2011 - 2012
Welcome to this year’s INNOVATION
The introduction of a new idea
Please read this entire packet
and complete the Annual
Mandatory Education To highly regard and show
Questionaire. If you have any esteem or concern for.
questions about the content of
this document or the exam, While our job descriptions tell
please contact your supervisor. us “what” to do, our values tell
To excel as a primary health us “how” to do it. As employees
Thank you. care network and community of Memorial Hospital of Rhode
Human Resources teaching hospital. This requires Island, we all share the same
us to: values. Those values should
Memorial Hospital is a not-for-
be reflected in our day-to-day
profit health, teaching, and • Continuously improve the
research center serving the quality, maximize the value,
Blackstone Valley region of and expand access to CONTENTS
Rhode Island as well as the patient services.
Bristol County region of Standards of Performance,
Massachusetts. • Build a learning
organization by creating an
OUR MISSION environment and structures
to foster role development. Cultural Diversity / Interpreter
Our Mission is primary care and Services / Patient Rights
preventative medicine providing • Support research efforts
advanced diagnosis and and translate research MHRI Code of Ethics / Abuse
treatment with a focus on findings into standards that Recognition / Impaired Clinicians
teaching and research. An measure and improve Care of Prisoners
essential resource in achieving patient care for high volume Staff Competency and
our mission is the medical and/or under served Responsibilities / Patient Safety
expertise provided by our vulnerable populations Goals/ Code Blue Response
competent and caring within our community.
professional staff. We strive to Infection Control / Bio-Terrorism
achieve the timely and efficient OUR VALUES Body Mechanics & Ergonomics
delivery of care in a INTEGRITY
compassionate atmosphere. Environment of Care -
A firm adherence to a code of Emergency Mgmt. Program
values. Hazardous Materials & Waste
Program / Medical Equipment
EXCELLENCE Mgmt. Program / Utility
Management Program / Safety
The quality of being superior to Management Program
others or the best of its kind. Safety Alert Program / Code Blue
Security Mgmt. Program / Life
To work jointly with others to
achieve a common goal.
Risk Management – Incident
Corporate Compliance Program
2 MHRI ANNUAL MANDATORY EDUCATION
Speak calmly and professionally.
Assist someone who Commitment to Co-Workers,
STANDARDS OF Physicians & Volunteers
PERFORMANCE appears to be lost.
Unacceptable: Curt rude Treat one another as a
behavior. Not listening professional deserving
All employees, professional
to what an individual is courtesy, honesty and
affiliates, students and volunteers
saying. Ignoring people respect. Avoid last minute
are expected to adhere to
who appear lost and not requests. Offer to help
acceptable principles in matters
trying to help them find whenever possible. Work as
of personal conduct. A high
their destination. a team. Cooperate with one
degree of personal courtesy and
Speaking in disruptive another. Give praise when
integrity must be exhibited in all
tones. Not answering ever possible. Do not
dealings with each other as well
the phone or answering chastise or embarrass
as patients, vendors and others
without stating the people in front of others.
with whom Memorial employees
department, your name Address problems by going
come in contact.
and “How may I help to the appropriate supervisor.
This involves a respect for the
rights, beliefs and feelings of
others regardless of their position
and requires the use of commonly CARES PROGRAM
accepted standards of
performance. C - Courtesy
A - Attitude
Attitude R - Respect
E - Excellence
S - Service
The CARES Program reinforces
the standards of performance that Elevator Etiquette
help to provide excellent service
to our patients, their families and Hold the door open for
to each other. others. Always smile and
Acceptable: The purpose of the CARES passengers. Step aside for
Acknowledge an individual’s recognition award is to encourage others. Always face
presence immediately. and recognize employees for wheelchairs toward the door.
Smile and introduce your self. achievements, behaviors, actions Exit with care. If a person in
Unacceptable: Ignoring an and contributions that go “above a bed or stretcher is being
individual. Not smiling and beyond” the expected job transported, wait for the next
and failing to introduce responsibilities. The program elevator.
your self. hopes to inspire and motivate all
employees to do what they can to Privacy
strengthen our spirit of service. Knock before entering
Acceptable: Follow MHRI dress
code. Wear your A CARES Recognition Award rooms. Close curtains or
identification Nomination form may be doors during exams and
badge. Keep your work completed by an employee, a procedures. Provide a robe
area in order. visitor, a physician or any other or second gown for
Unacceptable: Not following the individual who has been positively ambulating or wheelchair
dress code. Poor impacted by a staff member. bound patients. Make sure
hygiene. Not wearing Nomination forms are available in the patient is properly
your identification badge the public relations department as covered. Keep patient
or wearing it improperly. well as the hospital intranet. information confidential.
An unclean work area. Never discuss patients or
Communications their care in public areas.
Acceptable: Courteous behavior. Sense of Ownership
Answer phone calls
within 3 or 4 rings and Take pride in this
identify your organization as if you own it.
department, Adhere to the policies and
yourself (first name) procedures. Provide
and say “How may I superior service in all areas
help you?” of your job responsibilities.
3 MHRI ANNUAL MANDATORY EDUCATION
Live the values of the Tool” is supplied in every new
organization. employee orientation packet Bi-lingual staff is often recruited
and is available in Human for certain key areas of the
Resources as well as the Hospital.
Communication Devices for
the Deaf or Hearing Impaired
Patients and their families have
• A Telecommunication
the right to effective
Device for the Deaf (TDD)
communication regarding their
is available in the
Emergency Department. A
IMPROVEMENT (PI) The Human Resources checklist for its use is
Department responds to posted near the device.
requests for interpreter needs
In order to ensure that our from 8:30am - 5:00pm, Monday • A portable TDD and
patients are receiving safe quality through Friday. Call extension telephones with volume
care, treatment and services, we 2670 for the interpreter request control are available from
must first measure our procedure. Requests for the Operator in the
performance. The performance Communications
interpreters should be made as
data is collected, analyzed and Department. These phones
far in advance as possible.
then used to make improvements.
can be brought to a
The Nursing Administrative patient’s room if needed.
measuring ensures that we are
continually striving to do better. Coordinator in the Clinical
It’s about doing the right thing Operations Department at • A national relay line is used
well, at the right time, for the right extension 2299 responds to to handle voice to TDD or
requests for interpreters during TDD to voice calls. This
all other hours. enables two parties to
communicate when only
Patients are not responsible for one has a TDD. We may
providing their own interpreters. use the relay line to place a
voice call to a person who
LANGUAGE LINE uses a TDD. The Operator
can access this line.
A language line is available 7
days per week, 24 hours per • Communicating by writing
patient. messages on a pad of
day. The line provides
interpretation services in 135 paper is also an alternative.
CULTURAL DIVERSITY languages, and can be
accessed by dialing “0” for the • When more complex
Cultural Diversity refers to the Operator. This resource should communications are
variations and differences needed, it may be
between cultural groups necessary to obtain a sign
resulting from differences in life language interpreter. Sign
styles, languages and values. language interpreters can
It is necessary to understand be obtained by contacting
these differences when Human Resources at
interacting and caring for extension 2670.
patients and families to provide
culturally sensitive care. be used for all needs that PATIENT RIGHTS
require services for 30 minutes
The Cultural Tool or less.
The “Cultural Tool” has been Spanish translation cards are
developed to assist employees available on nursing and other
in understanding belief patient care units to assist staff
practices, nutritional members in communicating
preferences, communication with patients who speak
awareness, patient care and life Spanish. If you need a copy of
issues for the various cultural the cards, contact Human Each patient and/or family
groups we serve. The “Cultural Resources at extension 2670. member is informed of his/her
4 MHRI ANNUAL MANDATORY EDUCATION
rights. These rights are posted of a patient between
and are provided upon departments
admission in the Patient • Close doors or draw curtains
Information Guide. for treatments or interviews.
