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Presentation on theme: "ANNUAL REVIEW ONLINE Welcome."— Presentation transcript:


2 Print out all forms: Complete front and back
Test Compliance and Confidentiality Form TB Health Assessment Form


4 SAFETY KDMC Safety Officer: Clyde Sbravati
MSDS SHEET: Material Safety Data Sheet: This information is now available via phone. Information will be read for you or they will FAX the information to you.

Where product come from. Composition and information on the ingredients. Physical data. Boiling point Appearance Potential health effects Emergency and first aid measures. Fire fighting measures and procedures. Handling and storage of the chemical. PPE needed to handle the chemical spill. (The hospital will provide you with the equipment needed.

6 Your Nametag: Should be worn by all employees while at work.
Never loan your nametag to anyone.

7 Be Safety Alert: Report all unsafe practices, conditions, defective equipment and or injuries to your supervisor, Safety Committee or Safety Officer. Use required personal protective equipment in specified areas and on designated job duties. Operate equipment only after have been authorized and trained to do so, and follow all safety rules, procedures and practices. Respond to emergency situations in accordance with medical center and departmental polices and procedures.

Nursery Medical Records Back Loading dock Pharmacy Emergency Department

9 Chemical Spills Mercury spill kits are located at each nurses stations. There is a big gray barrel with red lettering, located in materials management for chemical spills

10 Electrical Safety: Unplug Equipment from wall immediately if you notice:
A burning smell. Equipment is hot to touch. Equipment is smoking You feel a shock or tingling feeling. Report Cords and Wall plugs if you notice: Cracks in insulation Bent or missing AC plug or prongs Burn marks on AC plug Warm or Hot power cords.

11 What is a Disaster or Code Black?
An external or internal disaster occurs when an incident produces casualties of such numbers, that the routine methods for patient care are not adequate. If a disaster occurs while you are off duty, you will received notice that you are needed at KDMC by phone, radio or TV announcement. It is your responsibility to respond to any disaster at KDMC. Be sure your home phone and cell phone numbers are up to date in the Human Resources office and with your immediate supervisor.

12 Code Force: Non-medical emergency
Available employees should report to the location called.

13 Code Gray: Tornado Move as many patients as possible to the hallway.
Move all others away from the windows. All other employees should move to 1st floor hallway by dietary.

14 Code Red: Fire Alarm, RACE
R-Remove anyone in the danger area. A-Alarm, dial 711 and announce the location of the fire. C-Control fire with extinguisher. E-Evacuate patients to a safe part of hospital

15 Code Red: Fire Get Fire extinguisher and report to area called.
Use Pass for fire extinguisher. P-Pull pin A-Aim Nozzle S-Squeeze handle S-Sweep at the base of the fire.

16 Code Pink / Code Adam: Missing baby or missing child.
Report to the nearest exit. No one should be able to leave or enter the building. Try to obtain a description of child Age Sex Race Hair and eye color Clothing Type and color of shoes

17 Code Blue: Cardiac Arrest
Available medical staff, Code Team, should report to the location called.


19 Proper Sitting: Sit in a chair that has proper low back support.
Keep your feet flat on the floor. Keep your hips at a 90% angle. Avoid slumped sitting. Keep your chin tucked in and avoid head forward posture. Avoid prolonged sitting. Change positions frequently.

20 Lifting Safely: Bend your knees, not your back, and you greatly reduce stress to your low back. Keep the load close to your body and carry heavy objects waist high.

21 5 Key Points of Proper Lifting:
1. Plan ahead, rearrange area and get help if needed. 2. Bend your knees not your back. 3. Keep the load or patient close to your body. 4. Use a good wide base of support. 5. Pivot your feet when turning-avoid twisting.

22 If you have a choice-PUSH!
Pushing or Pulling? If you have a choice-PUSH! Pushing is more mechanically efficient. Keep your back straight. Bend as you push. Reposition your body as you push. Don’t let the load get too far in front of you.

23 Carrying a Load: Support the load in two places, side and bottom.
Hold the load close to your body, keep your back straight. Carry with a slight bend in your elbows. If you carrying shopping bag or luggage- split the load and carry a lighter load on each side.

24 Reaching: Pace your work and get as close as you can.
Avoid standing on your ‘tip toes’, use a stool or ladder if necessary. Store frequently used items within easy reach. Use one hand for extra support if possible. Avoid prolonged overhead work without breaks.

25 Common Mistakes of Body Mechanics:
Lifting with the Back Bent and the leg Straight. Lift with your legs not your back. Using Fast Jerking Motions. This adds additional stress on back and joints Bending and twisting at the same time. This causes maximum stress on the lower back.

