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In 1984 nurses were found to be fifth among workers in all occupations who
claimed workers compensation for back injuries.
Only heavy laborers ranked higher.
Not only is there a need for education and training with a focus on body mechanics.
There is also a need to develop alternative methods to decrease the stress that
causes overexertion injuries. If a task produces undue stress this should be
communicated to the Director of Nursing. If this is done, an alternative method
may be found in order to decrease the chances of injury.
It is what we do to our body’s everyday that is the cause of most back problems.
Back problems are usually the result of:
Poor Posture
Poor Every Day work Habits
Poor Body Mechanics
Insufficiently Flexibility
Lack of Strength and Endurance
The following are triggers that have been found to affect back pain or injuries in the Nursing or
O.R. setting:
• Standing for long periods of time
• Lifting and holding patients’ extremities
• Holding retractors for extended periods of time
• Transferring patients on and off of OR beds
• Reaching, lifting, and moving equipment; and
• Repositioning patients on OR beds
Posture:
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Posture is important no matter what position (standing, sitting or lying down) you are in and at all
times whether you have an injury or not. To be in a balanced posture means that you are handling
the forces of gravity in the most efficient way possible. To be unbalanced places chronic stress on
ligaments, muscles, and other structures, so that over a period of time they may fail.
Normally, the low back has an inward curve, as does your neck. The upper back has a slight
outward curve. Too little curve or too much curve can be harmful.
The curves need to be balanced in order for the spine to function as a good shock absorber and to
ensure that no structure takes too much load.
Problem Postures:
Standing:
A flat low back places increased load on the disc. A low back unbalanced in this way is a poor
shock absorber because all of the curves that are above it are diminished also.
An exaggerated curve in the low back places increased load on the little joints of the back that are
located between the vertebrae. The abdominal muscles are lax so there is poor support to the
spine from the abdomen.
Sitting:
Sitting itself places increased load on the discs of the low back. Slumped sitting makes it worse.
It also causes the head to move forward that strains the neck. If this is constant, muscles and
ligaments shorten and flexibility is lost so that proper posture can no longer even be achieved.
Lying Down:
A sagging mattress or one that is too hard can cause you to get up and feel stiff or in discomfort.
Therefore:
Stand with your knees relaxed, your shoulders over your hips and hold the back of your
head high. If you must stand to work, your work height should not require you to bend
forward. If you must stand still, having one foot up on a low rail or a block is relieving.
Sit with your feet on the floor, your knees and hips both at 90 degree angles, a small
support at your low back so the curve is maintained, and hold the back of your head high.
The depth of the seat should be such that your hips are all the way back in the seat and
your thighs are supported to within two inches from the crease at your knee. Have your
work at the proper height. In sitting, this might mean that you need to adjust your chair.
Support your feet on a stool if they do not reach the floor. Your arms should rest on your
desk, without pushing your shoulders up or causing you to slump.
If you work at a computer, the keyboard should be close enough so that your upper arms
are by your sides. Your forearms should be parallel to the floor and your wrists straight.
In this position, your hands will “float” over the keyboard.
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Your document holder should be at eye level so that you do not need to move your head
very much when looking from screen to copy. The top two inches of the screen should be
at eye level so that your eyes can scan down easily.
Sleep on a mattress that supports you in good alignment, but conforms to all of your
curves.
Change your position if you work overhead often, you need to crouch or bring your knees
to your chest periodically in order to restore flexibility in the opposite direction. If you sit
or drive for a long period of time, stop, stand up and bend backwards a little to restore
flexibility in that direction. Position changes help relieve stress.
o Keep your feet apart when lifting. A wide base of support keeps the load centered
over your base of support.
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o Pivot or turn with your feet instead of twisting or turning with your body.
Twisting and turning can weaken and increase pressure on discs and supporting
structures.
o Plan and practice whether you are able to handle the load safely.
o Lift with your legs. Leg muscles are powerful muscles that are designed for power
activities. As you perform the lift, keep your back erect and squat with your legs
to perform the lift.
o Approach the lift close to your body. Keep the load as close to your body as you
are able. A load held at arm’s length would be much harder to lift than a load held
close to the body.
o Keep your head up while you are lifting. Keeping your head up and level helps
keep the spine in its normal curves.
o Tighten the stomach muscles as you lift. This will add support to your back as you
lift.
o Move slowly and easy when lifting. Quick jerky movements can cause more strain
on muscles, joints, ligaments and bones.
Workstation Ergonomics
The following 5 easy steps to good ergonomics can help you assess your work station and make
simple adjustments that can improve your comfort and safety on the job.
1. Assess how comfortable you are at your workstation.
2. Adjust your chair- your chair affects your comfort more than anything else in your work
environment.
3. Reorganize your work area. A well organized and properly adjusted workstation can
improve efficiency and help prevent injury.
4. Check the lighting. Proper lighting can reduce eyestrain and help avoid headaches.
5. Make lifestyle changes. Regular exercise and getting enough sleep will go a long way
toward helping you feel better and work more comfortably.
1. Backrest: The backrest should fit snugly against your lower back. If it doesn’t, adjust the
backrest until your back is fully supported. If you can’t adjust the backrest, use a small
pillow to support the lower back.
2. Arm and Keyboard Position: With fingers on the middle row of your keyboard, your
forearms should be parallel to the floor. Your wrists should be straight and relaxed.
3. Foot Position: Your feet should rest firmly on the floor with 3-6 inches of leg room
between your lap and desk or keyboard tray. Your knees should be bent to 90-100 degree
angle. If your chair is not adjustable, and your feet do not touch the floor, use a foot stool
to support feet.
4. Screen Position: The top of the monitor should be at or below eye level. The screen should
be 18-30 inches from your eyes, or about arm’s length.
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5. Workstation: Arrange things most commonly used within easy reach. Document holders
should be at same height and distance as monitor. Your workstation should be free of
glare from light coming through outside windows, and overhead lighting should not create
glare on your screen.
OSHA:
OSHA’s 1999 Compliance Directive to protect US health care workers follows the California bill
passed on September 30, 1998.
Failure of health care facilities to implement and use safe needle devices puts health care workers,
especially nurses, at serious risk for contracting life-threatening diseases. This type of
occupational risk is unnecessary and preventable.
OSHA’s blood borne pathogen standard: The bill requires sharps prevention technology to be
included as engineering or work practice control, excepting technology that does not promote
employee or patient safety or that interferes with a medical procedure.
Employees should:
RADIATION SAFETY:
Two ways that you can encounter radiation in the healthcare environment are through
external beam sources or x-rays and radioactive materials that are put inside patients’ bodies to
treat disease.
It is the employee’s responsibility to read the Radiation Safety Manual. The Manual will be kept
in the Nursing Station with the Policy and Procedure Manual.
If you have any questions or are unsure of something, ask your Nursing Director or Radiation
Safety officer.
Fluoroscopy has proven to be an integral part of diagnosis and treatment of patients with various
clinical conditions. However, in 1994 the Food and Drug Administration (FDA) became
concerned with serious radiation induced skin injuries from fluoroscopic procedures and issued
various public health advisories concerning this. As more and more procedures move to the
ambulatory setting, it is important for the healthcare worker to understand ways to minimize
fluoroscopic exposure and to monitor that exposure.
With fluoroscopy, there is a continuous beam of radiation from the x-ray tube delivered to the
patient, which produces a real time radiographic image. This allows the physician to monitor the
exam/procedure “live” in order to provide accurate treatment.
The fluoroscopic unit is composed of an image intensifier, fluorescing screen, film, and an x-ray
tube producing the x-ray beam. The image intensifier increases the image brightness without
increasing the radiation exposure by converting the x-rays transmitted into a brighter light image
for viewing.
Fluoroscopic procedures can be diagnostic or interventional, with the latter providing the greater
doses.
Sources of Radiation Dose:
Three main sources of radiation dose to patients and personnel during fluoroscopy are primary,
leakage, and scatter.
Primary dose is the radiation from the useful beam used to produce the image. Therefore careful
attention to the fluoroscopic design and setup in the room is important. Controlling the input and
direction of the primary beam and thus the resultant scattered radiation, can reduce the radiation
risk to the patient and staff in the room.
Secondary radiation during fluoroscopy is scatter and leakage radiation. Scatter radiation results
when the primary beam interacts with the patient or other objects. In general, the intensity of the
scatter radiation equals 0.1% of the useful beam at a distance of 1 meter from the patient.
Leakage radiation occurs when the beam is activated. X-rays pass through the tube’s housing.
