safety awareness - providence washington/media/files/providence...uniform fire code, and other...

Safety Awareness Providence St. Mary Medical Center Mandatory Education

Safety: Safety Information • Safety is everyone‟s responsibility

• Preventing injuries is essential • If you have questions or concerns regarding

safety, contact your supervisor, security, or one of the members of the Safety Committee.

Safety: Safety Committee • The Safety Committee meets at least 5

times per year • The designated Safety Officer is Larry Baer,

Director of Facilities • Minutes of the Safety Committee and a list of

members is located on the PSMMC Intranet

Safety: Emergency Safety Codes • Code Blue: Cardiopulmonary arrest • Rapid Response Team: Patient deteriorating –

I need help! • Code Red: Fire • Code Orange: Hazardous spill • Code Amber: Abducted or missing Infant/Child/

Adult and pediatric security • Code Gray: Protect or restrain combative,

severely aggressive, or hostile individuals who may be a danger to self or others

• Code Silver: Weapon (Person with a weapon, or hostage situation)

Safety: Emergency Safety Codes • Code Internal Triage (Internal disaster):

• Examples • Bomb Threat • Medical Gas interruption • Power outage • Major plumbing/flooding problem

• Code External Triage (Mass Casualty Incident or External Disaster)

• Code _____ All Clear: Announced when emergency is over. Normal duties can be resumed.

General Safety: Code Blue • Cardiopulmonary Arrest: (policy 9720.5900)

• Within the hospital: push the blue code button or Dial “6” and report Code Blue, naming the exact location/department, begin BLS interventions and apply the Automatic External Defibrillator (AED) if available.

• At office sites: staff should call 911, begin BLS interventions and apply the Automatic External Defibrillator (AED) if available.

• Code Blue – All available physicians • When more than one Code Blue is happening

Life Safety: Code Red • Life Safety: Code Red (policy 8610.7014)

• Fire safety includes fire prevention, fire safety and fire response training.

• The PSMMC Fire Response Plan provides clear instructions for staff responding to an emergency, protecting patients, visitors and staff from fire and products of combustion. Each department is responsible for specific emergency fire response procedures and the training of staff.


It is each employee’s responsibility to know where the nearest fire alarm and fire extinguisher is located in their department


• The proper response to fire and products of combustion is based on the acronym “RACE”.

R=Remove those from immediate danger A=Activate the nearest fire alarm pull station;

Dial “6” and report Code Red and give your exact location

C=Close all doors to contain the fire E=Evacuate as necessary upon instruction


• The role of all employees, medical staff, volunteers, and students away from the fire are to close doors and evaluate the situation including: placement of patients relocated from areas affected by the fire, review fire response plans, discussing and checking fire response equipment, and checking oxygen shut-off valves for access and responsibility for shutting off, if so instructed.

• PSMMC uses ABC, CO2, or halogenated agent fire extinguishers.

Hazardous Material: Code Orange • Hazardous Materials (policies 8610.7050 & 7055)

• The Hazardous Materials and Waste Management Plan can be found on the Intranet under Resources/Hazardous Materials. This plan addresses the potential risks to staff, patients, and visitors from the variety of hazardous substances used at PSMMC. The program also is designed to assure compliance with applicable local, State and Federal hazardous materials codes and regulations.

Hazardous Material: Code Orange • The inventory of hazardous materials at PSMMC is

defined by commonly accepted industry criteria, the Uniform Fire Code, and other chemical and radiological industry recommendations. The codes and standards for these materials help the facility determine the proper storage and disposal procedures as well as guide in inadvertent spill response plans.

Hazardous Material: Code Orange

• Hazardous Wastes are defined as: (Examples not all inclusive) • Dangerous Waste (flammable, corrosive) • Universal Waste (dry cell batteries, spent fluorescent lamps) • Special Waste (solid corrosives) • Pharmaceutical Waste (chemotherapeutics and sharps, other

drug solid and liquid) • Radioactive (nuclear medicine isotopes) • Biohazardous Waste (infectious and pathology waste, sharps) • Solid Waste (trash taken to landfill, or other disposal site)

Hazardous Material: Code Orange • Monitoring of gases and vapors, including

gluteraldehyde and waste anesthetic gases is performed at least annually where used, and the results reported to affected departments and the Safety Committee.

• Staff who work in areas where hazardous chemical materials are stored or used are trained to the First Responder/Awareness Level according to Washington‟s Emergency Response Training through completing mandatory Healthstream modules and other department-specific orientation and training.


