Huron Medical Center 2012 Annual Mandatory Review Hazcom, Safety - - PDF document

DIRECTIONS: At the end of this section/module, please complete the quiz

• nline with the corresponding topic. Results will be available to you at the

conclusion of each quiz. Please review, and if needed, arrange to meet with your manager to discuss any questions you may have.

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Huron Medical Center has an Education Policy (Number:831.800.02) that gives us guidance when developing and updating this Publication. The Purpose

• f this policy and the Education Grid is to help us ensure you have the information

and competency needed to perform your job functions safely and assure Huron Medical Center is compliant with regulatory requirements. Each department also has department specific education needs. Please re- view any departmental policies and procedures specific to your area for any top- ics covered in this newsletter. Thank you for your time and energy in completing the annual requirements! If you have any questions regarding anything that you have read, please refer them to your Manager. If they are unable to answer your question, they will help you find someone who can.

Thank you for reading this information! Your participation in the Annual Mandatory Safety Education is important for your safety and the safety of others at HMC.

December 2012

Huron Medical Center 2012 Annual Mandatory Review Hazcom, Safety & Risk Management

The Hazard Communication Standard developed by the Occupational Safety and Health Administration (OSHA) assures your ―Right-To-Know‖ about potential chemical hazards in your workplace. Huron Medical Center has a Hazard Communication Program (Policy Number: 997.404.03). This policy is found in the Safety Manual. The purpose of this program is to ensure that the hazardous chemicals used within Huron Medical Center are evaluated and that information concerning their hazards is communicated to employees. Huron Medical Center will rely on manufacturers’ labels and MSDS to meet hazard determination requirements. Material Safety Data Sheets (MSDS) are accessible 24 hours per day, 7 days per week by contacting the 3E Company at 1-800-451-8346 or 760-602-8703. The requested MSDS will be faxed within 15 minutes to the following fax machine upon request: Emergency Room/Triage Area fax #989-269-6884. When requesting a MSDS, please have the following information available if possible: Product Name and Number Manufacturer Name UPC Code MSDS Posting Requirements are in place. Department directors/managers are responsible for reviewing MSDS for information on any new hazardous chemicals introduced into the work area. The name of the new chemicals shall be listed on the MIOSHA Right-To-Know poster that shall be posted in a noticeable area within each department. An MSDS locator poster is posted in each department. Every employee should know the location of this poster. The locator poster will advise employees of the 3E Company phone number. Huron Medical Center’s response to chemical spills is currently limited to the immediate cleanup of small

• spills. Immediate cleanup means that the spill can be cleaned up within 15 minutes. Immediate management

is the responsibility of the first employee who encounters the spill or release. If a spill occurs – Remember SIN S – Safety – Most important – Protect yourself and act in a safe manner in responding to / cleaning up the spill I – Isolation – Shut doors, set up barricades / caution tape / post guards to isolate the spill area / turn

• ff ventilation systems that re-circulate air.

N – Notification – Call Central Registration to announce Code Hazmat (along with the location) over the PA. Also notify your Supervisor and the Safety Officer. Hazardous material spill clean up kits should be available in all departments that use hazardous chemicals. Departments that transport hazardous chemicals throughout the facility should carry a spill kit on the transport cart. If a large spill would occur and the MSDS indicates that there is an OSHA threshold that may be sur- passed, then an outside cleanup firm must be contacted to conduct the cleanup. Department managers are responsible for conducting any required training on hazardous chemicals and cleanup procedures used in their departments. All employees who handle hazardous chemicals should be trained to the HAZWOPER Awareness level. All employees who handle hazardous chemicals must be trained in self-decontamination techniques. In general, removing contaminated clothing will reduce the exposure to a large degree.

HAZARDOUS CHEMICAL SPILL RESPONSE

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2012 Huron Medical Center Annual Mandatory Module

You are responsible for knowing how to work with chemicals in your

• area. ASK IF YOU DON’T KNOW

HOW TO WORK WITH A CHEMI- CAL OR PRODUCT. Knowing how to read and use warning labels and MSDSs is critical when working with chemicals.