26 Common Mistakes Continue:
Load too far away. Load at arms length weights 7-10 time more. Poor planning Failure to anticipate needing assistance Poor communication Let patients know what to expect, they can help. Insufficient strength Not strong enough to lift the patient or load.

27 Remember: Lift with your legs and not your back. Keep back straight.
Bend at the legs. Lift your head before you lift. Maintain natural sway in lower back.


29 Fall Risk Assessment Should be completed on every patient.
If your patient does fall: 1.Complete Occurrence Report. 2.Complete Fall Report in Meditech Nursing 3.Place on “High Risk” Fall precautions if not on it already. 4.Notify physician and family.

30 “High Risk” Fall Precautions:
Yellow armband and door card. Room near nurses station. Possible bed alarm. 4 side rails up. Sitter at bedside. Bed in low position.

“Patient Rights & Responsibilities” Hand Book

32 The Patient Bill of Rights. Each Patient has the Right to:
Be treated with dignity & respect Expect privacy & confidentiality Make informed decisions Participate in all aspects of care Establish advance directives Receive impartial access to care Be given full financial information

33 Help Them Develop an Advanced Directive
Advising of their right to advance directives. Asking if they have an advance directive. Assisting them in developing advanced directives. Including the information in their medical record.

34 Patient’s Bill of Rights Each patient has the right to:
Know the identity & professional status of all healthcare workers. Participate voluntarily in research & education projects. Receive full knowledge of their rights and responsibilities.

35 Patient Restraints When Are Restraints Used?
Only with a doctors order to include: The type of restraint to be used. The length of time the restraint is to be used. Reason for the restraint. Document every two hours on restraint sheet circulation and skin condition. Checked at least every 15 minutes. Signed by physician within 1 hour. New order every 24 hours

36 How Are Restraint Used? Follow manufactures directions.
Use correct size. Fasten straps tight but not constrictive. Do not place over IV Site or wound. Tie knots for easy release. Only trained personnel should apply.

37 Problems That Can Occur From Using Restraints:
Increase agitation Circulatory impairment Asphyxiation D/T aspiration or restricted respiratory function. Seizure Pts can suffer fractures or trauma. Alternative: Have family stay with patient. Move them out to the desk. Try to fix what is bothering them.

38 National Bereavement Sign
If you see this sign on a patient door, it means there is a “sensitive” situation going on involving possible loss or death. Please be respectful.

39 Visitation Rights Patients have the right to choose who may visit them. They have the right to choose someone who is not related by blood or law. This includes, but is not limited to: A Friend A Domestic partner (any gender) A Neighbor A Significant Other

40 WORKPLACE VIOLENCE POLICY: KDMC does not tolerate acts of
workplace violence committed by or against employees.

41 If Conflict Occurs: 1. Stay Calm 2. Listen attentively
3. Maintain eye contact 4. Be courteous, but maintain your distance 5. Signal for someone to call for help 6. Never try to grab a weapon

42 Early Warning Signs: Nervous behavior. Loud, over bearing personality.
Threatening others. Getting in your face. Clinched fist. Flashing a weapon. History of violence.

43 If Violence Strikes: Take action to protect yourself.
Call for Code Force. Remove patients & visitors to safe area. Don’t try to take away a weapon. Don’t try to restrain the person alone.

44 Safe Practices: Don’t leave scalpels or needles unsecured.
Obtain history: ask about cuts & bruises. Know way to contact Security. Overhead page Pager Radio

45 Watch for Signs of Abuse to our Patients:
Physical Indicators: Unexplained bruises in different stages of healing. Complains of abuse at home. Patterned injuries. (Buckles, belts, burns) Untreated old injuries. Delay in receiving help. Attempted suicide.

46 Questioning the Suspected Abuse Patient.
Provide a safe environment. Interview patient alone. Have Security escort others out of the room if need. Ask direct, non-threatening, non-judgmental questions.

47 INFECTION CONTROL Bloodborne Pathogens

48 What are Bloodborne Pathogens?
They are viruses, bacteria and other microorganisms that: are carried (borne) in the person’s bloodstream and in certain other body fluids cause disease If a person comes in contact with infected blood or certain other body fluids, he or she might become infected too! revised: 2012

49 Non-Infectious Body Fluids for Bloodborne Pathogens:
Sweat Saliva Tears Urine Feces Vomitus Nasal secretions revised: 2012

50 Infectious Body Fluids for Bloodborne Pathogens:
Fluid around or in an organ Any body fluid that contains blood revised: 2012

51 Three of the Most Serious Bloodborne Pathogens
Hepatitis B virus (HBV) Hepatitis C virus (HCV) Human Immunodeficiency Virus (HIV) revised: 2012