This occurs as long as x-rays are produced within the tube, but this radiation falls well below the
regulatory level.
Dose Exposure:
Absorbed dose is the amount of ionizing radiation absorbed per unit per mass at a certain point
within irradiated matter. Some of the largest doses to patients in medical imaging and intervention
occur with fluoroscopy. The largest dose occurs at the skin, where the radiation enters the patient.
The radiation absorbed dose unit is the rad or Gray. One Gy equals 100 rads.
National dose limits for exposure to ionizing radiation for workers and the general public have
been set by various regulatory agencies. No legal maximum doses have been set for patients due
to the great variability in patients and the types of procedures they need. However, it is the
clinician’s responsibility to limit the volume of exposed tissue and to keep the total dose to the
minimum necessary to complete the procedure to protect the patient.
Permissible doses for healthcare workers have been set, but the ALARA principle (as low as
reasonably achievable) is emphasized as the most important mechanism when handling
occupational exposure to radiation.
Radiation injury to the skin does not occur at low doses, but when a certain threshold is resulted
(~2 Gy); it can result in errythema and hair loss and progress to chronic skin ulceration. The
severity increases with increasing dose above the threshold dose. Genetic susceptibility to
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radiation as well as previous high doses from earlier procedures increases the risk of fluoroscopic
skin radiation injury.
While time between doses to the skin permits the skin to recover somewhat, it may not fully
recover. Large patients, especially those with connective tissue disease, diabetes mellitus,
homozygosity for ataxia telengiectasia or previous high dose fluoroscopes are at a greater risk for
skin injuries.
Before 1990, few reports of radiation skin injury occurred. However, in the 1990’s, the number of
cases reported increased due to lengthy high dose interventional procedures. Most were related to
cardiac catheter ablation and other cardiac procedures.
Minimizing Exposure by Personnel:
Overall, dose limit for imaging personnel is 5 REM per year. In addition, a maximum permissible
dose of 50 REM per year is for skin, hands, and feet.
Dosimeters should be worn by all personnel participating in fluoroscopic procedures per
established policies and physicist recommendations.
All personnel should use ALARA principle to minimize dose.
All personnel should wear protective garments such as aprons, thyroid collars, lead gloves, and
lead eyeglasses. Type of garment is dependent upon types of procedures performed.
Keeping Fluoroscopic Radiation Exposure to a Minimum:
The most basic and important way to reduce dose is to reduce time, increase distance from the
source, and use protective shielding.
Other ways to keep the radiation dose down is to keep the field of view smaller by adjusting the
collimators. Use the last image hold or “freeze framing” mechanism so that decisions can be made
on this static image and not while the beam is on. Make sure that the radiation is not continuously
turned on, but rather use an on and off routine instead.
During interventional procedures, care should be given to ensure that extraneous body parts such
as arms and breasts are not exposed to the beam. Periodically rotating the fluoroscope around a
center within the area of interest will distribute the total dose over a larger area of skin and thus
decreases chance of injury.
References:
Teresa G. Norris, B.A., Radiation Safety in Fluoroscopy. Radiologic Technology.
2002, 73: 511-533
United States Food and Drug Administration, Centers for Devices and Radiologic
Health. FDA Public Health Advisory: Avoidance of Seriously X-ray
Induced Skin Injuries to Patients During Fluoroscopically Guided
Procedures. Rockville, Md: Food and Drug Administration; September 30,
1994.
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SEXUAL HARASSMENT:
It is the policy of the Center to maintain a working environment free of all forms of sexual
harassment or intimidation. Sexual harassment includes, but is not limited to, sexual advances,
unwelcome sexual jokes, propositions, commentary about an individual’s body, sexual ability or
sexual deficiencies, touching, pinching or assault, obscene comments or gestures, requests for
sexual favors, display in the workplace of sexually suggestive objects or pictures, and other verbal
or physical conduct of sexual nature. Sexual harassment in any form is a serious violation of this
policy and will not be condoned.
Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a
sexual nature, when
1. Submission to such conduct is made either explicitly or implicitly
a term/condition of
employment, or;
2. Submission to or rejection of such conduct is used as the basis of
employment decisions; or
3. Such conduct unreasonably interferes with an employee’s work
performance or creates an
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For example, sexual harassment can include, among other things, unwelcome propositions,
flirtations and requests, whether express or implied, for sexual favors. It can also include other
unwelcome verbal visual or physical conduct of a sexual nature, such as unnecessary touching of
an individual, graphic or verbal commentaries about an individual’s body, sexually degrading
verbal abuse, a display in the workplace of sexually suggestive objects or pictures, sexually
explicit or offensive jokes and physical assault.
Any employee who feels that he or she has been the subject of sexual harassment from a
coworker, manager, patient, or any other person in connection with employment at the Center
should immediately report the behavior in question to the Nurse manager or designee. The
Director of Nursing or designee will obtain from the employee a signed statement describing the
harassment.
Appropriate collective action will be taken when a report of sexual harassment is validated. Such
corrective action may include a counseling report, observation period, suspension and / or
termination. In the event that the offending individual is not an employee, the Director of
Nursing in consultation with the Administrator will
take action necessary to prevent a recurrence of the incident in the workplace. The Center
prohibits retaliation against an employee who complains of sexual harassment. An employee who
knowingly makes a false report of sexual harassment or who provides false information will be
subject to disciplinary action, which may include termination.
CORPORATE COMPLIANCE
1. Staff Screening
The Center will not employ any person who the Center knows has been convicted of a criminal
offense related to healthcare or has been excluded from the Federal program participation.
2. Patient referrals
3. Billing
The Center will bill only for services that are medically necessary
The Center will bill only for services provided under proper supervision and by a licensed
physician.
Correct billing codes will always be used and the billing standards will be followed.
Medical records will be maintained that support billing codes.
The Center will not bill separately for services included in the composite rate.
Claims will not knowingly be up-coded or submitted in duplicate unless the duplicate is a
resubmission and marked as such
Billing errors will be promptly corrected and overpayments returned.
4. Patient records
Patient records will be kept in accordance with all Federal, State and local laws.
The staff will follow the Medical Records policy.
Managers
Oversees the Compliance program
Reviews of the Compliance checklist three times/year to ensure that the standards are met
Ensuring resolution of any deficiencies found or any complaints filed.
Complaints:
Violations will be reported to the Director of Nursing.
The Complaint form will be completed and given immediately to the Corporate Compliance
Officer/Director of Nursing.
The Director of Nursing and the Managers will decide what corrective actions to take.
If the person reporting the violation wishes to be anonymous they may leave an anonymous
complaint in the complaint box.
The Center will not tolerate retaliation against staff that report violations of the Center’s Policy.
Government Investigations:
The Center will comply with any government investigation
If a search warrant is presented ask for a copy and their business card of the agent.
Request an inventory of any items taken and have the agent sign.
Conclusion:
The Center is committed to monitoring and documenting the Center’s compliance with
appropriate Federal, State and local laws and regulations.
All staff members and physicians associated with the Center must acknowledge understanding of
the compliance program and comply with these standards.
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CUSTOMER SERVICE:
Think about what you are saying and how you say it.
Say Don’t Say
May I ask who is calling? Who’s calling?
He’s not in the office at the moment. He hasn’t come in yet. (In the morning)
She’s away from her desk at the moment. She’s on her coffee break.
He’s out of the office today He left early today.
She’s not in the office today She’s sick today.
He’s out of the office for the next two He’s on vacation for two weeks.
weeks
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• Do you let people finish what they are trying to say before you speak?
• If the person hesitates do you try to encourage him or her rather than start your reply?
• Do you withhold judgment about the person’s idea even if you do not like the person?
• Can you listen fully even though you think you know what he/she is about to say?
• Do you stop what you’re doing and give full attention when listening?
• Do you question the person to clarify his/her ideas more fully?
• Do you restate/paraphrase what’s said and ask if you got it right?
A good listener:
Does not judge but listens for feelings and facts
Pays attention to the content of the conversation
Listens completely first because this often makes people feel valued
Listens for the main idea
Avoids getting off the subject
Keeps good eye contact
Listens carefully, gives feedback, and asks for confirmation that they have understood the
situation correctly
Makes positive statements
Maintains patience while listening
When on the phone with a customer avoids:
o Arguing
o Rationalizing
o Defending
o Complaining
o Reacting
o Emotionalizing
o Promising
o Insuring
Explain how the customer can complain further:
Give a phone number and a name
Avoid using irritating words, including:
Can’t
Can’t help you
You should have
All we can do
It is company policy
You have to
Instead, ask what they want:
• What would you like for us to do?
