howard county general hospital - Johns Hopkins Medical Institutions by yantingting


 Basic Packet for Contractors
          April 2011

      Clinical Contractor

          March 2007
                           TABLE OF CONTENTS
Mission Statement & Vision……………………………………………………….………..
Service Excellence Values & Behavior Standards………………………………….………..                       4
Diversity Philosophy...…………………………………………………………………………                                     5
Age Specific Competency.…………………………………………………………….………                                  6-14
   Age Specific Competency post-test………………………………………………….………                         71-72
Confidentiality………………………………………………………………………………….                                        15
HIPAA Training...……………………………………………………………………………..                                       15
   HIPAA Power Point Presentation.....................……………………………………….……..          16-21
   Acknowledgement of HIPAA Security Awareness Agreement……………………….…….                  67
   HIPAA Knowledge Assessment…………………………………………………….……….                              68-69
   Johns Hopkins Security Tips.………..………………………………………………………                              22
   Johns Hopkins HIPAA Security Awareness………………………………………………...                      23-25
Johns Hopkins Health System Corporate Compliance Ethics, Integrity and Values……..   26-28
Patient Bill of Rights..………...………………………………………………….…………….                            29-32
The Joint Commission National Patient Safety Goals for 2010…...……….………………..         33-35
Safety……………………………………………………………………………………………                                               36
   Patient Safety Net……………...………………………………………….………………….                              37-40
   Patient Safety Post-test………………………………………………….……………………                                76
Advanced Directives….……………………………………………………..………………….                                    41
Hospital Safety Management/Safety Plan……………………………….……………………                            42
   Employee Incident Report…………………………………………….……………………...                            43-44
   Emergency Preparedness Plan...…………………………………….………………………..                            45
   Rapid Response……………………………………………………..………………………...                                    46
   Uniform Emergency Codes…………………………………………..……………………….                                 47
   Hazardous Material and Waste Plan………………………………..…………………………                           48
   Security Management Plan…………………………………………..………………………..                               49
   Safety & Security Orientation Test…………………………………..………………………..                        72
Infection Control..………………………………………………………..……………………...                                  50
   Infection Control………………………………………………………………………………                                  50-51
  Highlights from the Exposure Control Plan……………………..…………………….                      52-56
   Annual Mandatory Training Test – Infection Control..………………………………………..               73
   OSHA’s Bloodborne Pathogen Letter of Certification..……………………………………….                74
   Infection Control-Policy Requirement………………………………………………………….                         75
   Policies & Procedures – link to intranet policy site
Administrative Topics…………………………………………………………………………….                                    57
Communications…...……………………………………………………………………………..                                      58
Directions to Hospital...…………………………………………………………………………..                                59
Phone List ………………………………………………………………………………………...                                     60-62
Meditech Information……………………………………………………………………………                                      62
Orientation quick reference…………………………………….………………………………..                               63
Hospital organization chart – populations served………………………………………………                  64-65
APPENDIX ……………………………………………………………………………………….
   Unapproved Abbreviations……………………………………………………………………..                                66
   Acknowledgement of HIPAA Security Awareness ……………………………………………                       67
   HIPAA Overview – Knowledge Assessment...………………………………………………...                       68
   Age Specific Competency Post-Test…………………………………………………………...                       69-70
   Safety & Security Orientation Test……………………………………………………………..                      71-72
   Annual Mandatory Training Test – Infection Control………….……………………………….                73
   OSHA’s Bloodborne Pathogen Letter of Certification………………………………………….                 74
   Infection Control-Policy Requirement………..………………………………………………….                       76
  Patient Safety Post-Test…………………..……………………………………………………...                             77

                                 Mission Statement

Provide the highest quality care to improve the health of our entire community through
  innovation, collaboration, servi ce excellence and a commitment to patient safety.


                 To be the premier community hospital in Maryland.


                                               Because we CARE

       Use positive language at all times when talking to patients about the hospital and co-workers.
       Maintain confidentiality
       Share your plan of action, timeframes, reasons for any delays and expected results.
       Practice active listening.
       Adapt your style to meet the needs of your customer.

Anticipate and Respond
   Be an expert in your job and share your knowledge.
   Know your customers’ needs.
   Always ask your customers if they need anything else.
   Ask for help when needed.
   Be resourceful; find a way to say ―yes.‖
   Express empathy and understanding.
   Close the loop/follow up.
   Provide directions and escort guests to their destination.

    Maintain the dignity of every patient.
    Keep your physical surroundings clean and clutter free.
    Value the Howard County team with punctuality and good attendance.
    Offer assistance to your co-workers.
    Honor cultural differences.
    Practice basic courtesies such as elevator, phone and e-mail etiquette.
    Address all patients and visitors by Mr. or Ms. unless invited to do otherwise.

   Create a positive first impression by making eye contact, smiling and offering assistance.
   Follow your departmental dress code and wear your badge at chest level.
   Report unsafe conditions such as spills or quality concerns.
   Clean up litter when possible.
   Report equipment or furniture that is broken or in poor condition.
   Practice teamwork.
   Make things right, practice Service Recovery
   Be a good example
   Take personal responsibility.

                                       DIVERSITY PHILOSOPHY
    Our staff is committed to performing above and beyond the norm to exceed our customer's expectations not
    only in health care but also spiritually and emotionally but also recognizing and valuing individual
    differences. What we do for our patients, we must also do for ourselves. Just as a diverse group of patients
    feel comfortable at Howard County General Hospital, so too must our employees. Only by appreciating and
    valuing our own differences, can we truly serve our patients and their families. To this end, we commit to
    utilizing our diversity to strengthen our working relationships, by:

         ● Being considerate in our comments, challenging others and being open to feedback when
           statements are made regarding race, gender, ethnic background, religion, appearance,
           disability, sexual orientation, religion or any other dimension of diversity.

         ● Actively attempt to communicate and learn about people that are different from me.
           Valuing people who are different from me for the opportunity they provide to learn and
           view things from a different perspective.

         ● Supporting the organization in valuing diversity by accepting the responsibility to
           challenge or report instances of discrimination against any individual for whatever

Steps in becoming culturally competent:
1. Understand your own cultural beliefs.
2. Learn about other cultures, especially attitudes toward health care and ways of communicating/interacting.
3. Ask for help. You cannot be expected to know all the nuances of each of the world cultures, customs and
   languages. You are, however, expected to ask for help when needed.

Family members, particularly children, should NOT be used for interpreting medical information.

Tips for Providing Culturally Competent Care

•    Try to understand people’s values, since values will influence their behavior.
•    Keep in mind that there is always individual variation within a group.
•    Use translated patient education materials and charts from the Micromedix.
•    Include and understand the family as much as possible.

•    Stereotype. Don’t project your own cultural perceptions and biases.
•    Expect that all patients make their own decisions. In some cultures, important decisions are made by the
     family. In cultures where males are dominant, the husband may make the final decisions regarding the
     health care of their wife and children.

                                  Age Specific Competency

Age-specific competency integrates developmental tasks with the health needs of specific age groups
such as infants, toddlers, adolescents and adults. Each patient is unique. Every person grows and
develops in his or her own unique way but follow general growth and development patterns.

                                 Healthy Growth and Development

Infant (birth to 4 weeks)
     Physical growth and development are rapid
           o Primitive reflexes present
                   Dance/Step
                   Tonic neck
                   Grasp
                   Placing
                   Startle/Moro
                   Rooting
                   Gag, suck, extrusion of tongue
                   Corneal and papillary responses
     Building muscle skill is important
           o Repetitious use of reflexes establishes a pattern of experiences
           o Lifts head intermittently & turns to side when prone
     Developing trust and a sense of being loved is important
           o Enjoys being held, cuddled, rocked, touched, talked to, smiled at, or sung to
     Communication
           o Cries when hungry or uncomfortable
           o Makes comfort sounds when fed
     Major fear
           o Separation
           o Stranger anxiety
     Safety and Nursing Considerations
           o Needs a consistent, constant caretaker
           o Minimize separation from parents
           o Educate parents about maintaining a patent airway and risk of suffocation
           o Stress the need for checkups, screenings and immunizations
                   Keep neonate warm and watch for jaundice
           o Stress car seat use in automobile

                                   Age Competency Cont.

                             Healthy Growth and Development
Infancy to Toddler (1 month to 3 years)
     Growth and development continue a rapid advance
          o Rolling and standing as an infant to running and drinking from a cup as a toddler
     Cognitive
          o Play is important to help build social and other skills
     Communication
          o Infants communicate by crying and making simple sounds
                 Becomes differentiated for hunger or pain
                 Socialization
                       Cries to obtain social stimulation
                       Smiles at 6-8 weeks in response to environmental stimulation or human
          o Toddler
                 4-6 words including names
                 Uses jargon
                 Asks for object by pointing
                 Understands simple commands
                 Uses head-shading to denote ―no‖
                 Socialization
                       Toddler views separation as punishment
                       Enjoys play with peers and stories
                       Sibling rivalry
                       Knows own sex
                       Sees gender differences
                       Tantrums/negative behavior decreasing
     Major fear
          o Infant
                 Separation
                 Stranger anxiety
          o Toddler
                 Separation
                 Loss of control
     Safety and Nursing Considerations
          o Educate parents about the need for checkups, screenings and immunizations
          o Ensure the child’s safety and comfort (crib rails up, toys, cuddling, soothing tones)
          o Explain procedures to parents and the child in simple terms
          o Allow time for questions
          o Use simple, concrete honest explanations
          o Let the child touch equipment, or use a doll or stuffed animal to explain procedures
          o Keep the child with parents if possible.
                 Limit exposure to large numbers of staff
                 Involve parents in care and demonstrate procedures to show understanding
                 Discuss questions and concerns about caring for child
                 Teach feeding, hygiene, safety and ways to promote healthy development

                                      Age Competency cont.

                               Healthy Growth and Development
Preschool (4-6 years)
    Physical growth
         o 4 year
                  Jumps, climbs, goes up and down stairs
                  Fine motor skills increasing
         o 5 year
                  Skips, hops, draws pictures, uses buttons and ties shoes
                  Brushes teeth
    Cognitive
         o Can view another’s perspective
         o Uses time-oriented words
         o Primitive ideas about body
         o Difficulty differentiating a ―good hurt‖ from ―bad‖
         o Can pretend
         o Difficulty separating fantasy from realty
         o Believes illness & separation caused by bad behavior, thoughts or wishes
    Communication
         o 4 years
                  Names colors, counts to 5
                  Comprehends ―cold‖, ―tired‖, ―hungry‖
         o 5 years
                  Counts to 10 syllable phrases
                  Knows days of week and names coins
    Socialization
         o Gets along well with parents
         o Uses play to express self
         o Enjoys board games, rhymes, riddles
         o Lives by the rules
    Major Fear
         o Loss of control
         o Bodily injury and mutilation
         o Fear of the unknown
         o Fear of the dark and being left alone
    Safety and Nursing Considerations
         o Give choices whenever possible
                  Allow time for the child to express feelings and ask questions
         o Avoid words like ―cut‖, ―take out‖, or ―dye‖ due to misinterpretation
         o Provide information in advance for major procedures
                  Use pictures models, dolls, games to explain procedures
                  Include what the child will see, hear, feel, smell and taste
         o Reassure the child that the procedure is not a punishment
         o Encourage a younger patient to bring a security object, such as a blanket
         o Stress to parents the need for checkups, screening and immunizations as well nutrition, hygiene
             and safety as the child grown more independent.

                                   Age Competency cont.

                            Healthy Growth and Development
Older Children (7 to 13)
    Physical Growth
         o Growth continues at a slower pace until puberty
         o Muscle skills continue to develop, jumps rope, catches ball
         o Can do a variety of activities, performs all self-help skills
    Cognitive
         o Literal
         o Beginning to understand the relationship between illness & therapy
    Communication
         o Uses all parts of sentence
         o Reads, writes, adds, subtracts, defines words
    Socialization
         o Cooperative family member
         o Loves peers
         o Easily distracted
         o Strives to be independent
         o Makes up simple stories, tells time, jokes and plays games (cheats to win)
         o Interest in God and religion
         o 10-13 years
                 Loves friends
                 Talks with them constantly
                 Has best friends
                 Beginning interest in opposite sex
    Major Fear
         o Loss of control
         o Bodily injury and mutilation
         o Failure to live up to the expectation of others
         o Death
    Safety and Nursing Considerations
         o Prepare for procedures days to weeks in advance to give child a sense of control
         o Use body diagrams, pictures and models
         o Allow time for the child to handle the equipment
         o Give child as many choices as possible
         o Help child maintain contact with peers
         o Emphasize ―normal‖ things child can do
         o Reassure child that he/she has done nothing wrong
         o Emphasize that procedures or surgery are not punishments
         o Respect privacy
         o Teach healthy and safe behaviors (including alcohol, tobacco and drug use)
         o Encourage parents to talk with their child about drugs and sexuality

                                    Age Competency cont.