• First responders should be able to activate a rapid, effective response in the event of a hazardous materials spill while clearing the impacted area of staff, patients, or visitors as indicated by the nature and extent of the spill. Activation of the internal spill response team is done by asking the PBX operator to announce a “Code Orange” to the impacted area.

Hazardous Material: Code Orange • The “Code Orange” spill response team should be

trained to the level of a First Responder/Operations Level or above according to the Washington Emergency Response Standard (WAC 296-824) to assist with proper clean-up procedures. The “Code Orange” team should be familiar with appropriate personal protective clothing (PPE) to be donned for various hazardous waste stored at PSMMC. Any response by the “Code Orange” Team will be reported to the Safety Officer, the Safety Committee and the department manager.


• Department Directors are responsible for orienting new personnel to any task-specific procedures for handling hazardous waste and chemicals found in their department including the segregation of regulated waste from non-regulated waste as appropriate to the department responsibilities. (Example: chemotherapy waste discarded into designated yellow bins versus routine trash or red biohazard bins).

Hazardous Material: Code Orange • All employees have responsibility for verifying that any

chemical containers stored in their department are in properly labeled containers. Information from the product label is needed to research chemical information on-line. All employees have 24/7 access to Materials Safety Data Sheets (MSDS) on the PSMMC Intranet. This resource uses the Hazardous Materials Identification System used by product manufacturers to provide clear, recognizable, hazard information to employees using color codes, assigned numeric and alphabetical codes that can guide employees as to the proper response while handling the product.

Hazardous Material: Code Orange • Employees who complete their department orientation

on hazardous chemicals and waste disposal, the Healthstream Safety Module, and the Healthstream MAXCOM MSDS Module are trained at the First Responder/Awareness level which includes: • Understanding of the hazardous substances and their

associated risks stored or handled by their department • Recognition of the presence and identification of

hazardous substances in an emergency • Can understand potential consequences of hazardous

substances in an emergency


• Have access to the employer‟s emergency response plan including site security and control. (See plan on intranet under Resources/Safety Information.)

• Recognize when it is appropriate to activate the “Code Orange” response team for spills the employee is not trained to contain or clean up.

• Understand how to report chemical spills and any associated exposure through the department and hospital chain of command.

• If exposure has occurred an Employee Incident report must be completed and Employee Health notified as soon as possible. The employee may need to be evaluated in the Emergency Department after-hours.

Continued:


• Training on the use of MSDS sheets is accomplished by completing the “MAXCOM MSDS” module on Healthstream. In addition, most department„s chemical inventory is kept on the MAXCOM- MSDS link on the PSMMC intranet. Any employee can access MSDS sheets from this program for any chemicals not found in the department inventory list or for victims of exposure from outside the facility. Other national MSDS research tools are also found on the intranet.


• Chemotherapy exposure prevention and spill procedures are found in the Patient Services Policy 8720.5640 “Chemotherapy Exposure Prevention/Spill Procedure”.

• Chemotherapy Spill kits are kept on the Medical/Oncology Unit, Pharmacy, and the Cancer Center.

Security: Amber Alert • Abducted or Missing infant/child/adult:

(policy 8610.7009) • Dial “6” on any phone within the main hospital

and report/describe the missing or abducted person. (To include a clothing description, etc.)

• In response, all available staff should report to the nearest unmanned exit, stairwell, elevator, or corridor

• If adult – call Amber Alert Adult

Security: Amber Alert • Abducted or Missing infant/child/adult:

(policy 8610.7009) Be alert for any suspicious looking person, if infant

abduction is suspected, look for large bags, purses, or loose clothing. Ask people if they will allow you to check their bags, explaining the reason. DO NOT forcibly detain or search anyone without their consent.

If you see a suspicious or non-cooperative individual leave in a vehicle, be sure to note the license plate and any description of the person or vehicle.

Security: Code Gray • Combative, Aggressive or Hostile

Person: (policy 8610.7011) • When a situation occurs in which the safety of

patients, visitors, or staff is threatened. • If you see a suspicious or non-cooperative individual

leave in a vehicle, be sure to note the license plate and any description of the person or vehicle.

• Staff should make an attempt to leave the location announced to adjacent areas, making a reasonable attempt to assure the safety of others who may be in immediate danger without increasing the risk to themselves or others.