• What will work best for you?
Be courteous and caring:
• Let me take care of that for you
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Reference: 1995, Fred Pryor Seminars, “How to Deliver Exceptional Customer Service.”
The Center promotes patient safety through the recognition and acknowledgement of risks to
patients, visitors and staff safety and the initiation of actions to reduce these risks. The Center
recognizes that the need for improvement is rarely the fault of an individual; therefore our
improvement activity focuses on the processes and systems of care and services that may be
changed to provide high quality of care in the safest environment.
At the Center all individuals are responsible for providing the highest quality of care and services
and maintaining a safe environment. Each individual that provides care in the Center must be
active in identifying all quality and safety concerns or ideas for improvement to the Director of
Nursing or designee. You will be asked to participate in specific improvement activities in the
Center to make every effort to ensure quality of care continues to be provided in the Center.
Electrical Safety:
Everyone needs to understand the hazards of electricity and to follow safety precautions.
Unsafe use of electricity can cause fire explosion, shock, and burns. This can result in injury,
disability, and death.
All electrical equipment used for patient care in the Center must be inspected by the biomedical
department before it is used in the Center.
Always grasp the plug, not the cord when removing it from a socket.
Keep all electrical lights and equipment clean and free of dust, paper or anything that could
possibly start a fire.
Check all cords for fraying and loss of insulation.
Do not use extension cords.
All electrical devices should be properly grounded with 3-prong plugs.
Avoid sparks in oxygen-rich environments as oxygen supports combustion.
Do not handle electrical equipment with wet hands. Never touch an electrical device and
plumbing at the same time.
Disconnect any electrical device that sparks, smokes, smells, stalls, blows a fuse or gives you a
shock.
Remove defective electrical devices from circulation and report it to the biomedical technician
immediately.
In a case of electrical shock, Do not touch the person, equipment or wire causing the shock
hazard. This could result in a shock to you. First, turn off the current from the main source.
All gas cylinders are color coded when they arrive to the Center. Green is oxygen, yellow is air,
black is nitrogen, gray is CO2, and blue is nitrous oxide.
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Never interchange regulators that are not intended for use with that specific gas or gas blend.
Do not attempt to modify or repair cylinders.
Always store cylinders in an upright position in a cylinder container or chained to the wall. If no
cylinder container is available, the cylinder may be placed lengthwise on the floor. Open valves
on cylinders or regulators slowly. Cylinder valves should remain in the closed position when not
in actual operation. Know your job responsibilities for working with medical gases. The Medical
Gas room is used for storage of all large supply tanks. It is kept locked at all times. The Director
of Nursing or designee will be responsible for switching over all main supply tanks. You are
responsible for reporting any alarms on the medical gas alarm panel immediately to the Director
of Nursing or designee. Knowing the location of all shut off valves in the Center is your
responsibility. Shut off valves are only used with prior authorization of the Director of Nursing or
designee.
Patient Safety:
Patient safety is everyone’s responsibility. Ways to keep patients safe includes:
• Verifying a patient’s identity at least two ways, (i.e. name and birthdate or name and
medical record number) before going ahead with any interaction.
• Washing hands between each patient encounter to prevent the spread of infection.
• Reporting abnormal lab values to an appropriate person.
• Repeating any verbal orders back to the prescriber to ensure the communication was
accurate.
• Reporting any environmental hazard immediately to the person in charge.
• Knowing what to do in an emergency.
Unexpected Outcomes:
Unexpected outcomes and events can result in the patient, employee or visitor being injured,
damaged equipment, loss of time at work and expense to the Center. Whenever an event occurs
that is in any way out of the norm it is important to report the occurrence so that the Center can
learn from it and prevent it from happening again. In order to facilitate this, the Center has a
reporting system of such occurrences. Everyone is accountable to report these unexpected events.
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If you are a State licensed center, serious preventable adverse events need to be reported by
calling 609-633-7759. See Revised Mandatory Patient Safety Reporting Requirement
Booklet for specific guidelines/definitions.
A confidential incident report must be completed whenever there is a patient or visitor occurrence
that is not consistent with the accepted routine of the Center which either did or could have
resulted in injury or loss to a patient/visitor or which might otherwise give rise to a claim against
the Center, employee of the Center or a member of the staff. Individuals discovering an incident
must initiate, process and deliver an incident report to the Director of Risk Management within 24
hours of the occurrence, if a patient/visitor should have an incident, which is not witnessed by an
employee, the person who is notified of the incident should complete the incident report.
Serious preventable adverse events need to be reported via faxing a completed form to 609-
984-7707 within 5 business days after the facility discovers the occurrence of the event.
“Reported” means completion of the event form and receipt of the form by Patient Safety
Initiative. Fax confirmation will be sent upon receipt.
Always remember that the purpose of reporting is to determine facts- not fault.
Be aware that an encounter with a lock or tag on an electrical switch or device indicates the
equipment is “out of service” and should not be used. Only the authorized person who affixed the
lock or tag may remove it.
Procedure:
It is part of the Center’s policy to provide continuous ongoing monitoring and evaluation of all
medical devices and equipment utilized in patient care.
Any mechanical electrical device utilized by this Center that results in death, serious injury, or
illness to any individual shall be reported to the manufacturer of said device if known and Food
and drug Administration FDA
Depending on the severity of the event, immediate telephone (or fax) contact will be made with
the manufacturer and the FDA
In all cases, written, detailed documentation shall be prepared by the Center and submitted to the
manufacturer and the FDA
Summaries from incident reports and medical records shall be provided as appropriate.
When possible and appropriate pictures shall be taken of the event
Hazardous Materials:
Healthcare workers use chemical substances every day. Some chemicals may be life-saving (such
as pharmaceuticals), but other s may put you and your co-workers at risk.
Material Safety Data Sheets (MSDS) provides detailed information on chemicals and their
hazards, and what to do in case of a spill or injury. There is a MSDS book located at the Nurse’s
Station that includes all of the chemicals stored and used. These chemicals are in alphabetical
order and also are divided in alphabetical order by location.
EMERGENCY PREPAREDNESS:
In the event of an internal or external disaster the Center has a plan of action to follow.
The Policies are located in the Emergency section of the Policy and Procedure Manual.
Internal Disaster is an unexpected occurrence within or immediately outside of the Center which
would render the Center unstable or unsafe for patient care.
External Disaster is a situation which occurs out in the community and involves the Center
receiving causalities.
The Code for Disaster is “Disaster Plan is in effect”. When this code is called you should report
to the Director of Nursing or designee for specific instructions.
The Administrator/Director of Nursing or designee is responsible for the overall direction of the
Center in case of a disaster.
Any employee who receives a telephone bomb threat should immediately call the
Administrator/Director or Nursing or designee who will contact the Police Department with the
specific details concerning the threat. If you receive the call you should report everything
possible about the call, tone of voice of the caller, time and location of the explosive device. See
the Policy on Bomb Threat located in the Emergency section of the Policy and Procedure Manual
for more information.
Refer to the Policy on Code “B” in the Emergency section of the Policy and Procedure Manual
for further instructions.
CODE BLUE
An emergency situation in which an individual in the Center stops breathing and or has no
palpable pulse.
Hit intercom 32* and announce CODE BLUE and give your location 3 times.
Refer to the Policy on Code Blue located in the Emergency section of the Policy and Procedure
Manual for further instructions.
CODE “5”
This is an emergency situation in which assistance is needed to control the behavior of someone
who is endangering themselves or others.
Refer to the Policy on Code “5” in the Emergency section of the Policy and Procedure Manual for
further instructions.
This is an emergency situation in which assistance is needed either internally due to an internal
disaster in the Center or for an external emergency in which assistance may be needed to care for
individuals who have been injured in the Community.
Refer to the Policies on “DISASTER” in the Emergency section of the Policy and Procedure
Manual for further instructions.
CODE “T”
Refer to the Policy on Code “T” in the Emergency section of the Policy and Procedure Manual for
further instructions.
CODE “H”
Refer to the Policy on Code “H” in the Emergency section of the Policy and Procedure Manual
for further instructions.
FIRE SAFETY:
Fire safety is an important part of your job. Fire is a serious threat to health care facilities. All
employees must know how to respond appropriately if a fire occurs.
