AMUT Submissions by wpr1947



            Complete AMUT and Win a
        In an effort to attain 100% completion goal,
   the staff education department is holding a drawing.
Each employee who successfully completes AMUT and
                        find the total # of
   bouncing          AMUT Dogs will be entered into a
    drawing. The winner of the drawing will receive a
      prize and bragging rights in the leadership
 Entry forms are located at the bottom of the AMUT Completion form.
         Send your name and # of bouncing           to attn: Kelli
Houston (Staff Education- PC). Entries must be received by December
 31st. The winner will be announced on Monday, January 3, 2011.
                                    Age Appropriate Care
Age-related competency means having the knowledge and skills required for a
specific developmental group of patients.

What are the developmental groups, their behaviors, and the best approaches
for care?                                                                             1.    Which developmental age group fluctuates in their willingness to
                                                                                            participate in
                                                                                            care because of their need for independence and approval?
Infant (Birth through 12 months):
                                                                                            A.     School age children
•      Clings to parents and cries when they leave                                          B.     Adolescents
•      Handle infant gently and speak in a soft, friendly tone of voice                     C.     Middle Adult
Toddler (1 to 2 years):                                                                     D.     Older adult/Geriatric
•      Experiences separation anxiety                                                 Correct answer: B. Adolescents
•      Give the child simple, direct, and honest explanations just before treatment
                                                                                      2.    The Joint Commission requires that staff members have the knowledge
       or surgery                                                                           and
Pre-school (3 to 5 years):                                                                  skills necessary to meet age-specific needs.
•      Experiences separation anxiety; may panic or throw tantrums, especially              True
       when parents leave                                                                   False
•      Use simple, neutral words to describe procedures to the child                  Correct answer: True
School Age (6 to 12 years):
                                                                                      3.    To maintain competencies in age-specific care, you must be updated on
•      Alternatively converts to adult standards and rebels against them                    new
•      Explain logically why a procedure is necessary                                       technologies, procedures or therapies for your patients.
Adolescence (12 to 18 years):                                                               True
•      Shows concern of how procedure may affect appearance
                                                                                      Correct answer: True
•      Give scientific explanations using body diagrams, models, or videotapes
Young Adult (19 to 39 years):                                                         4.    Children cooperate much better when they are not told a procedure
•      Directs and participates in his/her own care                                         may hurt
•      Use problem-centered teaching
Middle Adult (40 to 64 years):                                                              False
•      Directs and participates in care                                               Correct answer: False
•      Involve in decision-making
Older Adult/Geriatric (over 65):
•      Demonstrates anxiety over new procedures or a change in routine
•      Use simple sentences, concrete examples, and reminders such as pillboxes                                                                                 3
        Americans with Disabilities Act (ADA)
The Americans with Disabilities Act (ADA) was enacted on July 26th, 1990 by
the United States Congress. This federal law prohibits discrimination and
ensures equal opportunity for persons with disabilities in:
1) Public accommodations
2) Employment
3) Transportation                                                                      1.        Which of the following would be considered an ―inappropriate‖
4) State and local government services and                                                       action when serving a physically disabled member who uses a
5) Telecommunications (e.g. Telephone Device for the Deaf)                                       wheelchair?
                                                                                                  A. Calling the department next door to use their wheelchair weight
Under the ADA Act, disability is defined with respect to an individual as ―a                     scale as your department does not have one.
physical or mental impairment that substantially limits one or more of the
major life activities of such individual; a record of such an impairment; or                     B. Assume you will need the lift team to help transfer the member to a
being regarded as having such an impairment.‖ Major life activities includes
functions such as activities of daily living, walking, seeing, hearing, breathing
                                                                                                 C. Crouch to make yourself shorter when speaking to the member.
and working to name a few.
                                                                                                 D. Waiting for the member to respond after asking if they need
In health care the ADA definition of a disability is expanded to include                         assistance
individual’s temporary limitations which include:                                                  moving about in their chair.
Temporary Disabilities
•      Many members may not have permanent disabilities, but have a condition          Correct answer: B
       that affects them temporarily. The same suggestions for accommodation
       and rules of etiquette should be followed whether the disability is
       experienced on a permanent or temporary basis.
Physical Disabilities
•      A physical impairment as defined by the ADA is ―any physiological
       disorder or condition, cosmetic disfigurement or anatomical loss affecting
       one or more of the following body systems: neurological, musculoskeletal,
       special sense organs, respiratory (including speech organs), cardiovascular,
       reproductive, digestive, genitourinary, lymphatic and blood systems, skin
       and endocrine.‖
Proper Disability Etiquette
•      Crouch or sit when possible to converse at eye level.
•      Ask before pushing/assisting with a wheel chair, and wait for a response.
•      Do not make assumptions about what a person can or cannot do based on his
       or her disability. All people with disabilities are not alike and have a wide
       variety of skills and personalities.
Reporting Member Disability Issues
•      Local issues and concerns regarding members with disabilities that cannot
       be resolved through your manager should be reported to one of the PC ADA
       Representatives (Dionne Hunte, ext 3439, Bill West, ext 2020, or Debby
       Weissman, ext 2979) and/or the Member Services Department.
Visit the ADA Compliance Website for more info
                        Ergonomics/Body Mechanics
     Ergonomic tips for sitting at a computer:

                                                                              1.       The potential for back injury can be reduced by
                                                                                       understanding your back anatomy, maintaining correct
                                                                                       posture and using correct body mechanic during activities
1. Keep head upright;                   6. 1-4 between front                  Correct Answer: True
   ears, shoulders and hips in a           edge of seat and
   relaxed posture                         back of knees                      2.       When working in a sitting position which of the following
2. Shoulders relaxed;                   7. Feet flat on floor or floor rest
                                                                                      A.      Sit close to your work
   elbows by sides of
   Body                                 8. Top of monitor at                          B.      Maintain one static position for as long as possible
                                           or slightly below                          C.      Arrange your work to the side so you can twist back and
3. Adjust backrest to                      eye level (lower for bifocals)                     neck
  support curve in                                                                    D.      Maintenance of the spine’s three natural curve is not
  lower back.                           9. Monitor distance at                                necessary in sitting
                                           arm’s length                       Correct Answer: A
4. Sit in relaxed posture
   with buttocks against                10. Monitor, keyboard                 3.       Which of the following would be considered “inappropriate
   back of chair and close to your          and mouse inline;                          action” when carrying a load:
   work                                     keyboard flat on                          A.      Using your feet to change direction
                                            surface; mouse                            B.      Carrying a load over your head
5. Thighs parallel to                       beside keyboard.                          C.      Setting the load down and resting for a few moments
   floor or hips                            Adjust desk or
                                                                                      D.      Keeping your back straight or slightly arched
   slightly above                           keyboard tray so
   knees                                    forearms are parallel             Correct Answer: B
                                            to floor.

                         Lifting Safely
• Keep your back straight or slightly arched; use abdominal muscles
• Walk Slowly and surely
•Use your feet to change directions. Never twist your back
•Avoid leaning over
•Avoid lifting a load over your head
•If you become tired, set the load down and rest
•Ask for help especially if you believe the load is too heavy or use a cart                                                                             5
Compliance Expectations
Achieving compliance takes everyone’s commitment. Here are some compliance                 Fraud Awareness and Prevention
expectations for all workforce members:                                                    In the simplest terms, fraud occurs when someone lies to gain benefit or advantage.
      Use the Principles of Responsibility, our formal code of conduct, as a tool         An example of fraud is when someone uses another person’s medical identification
       for making decisions about compliance and ethics issues.                            card to receive treatment. Preventing fraud protects our member’s health, our
      Identify potential fraud, waste, and abuse and take appropriate action.             resources, and our reputation.
      Protect the confidentiality and security of patient information.
      Report potential instances of noncompliance as part of your job.                    There are many fraud risk areas throughout the organization.
                                                                                                 If you work with members, you may find medical-identity theft or members
The Principles of Responsibility                                                                  enrolling ineligible dependents.
You should understand The Principles of Responsibility (or POR), Kaiser                          If you work with vendors you may see conflicts of interest or kickbacks.
Permanente’s code of conduct, applies to everyone and is meant to help each of us                If you work with drugs you may see drug theft or forged prescriptions.
accomplish the organization’s mission in an ethical work environment.                            If you work with claims you may discover suspicious or false claims by
                                                                                                  members or providers.
                                                                                                 If you work with other employees you may see fraud, waste and abuse such
A few of the topics included in the Principles of Responsibility are:                             as cash theft, timekeeping fraud, misuse of assets or personal business on
      Non-Retaliation - Kaiser Permanente has a clear non-retaliation policy. We                 work time.
       do not tolerate retaliation against individuals who refuse to participate in or     As part of your job, you are required to report all instances of non-compliance.
       report illegal and unethical acts to KP or government agencies. Anyone who
       retaliates against these individuals is subject to disciplinary action, up to and
       including termination.                                                              To maintain competencies in age-specific care, you must be updated on new
                                                                                           technologies, procedures or therapies for your patients.
      Conflict of Interest - Conflicts of interest have the potential to damage the
       reputation of both you and the organization. A conflict may arise when your         Privacy and Security
       personal or financial interests influence—or appear to influence—your               Our members’ trust depends in large part on how we protect the confidentiality and
       judgment or interfere with your work responsibilities.
                                                                                           security of their information. Even though your job may not directly involve caring
                                                                                           for patients or working with members, you may come into contact with protected
      Safeguarding our Assets - Our organization’s assets are intended for
       business purposes. These assets include buildings, equipment, furniture,            health information (PHI) and other confidential information in your daily work
       supplies, company funds, electronic assets, knowledge, and information. We
       are all responsible for protecting them against misuse, waste, damage, loss,
       impairment, and theft.