Every patient has the right to:
• Considerate and respectful care MHRI’s CODE OF ETHICS
• Be well-informed about his/her
illness, possible treatments and
likely outcomes and be Each employee is required to
immediately informed of any follow the hospital’s Code of
unexpected outcomes Ethics - see hospital policy 21 for
• Satisfactory resolution of full text.
conflicts regarding care
• Refuse treatments
Maintain Patient Patient Access to Care /
• Advance Directives, such as Confidentiality Admission
Living Will or Durable Power of
Attorney for Health Care • Share patient information The hospital will admit and care
• Privacy and confidentiality and only with those providers for patients uniformly regardless
security directly involved in the of race, color, disability, gender,
• Review his/her medical record
and have information explained
patient’s care. sexual orientation, creed, age,
• Expect that the hospital will • Honor the patient’s right to national origin or availability of
deliver necessary services determine which friends or insurance or ability to pay.
including treatment or transfer family members are given
• Know about relationships the information about the Billing Practices and Disputes
hospital has with other parties patient’s diagnosis and
that may influence treatment
Patient billings include complete
treatment. Understand that information concerning services
• Consent or decline participation HIPAA regulations allow
in research studies rendered with an itemization of
patients to opt out of the
• Be informed of alternatives when procedures, dates of service
hospital care is no longer patient directory.
• Make sure discussions about and telephone number for
the patient occur only within questions. Patients can receive
• Be informed about and have
access to protective services the confines of the patient explanations for any charge or
• Be informed about charges and care areas. ask that charges be
payment methods • Properly dispose of copies of investigated to verify accuracy.
• Be informed of contacts to assist medical reports or
in resolving problems or conflicts Access To Protective Services
about their hospital visit or care
by calling: Public Relations at financial and/or patient The hospital supports patients
729- 2459 or nursing office after information, including and assists in determining a
5:00 computer printouts. patient’s need for special
• For more information call the • Use computer systems only services such as guardianship
Department of Health at 222- to access information and/or other protective services
5200 or The Joint Commission at relevant to your professional
800-994-6610 while keeping the patient’s best
practice. interest in mind.
• When using the computer
Every patient can expect system, your computer Confidentiality
appropriate medical care, activity is subject to audit.
effective management of • Speak to your supervisor or All staff must ensure the
pain and a safe environment the privacy officer regarding maintenance and protection of
while a patient at Memorial suggestions you may have a patient’s medical information
Hospital of RI without about patient confidentiality. and utilize proper procedures
regard to gender, culture, • Report any breach of for the release of information to
confidentiality to the privacy requesting parties.
background or source of
officer at extension 2148.
payment. Conflict Resolution and Ethical
To Respect Patient Privacy Dilemmas in Care. – see
hospital policy 19 for full text.
• Knock and wait before
entering a patient’s room The hospital has several
mechanisms in place to provide
• Address patients with respect support to patient, family
(as Mrs. J...do not use first members and health care
names unless asked to) providers when faced with ethical
questions and/or dilemmas.
• Provide appropriate attire
and blankets during transport DO YOU KNOW?
5 MHRI ANNUAL MANDATORY EDUCATION
Informed consent of the patient treatments if he/she has a Child Abuse: abuse and/or
must be obtained by the terminal condition and is no neglect of a person under 18
physician or advanced practice longer able to make years of age.
clinician before performing decisions.
Elderly Abuse: abuse and/or
surgery, blood transfusions or A person may change or revoke neglect of a person over 60
any invasive procedures. This an advance directive at any years of age.
consent must be documented in time.
the patient record and entails Health Care Facilities Abuse:
describing the risks, benefits Advance Directives at MHRI abuse and/or neglect of an
and alternatives in a manner adult resident or patient of a
Upon admission, patients are
the patient can understand. asked about an advance state licensed nursing home,
directive. If the patient does not shelter or hospital by staff
have one, information regarding members or by other patients.
Patients may refuse treatment. their right to make this decision is
In the event a patient wants to provided. If the patient has an
Abuse: abuse and/or neglect
leave the hospital against advance directive, a copy is
of a person 18 years of age or
medical advice, the physician placed in the patient’s chart. The
Rhode Island Advance Directive older who has a chronic
explains the risks and
forms are available in Public disability which limits the ability
document that the patient
Relations or on the hospital to care for his/herself.
understands these risks.
intranet. Only With Patient Consent
Resource Guide For Patients
Organ Donation is encouraged. Reporting
The New England Organ Bank
Domestic Violence: physical
works closely with our hospital to
This guide violence occurring between
educate clinical staff and provide
identifies support to patients and families in
spouses, former spouses, adult
financial or making choices to donate tissues relatives, adults living together,
legal or organs. adults who have lived together
support and in the past, adults who have
protective advocacy services. ABUSE RECOGNITION children, whether married or not
Contact Social Services, Public married, or living together.
Relations or the Administrative
Sexual Assault: any assault
Coordinator to obtain a guide.
involving sexual contact with an
It is also located on the hospital
MHRI’s Notice of Privacy State law and Hospital policy
Practices (NPP) is given to all dictate that any staff member IMPAIRED CLINICIANS
patients to explain their rights who suspects or witnesses
concerning confidentiality and abuse of a patient must contact
privacy and summarizes the his/her supervisor or the
ways in which the hospital uses Administrative Coordinator at
and discloses their health extension 2271 immediately.
Advance Directives are The law protects anyone who
documents that allow a person reports known or suspected While there are many
to designate how medical abuse/neglect. The attending components to ensuring patient
decisions should be made if physician or designated safety, there is one that
he/she is unable to make individual will contact Risk requires watchful eyes….YOUR
decisions. Management and the EYES.
appropriate agency within 24 In the event that you observe
• Durable Power of Attorney hours. that the physical, mental or
for Health Care names
emotional health of a patient
another person to act as the There is no state law requiring
person’s (patient) agent to
care giver might endanger the
reporting of domestic violence
make health care decisions if safety and well being of our
or sexual assault (rape).
the person (patient) is unable patients, you must report this to
However, if you suspect
to make his/her own. your Supervisor or the
domestic violence, notify your
• Living Will identifies a supervisor immediately or the
Policy #4, Medical Staff
person’s wishes to provide or Administrative Coordinator.
outlines the confidential process
withhold life sustaining
Mandatory Abuse Reporting
6 MHRI ANNUAL MANDATORY EDUCATION
for physician review and Prisoners will be subject to the What are some other staff
treatment referral. same restrictions at the hospital responsibilities?
that are in place for the prisoner Staff responsibilities
What To Look For…. at the correctional facility. can be found in
Physical limitations: may be Imposition of disciplinary individual job
important, based on each restrictions follows the descriptions and
individual’s role. For example, correctional facility’s policies performance appraisal
tremors may not impair a and procedures. tools as well as
physician from taking care of a professional
heart attack patient, but would STAFF COMPETENCY AND regulations and
create risks during surgery. RESPONSIBILITIES hospital procedures.
It does not matter what causes Staff Competency:
the impairment – Alzheimer’s, Staff members and managers
brain tumor or alcohol/drug share responsibility for
induced confusion – the focus providing high quality care and
remains on providing safe service to our patients and their
patient care. families. We need to evaluate
Mental capacity: may be in performance and maintain and
question - information must be improve competence.
repeated several times and/or
information recently provided is How is competency assessed?
misinterpreted. Staff Responsibilities: Performance appraisal tools are
Reading ability :may be in Human Resources Policy # 61 designed to measure core skill
question – numbers transposed provides staff with a mechanism competency, performance
as may occur with dyslexia can for declining to participate in improvement activities,
pose a risk for drug doses to be certain aspects of patient care customer service and
wrong or lab values to be due to staff member’s bona fide communication skills and
misinterpreted. religious, ethical and/or cultural general role responsibilities.