Four causes of fires are faulty electrical equipment, pressurized oxygen, flammable liquids and
gases and smoking. The Center has a no smoking policy. Smoking within the facility or by any
of the entrance areas will result in disciplinary action or termination.
Activate the nearest pull station located at the entrance or exit doors of the building
Hit intercom 32* and call the code overhead X 3 “Code Red” and the location of the fire.
Example:
“Code Red Soiled Utility Room O.R. Corridor”
“Code Red Soiled Utility Room O.R. Corridor”
“Code Red Soiled Utility Room O.R. Corridor”
Types of Extinguishers:
ABC Fire extinguishers are available in the Center. They are used on all types of fires.
If the threat of a real fire exists, a plan for the evacuation of patients must be initiated.
The evacuation policy is located in the Policy and Procedure Manual.
Procedure:
If a fire alarm or sprinkler system is out of service for more than 4 hours, the fire authority is
notified and the building is evacuated, or an approved fire watch is established until the system is
brought back into service.
The Fire Alarm and Sprinkler systems are serviced and tested twice a year.
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BIOTERRORISM:
When dealing with an act of bioterrorism the Disaster Plan will be put into effect. The
Evacuation Plan will be used if the act of bioterrorism is internal. If the act of bioterrorism is
external the Community Disaster Plan will be activated. It will be the responsibility of the
Director of Nursing or designee to contact proper authorities. This will be done to ensure that all
necessary actions are taken and to ensure that the building is deemed safe prior to re-entering the
facility.
First Call 911
Police will dispatch a police officer who will direct all further proceedings
CHEMICAL AGENTS: There are many chemical agents including Sarin, VX, Mustard gas,
Lewsite, CX (Phsogeneoxime) and Cyanide. A massive dose or close contact to the proximity in
which it is released will cause a very sudden and overwhelming reaction. Those who have a
minimal exposure will need treatment.
Most chemical agents will require some sort of decontamination. A person in contact with the
chemical agent may be required to just remove and bag their clothing. There might be cases
where complete decontamination will take place and require the use of personal protective
equipment by the Center staff. A specialized suit called a Tyvek suit, boots, gloves and a self-
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contained breathing apparatus PAPR will be used. It is necessary to be trained in the use of this
equipment. The Office of Emergency Management will instruct the Center on needed
decontamination.
BIOLOGICAL AGENTS
Anthrax is caused by a spore forming bacterium called Bacillus anthracis. It may occur in three
forms, cutaneous, inhalation and gastrointestinal. Person to person transmission is rare. Standard
precautions should be used. Disinfect surfaces with bleach and water 1:10 fresh dilution.
Plague is a bacterial infectious disease caused by Yersinia pestis. There are two types of plague:
bubonic and pneumonic. An intentional aerosol dissemination of Yersina pestis would produce
an outbreak of primary pneumonic plague. The incubation period is 1-4 days. Patient should be
placed on Droplet precautions. If the patient needs to be transported with in the Center a mask
will be applied to that patient.
Smallpox is caused by the variola virus. Skin lesions appear on the face and extremities
including palms of the hands and soles of the feet. It differs from chickenpox in that skin lesions
appear simultaneously all over the body. In chickenpox the skin lesions appear in waves of
vesicles.
Smallpox is transmitted by both airborne droplets and contact. Patients should be placed in a
negative pressure room (TB isolation rooms or use of HEPA filter). Disposable gowns and
gloves as well as a N95 respirator mask must be used. All personal protective equipment (PPE)
must be removed before leaving the patients room. Hands must be washed with either soap and
water or waterless soap. The small pox vaccine is the only known protection against smallpox.
Those caring for a smallpox patient should have been previously vaccinated and have a scar at the
vaccination site.
EVACUATION PROCEDURES:
Horizontal Evacuation:
Removing patients to a safe area on the same floor. Patients can be moved laterally by wheel
stretcher bed, non-wheeled stretcher, wheelchair, blanket or other conveyance to the nearest and
safest protected area on the same floor. Patients in immediate danger will be moved first,
including those who might be separated from safety if the danger should enter the area.
Ambulatory patients will move next to a safe area. Rooms will be searched for stragglers and all
doors closed when the rooms are vacated. A patient count should be made to insure that all
patients are accounted for.
Vertical Evacuation:
Removing patients to a safe area on a lower floor. Vertical evacuation or downward movement of
patients to a safe area on the floor below or out of the building may be necessary should danger
spread out of control. Ambulatory patients shall be instructed to line up outside the suite and
form a chain by holding hands and following a lead monitor. The monitor will lead ambulatory
patients to a safe area, stairway or exit. Non-ambulatory patients will be moved using the “carry
method” to a safe area.
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When traveling through smoke, keep low. Smoke and heat rises. Crawl along the floor if you
must, but remain low.
Do not run, or let anyone run in smoke filled areas.
When going through smoke, cover the patients face, as well as your own from the nose down.
Should evacuation be necessary through fire or extremely hot areas cover the patient with a wet
blanket.
Do not touch anything. Watch for falling debris, wires, etc.
Do not open a door into an area where a suspected fire might be. Even if the door is not warm, do
the following before opening the door. Should a fire be on the other side this will aid you in
closing the door instead of letting the fire blast through.
Exit/Assembly Areas:
A primary and secondary area has been established and must be used as instructed.
Primary is the front exit and assembly in the parking lot .
Secondary is the back exit and parking lot.
See the Emergency Section of the Policy and Procedure Manual for further details.
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According to 2009 State and Federal Requirements, patients have the right to receive information
on specific topics prior to the date of the procedure.
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PROCEDURE:
A. Advance Medical Directive: The patient will be asked if he/she has an Advance
Medical Directive in effect that the Center should be aware of. The status of such
Advance Medical Directives shall be noted in a prominent place in the patient's
chart. The patient will be advised that the Center does not acknowledge Advance
Medical Directives. If the patient wishes to have Advance Medical Directives
acknowledged, the Center will assist the patient in finding a hospital that will be
able to provide the patient care.
B. Patients’ Rights and Responsibilities: The patient will receive a copy of the
Patient Bill of Rights and Responsibilities. This document will also be posted at
the Center in the Waiting Room and Holding/Pre-Op area.
In such situations the ASC must provide the required notice prior to
obtaining the patient’s informed consent.
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All patients and staff shall be informed of and follow Patient Rights policies.
OBJECTIVE
To make every effort to ensure considerate and appropriate care with the patient's complete
understanding and cooperation.
PROCEDURE
Is posted in a conspicuous place in the Surgical Center. (The waiting room and Holding/
Pre-op area.)
In addition to this:
A sign will be posted regarding the address to file complaints about the
Center.
A complaint box will be placed in the waiting room for individuals to file
complaints.
Patient surveys will be placed beside the complaint box in order to facilitate the
filing of any positive or negative comments regarding the Center.
A complaint log will be kept in the Center to make every effort to ensure complaints are
investigated and addressed.
o Be informed if the facility has authorized other health care and educational institutions
to participate in the patient’s treatment. The patient also shall have a right to know the
identity and function of these institutions, and to refuse to allow their participation in
the patient’s treatment and to change physicians if he or she so wishes;
o Receive from the patient’s physician(s) or clinical practitioner(s), in terms that the
patient understands, an explanation of his or her complete medical/health condition or
diagnosis, recommended treatment, treatment options, including the option of no
treatment, risk(s) of treatment, and expected result(s)/outcome(s). This shall occur
prior to any treatment being performed. If this information would be detrimental to the
patient’s health, or if the patient is not capable of understanding the information, the
explanation shall be provided to the patient’s next of kin or guardian. This release of
information to the next of kin or guardian, along with the reason for not informing the
patient directly, shall be documented in the patient’s medical record;
o Receive as soon as possible, the services of a translator or interpreter if you need one
to help you communicate with the Center’s health care personnel free of charge;
o Make informed decisions regarding care.
o Participate in the planning of the patient’s care and treatment, and to refuse medication
and treatment. Such refusal shall be documented in the patient’s medical record;
o Change primary or specialty physicians if other qualified physicians are available.
o Continuity of health care. The physician may not discontinue treatment of a patient as
long as further treatment is medically indicated, without giving the patient sufficient
opportunity to make alternative arrangements;
o Be included in experimental research only when the patient gives informed, written
consent to such participation, or when a guardian gives such consent for an
incompetent patient in accordance with law, rule and regulation. The patient may
refuse to participate in experimental research, including the investigation of new drugs
and medical devices;
o Voice grievances or recommend changes in policies and services to facility personnel,
the governing authority and /or outside representatives of the patient’s choice either
individually or as a group, and free from restraint, interference, coercion, discrimination,
or reprisal;
o Use the grievance procedure to document the existence, submission, investigation, and
disposition of a written or verbal grievance to the Center.