      Confidential Information - We require passwords as part of our security to
       limit access to confidential information. It is very important to not let others
       use your password or account. Employees have been terminated for sharing

Here are some frequently asked questions and answers to clarify                      Avoid Conflicts of Interest, Do the Right Thing
some of the more common misconceptions:                                              What is a Conflict of Interest?
     Can I look up my coworker’s address in the system to send him/her a get-
      well card?                                                                     A conflict of interest arises when personal or financial interests influence your
NO. You must not look up this information for personal reasons. When it comes to                 professional judgment, business decision-making, or interfere with your
      the privacy and security of protected information, accessing demographics is               Kaiser Permanente responsibilities. In addition, a potential conflict of interest
      no different than accessing clinical information. You should contact the                   exists when it might appear to others that personal or financial interests could
      employee’s manager for instructions.                                                       influence professional judgment or decision-making.
     Can I look up my 5-year old daughter’s lab results?
                                                                                     For instance, Jane is a senior registered nurse who assists physicians in the Emergency
NO. As the parent of a 5-year old you do have a right to this information; however
      you must obtain it the same way a non-Kaiser Permanente workforce                          Department (ED). As a senior nurse, Jane is well-respected, and other
      member would obtain it.                                                                    employees, including physicians, rely upon her expertise and advice to keep
     I work in an open area with three other employees. When I leave my                         the ED running smoothly. Recently, Jane befriended John, a contractor who
      workstation, I don’t lock it up (Ctrl-Alt-Del buttons). Is that okay?                      sells emergency room equipment to hospitals and has previously sold
NO. Although your coworkers are employees, this does not automatically give                      products to Kaiser Permanente. John has offered Jane a gift, a high-quality
      them access to the information on your computer. Use the minimum                           digital camera in a case with the vendor's name and logo on it. The value of
      necessary principle. You must only use, access or disclose the minimum
      amount necessary to get the job done. Always lock up your workstation                      the camera is more than $25, and Jane knows John would like to sell his
      whenever you step away.                                                                    products at her facility.
                                                                                     The above scenario demonstrates a conflict of interest for Jane because her personal
The consequences for inappropriately accessing medical records can be severe.                    relationship with John may cloud her loyalties to Kaiser Permanente, and
Employees have been terminated for this very reason. In addition, individuals can                interfere with her job responsibilities. The right thing for Jane to do is to
be fined up to $25,000, per a new state law (SB 541)                                             decline the gift and inform her manager in writing of the relationship and the
                                                                                                 potential contracting issue.
Reporting Compliance Concerns
At KP, we foster a culture of compliance. In the POR, under Where to Get
                                                                                     Other Conflicts of Interest Examples
Help you will find several methods for reporting potential compliance
concerns:                                                                            Here are some conflicts of interest examples. They occur when an employee has:
      We encourage you to go to your supervisor first, however we realize           •          A financial interest with organizations doing business with Kaiser
       sometimes this may not be possible so there are other internal resources                 Permanente.
       available to you.
                                                                                     •          Accepted gifts or benefits for work related presentations.
      If your supervisor is not available, or if speaking with him or her did not
       produce results, speak to a higher-level manager.                             •          Influenced business decisions with organizations in which they or their
      If you are unable to speak to a higher-level manager, you can talk to Human              family hold a direct financial interest.
       Resources, or your Compliance Officer.                                        •          Supervised a member of his or her family as a job responsibility.
      If you are uncomfortable using any of the resources above, you can always
       call the KP Compliance Hotline at 1-888-774-9100.                             •          Served as an officer or member of a board of directors of another
                                                                                                organization that could pose a conflict as an employee of Kaiser Permanente.

When, How to Report Conflicts of Interest
Whenever you become aware of a potential conflict of interest, you are
      required to disclose it in writing to your manager, supervisor, medical
      center compliance officer, Human Resources representative, chief, or        1.        The KP Code of Conduct is my guide for telling me how to work
      department administrator. If you become aware of a conflict of interest               honestly and ethically at Kaiser Permanente, and I understand it is
      that is currently taking place in your work environment, you may also                 my obligation to report something that is a violation of the Code of
      call the anonymous Kaiser Permanente Compliance Hotline, 888-774-                     Conduct, to my supervisor, manager, my Compliance Officer, or
      9100 (toll free). KP has a non-retaliation policy that protects employees             call the Compliance Hotline.
      who report conflicts or potential conflicts of interest in good faith.                True
Learn More about Conflicts of Interest                                            Correct answer: True
•     Refer to our Principles of Responsibility, Kaiser Permanente's code of
                                                                                  2.        According to the KP Code of Conduct, the principle that tells me
•     Contact your Compliance Officer                                                       that I cannot take cash or gift cards from vendors is:
•     Visit the Southern California Compliance Web site                                    A.         The Principle for Respecting Confidentiality, Privacy and
•     Send an e-mail to SCAL-Compliance-and-Privacy-Office@KAIPERM.                                   Security
                                                                                           B.         The Principle for Safeguarding and Proper Use of KP
                                                                                                      A.     Assets
                                                                                           C.         The Principle for Protecting the Environment
                                                                                           D.         The Principle for Conflict of Interest
                                                                                  Correct answer: D

                                                                SERVICE EXCELLENCE
                                     “We interviewed some of our members about the service they had received in area medical offices and

                                      Customer Service
                                     what we can do to provide the best possible care experience. They provided us with valuable insights into
                                     how they define the qualities and characteristics they hope to see in our reception team, our medical
                                     assistants and our nurses.”—Tina Han, Panorama City, SCPMG Service Leader

KP Members have listed the following qualities and behaviors when describing
excellent service: What are the developmental groups, their behaviors, and the
best approaches for care?

Show Courtesy By —
•     Treating members politely and with respect.
•     Being friendly and greeting each member warmly.                                1.  Our members expect a smile, eye contact, attentiveness, and a
•     Engaging the member in conversation to reinforce your personalized,                 pleasant tone of voice to demonstrate courteous behavior.
      focused attention on them. Conversations with co-workers should end                 True
      immediately when a member approaches you.                                           False
•     Smiling and making eye contact.
                                                                                     Answer: True
•     Using a pleasant tone of voice.
•     Taking your time with each member and not rushing them through the
      check-in process.                                                              2.   Proactive offering of help is a key element of patient satisfaction
Show Helpfulness By —                                                                     False
•     Offering to help before being asked. Proactively offering instructions about   Answer: True
      where to wait, what to do with forms, giving directions to other KP
      departments and location (pharmacy, lab, parking, nearest exit, etc.).
•     Walking members to their destination whenever possible. If you can’t leave     3.   Listening attentively demonstrates caring and empathy
      your work area, provide members with a campus map and show them where               True
      they need to go. Maps are available online at http://voices-pc.
•     Always asking, ―Is there anything else I can do for you today?‖
                                                                                     Answer: True
•     Following up on requests made by the member.

Show Care and Concern By —                                                           4.   Kaiser Permanente’s Service Quality Credo says, ―Our cause is
•     Creating a cheerful, non-threatening environment that puts the member at            health. Our passion is service. We’re here to make lives better.‖
      ease and helps them to relax.                                                       True
•     Talking to the member and reducing any anxiety they may have about their            False
      visit.                                                                         Answer: True
•     Asking the member what else we can do to make them comfortable.
•     Answering any questions they may have about their provider, and reassuring
      them that that they are receiving the highest quality care.

      Our Service Credo—Our cause is health. Our passion is service. We’re here to make lives better.
    Service and SCPMG Leadership Dept. website:
           Service Advisor:
                                   Culturally Responsive Care
The United States, already one of the most diverse societies in the world, is becoming increasingly multicultural and multilingual. Immigrant, refugee, limited-English
and non-English proficient (LEP/NEP) populations are continuing to grow. According to the 2000 U.S. Census, 47 million residents were non-English speaking and this
population is expected to reach 40% by the year 2030. For health care organizations, providing linguistic and culturally appropriate health care services that ensures
quality of care to diverse populations has becoming increasingly imperative and complex.

At Kaiser Permanente, we believe it is our responsibility to protect a patient’s right to receive the information necessary to make informed health care decisions. To
continue providing quality of care to our patients’, especially those that are limited-English and non-English speaking, effective communication is key to the delivery
of culturally competent health care.

Qualified Interpreter Services available:
•      Qualified Bilingual Staff (QBS) Level 1 (L1) interpreter - can be used to provide language assistance to patients/members at a basic conversational level
       excluding medical terminology.

•      Qualified Bilingual Staff (QBS) Level 2 (L2) interpreter - can be used to provide language assistance to patients/members in encounters including those that are
       clinical interactions with the use of medical terminology.

•      Telephone Language Line Interpreter for all languages can be accessed 24 hours, 7 days a week.

Only qualified, tested, and trained bilingual staff for Spanish, Tagalog, and Armenian can be used to provide interpretation
services to members. Bilingual staff speaking a language outside of the three Panorama City Approved languages cannot provide
interpretation to patients. For language services where Qualified Bilingual Staff (QBS) is not available, the Language Line Service
must be used (please see How to Use the Language Line below).