52 HEPATITIS Hepatitis A Hepatitis B* Hepatitis C* Hepatitis D
Hepatitis E revised: 2012

53 Symptoms of Hepatitis B & C
The primary symptom of HBV & HCV is jaundice (yellowing of the skin and eyes) THERE IS NO CURE. revised: 2012

54 HIV HIV = Human Immunodefiency Virus
The virus attacks the body’s ability to fight disease and infection (immune system) The virus causes AIDS (acquired immune deficiency syndrome) revised: 2012

55 Symptoms of HIV Infection
The symptoms of HIV are: none weakness weight loss fever sore throat dark urine THERE IS NO CURE. revised: 2012

56 How are these pathogens spread
How are these pathogens spread? When infected fluids enter the body through: needle-stick injuries or sharps injuries cut, scrapes, and other breaks in the skin splashes in the mouth, nose or eyes revised: 2012

57 You will use equipment to protect yourself
STANDARD PRECAUTIONS Standard precautions (also known as universal precautions) means that you will consider the blood and certain other body fluids of another person INFECTIOUS at all times AND You will use equipment to protect yourself revised: 2012

58 Personal Protective Equipment PPE
You must use certain PPE items to protect yourself. This will place a barrier between you and the potentially infected material. These items include: gloves masks goggles gowns resuscitation equipment revised: 2012

59 Sharps MUST be disposed of properly!!!! You should dispose of sharps:
in a labeled sharps container only without recapping as soon as they are used revised: 2012

Warning labels and colors help you identify hazardous or regulated waste! RED CANS, CONTAINERS, LABELS OR BAGS MEAN “INFECTIOUS” UNIVERSAL BIOHAZARD SIGN revised: 2012

What is an exposure event? Did I get stuck with a needle or sharp used on another person… Did I get a splash of blood or *OPIM from another person into my mouth or eyes or up in my nose… Did the blood or *OPIM from another person enter my body through my non-intact skin (cut, scrape, open wound)... *OPIM = other potentially infectious material revised: 2012

62 What if I Am Exposed? Wash the exposed area thoroughly with soap and running water. If splashed in the eye or mucous membrane, irrigate with running water for 15 minutes Report the exposure to your supervisor as soon as possible Fill out the EOR form provided on the units* Your supervisor will advise you of the next steps to be taken. * students, physicians, visitors, contract staff are responsible for their testing costs. revised: 2012

63 That’s Why You Should Get Vaccinated!!
Hepatitis B vaccination is provided to you for free! You should take the vaccination unless: you have previously received the vaccination antibody testing reveals you are immune the vaccination is contraindicated (not recommended) The vaccination process involves a series of 3 injections given in the arm muscle over a 6 month period. That will protect you if you are exposed to the blood or OPIM of someone with Hepatitis B. HEPTITIS B VACCINATION ONLY PROTECTS YOU FROM HEPATITIS B, NOT ANY OTHER TYPE OF HEPATITIS! revised: 2012

64 RECAPPING NEEDLES Rule = Reality = No recapping!
Sometimes you have do it right! revised: 2012

65 Gloves Not a choice!!! revised: 2012

66 Transfer of Infected Patients
Nursing Staff and/or EMS staff who have knowledge of their patient having a known or suspected infection must notify the receiving facility PRIOR to the transport. revised: 2012

67 HANDWASHING Handwashing is the single and most important practice used to prevent transmission of bloodborne pathogens. ************************ IMPORTANT! My patient has diarrhea? Gloves, soap, water and friction! (no alcohol rubs) Wash hands after removing gloves! You touch your eyes, nose & mouth about 300 times/day! revised: 2012


HIPAA: Health Insurance Portability and Accountability Act: HIPAA was signed into law in 1996 by President Clinton. The purpose is to improve portability and continuity of health insurance coverage. It’s also used as an opportunity to improve the efficiency and cost-effectiveness of the healthcare industry. The HHS (Health and Human Services) has established regulations for transmitting data and protecting the security and confidentiality of all type of patient information.

70 HIPAA – Your Responsibilities:
One of the main focuses is the privacy of information within KDMC. We must take every precautions and measure to ensure the privacy of our patients information. This can be done in many ways, including: 1. Not leaving Medical Charts in an open area for others to see. 2. Being aware of others around you when discussing treatment or condition of patients. 3. Not leaving your computer screen with patient information visible. 4. Not giving out sensitive patient information over the phone. 5. Reporting misuse

71 Core members of the HIPAA Committee at KDMC:
Cathy Bridge-HIPAA Coordinator Carl Smith- Information Security Officer Teresa Brown-Privacy Officer Janet Wesselhoft-TCI Officer (Transactions, Code Sets, Identifiers)

72 ELECTRONIC SECURITY Electronic Security is based on Policy IM and is maintained by our HIPAA Committee. Please review both of these policies. Policy and actions are based on HIPAA regulations, as well as Joint Commission standards on Information Management. Meditech Patient Information Audits are conducted quarterly to determine if any potential violations have occurred. To do this, our committee chooses random employees and observes all patients that a particular employee has accessed. This not only pertains to clinical personnel, but to all employees of King’s Daughters Medical Center. Electronic Security extends beyond the Meditech System. It also relates to Internet access, faxing, , voice mail, and any other type of electronic information. Access to computerized patient information is handled the same way as a patient’s.