Hearing or vision ability :may be beliefs. Some examples of staff
in question – if corrected with beliefs that may conflict with When is competency
hearing aid or glasses there is patient care might include assessed?
no problem. If uncorrected, transfusing blood, assisting with Managers constantly monitor a
orders or information may be sterilization surgery or staff’s competence. Before
interpreted incorrectly, posing a withdrawing life support. hire, credentials are verified.
risk to safe patient care. Is refusing to treat a patient Upon hire, an orientation
Behavior may be in question – if because of the patient’s race checklist is completed. Other
behavior raises questions of or fear of contracting a measures or tools are utilized
being under the influence of disease or virus covered by such as written tests and/or
alcohol or other drugs, this policy? checklists. At the completion of
immediately notify your No. Patient caregivers orientation and at regular
Supervisor. may not refuse to intervals thereafter, a
provide care due to a performance appraisal
CARE OF PRISONERS patient’s background or documents competence and
because of fear of identifies goals.
The nurse assigned to care for
contracting a disease
the patient prisoner each shift
or virus. How is competency improved?
will discuss the expectations of
What is the staff member’s Staff is actively involved in the
the guard in supporting the
responsibility to provide competency assessment
medical and nursing care of the
patient care if a bona fide process along with his/her
patient or responding to an
conflict arises? manager in identifying areas for
emergency within the hospital
A staff member’s improvement. This may entail
and provide an Orientation
request not to specific coaching, more on-the-
Guide to each guard during
participate in an aspect job training or attending in-
his/her first shift at the hospital.
of patient care cannot service and continuing
The prisoner will be
negatively affect or education programs. Outside
accompanied by at least one
compromise the class registration may be
armed uniformed guard from
patient’s care. Thus, reimbursed with tuition
the correctional facility at all
staff must continue to assistance, professional
times. The guard is responsible
provide care to the development and/or
for maintaining visual contact
patient until relieved by
with the prisoner at all times.
another staff member.
7 MHRI ANNUAL MANDATORY EDUCATION
management directed • Provide constant supervision physical abilities and may also
education. and do not leave tools or be caregivers for their parents.
• Acknowledge their
Are special competencies
PRESCHOOLERS (4-6 years) responsibilities
Every role at MHRI has defined Preschool children learn • Provide thorough
competencies and social manners and respond to explanations but avoid
qualifications. All hospital staff rewards and punishment. They medical jargon
is expected to provide care and have strong and vivid
• Recognize that their health
services that address the imaginations.
behavior is influenced by
communication and safety personal values and past
needs for each individual’s age • Allow child to express experiences
and/or developmental level. feelings and make choices
The hospital is committed to when possible
providing the correct medical • Explain therapy and
treatment as well as providing unfamiliar objects
• Offer praise for good
services that are responsive to
the age-specific and cultural
needs of our patients and
How can all hospital staff
respond to age-specific needs? GERIATRICS (over 65)
It is important to understand the An older adult develops habits
characteristics of different age over time. They may lose the
groups and adjust your capacity that is needed to
approach to each. perform normal activities of
SCHOOL AGE (6 - 12 years)
daily life. They want to be
School age children want to
valued and respected.
achieve goals and try to test
rules. They ask questions and • Address by title (unless
are aware of other’s reactions. asked not to)
• Involve child in interactions • Foster and support
• Support privacy and
independence • Speak clearly in a normal
pitch. If asked to clarify,
• Foster friendships with peers rephrase what was said, do
INFANTS not just repeat it
ADOLESCENTS (12-18 years)
(Birth - 1 year)
Infants feel secure when needs Adolescents conform to peer
are met. They develop fear of pressure and want to be spoken PATIENT SAFETY GOALS
strangers (7-8 months) and to as adults. They may appear
tend to place objects in their moody and rebellious. MHRI’s goal is to provide
mouths. quality, age and culturally
• Allow adolescent to make sensitive care in a caring and
• Involve parent in interactions
and keep parent in infant’s safe environment. We are
line of vision • Communicate directly with committed to ensuring safety for
• Speak softly and in a calm the adolescent, rather than our patients, staff and visitors.
manner just with parents
• Keep small objects out of National Patient Safety Goals
reach • Provide full explanation
Goal 1: Improve accuracy of
TODDLERS (1 - 4 years)
Toddlers learn to walk, run and Use at least 2 patient identifiers
talk. They assert their ADULTS (18-65 years) (patient’s full name and date of
independence and will. They birth) when providing care,
are curious and like to explore. Adults are involved with treatment or services.
• Kneel or bend down when personal, social and
Use at least 2 patient identifiers
talking occupational issues, while when administering medications
• Use simple words and adjusting to subtle changes in or blood products and collecting
8 MHRI ANNUAL MANDATORY EDUCATION
Containers for specimens must Reduce likelihood of patient harm Patient Information Guide informs
be labeled in the presence of the from use of anticoagulation patients to report concerns.
patient. therapy. (Warfarin order sheet
and Heparin Therapy order form) Staff encourages patients and
The patient room number can not For patients receiving this their families to report concerns.
be used as an identifier. therapy, educate the patient and Goal 8: Identify patients at
Goal 2: Improve the their family regarding the risk for suicide.
effectiveness of importance of follow-up
monitoring, compliance, drug – Assess all patients for suicide
food interactions and potential risk.
caregivers. adverse drug reactions.
Meet patients’ immediate safety
When taking all telephone orders needs in an appropriate setting.
Goal 4: Reduce the risk of
or reports of a critical test result,
write the complete order or test health care –associated Provide Crisis Hotline information
result down and READ BACK the infections as appropriate to patient and
complete order or test result to Hand hygiene compliance at all family.
verify. The caller confirms times. Refer to Infection Control
accuracy of order and/or result. Goal 9: Improve recognition
section on page 9. and response to changes in
Critical test results must be Review cases of unanticipated a patient’s condition.
written down with two patient death or major permanent loss of
identifiers (patient’s full name and The hospital has a method for
functions associated with a health
date of birth). Room number staff to request assistance from a
care-associated infection as a
cannot be used. specially trained individual who is
part of the Rapid Response Team
A verbal or telephone order must Goal 5: Accurately and when a patient’s condition seems
be written down on the Physician to be worsening.
medications across the UNIVERSAL PROTOCOL
DO NOT use abbreviations for continuum of care.
any orders, medications, related
documents or pre-printed forms. Create or update a list of current
(Do not use QD, QOD, U, IU, MS, medications on each visit or
MS04, MGS04, AD, AU, AS, OD, admission with patients.
OU, OS, trailing or leading zero.) Compare list with any
Measure timeliness of critical test medications ordered for patient.
reporting and improve, if Provide complete list to next
appropriate. The physician must provider of care (at transfer within
be notified within one hour of the the hospital and at discharge). • To ensure the correct patient,
receipt of critical test results. correct procedure, correct
Give patient complete list of
Use standardized approach to site and as applicable,
medications upon discharge and
“HAND OFF” communication correct implants and/or
explain the importance of bringing
(report to next caregiver) that equipment.
the medication list to all medical
allows opportunity for questions. appointments. • Applies to all invasive
Always use complete patient procedures that expose
identification when transferring Goal 6: Reduce the risk of patients to more than
information to the next caregiver. patient harm resulting from minimal risk, including those
Goal 3: Improve safety of falls performed at patient’s
using medications bedside.