Material Safety Data Sheet (MSDS)

Section I: Identity (Product Name) Manufacturer’s Name, Address, Telephone Number, Date of Preparation of MSDS Sheet Section II: Hazardous Ingredients Are Listed Section III: Physical and Chemical Characteristics Section IV: Fire and Explosion Hazard Data Flash point and temperature at which it ignites Extinguishing media What to put on the fire to extinguish it safely Unusual fire and explosion hazards Section V: Reactivity Data Stability: stable or unstable Conditions to avoid Incompatibility Dangerous substances that can be produced in reaction with the other chemicals or in atmospheric change Section VI: Health Hazard Data Route of Entry (Skin, Inhalation, Ingestion) Health hazards caused by the chemical (Acute or Chronic) Carcinogen (Whether the chemical can cause cancer) Medical conditions that may be aggravated by exposure First Aid and emergency procedures Signs and Symptoms of exposure Section VII: Precautions for Safe Handling And Use Clean-up techniques for spill and leaks How to dispose of waste materials properly Precautions in handling and storage Section VIII: Control Measures

Respiratory Protection Eye Protection Protective gloves Other PPE Ventilation Work/Hygiene Practices Page 3

2012 Huron Medical Center Annual Mandatory Module

Electricity is more than a conven- ience—we can’t provide excellent pa- tient care without it. But electricity can also be dangerous. Here’s what you can do to pro- mote electrical safety: You should discontinue use of any equipment if you receive a shock from it. All electrical equipment used in a patient care area must be either: 3-wire, battery powered, or double insulated with UL listing Equipment plugs should fit snug when plugged into electrical outlets. Use of space heaters is prohibited. Do not use any outlet that is loose—notify Plant Operations. Never pull plugs by the cord—always grasp the plug itself. Use conduction gel with all EKG monitoring/ defibrillation equipment. Report any instances of static electricity to Plant Oper- ations. Check cords for fraying and

• nicks. It is unacceptable to

patch cords with electrical tape—they must be replaced. Do not ―daisy chain‖ electrical power strips by plugging one into another. If your work area needs more electrical outlets, please contact Plant Operations. Huron Medical Center has backup electrical generat- ing capacity to insure a continuous electrical power supply to critical care areas, emergency lighting, and life safety systems. However, for critical patient care equipment to operate, it must be plugged into the RED EMERGENCY RECEPTACLES. Do not overload electrical circuits by using multiple adapters on a single outlet. A fuse blows/a breaker trips when the current flow exceeds the rating of the fuse/circuit breaker. If a breaker trips in your area, contact Plant Operations. Extension cords when needed will be provided by Plant Operations on a temporary basis only. Do not use damaged electrical equipment. Immedi- ately take such equipment out of service and fill out a maintenance repair request with date, your name, as well as a description and a location of the specific problem. Radiation is something you can’t smell, feel, or touch, but it can harm you if you are over-exposed. At Huron Medical Center, our Radiation Safety Committee monitors policies and procedures, as well as radiation exposure to ensure the exposure to radiation is kept as low as reasonably achieva- ble (ALARA). This is monitored quarterly by a radi- ation physicist, along with periodic inspections from state and federal agencies. The Radiation Disaster Plan 997.403.34 can be found in the hospital Safety Manual kept in your de- partment and/or supervisor’s office. The Radiation Disaster Plan lists emergency and decontamination procedures in the event of a radiation accident. Our Radiologist, Dr. David Carter, who is the Radiation Safety Officer and/or the Nuclear Medicine Technol-

• gist monitors any radioactivity should there be a

spill, leak, or a terrorist attack using radioactive ma- terials. You can eliminate unnecessary exposure by doing the following: Limit the amount of time you are exposed Stay a safe distance from the source Use proper shielding Other safe practices also apply: Wear personal protective equip- ment as required – including gloves, thyroid col- lars, and aprons. Wear a monitoring badge when indicated by your job to indicate what your exposure has been. Consult the Radiation Safety Officer or your su- pervisor if you have to work around radiation and you are pregnant. Be aware of instructions from the Radiologic Technologist when portable films are being taken

• r during any other radiologic procedure.