73 Medical Record or Chart
Medical Record or Chart. The information is the same, whichever way you decide to view it. Please Review: 1) Policies IM 2.5 & IM 2.6 2) Non-Acceptable Justifications for accessing electronic information. 3) Notes and Guidelines for Security Badge Use. If you have any questions, please call Carl Smith at ex. 9278

“This is my child and I have a right to the data, I am paying the bill.” This is my spouse and he/she asked me to look up the information.” “I thought it was OK since I already have access to everyone’s information. I’m a professional and I won’t discuss it with anyone.”

“I thought it was OK since I wasn’t going to tell anyone.” “This is my co-worker and I am very worried about him/her.” “This is my Mom’s pathology report and I am really worried about it. I wasn’t going to tell her the results. That’s the doctor’s job.”

‘My co-worker called me from home and asked me to look up the information about their lab work. I had his/her permission to look at he lab results and tell them the results. They will verify that they gave me permission.” “I can look at my OWN information when I want to. It’s about me.”

“I go to church with this patient and I may need to pray for them.” “I know Dr Anderson is not his doctor but he is on staff and he asked me to look up his father’s x-ray report.”

The new Access Control Door Security System uses Proximity devices to recognize employees who wish to gain access to certain areas. A Proximity device is a small black box which you will see located at employee entrances and certain departments. It recognizes the employee by sensing a computer chip located in the employee’s badge or key-tag. To gain access to a door, you must simply hold your card in font of the reader until it beeps. The red light on the reader will turn green and the door will be unlocked. The first time you use the card, it will take about a second for it to read it. After that, it will only take a split second.

79 Internal Electronic Doors
This include departments that are sensitive in nature and need controlled access. External doors consist of basically all employee entrances. Your badge is not a standard generic card. It contains a number that is assigned strictly to you. Do not loan your security badge to anyone. You must report loss of badge to Human Resources within 24 hours of loss. No holes may be punched in the badge.

80 Security Badge Continues:
Loss or personal destruction of badge will result in a $10 charge for replacement. This may be payroll deducted. You must turn in your security badge to HR upon termination. Report misuse of security badge to HR or Security officer immediately. Violation of these rules will be strictly enforced Under HR 2.2 policies and could result in termination.


82 Age-Specific Competencies
Birth - 1 Year Preschoolers 1 - 5 Years Age-Specific Competencies Schoolagers 6 -12 Years Adolescents Years Geriatrics 65 yrs. & older

83 INFANTS Birth - 1 Year Communication – Comfort Growth and development
Speak softly, slowly, and calmly Involve parents Comfort Keep warm and dry. Infants are prone to hypothermia. Do not separate from parent unless necessary. Growth and development Dependent Communicates by crying Safety Keep side rails up. Prone to head injuries from falls. Airways obstruct easily. Collect data appropriately Furrowed brow, tightly shut eyes are signs of pain. Easily dehydrated with the loss of small amounts of blood, fluid or stool. Compromised with heart rates greater 200 beats per minute Poor gas exchange when congested. Modify care appropriately Adjust medications and fluids Use distractions Keep parent in baby’s line-of-vision INFANTS Birth - 1 Year

84 Preschoolers 1 - 5 Years Communication Growth & Development Comfort
Communicate at child’s eye level Talk in simple language Give honest explanations Be patient Growth & Development Clumsy and trips easily Self-centered thinking Has vivid fears and imagination Comfort Keep familiar things nearby Give praise Safety Do not leave unsupervised Transport with side rails Use caution around sharp edges Collect data appropriately Limited vocabulary Be alert for signs of trauma Look for dehydration Modify care Let child explore and touch equipment May accept procedures performed first on “Teddy” or other toy. Involve parent and child

85 Schoolagers 6 - 12 years Communications Growth & Development Comfort
Do not “talk down” to child Help child to fee useful Explain procedures using correct terminology Encourage child and parents to ask questions Permit child some input in decisions Growth & Development Active Seeks independence Understands cause & effect Comfort Make intent of actions clear before touching child Allow child some choices and control Collect date appropriately Use appropriate-size equipment Include parent & child Modify care Allow child to make decisions (e.g. “In which arm to do you want to draw blood?”) Adjust fluids and medications for child’s weight