                             Healthy Growth and Development

Adolescent years (ages 13-20)
   Physical growth
        o Girls begin puberty approximately 2 years earlier than boys
        o Growth spurt may affect coordination
        o Sex features develop such as breasts in girls and facial hair in boys
        o Fine motor skills well developed
        o Participates in sports and extracurricular activities
        o Seeks employment outside the home
   Cognitive
        o Thinks abstractly
        o Analyzes arguments
        o Forms hypotheses
        o Applies theories and ideas
        o Considers potential alternatives to situations not yet experienced
        o Has limited understanding of the structure and function of the human body
                May be self-conscious about body image
                Eating disorders and depression may be of concern
   Communication
        o Verbal, reads and writes well
        o Emotional swings
        o Peer pressure
   Socialization
        o Peers are role models
        o Peers influence decision making
        o Identifies feelings of self and others
        o Considers own feelings to be unique
        o Interested in sports
   Major fear
        o Loss of control
        o Altered body image
        o Separation from peer group
   Safety and Nursing Considerations
        o Emphasize the continued need for checkups, screenings and immunizations
        o Maintain privacy
        o Allow decision making and control
        o Encourage safety regarding smoking, drinking, sexual activity and drugs
        o Provide information in a sensitive manner
        o Be an active listener, supportive and non-judgmental
        o Teach correct terms and visual aids
        o Discuss concerns
        o Teach coping techniques of relaxation, deep breathing and imagery
        o Teach healthy habits regarding seat belts, nutrition, exercise, hygiene and safet y

                                   Age Competency cont.

                            Healthy Growth and Development
Young adult (ages 21-39)
   Physical growth
        o Young adults reach sexual maturity and their adult height and weight
   Cognitive
        o More comfortable with their body image
        o Develop a personal identity and self-reliance
        o Experience sexual intimacy, choose a mate and raise a family
        o Establishment of a career that provides personal satisfaction, economic security and a
            feeling of contributing to the welfare of society
                 Support, honesty and respect
        o Establishing a personal set of values and formulating a meaningful philosophy of life
        o Evaluate new information in terms of their experiences
   Common health problems
        o Four major causes of death related to violence
                 Vehicular accident
                 Other accident
                 Suicide
                 Homicide
        o Anxiety and depression related to pressures of
                 Independence
                 Competition in the work place
                 Acceptance by peers
        o Stress and new-found freedom may lead to
                 Experimentation with various lifestyles
                 Contributes to substance use and abuse
        o Other physical health problems
                 Pregnancy complications
                 Cervical or breast cancer
                 Orthopedic injuries
   Safety and Nursing Considerations
        o Continue to encourage immunizations, checkups and screenings
        o Keep contact with family and friends
        o Assess for stress related to new adult roles
        o Encourage discussion about feelings and concerns regarding illness, injury, family and
        o Involve the patient and family members in decision making and education
        o Educate about injury prevention and a healthy lifestyle
                 Stress management
                 Resources and instructional courses in household management and parenting
                 Encourage exercise, weight control and hygiene
                 Awareness of the dangers of substance abuse
        o Encourage group learning situations and support groups
        o Periodic assessment to screen for hypertension, anemia, cholesterol, breast, cervical,
            and testicular cancer

          Age Competency cont.                 11
                            Healthy Growth and Development
Middle Adult (ages 40-64)
    Physical growth
         o Experience physical changes, such as decreased endurance
         o Women experience menopause
         o Illness or injury may interfere with plans
         o Chronic illness may develop
    Cognitive
         o Concern for the next generation
                 Help children gain independence
                 Helping children grow to become happy, responsible adults
         o Become active in the community
                 Achieve mature social and civic responsibility and involvement in altruistic
                   activities and concerns
         o Balance work with other roles and prepare for retirement
         o Accept role reversal with aging parents
                 Sandwich generation (caring for parents as well as children)
                 Prepare emotionally for the death of living parents
         o Accept and adjust to physical changes of middle adulthood
         o Maintain healthful ways of living
    Common health problems
         o Major causes of death
                 Cardiovascular disease
                 Stroke
                 Lung cancer
                 Breast Cancer
                 Cirrhosis of the liver
         o Other Major health problems
                 Chronic respiratory disease
                 hypertension
    Safety and Nursing Considerations
         o Annual physical exam to screen for hypertension, diabetes, respiratory disease and
         o Assessment of nutrition, exercise, occupational hazards, sexual dysfunction and
            adjustment to menopause
         o Assessment of over the counter use of medications, alcohol and tobacco use.
         o Encourage self-care
         o Allow time to talk about frustrations, accomplishments, dreams and any concerns
         o Talk about stress
         o Assist client with referrals to meet health-care costs
         o Involve the patient and close family in decisions about care

                                   Age Competency cont.

                             Healthy Growth and Development
Older Adult (ages 65-79)
    Physical growth
        o Experience changes in skin, muscles and sensory abilities
        o Higher risk of health problems such as infection and chronic illness
        o Sleep more, often napping during the day
        o Many older adults stay in good health
    Cognitive
        o Adapt to changes
        o Take up new activities and roles
                 Redirection of energy and talents to new roles and activities
        o May experience depression, loneliness and anxiety over changes or about the future
        o Development of a personal view of death that prepares one for this final stage of life
        o May have reduced attention span
        o May remember things more slowly
    Common health problems
        o Cardiovascular disease
        o Cancer
        o Diabetes
        o Respiratory disease
        o Gastrointestinal problems
    Safety and Nursing Considerations
        o Stress the need for immunizations, checkups and screenings
        o Encourage healthy habits and social activity
        o Educate client about safety measures that include
                 Fall prevention
                 Safe medication use
                 Caution with hot water
        o Provide a safe, comfortable environment
                 Night light
                 Temperature
        o Give the patient chances to reminisce to help promote a positive self-image
        o Speak clearly and avoid background noise during teaching
                 Use larger-print materials and adequate lighting
        o Encourage the patient and family to take an active role in care
                 Discuss concerns
                 Talk about family and other support systems
                 Involve patient in care decisions

                                     Age Competency cont.

                              Healthy Growth and Development

Late Adulthood (80 and older)
    Physical growth
         o Higher risk of infection, dehydration, poor nutrition and chronic illness
         o Effects of chronic illness may be more severe
         o Mobility becomes difficult
    Cognitive
         o May feel isolated or upset due to loss of family, friends, sensory abilities or financial
         o May lose self-confidence as their abilities decline
         o Reflect on life and built toward the acceptance of death
         o Learning may be slower with a reduction in attention spans
    Safety and Nursing Considerations
         o Continue to stress the need for screenings, checkups and immunizations
         o Encourage physical and social activity
         o Encourage reminiscing
         o Promote, and assist with self-care and independence as much as possible
                Allow choices whenever possible
                Avoid treating the patient as a child
         o Assist with end-of-life planning
         o Monitor age-related risks
         o Ensure safety measures to prevent falls and burns
         o Educate about home safety and safe medication use
         o Educate in an appropriate environment with suitable materials
         o Involve the patient and family or other caregivers
         o Teach while the patient is a peak energy

(See appendix, pages 71-72 for competency)


Every patient treated at HCGH has the right to expect that personal and medical information will be
kept confidential. Access to patient medical and non-medical information is permitted only to provide
appropriate and necessary care, according to Maryland law and HCGH policy. To gain access to
records for a personal reason, one must complete the necessary paperwork with HIM.

Confidential information includes the medical record, lab reports, lists of hospital admissions,
procedure schedules, billing and insurance information.

To protect patient confidentiality:
   Avoid discussing patients in public places, such as elevators, hallways, and cafeterias.
   Protect the patient's medical record from use by unauthorized persons.
   Protect computer screens and phone conversations from unauthorized observers.
   Do not discuss patient information unless authorized by the patient or law.
   Do not look at medical record information unless you have a ―need to know.‖
   Do not give information on the telephone.

                                          HIPAA Training
All contracted employees are required to complete the following prior to starting on the units:

    1. The Health Insurance Portability and Accountability Act (HIPAA) training prior to starting on the
    2. Acknowledgement of HIPAA Security Awareness and Agreement to Comply for Howard
       County General Hospital- General Workforce Members

Non clinical contracted employees are required to complete the HIPAA Overview module, sign the
Acknowledgement of HIPAA Security Awareness Agreement to Comply and the complete the HIPAA
Overview Knowledge Assessment post-test (passing score 70%).

Clinical contracted employees are required to complete the HIPAA modules: #1 General Privacy;
# 2 Tracking and Accounting; #3 Release of Patient Information. Contracted employees must
also complete the HIPAA Overview Knowledge Assessment with a score of 70% or better and the
Acknowledgement of HIPAA Security Awareness Agreement to Comply. Completed tests must be
kept on file at the contracted company.

The contracted company must be able to immediately present completed test and signed
Security Agreement for any individual upon request from the hospital. Occasional audits are
performed (See appendix pages 68-70 for competency and forms).

                                                                     Identify HIPAA, why it became a law, how it is
                                                                      enforced, and its requirements.
                                                                     Define Protected Health Information (PHI),
                         HIPAA                                        guiding principles, use, and disclosure.
                                                                     Identify the rights given to patients under HIPAA.
                                                                     Identify what types of disclosures must be
                                                                      accounted for and tracked.
                                                                     List what information must be provided for each
                                                                      accounting of a disclosure
                                                                     Identify the type of PHI that can be released
                                                                      under various circumstances

                                                                     Why was the new law passed?
What is HIPAA
                                                                    Privacy rights were violated
                                                                    Examples:
 Health Insurance Portability and
                                                                      Stolen computer disk with list of HIV+
  Accountability Act
 Federal law governing use, transfer and
                                                                           4000 names disclosed by Health Dept employee
  disclosure of identifiable health                                    Banker    on the county health board
  information.                                                             called in mortgages on Cancer patients
 Passed in 1996                                                       Pressgained access to psychiatric
 Went into effect on April 14, 2003                                   records of famous people

    Law Passed                                                   What does HIPAA do?
       Government reacted
                                                                  Gives  rights to individuals (both living
       Passed federal law to protect privacy and
        confidentiality of Protected Health                        and deceased) regarding protection
        Information (PHI).                                         of their health information (PHI).
       New regulations include:                                  The HIPAA Privacy Regulations state
          Rights for patients
                                                                   that use and disclosure of an
          Privacy requirements for healthcare
                                                                   individual’s health information can be
              Includes all Johns Hopkins Medicine staff,
                                                                   used only as it is expressly permitted
               students and faculty.                               by that individual.

              Things Hopkins Must
              Do Under HIPAA Law
      Provide patients with Privacy Notice
      Create policies and practices regarding                Protecting   the privacy of
       the use of medical records
                                                                our patients’ health
      Use medical records only as allowed
      Create methods to respond to patients
                                                                information is part of
       rights                                                   providing for our patients’
      Train all workforce members including
       physicians, staff, employees and
                                                                health needs!

      What is Identifiable
      Health Information?                                       Violations
        Information about living or deceased:                     Accessing health information on
          Diagnosis, health condition                              coworkers, family members or celebrities
          Test results                                            Throwing PHI in trash
          Name, address, gender                                   Sharing patient information to those who
          Vital signs, lab results                                 do not need to know
          Treatment, procedure or medications
                                                                   Sending PHI in e-mails
          Department or unit
          Name of physician                                       Discussing PHI in public areas
          Billing and payment information                           Elevators

        Verbal, written, recorded (x-ray) or                        Cafeteria
         electronic                                                  Lobby

                                     Hibernate or exit screen
                                                                    Violations cont.
                                                                       Leaving PHI unattended
                                                                        in public areas
                  Messages: Only include name                            Clipboard
                  and call back number                                   Computers
                                                                         Hallways
                                                                         Nurses  station
Double rooms – talk                                                      Spectra  link phones
softly, draw curtain                                                     Elevators
                                                                         Patient rooms

                                                                       Failing to log off computer

Non-compliance                                                     Main Principle: One
   Fines:
                                                               Need             to know:
     Institutions - $100 per violation and
      up to $25,000 for all violations of                           What        do you need to know to do your job?
      same year                                                            Example need to know:
     Individual - $250,000 +                                                 Nurse – needs PHI to provide care for the patient in
      imprisonment to 10 years for                                             his/her care but not patients on other units
                                                                              Security guard – needs name and location of patients but
      intentional use of PHI with intent to
                                                                               does not need diagnosis or treatment information
      cause harm.
                                                                           Example do NOT need to know:
     Office of Civil Right enforces HIPAA
                                                                                Worker wants to send a birthday card to friend
           Incident reporting:
                                                                                   Friend was patient at a Hopkins facility
                 JH Compliance Hotline:
                                                                                   Wants to look up date of birth on electronic record
                                                                                   Worker does not have an official need to know
                  or 1-877-932-6675

    Main Principle: Two                                       Disposal of PHI
       Minimum Necessary:                                        Dispose in a secure way
         Are    you using or disclosing the
            smallest amount of PHI necessary to                   Shred or put in secured bins for later
            complete the job?                                      shredding or incineration
              Billing – needs to view the patient’s              PHI should NOT be placed in trashcans or
               current visit information but does not              recycle bins.
               need the entire patient history for
               reimbursement.                                     PHI should NOT be accessible to others who
              Case study for teaching – Needs                     do not require access to information
               to know patient information but not                Examples?
               name, social security number or
               other identifying numbers to teach.