All providers, managers, and staff should be aware of how to assist limited-English proficient (LEP) members needing language
interpretation and to assist those needing American Sign Language (ASL). LEP –
In the absence of qualified bilingual staff to provide interpretation in the Panorama City approved and tested languages (Spanish, Tagalog, and Armenian), assistance
shall be provided through the Language Line Service (LLS). ASL – The Communications Department is the designee for arranging for
outside sign language interpreters. When interpreter services are needed for the deaf or hard of hearing, contact
Communications at 8-350-2218.

The use of adult family members and/or friends to provide interpretation for patients is discouraged.
•     We must first offer qualified language assistance to the patient via a Qualified Bilingual Staff (if available) or the Language Line.
•      If the member/patient refuses or declines language assistance services offered, consideration will be given to member/patients request for use of a family
      member and/or friend (18 years or older) for interpretation.
•     The refusal by the patient to utilize language assistance services must be documented in the patient’s medical
•     record. If we use a Qualified Bilingual Staff member to provide interpretation, this must also be
•     documented i.e. the name of the QBS employee and QBS Level.

                                         Culturally Responsive Care
How to Use the Language Line: Telephone Interpreting Services (non-English language only)
1. Establish a conference call between you, the member/parent and the language interpreter
•       Language Line Services: 1-800-523-1786
•       Client I. D: #136520 (Panorama City & outlying MOBs)
                                                                                                     1.        For Clinical interactions where medical terminology is used,
•       #295204 (Antelope Valley only)
                                                                                                               what type of Qualified Bilingual Staff member may be used for
2. When you reach the Language Line Representative, you will be asked for a client identification              interpretation?
   code (Client I.D.) You must also give her/him your full name, your department and the language               A. Language Line
that the member/parent speaks. If you are not sure what language the member/parent speaks, use                  B. QBS Level 1
the Language Identification Card to assist you in identifying the language. For Language Line                   C. QBS Level 2
Identification cards, please contact Dionne Hunte, x3439.
                                                                                                                D. Family Member/Friend
3. Within minutes you will be connected to an interpreter. Stay on the line with the member/parent   Correct answer: C. QBS Level 2
       until you are sure that the interpreter and the member/parent have connected.
                                                                                                     2.        The language line can only assist in the following languages:
4. When using two hand held phones:                                                                            Spanish, Tagalog, and Armenian
         –     Give one to the patient
         –     Provider/Staff uses the other                                                                   True
         –     Begin dialogue between yourself, patient, and interpreter                                       False
                                                                                                     Correct answer: False
5. When using a Speaker Phone:
         –     Once the interpreter is connected press the “Speaker” function on the phone,
               hang up the headset and begin the conversation. Remember, if you are in a
               patient care area to close the door to protect the patient’s privacy.

6. When using a dual hand held phone:
•     When the interpreter comes on the line, give one of the phones to the patient.

 Under no circumstance, should a member/patient ever be asked to bring their own interpreter to
 an Administrative or Clinical Point of Contact.

                               Emergency Management
When a disaster strikes, the Medical Center may become a center of activity:        Crush injuries or death occur from falling debris and breaking glass or when
    The community may look to the organization for leadership and safety           people fall from shaking. Fires may be caused by gas leaks. Most common
    The injured may be brought for treatment                                       injuries:
    The facility itself may also be directly affected by the disaster              Burns
                                                                                    Crush or orthopedic injuries
If a disaster strikes, Medical Center employees are expected to follow the          Lacerations
        Medical Center’s Emergency Operation Plan (EOP) and know what is            Lung damage from inhaled debris
        expected. Here are some of the roles that you may need to perform during    When many people are hurt by the same event, this is called a ―Mass
        and emergency:                                                              Casualty Incident... When mass casualty incidents involve more patients than
       Provide care to the injured                                                 the Emergency Room can treat under relatively normal conditions, the
       Minimize confusion by being calm and knowledgeable                          emergency management plan may be activated.
       Provide support and services to other staff involved in disaster response   Plane crashes and bombings are other examples of mass casualty incidents.
                                                                                    Plane crashes cause crush injuries. Bombings cause crush injuries and
                                                                                    concussions. Both plane crashes and bombings result in burns. Plane crash
The Medical Center has developed an Emergency Operation Plan (EOP) for              burns can be particularly severe. Respiratory damage is a common injury in
dealing with disasters and emergencies. The EOP outlines what you and your          both plane crashes and bombings.
Department are expected to do if a particular situation arises. Disaster drills     Multiple motor vehicle accidents and train derailments may also be multiple
are also conducted at least two times each year. Knowing what to do will help       casualty incidents, and may likewise cause the activation the emergency
                                                                                    management plan. Vehicle and train accidents often cause the following
you stay calm in a disaster.                                                        injuries:
                                                                                    Head trauma
Be prepared:                                                                        Crush injuries
     Locate where the Emergency Operation Plan (EOP) in DMS                        Hemorrhage
     Be familiar with the plan’s contents                                          Amputation
     Respond to each drill as if it were a real disaster                           Burns from fuels fires

When a disaster strikes, the normal operation at the Medical Center may             When a disaster strikes, the Medical Center’s Emergency Operation Plan
change. Response to the emergency is generally directed by a Command                (EOP) may be activated. Typically, a message is sent out on the overhead
Center, Emergency Operations Center, or some other designated group. This           paging system to indicate what type of disaster has occurred. The paging
helps promote effective communication and safety.                                   code for disaster is Code Orange – Disaster

Disasters and emergencies are generally classified as ―external‖ and                Review the information in the EOP that applies to you and your department
―internal.‖ External disasters are emergencies that take place outside your         prior to a disaster. Knowing what to do will help you respond calmly and
                                                                                    effectively. Depending on the scope of the situation, expect to:
facility. Internal disasters and emergencies that take place inside the facility.

                        Emergency Management
                                                                                 If there is a loss of electricity:
                                                                                 Locate flashlights or light sticks in your department
Review the information in the EOP that applies to you and your                   Note whether the emergency generator goes on
department prior to a disaster. Knowing what to do will help you                 Locate emergency outlets. These have red cover plates
respond calmly and effectively. Depending on the scope of the                    Verify that all patient equipment is plugged into emergency outlets and that
                                                                                 it is operating correctly
situation, expect to:
                                                                                 Call or send a runner to the Command Center or Maintenance for additional
•      Maintain normal working patterns, but stand by. DO NOT plan to
       leave the facility unless you are released by your manager
                                                                                 If there is a loss of water:
•      If directed, stop nonessential functions and prepare for reassignment
                                                                                 Obtain safe bottled drinking water supplies
                                                                                 Use waterless hand cleaner
When a disaster strikes, the Medical Center’s Emergency
Operation Plan (EOP) may be activated:
                                                                                 During some internal disasters, it is necessary to evacuate a specific area or
                                                                                 building. If the Command Center or outside emergency response groups
•      Typically, a message is sent out on the overhead paging system to         (such as fire or police department) determines that your unit must be
       indicate what type of disaster has occurred. The paging code for          evacuated, remember:
       disaster is code Orange.                                                  Rescue anyone in immediate danger first
•      Review the information in the EOP that applies to you and your            Evacuate ambulatory patients before those who are non -ambulatory
       department prior to a disaster. Knowing what to do will help you
       respond calmly and effectively. Depending on the scope of the             Don’t use the elevators
       situation, expect to:
•      Maintain normal working patterns, but stand by. DO NOT plan to            A responsible person should be designated to make a final work-through to
       leave the facility unless you are released by your manager                be sure that everyone has been evacuated.
•      If directed, stop nonessential functions and prepare for reassignment     When a disaster is over, staff members will need to talk. If the situation is
•      In certain types of disasters, internal utility system interruption may   prolonged or traumatic, shift debriefings help provide comfort and rumor
       occur. Downed power lines can cut electrical power to lighting and        control.
       equipment. Broken pipes cause loss of running water and toilet
       flushing. Phone lines can overload or be damaged. This will require       Debriefings include:
       you to use other methods of communication. If oxygen lines break,         Updates acknowledging work that has been completed
       alternate oxygen sources will be needed for oxygen-dependent
       patients.                                                                 Plans and directions for further work
                                                                                 Potential referral sources for counseling and support
                                                                                 A disaster or emergency can strike at any time. Your ability to stay calm and
                                                                                 know what to do will directly affect how successfully the Medical Center
                                                                                 responds to the situation.

