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policies and protocols for infection control, the prevention of infection, the ability to demonstrate extreme measures are taken to prevent the cause of infection in and around the workplace. This protocol is geared more towards the surgical setting but can be customized to meet any health care setting as most of them are universal precautions based policies.
General Safety Policy # 0115 Effective: Reviewed: Revised: 1. PROCEDURES. 1.1 Nurse Manager is responsible for maintaining safety standards, developing safety rules, supervising and training personnel in departmental standards. 1.2 The staff should notify the Nurse Manager in case of any safety hazard. 1.3 All department employees shall report defective equipment, unsafe conditions, acts or safety hazards to Nurse Manager. 1.4 Keep electrical cords clear of passageways. 1.5 All equipment and supplies must be properly stored. 1.6 Scissors, knives, pins, razor blades and other sharp instruments must be safely stored. 1.7 All electrical machines with heat producing elements must be turned off when not in use. 1.8 Smoking is prohibited in La Peer Surgery Center. 1.9 Do not permit rubbish to accumulate. 1.10 Furniture and equipment must be arranged to allow passage and access to exits at all times. 1.11 Spills will be cleaned by the employee who discovers the spill. This will be done immediately. 1.12 Report faulty equipment to the Nurse Manager. 1.13 Obey warning signs. 1.14 File drawers and cabinet doors shall be closed when not in use. 1.15 Wear suitable clothing. 1.16 Closed heel and toe shoes to be worn in patient care areas. 1.17 Cotton scrub suits are to be used. Page 1 of 3 1.18 Only nonflammable anesthetics will be used. 1.19 Only authorized personnel may enter surgery or recovery room suites. 1.20 Woolen and synthetic blankets shall not be permitted in surgery or recovery room. 1.21 Flammable germicides or any fat-solvent preparations shall not be applied for preoperative preparation of the field. 1.22 When the ground contact signal (red light) lights and/or the audible warning sounds, the use of electrical equipment shall be discontinued as soon as feasible. Following the completion of the operation, the operating room in which the signal malfunctioned shall not be used until a report the electrical defect has been remedied. 1.23 A patient will be attended by an anesthesiologist until the patient is transported to post anesthesia care unit. If no anesthesiologist is involved in the care of the patient, the surgeon shall perform those duties in the PACU for which an anesthesiologist would normally have been responsible. 1.24 All equipment must be grounded to maintain a constant path to floor. 1.25 Only 3-prong plugs are to be used. 1.26 Routine inspection of anesthesia machines is to be done, per policy. 1.27 Grounding pads are to be used on patients, when electrocautery is used. 1.28 All new equipment is to be checked before use. 1.29 Only non-conductive rubber mattresses and pillows are to be used. 1.30 All oxygen and gas connections and controls shall be checked by the anesthesiologist, before actual use. 1.31 Wheels on the operating room table and on all gurneys must be locked before the patient is moved from gurney to the table and vise versa. 1.32 A check of the generator system will be done weekly and a log will be kept in Mechanical Room. 1.33 Defibrillators shall be used only when staff members are standing on dry floor and no part of their body is in contact with the patient's bed or the patient receiving the cardioversion. 1.34 To reduce possible shock, use all electrical equipment per manufacturer's instructions and always with dry hands. 1.35 No modification of equipment is authorized, except as specified in the manufacturer's recommendations. 1.36 No equipment will be placed into use until a written verification of proper operation, per manufacturer's standards, has been made. Equipment Page 2 of 3 which has been subjected to temporary repair (taping, wiring, etc.) will NOT be placed in use. 1.37 Discard needles, razors, scalpels and broken glass only into approved sharps containers. 1.38 Gurney siderails will be kept in the up position when patient is present and Phase I. 1.39 Operating table safety belts will be used for all patients. 1.40 Understand and practice good body mechanics. 1.41 Keep to right when going down corridors. Approach intersections carefully. Be sure traffic lane on other side is clear, when opening swinging doors. Do not push doors open with equipment. Use push panel or door knob. 1.42 Do not leave equipment standing in traffic lanes. Return equipment to its proper location when not in use. 1.43 Do not obstruct fire equipment. Know location of fire fighting equipment and how to use it. Know evacuation routes and what to do in case of fire. Page 3 of 3
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