Table of Contents • Section 1: Employee Code of Conduct • Section 2: Fire Safety (Code Red) • Section 3: Utilities Management • Section 4: Hazardous Materials • Section 5: Radiation Safety • Section 6: MRI Safety • Section 7: Public Safety • Section 8: Disaster/Emergency Preparedness • Section 9: International Patient Safety Goals
Table of Contents (cont.) • Section 10: Patient/Visitor Incident Reporting • Section 11: Employee Work-Related Accident, Injury, or Illness Reporting • Section 12: Patient Care Equipment • Section 13: Infection Control • Section 14: BloodbornePathogens • Section 15: Tuberculosis • Section 16: Age-Specific Care • Section 17: Confidentiality and Personal Information
Table of Contents (cont.) • Section 18: Receiving Gifts • Section 19: Policies, Procedures, Guidelines and Directives • Section 20: Employee Training Next Steps
Our Commitment • MSKMC is committed to helping all our employees, physicians, volunteers, and contractors act in a way that preserves the trust and respect of those whom we serve and with whom we deal. • Our goal is to do the right thing
Code of Conduct • Is a guide to MSKMC staff in making decisions and choosing actions
No Patient or Employee Abuse, Neglect, or Harassment is allowed at MSKMC • MSKMC protects patients from abuse, neglect and harassment of all forms whether from staff, other patients or visitors. In the event that an individual alleges abuse, neglect or harassment by other patient, Medical center employee or member of the medical staff the hospital will ensure a prompt and complete investigation of all serious complaints • The Medical Center has a ZERO tolerance for violence, also committed to maintaining a Drug and Alcohol Free work place
Fraud, Waste and Abuse - Definitions • Fraud – e.g.: spouse medical insurance • Waste – e.g.: spilling , improper size , paper abuse ……….etc • Abuse – Improper behaviors or practices that are inconsistent with policies/laws and create unnecessary costs.
Fraud, Waste and Abuse - Examples • Pharmacy and Prescriptions: • Billing for brand when generic was dispensed • Billing Multiple Payers for the Same Prescription • Identity Theft
Integrity We live our mission, keep our promises, follow applicable laws.
Respect We treat everyone with dignity, kindness, and significance.
Compassion We listen attentively, help solve problems, apologize when necessary.
Excellence • We commit to high standards, take accountability, and strive to grow.
Stewardship We live within our means so that we can be better tomorrow.
Community We practice cultural competency by honoring patients’ and each other’s cultural orientation.
Service to the Community “Service to the community is at the core …and an important part of our mission. We have a covenant to care for the underserved
The Medical Center uses the phrase CODE RED for all fire emergencies • We have an acronym all employees should remember. This acronym helps you remember what you need to do in the event of a code red R.A.C.E.
R.A.C.E. Rstands for Rescue • Remove anyone from harms way who is not capable of self rescue • Do not put yourself in danger while rescuing
R.A.C.E. A stands for Alarm • Sound the Alarm by activating a pull station and • Always call the emergency line #___________ from a safe distance to notify responders of the precise location of smoke/fire. • When contacting the emergency number, employees must be prepared to give the following information: Type of Code emergency (Code Red); Location of emergency (building, floor, room number); caller’s name and call back number.
R.A.C.E. C stands for Contain • Contain the fire by closing all doors, windows and other openings. • By closing doors you trap smoke and heat allowing time for evacuation • By trapping heat you activate the sprinkler system quickly
R.A.C.E. E stands for Extinguish / Evacuate • Use portable fire extinguishers to put out small fires, if trained and can be done safely. • Execute your specific department evacuation plan including taking direction from the Floor Marshal, Fire Department and /or Safety Officer. evacuation of the whole area either horizontally or vertically.
Know the Following Department Specific Fire Safety Information • Fire alarm pull stations, extinguishers, and emergency exit locations • Identification of your Floor Marshal • Location of your department’s evacuation plan • Doors that need to be shut • Location of oxygen shut-off (if applicable) • Location of designated meeting spot • Recognition of the all-clear notification
Prevention Strategies • Smoking is NOT permitted inside the hospital or outside on hospital property-Refer to the hospital No Smoking Policy • Keep and store flammable or combustible materials away from heat sources. • Keep all exits, stairwells and corridors free of obstructions. • Doors are not to be propped open or blocked from closing freely.