                                                                                 The overhead page (code orange) at your facility indicates that your disaster
                                                                                 plan is now in effect. Maintain your normal working pattern, but stand by
                                                                                 for possible reassignment. Stay at the facility unless you are released by your
                                                                                 supervisor or manager. Evacuation is only necessary when the safety of staff
                                                                                 or patients is directly threatened--such as when in immediate danger from
                                                                                 fire or the building itself is no longer structurally sound.                13
                                                                                 For more information about the Medical Center’s Emergency Operation
                                                                                 Plan (EOP), contact Environmental Health & Safety.
                                           Fire & Life Safety
                                                                                         •     Smoke can confuse you, making escape more difficult. Smoke is lighter
Life Safety                                                                                    than air and rises, so stay low where you can breathe the best air even if it
                                                                                               means crawling. Patients who are able to walk should be moved in a group.
Fire can only occur when Fuel, Heat and Oxygen combined in a fire                              Provide blankets or towels for protection as they move to safety.
triangle. By keeping these elements from coming together, you can
prevent fires.                                                                           •     Since beds can block halls, they should not be used to move patients unless
                                                                                               nothing else can be used. Use techniques taught in the fire certification class
In a fire, think P.C.A.E                                                                       to get patients to safety.
P – Patients are to be removed from immediate danger
C – Contain the fire by closing doors                                                    •     Although you must get people away from the fire, you must also move to an
A – Activate the alarm system by pulling the fire alarm box and by dialing                     area that can support any necessary medical equipment. Think ahead of time
                                                                                               where that will be or bring the medical equipment with you. Take patient
extension 2222                                                                                 records with you so that you can account for everyone later and to facilitate
E- Extinguish the fire with a fire extinguisher only if safe to do so                          the necessary on-going treatment.

Fire safety calls for a team effort. A fire plan, fire drills, and working with the      •     If you need to open a door on the way to your exit but you are not sure is
local fire department are parts of that effort. The most important part of the                 there is fire burning behind it, first feel the door with the back of your hand
team, however, is you. Hospital fires can be dangerous because moving                          first. If hot, do not open it, since a burst of flames could come at you. If you
                                                                                               must open the door, stand behind it to protect yourself, and open slowly.
patients is not easy. The key will be to gain time.                                            Always remove the patient first in the event of any type of fire if it is safe to
Even if the fire does not look big, after removing the patient from immediate                  do so.
danger, contain the fire by closing the door and pull the alarm and dialing
extension 2222. Smoke can make it hard to see, breathe and think. Smoke                  •     An ABC extinguisher can be used for all types of fires. Never use a type A
can make it harder to escape. Closing doors will contain the fire and limit the                or water extinguisher to fight electrical fires. Check what kind of
spread of smoke in the hospital, giving you the time needed. This simple                       extinguishers you have in your work area.
action can gain 20-40 minutes of safe time.                                              •     Never block fire doors from closing by the placing of either equipment or
                                                                                               doorstops. A piece of improperly stored equipment could slow down or even
                                                                                               prevent exit in a fire. Fires occur when you least expect, so keep passages
It is important to know your surroundings if a fire occurs. Do you know                        and exits clear at all times.
where these items are in your department?
•       Alarm pull stations                                                              Remember P.A.S.S. when operating a fire extinguisher
•       Extinguishers                                                                    P: Pull the pin on top of the extinguisher.
•       Fire Doors                                                                       A: Aim at the base of the fire.
•       Patient transportation equipment                                                 S: Squeeze the extinguisher trigger.
•       Exits                                                                            S: Sweep over the fire.
Can you close your eyes and picture where the alarms and extinguishers are in your
        work area? When you are done with this newsletter, the first thing you           •     Don’t try to put out a fire that is too big for you. Your time will be better
        should do is locate these items in or near your work area. Knowing where               spent alerting others. The fire extinguisher will only last for a few seconds,
        these items are in advance will help you act quickly and prevent the loss of           so remember to aim carefully. A sweeping motion will ensure that the base
        life and property.                                                                     of the fire is saturated.
When moving or evacuating patients in an extreme emergency, move people to a
        smoke-free area on the same floor. Move those closest to the fire first. Use
                                                                                         •                                                                                  14
                                                                                               In a fire, thing P.C.A.E. Familiar yourself with the written fire plan for your
                                                                                               department. For any questions contact Security or Environmental Health &
        the stairs to move down to a floor that is safe. Do no allow anyone to use the         Safety.
                              PC Facility Codes
               Emergency/Urgent--Dial: 2222

                        CODE ORANGE
                   Internal & External Disaster
                                                                           1.    Which Emergency Code indicates Hemorrhage Protocol?
                           CODE RED                                                 A.    Code Purple
                             Fire                                                   B.    Code Red
                                                                                    C.    Code P
                         CODE STORK                                                 D.    Code H
                 Infant Security Alarm Activation                                   E.    None of these above
                                                                           Correct answer: A
                   PATIENT CARE CODES
             AMBULATORY RESPONSE TEAM                                      2. Which of the following is the most appropriate way to initiate a code
 Persons requiring assistance in any area of the hospital/medical center         from the hospital?
       (hallways, elevators, cafeteria, lobbies, parking lot).                      A.      Dial 3333 and provide code
             Any injury or illness to a person in the                               B.      Dial 911, provide code and location
Medical Center who is conscious but NOT in a Code Blue situation.                   C.      Dial 2222, provide code type and exact location
                                                                                    D.      Dial 911 only
                          CODE BLUE                                                 E.      All of these above
              Adult/pediatric cardiopulmonary arrest                       Correct answer: C

                       CODE APGAR                                          3. Which Emergency Code indicates baby in distress during C Section
              Emergency C-section; baby in distress
                                                                                    A.     Code Blue
                          CODE PINK                                                 B.     Code Apgar
                Neonate in cardiopulmonary arrest                                   C.     Code ART
                                                                                    D.     Code Stark
                       CODE PURPLE
                      Hemorrhage Protocol                                           E.    None of these above
                                                                           Correct answer: B
                       How to Call a Code

                     To Initiate a Code from:

            Panorama City Medical Center (PCMC)
                       •      Dial 2222
          •     Provide the code type and exact location
         Medical Office Buildings (MOBs) with Paging
                       •       Dial 3333
                             Hazardous Communications
Many chemicals don’t pose a risk, but others can be harmful if handled improperly.     If a container has lost its label, and the liquid is clear and has no odor. If it’s
To reduce the risk of chemical illness and injuries caused by chemicals, the Hazard    unlabeled, assume it’s unsafe. Also, many hazardous chemicals have no smell,
Communication Standard has been developed by the Occupational Safety and               so never sniff anything on purpose.
Health Administration (OSHA). You have ―THE RIGHT TO KNOW‖ about the
hazards you are exposed to at work and a responsibility to use safe practices at all   Flammable is a physical hazard because it tells you that the chemical can be
times. Chemicals come in solid, liquid and gas form. When handled improperly,          ignited easily. Toxic is a health hazard, meaning it could cause sickness or
some chemicals can cause illness ranging from skin rashes to more serious health       even death. Explosive could cause physical harm from a rapid and violent
hazards. Other chemicals can cause physical hazards like fires or explosions.          expansion of gases. A sensitizer is a health hazard because it causes a large
                                                                                       portion of exposed people to develop an allergic reaction after repeated
The purpose of the Hazard Communication Standard is to provide information. You        exposure.
receive this information from labels and from Material Safety Data Sheets (MSDS).
Always read the label before and every time you use any chemical. The label and        An irritant is a health hazard because it causes a reversible
MSDS inform you about safe handling practices of the chemicals you work with.          inflammatory reaction at the site of contact. A carcinogen is a health hazard.
The Medical Center is required to have a written Hazardous Communication               Carcinogenic chemicals are those considered to cause or promote cancer.
Program. It should contain information on:                                             Compressed gas represents a physical hazard because if tanks are handled
       OSHA Standards                                                                 improperly, they could be propelled with enough force to blast through a wall.
       Safe procedures                                                                Corrosives are a health hazard because they erode things they touch and can
       List of hazardous chemicals                                                    cause damage at the site of contact. Corrosives are commonly found in
       Labels and MSDS forms                                                          cleaners and solutions, and in many pharmacy or laboratory products.
       Training procedures
       Steps to be taken in an emergency                                              Keep containers tightly closed when not in use and in their proper storage
Labels provide an immediate source of information and tell you whether or not          location. Don’t put yourself or co-workers in danger. Keep work areas clean
a chemical is hazardous through warning works like ―corrosive‖ or ―toxic.‖             and dispose of chemicals you no longer need using approved disposal
They communicate the chemical’s name, who made it, emergency phone                     procedures. You should not eat, drink, chew gum, apply make-up, etc. in areas
numbers, why it’s hazardous and how to protect yourself. Labels come in many           where hazardous substances are in use. Some chemicals will have long term
forms. A box on the label itself is sometimes used to represent levels of risk         or chronic effects. Others have immediate or acute effects like
for health, fire and reactivity with a numbers ranging from 0 (minimal hazard) to      nausea/vomiting, rash, headaches, and more.
4 (severe hazard). An additional box can tell you about special hazards. Study         If a hazardous substance splashes in your eyes, you should immediately rinse
it carefully.                                                                          with water for 15 minutes and then seek medical attention. Your eyesight is
                                                                                       priceless. Remember, if you think you could get splashed, wear the appropriate
A Material Safety Data Sheet or MSDS is an important source of current and             personal protective equipment.
reliable information on hazardous materials. It contains more complete
information than a label. Manufacturers supply MSDS to the Medical Center.             For a hazardous spill, take quick action with the appropriate spill kit and
Although they can differ in format, they all must provide the same information.        communicate the occurrence to your supervisor. Don’t let untrained employees
If you don’t know where MSDS forms or the written Hazardous Communication              clean up a spill for a chemical they have not received training on.
Program are in your work area, check with your supervisor. They should be                                                                                                    16
readily available to you on your shift.
                                   Hazardous Communications
NFPA label
Red = Fire Hazard (Flammable chemicals such as gasoline, oxygen, etc.)                  Section VI – Health Hazard Data
Blue = Health Hazards (Carcinogens and similar dangers to health.)                      Chemicals can enter your body through breathing, skin contact, or
Yellow = Reactivity Hazard (Radioactive dyes and other substances.)                     swallowing. Section VI tells you how you could get exposed, what
White = Other Hazards (Poisons, corrosive materials, explosives, etc.)                  effects to expect if you are exposed, and what to do about it.
                                                                                        Remember, it’s important to know what to do in an emergency before
Reactivity tells you that the substance reacts violently with water or can              you get into the emergency.
explode at higher temperatures.
                                                                                        Section VII – Precautions for Safe Handling and Use
Use the following information to help you become familiar with the MSDS                 Section VII gives you vital information on handling and use. Here you will find out
(Material Safety Date Sheet). This standard form with 8 sections has been               exactly how to handle a spill, the method of waste disposal, and any special
developed by the Department of Labor:                                                   precautions you need to take.