Security: Code Gray • Within the Hospital: Code Gray is activated when

there is a need to protect or restrain the combative, severely aggressive, or hostile individual who may be a danger to themselves or others. The team leader is trained in verbal de-escalation techniques.

• To Activate: Dial “6” requesting a Code Gray and give your location

Security: Code Gray Combative, Aggressive or Hostile

Person: (policy 8610.7011) • At campus office sites: Staff should call 911 to

activate local law enforcement support when individuals are acting in a manner suggestive of danger to self or others.

• Also notify hospital security at pager #4028. • Do not touch the individual unless instructed to do

so by the team leader.

Security: Code Gray Combative, Aggressive or Hostile

Person: (policy 8610.7011) • The team leader is the only person to verbally

communicate with the individual to avoid confusion. • Remove all objects from the area that can

potentially be used as weapons. • Do not attempt to independently chase or restrain a

violent patient attempting to leave against medical advice.

Security: Code Silver • Concern for Own Safety or Safety of Others

(policy 8610.7006) • Should be initiated when:

• You are concerned about your own safety or the safety of others and you believe that someone has a weapon

• NOTE: This type of code will generally not be announced overhead but a response team from local law enforcement will be notified.

Important Information: • Do not attempt to intervene or negotiate but wait for

the emergency team to arrive • Keep others away from situation

Emergency Management: Activation of a Disaster • External Triage/Internal Triage • Within the hospital: “External Triage or Internal Triage” will

be paged overhead when an emergency incident is expected to exceed the normal operating capacity for the hospital for an external or internal disaster. • At campus office sites: “External Triage or Internal

Triage” will be initiated through the phone tree. • Report to your department and follow procedures outlined

in the Emergency Operations PLAN, Safety Manual and other department specific guidelines. Staff on-duty at locations outside the main hospital will be notified by supervisory staff.

Emergency Management Department activities during an Internal or External Triage

(mass casualty incident or other disaster) include: 1. Assess your department needs. 2. Employees not needed in their departments are sent to the

manpower pool located in the Poplar Street lobby. 3. Assignments will be made based on the situation and the available

manpower. 4. Employees may be called in from home by the Emergency Phone

Tree procedures. It is essential to bring your photo ID badge. 5. Employee‟s use of elevators and telephones should be limited as

much as possible. 6. The Emergency Operation PLAN (Disaster Plan) is located on the

intranet under Resources/Safety Information/Providence St. Mary Medical Center Emergency Operations Plan. Employees should review the following sections: ”Information for all Employees”, “Activation of Emergency Response Plan” and “Hospital Incident Command Structure Organizational Chart”

Emergency Management International Disaster Triage Tag and

Coding: RED: Life threatening injuries (prioritized for

treatment in the ER, OR, or ICU), YELLOW: Urgent-serious injuries where definitive

treatment can wait for several hours may be taken to “Urgent” holding area once screened.

GREEN: ambulatory, minor injuries (taken to the or SMPG clinic sites or other designated areas as indentified through hospital Incident Command)

Emergency Preparedness • Internal Triage: Bomb Threat

• Within the hospital: Dial “6” and report “bomb threat” and give information to the operator. The operator then notifies Administration, Hospital Administrative Supervisor, Security, and calls 911

• This code will not be paged overhead. Instead, you will be notified by some means such as runners or other means of communication as to next instruction. Once the bomb threat is communicated, all radio communication ceases and pocket pagers must be turned off

• Information will be provided by runners, or email, depending on what security determines is appropriate.


• At campus office sites: Call 911; notify your supervisor and Hospital Administration. Notify all on-duty staff at the site involved.

• If you encounter a suspicious object, DO NOT TOUCH, report it immediately!


• Employees who receive a bomb threat should try and keep the caller on the phone as long as possible while obtaining information (such as when the bomb going to explode, where is it now, what kind of bomb, how can we contact you, background sounds, the caller‟s voice and use of threatening language, etc). A hand written note can be passed onto another employee to alert the operator and 911 while the caller is still on the line.

Utility Systems • Internal Triage

• If a malfunction occurs: • Dial “6” and report “Internal Triage” (specify

gas or medical vacuum) and the location • Check the status of patients who are

dependent of oxygen, medical air or vacuum for frequent suctioning. Portable oxygen and/or suction devices will be used until wall gases or vacuum have been restored


• If a malfunction occurs: • In departments where oxygen shut-off

valves are located, it is the employee’s responsibility to know the location and if directed by Administrative staff or the Fire Department, to shut the valve on or off.