The Hospital has a fall reduction
program (patients at risk are • Site should be marked by
Drug concentrations are
identified with a yellow ID bracelet performing physician.
standardized and their number is
and yellow star on name board
limited (per hospital policy • Entire team participates in
and outside patient room).
Medication Use Policy #20). final verification of patient,
Staff educates patient and family procedure, site and implants
The P&T Committee annually
about fall risk and interventions to (if applicable)
reviews the list of look-
alike/sound- a - like drugs used • Documentation of completed
and takes steps to prevent errors. Goal 7: Encourage patients’ time out is done on the
Label all medications and active involvement in their Procedural Safety Checklist.
containers (i.e. sterile bowls) or own care as patient safety
other solutions on and off sterile strategy.
9 MHRI ANNUAL MANDATORY EDUCATION
This team approach to patient the Rhode Island Cabinet on SPEECH
safety comes from more than 25 Nursing Practice. All admitted Is the speech
years in the military, aviation. patients will still wear a white slurred? Have the
nuclear power and business identification bracelet but will also person repeat a
industries. Because Health Care be appropriately banded with the
is a dynamic, complex and high following colored wristbands:
risk environment, this approach is TIME
YELLOW - Fall Risk Time is of the
an idea one to provide the
opportunity for improvement in PINK - Restricted Extremity essence. Call the
communications and teamwork. GREEN - Latex Risk stroke team!
RED - Allergy
Research shows that even highly
CODE BLUE RESPONSE Early recognition is important in
skilled professionals are
the prevention of devastating long
vulnerable to error. When team
If you discover a person who term complications.
of individuals communicate
effectively, back each other up appears to be unconscious,
and “catch” errors before they bleeding, short of breath or who
happen, the result is an has stopped breathing, call a
improvement in the quality of Code Blue. Dial extension 2222
health care, the prevention of and tell the operator that there
medical error and patient harm. is an adult or pediatric code and
Every employee is part of the give the exact location. Always
Team STEPPS Safety program. stay with the person until help
By being aware of the actions of arrives. Competent staff is
other team members, a “safety expected to initiate CPR
net” is provided to ensure (cardiopulmonary resuscitation) INFECTION CONTROL
mistakes and oversights are per American Heart Association
caught on. Watch each others guidelines. Standard and Contact
back-speak up if you think Automated External Precautions
something is not “right”. I am Defibrillators (AED) are
CONCERNED. I am
Standard and contact
stationed on key locations
UNCOMFORTABLE. This is a precautions must be followed
throughout the hospital. The
SAFETY issue. Using this “CUS” to minimize and prevent the
AED’s may be used by anyone
approach will alert your team to spread and transmission of
trained in basic life support.
potential situations that could They are in the main lobby, infections to patients, visitors
result in compromised patient
Medical Staff Auditorium, the and other staff members. All
care. human blood and body fluids,
corridor outside the
How do we achieve safe quality Communications area, in 555 contaminated surfaces and
patient care? Prospect Street and the equipment are considered
ambulatory care building. infectious and protective
Safety begins with you
equipment must be used such
and your communication
and collaboration with STROKE TEAM RESPONSE as those listed below:
your team members. • Gloves
MHRI is an accredited stroke • Gowns
center. Part of the stroke • Masks
COLORED ALERT program includes a dedicated • Protective eyewear (not
WRISTBANDS stroke team to respond to personal glasses)
patients with questionable
nurses stroke-like symptoms.
and To remember what to look for
providers think of the word FAST:
employed at more than one Hospital Acquired Infections
facility, there is a need to have FACE Hospital acquired infections
certain medical conditions Does one side droop? are those infections that occur
conveyed in a transparent and within the hospital
Ask the person to
universal fashion so that patient
smile. environment. These
safety is maintained. Standard
colored wristbands will provide a ARMS infections, most commonly
quick recognition of medical Is one arm weak or spread or transmitted by
conditions. MHRI has adopted numb? Does one arm hospital staff, are primarily
this initiative recommended by drift downward?
10 MHRI ANNUAL MANDATORY EDUCATION
preventable by four basic Prevention of Central Line- surgery. Interventions that
steps: Associated Blood Stream are known to help reduce the
1. Hand Hygiene Infections risk of surgical site infections
All staff include:
members Patients who have central
(this lines that are placed or used 1. Hand Hygiene
includes during hospitalization are at before and after
non- increased risk of infection. caring for each
clinical Strategies to prevent central patient.
staff) are line infections include the
2. Removing any
required to wash their hands following:
hair prior to
with soap and water or alcohol-
1. Use of central line surgery with
based gel before and after
EVERY patient contact, before checklist during electrical clippers-
and after glove use, as well as insertion procedures not razors.
after contact with a patient’s to ensure adherence
environment. When providing to infection prevention
care to patients in their hospital practices.
rooms, the phrase “Foam IN, 2. Strict adherence to 60 minutes before
Foam Out” might be a useful
hand hygiene prior to surgery starts.
way to remember to wash your
insertion and at any
hands. 4. Controlling blood
time the central line
may be manipulated.
Respiratory during the
Etiquette 3. Avoidance of the use immediate post-
of the femoral vein for operative period.
All staff central venous
should cover 5. Maintaining
a cough or normal body
sneeze with a 4. Use of an all-inclusive temperature
tissue or the catheter cart or kit. through out the
elbow/upper arm. surgical
5. Use of maximum
3. Personal Protective insertion.
6. Use of a
antiseptic for skin
preparation prior to
7. Disinfection of
When indicated, all staff are catheter hubs, needle
required to use appropriate less connectors and
Safe Injection Practices
protective equipment when injection ports before
caring for patients. accessing the Healthcare providers should
catheter. never reuse a needle or
4. Disinfection of Equipment syringe. One needle only for
8. Removal of all
It is a new policy at MHRI that one patient only should be
all equipment (dinamaps, used. Both needle and
glucometers, stethoscopes, IV syringe must be discarded. It
Poles, etc.) used on patients is also not safe to change the
must be disinfected between needle but reuse the syringe –
Prevention of Surgical Site this can transmit disease.
each patient use. Infections Once a needle and syringe
Surgical site infections are used on a patient, they
develop in about 1 to 3 out of should be discarded into a
every 100 patients who have sharps container. Safe
11 MHRI ANNUAL MANDATORY EDUCATION
injection practices and sharps There is no vaccine against • Enteric diseases such as
safety go hand-in-hand. Hepatitis C or HIV. diarrhea, salmonella, ecoli,
By following safe injection Exposure to Blood/Body
practices to protect patients, Fluids
healthcare providers are also If an exposure occurs, the
protecting themselves. The employee should: Clostridium Difficile
unsafe practice of syringe 1. Wash area with soap
Closridium difficile, sometimes
reuse puts healthcare and water. Rinse
called C. difficille or C Diff, is a
providers at risk of needle bacterium that can cause
stick injury and potential blood symptoms ranging from
2. Report exposure to the
borne pathogen exposure. supervisor.
diarrhea to life-threatening
inflammation of the colon.