    Use verses                                                      Hopkins Family
    Disclosure                                                         JHH
                                                                       Bayview                               JH School of Medicine
     Use                                                              Howard County General                 JH School of Nursing
         Sharing   of PHI within the Hopkins family of                 Hospital                              Parts of the Bloomberg School
            covered health care providers and health plans.            JH Home Health Services                of Public Health
                                                                       JH Pediatric at Home
     Disclosure                                                       JH Pharmaquip
                                                                                                              The Whiting School of
         Sharing  of PHI with any person or entity not                JH Community Physicians
                                                                                                              The School or Arts and
          within the Hopkins family or outside of a                    Priority Partners Managed
                                                                        Care                                   Sciences
          covered entity
         Examples:                                                    JH Ophthalmology Associates           Kennedy Krieger Institute
                 Consultants
                 Outside counsel
                 Sponsors of research
                 Non-Hopkins care providers
                 Individual’s family members

  How to Account for                                 YES, need to be accounted for:
                                                      Required by law
                                                      Public health activities
                                                          Births,   Deaths, diseases, injuries
   Name   of entity or person                        Abuse, neglect or domestic violence
    receiving PHI                                     Reports to FDA regarding a medical
   Date of disclosure                                 devise - cause of death or injury
                                                      OSHA rules
   Address of the entity or person
                                                      Law enforcement purpose
   Description of PHI disclosed
                                                      Coroners and funeral directors
   Brief statement of purpose
                                                      Organ, tissue, eye or organ donation

   NO, do not        need to be accounted for:
                                                          Patient’s Rights
      Made during course of treatment
      Made in connection with payment                    Receive the Privacy Notice
      Made in carrying out health care operations        Access PHI
      Made to the patient                                Request an amendment to PHI
      Authorized by the patient                          Request an accounting of
      Person involved in care                             disclosures of PHI
      Covered entity’s facility directory                Request restrictions on the use of
      Disaster notification purpose                       PHI
      National Security purpose                          Request confidential
      Law enforcement purpose r/t correctional            communications

Right 1 – Receive the Privacy Notice
Clear and complete notice of Hopkins privacy practices
Each patient will be asked to sign acknowledgement
Refusal to sign acknowledgement must be documented
One acknowledgement form is required but JHH does not have database to track record.

Right 2- Access PHI
1. Right to see and get copies of medical treatment and billing records
Psychotherapy notes
Information put together for use in a legal proceeding
2. Medical Records – for copies or viewing
3. Family members, close friends or representative
Access if provider reasonably believes that individual is involved with patient’s care or billing
May pick up x-rays, medical supplies, or prescriptions

Right 3 – Request an amendment to PHI
Refer to Medical Records Department
Only Hopkins created PHI
If Hopkins finds the PHI is accurate, Hopkins does not have to agree to the amendment

Right 4 – Request an accounting of                   19disclosures       of PHI
Required to account for certain disclosures of PHI:
Whom a disclosure was made
What PHI was disclosed?
When disclosure occurred
Why it occurred

Right 5 – Request restrictions on the use of PHI
Patient asks for false name to hide identity
Hopkins may not agree
If Hopkins agrees, must ensure request is followed.
Hopkins currently allows the masking of VIP names from the facility directory.

Right 6 – Request confidential communications
Communications via regular mail
Communications via e-mail
Use a different address
If asked to do this, comply as long as it is reasonable to do so.

   Facility Directory                                            Release of Information
   If State law is more stringent than HIPAA,                                  Minors – under 18
    than State law prevails                                                         Only with parent or guardian consent
                                                                                    Legal representative of child
   Includes Name, Location, Patient’s                                              Emancipated minor
   Inpatients only, not outpatient                                          Clergy
                                                                                    Requests access to names and locations
   Opt-in or out
                                                                                    May have access to location only if the
        Patients    are informed upon admission                                     patient has agreed to be in the facility
             If objects – must sign the Request for Non-                            directory
              Disclosure of Facility Directory Form
        Psychiatric    patients not listed in directory
             Must opt-in to be included

  Emergency Circumstances                                    Deaths
                                                                Deaths reported as required by law
 Consistent with a prior expressed preference
                                                                After efforts to notify next-of-kin
 Individual’s best interest as determined by
                                                                Hospitals cannot share any information with
  physician                                                      media regarding:
                                                                     Specifics about death
 Patient must be informed asap regarding facility                   Accidental deaths
                                                                     Natural causes
  directory                                                          Need permission from next-of-kin or legal representative

 EMS considered covered entities under HIPAA                   Disclosure allowed:
                                                                     Law enforcement
 Disasters                                                          Medical examiners
                                                                     Funeral directors
   Information may be released to contact family or                 Family
                                                                     Personal representative
      person responsible for care

                                                               Electronic Protected
Media                                                        Health Information (E-PHI)
 Contact   public affairs regarding
                                                Enforceable as of April, 2005
  interview or photograph of a
                                                Must sign confidentiality agreement prior to
  patient                                        access
 Patient’s authorization is                    Use only E-PHI needed to do your job
                                                Avoid disclosing unencrypted E-PHI
                                                Never store E-PHI on handheld device
 If patient is arrested, permission            Login and password information
  from law enforcement officer                  Log off computer when not in use
  required                                      Report computer security problems ASAP

                                                 Tell department manager if you see an
 At least 8 characters long                     unattended PC displaying patient
 Difficult to guess
  Adding  a number at beginning or end          Remove patient information from trash
   does not make it difficult to guess           bins and shred it
  Try using the first letter of a phrase
                                                 Do not access health information of co-
  Try adding special characters or
                                                 workers, family members or celebrities and
   numbers                                       only access the information required for
 Change    password frequently                  your job

                  Treat all patient information
                   with the utmost concern for
                   confidentiality and privacy.


 Keep your user ID and password to yourself.

 Make your password hard to guess and change it frequently.

 Use only the computer systems, programs and files you are authorized and required to
  access to perform your job.

 Make sure others are not looking over your shoulder at the screen while you are accessing

 Avoid sending protected health information (PHI) in e-mails over the Internet.

 Save PHI only to a secure network, not to your local PC drive or portable device.

 Beware of downloading or opening software, documents or e-mail attachments from
  unknown, untrustworthy sources.

 Log off or lock your computer when not in use.

 Promptly get your printed documents from the printer.

 Do not leave unattended printouts in an open area.

 Seek approval from your systems administrator before installing computer programs.

 Use and update antivirus software regularly.

 Report all security incidents to your Help Desk or LAN administrator.


Introduction to Information Security
Johns Hopkins processes a lot of information. Most of what we do—whether in education, patient
care, benefit administration or research and operations—demands that we protect sensitive
information throughout various systems. We need that information to be accurate and on hand, and
we must be able to trust that it will be used only by those who need it.

Since we use computers in our daily work duties, we should follow the best computer security
practices. Our use of computers must be:

      Legal and ethical
      Considerate of others
      Proper in order to limit security problems


The Health Insurance Portability and Accountability Act is referred to as ―HIPAA‖. The HIPAA
privacy regulations protect individually identifiable patient and health plan member information, no
matter what form it is in—paper, oral, or electronic. This information is called Protected Health
Information or PHI. The HIPAA security regulations cover only electronic forms of this information
called Electronic Protected Health Information or E-PHI. The HIPAA security regulations are
enforceable as of April 20, 2005. How you use your computer can impact the security and privacy of
patient and plan member information.

To protect E-PHI, follow these steps:

      Avoid disclosing unencrypted E-PHI in e-mails and shared files over the Internet.
      Avoid saving E-PHI to your computer hard drive. Save files on a Johns Hopkins server.
      Never share your login with another user.
      Never store E-PHI on a handheld device that lacks strong security controls.
      Use only the E-PHI needed to do your job.
      Log off or lock your computer when you are not using it.
      Report computer security problems quickly.

Many computer systems track your actions. Be aware that inappropriate actions on computers can
cause damage, and that such actions may be traced to a specific user.


Authorization to Use E-PHI
To do your job, you may be given access to some computer applications with E-PHI. But first, the
security administrator of the computer applications must get authorization from your management.
Also, you may have to go to computer training and sign a confidentiality agreement before access is

If you change jobs within Johns Hopkins, your computer access may change. You may be given
access to other computer applications, and/or your existing access may be increased, reduced or

User IDs and Passwords
Computer applications ask you to prove who you are before giving access. Proving who you are
before you can do something is called ―authentication.‖ For most computer applications,
authentication consists of a user ID (for example, jsmith1) and a password. Good passwords can be
effective security controls when you follow these steps:

         Make passwords that are at least eight (8) characters long.
         Make your passwords hard to guess. Use a mix of letters, numbers and special characters
         Do not use your user ID, your name, your birthday, or your child’s birthday as your
         Do not use names or other words found in a dictionary as your password.
         Adding a number at the beginning or end of a word does not make it a hard to guess
         Try using the first letters of a phrase that you will not forget and put in some special
          characters and numbers (e.g., Four Score and Seven Years Ago can become FS^a7YA;
          My Wife’s Birthday is January 1 can become MWBIJ1; etc.).
         Try using vanity license plates, such as UR2COOL, or try combining two words to make a
          good password (i.e., blue jays and hawks can become bj/hawks)
         Do not write down your password in your work area.
         Do not share your password with anyone other than your computer or LAN administrator to
          fix or maintain your computer.
         Change your password at least every 90-180 days.
         Avoid re-using old passwords.
         Change your password if you think someone knows your password or has used it. Also, tell
          your LAN administrator or Help Desk.


Preventing Viruses

Computer viruses are designed to damage or destroy a computer, even without you knowing it. It is
standard practice to use and maintain anti-virus software on your computer. Follow these steps to
help limit viruses:

          Make sure anti-virus software is on your computer. Use the software and update it often.
          Your computer should protect against new viruses or tell you when updates are available.
           Every Johns Hopkins user can get this software at
          Question all e-mail attachments. The attachments ending in .doc and .xls (MicroSoft Word
           or Excel documents) are mostly safe, but virus writers may trick users by using them.
          Do not open any e-mail attachments with extensions of .exe, .vbs, .js, .hta, .pif and .shs
           unless you know the sender and the contents of the file.
          Do not assume that all e-mails and attachments are virus free, even if the e-mail appears
           to come from someone you know.
          Be careful downloading programs from the Internet and ask your LAN administrator if you
           have questions.

Reporting Incidents
Even with good security habits, there will be incidents from time to time that need a response. An
incident could be:

          Unauthorized access to gain the ability to monitor computer activity
          Unauthorized access to steal or alter data
          Tampering with or destroying a computer, handheld device or server
          A computer virus
          Belief that someone used your account when you were not using it (for example, when on

Incident reporting is important. You should watch for unusual activity and tell your LAN administrator
or HELP Desk.

What You Can Do

You need to be aware of how you use computers. You need to think of how your actions might create
a security issue. Report incidents and unusual activity. And, if you are not sure of what to do, always
ask your LAN administrator.

          Johns Hopkins Health System (JHHS) Corporate Compliance
                               Ethics, Integrity and Values

JHHS Corporate Compliance:
Who, What, When, Where & How
•What is Corporate Compliance & Why have a program?
•Who oversees Compliance?
•How does it affect me?
•When do I need to think about Compliance?
•Where do I turn to if I have questions?
What is Compliance & Why have a program?
Compliance: meeting the rules and regulations required by Federal, State & Local laws, rules,
regulations and by contract.

The Compliance program is designed to assure that we:
     Protect our organization, employees, and customers;
     Preserve the level of integrity that JHHS is known for;
     Promote the continued effort do the right thing;
     Maintain effective internal controls that promote adherence to legal and ethical
     Promote prevention, detection and resolution of illegal or unethical conduct.

What do I need to know?
  • That JHHS is committed to following all applicable laws and regulations and in
 particular, those laws and regulations that address health care fraud, waste, and abuse
 and the proper billing of Medicare, Medicaid, and other government funded health care
 programs. This includes the Federal False Claims Act and State law or related
 enforcement policies.

   • The reputation and integrity of both the organization and our employees are valued.
 JHHS recognizes its employees rights under these laws and are committed to abiding by
 them. We rely heavily on you, our employees, to help us comply with all of the legal
 and regulatory requirements applicable to us by identifying potential problems,
 reporting them and asking questions.

►Proper decision making is critical to continued financial success.

Areas of Government Oversight: Civil Fraud
• Civil: burden is a preponderance of the evidence.
• Civil penalties increased up to $11,000 per false claim and up to 3 times the
         amount of each claim as damages.

►Penalties include acts that the provider knew or should have known were not accurate.

             Johns Hopkins Health System (JHHS) Corporate Compliance
                         Ethics, Integrity and Values, Cont.

Special Compliance Issues
• Compliance with policies or laws isn’t always easy, even with the best intentions.
     • The following areas can create complex situations where, due to complicated
            laws, or human nature, it is unclear what actions are needed to
                    ―Do the Right Thing‖………………..