• If a malfunction occurs: Portable tanks are available at all times in the

Emergency Department, Operating Room, Intensive Care Unit as well as the 3rd and 4th floor clean hold and on each crash cart. Respiratory Therapy will provide extra tanks as needed. Compressed gas cylinders are to be secured in an approved stand at all times.


• If a malfunction occurs: • Portable suctions machines are available in

the Emergency Department, Operating Room, Cardiac Stress Test Lab, as well as 3rd and 4th floor clean holds. Additional portable suction units are available from SPD, as needed.

• Wall oxygen and medical vacuum is not available outside the main hospital building


Medical gas systems include oxygen, medical air, nitrous oxide, nitrogen, and medical vacuum. Oxygen, medical air, and vacuum are available on all levels of the main hospital building

Utility Systems • Power Failure

In the event of a power outage with no other emergency situation: • Remain in your area and wait for

instructions • Emergency power in the main hospital

building is designed to activate within 10 seconds- power will momentarily be off until generators are fully functional

Call Internal Triage code


In the event of a power outage with no other emergency situation: • Check the status of patients who are

dependent of electrical devices. Verify that critical medical devices are plugged into appropriate outlets: Only red wall outlets and red light switches are served by emergency power.

• Battery powered lights are installed to provide exit path illumination and for illuminating critical task areas


In the event of a prolonged power outage: • Locate flashlights and battery lanterns as

needed for patient care or for safe access to lighted areas

• Inform patients of the plan of care

Security: Internal Triage • Locking Down the Facility if you are informed

that there is a lockdown • No one will be allowed to enter the affected area

without specific instructions from the Hospital Administrative Supervisor, designee, or local law enforcement.

• All departments will secure their areas as much as possible from outside access and remain there until “Code Internal Triage All Clear” is announced.

Security: Internal Triage • Staff should be prepared to assist with

evacuations, accept admissions from other areas, provide supplies or equipment, and provide alternative communication methods

• Also see polices #8610.7004, #7170.7100, #9570.7400

Emergency Management • Evacuation of Patients: (policy 8610.7019)

• Evacuations can only be authorized by the Medical Center Administrator on-call and the Fire Department

• Elevators are not normally used during fire, but may be authorized for use by the Administrator or Fire Department during an evacuation.

All patients will be moved to areas of safety, first evacuating to safe areas in adjacent wings (lateral transfers)


If not able to evacuate to adjacent wings in a lateral transfer: FOURTH and THIRD FLOOR PATIENTS are led or slid down chutes to the next floor and then outside the hospital if directed. FIRST FLOOR PATIENTS will be directed to the main floor using the ramp at the east end of the hospital or arc of the outside exits and directed outside. MAIN FLOOR patients will be directed to one of the outside exits.


The manpower pool will send two teams to the area(s) being evacuated. Team one assists staff from the area setting up patients for evacuation and brings mattresses (Located on carts in the main elevator lobbies on Level 3 and 4) to the stairwell identified as the evacuation route. Team two moves the patients from beds to the appropriate stairwell, and then sets up the chute with the assistance of team one. Staff are stationed in the stairwell following the diagram posted in that stairwell. The patients are then slid down the chute by staff, grasping the sheet and passing the patient from one staff to the next, slowly, feet first, with the feet elevated to control descent.


• All stairwells require 18 mattresses to form the chute. They should fit snuggly to prevent slippage and holes should be filled in with pillows as needed.

• All patients being evacuated should be accompanied by a staff member who is familiar with the evacuation route for that area.

At campus office sites: follow the evacuation plan for that area.


• Babies may be carried by their mother or staff • Always verify that all patients are accounted

for from your department. Supervisor or lead staff member should report patient count to Hospital Incident Command

• The hospital medical record should accompany all evacuated patients


ORDER OF PRIORITY EVACUATION: 1st priority: Ambulatory patients close to danger, 2nd priority: All other ambulatory patients who can

be led to safety, 3rd priority: Semi-ambulatory patients who can be

assisted in a wheelchair, 4th priority: Total assist patients (very ill, non-

ambulatory, in traction, etc) using the chute in the stairwell.