Remember: ONE needle, 3. Fill out incident report
Illness from C. difficile most
ONE syringe, only ONE Time and bring to Employee
commonly affects older adults
in hospitals or long term care
4. Go to employee Health
facilities. In recent years, C
Blood borne Office Monday through
difficile infections have become
Diseases Friday (8am to 4pm) or
more frequent, more severe
Certain the Emergency
and more difficult to treat. Each
healthcare Department (evenings,
year, tens of thousands of
workers are weekends and
people in the United Sates get
at risk for an holidays) to be
sick from C. difficile, including
occupational evaluated by a
some otherwise healthy people
exposure to blood and body Healthcare Provider.
who are hospitalized.
fluids during the performance of In an effort to reduce infections
their duties. The most common The Exposure Control Plan is
as a result of clostridium
blood borne pathogens in the part of the Infection Control
difficile, MHRI personnel, when
hospital setting include Program, and has been providing care to infected
Hepatitis B and C and HIV. The developed to control hospital- patients, are required to (1) use
exposure can occur to the eyes, associated infections and gloves and gowns, (2) wash
mouth or other mucous protect employees from their hands with soap and water
membranes, non-intact skin or acquiring infections. A copy instead of using the alcohol-
parenteral contact by: of the plan is maintained by based gel and (3) clean patient
each department in the rooms with a bleach water
• A puncture wound or cut
from a needle or sharp.
Infection Control Manual, and solution.
• Blood or body fluid can be obtained from your
splashes to the eyes, nose, supervisor.
• Contact with non-intact
wounds or lesions Exposure to Communicable
especially to chapped, Diseases
abraded, or skin afflicted The Employee Health Office
with dermatitis. provides evaluation and chemo
• A human bite. prophylaxis as appropriate, to
employees exposed to
communicable diseases both Multi-drug-resistant
All health care workers are on and off the job. Organisms
encouraged to receive the Multi-drug-resistant organisms
Hepatitis B vaccination, which is If an exposure occurs, the (MDROs), such as methicillin-
free of charge. This vaccine employee should report to the resistant staphylococcus aureus
offers protection against Employee Health Office for (MRSA), vancomycin-resistant
Hepatitis B and may eliminate evaluation. Examples of the entercocci (VRE) and extended
the need for Hepatitis B types of infections that need to spectrum beta-lactamase
immune globulin as post- be evaluated by the Employee producers (ESBLs) have
exposure prophylaxis. Hepatitis Health Office are: important infection control
B vaccine is offered to newly • Shingles/ Varicella implications in all healthcare
hired staff, at the time of (Chicken Pox) settings.
exposure, and is available at • Influenza (Flu) The prevention and control of
any time during employment. • H1N1 (Swine Flu) MDROs is a national priority
12 MHRI ANNUAL MANDATORY EDUCATION
that requires all healthcare posted. Watch for these terrorism-related outbreak are
facilities and agencies to announcements so you can identified.
assume responsibility. At make plans to receive your flu
If a bio-terrorism event is
MHRI, patients who are vaccine. Staff members who
suspected or known to be decline a flu vaccine will be
notification of the following key
infected or colonized with an asked to complete a declination
people must be initiated: your
MDRO are placed on form.
Supervisor (off shifts- call
precautions. In some
instances, nares swabs and Tuberculosis
Hospital Administrator (off
rectal swabs may be obtained. Tuberculosis (TB) is caused by
All staff members, as well as bacteria that are spread when
coordinator will notify hospital
visitors are expected to observe an infected person coughs or
administrator on call, Program
strict adherence to hand sneezes.
Manager of Infection Control
hygiene and the appropriate
(off shift call the Infectious
use of personal protective Most common symptoms of
Disease Fellow ), Infectious
equipment when providing care tuberculosis are a persistent
Disease Physician (infection
to patients with a known or cough for greater than 3 weeks,
control officer). The response
suspected MDRO. anorexia, fever, night sweats,
to the event will be activated
weight loss and bloody sputum.
according to policies delineated
Influenza Health care workers are at risk
in the Environment of Care
when a patient with TB is not
yet identified and infection
control precautions are not Standard precautions are to be
implemented. utilized for all patients. This
To prevent the spread of TB: includes proper hand washing
techniques, gloves when in
• Insure patients identified contact with blood/body fluids,
with confirmed or and gowns, masks and eye
suspected TB are assigned protection when splashing of
Influenza (The Flu) is a
to a negative pressure blood and/or body fluid is
contagious respiratory illness
room that vents the air anticipated. Depending on the
caused by influenza viruses. It
directly to the outside or to suspected pathogen, droplet or
can cause mild to severe illness
a private room with a U/V airborne precautions may be
and at times can lead to death.
light. required. Consult with ID
Some people, such as older physician and/or Infection Control
• Instruct patients to cover
people, young children and Practitioner for guidance.
their nose and mouth when
people with certain health
coughing or sneezing. BODY MECHANICS
conditions, are at high risk for
• All staff must wear an N-95
serious flu complications. The AND
respirator or PAPR when
best way to prevent The Flu is
entering the room.
by getting vaccinated each
• Insure you have been fit
tested and trained to wear
In 2009-2010, a new and very
the N-95 respirator or
different influenza virus (H1N1)
spread worldwide causing the
• When transporting patients,
first flu pandemic in more than
insure that the patient
40 years. During the 2011-
wears a surgical mask and
2012 flu season, The Centers
other people are not
for Disease prevention and
allowed on the elevators
Control expects the H1N1 virus
to cause illness again along
with the patient. ERGONOMICS
with other influenza viruses.
Staff are tested for TB upon To prevent back injuries, the
The 2011-2012 flu vaccine will
hire, on an annual basis, and following body mechanics
protect against H1N1 and two
after potential exposure to TB. should be considered:
other influenza viruses.
• Always stand with your feet
MHRI makes influenza vaccine Health care facilities, including slightly apart (shoulder
available to hospital employees. hospitals and clinics, may be width).
When Flu Season begins, one of the first institutions • Bend at your knees and
information announcements where victims from a bio- hips, not your waist.
and vaccine dates will be
13 MHRI ANNUAL MANDATORY EDUCATION
• Lift with your legs, not your o Change the side employee who believes that a
back, keeping patients or your mouse and patient and/or an employee has
objects close to your body. monitor are on been exposed to an
• Lower patients or objects periodically. unacceptable risk or injury may
slowly. report the incident to the Safe
o Make sure your
• Work as a team with co- Patient Handling Committee
arms are parallel to
workers when lifting heavy who reports annually to the
the floor when
patients or objects. Safety Committee and
• Ask for help when you need Performance Improvement
it. o Do head turns and Committee.
• Use mechanical aids, such shoulder rolls
as a lifting belt, dolly, cart, frequently to EMERGENCY MANAGEMENT
gait belt, sliding board, or prevent injury. PROGRAM
Hoyer lift whenever
o Look away from This program provides an “all-
the monitor hazards” approach to
• Anticipate lifting and plan
occasionally to emergency management that
your move before you lift.
avoid eye strain. permits appropriately flexible
• Avoid twisting your body -
and effective responses. The
move your feet instead.
focus of the program is to plan
• Test the load before you lift
for managing six critical areas
of the organization.
