it in the
designated area or container for disposal prior to leaving the work area (i.e.
patient room, surgical or invasive area).
It is the medical staff member’s responsibility to use PPE when indicated and to remove any
PPE that becomes penetrated by blood or other potentially infectious material as soon as
possible. If at any time a hospital or medical staff member fails to wear PPE when indicated, an
occurrence report should be completed.
ISOLATION of PATIENTS and SPECIAL PRECAUTIONS
Three types of isolation and special precautions are used to prevent the transmission of certain
infectious organisms not confined by standard precautions. A brightly colored sign is hung on
the door to the patient’s room and it is noted in the patients chart. The colored sign provides
instructions on the type of isolation and special precautions required. PPE is kept in the lower
cabinet or the gray isolation cart for ADA rooms.
Contact Precautions = Green Sign
Contact precautions include wearing gloves when entering the patient’s room and a gown if
substantial contact with the patient, environmental surfaces or items in the patient’s room is
anticipated.
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Droplet Precautions = Orange Sign
Droplet precautions include wearing a surgical mask within 3 feet of the patient.
Airborne Precautions = Pink Sign
Airborne precautions include placing a patient in a negative pressure room, entering through the
ante room and keeping the door shut when the patient is in the room. Staff should wear N-95
masks upon entering the room.
Tuberculosis (TB) is a disease caused by bacteria called Mycobacterium tuberculosis. The
bacteria usually attack the lungs. But, TB bacteria can attack any part of the body such as the
kidney, spine, and brain. If not treated properly, TB disease can be fatal. TB disease was once
the leading cause of death in the United States.
TB is spread through the air from one person to another. The bacteria are put into the air when
a person with active TB disease of the lungs or throat coughs or sneezes. People nearby may
breathe in these bacteria and become infected.
In most people who breathe in TB bacteria and become infected, the body is able to fight the
bacteria to stop them from growing. The bacteria become inactive, but they remain alive in the
body and can become active later. This is called latent TB infection. TB bacteria become active
if the immune system can't stop them from growing. Some people develop active TB disease
soon after becoming infected, before their immune system can fight the TB bacteria.
A Person with Latent TB Infection A Person with Active TB Disease
• Has no symptoms • Has symptoms that may include:
- a bad cough that lasts 3 weeks or longer
- pain in the chest
- coughing up blood or sputum
- weakness or fatigue
- weight loss
- no appetite
- chills
- fever
- sweating at night
• Does not feel sick • Usually feels sick
• Cannot spread TB bacteria to others • May spread TB bacteria to others
® ®
• Usually has a positive skin test or QuantiFERON-TB Gold test • Usually has a positive skin test or QuantiFERON-TB Gold
test
• Has a normal chest x-ray and a negative sputum smear • May have an abnormal chest x-ray, or positive sputum smear
or culture
• Needs treatment for latent TB infection to prevent active TB • Needs treatment to treat active TB disease
disease
TB screening occurs at all points of entry into the facility with procedures in place for those
patients identified with risk of TB.
TB Skin Testing
TB skin testing is the only method we have today for identifying TB infection. Intradermal
Mantoux PPD is the only acceptable method of TB skin testing.
1. A TB skin test will usually become “significant”, or positive, about 12 weeks after the
2. The TB skin test must be read at the correct time – from 48 to 72 hours after
administration. A large, significant reaction may be present and accepted for reading for
longer periods.
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3. Persons who were infected many years ago may not respond to a current TB skin test,
but will respond to a second test given within a few weeks of the current skin test. (2-
step PPD)
TB skin test interpretation
5mm induration is interpreted as positive in HIV –infected persons, close contacts to an
infectious TB case, persons with chest xrays consistent with prior untreated TB, organ
transplant recipients and other immunosuppressed patients (steroid therapy).
10mm induration is interpreted as positive in recent immigrants, injection drug users, and
other persons with clinical conditions.
15mm induration is interpreted as positive in persons with no known risk factors for TB
Employees are screened annually by PPD and/or symptom
review. Medical staff may request screening at any time.
Hospital and medical staff are notified of exposure to TB
and any recommendations for evaluation or screening
related to the exposure. Post-exposure screening and follow
up is provided at no cost. Compliance with annual and post-
exposure screening is mandatory and is included in
performance evaluations.
Preventing Exposure to TB and Reducing Risk of Infection with TB
Airborne Isolation
Follow precautions listed for airborne isolation. Do not enter airborne isolation areas without
approved N95 respirator mask.