Safety: Electrical Safety • Precautions to prevent shock:

• Never use 3 prong to 2 prong adaptors • All extension cords and power strips much be

approved by Bio-Med or Engineering • Pull on plugs, never on the cord • Immediately report any electrical shock • Report any electrical device that is damaged

or has a frayed electrical cord (remove it from service and the patient‟s environment)

Safety: Electrical Safety • Precautions to prevent shock (continued):

• Electrical heating pads are not allowed • Report any “60 cycle” interference on cardiac

monitors • Precautions to prevent “micro shocks” will be

in place in those clinical areas where patients have temporary transvenous pacemakers, permanent implantable pacemaker insertions, and pulmonary artery catheters

• Refer to policy # 8720.5900 (Code Blue: Cardiac arrest)

Security: General Information • On-duty Security Officer can be reached 24/7

at pager 4028 • Escorts: Security provides 24 hour a day

staff/visitor escorts to and from vehicles from every building on the PSMMC campus

• Personal Security: take time to secure your personal valuables in a locked area, including your vehicle

• Visiting hours are from 11:00 AM to 8:30 PM

Security: General Information • Emergency Exits: Signed doors with

posted Emergency Exit signs are to be used in an emergency situation only, use at other times will result in false alarms

• Parking: Employees are asked to observe posted parking signs

Security: General Information • Property Removal Authorization: Before

removing any property from any PSMMC facility proper authorization (property removal form) must be completed and returned to Security or the Purchasing department.

Security: General Information • Lost and Found: The Lost and Found

hotline extension is 5678 (LOST). All lost/found items should be bagged, tagged, and reported to this extension. Volunteers will pick up the items and get them into the Lost and Found. To reunite lost items with their owners, contact LOST (extension 5678) or Security.

General Safety: Infection Prevention

Preventing the spread of infection • Hand hygiene is the number one means to

prevent transmission of infection • Wash hands with soap and water when visibly

dirty, before eating or handling food, or after using the rest room

• Decontaminate hands with alcohol hand rubs when NOT visibly dirty, before/after patient contact, after contact with objects or equipment, between gloving and after removing gloves


Standard precautions assume that every person is potentially infected with germs that could be transmitted in the healthcare setting. Standard precautions are used for every patient.

requires you use a protective barrier between yourself and the potentially infective materials.

personal protective equipment (PPE)=gowns, gloves and sometimes mask and eye protection.


Preventing the spread of infection Standard Respiratory Etiquette assumes all

coughs and sneezes have potential to transmit infections.

Offer masks and tissues to coughing persons, if they are unwilling/unable to wear a mask- you wear the mask when close to them.

If you have a cough, wear a surgical mask while at work. If you are ill, stay home.


Preventing the spread of infection is a patient safety action

Employee illness: employees are asked not to report to work if they are ill or have wounds that cannot be covered. All illnesses that may be contagious should be reported to Employee Health (extension 2121)

Immediately report work related exposures to blood or body fluids to Employee Health (extension 2121), or after hours, to the Emergency Department

Intranet Infection Prevention site contains additional prevention information.

You may call x2267 to speak with the Infection Preventionist.

Medical Equipment • Safe Medical Devices Act (policy 8610.0311)

It is PSMMC policy to report all deaths, serious illness, or injury sustained by a patient, visitor, or staff, which may have been associated with a medical device to the Food and Drug Administration (FDA) and/or the manufacturer.


All Medical Center personnel who: discover, witness or are notified of an illness or injury that even may have been caused by a medical device are required to: 1. Immediately report the medical device malfunction to your Department Director or Administrative Hospital Supervisor and the patient‟s physician (if applicable), 2. Remove the device from service immediately and 3. Complete a report on Quantros as soon as possible, but no more than 24 hours from the occurrence.


• Serious illness or injury is defined as life threatening or resulting in permanent impairment of a bodily function or damage to a bodily structure or necessitating medical or surgical intervention to preclude permanent or serious impairment.

• Medical device is defined as any device, instrument, apparatus, or 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 pharmaceuticals).

General Safety: Body Mechanics • Maintaining good body alignment is

important in preventing back strain and injury. When your back is in the “neutral” position, your ears, shoulders, and hips are in a straight line. When your back is in the “neutral” position, it is resistant to injury and pain.

General Safety: Body Mechanics • Lifting even a light weight can strain your

lower back if you do not hold the weight close to your body

• Your leg muscles should help with the lift. Bend your knees before lifting

• To turn while lifting a heavy load, turn with your feet first, then let your body follow

General Safety: Body Mechanics • When sitting, your lower back should have

adequate support, keep one or both knees at or above hip level

• If the load is too big or heavy get help or use an assistive device

• Push, don‟t pull!

safety awareness - providence washington/media/files/providence...uniform fire code, and other...

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