Interactions with Others
        •   Gifts
                ○ Is it edible or usable in the workplace?
                ○ Anything else should be questioned.

           Supplier, vendor and consultant relationships
               ○ JHHS and its staff may not accept gifts or contributions to influence
                 with whom we do our daily business.
           Physicians and provider relationships
               ○ Contracts and other formal relationships should always be reviewed by
                 our General Counsel.

Conflict of Interest
       An Officer, Trustee or other Disqualified Person connected to JHHS Corporation is deemed to
have a ―conflict of interest‖ if the person has a financial interest, directly or indirectly, through
business, investment or family:

–  An ownership or investment interest in any entity with which the Corporation
        has a transaction or arrangement
– A compensation arrangement with the Corporation or with any entity or
         individual with which the Corporation has a transaction or arrangement,
– A potential ownership or investment interest in, or compensation arrangement
        with, any entity or individual with which the Corporation is negotiating a
        transaction or arrangement.
• Compensation includes direct and indirect remuneration as well as gifts or favors that are
substantial in nature.

Workplace Conduct and Responsibility
• Obey applicable laws, rules and policies
•   Behave honestly, use good judgment with high ethical standards
•   Strive for mutual respect and trust
•   Avoid personal conflicts of interest
•   Report actual or suspected violations to management or Compliance staff

Failure to follow the Code may put yourself, patients, co-workers, institutions and/or the
System at risk!

       Johns Hopkins Health System (JHHS) Corporate Compliance
                   Ethics, Integrity and Values, Cont.
Who Oversees Compliance?
        The Office of Corporate Compliance is designed to educate and train employees, preserve
continued ethical and legal conduct and protect organizational and employee reputations.
• Thomas Staffa, Chief Compliance Officer
• Compliance Office, 410-614-6693
• Visit our website at:

Who do I ask if I have some questions?
      There are several options you have for answering questions about Compliance:
            1. Talk to your supervisor.
            2. Review written materials.
            3. Contact the Compliance Office: 410-614-6693
            4. Utilize the Compliance Hotline.

Where can I report Compliance and/ or Privacy Issues?
• Compliance Hotline: 1-877-WE COMPLY
• 24/7 availability
• Non retaliation
• Anonymous, confidential

                                  PATIENT BILL OF RIGHTS

Patient Rights and Responsibilities

As a patient at Howard County General Hospital, we want you to be well informed, participate in your
treatment choices, and communicate openly with your health care team. As a patient and as a partner, we
want you to know your rights as well as your responsibilities during your stay at our hospital.

Patient Rights:

Provision of Care
    You have the right to receive considerate, respectful and compassionate care in a safe
      setting regardless of your age, gender, race, national origin, religion, sexual orientation,
      disabilities, diagnosis, ability to pay or source of payment.

      You have the right to be addressed by your proper name and to be told the names of
       the doctors, nurses and other health care team members involved in your care.

      You have the right to have a family member or representative of your choice and your
       own physician notified promptly of your admission to the hospital.

      You have the right to be informed by your doctor about your diagnosis and prognosis,
       as well as the benefits and risks of each treatment, expected outcome and options. You
       have the right to give written informed consent before any non-emergency procedure or
       treatment begins.

      You have the right to be informed about outcomes of care, treatment and services
       provided, including unanticipated outcomes.

      You have the right to be informed about pain and pain relief measures and to actively
       participate in your pain management plan.

      You can expect full consideration of your privacy and confidentiality in care
       discussions, examinations and treatments. The presence of a chaperone during any
       type of examination may be requested.

Provision of information
    You have the right to sign language or foreign language interpreter services. We will
      provide an interpreter as needed.

                                 PATIENT BILL OF RIGHTS
      You have the right to be involved in your discharge plan. Prior to your discharge from the
       hospital, you can expect to receive information about follow-up care that may be needed
       after you are discharged.

      You can expect that all communications and records pertaining to your care are
       confidential, unless disclosure is permitted by law. You have the right to review or obtain a
       copy of your medical records and receive an accounting of disclosures regarding your health
       information, within a reasonable timeframe. You may also request amending your medical
       record by contacting the Health Information Management Department.

      You have the right to receive detailed information about your hospital and physician

Personal rights
    You have the right to be free from restraints and seclusion in any form that is not
     medically required.

      You have the right to be free from all forms of abuse, neglect and exploitation.

      You have the right to access protective and advocacy services. The hospital will provide
       a list of state protection and advocacy groups upon request.

Refusal of Treatment
    You and your family, as appropriate, have the right to actively participate in decisions
     regarding your care, treatment and services provided, including the right to refuse
     treatment to the extent permitted by law and to be advised of the medical
     consequences of your refusal. If you choose to leave the hospital against the advice of
     your doctor, the hospital and doctors will not be responsible for any medical consequences
     that may occur.

      You have the right to agree to or to refuse to, take part in medical research studies.
       You may at any time withdraw from a study and it will not affect your usual medical care.

Advance Directives
   You have the right to make an advance directive, such as a living will, and appoint
     someone to make health care decisions for you if you are unable. If you do not have
     an advance directive, we can provide you with information and assistance to complete one.
     You have the option to review and revise advance directives.

                              PATIENT BILL OF RIGHTS

Concerns or complaints
   You have the right to voice your concerns about the care or services you receive. If
     you have a problem or complaint, you may talk with your doctor, nurse manager
     or a department manager. You may also contact the Quality & Patient Safety
     Department to assist you with your concerns by calling 410-740-7912, or by writing to
     Quality & Patient Safety Department, Howard County General Hospital, 5755 Cedar
     Lane, Columbia, Maryland 21044. If your concern is not resolved to your satisfaction,
     you have the right to request a review by the Maryland Department of Health &
     Hygiene, Office of Health Care Quality, Hospital Complaint Unit, Spring Grove
     Hospital Center, Bland Bryant Building, Catonsville, Maryland 21228, 410-402-8016.

   Following discussion with your health care team, if you need to discuss an ethical
     issue related to your care, a member of the Ethics Service is available at all times.
     The Ethics Service can be contacted through members of the health care team.

 Chaplains are available to assist you with your religious and spiritual needs or to contact
               your own clergy. A chaplain can be reached at 410-740-7898

Patient Responsibilities:

Provision of Information
    You are expected to provide complete and accurate information, including your full
      name, address, home telephone number, date of birth, Social Security number,
      insurance carrier and employer when it is required.

      You should provide the hospital or your doctor with a copy of your advance directive
       if you have one.

      You are expected to provide complete and accurate information about your
       health, including present condition, past illnesses, hospital stays, medicines, vitamins,
       herbal products and any other matters that pertain to your health, including perceived
       risks in your care and unexpected changes in your condition.

      You are expected to provide complete and accurate information about your
       health insurance coverage and to pay your bills in a timely manner

                             2010 National Patient Safety Goals

Goal 1 - Improve the accuracy of patient identification.
Use at least two patient identifiers when providing care, treatment, and services.
Eliminate transfusion errors related to patient misidentification.

Goal 2 - Improve the effectiveness of communication among caregivers.
Report critical results of tests and diagnostic procedures on a timely basis.

Goal 3 - Improve the safety of using medications.
Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other
procedural settings.
Note: Medication containers include syringes, medicine cups, and basins.
Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

Goal 7 - Reduce the risk of health care–associated infections.
Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current
World Health
Organization (WHO) hand hygiene guidelines.
Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in
acute care hospitals.
Implement evidence-based practices to prevent central line–associated bloodstream infections.
Implement evidence-based practices for preventing surgical site infections.

Goal 8 - Accurately and completely reconcile medications across the continuum of care.
A process exists for comparing the patient’s current medications with those ordered for the patient while under the care of
the hospital.
When a patient is referred to or transferred from one hospital to another, the complete and reconciled list of medications is
communicated to the
next provider of service, and the communication is documented. Alternatively, when a patient leaves the hospital’s care to
go directly to his or her
home, the complete and reconciled list of medications is provided to the patient’s known primary care provider, the
original referring provider, or a
known next provider of service.
When a patient leaves the hospital’s care, a complete and reconciled list of the patient’s medications is provided directly
to the patient and, as
needed, the family, and the list is explained to the patient and/or family.

                      2010 National Patient Safety Goals, cont’d.
In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation
processes are performed.

Goal 15 - The hospital identifies safety risks inherent in its patient population.
Identify patients at risk for suicide.

Universal Protocol for Preventing Wrong Site, Wrong Procedure, and
Wrong Person Surgery™
Hospitals can enhance safety by correctly identifying the patient, the appropriate procedure,
and the correct site of the procedure, prior to all surgical and nonsurgical invasive

Conduct a preprocedure verification process.
Mark the procedure site.
A time-out is performed before the procedure.

   Ancillary departments such as Cardiac Rehab, Diabetes Management, EECP, Pulmonary
         Rehab, Rehab Services (PT,OT,SLP) and The Center for Wound Healing assess patients via
         the Morse Fall Scale.
        If a Patient is identified as ―at risk‖ for falls according to the Morse Fall Scale, they are placed
         on appropriate fall precautions. A sticker is positioned on the patient’s badge which is an
         indication to the health care professional that the patient is at risk for falls.

Wound Center
  Low Risk:
     Exam stools labeled for ―staff use only‖
     Patient advised not to sit on rolling exam stools
     Monitor for change in status
     Bed brakes on
     Ensure adequate footwear when ambulating to the bathroom
     Place bed in low position when patient unattended
     Place upper side rails up when unattended

                 2010 National Patient Safety Goals, cont’d.
   High Risk:
        all of the above plus:
        Assist with ambulation to the bathroom as needed
        Assist with transfers to bed and wheelchair as needed
        Evaluate for referral to PT for assistive devices/strengthening
        Orient patient to environment to decrease confusion
        Caregiver requested to remain with patient
        Frequent safety checks by staff
        Patient name badge marked with a green dot and worn in a visible location during visit

Outpatient Rehab (OT/PT/SLP)
  High Risk:
          Green dot placed on patient ID badge
          Fall prevention handout issued to patient/family
          List assistive device and/or need for positioning belt in wheelchair if applicable
          Level of assist for transfers/ambulation

Cardiac Rehab
  High Risk:
          Apply leaf sticker to patient’s ID and medical record
          Safety brochure reviewed
          Non-skid footwear on
          Instruct-call for assist before ambulating
          Patient/family involved
          Chair stretches
          Modified exercises
          Review Oxygen safety

Encourage patients’ involvement in their own care.
       Define and communicate the means for patients and their families to report concerns about
       safety and encourage them to do so.

The organization identifies safety risks inherent in its patient population.
The organization identifies patients at risk for suicide. [Applicable to patients being treated for
emotional or behavioral disorders in general hospitals.]


What can you do to promote patient safety?

•   Think before you act.
•   Use two patient identifiers.
•   Ensure complete communication (using SBAR) during hand-offs of care.
•   Speak out, report mistakes.
•   Use write down, read-back confirmation to ensure accuracy of telephone or verbal
•   Label all medications and medication containers with drug, strength, and amount.
•   Identify fall risk and institute recommended risk reduction strategies.
•   Look for system flaws and assess your own practice for potential threats to safety.
•   Share ideas for safety improvement.


                                 Patient Safety Net (PSN)
                          At Public Workstations near You.......

What is Patient Safety Net (PSN)?
     A non-punitive web-based event reporting system
         o Prevention - NOT Blame!
                 The focus will be on a systems approach to understanding events and not on
                    "punishing" the involved parties.
         o PSN is organized under a medical peer review committee structure. The information
             entered into the system isn't considered discoverable in litigation. In essence, entering
             the report into PSN actually protects the information.
     Available on all public workstations
     PSN is NOT a substitute for documentation or placing a service request.

PSN Features
     Captures patient, visitor, and service events
     "Near miss" reporting
     Reporting triggers e-mail alerts to appropriate manager(s), physician(s) and others

What do I report in PSN?
     Medication events
     Adverse drug reactions
     Equipment/supply and device events
     Falls
     Skin breakdown (pressure ulcers, burn, lacerations)
     Unexpected events during surgical or invasive procedures (break in sterile technique,
      incomplete sponge count (sponges, needles, etc.), inadequate preparation, wrong procedure,
      wrong site/side)
     Unexpected events during respiratory care procedures and treatments (self extubations,
      ventilator events, missed treatment, etc.)
     Events related to laboratory and/or radiology tests (test not ordered or performed, wrong test
      ordered or performed, specimen delivery problem, mislabeled specimen or results, delay,
      wrong interpretation)
     Unexpected complications of procedures, treatments, and tests (Death, CPR, unplanned
      transfer to ICU, wound dehiscence, DVT, pneumothorax, Anesthesia/sedation event,
      Maternal/neonatal complications, Nosocomial infections, IV site complications)
     Behavioral events (Assault by patient, visitor, or staff, Threat by patient, Patient self harm,
      Refusal of therapy)
     Communication and records (Inadequate communication, Records/charts unavailable,
      Records/chart incomplete, Access to care problem, Referral information problem)
     Miscellaneous (Discharge against medical advice, Elopements, Inadequate privacy, Missing or
      incorrect patient ID, Patient/family complaints)
     Other: Property damage or loss, Environmental hazard or fire, Narcotic discrepancy or drug
      diversion, Inappropriate behavior by staff
     Blood transfusion reactions

                              Patient Safety Net (PSN) cont.