Respiratory Protective Devices –N-95 Respirator mask
Use only the approved N95 when entering airborne isolation areas.
Do no use surgical mask or dust-mist-fume masks.
Do no use approved N-95 until you have been fit tested and trained in the use.
Use only the type and size N-95 that you were fit tested and trained to use. Do not use other
types or sizes.
OSHA BLOODBORNE PATHOGEN STANDARD
This standard was developed to establish rules designed to reduce the risk of contracting
bloodborne diseases while performing assigned work duties.
Bloodborne pathogens are diseases that are transmitted through blood or other potentially
infectious material (OPIM). You can expect to find bloodborne pathogens in body fluids such
as:
• Semen • Vaginal secretions
• Synovial fluid • Peritoneal fluid
• Pleural fluid • Pericardial fluid
• Cerebrospinal fluid • Amniotic fluid
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Bloodborne pathogens can cause diseases such as Hepatitis B, Hepatitis C, Delta Hepatitis and
HIV/AIDS. You have a higher risk of exposure at work to Hepatitis B (inflammation of the liver)
than to the HIV virus.
Bloodborne pathogens may also be found in unfixed tissue or organs and in cell, tissue or organ
cultures.
Hepatitis B (HBV) is the major bloodborne hazard you face on the job. Approximately 8,700
health care workers are infected each year. If you become infected you may:
Suffer from flu-like symptoms
May need to be hospitalized
May feel no symptoms at all
May severely damage your liver
Blood, saliva and other body fluids may be infectious
May spread the virus to sexual partners, family members
and unborn infants.
HBV virus can survive on dried surfaces and at room temperature
for at least one week. Surfaces and objects can be heavily
contaminated without visible signs. A vaccine is available through Employee Health Services at
no cost to you. It is a series of three injections over a six-month period. You will receive a
blood test to determine the effectiveness of the vaccine. Studies show that the vaccine is 85-
97% effective.
Hepatitis C is the most common chronic bloodborne infection in the United States. It is a viral
infection of the liver, almost exclusively transmitted through blood. A major way of transmitting it
is exposure to needles and syringes contaminated with the hepatitis C virus. It is highly
associated with liver cancer. No vaccine is available at this time.
HIV (Human Immunodeficiency Virus) attacks the body’s immune system,
AIDS (Acquired Immune Deficiency Syndrome), which is a severe disease
syndrome. A person infected with HIV may not develop symptoms for years,
but will eventually develop AIDS. They may suffer flu-like symptoms and
develop AIDS-related illnesses (cancer, pneumonia, neurological problems,
etc.). No vaccine is currently available. HIV is primarily transmitted through
sexual contact. It may be transmitted through contact with blood and some
body fluids or through exposure to needles and syringes contaminated with
human immunodeficiency virus.
Health care workers must use barrier precautions when there is a potential for
coming into contact with blood, body fluids, secretions, excretions and non-
intact skin. These precautions must always be followed with every patient, no
matter what the circumstances.
Risk of Transmission:
HIGH: Infection rate .3% or 3 in 1000 (Ex: deep injury with large needle
blood contaminant HIV with high titer)
LOW: Infection rate .1% or I in 1000. (Ex: injury with solid suture needle or splash to
intact skin from patient with low HIV titer)
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AFTER INFECTION TO OTHERS: Can be transmitted to sexual partner, anyone
exposed to your blood/body fluids, to fetus if woman is infected during pregnancy, or by
breast-feeding.
FRAGILE VIRUS: Survives in environment very brief time. Killed by 1:10 bleach solution.
Preventive therapy: Post exposure – drugs available /Must be started within 2 hours for
most benefit.
Treatment: Drugs available to treat HIV and AIDS, NO known cure.
EXPOSURE CONTROL PLAN
The CRMC Exposure Control Plan is designed to minimize risk of exposure to bloodborne
pathogens. The Exposure Control Plan is available to review.
Reducing Risk of Infection and Reporting Exposures
Exposure incidents can potentially lead to infection from Hepatitis B (HBV) or HIV. How do
exposures to bloodborne pathogens happen? The most obvious exposure incident is a needle
stick. They can also occur in any one of the following ways:
Accidental injury by a sharp object that is contaminated (i.e., needle, scalpel)
Exposure through broken skin or mucous membranes (i.e., eyes, nose, mouth)
Touching a contaminated object or surface and then touching your nose, eyes, mouth or
open skin
To avoid needle stick injuries, do not bend, hand-recap or break used needles or other sharps.