• Lift, carry or push only what
you can handle safely. The six critical areas are:
• When standing for long
periods of time, balance 1. Communication
one foot on a low object. 2. Resources and assets
• Support your lower back
with a cushion or rolled up 3. Safety and security
towel if you sit a lot. 4. Staff responsibilities
• When sitting, adjust your SAFE PATIENT HANDLING
chair to allow both feet to AND MOVEMENT 5. Utilities management
6. Patient clinical and
The Hospital seeks to ensure support activities
that patients are cared for
safely, while maintaining a safe Exercises are conducted to
work environment for assess the Emergency
employees. To accomplish this Operations Plan’s
both inpatient and outpatient appropriateness, adequacy and
employees must identify and effectiveness of logistics,
assess movement techniques human resources, training,
associated with lifting, policies, procedure and
transferring, repositioning or protocols.
movement of a patient in The hospital’s emergency
be flat on the floor. advance of the move to management plan is activated
• Don’t slouch. determine the safest technique when an unexpected or sudden
Ergonomics: to reduce risk of injury. Safe event in the community or in the
patient handling techniques hospital significantly disrupts
• Change your position should be practiced at all times. the organization’s ability to
frequently. If you sit a lot, Staff education will include provide care, disrupts the
stand up occasionally. identification, assessment and environment of care itself or
use of devices and/or handling results in a sudden, significantly
• At the computer:
aids. changed or increased demand
o Keep the screen Supervisors will ensure that for the organization’s services.
directly in front of mechanical lifting devices and
you, 18” to 24” other safe patient equipment
away at eye level and/or aids are accessible to
Consider a staff. Devices will be regularly
document holder if maintained, kept in proper Emergency Management
typing frequently. working order and stored in a Codes
convenient location. Any
Code “Triage Standby”
14 MHRI ANNUAL MANDATORY EDUCATION
• Announcement to be used Physician on duty. The Senior • Common language to
to alert administration that Vice President or designee promote
the Department of working with other members of communication and
Emergency Medicine has the EDCT, notifies (if facilitate outside
become aware of a Mass warranted) senior management assistance and cost
Casualty Incident (MCI) who will in turn decide whether effective emergency
with a potential for an or not to activate the Incident planning with the
increased influx of patients Command System. health care
to the hospital. organization.
Internal Disaster – When a
Code “Triage External” disaster that impacts patient Specific roles are assigned
care occurs, staff in the based on the HICS Incident
• Announcement to be made
immediate area will: initially Management Team (see
over the hospital’s public
manage the safety of the last page of this Annual
address system to inform
patients and call the hospital Mandatory Education).
staff that the Incident
Operator and explain the
Command System has Pre-assigned areas in
situation. The Operator will
been activated due to an effect during a Code Triage
notify senior management who
emergency outside the (Memorial Hospital only):
will decide whether or not to
activate the Incident Command Command Center
Code “Triage Internal + System.
• Administrative conference
Each associated facility area – 2nd floor Sayles
• Announcement made over maintains an evacuation plan Bldg.
the hospital’s public that is flexible and able to
respond to any disaster Media Center
address system that the
Incident Command System situation that may place • Physicians’ Auditorium –
has been activated due to patients in harms way. ground floor Richardson
an emergency inside the Bldg.
Hospital Incident Command
hospital (applies to Notre
System Inpatient Discharge Area
The Hospital Incident • Dining Room 3/Cafeteria –
Code “Triage All Clear”
Command System (HICS) will ground floor Wood Bldg.
• Announcement to be made be placed into operation
over the hospital’s public whenever an internal or Disaster Patients’ Discharge
address system to inform external “Code Triage” is Area
staff that the facility has initiated. This system allows • Coffee Shop – 1st floor
been returned to normal the hospital to respond quickly Sayles Bldg.
operation (applies to Notre with structure and a focused
Dame also) direction of activities. Labor Pool Holding Area and
Incident Command System HICS features:
Activation • Physical Therapy Gym –
• Predictable chain of ground floor Sayles Bldg.
External Disaster – When management.
notified of a disaster or MCI Psychological
• Flexible Incident Casualties/Families
occurring in the hospital’s
emergency service area, the Sayles Conference Room –
that allows a scaleable •
Department of Emergency ground floor Sayles Bldg.
response to specific
Medicine Nurse Manager or
emergencies. See your supervisor/manager
Charge Nurse immediately
forms a unified command called • Prioritized response for specific details on your role
the Emergency Department checklist. and responsibility in preparing
Command Team (EDCT) for building evacuation. Refer
• Accountability of to the Environment Of Care
consisting of Senior Vice
function. Manual for further information.
President- Operations, the
Patient Care Director- • Improved
Emergency Department or documentation for
Administrative Coordinator (off improved accountability
shifts) and the Physician-in- and cost recovery.
Chief of Emergency Medicine or ENVIRONMENT OF CARE
senior Emergency Department
15 MHRI ANNUAL MANDATORY EDUCATION
The Environment Of Care Safety Data Sheets (SDS) The Bio-Medical Engineering
(EOC) Program ensures that The Safety Data Sheet, SDS Department is responsible for
the facilities of Memorial (formerly Material Safety Data inventorying, inspecting, and
Hospital provide a safe, Sheet) furnishes hazard and managing the repair of all
functional, supportive and toxicological information medical equipment.
effective environment for required by the OSHA's Hazard
patients and staff. Each Communication Standard, and A Bio-Medical Engineering
department has a copy of the is provided by the manufacturer Department inventory sticker is
EOC Manual. for all potentially hazardous attached to all equipment listed
substances. in the Medical Equipment
HAZARDOUS MATERIALS Inventory.
AND WASTE SDS’s can be found in the If you notice a piece of
MANAGEMENT PROGRAM bright yellow binder located in equipment that should be in the
A hazardous material or waste each department. inventory, but does not have an
is any substance that is toxic, inventory sticker, call the
flammable, corrosive, reactive, Clinical Engineering
or capable of causing harm or LATEX GLOVES AND Department at extension 2345.
serious injury, and also includes OTHER LATEX PRODUCTS
hazardous energy sources such Medical Equipment
as ionizing or non-ionizing Although the hospital no longer Management Program
radiation, lasers, microwave, or uses latex gloves and is phasing Requirements
ultrasound. out all latex products, it should be • Present all personal,
Hazardous Materials and noted that repeated contact with Hospital or
Waste Management Program any latex may cause a latex patient-
allergy or may worsen a present owned
latex allergy. Reactions to latex electrical
• Use all
may include: skin rashes, hives, equipment
safety asthma, nasal, eye or sinus
symptoms and allergic shock
(anaphylactic shock). If you or
protective to the Bio-Medical
your family is having these
clothing required. Engineering Department for
symptoms, call your health care
• Attend department provider (your doctor, nurse or inspection prior to use.
hazardous materials dentist) immediately. • Do not use equipment that
training. is in disrepair.
• Know the location and • Contact the Bio-Medical
operation of the nearest Engineering Department
eyewash/emergency immediately to have
shower station. medical equipment
• Never use material from an repaired.
unmarked container. • Contact the Purchasing
• Never clean up a Department if you become
hazardous material or aware of a product recall or
waste spill unless you have safety alert.
been trained. • Notify your supervisor and
• Know the precautions for complete the appropriate
and hazards of selecting, MEDICAL EQUIPMENT Incident Report if you
handling, storing, using, MANAGEMENT PROGRAM experience an incident
and disposing of hazardous involving a patient, staff, or
materials and waste. visitor resulting from
The Medical Equipment
• Know the emergency Inventory consists of all malfunction or misuse of
procedures to be followed equipment used for the medical equipment.
in case of exposure. diagnosis, treatment, monitoring • Know the medical
and care of patients, including equipment’s capabilities,
If you are involved in a spill, limitations, and operating
property damage, or patient, electrically operated beds, and
all equipment including non- and safety procedures.
staff, or visitor injury/illness due • Know the proper
to exposure to hazardous clinical equipment located in
patient care areas or emergency procedures
materials or waste, notify your including clinical
supervisor and complete the laboratories.
intervention if the medical
appropriate Incident Report.
16 MHRI ANNUAL MANDATORY EDUCATION
equipment fails while in Utility Management Program • Never leave valuables in
use. Requirements your car or work area.
• Report all medical • Report any utility system • Keep your lockers locked.
equipment problems, failure to Maintenance • Notify your supervisor of
failures, and user errors to immediately. any breach of security,
the Bio-Medical • Know your department’s such as theft or vandalism,
Engineering Department. policy for turning off the and complete the
oxygen supply. appropriate Incident
SAFETY MANAGEMENT • Know the capabilities, Report.