What should I NOT report in PSN?
      Staff related events
      o Staff injury (falls, back injury, sharps injury)
      o Exposure to blood or body fluids
      o Exposure to chemicals/hazardous material

What paper forms will stay?
     Code Blue Evaluation Form (used whenever emergent defibrillation, CPR and/or respiratory or
      cardiac arrest occurs)
     Employee Injury Report
     Report of Suspected Transfusion Reaction

Contact the Nurse Manager or Shift Director immediately if any of these patient
events occur:
     Temporary harm and required initial or prolonged hospitalization
     Permanent harm
     Near-death event (e.g., required ICU care or other intervention necessary to sustain life)
     Death

You still need to notify appropriate personnel of events, according to hospital
and departmental policies:
     Physician for patient errors
     Nurse manager for patient complaints or significant errors
     Senior Vice President for Quality, Risk Services, Administrator on call, and/or Johns Hopkins
      legal department for significant events
     For emergencies (power outages, fire, arrest, security issues, broken equipment): Remember
      to follow the normal channel of reporting (make a phone call, then report in PSN)

What happens after an event has been submitted?
     An e-mail notification goes to the manager and/or performance improvement representative responsible
      for the floor/unit where the event occurred.
     The manager can access the report on-line and add or edit the report, as needed.
     Others will receive the report as appropriate (e.g., Pharmacy will receive medication events; Clinical
      Engineering Services will receive equipment events; The Johns Hopkins Legal Department will receive
      significant events = Harm Score E and above, etc.).
     Follow-up of the error will be done at the unit level, as needed.
     The Patient Safety Manager in the Quality, Risk Services Department reviews all events entered in
     Monthly, In Step with PSN (INvestigating System Trends and Event Processing)
           o Monitors reported events
                    PSN
                    calls to Risk Management
                    complaints
           o Identifies trends
           o Assigns responsibility for investigation of events, and identification of system improvements.
                              Patient Safety Net (PSN) cont.
How do I get started?
      To enter a report: Go to the Public Workstation home page ( and click
       on the link "PSN-Report an Event or Service Concern."
      To Review events as a manager go to the UHC website ( and click on the UHC
       PSN logo in the bottom left of the screen. Here you will be prompted for your user name and

                  UHC P ATIENT S AFETY N ET – H ARM S CORING
⇒ Select the highest level of harm presented at the time of the event report. If harm cannot be
determined at the time of the report, then select D as the event level of harm.

No Actual Event
A. Unsafe Conditions (*NOT for Events Involving Patients)

Event, No Harm
B1. The event did not reach the individual because of chance alone. (―near-miss‖)
B2. The event did not reach the individual because of active recovery efforts by the caregivers.
C. The event reached the individual but did not cause harm.
D. The event reached the individual and required additional or treatment monitoring.

Event, Harm
E. The individual experienced harm and required treatment.
F. The individual experienced harm and required initial or prolonged hospitalization.
G. The individual experienced permanent loss.
H. The individual experienced harm and required intervention necessary to sustain life.

Event, Death
I. The individual died.

For additional help with PSN, contact: Kelly Fadrowski (x7657, or Mary
Moore (x7949,

                                Patient Safety Net (PSN)
                              Tips for Easy PSN Reporting

The PSN on line reporting system replaces the HCGH paper Adverse Event form and the Medication
Variance form

A list of what to report and what not to report in PSN can be found when you click on the PSN link.

To prevent incomplete reports from being submitted:
    Some fields are required, and you won’t be permitted to proceed to the next page unless they
      are completed.
    If you close the PSN before you submit the report, you will lose all the information you just

For successful reporting—be prepared before you start entering information into PSN:

For all patient events, you will need:
    Patient name
    Patient MOO#
    For medication events, you will need the name of the medication and dose.
    For patient falls, you will need the most current Morse Score.
    For reporting any type of skin breakdown, you will need the most current Braden Score.
    To assign a HARM score. See the back of this sheet for HARM score examples.

There is a timer in the top right corner—you have 15 minutes to complete the report or it will kick
you out and you will have to start all over! How can you avoid this?
           Fill out a report when you know you will not likely be interrupted. Periodically click on
              ―reset timer‖. This will ―restart‖ the clock

                                  ADVANCE DIRECTIVES

Policy of HCGH
      Howard County General Hospital will honor a valid living will.
      Living wills made prior to October 1, 1993 will be honored even if not in accord with the
       requirements for living wills made after October 1, 1993.

Copies of Advance Directives will be found in the front of the patient chart. If the patient does
not bring in a copy of the Advanced Directives, the documentation of the intent of the
Advance Directive is found in the admission assessment (except 1N)

Stress to patient and the family the importance of bringing a copy of the Advance Directives to
the hospital

If patient does not have Advance Directives, offer the patient the opportunity to formulate Advance
Directives while they are in the hospital.

Inpatients who have elected not to be resuscitated in the event of a cardiopulmonary arrest will wear
a blue bracelet. A physician’s order stating this must be written in the order section of the chart.
Two nurses will complete the blue ―Do Not Resuscitate‖ sheet and place it as the first page in the
patient’s chart.

At the time of registration, outpatients who attend ongoing treatments (PT/OT/SLP, Cardiac Rehab,
Pulmonary Rehab, The Center for Wound Healing, Anticoagulation, and EECP) are asked if they
have advanced directives identified in the event of a cardiopulmonary arrest. The patients are to
bring a copy of their advanced directives (especially individuals who are returning for ongoing
treatments) and it is permanently placed in the patient’s active medical record. Each department will
assure it is easily removable in the event of a cardiopulmonary arrest, to provide to the code team.

                       SAFETY MANAGEMENT/SAFETY PLAN
Emergency Notification

For all emergencies that require immediate response, dial 5151. This line is answered immediately.
If you dial the operator, the call will be answered in the order in which it was received – the operator
has no idea that any call is urgent.
Examples: cardiac arrest, fire, and threat of fire
    For cardiac arrest: Departments in the Ambulatory Care Center, state floor and location.
In addition, each bed has a code button, which immediately notifies the hospital operator to call a
code for that unit. In most rooms, the button is located behind the bed on the nurse call system.

Fire Safety

1. Review of the CODE RED PROCEDURE:
   a. Actions to take if the fire is in your immediate area: RACE
         REMOVE: anyone in immediate danger to a safe location.
         ALARM: sound the fire alarm by: Pulling the nearest alarm pull station OR call the
                     switchboard on ext 5151
         CONFINE: the fire and smoke by closing all doors.
         EXTINGUISH: the fire if you can do it safely.
   b. Actions to take if the fire is NOT in your immediate area:
     Remain in your area until notified. DO NOT GO TO THE FIRE LOCATION.
     Close all windows and doors
     Locate all patients and staff
     Clear exits and corridors
     Call communications ONLY if you have information related to the fire.
   Operating a Fire Extinguisher: PASS
     PULL the pin.
     AIM the nozzle at the BASE of the fire.
     SQUEEZE the handle.
     SWEEP the nozzle from side to side.
2. When a Code Red or Code Red Drill is announced, promptly:
      Close all doors to the rooms.
      Check the hallway for adequate clearance, clear stretchers and wheelchairs if needed.

Personal Safety - Incident Report
These reports are completed when something ―out of the ordinary‖ happens to an employee, such as
a needle stick, fall, etc. These reports are given to the manager on duty or Nursing Supervisor
immediately if the unit manager is not present. The incident should be reported as soon as possible
after the injury occurs. Typically, an employee is advised to see the Employee Health Nurse or go to
the emergency department, when the Employee Health Nurse is not available, for assessment and

Part I. Employee Information:
Name: (Last)_________________________________________                 (First)_______________________________________                 (MI)______________
Address:_______________________________________________                  City:_________________________            State:______      Zip
Marital Status: Married ___ Single___ Widowed ___ Divorced ___                  Male___ Female___                    Date of
SS#:_____________________ Job Title:______________________ Dept:__________________________
                                                                                                          Alternative Phone#:_______________________
Part II. Employee Incident Information:
Date of Incident:____________________ Time of Incident:__________ AM/PM Date Reported to Supervisor:_____________________
Time Work Day Began:________________ AM/PM                    If Applicable: Years of Clinical Experience:__________________
Location of Incident:___________________________________Building:____________________________Room:_____________________
Was there a safety procedure or mechanism available? Yes ___ No___            Was it in use at the time of incident? Yes ___ No ___
Is the activity part of the normal job duties? Yes___ No___ If Applicable: Date of last training session on safety equipment _________________.
Frequency of using safety equipment: always____            sometimes____      rarely/never _____
List names of anyone present at the time of the incident:____________________________________________________________________
Probable cause of incident (object or substance responsible for injury/illness):_________________________________________________________
Is this a new or repeat injury to the same body part? New ____ Repeat ____
Date:________________          Time:________________            Employee
I hereby affirm that these statements are turn and correct to the best of my knowledge.
Part III: To be completed and signed by Supervisor or Dept. Head.
If indicated, what was discussed with employee to prevent recurrence?______________________________________________________________
Date:________________ Supervisor or Dept. Head

Note: Any additional comments you feel are pertinent to an investigation of this incident can be made on a supplemental sheet and attached.
Part IV: For Occupational Injury Clinic Use Only Inc.#. __________________________________ICD9 DX Code:________________

Disposition: Full Duty ___ Restricted ___ Off Duty ___ Restrictions           not accommodated ___ Referral ___ (ED, Ortho, etc.)
RTC Scheduled ____RTC PRN _____ Recordable* Yes ___ No ___ *as defined by OSHA   Safety Investigation Requested: Yes ____ No____
If yes,

Date:________________ Time:______________         Healthcare Provider's

1800-1 10/06 (REV. 06/24/10)


Location of Emergency Preparedness Manual/Content Overview

The Emergency Preparedness Manual gives specific information on procedures for the following
emergency situations:
   External Disaster
   Internal Disaster
   Bomb Threat
   Ethylene Oxide Mishap
   Fire
   Hostage Situation
   Loss of Power
   Weather Emergencies
   Loss of Telecommunications


The decision to evacuate is made by the Security Department and the Fire Department. There are
three phases:
    1. Remove patients to a safe area on the same level.
    2. Remove patients to a safe area on the floor below.
    3. Remove patients to a safe area outside the building.

Department/Position Specific Procedure
Statewide Code Notification (reminder call 5151 for all codes, never dial 0): See Uniform
  Emergency Codes on page 47

Please note that at HCGH, we have a dedicated Code Blue response team. Key members from
certain units will always respond to a Code Blue.

Rapid Response

                                            UNIIFORM EMERGENCY CODE
                                            UN FORM EMERGENCY CODE

The Department of Health and Mental Hygiene with the State of Maryland has adopted regulations requiring all Maryland
hospitals to use a uniform set of emergency security codes effective.
                                          November 11, 2004


               Code Red                                                 Code Pink

                Code Blue Adult                                          Code Blue Child

                Code Blue Infant                                         Code Green

                Code Gold                                                Code Orange

                Code Gray                                                Code Purple

                 Code Yellow


MSDS Sheets (Material Safety Data Sheets)
MSDS sheets can be obtained via a phone call to 3M (a contracted agency) at 1-800-451-8346.
Turnaround time is typically 2 days unless an immediate need or ―stat‖ reason for obtaining this
information is indicated. MDSD sheet contain detailed and specific information about each potentially
hazardous material. The 1-800 451-8346 for MSDS sheets should be posted in a clear location in the
event of an emergency. To obtain MSDA sheet in an emergency notify immediate supervisor and/or
Security Department (x 7911) that a Material Safety Data Sheet is needed on an emergency basis or
call directly 3M company 1-800-451-8346 and provide the following information:
                  1. Product name and code
                  2. UPS code, it available
                  3. Manufacturer name
                  4. A FAX number so the 3M Company can fax request to you

Department Specific Information

   Soiled linen hampers should be kept covered at all times, and never be allowed to overflow.

   Clean linen should be kept covered with the cover of the cart and should not be stockpiles in
    patient rooms.

   Nothing should be kept beneath the sinks except for cleaning materials.

   Keep all chemicals properly labeled and stored to prevent mishaps.

   Sterile water and sterile saline bottles and irrigation sets should be dated when opened so that
    they can be discarded before they become contaminated.

   Supplies for measuring output need to be labeled with patient name to prevent cross

   Refrigerators for patient nourishment and medications need to have temperature recorded daily
    (maintain at 38 degree F or below) Medication refrigerators should contain only medications and
    patient nourishment refrigerators should contain only labeled food items.

   Employee food is to be kept in the employee refrigerator in the staff lounge. It is the responsibility
    of each employee to maintain a clean food environment.