Recap or remove needles from disposable syringes only when medically
necessary. Use Safety Glide needles whenever possible. Place
needles and sharps in a puncture resistant, leak-proof sharps container
immediately after use.
In addition to the standard precautions, there are five major tactics that
help reduce your risk of exposure when used together:
1. Engineering Controls – physical or mechanical systems that
eliminate hazards at their source. (i.e. self-sheathing needles,
autoclaves, used needle deactivation devices and sharps disposal
containers.)
2. Work Practice Controls – specific job procedures to be followed.
(i.e. methods for avoiding needle sticks, effective hand washing
and other self-protective practices such as minimizing splashing and safe food storage.).
In the event of a spill of 16 ounces or less, the spill is cleaned up by trained
departmental staff within the department where the spill occurred.
3. Personal Protective Equipment (PPE) – properly fitting disposable gowns, masks,
goggles, N-95 masks and booties.
4. Housekeeping – proper techniques that must be practiced by all staff such as using
forceps to pick up broken glass, rather than gloved or bare hands, and handling
contaminated laundry as little as possible.
5. Getting the Hepatitis B vaccine if you are exposed to blood or other potentially
infectious materials as part of your job duties.
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Reporting an exposure incident right away permits immediate medical attention. Early action
and immediate intervention can prevent the development of HBV or helps to track a potential
HIV infection. Prompt reporting also helps to avoid the spread of a bloodborne pathogen to
others.
Reporting exposures allows for follow-up, which includes testing the blood of the source
individual and the affected person. An exposed employee will be informed of the test results.
At CRMC we expect employees and medical staff to seek immediate assistance if they have
had an exposure incident by informing the employee health nurse or Infection Control
Practitioner, or the Emergency Department if the exposure occurs after hours. .
QUESTIONS AND ANSWERS
All staff are covered by the OSHA Bloodborne Pathogens standard because of job duties that
expose them to risks within the health care setting. OSHA mandates that employees have
access to the regulatory text of the OSHA Bloodborne Pathogens standard, published in Title 29
of the Code of Federal Regulations 1910.1030. It can be found by going directly to
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=2570
SECTION 5 – RISK MANAGEMENT
Risk is defined as exposure to the chance of injury or loss. Capital Regional Medical Center is
considered to be a high risk environment. In order to minimize those exposures, we have a Risk
Management program which monitors daily activities.
Through this program, we can:
Minimize the number of patient occurrences
Minimize the number of losses (claims) relating to patients, employees, visitors,
volunteers and property
Select and maintain our equipment appropriately
Conserve hospital property
Our Risk Management program is part of our performance improvement activities and helps
identify opportunities to improve processes. The RM program will assist with information and
direction on any of the following issues:
Advance directives Confidentiality
Do Not Resuscitate (DNR) Informed consent
Living wills Lawsuits/subpoenas
Patient grievances Safe Medical Devices Act
Surrogates/power of attorney/proxy Withholding/withdrawing life support
Who is our Risk Manager? LINDA DEEB EXT. 5056
SERIOUS INCIDENTS
If an unfavorable incident (occurrence), whether occurring in the licensed facility or arising from
health care prior to admission in the licensed facility, results in:
The death of a patient, a fetal death
Brain or spinal damage to a patient
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The performance of a surgical procedure on the wrong patient, the wrong site
A surgical procedure unrelated to the patient’s diagnosis, or a wrong surgical procedure
being performed, including repair of injuries from a planned surgical procedure, or a
surgical procedure to remove foreign objects remaining from a surgical procedure
Serious incidents must be reported to the Risk Manager immediately as required by the
Agency for Healthcare Administration.
DEFINITION OF AN OCCURRENCE
Any event that involves an unusual situation with a patient, visitor, employee, or volunteer that
results in injury or potential injury can be considered an occurrence.
Medical staff should report any occurrences to the Director of the Department or the Risk
Manager.
1. Mishaps due to faulty or defective equipment. (i.e., burns from equipment, IV pump alarm
did not work causing patient to receive overload of fluid)
2. Medication errors.
3. Patient leaving against medical advice.
4. Wrong diagnostic or surgical procedure performed on a patient.
5. Unexpected adverse results of professional care and treatment which necessitates
additional hospitalization or a dramatic change in patient or treatment regime.