o Documentation by the Center of all alleged violation/grievances relating, but not limited
to, mistreatment, neglect, verbal, mental, sexual, or physical abuse.
o Have all allegations reported to the person in authority of the Center.
o Have substantiated allegations reported to the state authority or the local authority, or
both.
o Be provided with timeframes for review of the grievance and the provisions of a
response.
o Voice grievances and to investigation of all grievances made regarding treatment or
care that is (or fails to be) furnished.
o Written notice of the Centers decision which must contain the name of a facility contact
person, the steps taken to investigate the grievance, the results of the grievance
process, and the date the grievance process was completed.
o Exercise his/her rights without being subjected to discrimination or reprisal.
o Be fully informed about a treatment or procedure and the expected outcome before it is
performed.
o Have the person appointed under State law to act on the patient’s behalf if the patient
is adjudged incompetent under applicable State health and safety laws by a court of
proper jurisdiction
o Be free from mental and physical abuse, free from exploitation, and free from use of
restraints unless they are authorized by a physician for a limited period of time to
protect the patient or others from injury. Drugs and other medications shall not be
used for discipline of patients or for convenience of facility personnel;
o Appropriate assessment and management of pain. To education, including education
for the patient’s significant others (if applicable), regarding pain and symptom
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o The administrator shall provide all patients and/or their families upon request with the
names, addresses, and telephone numbers of the following offices where complaints
may be lodged:
The Office of Acute Care Assessment and Survey
Division of Health Facilities Evaluation and Licensing
New Jersey State Department of Health
PO Box 358
Trenton, New Jersey 08625-0358
Telephone: (800) 792-9770 (609) 292-9900
State of New Jersey
Office of the Ombudsman for the Institutionalized Elderly
PO Box 852
Trenton, New Jersey 08625- 0852
Telephone 1-877-582-6995
www.cms.hhs.gov/center/ombudsman.asp
The Administrator shall also provide all patients and or families upon request with the names and telephone numbers of offices
where information concerning Medicare and Medicaid coverage may be obtained.
Addresses and telephone numbers shall be conspicuously posted throughout the facility, including, but not limited to, the
admissions waiting area or room, the patient service area of the business, office and other public areas. The Center needs the
cooperation of its patients to ensure that efficient, safe and considerate care is available to all patients.
Patients are responsible for:
a. Providing physicians, center personnel and healthcare providers
with complete and accurate information about their medical
history and complete and accurate information related to their
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All services provided by the Center are available without distinction to all patients and visitors
regardless of race; creed; color; ethnic origin; nationality; sex; handicap; age; affiliation with
fraternal or religious organizations; cultural, economic, or educational background; or source of
payment for care.
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In addition, to all persons and organizations having occasion either to refer persons for services or
recommend the Center are advised to do so without regard to: race; creed; color; ethnic origin;
nationality; sex; handicap; age; affiliation with fraternal or religious organizations; cultural,
economic, or education background; or source of payment for care.
The Center will provide qualified sign language interpreters and other auxiliary aids to sensory
impaired persons and translators for individuals whose primary means of communication is not
the English language.
It is the responsibility of the attending surgeon to notify the Center in advance that a sensory
impaired or non-English speaking person has been scheduled for surgery and will require this
type of service so that arrangements can be secured.
Such interpreters and auxiliary aids will be made available at no cost to the patient.
RESPONSIBILITY:
The Administrator/Director of Nursing is designated to coordinate compliance with Title IX of
the Educational Amendments of 1972, Section 504 of the Rehabilitation ACT of 1973 (non-
discrimination against the handicapped), Title VI of the Civil Rights Act of 1964, and the Age
Discrimination Act of 1975.
PROCEDURES:
A. All new personnel are to be instructed to review this policy as part of their general
employee orientation.
B. When the facility is notified that a patient will require an interpreter and/or
auxiliary aids, the Nursing Director/Administrator will be notified so that
appropriate arrangements can be made with an outside source or a family member.
C. If a member of the patient’s family is available and willing to provide these
services for the patient, he/she will be permitted to do so, with the patients consent.
D. The admitting nurse will document on the consent form the interpreter’s name, and
if applicable, the type of auxiliary aids used.
E. An appropriate copy of this policy will be conspicuously posted in the Center.
F. This policy shall apply to all employment opportunities, Professional Staff
applications, patients, visitors, and Board of Director Memberships.
If an interpreter is not available on site, the ATT Language Line will be utilized to
communicate with the patient. The number is: 1-800-528-5888.
New Jersey Relay Service (NJRS) will be utilized to communicate with hearing impaired
patients. The number is 800-852-7897. 711 may also be dialed from most phones in New
Jersey.
CONFIDENTIALITY:
Patient confidentiality is making sure that you keep the information about the patients’ health care
private.
Confidentiality protects patients from embarrassment, disclosure of information to the wrong
people and discrimination. It also safeguards your patient’s right of privacy.
Examples include:
Details about their illness or condition
Information about treatments
Photographs or videos of a patient
Conversations between a patient and a health care provider
Patient information on a computer
PROCEDURE:
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A. Prior to the procedure and at the time of registration, the patient will be asked if
he/she has an Advance Medical Directive in effect that the Center should be aware of.
Advance Medical Directives address such issues as living wills and durable powers of
attorney. Patients will be provided, in advance of the date of the procedure, information
concerning policies on advance directives, including a description of applicable State
health and safety laws, and if requested, official State Advance Directive forms, unless the
referral to the ambulatory surgical center for surgery is made on that same date; and the
referring physician indicates, in writing, that it is medically necessary for the patient to
have the surgery on the same day, and that surgery in an ambulatory surgical center setting
is suitable for that patient. In such situations the Center will provide the required notice
prior to obtaining the patient’s informed consent.
If the patient does not have an Advance Directive, he/she will be offered
information regarding an Advance Directive and may fill one out in the Center, if
he/she wishes.
B. The existence of such Advance Medical Directives shall be noted on the patient's
chart. The Center does not acknowledge Advance Medical Directives. If the patient
wishes to have Advance Medical Directives acknowledged, the Center will assist the
patient in finding a hospital that will be able to provide the patient care.
C. The Center Administration shall periodically monitor the legal status of Advance
Medical Directives with the Center's attorney and track State and
Federal Regulations as they are modified.
Note: The patient has the right to documentation in a prominent part of the
patient’s current medical record, whether or not he/she has executed an
advance directive.
All employees as members of the health care team must establish relationships with the patient
and/or family member or significant other and take into consideration the age and developmental
stage of the individual.
Be Aware that:
The adult has a need to be valued and a productive member of society
The economic responsibilities of the adult may cause denial of illness and resistance to
compliance with treatment and the discharge plan.
There is a need to be active in all aspects of the decision–making related to their care.
Be honest with them.
Encourage them to ask questions about their care.
Be complimentary, encouraging and interested.
There is an increased risk of stress related illnesses. There is a desire for independence.
Recognize fear of loss for self, spouse and friends that will influence their response to treatment.
Encourage them to be independent in their activities as much as possible.
Speak clearly and slowly with direct eye contact.
Speak with respect and utilize language appropriate for an adult.
Do not treat the older adult like a child.
Speak directly to the patient regarding their care.
Facilitate safety in their environment.
Allow the patient to express his/her feelings of anger, frustration, powerlessness or anxiety.
These patients are vulnerable to injury due to slower decision-making and responses to stimuli
reduced visual and hearing acuity and reduced balance and equilibrium. Maintain lighting and
make sure hallways are clear of obstructions. Remove unnecessary equipment from treatment
areas and patient’s rooms. Keep noise to a minimum.
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Procedure:
1. Any physician/staff member suspected of drug/alcohol impairment is to be
reported to the Nursing Director or her designee immediately
2. The Nursing Director or her designee, after speaking with the person, may deem
him/her unfit to function in their required capacity.
3. The Nursing Director will immediately notify the Medical Director of the situation
if it involves another physician. The Medical Director will speak to the physician in
question. In the meantime, the Nursing Director has the authority to postpone the surgery
until the Medical Director speaks to the physician.
4. If the person in question is a center employee, the Nursing Director will not allow
the person to work. The employee will be sent home as an unpaid day off. Arrangements
will be made to get the employee home safely. An incident report will be written and
follow-up disciplinary action will proceed when the employee reports to work next.