86 Adolescents 12 - 18 years Communication Comfort Safety
Permit peer group contracts as much as possible Maintain privacy; protect modesty Safety Transport as adult Help recognize danger Collect data appropriately Prepare for procedure separately from parents Explain procedures completely in adult language Communication Show acceptance & respect Use adult vocabulary Encourage open communication Growth & Development Grows in spurts Maturing physically and sexually Able to think abstractly Concerned about appearance Challenges authority Adolescents years

87 Young Adults 20 to 45 years Nursing Interventions
Assess emotional, financial & physical support systems Allow patient to set own pace & be self-directed Encourage participation in care Identify values that may affect health care. Physical Characteristics Skeletal growth completed at 25 years Coordination & response speed are at maximum Sensory functions are at their peak Good problem-solving abilities Violence major cause of death (MVA, etc.) Psychosocial Characteristics 20 – 30 Intimacy vs Isolation Developing interpersonal relationships Capacity for intimate love Influenced by social & cultural concerns 30 – 45 Generatively vs. Stagnation Productive Nurtures next generation with care & concern Young Adults 20 to 45 years

88 Middle Adult 45 to 65 Years Physical Characteristic
Muscle mass & strength begin to decrease Loss of agility On-set of arthritis Presbyopia occurs Sensory functions decrease Reaction times slow Memory changes occur Cardiovascular disease is major cause of death

89 Middle Adults 45 to 65 Years Psychosocial Characteristics
Generatively vs Stagnation Care & concern for next generation Gender differences decrease Begin personal freedom & planning for retirement Reverses roles with parents Nursing Interventions Support patient’s right to make an informed choice Support & affirm coping skills Provide referrals for emotional, financial & physical support systems Allow patient to set own pace & be self-directed Encourage participation in care Identify values that may affect health care Middle Adults 45 to 65 Years

90 Geriatrics 65 years & older Growth & Development Communication Comfort
Decreased auditory and visual acuity Decreased ability to regulate heat Memory skills begin to decline Increased learning and reaction times Nutritional needs for maintenance. Comfort Keep patient warm (may need extra blankets) Follow home or nursing home schedule as much as possible. Maintain adult privileges (e.g. decision making, privacy, personal habits Communication Show respect and consideration. Do not patronize patient. Speak distinctly and slowly Call patient by title and last name unless patient asks to be called by another name. If patient is hearing impaired: If patient uses a hearing aid, make sure it is worn. Check hearing aid batteries periodically. Look at patient while you speak. Use a deeper voice, not a louder voice.

91 Geriatrics 65 years & older Safety Collect data appropriately
Do not rush Keep cords and equipment out of patient’s path Weak or confused patients may need a safety belt while in wheelchair If patient wears glasses Offer to clean patient’s glasses. Have patient to wear glasses while awake. Collect data appropriately Perform assessment slowly Ask clear, precise questions – listen carefully Assess for confusion, orientation, and unsteady gait Monitor cardiovascular functions Modify care Involve patient in decision-making and control pain Use caution with temperature of fluids, bath water, etc. Elderly patients may have complex care requirements Use extra precautions to prevent skin breakdown Maintain hydration and fluid and electrolyte balance.


93 Risk Management Risk is the chance of loss or injury
Risk Management is an organized effort to identify, assess, reduce, and eliminate risk revised: 2012

94 How Safe is Healthcare? revised: 2012

95 revised: 2012

96 revised: 2012

97 revised: 2012

98 revised: 2012

99 revised: 2012

100 Transparency in Healthcare
The public is better informed about healthcare issues now than they ever have been before. Accountability for outcomes is at an all time high. “” is a public website. Facility information available: What facility left a surgical instrument/sponge in a patient. What facility has the happiest patients. What facility has the most patient falls. What facility gave a patient an infection they did not have when they came in. And on and on and on… revised: 2012

101 Is It Really That Bad? revised: 2012

102 Risk Management Program Focus and Objectives
To improve patient care by being aware, identifying, correcting, and preventing potential hazards or areas of risk exposures To investigate and follow-up on incidents that do occur Claims management Risk prevention education The Medical Center has established a Risk Management department to direct, supervise, and manage the risk management activities. revised: 2012

103 Occurrence Reporting Depends On YOU!!!!
Major tool for the identification of risk is the “Occurrence Report” Reporting is the responsibility of each person who provides care, treatment, or a service for a patient or witnesses an event. Never assume someone else will do it! Incidents should be reported, documented, and investigated immediately for facts to be clear and to ensure thorough follow-up. If a trend becomes apparent, quick action can avoid unnecessary risks. It is very important that you advise RM when you become aware of any incident involving patient care that might result in a claim or lawsuit. All employees have a responsibility to report all situations of patient injury or dissatisfaction a soon as possible and to cooperate with risk management in its investigation of incidents. In addition, it is important to report immediately any incident involving equipment or product malfunction or defect that may have caused or contributed to a patient’s injury, illness, or death to ensure compliance with the Safe Medical Device Act of 1990. revised: 2012