                              SECURITY MANAGEMENT PLAN
Patient Security
Special Reminders to all staff:
   1. Report any suspicious activity, especially in the areas of 1 North, MCU, ED and Pediatrics.

   2. Visitors must have a pass at all times.

   3. Security officers are on duty 24 hours a day, 7 days a week.

Security Notification
   1. Non emergency number 7911

   2. Panic button and/or Security button (these are present in the ED and 1 North depts.)

   1. Free parking is available in the employee parking area, located off of Charter Drive

   2. Do not park in designated patient parking areas.

   3. Escort service is available 24 hours a day.

                                         INFECTION CONTROL

Infection Control/Exposure Manual
    Infection control information can be obtained in two ways:
        1. The Infection Control Manager
        2. Review the policies & procedures on infection control issues that can be found on the
        HCGH intranet –scroll to infection control
        You must review the following policies:
     A 2.1 (HR EHS 13) – Healthcare Worker Exposure to Blood or Body Materials
     H 1 – Hand washing
     U 1 Standard/Universal Precautions

Personal Protective Equipment (PPE)

   Personal protective equipment must be available at the bedside
   Replace if you used it.
   When to use:
       Anytime you anticipate the chance of exposure to body fluids could occur. PPE is just
       like wearing a seat belt in a car—it doesn’t do you any good to put the equipment on
       AFTER the accident occurs.

Infection Control Measures on Your Unit:
1. Objectives:
    Prevent hospital acquired infections
    Prevent the transmission of all infections
2. Always comply with Standard Precautions
3. Hand washing before and after treatment
4. Avoid food or drinks in the unit near blood and other body fluids
5. Equipment to be wiped down with disinfectant after each use:
   * Telemetry Equipment, SCD machines
   * Nurse Servers                 * Blood Pressure monitoring devices
   * Pulse ox devices                     * PD Supply box
   * Glucometers                   * Wheelchairs
   * Gerichairs                    * IV pumps
6. Isolation Supplies – most units now have a plastic caddy that is placed on the door of the patients’
   room to store gowns, gloves, and masks. Some units still use an isolation cart that is available
   from sterile supply. Be sure the appropriate isolation sign(s) are visible at the entrance of the patient
Hand Hygiene

The following products are used for hand hygiene at HCGH:
    Waterless hand sanitizer – Acceptable alternative to soap and water hand washing unless there is
        visible soil on the hands. It effectively destroys organisms and penetrates under fingernails better than
        soap. It contains emollients and is less drying than soap and water.
    Soap and water – Take 15 seconds to vigorously rub together all surfaces of lathered hands and rinse
        under a stream of water. Dry with a paper towel. Use the paper towel to turn the faucet off.
    Specific hand washing procedures will be required for NICU and in the well baby Nursery.
                                  INFECTION CONTROL Cont.
Artificial Nails
       Artificial nails, including overlays, gels wraps, acrylics, are NOT permitted when working in a
        clinical area.
       Nail length must not be longer than ¼ inch beyond the fingertips.
       Nail polish is permitted as long as it is not cracked or chipped.

Fragrance-free Policy
Fragrance products such as perfume, cologne, aftershaves, or strongly scented cosmetics, hair care
products and skin lotions are associated with a variety of adverse health effects. Howard County
General Hospital has instituted a fragrance-free policy. Please refrain from wearing scented or
fragrance products while functioning in the clinical field.

Standard Precautions
•   Standard precautions are to be used on all hospital patients, regardless of their diagnosis or
    presumed infectious status, when coming into contact (or risk of contact) with any of the following:
    blood, all body fluids, secretions and excretions except sweat, nonintact skin, or mucous
•   Consistent and thorough hand hygiene.
•   Extreme care to prevent needle stick and other injury from sharp instruments.
•   Barrier precautions:
         Gloves for contact with any body fluids or surfaces soiled with fluids.
         Gowns face masks, and eye coverings during procedures in which there is any expected
            or splash. High risk activities for spraying/splashing include: drawing arterial blood gases,
            suctioning respiratory secretions, emptying urine containers, changing dressings,
            administering blood.
•   All equipment must be cleaned with a hospital approved disinfectant/ germicide following
    manufacturers recommendations.
•   Small used equipment is placed in unwaxed bags, closed, and labeled before being returned to
    the dirty utility room /CSD.
•   Large equipment is wiped with disinfectant before being removed from the patient's room.
•   When isolation is discontinued, the door sign is left in place until the Environmental Services has
    completed cleaning of the room.

                       HIGHLIGHTS FROM THE EXPOSURE CONTROL PLAN                  
Standard/Universal Precautions will be observed at this facility in order to reduce the risk of
transmission of microorganisms from both recognized and unrecognized sources of infection.

Standard/Universal Precautions applies to all patients and includes:
   o Blood
   o All body fluids, secretions, and excretions except sweat, regardless of whether or not they
      contain visible blood
   o Nonintact skin
   o Mucous membranes
   Note – A person can look healthy and still transmit bloodborne disease such as HIV.
   Work Practice Controls

   Hand Hygiene – the use of gloves and other personal protective equipment (PPE) does not
   reduce the importance of hand hygiene. Hand hygiene needs to be performed after removing
   When hands are not visibly soiled, an alcohol based hand rub may be used to sanitize hands.
   When hands are visibly soiled, soap and water are to be used for handwashing. Hand hygiene
   reduces the risk of spreading infection.

                                    To use the alcohol based hand rub:

   1.   Hands should be free of visible debris.
   2.   Apply sufficient amount to wet hands thoroughly.
   3.   Rub hands together, covering entire surface, including nails.
   4.   Allow to dry completely

   Needles/Sharps Disposal 

   Contaminated needles and sharps will not be bent, recapped, removed, sheared, or purposely
   Needle/sharp safety devices are required for use whenever they are provided by the hospital.
   Sharps containers are routinely changed by the vendor, but containers must be sealed and
   removed when ¾ full.

                   HIGHLIGHTS FROM THE EXPOSURE CONTROL PLAN                     
Work Area Restrictions     
In work areas where there is a reasonable likelihood of exposure to blood or other potentially
infectious material, employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle
contact lenses.
Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter
tops or bench tops where blood or other potentially infectious materials are present.

Contaminated Equipment        
In general, the hospital approved disinfectant meets all CDC and EPA guidelines for
decontamination of environmental surfaces. Employees must exercise caution when handling
contaminated environmental surfaces. Personal protective equipment (PPE) and hand hygiene
are essential.

Infectious Waste    
Red is the universal symbol for infectious material. All infectious material is to be disposed of in a
red bag or an infectious waste container lined with a red bag. A list of infectious waste items is in
this packet.
Red bags are to be sealed when ¾ full.
Red bags are not to be placed in containers with clear bags.

Personal Protective Equipment (PPE) 

Uniforms, warm-up jackets and lab coats, purchased by individual employees are not to be used
as PPE. If personal uniforms or scrubs become contaminated, notify your supervisor for
assistance in obtaining clean scrubs and having the clothing laundered. Contaminated clothing
should be removed in a manner to prevent inadvertent contamination of the body.

Disposable gowns that are fluid resistant and or/impermeable should be worn over uniforms
or hospital scrubs whenever there is a need to prevent splattering or soiling of uniforms with
blood, body fluids, or substances. They are not to be worn in the hallway. Gowns should be
removed by gently pulling the gown off of the arms, turning it inside out to prevent
contact/touching the outside.

Eye protection/face shields must be worn whenever splattering of blood or body fluids into the
eyes is a possibility.

 A surgical mask is to be worn when contamination of the mouth, nose, or nonintact skin of
that area is anticipated. For example, wear a mask when you are in close range of another’s
respiratory secretions. To remove, untie and hold by the strings to discard. The N95 (orange)
mask is used in certain situations and is only to be used by those who have been fit tested.

                   HIGHLIGHTS FROM THE EXPOSURE CONTROL PLAN                     
   Gloves must be worn when handling           52       items contaminated with body fluids or
       when doing a procedure that may result in an exposure to body fluids.
      Gloves are to be removed at the point of use and not worn in the hallways.
      To remove gloves, peel one glove off from the top to the bottom and hold it in the other gloved
       hand. With the exposed hand, peel the second glove from the inside, tucking the first glove
       into the second. This minimizes the risk of touching the contaminated portion of the glove.

Labels 
Look for the biohazard symbol, but keep in mind that labels to warn of biohazard are not required
Red bags or containers are used.
Containers of blood or blood products are labeled as to their contents and have been released for

Laundry/Linen 
All used linen is considered contaminated and potentially infectious. Used linen is to be handled as
little as possible – When removing soiled linen from a bed prior to bagging wear gloves and a gown if
Linen is not to be agitated, thrown on the floor, stored in patient rooms, or carried against the body.

Hepatitis B Vaccine 
The best defense against acquiring Hepatitis B is vaccination. The vaccine is a non-infectious, yeast-
based vaccine given in three injections, in the arm. Hepatitis B vaccine is available, without charge,
to all employees in Category I – those who may have regular occupational exposure to blood or body
fluids and substances of patients. New employees must be given the opportunity to start the vaccine
series within 10 working days of beginning the job.
An employee who is eligible for the vaccine and declines to receive it must sign a waiver. Although
the vaccine is recommended for all employees at risk, it is not required. If a waiver is signed
declining the vaccine, the employee still has the right to change his/her mind and accept it at a later
date if he/she remains in a job at risk.
At the current time, CDC does not recommend routine Hepatitis B vaccine boosters. If this should
become a public health recommendation, the hospital will provide the booster vaccine free of charge
to employees.

Post Exposure Evaluation and Follow-Up 
In accordance with CDC guidelines, the OSHA standard, and Maryland State Law, the hospital
provides post exposure evaluation and follow-up. The policy A -2.1, Healthcare Provider Exposed to
Blood or Body Fluids, can be found in the Meditech library under Human Resources Policy. In
addition, it can be found in the Exposure Control Manual.

                      HIGHLIGHTS FROM THE EXPOSURE CONTROL PLAN                   

Employee Responsibilities Following an Exposure to Blood or Other Potentially Infectious
Body Fluids:
Time is of the essence – Begin this process immediately after the exposure. Report to Employee
health or to the ED within ½ hour following your exposure.
   1.      Wash the affected area with soap and water. For splashes to the eye, flush with water or
   2.      Call your supervisor or designee to report the exposure.
   3.      Report to Employee Health. (During off-hours, report to the ED Triage Area.
   4.      If you were seen in the ED, call Employee Health (ext. 7838) on the next business day
           (Monday- Friday) to arrange for a follow-up appointment.

Tuberculosis (TB) is a serious disease caused by a tiny germ called
Mycobacteria tuberculosis.

The TB germ is spread from person to person through the air. The germ gets
into the air when a person with TB disease of the lungs, or throat, coughs,
sneezes, talks, or sings. The risk of getting TB is greater if a person
spends long periods of time indoors with someone who has active TB.

A skin test called a PPD can determine when a person has the germ.
   A negative result means you probably do not have the TB germ.
   A positive result usually means you do have TB germs.
A person with a positive result will need a chest x-ray &/or sputum tests to
determine if they have TB disease.

A person can carry the TB germ without having tuberculosis disease. This is
referred to as TB infection. People with TB infection:
   - do not feel or look sick
   - are not infectious and cannot infect other people
   - are not considered a case of tuberculosis
   - usually have a positive PPD.
Medication is recommended, in some people, to prevent TB disease.

People with TB disease or active TB can infect others unless they are being
treated for tuberculosis. People with TB disease or active TB usually show
symptoms of illness such as:
     - coughing up blood                    - loss of appetite
     - unexplained weight loss              - night sweats
     - fever/chills                 - tires easily
     - cough of more than three (3) weeks duration
It is important that people with TB disease take the proper medication, for
the correct period of time, to cure the disease.

Some people are at higher risk for TB disease. They include:
  - close contacts of a person with TB
  - people with HIV
  - alcoholics and drug users
  - people with certain medical factors (diabetes 54mellitus, chronic renal
     failure, silicosis)
   - people who reside in high risk settings (correctional facilities,
     shelter, long-term care facilities)

TB transmission can be prevented in the hospital by:
  - identifying patients with TB early in hospitalization &
  - initiating Airborne Isolation for patients with known or suspected TB.
    This includes:
      Private room with negative air pressure.
      Keeping isolation room doors closed.
       Employee use of N-95 mask (orange) when entering the room. Patient wears regular surgical
       mask if they need to leave the room.

See Infection Control Procedure T-2.2 for specific steps to prevent

                                 ADMINISTRATIVE TOPICS

1. Each department within the hospital operates under policies and procedures. The Patient Care
   Services division contains policies that are applicable to the Nursing units as well as same
   applicable to Ancillary Services departments. Many units also have additional policies and
   procedures that are specific to for their unit.
   Some units that have additional policies and procedures are:
      Emergency Department
      Intensive Care Unit
      Intermediate Care Unit
      Ancillary departments such as Cardiac Rehab and Rehab Services (OT, PT, SLP)

   As an example, the staff on the IMC needs to be familiar with the entire General Nursing policies
   as well as the policies and procedure in the IMC Policy and Procedure Manual. The staff in the ED
   needs to be familiar with the General Nursing Polices and the ED specific policies, etc.