Section I The Basics                                                                    Section VIII – Control Measures
Section I contains the basics. It tells the name of the product or chemical, who made   Section VIII details how to prevent exposure through the use of protective clothing.
it, and what phone number to call for technical information or emergencies.             These include face shields, respirators, gowns/suits, gloves and boots.

                                                                                        Remember, Safety First
Section II – Hazardous Ingredients/Identity Information
                                                                                        Most accidents occur when you’re in a hurry. Even if it’s inconvenient, your safety
Section II tells you the chemical and brand names of the components of a substance
                                                                                        is important. Read the MSDS. Protective clothing can be uncomfortable and hard to
unless it is a trade secret. Assume a substance is as dangerous as its most
                                                                                        work in when you’re not used to it, but wear it anyway. It’s more comfortable than
hazardous component.
                                                                                        getting injured. Looks can be deceiving. If you don’t know what the substance is,
                                                                                        assume it’s unsafe. Some chemicals cannot be recognized as hazardous by their
Section III – Physical/Chemical Characteristics
                                                                                        look or smell.
Section III describes physical characteristics of the substance including boiling and
melting points, evaporation rate, solubility and normal appearance and odor.
                                                                                        Check with Environmental Health & Safety to find out how detection and the
Chemicals can change with age, evaporation, and temperature. Beware! Changes
                                                                                        release of these gases are monitored, if needed, in your work environment. Read the
could indicate trouble.
                                                                                        label and MSDS before using a chemical.
Section IV – Fire and Explosion Data
                                                                                        Remember, when in doubt about a substance’s use or handling, ask your
Section IV explains fire and explosion hazards, and can help you understand the
                                                                                        supervisor or Environmental Health & Safety.
physical risks you face when working with a substance. The flashpoint tells you
when to worry about flammable vapors. The lower the flashpoint, the more
dangerous the substance.

Section V – Reactivity Data
Section V tells you how reactive or unstable a substance is, and what conditions to                                                                                     17
avoid. Remember, never mix chemicals unless trained to do so because some
mixtures could produce hazardous gases or worse.
                                                         Electrical Safety
                                                                                        Never try to fix an item yourself. Always allow the experts in the
Medical Center employees need to think and act when they see electrical
                                                                                        Biomedical Engineering to service electrical repairs.
hazards. Everyone needs to keep the workplace safe from electrical hazards.
Report all accidents and equipment problems immediately.
                                                                                        Either the ABC or CO2 extinguishers can be used on electrical
Hospital Grade Plugs and Cords must be used where there are patients. These
plugs have three prongs and a green dot. Both the plug and the cord are heavy duty.
                                                                                        There are three steps to take when you find an electrical hazard.
The three prong plug grounds the electrical current through the third prong. The
                                                                                        1.) Turn off the device and unplug it, if possible;
heavy duty cord and plug are not as easily damaged as ordinary plugs. The hospital
                                                                                        2.) Call Biomedical Engineering to report the hazard;
grade cords and plugs provide additional protection from short circuits and
                                                                                        3.) Remove the item from the patient area, if possible; If the
electrical current leakage. Hospital grade outlets provide stronger prong tension
                                                                                            item is small, then take it to Biomedical Engineering.
which secures the plug more firmly in the socket. NEVER USE ADAPTER (or
                                                                                           Otherwise, label it and write the details to the problem on the
―CHEATER‖) PLUGS. The hospital maintains documentation that its electrical
                                                                                           service request.
Equipment is safe. But you should also check for hazards every time you use
electrical equipment.
Biomedical Engineering inspects the Medical Center’s medical equipment. Be
sure to check that the item has been inspected by looking for the inspection sticker
or tag. As long as the equipment is not outside the inspection period, it is fine to
use. A visual inspection for loose parts and cracks in the plastic should be made
each time you use an outlet. Likewise, outlets should be tested each time you use a
plug to make sure that the plug stays securely in place. Cables, especially on
movable equipment, need to be checked for wires that have become exposed and
insulation that has become frayed. You should always unplug a cable or cord by the
plug, never yanking it by the cord. You should always coil your cords to avoid
kinking and damage.
Electricity travels through water easily and can give you a shock if you touch
an electrical machine at the same time that you touch water. You should never run
                                                                                        After de-energization of certain pieces of large-scale equipment requiring
over a cord or the plug with a rolling cart. DO NOT USE EXTENSION CORDS.
                                                                                        lockout/tagout procedures, locks and tags need to be applied to all disconnecting
If there arises the need for one, contact the Biomedical Engineering for assistance .
                                                                                        devices to ensure circuits cannot be re-energized. Engineering Services has operating
Patient electrical equipment is maintained by two departments:
                                                                                        procedures regarding where locks and tags are located, who is authorized to place and
Biomedical Engineering
                                                                                        remove them, and under what circumstances locks and/or tags need to be used.
-       Responsible for all patient care equipment external to the wall, removable
        and electronic.
Engineering Services                                                                    Remember the warning signs of dangerous electrical equipment:
-       Responsible for all electrical equipment and wiring within the wall and all     SPARKS
        non-patient care equipment.                                                     STRANGE SMELS OR SOUNDS
Problems with electrical equipment should be reported to the appropriate                OUT OF INSPECTION PERIOD
department, and an appropriate work order completed.                                    DROPPED OR DAMAGED
                                                                                        Remember to always check the manufacturers’ policies for                        18
                                                                                        additional equipment safety features.
                                      LMP Workplace Safety
Kaiser Permanente and the Coalition of Kaiser Permanente Unions believe that
an injury –free workplace is the goal and responsibility of every physician,
                                                                                         Safety Observation Process
manager and employee, and an essential ingredient of high-quality, affordable
                                                                                              Must have 2 components to complete the process:
patient care. Working in Partnership, we are establishing the health care
industry standard by setting the goal of eliminating all causes of work-related
injuries and illnesses, so as to create a workplace free of injuries.                                                                           Observation
                                                                                          Observation               Discussion

                                                                                                        +                              =
Our goal is to eliminate workplace injuries throughout Kaiser
•     Foster a Culture of Safety by engaging all staff
•     Reduce workplace injuries
•     Involve employee safety in Operations                                                                 NO DISCUSSION = NO OBSERVATION!
•     Discuss Safety issues at department staff meetings

What Role can you play in Workplace Safety (CWPSS)?                                            The Benefits of Safety Observations
      Be accountable for your personal safety                                                  1.   Prevents injuries
•     Help keep your co-workers safe                                                           2.   Involves Everyone in identifying both Safe and
•     Work Safely at all times                                                                      At-Risk
•     Report all safety hazards and incidents immediately                                      3.   Sets forth the expectation that we all work safely
•     Follow all safety rules and safety procedures                                            4.   Increases ownership of safety which is felt
•     Encourage safety awareness, work safely and injury prevention                                 among all employees, managers, and physicians
                                                                                               5.   Reveals System Failure
Safety Observations and Incident Investigations are the keys to reducing injuries
       in the workplace environment. Safety Observations are a fundamental           AT-RISK ACT                       SAFE ACT
       component in creating a culture of safety.

Why Safety Observations?
•    Focuses on preventing injuries by observing employees working in their
     normal environments
•    Are Proactive instead of reactive
•    Assumes employees will change their behaviors as a result of a verbal
•    Serves to heighten the general awareness of safety as an expectation
•    Identifies risks in both actions and conditions
•    Above all, gives managers and staff an opportunity to focus on doing work