104 Talking to Attorneys If you are contacted by an attorney about an occurrence involving KDMC, you are requested not to discuss any information. If you are approached, please contact me right away. revised: 2012

105 What Should Be Reported To Risk Management?
Any Event or Condition Which: May result or has resulted in an injury to a patient or impairment of patient care Reflects a major deviation from hospital policy, procedure, or practice revised: 2012

106 Examples of an Occurrence
Medication Events Patient/Visitor Falls Equipment Malfunction Policy/Procedure Variance Serious Complaints Behavior Events Property Loss/Damage AMA/Walkouts 1-Medication Events (a) Wrong drug (b) Wrong dose (c) Wrong route (d) Wrong time (e) Wrong patient (f) Omitted dose (g) IV-Related (1) Wrong fluid hung (2) Infiltrated (3) Wrong rate (h) Adverse Drug Reaction 2-Falls (a) Witnessed (b) Un-witnessed (c) Near fall 3-Equipment Malfunction (a) Injury to patient/visitor (b) Malfunction when needed (c) Not available when needed (d) Disposed of or cleaned incorrectly (e) Incorrect instrument count. The Safe Medical Device Act of 1990 requires user facilities to report to the manufacturer and/or FDA any occurrence in which a medical device caused or contributed to the serious illness, injury, or death of a patient. Medical Devices can include instruments as simple as a tongue depressor or as complex as a heart-lung by-pass machine. Implantable Devices are also included in the act. Incidents that appear to be the result of user error should be reported, whether or not the device itself was at fault. A Report to the manufacturer and/or the FDA must be filed in 10 working days of the hospital receiving the information or becoming aware that a device may have contributed to a patient’s illness, injury, or death. Report all incidents of patient illness, injury, or death related to a medical device to Risk Management immediately, followed-up with an occurrence report. Impound all devices and associated products involved in an incident until Risk Management has an opportunity to investigate the occurrence. Protect devices with memory abilities from memory erasure. Tag Device as “Defective” and remove from service. 4-Policy/Procedure Variance (a) Deviation from transfer policy (b) Transcription error (c) Procedure performed incorrectly/omitted (d) Wrong/Incomplete requisition (e) Wrong test ordered (f) Wrong patient tested 5-Serious Complaints (a) Nursing care (b) Physician care (c) Concern other department (d) Pest problem 6-Behavior Events (a) patient (b) visitor (c) staff 7-Property Loss/Damage (a) patient (b) hospital (c) staff 8-AMA/Walkout (a) Inpatient (b) Outpatient revised: 2012

107 Medication Events How To Reduce The Risk!
Remember the 5 Rights to Medication Administration: Right Patient Right Drug Right Dose Right Route Right Time 1-Right Patient: Did you check the patient’s name on the MAR and the chart? Did you check the patient’s armband? 2-Right Drug: Did you check the patient’s allergies? Did you check the drug labels against the MAR? 3-Right Dose: Did you check the drug labels against the order? Did you check and double check your calculations? 4-Right Route: Did you check the order? Did you check the labels against the order? 5-Right Time: Did you check the ordered frequency of the drug? Did you check the time? revised: 2012

108 If You Administer Medication:
Know the drug: Use: Why is your patient receiving this drug? Dosage: Did the physician order the correct dose? Side Effects: Is your patient’s complaint a side effect? Name: Do you know the drug’s trade and generic name? Educate Your Patient and Their Families! Resources are available-PDR, Nursing Drug Books, Monograph in Meditech revised: 2012

109 Sentinel Events!!! An event resulting in an unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition. Sentinel Events must be reported immediately to RM in person or by phone. In the absence of the Risk Manager report such events to the Administrator on Call! revised: 2012

110 Ten of the Most Common Sentinel Events
Patient Falls Assault/Rape/Homicide Patient Death/Injury due to restraints Patient Elopement Transfusion Error Patient Suicide Medication Error Operative or Post-Operative Complication Wrong Site Surgery Delay in Treatment 1-Most sentinel events (622/ %) occur within general hospitals, with psychiatric hospitals/units/behavioral health facilities comprising the next largest setting. Of the Sentinel Events 78% have resulted in patient deaths. 2-To date, 661 (66%) of sentinel events have been self-reported, with 233/293 (80%) of sentinel events in the year 2000 being self-reported. The largest other source for identifying sentinel events has been the media (15.4%). revised: 2012