Operating Fire Extinguishers Pull the pin. Aim low, at the base of the fire. Squeeze the handle. Sweep from side to side. • Use your judgment. Never jeopardize personal safety! • Initially stand 6-8 feet away from the fire and aim at the burning material • Position yourself so you can exit the area easily. • Fire extinguishers should only be deployed by those trained in their use. • You are not required to use an extinguisher • Only use a fire extinguisher if the fire is small
Utility Examples • Steam • Plumbing System • Heating, Ventilation, and Air Conditioning • Medical Gas System • Natural Gas System • Electrical • Elevators
What should you do in the event of failure or problems with these utilities?
Utility Failure • Call Maintenance • Be careful around leaking steam; . • If you suspect a natural gas leak, do not turn on lights, electrical appliances, or other sources of ignition; open all windows. • Be aware of electrical hazards: • Do not use frayed/broken power cords. • The use of extension cords is prohibited. • All equipment should have hospital grade, grounded 3-prong plugs.
Chemicals and Hazardous Materials in Your Department • All departments must maintain an accurate inventory of hazardous materials in use. • You must be familiar with the contents and location of the Inventory. • Each hazardous material must have a Material Safety Data Sheet (MSDS).
What Information is on the MSDS? The MSDS includes information about: • Chemical components • Safe use & Protective equipment • Storage &Disposal • Routes of exposure • Symptoms of acute and chronic exposures • Emergency response guidelines (spills or exposures)
Master Files of All MSDS • Electronic database • For 24-hour MSDS access
All Containers Must Be Appropriately Labeled • Original containers from suppliers must be pre-labeled with • Product name • Hazardous ingredients • Hazard warnings • Name of the manufacturer • All secondary containers should be labeled with contents. • All labels should be printed in English; additional language translations may be added if necessary.
Hazardous Material Spills – Chemical, Biological, or Radiological • Small, incidental spills can be cleaned up by users, if trained and personal protective equipment & spill kit available. • For large or acutely hazardous spills: CODE ORANGE • Address any medical emergencies first • Evacuate spill area • Call #____________ - Identify location, material &quantity spilled, name & contact information • Remain in safe location to provide incident specifics to response team
Identifying Radiation Areas This symbol may be found on: • Hallway doors • Work areas within restricted areas • Waste cans • Packages • Fume hoods, sinks, and refrigerators
What Should You Do If You See A Radiation Symbol? • Do NOT enter the area unless: • You have received specialized education. OR • There is a trained radiation worker present to supervise your work.
Will I Be Exposed to Radiation inX-Ray Rooms? • There is no residual radiation present immediately after the machine is turned off. • The operator or technician is ALWAYS present when radiation is being produced. • Door interlocks cut off radiation immediately when the door to an X-Ray room opens during radiation use.
5 Basic Methods to Keep Radiation Exposure to a Minimum • Time • Distance • Shielding • Contamination Control • Training
Time • Spend as little time as possible near a radiation source.
Distance • Work as far away from the radiation source as possible.
Shielding • Inside a radiation use area, lead containers, Plexiglass shields, and lead aprons are used to minimize the exposure to radiation.
When can you safely enterthe MRI Scan Rooms? • Before you go into the scan rooms you MUST be screened by the MRI Technical staff. • This screening will identify whether you have anything in your body that can harm you in the presence of the magnetic field. • DO NOT ENTER THE SCAN ROOM UNTIL THE TECHNOLOGIST SAYS YOUCAN!
All MRI Sites Have Restricted Access because the MRI Magnets are Always On!
Other Objects that Should NOT Enter the Magnetic Field • Metallic objects can become projectiles and can cause severe injury or death. The following list identifies some of the many objects that may NOT be brought into the MRI scan rooms: • Pens, scalpels, screwdrivers, hammers, or other common metal tools • Stretchers, wheelchairs, IV poles, oxygen tanks, code carts, monitoring devices • Cleaning or custodial supplies such as mops, buckets, ladders • Credit cards and ATM cards, pagers, cell phones, and watches • Any person entering the room should be reminded to check and empty their pockets.
Section 7:Security Name
What Can You Do to Help Maintain a Secure Environment? • Wear your ID badge at all times and in a visible manner. • Secure your work area—even if away for 5 minutes. • Sign out of the computer • Lock you door/desk • Report all missing items promptly. • Report all unusual activity