2. Policies and procedures are accessed through the Meditech library.



Areas to include in a tour of the department include:
         Supply Room
         Dirty Utility Room
         Lounge
         Nutrition Refrigerator
         Pyxis
         Code Cart/Defibrillator
         Linen Supplies
         Glucometers
         Par Excellence System
         Central Monitoring Station

Things to point out on tour:

         Patient Locator Board at Nurse’s Station
         Location of equipment and supplies in rooms
         Lounge
         Location of code carts, EKG machines
         Employee restroom(s)
         Label printer


  1. Voice Mail -- When leaving a message, speak clearly and slowly; leave name, department and
     telephone number.

  2. Hospital Overhead Paging – Dial (5050); ask the operator to page the person or department.

      Reminders: speak clearly, if the individual is required immediately ask the operator to ―STAT
      page‖ the individual, be sure to tell the operator the call back number. Except for emergencies,
      there is no overhead paging from 11pm-7am. Visitors are not paged and patients are not
      paged back to their rooms.

  3. Note:
     Numbers beginning with    ―6‖ CAN NOT BE DIALED DIRECTLY
     Numbers beginning with    ―7‖ have an exchange of 740
     Numbers beginning with    ―8‖ have an exchange of 720
     Numbers beginning with    ―4‖ have an exchange of 884

How to Page
  1. Dial 7500 (or 410-740-7500 from outside the hospital)
  2. Enter the beeper number (called ID to page)
  3. Enter the extension that you need the individual to call, then type # and hang up. Note: Please
     type this number slowly or the person you paged may not see your call back number.
  4. The 10 digit page number is also an alternative and required when the system is

Answering the Phones
     Answer phone courteously, clearly stating your department and name.
     Patients requesting medical advice refer to the charge nurse, or supervisor or manager(no
      medical advice over the phone)
     Do not give information about patients over the phone; allow the patient or family member to
      speak to the caller when possible or take a number to have them call back.
     Respect patient confidentiality.

                                      Directions To Hospital

Howard County General Hospital
5755 Cedar Lane
Columbia, Maryland 21044

From Baltimore

       Take Baltimore Beltway 695 to Exit 16 - Route 70 West toward Frederick (this exit is after
        Security Boulevard.)
       Exit at Route 29 South - toward Columbia.
       Continue on Route 29 to Exit 18 - Columbia Town Center. Upon exiting, stay in the left lane
        and turn left at first light onto Broken Land Parkway.
       At second traffic light, turn left onto Little Patuxent Parkway.
       Continue on Little Patuxent Parkway for approximately 1 mile - you will pass Howard
        Community College and Central Maryland Oncology Center on your left.
       Turn left to enter Howard County General Hospital just before the traffic light at the intersection
        of Cedar Lane and Little Patuxent Parkway.

From Baltimore taking 95 South
   Take 95 South to Exit 38-B - Route 32 West.
   Follow Route 32 to exit 17 for Cedar Lane. Upon exiting, bear right onto Cedar Lane.
   Continue on Cedar Lane (approximately 2.5 miles) - after the third traffic light, stay in right
   lane and Howard County General Hospital is located on the right just before the intersection
   of Cedar Lane and Little Patuxent Parkway.

From Frederick
   Take Route 70 East towards Baltimore.
   Bear right onto 32 East towards Columbia.
   Follow Route 32 to Exit 17 for Cedar Lane. At the light, turn left onto Cedar Lane.
   Continue on Cedar Lane (approximately 2.5 miles) - after the third traffic light, stay in right
   lane and Howard County General Hospital is located on the right just before the intersection of
    Cedar Lane and Little Patuxent Parkway.

From Washington D.C. and Points South
   Take Route 95 North or Route 29 North from the Beltway 495 to exit 38B for Route 32 West
    towards Columbia.
   Follow Route 32 to exit 17 for Cedar Lane. Upon exiting, bear right onto Cedar Lane.
   Continue on Cedar Lane (approximately 2.5 miles) - after the third traffic light, stay in right lane
    and Howard County General Hospital is located on the right just before the intersection of Cedar
    Lane and Little Patuxent Parkway.

From Annapolis and Points East
   Take Route 50 West to Exit 21 for Interstate 97 North. Follow Interstate 97 to Exit 7

                                                                      Phone List

  Phone Number 443-718-      Brief Description                           Phone Number 443-718-   Brief Description
                    5015      OT Treatment 2                                                                    FAXES, FAXES, FAXES
                    3109     Admitting                                                 3013      Ancil Admin Asst/Eileen FAX
                    3110     Admitting                                                 3158      Anticoagulation FAX 1          Main Line
                    1111     Admitting Notification                                    3157      Anticoagulation FAX 2
               3123-3126     CDS Staff Office                                          3156      Anticoagulation FAX 3
                    5013     Classroom by door                                         3130      CDS Transcription FAX
                    3113     Classroom by screen                                       3017      DM Mgr FAX
                    3131     CP Exam                                                   3015      Gym Cardiac Rehab FAX
                    3132     CP Exam                                                   3108      HIM Analyst FAX
                    3133     CP GYM                                                    3018      Inpatient Rehab Mgr FAX        Jamie Politzer
                    3128     CP Physician Reading                                      3019      OP Rehab Staff Office FAX
               3119-3122     CP Staff Office                                           3020      Outpatient Rehab Mgr FAX       Dianne Braun
                    3117     CP Stress Test                                            3112      Phlebotomy FAX
                    3129     CP Transcription                                          3101      Reception (back)FAX
                    5010     Diabetes Teaching                                         3114      Reception (front)FAX
                    5011     Diet Counsel                                              3150      RT Work Area FAX
                    3115     ECP                                                       3001      Scheduling FAX
                    3106     HIM Coder                                                 3171      WC Clinical Office FAX
                    3107     HIM Docum. Analyst                                        3170      Wound Center Fax               Main Line
                    3136     Inpatient Rehab Office 1   Main line                                Wound Center
                    3137     Inpatient Rehab Office 2   was Lolly's       2266          3012     WC Managers' Office            Larry Raymond
2191                3138     Inpatient Rehab Office 3   Karen Allen       2209          3137     WC/Ostomy Managers' Office     Lolly McCance
2199                         IP Ed Myer                                                 3160     Wound Center
2203                         IP Jamie Riordan                                           3161     WC Treatment Room 1
2201                         IP PT #2                                                   3162     WC Treatment Room 2
2200                         IP Rehab                                                   3163     WC Treatment Room 3
2193                         IP Sandra Acs                                              3164     WC Treatment Room 4
2197                         IP Sejal Vyas                                              3165     WC Treatment Room 5
2202                         IP Sheila Caldis                                           3166     WC Treatment Room 6
                      5012   Nursing or Diet                                            3167     WC Treatment Room 7
2192                         Occupational Therapy                                       3168     WC Clinical Office 1
                      3118   OP CP Staff Lounge                                         3169     WC Clinical Office 2
                      5019   OP Lymphedema Passage                                      3170     Wound Center Fax

       5017   OP Lymphedema Tx 6                                   3171   WC Clinical Office FAX
       5018   OP Lymphedema Tx 7                                   3172   WC Physician Office
       5021   OP Lymphedema Tx 8                                   3173   WC Physician Office
       5020   OP Lymphedema Tx 9                                   3174   WC Staff Lounge
       3147   OP Patient Consult                                   3175   WC Coding
       5022   OP PT Adult Gym                                             Anticoagulation Clinic
       5024   OP PT Baby Treatment                                 3155   Anticoagulation Clinic 1        Tami Kozlowski
       5025   OP PT Ped's Gym                                      3155   Anticoagulation Clinic 2
       5023   OP PT Traction                                       3155   Anticoagulation Clinic 3
       3139   OP Rehab Office 1        Main Line                   3156   Anticoagulation FAX 3
       3140   OP Rehab Office 2        Kelly M.                    3157   Anticoagulation FAX 2
                                       Heather K & Andrea
       3141   OP Rehab Office 3        G                           3158   Anticoagulation FAX 1
       3142   OP Rehab Office 4        Jen Jackowski               7935   AC Phone # 3155 rolls over to   Annette Young
       3143   OP Rehab Office 5        Monica S & Judy H                  ASCOMs
       3144   OP Rehab Office 6        Carla T & Tom C      2204          CDS Tech                        Tony Gibson
       3134   OP Speech                Lina Chauhan         2093          DI ECHO Tech
                                       Christopher Klein
       3135   OP Speech                                     2094          DI ECHO Tech                    Biddinger
       5014   OT Treatment 1                                2207          ECHO Tech
       5016   OT Treatment 3                                2093          ECHO Tech
       3121   OT/PT/SLP Staff Lounge                        2206          EEG Tech
       3116   PFT                                           2199          IP Ed Myer
       3111   Phlebotomy                                    2203          IP Jamie Riordan
2196          PT #1                                         2201          IP PT #2
2198          PT/OT                                         2200          IP Rehab
       3100   Reception 1                                   2193          IP Sandra Acs
       3102   Reception 3                                   2197          IP Sejal Vyas
       7620   Admitting Manager        Christine Butler     2202          IP Sheila Caldis
       7672   Admitting Supervisor     Laura Hucik          2192          Occupational Therapy
       3105   Referral Assistant       Joann Perry          2196          PT #1
       3104   Referral Coordinator     Jomika Tatum         2198          PT/OT
       3000   Scheduling                                    2216          RT #1
       8134   Scheduling Supervisor    Patricia Robinson    2217          RT #2

              Leadership                                      2211          RT ICU
2190   3002   Director                     Eileen Harrity     2212          RT IMC
       3003   Assistant to the Director    Deborah Robinson   2214          RT Lead Therapist
              Outpatient Administrative
                                           Pam Mintz
2208   3004   Services                                        2213          RT NICU & OB STAT
              Cardiac & Pulmonary Rehab,
                                           Preeti Benjamin
2205   3005   Mgr                                             2222          Spanish Interpreter
2210   3006   Pulmonary Mgr.               See Respiratory    2267          WC Kimera Shields
2079   3007   Diabetes Management CPM      Mike Taylor                      Respiratory
2195   3008   Inpatient Rehab CPM          Jamie Politzer            3148   RT Staff Lounge Phone
2194   3009   Outpatient Rehab CPM         Dianne Braun              3149   RT Work Area Phone
2210   3011   Teri Beck - RT CPM           Teri Beck                 3150   RT Work Area FAX
2266   3012   Wound Center CPM             Larry Raymond             3151   RT Safety/Edu Room Phone 1
2209   3137   Wound/Ostomy CPM             Lolly McCance             3152   RT Safety/Edu Room Phone 2


Instructions for requesting Meditech Access:
  1) Complete one Computer Password Request form per employee, including all of the
     following fields:
         a) Date requested
         b) Date needed
         c) User’s First Name
         d) User’s Last Name
         e) User’s Middle Initial
         f) User’s phone number/extension (employee’s name)
         g) Users’ Supervisor
         h) Expiration Date (for contracted employees only)
         i) Signature of employee and manager

  2) Fax completed forms to HCGH Information Technology department at 410-740-

  3) IT department will complete requests within 1 week and will forward Password
     Request forms to appropriate department in envelope with employee’s name on

  4) Department manager is responsible for picking up Password Request forms from
     and for training contracted employees.

  5) Once training is completed, signed forms should be sent back to IT.


Dial x-5151 to report any of the following:
    Bomb Threat-―Code Gold‖
    Cardiac Arrest (Adult, Child, Infant)-―Code Blue‖
    Emergency or Disaster-―Code Yellow‖
    Fire-―Code Red‖

RACE:        R emove anyone in immediate danger
             A larm-sound the fire alarm
             C onfine-the fire and smoke (close the door)
             E xtinguish the fire if you can do it safely

    Hazardous Material Spill/Release-―Code Orange‖
    Infant or Child Abduction-―Code Pink‖

Identification -Contracted employees and faculty are required to wear identification
specific to the agency.

Parking -Free parking is available in the employee parking area, located off of Charter
Drive. Do not park in designated visitor parking areas.

Security Emergency- dial X-5151 (7911 non-emergency)

Service Excellence-Hospital Mission: Provide the highest quality care to improve the
health of our entire community through innovation, collaboration, service excellence and a
commitment to patient safety.

Our goal is to communicate a caring attitude and to anticipate needs.

   Greet the patient-make eye contact and smile.
   Introduce self. State role.
   When leaving the patient, ask ―Is there anything else I may get for you?‖
   Always identify a timeframe when you will return.