111 Completing an Occurrence Report
The employee who was directly involved should complete Fill out all information correctly, completely, and sign and date the occurrence report Forward the report to the Risk Manager within 24/48 hours Do Not Make Copies! If follow-up is initiated, document findings on the form, return to RM after investigation and documentation is completed All copies are maintained by the Risk Manager. 2-(Patient Information)-If you use a patient label instead of handwriting the patient information on the form REMEMBER to place a label on page two (yellow copy) of the occurrence report! revised: 2012


113 Healthcare Compliance
Following all local, state and federal laws consistent with the highest standards of business and professional ethics. To make sure that happens, KDMC has a COMPLIANCE OFFICER – Cathy Bridge Privacy Officer – Teresa Brown Security Officer – Carl Smith Compliance Officer reports to the Board of Trustees revised: 2012

114 Examples of Laws and Regulations
Laboratory Mail/Wire Fraud Marketing OSHA Patient Referrals Patient Self Determination Physician Recruitment Political Contributions Purchasing/Bidding Record Retention/Disposal Safe Medical Device Act Securities State Licensure Tax Trade Associations Anti Kickback Antitrust Billing/Coding Boycotts Competitor Discussions Confidentiality (HIPAA) Conflict of Interest Controlled Substances Credentialing Employment EMTALA False Claims Act Fund Raising Gifts/Tips Hazardous Waste Disposal 3-Billing/Coding-Bill for only those services/procedures provided, Documentation has to support the services/procedures rendered for Coding/Billing purposes. 4-Boycotts-KDMC prohibits any agreement with competitors to refuse t deal with a particular vendor, payer, or other provider. 5-Competitor Discussions-Charges must be set solely by the individual facility. 10-Employment-a process is in place to insure that our employees will not put the facility at risks, i.e.: *Background Checks *Competency *Job Descriptions *Monitor Conduct *Educational Requirements *Clear Expectations 11-Patient Transfers (EMTALA) 14-Gifts/Tips-Giving and Receiving 19-Patient Referral-Patient or Patient Representative is free to select their healthcare provider 20-Patient Self Determination Act-Living Wills, Durable Power of Attorney for Healthcare, Advance Directives 21-Physician recruitment-Have to be careful due to anti-kickback, Stark Law, Financial Relationships-Report any irregularities. 29-Trade Associations-if ask to provide charges, costs, salaries, other business matters consult with the Compliance Officer before giving out this information. Surveys conducted by 3rd parties should involve at least comparably sized facilities and the information provided should be at least 3 months old. revised: 2012

115 Employee Responsibilities
Read your Compliance Handbook Read the False Claims Act Policy Conduct yourself in a professional and ethical manner at all times Report any concern or suspected violation(s). It is your duty! revised: 2012

116 Social Media Please read policy LM.1.19 Key Point: Under no circumstances will patient information, written or visual, be published by a KDMC employee. revised: 2012

117 Duty To Report Concerns And/or Suspected Violations
If you suspect it, report it! It is the duty of each employee to report promptly any concern and/or suspected violation(s) The following is the mechanism for reporting: Supervisor Compliance officer ( ) Hotline ( ) 1-No matter how well intended someone’s actions are to benefit the patient, if you suspect a violation(s) you are responsible for reporting it. Although it can be uncomfortable it is your responsibility to report and in the long run it benefits everyone, including you! 2Hotline-Reports made by using the Hotline can be done so anonymously. 3-All reports received will be investigated in a timely matter. Reports will be kept confidential and only those individuals with a bona fide reason to know will be involved. Reporting can be done without fear of retaliation or retribution, as long as the concern or suspected violation is reported in “good faith.” However, anyone deliberately making false accusations with the purpose of harming or retaliating against another employee will be subject to disciplinary action. revised: 2012

118 Disciplinary Action Employees who willingly and intentionally commit acts which are in violation of the law are subject to disciplinary action, including criminal and civil penalties No disciplinary action will be taken against an employee for asking a question or reporting a concern or suspected violation of KDMC’s code of conduct Employees are subject to disciplinary action for NOT reporting a concern or suspected violation revised: 2012


120 Prevent Mistakes in Procedures. Use “Time Out” Before Procedures.
Correct Patient Correct Procedure Consent signed Correct site marked Diagnostic studies in room.

1). Get important test results to the Doctor or Nurse on time. 2) “Do not use Abbreviations” 3) Good “Hand Off” patient reports

122 Hand off Communication: SBAR
Allow time for questions and answers about your patient’s: S-Situation B-Background A-Assessment R-Recommendation

123 Use Meds Safely 1.Label all medicines even during a procedure.
2. Double check doses of blood thinning medicines. 3. Be on alert for: “Look alike” & “Sound alike medicines”

124 AVOID !!!!! “Do Not Use Abbreviations”
U, u, IU QD or qd QOD or qod MS, MSO4, MgSO4 Trailing zeros (3.0mg) Lack of leading zeros (.3mg)

125 Reduce Risk of Infection:
Proper hand hygiene is the best defense against spreading germs. Clean your hands whenever you go into a patients room and before you leave out, Every Time.