                                              LMP Workplace Safety
Incident Investigations
The purpose is to establish and maintain an effective workplace safety
incident investigation process in a way that ensures methodical
examination, determination of facts and key contributing factors, and                 1.        Kaiser Permanente and the Coalition of Kaiser Permanente Unions
appropriate measures to prevent recurrence of incidents.                                        believe that an injury –free workplace is the goal and responsibility of
                                                                                                every physician, manager and employee, and an essential ingredient of
                                                                                                high-quality, affordable patient care.
The Incident Investigation process contains 10-Steps:
1.    Employee is injured and immediately notifies their Supervisor/Manager
2.     Manager Reports the Incident within 24 hours
                                                                                      Correct answer: True
3.    An investigation team is formed
4.    Determine the facts
                                                                                      2.        Our goal at Kaiser Permanente is to eliminate workplace injuries. What
5.    Determine the key factors                                                                 and how can you contribute?
6.    Determine systems to be strengthened                                                      A. Discuss Safety Issues at dept staff meetings
7.    Recommend an Action Plan to prevent recurrence                                            B. Be accountable for your personal safety
8.    Document findings within 7 days                                                           C. Report all Safety Hazards and incidents immediately
9.    Communicate findings                                                                      D. Think ―Safety Begins With Me!‖
10.   Follow-up and close action plan                                                           E. All the Above
                                                                                      Correct answer: E
If your Injured at Work, What should you do?
      Report it to your Supervisor, Manager, or floor Supervisor right away and      3.        The ultimate purpose of the incident investigation is to find the root
       seek Medical Attention.                                                                  cause and recommend an action plan to prevent recurrence.
      You will also receive a Division of Workers Compensation Claim Form                      True
       (DWC-1) within 24 hrs.
      For Needle Sticks and First Aid, visit Employee Health, located North 3,
       lower level (818) 375-3744.                                                    Correct answer: True
      For other work related injuries, visit Occupational Health, located North 2,
       (818) 375-3767                                                                 4.        When an injury occurs the employee reports injury to the manager
      After Hours & Weekends, visit Urgent Care or the Emergency Room.                         immediately. The Manager reports the incident within 24 Hours and the
       Please inform the receptionist you are seeking care because of a workplace               document findings from the Incident Investigation are conducted within
       injury.                                                                                  7 days.
REMEMBER:                                                                                       False
If there is any hospitalization or fatality, your manager needs to report the         Correct Answer: True
Injury immediately within 8 hours to the EH&S Manager. If it is not reported
within the specified time, there could be a Cal-OSHA fine of $7,000 that will         5.        How much is the fine for not reporting injured workers who are
be charged to the department.
                                                                                               A.       $100
                                                                                               B.       $7,000
                                                                                               C.       $1,000
                                                                                      Correct answer: $7,000
                                       2010 Joint Commission
                                   National Patient Safety Goals
Patient Safety Goal #1: Improve the accuracy of patient identification
•      Use at least two patient identifiers when providing care, treatment or services.
•      Prior to the start of any invasive procedure, conduct a final verification process (such as
       a ―time out‖) to confirm the correct patient, procedure, site, using active – not passive –
       communication techniques.
•      Label containers used for blood and other specimens in the presence of the patient.

Patient Safety Goal #2 : Improve the effectiveness of communication among caregivers.
•      For verbal or telephone orders or for telephonic reporting of critical test results, verify
       the complete order or test result by having the person receiving the information record
       and ―read back‖ the complete order or test result.
•      Measure, assess, and if appropriate, take action to improve the timeliness of reporting,
       and the timeliness of receipt by the responsible licensed caregiver, of critical tests and
       critical results and values.
•      Standardize a list of abbreviations, acronyms, symbols, and dose designations that are
       not to be used throughout the organization.
•      Implement a standardized approach to ―hand-off‖ communications, including an
       opportunity to ask and respond to questions.

―REMEMBER‖: When reading back a number, sound out each number such as ―one, five‖ (15)
     not fifteen, or ―five, zero‖ (50) not fifty when reading back orders.

Patient Safety Goal #3: Improve the Safety of using medications.
•      Label all medications, medication containers (for example, syringes, medicine cups,
       basins), or other solutions on and off the sterile field.
•      Reduce the likelihood of patient harm associated with the use of anticoagulation
•      Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used
       by the organization, and take action to prevent errors involving the interchange of these

Patient Safety Goal #7 : Reduce the risk of health-care associated infections
      Comply with current World Health Organization (WHO) Hand Hygiene Guidelines or
       Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
      Manage as sentinel events all identified cases of unanticipated death or major
       permanent loss of function associated with a heath care-associated infection.
      Wash your hands for a least 15 seconds.
                                         2010 Joint Commission
                                     National Patient Safety Goals
Patient Safety Goal #8: Accurately and completely reconcile medications
       across the continuum of care
•      There is a process for comparing the patient’s current medications with         1.      How do we know that we have the correct patient?
       those ordered for the patient while under the care of the organization.
•      A complete list of the patient’s medications is communicated to the next        Correct answer: Check their ID band and ask the patient to state his or her
       provider of service when a patient is admitted, referred or transferred to                       name.
       another setting, service, practitioner or level of care within or outside the
       organization. The complete list of continued medications is also provided to    2.      What two identifiers are used when administering medications or
       the patient on discharge from the facility.                                            taking/giving blood?
                                                                                       Correct answer: The patient’s Name and MRN on the order form and ID band
Patient Safety Goal #9: Reduce the risk of patient harm resulting from falls.
•      Implement a fall reduction program including an evaluation of the               3.      What is the process for taking verbal or telephone orders and critical
       effectiveness of the program.                                                          test results that requires verification?
                                                                                       Correct answer: Write the order out in its entirety “read” it back and wait for
Patient Safety Goal #15: The organization identifies safety risks inherent in its                       confirmation from the person giving the order/critical test
•      The organization identifies patients at risk for suicide. [applicable to
       psychiatric hospitals and patients being treated for emotional or behavioral
       disorders in general hospitals]                                                 4.      When does labeling of medication need to happen?
•      The organization identifies risks associated with long-term oxygen therapy      Correct answer: Anytime you do not have continuous contact with the medication.
       such as home fires.
                                                                                       5.     What are two easy and most effective ways to prevent the spread of
Universal Protocol (UP1)                                                                      infection?
•     The organization fulfills the expectations set forth in the Universal Protocol   Correct answer: By washing your hands and if you take care of patients, by
      for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery and                    removing artificial nails.
      associated implementation guidelines.
•     Conduct a preoperative verification process, as described in the Universal       6.      When is medication reconciliation initiated?
      Protocol.                                                                        Correct answer: On admission
•     Mark the operative site as described in the Universal Protocol.
•     Conduct a “time out” immediately before starting the procedure as described      7.     When a patient with suicidal ideation is admitted, what is completed on
      in the Universal Protocol.                                                              admission?
                                                                                       Correct answer: Safety Screening Checklist for Patients at Risk for Suicide, located
                                                                                              in DMS Policy/Procedure 1745.

Kaiser Permanente Patient Safety Themes:                                               8.     Before starting a procedure, what 3 elements should you double check
                                                                                              to make sure that they are correct?
                                                                                       Correct answer: Patient (name, MRN), site, and procedure.
    Safe Culture, Safe Care, Safe Staff, Safe Support Systems
                    Safe Place, Safe Patients
                                                              Security & Threat
At Kaiser Permanente, we want to ensure a safe environment for all employees,
physicians, members, students, volunteers’ contractors and visitors in which
to ensure the best care possible. Kaiser Permanente will not tolerate Acts
and/or threats of violence.

Acts and/or threats of violence include physical assaults and actions or             1.        Which of the following are examples of skills and techniques for de-
statements which, either directly or indirectly, by words, gestures, symbols,                  escalation?
intimidation, or coercion give reasonable cause to believe that the
personal safety of the affected individual or others may be at risk. Intimidation             A.   Stay professional and in control
includes behavior, which has the purpose or effect of inspiring fear in a
                                                                                              B.   Remain non-threatening
reasonable person. All physicians and employees are obligated to report any
incident where they believe they have been the subject of threatened violence                 C.   Provide choices and consequences
arising out of their relationship with Kaiser or if they observe or otherwise                 D.   All of the above
learn of such conduct by any person employed by Kaiser, using Kaiser                          E.   None of these above
services or on Kaiser premises.                                                      Correct answer: D
Reports can be made to any of the following:
Department Manager/Supervisor
Human Resources                                                                      2.        All Physicians and employees are obligated to report any incident of
Security                                                                                       threatened violence

Any employee or physician who is reporting acts and/or threats of violence                     True
must fill out the Threat Management Form. No retaliation of any kind will be
taken against anyone who, in good faith, reports acts or threats of violence, or
who participates in any action or investigation related to such                      Correct answer: True
       Skills and Techniques for De-escalation:
      Acknowledge your own physical responses – try not to let them overwhelm
       or distract you.
      Stay professional and in control of yourself – remain calm.
      Remain non-threatening – verbally and physically.
      Listen carefully and empathetically for clues to the conflict – try to
       understand how the other person feels.
      Neutralize language to lower the emotional levels – try to restate
       accusations, blame and insults so they are more neutral statements of
       behavior that can be addressed.
      Don’t respond to manipulative or threatening behavior – focus on ending the
      Provide choices and consequences you can enforce – clear choices, clearly                                                                               23
       understood consequences.
For more information, talk to your department manager, or contact the
Security Department.
                                             Radiation Safety
                                                                                    Radiation Protection Concepts:
Ionizing Radiation:
                                                                                    The ALARA acronym is ―As Low As Reasonably Achievable.‖ This program is in
Defined: Energy and/or energetic particles that are emitted from
                                                                                               place to reduce the risk of the possible harmful effects of radiation.
radioactive atoms and/or x-ray machines that can ionize tissue.
                                                                                               Every effort is made to keep the exposure levels well below federal and
                                                                                               state limits.
This ionizing radiation, if absorbed, may cause damage to tissue.
Radiation to humans is measured in dose units traditionally called ―rem.‖ The new   Time –If you decrease the amount of time you spend near the source of
Standard International (SI) term is ―sievert‖ (Sv).                                            radiation, you will decrease the amount of radiation exposure you
Sources of Ionizing Radiation:                                                      Distance –The farther away you are from a radiation source, the less exposure
Natural Sources of Ionizing Radiation:                                                         you will receive.
Approximately 80% of human exposure to radiation comes from natural                 Shielding –If you use shielding (gloves, aprons, lead barriers) correctly you will
sources: radon gas, the human body, outer space, rocks and soil. An                            decrease your exposure.
average American is naturally exposed to 300 mrem/year or 3 mSv/year .              Dosimeters: If you are required to wear a radiation monitoring device (badge) do
                                                                                               not take them home, leave them in your car, put them in the wash, share
Man-Made Sources of Ionizing Radiation                                                         them, or leave them near the source of radiation. Turn them in for
About 20% of human exposure to radiation comes from man-made                                   monitoring in a timely fashion.
sources. Approximately 15% of this man-made radiation comes from
medical imaging.
                                                                                    Recognition –
                                                                                    Radiation sources are marked by the International Radiation Hazard Symbol; a
Classification of Hospital Workers:
                                                                                    magenta trefoil on a bright yellow background.
Non-Radiation Workers:
These are hospital workers who do not work with radiation as part of their daily    Did you know…..?
activities. (Example: receptionist, transporters, and EVS staff.) Non-radiation     There are sites to help you calculate your annual dose. One example is:
workers are limited to 100mrem/year (1 mSv).                               yourraddose.htm