6. Complaints related to patient care made by any patient, visitor, physician or an employee.
Reporting & Recording a Patient/Family Member/Physician Complaint
Medical staff should report any complaint or concern to the Director of the unit, the Risk
Manager or Administration.
A SENTINEL EVENT is a more serious type of occurrence or risk that could happen to a
patient. It may involve serious physical or mental injury or the death of a patient.
Serious incidents must be reported to the Risk Manager immediately.
FALLS SAFETY PROGRAM
Every patient will be assessed on admission and every shift for the following risk factors:
confused or disoriented
history of falls (2 or more falls in past six weeks)
impaired judgment/memory (unable to use call light or
wanders)
gait disturbance (needs assistance with ambulating,
unable to walk or get up without assistance)
generalized weakness (unable to get up and down on own,
unable to understand to call for assistance, would attempt
to get out of bed on own)
altered elimination (incontinent of bowel/bladder, preps
that would make patient jump up quickly, or patient does
not understand to call for assistance)
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sensory/perceptual deterioration (positive orthostatic vital signs, dizziness,
lightheadedness, recent syncopal episodes)
medication induced risk (patient is on medications that would alter their ability to get up
and move normally)
immediate postoperative period
blind or severely impaired vision
A “yes” answer to any of the above questions would place the patient at risk for a fall and fall
precautions are to be initiated. Falls precautions procedure includes: placing a purple magnet
on the room door frame; and a purple armband on the patient wrist to alert all staff of the risk to
the patient.
RISK MANAGEMENT EXPECTATIONS
RISK PREVENTION
At Capital Regional Medical Center we prevent occurrences by promoting risk prevention and
error reduction activities on a daily basis.
The following are examples on how we practice Risk Prevention:
☺Credential and Licensing
☺Education and Training
☺Employee Health Program
☺Human Resources Processing of Employees
☺Infection Control Program
☺Performance Improvement
☺Policies and Procedures
☺Quality Control Program
☺Safety Committee Activities
☺Scope of Practice
PATIENT RIGHTS
Privacy
Confidentiality of their patient information, written, verbal or electronic
Courtesy and respect by staff
Prompt response to questions and requests
To know who is providing their care (you must wear your name tag)
Information in their own language (AT&T language line services)
To consent to treatment (including experimental research)
To refuse care (including experimental research, transfusions, surgery, and mechanical
ventilation)
Ability to make advanced directives
Information concerning their diagnosis, planned course of treatment, alternatives, risks,
and prognosis
Information in the event that an adverse event or medical error has happened to them
Full financial information and financial counseling & an itemized bill upon request
Access to care and treatment for emergency medical conditions
To express grievances (see patient complaint/ concern/ grievance policy 901.161 & use
patient complaint form.)
Access to protective services (report abuse to the appropriate protective agency/
agencies)
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CONFIDENTIALITY/HIPAA
Limit discussions regarding patient conditions to only those persons who require the
information. Also be aware not to discuss patient information when at lunch, while
walking in the hallways or the elevators.
NEVER discuss any employee or another member of the medical staff who is a
patient in the hospital without permission.
The Health Insurance Portability & Accountability Act (HIPAA):
Establishes standards for the use and disclosure of protected health information.
Defines ways that patient health information is used and disclosed.
Allows a patient to have control over their protected health information.
PATIENT PRIVACY
Patients receive a Notice of Privacy Practices
informing them of how we use and disclose
their protected health information.
All employees should be familiar with this
notice and know the Privacy Officer.
Protected Health Information (PHI) includes
medical, billing information and electronic
Protected Health Information (ePHI).
PHI and ePHI is among the most sensitive
and personal information collected or shared.
Use of PHI is restricted and confidential and
is protected by Federal and State law.
PHI can only be used without patient
authorization for treatment, payment and
health care operations - in other words, only
to carry out your job duties.
When to Protect a Patient’s Privacy
When discussing a patient’s condition or orders with other caregivers speak softly. Pay
attention to who can hear you. Follow these simple guidelines:
Do not provide information to family members/friends of patients unless they have the
access number to ensure that the patient wishes regarding who has access to their
health information is preserved.
When using computers, log-off when walking away.
Only people that have a “Need to Know” for their job
responsibilities should have access to the PHI.
If you think someone knows your password, change it immediately.