126 Check!! Use Medicines Safely.
Check all Patients Medicines: Before, during and after hospitalization. List medicines accurately and completely. Update medicine list each time patient changes settings.

127 Identify Patient Safety Risks
Help to identify patients at risk for suicide. Signs of abuse Depression Talk or history of suicide

128 Involve Patients In Their Care:
Educate patients and family about safety strategies. Encourage patients’ active involvement in their own safety. Provide and communicate the means for patients and families to report concerns about patient safety issues.

129 Identify Patients Correctly
Use two ways to identify patients. Make sure the correct patient gets the correct blood transfusion.


What you must know in today’s workplace.

132 What is Inappropriate Conduct? (Harassment)
Discrimination or segregation based on: Race Color Religion National origin Gender Age or Genetics

133 Three Things about Inappropriate Conduct: (harassment)
How it is defined, and how the courts and the government apply that definition. What specific steps you can take to ensure that you are not breaking the law. What behavior can you expect from others.

134 EEOC’S Definition of Sexual Harassment:
Unwelcome sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature constitutes sexual harassment when: Submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment. Submission to or rejection of such conduct by an individual is used as the basis for employment decisions effecting such individual or: Such conduct has the purpose or effect of unreasonably interfering with an individual ‘s work performance or creating an intimidating, hostile, or offensive working environment.

135 The Quick Picture: (THE DANGER ZONES)
The law defines three kinds of conduct that are considered sexually harassing: Unwelcome sexual advances. Request for sexual favors. Other verbal or physical conduct of a sexual nature.

136 Defining Harassment: The conduct must be unwelcome.
Participation in the conduct is made a term or condition of employment or is used as the basis for employment decision. The conduct has the purpose or effect of unreasonably interfering with work performance, or of creating an intimidating, hostile, or offensive working environment.

We must treat Co-workers fair and with respect. It is unpleasant to work in an inhospitable environment. It is a violation of Federal Laws. Consider the bottom line. Lost time and resources Legal fees Possible judgment

Avoid the danger zone behaviors. Quid pro quo harassment. (Something for Something) Hostile environment harassment. Situations you might not think of : Within your office walls Beyond the office walls Computer, , and the web Non-employees

Ask yourself: Do I feel uncomfortable? Step #1: Talk to the harasser. Step #2: Tell your supervisor. Step #3: Tell Human Resources.

140 King’s Daughters Medical Center will take action and investigate.
WHAT WILL HAPPEN??? King’s Daughters Medical Center will take action and investigate.

141 Cultural Diversity

142 What are Cultural Competencies?
They’re the skills you use to work well with co-workers and patients of all cultures. Considering a patients culture when giving care. Relating to each patient & co-worker as an individual.

143 Why Do We Have Cultural Competencies?
Help patients receive more effective care. Help our organization meet TJC standards. Improve your job performance.

144 Gaining Self Awareness
Know your own beliefs & practices Think about how your culture & upbringing affect you. Showing politeness Expressing pain Appropriate ways to treat children or older adults

145 Cultural Factors To Be Aware Of:
Country of origin Preferred language Communication style Views of health Family & community relationships Religion Food preferences Consider other factors that may affect care. Age, Gender, Sexual orientation Socio-economic status Presence of a physical or mental disability.

146 Cultural Competencies
Developing cultural competencies does not mean knowing everything about every cultural group you work with. It does mean: being aware of cultural factors taking appropriate steps to learn about each individual.

147 Stereotypes v/s Cultures
What is a Culture? Religion, Family, Nationality What are Stereotypes? Filters by which We view & hear others. Mostly negative Where do Stereotypes come from? Developed by groups due to their lack of knowledge about another group. (Ignorance) Most are taught to us as children by parents, grandparents, aunts and uncles.

148 Communicate Effectively
Listen to how the patient talks about his or her condition. Ask indirect questions, if needed. Look for clues. Talk with others who know the patient. Ask for the patient’s views on treatment. Use interpreters effectively.

149 Use Cultural Knowledge to Improve Patient Care
When staff members make the effort to work well together: Job satisfaction increases. Patients receive the best care. Challenge Stereotypes Ask questions to avoid cultural stereotypes. Get to know co-worker and patients as individuals rather than as a member of a group.

150 Change… The One Constant in the Universe.
We must change to master change. Lyndon B. Johnson


152 How to complete Annual Review
After filling out your test packet in it’s entirety, YOU must turn it in to get credit to: Kim Bridge or Tammy Calcote Education Annex (601)

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