5. In the event that surgery has begun and a physician becomes incapacitated, the
PACU nurse will take the physician to PACU and take charge of caring for him/her while
the Nursing Directors will notify the Medical Director and any Professional Staff Member
that can be reached, to the degree permitted by his/her license, to do everything possible to
save the patient’s life or prevent serious harm.
6. In the event that surgery has begun and a Center employee involved in the case
becomes incapacitated, the person will be taken to PACU for care while the Nursing
Director will complete the surgical procedure.
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When abuse is suspected, many victims will confirm the diagnosis when question in a
direct, non-threatening, non-judgmental manner.
For Example:
Have you ever experience a relationship in which you were hit, punched, kicked,
threatened or hurt in anyway? Are you in such a relationship now?
You mentioned your partner uses drugs/alcohol. How does your partner act when
drinking or on drugs. Is he verbally abusive? Is he physically abusive?
You mentioned that your partner loses her temper with the children. How are
things between the two of you.
Your seem to have some special concern about your partner. Can you tell me
more? Are you fearful? Has he ever hurt you?
Do your verbal fights include physical contact?
Many patients tell me that they had an argument with a partner and later state they
were beaten. Could this be happening to you? Are you being beaten?
Sometimes when a partner is overprotective and is jealous as you describe, they
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react strongly and use physical force. Is this happening in your situation?
I notice you have a number of bruises. Could you tell me how they happened?
Did someone hit you?
Health professionals need to be alert for signs and symptoms of elderly abuse and/or
neglect and to be aware of situations that provoke these incidents so that appropriate intervention
can result. The elderly person may openly admit that they have been abused or neglected, but
more often they deny the situation due to pride or fear of retaliation, isolation, abandonment, or
institutionalization. A thorough assessment is essential to identify subtle characteristics that
might suggest abuse/neglect is occurring.
When abuse is suspected, many elderly victims will admit to the abuse when asked questions in a
straightforward and non-judgmental way such as the following. Be sure to allow enough time for
the patient to respond:
Have you ever been hit, punched, kicked or hurt in any way?
What is your relationship with your caregiver? How does she/he treat you?
I have notice you have a number of bruises, could you tell me how they
happened?
How many meals a day do you eat? What do they consist of?
1. Child abuse/neglect must be reported to the Nursing Director or her designee who
will contact the Division of Youth and Family Services at 1-800-792-8610.
BY LAW, HEALTHCARE PROVIDERS MUST REPORT CHILD
ABUSE/NEGLECT.
2. Adult and Elder abuse/neglect must be reported to the Nursing Director or her
designee who will contact the appropriate social service. If the victim is from the
community, the Warren County Department of Citizen Services, Division of
Welfare would be contacted. Ask for Adult Protective Services. The telephone
numbers is 908-475-6591.
Somerset County Adult Protective Services: 908-526-8800.
Morris County Adult Protective Services: 973-326-7282.
3.
If the elder victim is from an institution (boarding home, nursing home), that
situation would be reported to the Office of Ombudsman, State of New Jersey
at 1-877-582-6995.
In addition to contacting the Social Worker and Protective Services call the local police
department for assistance.
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Purpose: To attempt to identify and/or report suspected child abuse to the proper authorities
Policy: Cases of suspected child abuse must be reported to the proper authorities
Procedure:
Questions parents as to possible cause if initial examination discloses bruises,
scratches, etc. Also note parents’ reactions to the questioning.
Record rapport between parents and child, post findings on patient’s chart and
report same to physician
Follow the procedure for reporting child abuse in New Jersey whether the
physician agrees with your findings or not.
Under the law an abused or neglected child is defined as any child under 18 years of age:
- Whose parent or guardian inflicts or allows to be inflicted upon the child
physical injury through other than accidental means which results, or
potentially could result, in a substantial risk of death, a serious prolonged
disfigurement, or impairment or loss of the function of any bodily organ;
Any staff member who suspects a child is being abused must report this to the Nursing Director or
their designee immediately. It is the responsibility of the Nursing Director or designee to report
suspected cases of abuse to the appropriate authority.
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LATEX ALLERGY:
Latex allergy or hypersensitivity is a recognized health problem and occupational risk for
healthcare workers. The risk of developing a latex allergy keeps rising because the more frequent
the contact with latex products the higher levels of the latex allergen you are exposed to.
People at highest risk are healthcare workers or any person whose job regularly requires them to
wear latex gloves and people who have had multiple surgeries.
Other people at high risk are people with certain food allergies such as banana, kiwi, avocado,
chestnut, and pineapple.
Contact Dermatitis: this is an irritant reaction to the chemicals used during the processing of the
latex or to the powder that’s added to the gloves. The usual symptoms are skin redness and
itching.
Type IV Hypersensitivity: a cell-mediated allergic reaction to the chemicals that are used during
the processing of latex, not the latex itself. This is not a true latex allergy. The symptoms are
redness, itching and possibly hives. If the powder is inhaled there may be red, itchy, runny eyes or
nose and coughing.
Type I Hypersensitivity- an IgE-mediated allergic response, which has the potential to be life
threatening. This is a true latex allergy. Symptoms may be localized or systemic and can include
hives, generalized edema, itching, rash, wheezing, difficulty breathing, diarrheas, nausea, low
blood pressure, rapid heart rate, feeling faint and in severe cases- respiratory or cardiac arrest.
The admitting RN will assess all patients for a history of latex allergy during the pre-op phone
interview.
Patients identified with a latex allergy who are admitted to the Center will be provided with a
latex-free environment.
Patients with a latex allergy will be identified with an allergy sticker placed on the front of the
patient’s chart.
55
POLICY: SURGICAL HAND SCRUB PROCEDURE
Purpose: Although scrubbed members or the surgical team wear sterile gloves, the hands
and forearms should be cleaned preoperatively for every invasive procedure to
reduce the number of microorganisms in the event of glove tears. The purpose of
the hand scrub is:
1. to remove debris and transient microorganisms from the nails,
hands and forearms;
2. to reduce the resident microbial count to a minimum; and
3. to inhibit rapid rebound growth of microorganisms.
Policy: A surgical hand scrub shall be done by surgeons and scrub personnel prior to surgical
intervention
General information: Prior to each scrub, use A) a disposable pre-filled brush of Iodophor
Solution with detergent or a pre-filled brush of parachlorometaxylenol
(PCMX) cleansing solution or B) Chlorhexadine Gluconate 1% Solution
and Ethyl Alcohol 61% w/w (Avagard):
Fingernails should be free of polish and trimmed short. Cuticles should be in good
condition. Artificial nails should not be worn.
Hands and forearms should be free of open lesions and breaks in skin integrity.
Procedure A:
Thoroughly moistened hands and forearms should be washed using an approved scrub
agent before beginning the surgical scrub procedure.
Subungual areas should be cleaned under running water using a nail cleaner.
An antimicrobial agent should be applied with friction to the wet hands and forearms.
Fingers, hands and arms should be visualized as having four sides; each side must be
scrubbed effectively.
Hands should be held higher than the elbows and away from surgical attire.
56
Brushes or sponges used should be discarded appropriately.
57
Care should be taken to avoid splashing water onto the surgical attire.
Rinse each hand and arm with clear water being sure to hold hands above elbows, so that
the water from above elbow does not flow back onto arms. Caution must be taken
not to hit faucets during rinsing. Hold arms in upright position allowing most of
water to run off before entering operating room.
Procedure B:
1. Apply to clean, dry hands and nails.
2. For the first use of each day, clean under nails with a disposable, surgically
clean
(not sterile) nail cleaner.
3. Do not use water. Be sure hands are dry when using Avagard hand prep.
4. Pump #1: Dispense 1 pump (2ml) of Avagard antiseptic hand prep into the
palm of
One hand. Dip the fingertips of the opposite hand into the hand prep and work it
under the nails. Spread the remaining hand prep over the hand and up to just above the
elbow, covering all surfaces.
58
THE CHAIN OF INFECTION:
Contact Transmission: This is the route most common mode of transmission. There are two
forms of contact transmission.
Direct Contact: typically spread from staff to patients via unwashed hands.
Indirect Contact: Organisms spread on contaminated equipment used from patient to patient (i.e.
blood pressure cuff)
Airborne transmission: occurs when organisms are coughed, talked, or sneezed into the air by an
infected person. The organism is suspended on dust particles in the air and are then inhaled into
the body.