                         Howard County General Hospital

                List of Sites Eligible for Joint Commission Survey

The Center for Ambulatory Surgery (TCAS)
Little Patuxent Specialty Care Center

                    List of Departments/Units/Areas/Programs

Ground Floor
Perioperative Services: Operating Rooms, Post Anesthesia Care Unit, Endoscopy
Surgical Pathology
Sterile Supply
Center for Sleep Disorders
Clinical Engineering
Food and Nutrition Services/Cafeteria
Clinical education
Information Systems
Clinical Information Systems
Environmental Services Offices
Supply Chain Management
Plant Operations
Volunteer Services Office

    First Floor
Emergency Management Office
Admitting Services
Emergency Department – 36 adult beds
Pediatric ED – 12 emergency beds
Pediatrics – Observation and inpatient – 6 inpatient beds
Short-Stay Unit – 23 beds. Serves as observation unit and
                  inpatient telemetry overflow unit
1 North – Psychiatry – 20-bed inpatient voluntary/involuntary adult unit
Outpatient Services – 1P:
        Outpatient Rehabilitation, Physical Therapy, Occupational Therapy, Speech
        Cardiac Rehabilitation
        Pulmonary Rehabilitation
        Cardiac/ Pulmonary Diagnostic Services
        Diabetic Clinic, Wound Clinic and Anticoagulation Clinic
Diagnostic Imaging Services
Clinical Laboratory
Health Information Management
Health Sciences Library
Medical Staff Services
Central Transportation Office                 64
Security Services
Respiratory Care Department Offices
Gift Shop
Coffee Kiosk
Pastoral Care/Chapel

                                 SECOND FLOOR
Maternal Child Services
       Neonatal Intensive Care Unit (NICU) – 18-bed unit
       Labor & Delivery (L&D) – 12 LDRs, examination and recovery rooms;
                          2 C/S ORs
       Maternal Child Unit (MCU) – 34 beds, 30-bed Newborn Nursery; antenatal
                             and postpartum unit
2 Pavilion - 30 bed medical/surgical unit; predominantly surgical unit
2 South – 21 bed Surgical Orthopedic Unit
Nursing Administration

                                   THIRD FLOOR
Intensive Care Unit (ICU) – 16-bed adult medical and surgical ICU
3 Pavilion – 30 beds, telemetry unit
3 South Specialty Care Unit – 19 beds, telemetry step-down unit

                                 FOURTH FLOOR
4 South – 22-bed medical/surgical unit; predominantly medical unit; oncology and urology

4 Pavilion – 30 bed medical/surgical unit; predominantly medical

The Center for Ambulatory Surgery

Ground Floor
Outpatient Surgery
Post Anesthesia Recovery Unit

First Floor
Infusion Clinic
Center for Breast Health
Reception/Admitting functions

Second Floor
Employee Health Services
Human Resources
Administrative Offices

Little Patuxent Specialty Care Center

First Floor
Maternal Fetal Medicine Office Practice
Vascular Surgery Office Practice

4-2011                                     65

                           UNAPPROVED ABBREVIATIONS

      Do Not Use                                                       USE INSTEAD

            U (unit)               Mistaken for ―0‖ (zero), the             Write ―unit‖
                                    number ―4‖ (four) or ―cc‖

     IU (International Unit)      Mistaken for IV (intravenous)       Write ―International Unit‖
                                     or the number 10 (ten)

   Q.D., QD, q.d., qd (daily)        Mistaken for each other                Write ―daily‖

Q.O.D., QOD, q.o.d., qod (every     Period after the Q mistaken       Write ―every other day‖
          other day)              for ―I‖ and the ―O‖ mistaken for

     Trailing zero (X.0 mg)          Decimal point is missed                 Write X mg

 Lack of leading zero (.X mg)        Decimal point is missed                Write 0.X mg

              MS                  Can mean morphine sulfate or       Write ―morphine sulfate‖ or
                                       magnesium sulfate               ―magnesium sulfate‖

      MSO4 and MgSO4                Confused for one another         Write ―morphine sulfate‖ or
                                                                       ―magnesium sulfate‖

                          AGREEMENT TO COMPLY
                       GENERAL WORKFORCE MEMBERS

      I am a user of one or more Howard County General Hospital information
      technology devices or systems that may include Electronic Protected Health
      Information (―E-PHI). I hereby certify that:

      1. I have reviewed the ―Johns Hopkins HIPAA Security Awareness‖ handout
         and the ―Johns Hopkins Computer Security Tips‖ handout.

      2. I recognize the importance of maintaining the confidentiality and integrity of
          the E-PHI that I work with for my job duties.

      3. I agree to abide by Johns Hopkins policies and procedures as explained in the
         Johns Hopkins HIPAA Security Awareness handout.

      Witness my signature as of the date set forth below.

      Signature                                        Printed Name

      Date                                             Telephone Extension


Copies to be placed in personnel record and maintained in department where employee

Contractor’s Name:__________________________
Hopkins Entity______________________________
Department/Division _____________________________

                  HIPAA Overview – Knowledge Assessment

Circle the letter of your answer:

1. HIPAA is:

A. A state law covering patient privacy
B. A federal law and regulation covering how medical information can and cannot be
C. A Hopkins policy that is used to tell patients what they must do.
D. All of the above
E. None of the above

2. As a Hopkins employee you must:

A. Remove patient or plan member medical information from plain view of the public.
B. Report suspicious activities related to patient or plan member information to
supervision or        security.
C. Verify identity of anyone requesting patient or plan member information.
D. All of the above
E. None of the above

3. As an employee, you may work on one of the Wilmer units. It’s ok to tell your
brother that Stevie Wonder is coming for an examination next week.

A. True
B. False

4. Why was HIPAA passed?

A.   Medical information was used inappropriately.
B.   Congress was asked to do something about insuring patient privacy.
C.   All of the above
D.   None of the above

5. HIPAA does not give any rights to patients regarding their medical records.

A. True
B. False

                   HIPAA Overview – Knowledge Assessment, page 2

6. What are some examples of Health information?

A.   Patient’s name
B.   Doctor’s name or office where a patient was seen.
C.   Billing information
D.   All of the above
E.   None of the above

7. Bayview and Howard County Hospital are Hopkins Institutions that are not
covered under    HIPAA.

A. True
B. False

8. As an employee of Hopkins, I may:

A.   Tell a co-worker my PC password
B.   Open confidential envelopes that come to my work area.
C.   Share patient information with anyone who asks me
D.   All of the above
E.   None of the above

9. As long as my supervisor knows about HIPAA, I have no responsibilities to know
anything    about the Federal Privacy Regulations.

A. True
B. False

10. My friend was treated at Hopkins on a unit where a co-worker is assigned. It is
OK for      that co-worker to tell me what they know about my friend or make a
copy of the doctors’ notes for me.

A. True
B. False




                               Age Specific Competency

Directions: Answer each multiple choice questions by circling the correct answer. There
is only one correct answer for each question.

1. In caring for adults over the age of 80, staff members should avoid which of the

      A.    giving them choices whenever possible
      B.    positioning yourself in front of the patient when talking to him/her
      C.    treating him/her as a child

2. One method of establishing trust with the adolescent (13-20 years) is by using good
   Communication skills. Which of the following will hinder communication?

      A.    active listening
      B.    providing encouragement
      C.    giving advice.

3. Which key health care issue needs to be explained to the parent of the neonate (1-28
days) prior
   to discharge?

      A.    keeping the neonate warm and watching for jaundice
      B.    placing gates on open stairways
      C.    baby-proofing the house

4. One action that may help reduce stranger anxiety in infants and toddlers (1 month-3
years) is:

      A.    limiting exposure to large numbers of staff
      B.    limiting parent visitation
      C.    speak in a loud voice to the child

5. The young child (4-6 years) has a vast imagination, which action will help the child
   what is happening to him/her?

      A.    have him/her keep a journal of the hospital stay
      B.    allow them to talk on the phone with friends
      C.    allow them to practice procedures on a doll or stuffed animal

                      Age Specific Competency
                         Post-Test, Page 2

6. Which of the following are needs of the young adult (21-39)?

       A.   owning a home
       B.   having children
       C.   support, honesty and respect

7. One of the concerns of middle adulthood (40-65 years) is likely to be:

       A.   a sense of being invincible
       B.   caring for their parents and their children
       C.   social contacts

8. Which of the following is a goal in caring for the older adult (65-79 years)?

       A.   prevent them from talking about the past
       B.   avoid involving them in care decisions
       C.   prevent isolation

9. Which of the following might be warning signs of depression in the adolescent?

       A.   spending a lot of time talking on the phone
       B.   asking many questions
       C.   lying huddled in a ball in the bed

10. Which of the following health teaching technique would be effective when working with
    older child (age 7-12 years)?

       A.   allowing the child to handle equipment
       B.   provide them with reading material
       C.   have the child attend a support group




INSTRUCTIONS: Read each question carefully, then write (T) or (F) False next to the question

1. _______    The Fire extinguisher’s nozzle should always be aimed at the top of the fire.
2. _______    A Fire alarm at Howard County is called a ―Code Orange‖.
3. _______    The design of a building helps prevent the spread of fire in hospitals.
4. _______    It’s O.K. to block a fire exit, if you are only going to be working in the area a few
5. _______    The Material Safety Data Sheets list possible health and safety hazards to users.
6. _______    If an employer cannot furnish any information on a chemical, the employee must
              continue to work with it under threat of dismissal.
7. _______    The hospital’s hazardous communication program is required by law.
8. _______    It’s O.K. to ignore a threat if it doesn’t seem serious.
9. _______    All security incidents should be reported immediately to Security, no matter how
10. ______    The Hospital emergency number is 5911.
11. ______    Desks, lockers and storage areas should be locked when not in use.
12. ______    Hospital employees are not required to wear I.D. Badges when at the hospital and
              on duty.
13. ______    A MSDS is available 24hrs a day, seven days a week by contacting the 3M
14. ______    Employees can request an escort to their car only during the evening.
15. ______    The hospital lost and found is located in the Security Office.
16. ______    During a disaster, all employees should immediately report to work.
17. ______    The Code for a disaster is ―Code Orange‖.
18. ______    The code for a bomb threat at Howard County General Hospital is called ―Code
19. ______    Smoking on hospital property is allowed only in designated areas.
20. ______    Security is everyone’s responsibility, not just the Security Department





                        ANNUAL MANDATORY TRAINING TEST
                              INFECTION CONTROL

Directions: Answer True (T) or False (F) to each statement.

_______ 1. Universal Precautions apply to blood, nonintact skin, mucous membranes, and all
body        fluids, secretions, and excretions except sweat.

_______ 2. A person can look healthy and still carry and transmit HIV (the AIDS virus).

_______ 3. Vaccinations are available for Hepatitis B and Hepatitis C.

_______ 4. Staff do not need to use safety needles if the patient does not have a bloodborne

_______ 5. Gloves are not to be worn outside of the patient care area (hallways, elevators, etc.).

_______ 6. You can fight the spread of nosocomial infections by proper hand hygiene.

_______ 7. Exposures to blood or other potentially infectious body fluids should be evaluated
            within 3 days of the injury.

_______ 8. Patients who must leave the TB isolation room are required to wear a surgical mask.

_______ 9. Hand hygiene is not necessary if gloves are worn.

_______ 10. Doors to the TB isolation room must remain closed at all times.



                              INFECTION CONTROL
                             POLICY REQUIREMENT

I have read and understand the following policies:
(Place date and initials next to each)

H-1 Hand Hygiene __________

A-2.1 (HR EHS 13) Exposure __________

U-1 Standard Precautions ________

Employees Signature and Date

Please contact Barbara O’Connor – Infection Control Manager at X7765 or pager during
off-shifts (410)890-5594 for any questions or comments on this material. Thank you.

          HO    Name________________________________________
    C s.
       e ews
C   G  Res
      E er
      ct h
    oo ir
    t n.
    HentHo      Date_________________________________________
      s ort
    o aP
       er       Department___________________________________
    ae P
    t ix

    t re
        t                                   Patient Safety Post Test
    f  a

      n f
    O ge
    ey            1. At HCGH, our two patient identifiers are ___________ and ____________.
                  2. True or false: Critical test results and values must be reported to a responsible
    eI               licensed caregiver.
    sG p

      R           3. The best way to prevent the spread of infection remains________________.

       g          4. True or false: Psychiatric hospitals and acute hospitals that treat patients for
       t.            behavioral or emotional illnesses need to have a process in place to identify
     r               patients who are at risk for suicide.
     l            5. True or false: Medication reconciliation includes a comparison of the medications
     H               ordered during a hospitalization to the medications taken at home with all
     o               discrepancies addressed and resolved.
     p            6. True or false: Because of the potential for allergic or adverse reactions, it is
     i               important to know a patient’s home medications before administering contrast,
     t               anesthesia, or pain medication.
     l            7. True or false: The Universal Protocol™ (UP) only applies to procedures performed
                     in operating room suites.
                  8. UP includes which of the following:
                       a. Preoperative verification
     a                 b. Surgical site marking
     n                 c. Timeout
     i                 d. All of the above
     z                 e. A and C only
     t            9. The preop verification process helps you to ensure that you have the correct
     i               ___________, ______________, and ____________.
     n            10. True or false: The process for surgical site marking must be consistent across the
     a                hospital or organization.
                  11. At HCGH, the site should be marked with ___________________.
                  12. True or false: Timeout occurs immediately prior to the start of the procedure. If two
                      or more procedures are to be done, a timeout occurs before each procedure.
     e                                                      77

To top