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2011 Huron Medical Center Annual Mandatory Module

2012 Huron Medical Center Annual Mandatory Module

Huron Medical Center prohibits physical, verbal, nonverbal or visual harassment, threats, intimida- tion or violence to employees, patients, visitors or guests of the organization. Any violence which

• ccurs on HMC’s property will not be tolerated.

In the event of a violent incident: A zero tolerance is applied for those engaging in verbal or non-verbal threats or related ac- tions of violence at HMC. No reprisal will be taken against any employees or medical staff members who reports or experiences work- place violence. An ―Occurrence Report‖ must be filled out to record any and all violent events, and filed with Risk Management within 24 hours. All employees, physicians and volunteers are responsible for the security of the facility. All incidents must be reported to your manag- er and documented on a ―Occurrence Re- port‖. Examples of conduct that may be considered a threat or acts of violence prohibited under this policy include, but are not limited to, the follow- ing: Hitting or shoving an individual. Threatening to harm an individual or his/her family, friends, associates or their property. The intentional destruction or threat of de- struction of property owned, operated or con- trolled by HMC. Making harassing or threatening telephone calls, or sending harassing or threatening let- ters or other forms of written or electronic communications. Stalking or making a credible threat with the intent of placing the other person in reasona- ble fear for his or her safety. Possession of firearms, weapons or any other dangerous devices on HMC property. How Do I Respond to Violence? In the event of imminent danger or in-progress physical assault: Employees should remove themselves from danger and call 911 immediately. If a firearm is involved, take whatever measures are necessary to protect yourself and others. An employee should never place herself or himself in harms way. Err on the side of cau- tion. In the case of a robbery, employees should not attempt to intervene. All employees should be aware of their envi- ronment and the people in it. Suspicious per- sons should always be reported to your man- ager and/or Safety Officer. Unauthorized persons should be escorted out

• f the building or to their appropriate destina-

tion. NO DOOR should be wedged or propped

• pen for any reason.

What Can Be Done to Help Prevent Violence? A ―Lockdown‖ may be initiated to restrict ac- cess into HMC buildings Contact law enforcement or other investiga- tion agencies. Non-employees may be expelled from HMC grounds, denied visitation rights or discharged from patient care if medically feasible, de- pending upon the severity of the threat or vio- lence. The Safety Officer will inform employees of threats to security and safety on a need-to- know basis. Descriptions of perpetrators or suspicious persons will be circulated to staff a s necessary. The Safety Committee will continue to assess risks and implement actions to improve safety and security.

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211 Huron Medical Center Annual Mandatory Module

2012 Huron Medical Center Annual Mandatory Module

The quality improvement/risk management process enables us to recognize problematic process issues, and to put safeguards in place to prevent human er- ror from reaching the patient. Tracking and trending process issues is an integral component of the risk management program. It is important for staff to be aware of their role in process improvements. Occurrence report forms are available on the hospital

• Intranet. Once completed, send them directly to risk
• management. Follow-up will be coordinated with the

department directors for process improvement activi-

• ties. The process for reporting employee incidents

and medication errors is different; please refer to those specific sections. If you have suggestions or ideas for improvement, please contact the risk man- agement department or your department director. The mission and vision of the risk management pro- gram is to focus on risk reduction and quality patient

• utcomes.

There are a number of essential functions related to the management of risk. Some risk management activities include, but are not limited to: Insurance coverage Claims monitoring Interfacing with defense counsel Complying with state and federal rules and regula- tions Implementing proactive risk evaluation and loss control Collecting, analyzing and reporting risk manage- ment data Coordinating the risk treatment and evaluation process Assisting in quality review and performance im- provement activities. Ensures data abstraction for core measures to op- timize compliance with standards.