Droplet Transmission: This occurs when infectious organisms are coughed or sneezed into the
air by an infected person and immediately inhaled into the body by someone in the close vicinity.
An example of droplet transmission is meningococcal infection.
According to the Centers for Disease Control and Prevention (CDC) hand washing is the single
most important procedure for preventing the spread of infection. This is because
microorganisms can enter your body by hand-to-hand, food-to-hand, and surface-to-hand
contact.
General Directions:
A. Hands must be washed with an approved antiseptic agent before preparing for the
first case of the day.
C. When washing hands, wet hands and wrist thoroughly holding them downward
over the sink so that the water runs toward the fingertips.
D. Rinse hands thoroughly keeping the hands higher than the elbows to keep water
from running down and contaminating the clean skin.
Skin Care:
1. Healthcare workers should be provided with hand lotions or creams in order to minimize
the occurrence of irritant contact dermatitis associated with hand antisepsis or
handwashing.
2. Information should be requested from the manufacturer regarding the effects that hand
lotions, creams, or alcohol-based hand antiseptics may have on the persistent effects of
antimicrobial soaps being used in the Center.
Other:
1. Artificial fingernails or extenders should not be worn when providing patient care.
2. (Strongly recommended for implementation and strongly supported by well-designed
experimental, clinical, or epidemiologic studies.
3. Nails should be kept less than ¼ inch long.
4. (Suggested for implementation and supported by suggestive clinical or epidemiologic
studies or a theoretical rationale.)
5. Gloves should be worn when it can be reasonably anticipated that contact with blood or
other potentially infectious materials, mucous membranes, and non-intact skin will occur.
6. (Required for implementation, as mandated by federal and/or state regulation or
standard.)
7. Gloves shall be removed after caring for a patient. Do not wear the same pair of gloves
for the care of more than one patient, and do not wash gloves between patients.
8. Change gloves during patient care if moving from a contaminated body site to a clean
body site.
Administrative measures:
Healthcare workers shall be provided a readily accessible waterless antiseptic agent such as an
alcohol-based hand rub product.
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Competency for PPE
Employee name: ________________________________________________
Observation/Demonstration Competency met Competency not Comments
met
Verbalizes understanding
of Standard Precautions
Wears scrub attire in semi
restricted and restricted
areas.
Wears bouffant cap or hair
covering in designated
areas.
Wears shoe covers if
soiling of shoes is likely.
Wears goggles or face
mask when splashing is
possible.
Wears mask in restricted
areas.
Changes mask after use.
Does not leave mask tied
around neck for reuse.
Wears gown when
applicable
Wears gloves when
touching body fluids/ Uses
standard precautions.
Dons gown appropriately
Dons gloves appropriately
Dons mask appropriately
Removes PPE in correct
order and disposes of
properly.
Washes hands between all
patient encounters.
Washes hands after taking
off gloves.
Washes hands when gloves
are removed following
contact with body fluids.
Supervisor’s signature: ________________________________________
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Employee’s signature: _________________________________________ Date: _____
Blood Pathogens are diseases which are spread through direct contact with blood or other body
fluids. Examples of blood borne pathogens are HIV, Hepatitis B and C (HBV,HCV), syphilis
and Malaria.
OSHA is the Occupational Safety and Health Administration. They are responsible for
developing guidelines to protect workers form potential hazards in the workplace.
All employees who may come in contact with blood or blood products are at risk of contact with
blood borne pathogens.
Standard Precautions means treating everyone’s blood, body fluids and excretions as infectious
at all times. If contact with blood or other body fluids or contaminated equipment is likely, you
must wear gloves. People infected with HIV, HBV and/or HCV are found in all age groups from
all socio-economic groups.
Personal Protective Equipment are items that are used to protect you from contact with
potentially infectious substances. The equipment includes gloves, masks, gowns, aprons, face
shields, goggles, resuscitation bags or other ventilation devices. If your job requires you to be
exposed to blood borne pathogens the Center will provide you with the appropriate protective
equipment at no cost to you.
Gloves:
Never use petroleum-based lubricants with latex gloves because it will break down the latex and
cause holes.
Cover any cuts or scrapes on your hands before putting on gloves
Inspect all gloves for holes or weakness and discard if necessary
Remove gloves so that the outer surface is turned inside out and discard appropriately.
Gowns, masks, Goggles, Face Shields:
Should be worn whenever blood or body fluids may be splashing.
65
The Exposure Control Plan can be found in the OSHA BOOK or in the Policy and Procedure
Manual under Infection Control/Blood borne Pathogens/ Exposure Control Plan.
New forms of Hepatitis have been determined and labeled Hepatitis D, Hepatitis E, and Hepatitis
G. These are more fully described in the Infection Control/Bloodborne Pathogen/Exposure
Control Plan in the Policy and Procedure Book.
Hepatitis B Vaccine:
Hepatitis is an inflammation of the liver which can be caused by a blood borne virus. Two
viruses are Hepatitis B and Hepatitis C
Hepatitis B is the most common blood borne pathogen a healthcare worker encounters. It can
last for months and mimics a flu illness.
Chronic carriers may not have any symptoms but can still p ass the virus to others. Long-term
effects are cirrhosis, liver cancer and death
Hepatitis C is another virus and when in the active stage may have similar symptoms to HBV.
Usually the symptoms are milder. 70% of the people have no clinical signs or symptoms.
People with HCV are more likely to be carriers. Long-term effects are cirrhosis, liver cancer and
death.
New forms of Hepatitis have been determined and labeled Hepatitis D, Hepatitis E, and Hepatitis
G. These are more fully described in the Infection Control/Bloodborne Pathogen/Exposure
Control Plan in the Policy and Procedure Book.
The Hepatitis B Vaccine is recommended and offered by the Center at no cost to the employee.
All employees are encouraged to have the vaccine. New forms of Hepatitis have been
determined and labeled Hepatitis D, Hepatitis E, and Hepatitis G. These are more fully described
in the Infection Control/Bloodborne Pathogen/Exposure Control Plan in the Policy and
Procedure Book.
66
Employees most at risk and who should ensure that they are vaccinated are employees who care
for patients, handle specimens or clean and repair patient equipment.
HIV is the virus which causes AIDS. HIV attacks and destroys the immune system making the
patient more prone to developing infections. In most instances it is an infection which causes the
death of the AIDS patient. There are many effective drug treatments for HIV, but these drugs
are not a cure. There is no vaccine for prevention of HIV.
*See the Policy and Procedure manual for information regarding additional Hepatitis viruses.
Tuberculosis is a disease which is spread by the airborne route. The organism is inhaled into
the lungs.
Active TB Disease: This is the form that is infectious. The infected person will exhibit a
productive cough, hemopysis, low grade fever, weight loss, loss of appetite, positive chest X-ray
and a positive skin test (PPD)
Latent TB Infection: This is the form where the person is no longer infectious.(cannot pass the
TB organism to another person) but the organism is still carried in their system. The person will
no longer exhibit any clinical symptoms and will have a negative chest x-ray but will still have a
positive skin test (PPD)
Patients with TB or are known to have Active TB should be on Airborne Isolation Precautions in
a negative air pressure room which is exhausted to the outside. These patients are not seen at the
Center because the facility is not built to provide this type of care.
Treatment for TB
There are several medications available to treat TB patients. Most patients will be prescribed
three of these drugs for a period of none to twelve months. It is important to educate the patient
about the necessity for taking their medications as prescribed to prevent possible relapse or
development of a resistant form of TV. Multiple Drug Resistant TB (MDRTB) is the most
difficult form of TB to treat. Many of the common drug therapies do not word with MDRTB.
67
The infectious disease specialist for the Center is: ________________________________
Address: ___________________________________________________________________
Phone: __________________________________________________________________
Address: ____________________________________________
Phone: _________________________________
68
REVIEW AND PROVIDE EACH EMPLOYEE WITH THE INFECTION CONTROL
POLICIES AND PLAN INCLUDING:
BLOODBORNE PATHOGENS/EXPOSURE CONTROL PLAN/SHARPS
69
XNew □Revised
Replaces:
Approval Date:
1. Photocopy the patient’s consent. Highlight section indicating authorization for testing
(The surgical consent contains language authorizing blood testing in the event of an
exposure to blood/body fluids. Statement reads:
Should a bloodborne exposure occur during the procedure, I consent to the drawing of
blood for HIV and Hepatitis testing. The results of this test will be placed in my medical
record and protected in accordance with the applicable state laws.)