Store patient information in a safe place away from the public view
and access and public areas.
Recycle containers should not be in high traffic.
Once paper goes into a recycle bin, it must stay there.
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HIPAA States:
It is a violation to access patient information that is not included in your job function.
You can access a patient record only for the following: treatment, payment and health care
operations. Under HIPAA any other access requires a valid patient authorization.
ACCESS TO CARE
When any individual comes upon or within 250 yards of the property of Capital Regional
Medical Center and a request is made on the individual’s behalf for medical treatment,
hospital personnel will respond to the individual’s request with a prompt assessment of
the patient’s need for health care. In all circumstances, common sense and human
judgment must prevail.
Capital Regional Medical Center will not discriminate in the provision of emergency
medical treatment on the basis of race, religion, national origin, age, sex, handicap or
economic status.
A medical screening examination, stabilizing treatment, or appropriate patient consented
transfer will not be delayed to inquire about the individual’s method of payment or
insurance status.
See CRMC EMTALA policies on Access to Emergency Care, Medical Screening,
Medical Stabilization, Transfer and administrative procedures for additional information
and patient transfer forms and instructions.
DISRUPTIVE STAFF
Capital Regional Medical Center values the contributions that each member
of the health care team makes to the care of the patient. Our Code of
Conduct, Employee Standards of Behavior and other policies delineate
expected and prohibited behaviors. Disruptive behavior will not be tolerated
and should be reported to your supervisor, Human Resources or
Administration. In the event that a staff member, physician or other health
professional displays unprofessional behavior toward a staff member,
physician, patient, or family member a reporting mechanism is in place. The Risk Manager or
Administration should be notified immediately OR a “purple form” may be completed and
forwarded to the Quality Department.
REDUCE YOUR CHANCE OF BEING SUED
Use the medical record to your advantage. Remember the medical record is the only
witness that never dies. Record all patient information in the patient’s medical record.
Never alter a medical record - to do so is a criminal offense. Use a late entry if
necessary.
If you believe an employee, medical staff member or other health professional is
practicing outside of their job description/scope of practice, you have an ethical
responsibility to report this information to Administration IMMEDIATELY. .
Contact the Risk Manager for Risk Management questions or concerns at #5056.
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SECTION 6 – QUALITY IMPROVEMENT
Performance Improvement at Capital Regional Medical Center
Performance Improvement (PI) is one of the methods that we use at Capital Regional Medical
Center to achieve the mission of the hospital. PI is a planned, systematic process and includes
all departments in the hospital. By participating in the performance improvement program, each
department and each individual contributes to the achievement of our mission.
The goal of performance improvement is to continually improve our performance by designing,
measuring, assessing or analyzing services and processes so that they meet or exceed
standards. The patient is the focus of all our efforts. We plan and design systems and
processes to improve patient services, patient care and patient outcomes.
Measuring Performance: we continually collect information to measure processes. Indicators
are measurement statements about patient services, processes and outcomes. Every
department in the organization has selected monitors or indicators which assist in measuring
the effectiveness of their work.
Performance improvement measurements or indicators can be classified into 3 main categories:
Clinical Performance- clinical performance indicators measure patient outcomes, such
as: surgical or invasive procedure and anesthesia outcomes; medication and blood use;
the management of the patient’s pain; patient safety indicators such as the rate of falls;
etc.
Resource Performance- financial and human measurements or indicators related to
resource management are important to determine that we have an adequate amount of
staff and supplies. We need to know that the staff are competent to perform their
responsibilities. We develop and work by budgets to replace outdated equipment.
Perception or Satisfaction Performance- these indicators are measurements of how
our patients, staff and physicians evaluate our organization. Our goal is to have satisfied
patients, staff and physicians. Patients who want to come to our facility for medical care
and treatment, staff who enjoy working in our hospital and physicians who are confident
in our ability to care for their patients.
Analyzing information: it is not sufficient to collect data; we must analyze it to determine if we
are meeting standards. We utilize analysis tools and data bases to measure ourselves against
national standards to determine how we are performing. We participate in the Hospital Quality
Alliance, Joint Commission and other comparative data bases.
Improving Performance: once we know what needs to improve, we set up teams to bring
about the change. Staff who work closest to the process that is being improved are selected to
be members of the PI teams. The teams analyze the process to determine causes that may
contribute to a less than desired outcome, determine improvement options or actions and
implement the improvement solutions.
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