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211 Huron Medical Center Annual Mandatory Module

ABBREVIATION POTENTIAL PROBLEM PREFERRED TERM

U for unit Mistaken as a zero, four or cc Write out ―unit‖ IU for international unit Mistaken for IV or 10 Write out ―international units‖ Trailing zero (2.0mg) or lack of leading zero (.2mg) Decimal point is missed and dose is to much or to little Never write a zero by itself after a decimal point (2mg) and always use a zero before a decimal point (0.2mg) MS, MSO4, or MgSO4 Confused for one another. Can mean morphine sulfate or mag- nesium sulfate Write ―morphine sulfate‖ or ―magnesium sulfate‖ QD for daily Mistaken for QID (four times daily) or QOD (every other day); the period can be mistaken for an ―I‖ or ―O‖ Write out ―daily‖ QOD for every other day Mistaken for QD or QID Write out ―every other day‖

Don’t Use These Abbreviations

2012 Huron Medical Center Annual Mandatory Module

2012 Huron Medical Center Annual Mandatory Module

The Utilization Review Department evaluates

• bservation and inpatient stays to ensure that

criteria set forth by insurances while being in the hospital is met. In conjunction with that, we make sure that patients meet criteria for staying within the hospital and are ready for

• discharge. We try to contain the cost of care
• provided. During normal business hours, this

review is done by the UR Coordinator, and after hours, the Nursing Supervisor fills this role. From the day of admission, discharge planning begins. Post-discharge plans and patient needs are assessed, and from that point, a Plan A/Plan B discharge is set

• up. The hospital Social Worker also assists those in

crisis and can help with agitated patients and/or fam- ily members. The social worker also does Mental Health and Substance Abuse evaluations. She can and will petition for guardian as needed. She should be first contact for these needs when she is in house

• r the consult is non-emergent.

Thorough documentation is a vital part of proper Utilization Review! The UR Coordinator also monitors for real time compliance with core measures.

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The purpose of the Safety Committee is to organize the efforts of the individuals to establish, sup- port and maintain the Safety Program that is based on Monitoring and Evaluation of organization- al experience and regulatory requirements.

The committee meets every other month. Committee Members: Dave Eilers - Chair; Utility and Life Safety Management Terry Peplinski - Sub Chair; Medical Equipment and Security Management, Safety Inspections Michelle Hammond - Employee Health Coordinator and Infection Preventionist Jeff Longbrake - Administration Representative Nancy Bouck - HR Representative Denise Warczinsky - PT/Rehab Representative Kathy Azarovitz - Sub Chair; Emergency Preparedness Becky Forster - Safety Education Rose Bucholtz - OR Representative Martha Van Belle - Pharmacy Representative Marc’l Neumann– Director of Nursing Elaine Jias– Director, Business Office Charlene Marks - Safety Committee Secretary Danielle Renn– Lab Representative Kirsten Schenk– Emergency Department Karen Collings- Nursing Admin

SAFETY COMMITTEE

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We’re on the Web: www.huronmedicalcenter.org

CDC HMC Respiratory Protection Program CMS Conditions of Participation QA/RM Plan HMC HAZCOM Program False Claims Act John Hopkins FEMA MIOSHA HIPAA Privacy Law MHA HIPAA Security Law OIG Compliance Guidance HMC Bloodborne Pathogens Plan Oklahoma State University HMC Emergency Preparedness Plan OSHA

Resources Newsletter Contributors

“Huron Medical Center is committed to providing excellence in healthcare to our communities in a caring, compassionate manner.”

Hospital Education/Community Outreach: Terry Atwell, Becky Forster and Heidi Walker Diagnostic Imaging: Matt Rick Human Resource Health Coordinator: Michelle Hammond Pharmacy: Martha VanBelle Rehabilitation Services: Matt Rick & Denise War- czinsky Quality and Risk Management, Compliance, Priva- cy: Carrie Franzel Safety Officer, Plant Operations: Dave Eilers and Jason Talaski

2012 Huron Medical Center Annual Mandatory Module