PROGRAM limitations, and basic
operating and safety
The Infant / Child Abduction
Safety Management Program procedures of the utility
Program was established to
Requirements systems you use.
facilitate the prompt and safe
• Keep hallways and work • Know the location and use
recovery of an abducted infant.
areas free of clutter and of emergency shut off
• Know the proper
• Use only approved ladders
emergency procedure to be There are occasions when an
for climbing, and step
followed when the utility individual becomes so
stools with rubber feet.
• Do not use extension cords system fails. disturbed that they present a
in patient rooms unless • Oxygen Cylinders (full, potential for violence. When
absolutely necessary and partially full or empty) must the immediate staff, including
then only those prepared be secured at all times to Security, are unable to safely
by Maintenance up to a prevent them from falling or control the situation
maximum of two hours. being knocked over. employees at the Memorial
• Never pull on a cord to . campus are directed to
remove it from the outlet. SECURITY MANAGEMENT request intervention.
• Follow all safety rules. PROGRAM • Call the Operator at
• Only use equipment you Security Management extension 2222
have been trained to Program Requirements • Request the Code
operate. • Wear your Grey Team
• Only use equipment if it is name Employees at all other
in 100% operational badge at all locations:
condition. times. Do • Call 911
• Report all safety risks to not leave • Request the local
your supervisor your badge
authorities to respond
immediately. at work.
• Ask anyone who appears FIRE SAFETY
lost if you can help direct MANAGEMENT
him or her to the PROGRAM
appropriate area. Fire Safety Management
• If you see anyone • Understand what is
attempting to access a required of you if a fire or
restricted area or who you fire hazard exists within the
feel is a security threat facility.
contact security • Know the evacuation routes
immediately. in your area.
Utility systems include: Security Emergency
electricity, heating, steam, Telephone Numbers:
medical gases (oxygen), Memorial Campus…ext. 2222
communications, potable water, Notre Dame….ext 3333
wastewater discharge, data All other facilities: call 911 for
systems, emergency power, air local authorities.
conditioning, ventilation, natural • Do not leave doors open or
gas, elevators, fuel, and place objects in the
doorway to keep them from • Know the location of the
hazardous waste disposal.
closing /locking. nearest and next nearest
areas of safe refuge.
17 MHRI ANNUAL MANDATORY EDUCATION
• Know the location of the If you are in the location of the Administrative Staff or the Fire
nearest fire alarm pull fire’s point of origin, follow Department.
station and fire R.A.C.E:
The Operator will announce
• Observe the Tobacco Use (R) RESCUE – Anyone in
“Code Red + Location” to notify
Policy. immediate danger.
staff of a fire emergency.
• If a patient or visitor is
found smoking on Hospital (A) ALARM - Pull the nearest
The Operator will announce
property, explain Hospital fire alarm pull box. Dial the
“Code Red All Clear” when
policy emphasizing our Operator at extension “2222”
there is no longer any fire
intent to provide a safe and and report the type of fire and
healthful environment, and the exact location.
if the patient continues to Evacuation
smoke, contact your (C) CONTAIN - Close all doors Anyone in immediate danger
supervisor or the and windows, shut off fans and shall be moved immediately
Administrative Coordinator air conditioners. during a fire emergency. All
in the Clinical Operations other patients, visitors, and staff
Department. (E) EXTINGUISH * -Try to shall evacuate only when
• Store combustible materials extinguish the fire only if you directed to do so by Senior
in designated storage areas are not needed to assist Management or the Fire
only and not on top of patients, visitors or staff to the Department, following your
microwaves, toasters, nearest safe area of refuge. department’s evacuation plan.
coffee pots, etc.
• Exercise extreme caution Nursing personnel not in their For the Ambulatory Care
when handling oxygen. work area when a “Code Red” Complex: (Includes the Center
• Report frayed cords, bare is announced should remain for Primary Care, Cancer
wires, damaged electrical where they are until a “Code Center, Ambulatory Care
outlets, etc., to your Red All Clear” is announced. If, Building, Goff Mansion, and
supervisor immediately. however, the “Code Red” is ABC Complex)
• Do not block doorways, fire located in your work area, If you are in the location of the
doors, stairways, fire return to assist unless directed fire’s point of origin:
extinguishers or fire alarms otherwise. Do not return to (R) RESCUE - Anyone in
with furniture, equipment or your area if your safety will be immediate danger.
• Move wheeled devices out (A) ALARM - Pull the nearest
of corridors during a Code If you are away from the fire’s fire alarm pull box. Dial the
Red or Code Triage point of origin: Operator at extension “2222”
Internal. and report the type of fire and
• Do not prop open fire 1. Reassure patients/visitors. the exact location.
doors. 2. Close all doors.
• Do not leave toasters, 3. Prepare for evacuation by (C) CONTAIN - Close all doors
coffee pots, or microwaves insuring patients are able to leading to the fire’s point of
unattended when in use. be safely evacuated, and origin.
• Know the types of fire all vital supplies and
extinguishers available and equipment are identified to (E) EXTINGUISH * - Try to
what types of fire they assure continuous patient extinguish the fire only if you
extinguish. care; and evacuate only if are not needed to assist
necessary or you are told to patients, visitors or staff to the
If you discover fire, smoke, a do so. nearest safe area of refuge.
burning odor or hear the fire 4. Stay where you are until
alarm, the steps you take will “Code Red All Clear” is (E) EVACUATE – the smoke
differ depending on the building announced. compartment in which the fire
in which the fire emergency is 5. Do not pass through fire emergency is located in an
located. doors unless you are orderly and timely fashion, by
evacuating the area. checking all exam rooms,
For the Main Hospital:
(Includes MacColl, Sayles, restrooms, and waiting areas
Do not use the elevators or turn and assisting all patients and
Wood, Hodgson, Richardson,
off water valves unless directed visitors to the nearest safe area
to do so by a member of the of refuge.
Garage and the Boiler Room).
18 MHRI ANNUAL MANDATORY EDUCATION
If you are away from the fire’s patients, visitors or injured staff Management or the Fire
point of origin: to the nearest safe area of Department, following your
refuge. department’s evacuation plan.
1. Reassure patients/visitors. * See portable Fire Extinguisher
For all facilities other than
2. Close all doors.
those located on the
3. Prepare for evacuation by
Nursing personnel not in their Memorial Hospital Campus
insuring patients are able to
work area when a “Code Red” and Notre Dame:
be safely evacuated, and
all vital supplies and is announced should remain
where they are until a “Code If you are in the location of the
equipment are identified to
Red All Clear” is announced. If, fire’s point of origin:
assure continuous patient
care, and evacuate only if however, the “Code Red” is
located in your work area, (R) RESCUE - Anyone in
necessary or you are told to
return to assist unless directed immediate danger.
4. Stay where you are until otherwise. Do not return to
your area if your safety will be (A) ALARM - Pull the nearest
“Code Red All Clear” is
endangered. fire alarm pull box.
5. Do not pass through fire
If you are away from the fire’s (E) EVACUATE - In an orderly
doors unless you are
point of origin: fashion, check all exam rooms,
evacuating the area.
restrooms, and waiting areas
1. Reassure patients/visitors. and assist all patients, and
Do not use the elevators or turn
2. Close all doors. visitors to the nearest exit and
off water valves unless directed
3. Prepare for evacuation by then to the outside of the
to do so by a member of the
insuring patients are able to building following your
Administrative Staff or the Fire
be safely evacuated, and department’s evacuation plan.
all vital supplies and
equipment are identified to If you are away from the fire’s
Notification assure continuous patient point of origin:
The Operator will announce care, and evacuate only if
“Code Red + Location” to notify necessary or you are told to (E) EVACUATE - When you
staff of a fire emergency. do so. hear the fire alarm, check all
4. Stay where you are until exam rooms, restrooms, and
The Operator will announce “Code Red All Clear” is waiting areas and in an orderly
“Code Red All Clear” when announced. fashion, assist all patients, and
there is no longer any fire 5. Do not pass through fire visitors to the nearest exit and
danger. doors unless you are then to the outside of the
evacuating the area. building following your
For the Notre Dame department’s evacuation plan.