Radiation Workers:                                                                   Barium used in medical imaging is not radioactive.
People who work with or near radioactive materials or radiation producing            In X-ray the machines generate the source of radiation. In Nuclear Medicine,
machines and equipment. State and Federal exposure level for a radiation            the radioactive isotopes are the source of radiation, not the
worker is 5000 mrem/year (50mSv), or 5 rem Effective Dose Equivalent.               machine. In medical imaging, at a six-foot distance from the radiation source, the
Kaiser’s level in 1000 mrem/year and 150 mrem per month.                            radiation reading is substantially reduced. This is why the cord on the portable
Sources of Ionizing Radiation from Medical Imaging Include:                         x-ray machine will stretch to six feet.
X-ray producing equipment found in departments such as radiology,
orthopedics, surgery, ER, and mammography; from x-ray producing                     Only someone who is properly certified by the state may activate a x-ray
equipment, such as portable x-ray machines and c-arm fluoroscopy units, and         machine or work with radioactive items.
from Diagnostic Radionuclides (radioisotopes) usually found in the Nuclear          Not all lead aprons are made out of lead. To make them lighter they are made    24
Medicine Department.                                                                out of a lead equivalent.
                                                                                    Remember: You will not glow after an x-ray.
                                           Radiation Safety
Tips To Avoid Contamination from Radioactive Material
      Wear gloves
      Avoid contact with objects or areas that may be contaminated
                                                                                    1.    The average American is exposed to how much ionizing radiation
      Don’t eat, drink, or smoke in areas where radioactive materials are in use
                                                                                          from natural sources?
      Don’t apply cosmetics or groom your hair while in the area
      Wash your hands when leaving the area                                             A.      100 mrem/year
      Read and follow all signs and instructions                                        B.      200 mrem/year
      Don’t handle radioactive materials unless you are trained to do so                C.      300 mrem/year

                                                                                    2.    Non-radiation hospital workers have an ionizing radiation exposure
                                                                                          limit of                                    ?
                                                                                         A.        100 mrem/year
                                                                                         B.        200 mrem/year
                                                                                         C.        300 mrem/year

                                                               Quality Improvement
Quality is a central priority for Kaiser Permanente. As a quality health care
       organization, we strive to ensure that our members will remain healthy and
       safe and that our processional staff and employees will continue to support
       our goal of quality improvement to better patient outcomes. Improving
       quality improves our organization performance.
                                                                                     1.   How do know we are performing well or need to
All employees are involved in quality improvement. Improvement measure are
       linked to the organization’s strategic goals, hospital or department goals.
       As an employee you participate in the work processes of this Medical          Correct answer: Performance data.
       Center and lead or participate in improvement processes.

In health care, quality is the delivery of outstanding patient care that includes:   2.   Where do performance goals and measures come from?
      Patient safety
      Identifying process which can be improved                                     Correct answer: National Patient Safety Goals, National
      Clinical outcomes                                                                             performance benchmarks, Regional
      Patient satisfaction                                                                          Comparative data and Unit-Based Goal setting

Quality means doing the right thing the first time. Examples of high quality of      3.   What 3 questions should you ask before starting
       care:                                                                              performance improvement project.
      Patient focused/centered
      Correct level of care                                                         Correct answer
      Correct diagnostic procedures                                                 1.    What you trying to accomplish?
      Correct medications                                                           2.    What change can we make that will lead to improvement?
      Correct site surgery                                                          3.    How will we know the change was an improvement
      Relieving pain by assessment.. right medication, right dose, right time and
       right route

Plan-Do-Check (Study)-Act = PDCA/PDSA is our improvement methodology

                    1.    Identify outputs and customers and
                          their expectations.
                    2.    Describe current process.
                    3.    Measure and analyze.
                    4.    Focus on an improvement
                    5.    Identify root causes.
                    6.    Generate and choose solutions.

             Do     7.    Map out a trial run.
                    8.    Implement the trial run.

                    9.    Evaluate the results.
          Check     10.   Draw conclusions.

                    11.   Standardize the charge.
                    12.   Monitor, hold the gains.
                                                               Infection Control

Standard Precautions are routine precautions designed for the care of all patients
regardless of their diagnosis or presumed infection status.
The precautions are designed to reduce the risk of transmission of organisms from
both recognized and unrecognized sources of infection.

Based on the anticipated contact with the patient’s blood and body substances, non-
intact skin such as rashes and mucous membranes (eyes, nose, mouth) personal
protective equipment (PPE) is worn. Each department has a supply of the PPE
required for both Standard and Transmission Based Precautions. Ask your
Department Administrator if you do not know where these are kept.

Gloves for any anticipated contact with blood, body fluids, non-intact skin or rashes.
Hand Hygiene after removal of gloves.
      Gloves must be worn when your hands have any open areas, cuts, or abrasions
      If the glove is torn or punctured, remove the glove, wash hands immediately, and put on a new
       glove as promptly as patient safety permits.
      Gloves must be changed after completing procedures in different body areas, after contact with
       each patient or when contaminated.
Mask and Eye Protection for any anticipated splash or spray of blood or body fluids to prevent exposure
       of mucous membranes of the mouth, nose and eyes.
      Reusable eyewear or face shields should be cleaned with appropriate disinfectant per
       manufacturers’ recommendation.
      Protective eyewear includes goggles, full face shields, mask with shields or glasses solid side
      Long sleeve impervious gowns for any anticipated contact of clothing with blood or body fluids

Eating and Drinking in the Work Area
To avoid cross-contamination in the work area, OSHA regulations do not allow eating, drinking,
application of cosmetics, lip balm or handling contact lenses in patient areas, where the possibility of
       contamination exists.

Transmission Based Precautions:
In addition to Standard precautions, Transmission Based Precautions are used for patients known or
suspected to be infected by epidemiologically important organisms spread by the:
       Airborne Transmission
       Droplet Transmission or,
       Contact with skin or contaminated surfaces
                                                              Infection Control

These are used in addition to Standard Precautions:
Airborne Precautions includes diseases such as Tuberculosis, SARS, Chickenpox,
       and Measles. The N95 respirator is used for Tuberculosis, SARS and other          1.     What is the single most important way of stopping the spread of
       significant but rare diseases such as many of the Bioterrorism agents. A Blue
       Airborne sign that lists the necessary PPE is used for this precaution.                  MRSA that a person can do?
                                                                                                 A.    Wash hands or use alcohol foam
Droplet Precautions includes diseases transmitted via large particles which require
       close contact usually 3ft or less. These diseases include Pertussis, Mumps,               B.    Eat more vegetables
       Meningococcal disease and Plague. A surgical mask is worn when within 3                   C.    Exercise frequently
       feet from the patient to prevent exposures. An Orange Droplet sign that lists
       the necessary PPE is used for this precaution.                                    Correct answer-A
Contact Precautions reduces transmission by direct or indirect contact. Direct contact
       transmission involves skin to skin contact and indirect transmission is to
       contact via a contaminated item in the patient’s environment. Gowns and
       gloves are worn every time upon entering the room of a patient on Contact         2.     What other ways is there to protect the patients and staff from the
       Precautions. MRSA, VRE, Scabies, Lice, RSV are included in this category.                spread of infection besides Standard Precautions?
       A Green Contact sign has been developed that includes all the necessary PPE is
       used for this precaution.                                                                 A.    Take a bath
                                                                                                 B.    Use transmission based precautions
Precautions for Creutzfeldt-Jacob Disease (CJD)                                                  C.    Eat more vegetables
In addition to Standard Precautions, follow the CJD policy on DMS for Infect Control
and care of the patient with suspected or confirmed CJD.                                 Correct answer B

What do I need to know about Multi-drug resistant organisms (MDRO) like
methacillin resistant staphylococcus aureus MRSA?
One of the germs that commonly live on the skin and in the nose is called
staphylococcus or ―staph‖ bacteria. Usually this germ causes no harm. However
sometimes it enters the body through a break in the skin or contact with mucous
membranes like the nose, mouth and eyes and causes infection. When staph cannot be
killed by common antibiotics this means that the bacteria has developed resistance to
those antibiotics and is called MRSA.
MRSA is spread by contact with body secretions, skin to skin contact and contact with
the environment if contaminated with MRSA. Anyone can get MRSA as it is found in
the community and in healthcare facilities.
There are two ways that you can have MRSA bacteria. You can have active infection
with clinical symptoms or you can be colonized (also known as carrier) with out any
To prevent problems of spread of MRSA the most important thing to remember is to
wash your hands with soap and water for 15 seconds or used alcohol foam for
hand hygiene. Cleaning of equipment and not sharing equipment between patients,                                                                                       28
use of transmission based precautions that include PPE is also needed to stop the
spread of MRSA and other resistant organisms.
                                              Airborne Transmissible
California has adopted this protective standard to control occupational exposure to
Aerosol Transmissible diseases (ATD) this standard applies to hospitals, clinics,
laboratories, home health care, emergency services, homeless shelters, drug
treatment programs, police departments and prisons.

What information does the ATD Plan provide?
The ATD Plan explains to the employer and healthcare worker responsibilities in
preventing aerosol transmissible diseases .It presents information regarding:
       TB transmission, symptoms and risk factors
       TB disease versus TB infection
       TB screening and Prevention
       Other organisms requiring aerosol transmission precautions
       Other organisms requiring droplet transmission precautions
       Reporting requirements
       Use of N95 respirator masks and requirements for fit-testing
Airborne isolation for patients with known TB or suspected aerosol transmissible
Disease. Discharge process for a patient with known or suspected TB or other aerosol
transmissible disease of concern.

What key information about Tuberculosis should I know?
Tuberculosis (TB) is an infectious and potentially life-threatening bacterial infection
caused by Mycobacterium Tuberculosis. We commonly think of TB as a respiratory
illness, but it can involve many organs or tissues.
TB is very contagious. It is spread primarily when people with active lung disease
expel bacteria from their lungs into the air through coughing, singing, talking or
sneezing. Other people breathe the infectious droplets into their lungs, where the
bacteria begin to multiply and spread. Most people can be cured by taking a
combination of antibiotics. Stopping medicines early or taking them only occasionally
sets the stage for drug-resistant bacteria to develop.

TB is a major concern for the health of the general public. The law requires that
persons with active TB disease be reported to the Department of Health. The
Department of Health assures thorough and complete treatment of infected and
diseased TB patients and evaluates other close contacts for TB. Children less than 5
years of age, the elderly and people whose immune systems are suppressed (e.g.,
HIV, cancer or diabetes) are high-risk populations.

                                                                                              For Patients with Known or Suspected TB
TB skin tests, chest x-rays and examinations of TB sputum cultures are used to see if an      Patients admitted to the hospital are placed in a negative pressure room with the
active TB infection exists. Understanding the difference between TB infection and TB                 ventilation to the outside. The “Airborne” signage provides instructions for
disease is important. TB Infection: TB infection (“latent,” “non-contagious”) means the              visitors and healthcare workers. These rooms are entered by all through the
person was exposed to and infected by the TB germs. This is usually detected by a                    anteroom not the hallway entrance The negative pressure room must be
                                                                                                     monitored with results recorded daily while in use. If the patient must leave
positive skin test, without the presence of signs and symptoms of TB.                                his/her room for treatments or procedures, provide standard
TB Disease: TB disease (“active,” “contagious”) means that the germs have multiplied                 procedure/surgical masks to the patient, with instructions to wear it over the
and invaded organs and tissue, producing signs and symptoms of TB. At this point the                 nose and mouth.
disease can be spread to others.                                                              Are there any special considerations in discharging a patient with known or
Symptoms of TB Disease: Cough, Night sweats, Bloody sputum, Fever, Unexplained                suspected TB?
weight loss, Chills, Loss of appetite and/or Fatigue.                                         Before a patient with known or suspected active TB can be released (discharged or
People at Risk include:                                                                              transferred), an approval from the Department of Health Service — TB
                                                                                                     Control for the county or city in which the member resides, must be obtained.
Immune compromised persons                                                                           This is to ensure the patient will not expose others in the community.
Immigrants from countries where TB is common                                                  The discharge planner, infection preventionist, and the physician will work together to
Medically under-served persons who don’t receive needed medical care                                 ensure TB Control has approved the patient’s release before discharge.
Persons in crowded living conditions (prisons, shelters for the homeless, nursing homes)
Health care workers                                                                           Where can I find a copy of the Blood borne Pathogen Standard Policy?
What type of screening is done for Tuberculosis?                                              This Plan can be obtained on request from your Supervisor, Infection
TB screening is done at least once a year by questionnaire to determine if a healthcare       Prevention, Employee Health, and is available on the Kaiser Intranet
        worker has symptoms of disease. Compliance with this policy is a condition of         Documentation Management System (DMS).
        employment at Kaiser Permanente.
In addition to the questionnaire, a Tuberculin skin test (TST) is administered to
        healthcare workers who have not had a positive skin reaction to the test in the       What information does the Blood borne Pathogen Standard Policy provide?
        past. The skin test must be read at 48-72 hours after the test is administered.       The facility’s Blood borne Pathogen Exposure Plan explains the employer and
Infected healthcare workers are offered treatment at no expense. If you think you have        healthcare worker responsibilities in preventing exposure to
        been exposed to a person with active TB disease, notify your chief/supervisor         organisms/pathogens that are transmitted by blood or other potentially
        and Employee Health Department.                                                       infectious materials (OPIM). It includes information on:
What is my role in preventing the spread of TB?                                               Types   of Blood borne Pathogens Transmission risks
For Healthcare Worker:                                                                        •       Exposure prevention
Complete scheduled health screening through Employee Health Services                          •       Work Practice Controls
Report TB exposures to your Employee Health Department and Infection Prevention.              •       Engineering Controls
Follow-up when referred for preventive therapy: you are responsible for taking                •       Exposure and Post-Exposure treatment
         medication as ordered and obtaining lab work and /or chest x-rays, as
         prescribed. Do not stop your therapy without the direction of your provider.         •       Use of Personal Protective Equipment (PPE)
Be fit tested with special masks know as N95 respirators if you are a staff member            •       Reporting requirements
         whose duties make TB exposure likely. Protect yourself by using an N-95
         respirator. A proper fit of the TB mask is necessary to ensure all the air inhaled
         by the user is filtered. Each time the mask is worn, the proper fit is assured
         through fit checking by the user.

                                                   Blood borne Pathogens
What is a Blood borne Pathogen?
A blood borne pathogen is an organism that is transmitted by direct contact with
blood and/or body substances. These organisms are also transmitted sexually
and through IV drug use. They include:                                                         1.         Besides blood name 2 other body fluids that are considered other
                                                                                                          potentially infectious material (OPIM) (choose 2)
•       Hepatitis B: This viral disease is vaccine preventable. Vaccination is available
        through Employee Health at no cost to the healthcare worker, and is strongly
        recommended.                                                                           Possible correct answers:
•       Hepatitis C: This viral disease does not currently have a vaccine available.                              Fluid from around the heart
•       Human Immunodeficiency Virus (HIV): This viral disease does not currently                                 Joints
        have a vaccine available.                                                                                 Lung
What key information should I know about Blood borne Pathogens?                                                   Amniotic
Although unprotected exposure to blood is a key factor in the risk of developing                                  Semen
        infection from a blood borne pathogen, Other Potentially Infectious Materials                             Vaginal secretions
        (OPIM) is also considered to present a risk. OPIM include fluids from around
        the heart, lungs, joint, and spine, amniotic fluid from around the baby before
        and during birth, and semen or vaginal secretions.                                     2.         TB is caused from bacteria
The BBP Exposure Plan provides specific job classifications, tasks, and procedures in
        which healthcare workers are at risk for occupational exposures, with                              A. Mycobacterium Tuberculosis
        recommendation for prevention of exposure.                                                         B. Avian Flu
If exposure to a BBP occurs, such as a contaminated sharps injury or a body fluid                          C. Streptococcus
        splash to mucous membranes or non-intact skin, it is important that you cleanse
        the exposure area immediately, report it to your supervisor and seek medical           Correct answer A
        evaluation through Employee Health or if after business hours, through the
        Emergency Department. PROMPT REPORTING OF AN EXPOSURE IS
All lab specimens and linens are treated as contaminated with blood or OPIM, and
are handled using Standard Precautions.
Any article contaminated with blood or OPIM is to be discarded into the Biohazardous
        Waste, which is identified by the biohazard symbol as seen below. Articles
        with small amounts of blood or OPIM that is not in danger of dripping or
        flaking may be discarded into the regular trash stream, such as band aids or
        small dressings. Needles and other sharps must be discarded into a rigid
        container designed to hold these objects.                                          For any questions about Airborne transmissible diseases, TB or Blood borne
                                                                                           pathogens information provided in this document you may contact Employee
What has been done here at Panorama City to help prevent BBP exposure?                     Health Department Staff (Mafi or Anita) at 818 375 3744 or Infection
Work Practice Controls, designed to reduce the likelihood of exposure by altering the      Prevention Department at 818 375 3658 (Mellina) and 818 375 2010 (Leslie)
      manner in which a task is performed, are an integral part of our BBP Exposure
      Control Plan. Examples include: activating sharps safety devices, use of PPE
      while cleaning used instruments, wearing gloves when emptying Foley
      catheters, prohibiting recapping of needles except when absolutely necessary
      and then by employing a single hand technique only, use of resuscitation bags
      and other ventilation devices in emergency situations, spill kits to contain

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