Ambulatory Care Center: Notification
The Receptionist will announce • Do not use the elevators or
If you are in the location of the “Code Red and Location” to turn off water valves unless
fire’s point of origin, follow notify staff of a fire emergency. directed to do so by the
R.A.C.E.: The Receptionist will announce Fire Department or a
“Code Red All Clear" when member of the
(R) RESCUE - Anyone in there is no longer any fire Administrative Staff.
immediate danger. danger. • Move to the designated
area of the parking lot as
(A) ALARM - Pull the nearest Do not use the elevators or turn stated in your department’s
fire alarm pull box. Dial the off water valves unless directed evacuation plan and count
Reception Desk at extension to do so by a member of the staff, patients and visitors.
“3333” and report the type of Administrative Staff or the Fire • Notify the Fire Department
fire and the exact location. Department. immediately upon their
arrival of anyone presumed
(C) CONTAIN - Close all doors Evacuation to be still in the building.
and windows, shut off fans and Anyone in immediate danger • From a phone outside the
air conditioners. shall be moved immediately building, call the Operator
during a fire emergency. All at Memorial Hospital of
(E) EXTINGUISH *- Try to other patients, visitors, and staff Rhode Island to notify the
extinguish the fire only if you shall evacuate only when Vice President of
are not needed to assist directed to do so by Senior
19 MHRI ANNUAL MANDATORY EDUCATION
Environmental and Support ordinary materials (burning Squeeze the lever - to
Services. paper, cardboard, plastics and discharge the extinguishing
• Do not re-enter the wood) where a potential agent.
building, until the Fire electrical shock hazard may
Sweep from side to side -
Department has announced exist. Unlike a water
watching the fire, sweep from
that the building is safe to extinguisher, the misting nozzle
side to side until the flames
re-enter. provides safety form electric
appear to be out. If the fire re-
shock and reduces the
ignites, repeat the process.
scattering of burning materials.
This is one of the best choices
for protection of hospital RISK MANAGEMENT
environments, books, PROGRAM
documents and clean room Incident Reporting
CLASS B FIRES
Class B fires involve flammable
or combustible liquids such as
gasoline, kerosene and
common organic solvents used
Portable Fire Extinguisher in the laboratory. Use CLASS
Safety Rules BC EXTINGUISHERS (Red A reportable incident is any
• Only attempt to put out a container with large nozzle) or unusual occurrence or event
fire with a portable fire CLASS ABC such as:
extinguisher if the fire is EXTINGUISHERS (Red • Work-related injury or
small and confined to a container with a small nozzle) illness
small area. • Any incidents involving
• Use the proper fire CLASS C FIRES
patient safety, falls,
extinguisher. Class C fires involve medication errors or
• NEVER turn your back to energized electrical incorrect surgery
an extinguished fire. Medical equipment/device
equipment, such as •
• NEVER place your hand on malfunction/incidents
appliances, switches, panel
the cone of a CO2 Theft, vandalism and lost
boxes, power tools, hot plates •
extinguisher. patient items
• NEVER use water and stirrers. Water can be a
dangerous extinguishing • Needle stick or blood/body
extinguishers on an fluid exposure
electrical fire or a medium for Class C fires
flammable liquids fire. because of the risk of Your role is to:
• NEVER attempt to electrical shock. Use a
CLASS BC EXTINGUISHER • Immediately inform your
extinguish a fire if there is a
supervisor if you become
possibility you may (Red container with a large
involved in, or aware of a
endanger yourself or nozzle) or a CLASS ABC
others. EXTINGUISHER (Red • If you need medical
container with a small nozzle) attention, seek treatment
Which Type of Fire Requires
CLASS K FIRES from Employee Health, the
Which Type of Extinguisher?
Emergency Department, or
CLASS A FIRES Class K fires are kitchen fires. Notre Dame Center for
Use a CLASS K Occupational Health,
Class A fires are ordinary EXTINGUISHER. depending on the
materials like burning paper, seriousness of the
lumber, cardboard, plastics, etc. Follow the PASS procedure
when using a fire injury/illness.
Use CLASS A FIRE • Complete and send the
EXTIGUISHERS (Chrome extinguisher:
appropriate Incident Report
container, water filled) or Pull the pin - to unlock the within 24 hours of the
CLASS ABC FIRE operating lever and discharge incident to the Risk
EXTIGUISHERS (Red the extinguisher (twist the pin Management Department.
container with small nozzle) or as you pull it).
WATER MIST EXTIGUISHERS See your supervisor for blank
(White and Blue colored) Water Aim low - keeping your back to Incident Report forms. The two
mist extinguishers are ideal for an exit, point the extinguisher Incident Report forms are:
nozzle at the base of the fire.
20 MHRI ANNUAL MANDATORY EDUCATION
1. Employee Incident Report of the laws that are designed to
deter non-compliance, including
For staff incidents only.
the Federal Civil False Claims QUESTIONS OR
2. Confidential Report of Act, the Federal Civil Monetary COMMENTS
Incident Penalties law, the Federal
Program Fraud and Civil If you have any questions or
Specifically for patient, Remedies Act and the Rhode comments about the Annual
visitor, volunteer, and Island Medicaid Fraud Act. Mandatory Education, please
environment of care share them with your supervisor.
related incidents. Another important part of MHRI’s
Corporate Compliance Program is the
(Refer to the Hospital Policy, policy of encouraging employees to
Administration 2 for further report possible instances of non-
information). compliance with legal and ethical
requirements. Any hospital employee
Sentinel Event is an may communicate such concern
unexpected occurrence directly to his/her immediate
involving death or serious supervisor or to an operations
physical or psychological injury manager or vice president in charge
of the employee’s department.
to a patient. When there is any Alternately, employees may report
question of a sentinel event, these concerns to the corporate
staff must report the event compliance officer either in writing or
details to the Risk Manager. All by voice mail at extension 2148.
staff involved in the event join Reports may be made anonymously if
so desired. Per hospital policies
together to analyze the event
Human Resources 66 and Corporate
and identify the root cause. Compliance 5, no employee will suffer
Often, we look for root causes any discipline in retaliation for
when a situation involves reporting a corporate compliance
potential injury, so we can concern.
modify our practices to avoid
sentinel events in the future.
CORPORATE COMPLIANCE Thanks for your
PROGRAM contributions to a safe and
Memorial Hospital has in place
a Corporate Compliance
Program that is designed to
maintain the hospital’s culture
of ethical integrity and to
promote continuing adherence
to legal requirements related to HRBEV911
billing, reimbursement and For more information details
other business functions. An and to keep up-to-date on
important part of this program is activities and performance
the Corporate Compliance improvement initiatives
Code of Conduct, hospital within the hospital, please
policy Compliance 2, which read our Survey Readiness
outlines principles and Update Booklet to prepare
standards for the way in which and be confident during The
MHRI personnel are expected Joint Commission (TJC) and
to conduct the hospital’s other regulatory surveys.
business. These principles and
standards address, among Visit the MHRI intranet
other things, business ethics (http://office.mhri.org) for
and business relationships, policies, information and
conflicts of interest and
other hospital news.
protection of MHRI assets. The
principles and standards also
address legal compliance and
provide information about some