2. Draw blood (10 cc) for 2 Gold top tubes (these tubes have gel in the bottom)
3. Label blood with patient stickers including date, time and initial.
4. Send blood tubes with completed form signed.
5. Call Lab. Place the 2 source patient tubes in one specimen bag. Place both in an outside
bag.
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EMMAUS SURGICAL CENTER
Date:
The person listed below requires the following blood tests due to a blood borne pathogen
exposure or similar incident. Please perform the tests as requested and send/fax the
results to the Surgery Center. If you have any questions please notify the
Administrator/Director of Nursing, Kathleen Vaezi at 908-813-9600.
Hepatitis B
Hepatitis C
HIV-1, HIV-2
Other______________________
Name: ____________________
DOB: _____________________
SS#: ______________________
All bills for these blood tests will be paid by the Surgical Center.
Sincerely,
__________________________
Medical Director
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Manager/Supervisor Actions:
1. Obtain exposure control packet from cabinet in the PACU
2. Fill out paperwork and obtain blood samples from source patient and employee if
indicated.
3. Complete OSHA 300 log and Sharps Injury log
4. Complete Occupational Injury/Illness Report. Ensure that employee section is completed
within 15 days of the incident.
5. Contact Infectious Disease Physician/Infection Control Nurse Consultant, advise him/her
of the injury and get their recommendations for post exposure prophylaxis/treatment.
Arrange for a consultation for the employee.
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Employee Action:
The exposure kits are located in the PACU, follow the steps below.
I understand that the blood tests for the virus which is the probable cause of Acquired Immune
Deficiency Syndrome (AIDS) are not 100% accurate, and that these blood tests sometimes
produce false positive or false negative test results. I further understand that the presence of
antibodies means that a person probably has been infected with the AIDS virus, but does not
necessarily mean that a person will develop AIDS.
I have been provided with information about the test for antibodies to the HIV virus, about the
HIV virus, and about AIDS, and I have been given the opportunity to ask questions regarding
this information and have my questions answered. I have been informed by my physician(s) that
the test, in the opinion of the physician(s), is important both to my health care and to ensure that
appropriate evaluation can be undertaken and adequate precautions taken to prevent transmission
of the virus to others.
I understand the Practitioner will notify me of the results of the blood test and that the results
will be explained to me.
I have been informed that the performance and results of the HIV antibody test are considered
confidential. I have been informed by the physician(s) that the test results in my health record
shall not be released without my written permission, except to the individuals and organizations
74
that have been given access by law who also are required to keep my health record information
confidential.
On this basis, I authorize the Center, Practitioner, and anyone authorized by them to perform
the blood tests for the above described communicable diseases.
____________________
_____________________________
_
Date Signature of Patient
____________________
_____________________________
_
Witness Signature of Practitioner
I have been informed that by declining permission for this test, decisions concerning infectious
disease precautions will be made on the basis of other medical information concerning me. I
have been informed that if I refuse permission for the HIV antibody test, my health care,
including diagnosis and treatment, may be adversely affected.
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I agree to assume all risks that may result from my refusal to consent. I also agree not to hold
my practitioner(s) any other personnel or the Center responsible for any adverse results that may
arise from my refusal to consent to the HIV antibody test.
On this basis, I refuse to have Center, Practitioner and anyone authorized by them to perform
the blood tests for the above described communicable diseases.
____________________ ___________________________________
Date Signature of Patient
____________________ ___________________________________
Witness Signature of Practitioner
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(CHECK ONE)
_____ I do not consent to the release of the nature of the test(s) to my insurance company or
medical assistance program.
_____ I authorize the Center to furnish my insurance companies and other third party payers
with any and all information it has or may hereafter have either written or oral, pertaining to or in
any manner connected with the tests authorized herein, that may aid in payment of any account
presented to me or us, jointly or separately, and I further agree that no person, firm, or
corporation shall be held liable in any manner for furnishing or having furnished such
information.
____________________ ___________________________________
Date Signature of Patient
____________________________________________________
Witness
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Step 6 – Develop an Exposure Control Plan
Attachment 5
This letter is to inform you of the results of the evaluation that followed your recently
reported exposure to blood or other potentially infectious materials. Current guidelines
recommend that the hepatitis B vaccine be given after an exposure. In your situation:
❒ You were given medications for post-exposure prophylaxis (these are not indicated for all
exposures): _______________________________________________________________
This letter also confirms that you have been informed of the results of the evaluation and have
been told about any medical conditions resulting from exposure to blood or OPIM. If you
need additional information regarding your exposure evaluation please contact us at:
__________________________________________________________________________
Attachments: _______________________________________________________________
____________________________________________________________________
_________________________________ _______________________________
Signature of health care professional Title/Department
____________________________________
Please print name
RECORD OF HEPATITIS B VACCINE DECLINATION
I understand that due to my occupational exposure to blood or other potentially infectious
materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the
opportunity to be vaccinated with hepatitis B vaccine, at no charge to me. However, I decline
hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be
at risk of acquiring hepatitis B, a serious disease. If, in the future, I continue to have occupational
exposure to blood or other potentially infectious materials and I want to be vaccinated with
hepatitis B vaccine, I can receive the vaccination series at no charge to me.
_______________________________
Employee Name
_______________________________
Employer Representative
_______________________________ _____________________________
Employee Signature Date
2009 INFECTION CONTROL PLAN
Goal: To prevent post procedure infections.
Indicator 2:
Infection Complication log will be used to monitor post-op infections and complications
Indicator 3:
Intraoperative QI indicator will monitor sterilization of instruments
Indicator 4:
Refrigerator and Freezer temperatures will be monitored daily.
All of the indicators will be reviewed monthly and reported three times a year at the Medical
Advisory Committee Meeting and Managers’ Meeting
POLICY: PREVENTION OF WORKPLACE VIOLENCE
Although no single set of actions guarantees reduced violence, experts in the workplace violence
have provided some suggestions. The Center has a policy of disciplinary action for any
workplace harassment, threat, or physical action. It is the responsibility of the supervisor and
employees to report any potentially violent signals or incidents.
Recognizing early warning signals can help avoid tragedy. Supervisors are asked to document
any incidents.
Keep in mind that employee safety is paramount, we take threatening situations very seriously.
Following are some tips for handling difficult people or situations. Don’t put a difficult person
off. Address their concerns immediately. Use phrases like I’ll do what “I can to help” and
“Let’s get this taken care of”
1. Use your” talking hands” to provide calming, non-threatening hand motions.
2. Be aware of your “personal danger zone” keep the person at least arms length away.
3. Never accuse, shake your finger in the person’s face or say “Calm down”
4. Supervisors should encourage courteous customer service.
5. Management should create a culture of mutual respect to lower stress and reduce the potential
for conflicts.
Procedure:
1. It is the responsibility of every employee to know what Code 5 is, and how to implement this
at the facility.
2. If you encounter a verbally abusive or hostile visitor call a Code 5 X 3 at your location.
If the person is in the waiting room area or around patients or their families ask them (the hostile
visitor) to step into a more private location.
3. Always assume that the person could be dangerous and never allow yourself to be alone and
isolated with such a person. Try to keep the person calm while you wait for the safety team to
respond. Do not tell the person to calm down as this may not produce the desired effect.
Listen to their complaints and remain non-committal while you are waiting.
4. If the person threatens you, one of the physicians, another employee, a patient or their family
member with violence or indicates they are armed or have a weapon with them, the situation
becomes an emergency. You should notify the police immediately.
5. If you receive a phone call threatening any of the above-mentioned people, immediately
notify your supervisor. A police report will be filed for all significant threats to their person and
may file a police report at his discretion.
6. You should avoid leaving or entering the building alone. If you are accosted for drugs,
money, equipment, etc., give them whatever they ask for. Remember there is nothing that can’t
be replaced and nothing that is worth risking your life for. See attached sheet to be used in case
of a robbery to help describe the assailant.
POLICY: DANGEROUS INTRUDER/HOSTILE VISITOR CODE “5
Procedure:
1. It is the responsibility of every employee to know what Code 5 is, and how to implement this
at the facility.
2. If you encounter a verbally abusive or hostile visitor call or dial page and announce CODE 5
times three at your location. If the person is in the waiting room area or around patients or their
families ask the hostile visitor to step into a more private location.
3. Always assume the person could be dangerous and never allow yourself to be alone
and isolated with such a person. Try to keep the person calm while you wait for the Safety Team
to respond. Do not tell the person “Calm down” as this may not produce the desired effect.
Listen to their complaints and remain noncommittal while you are waiting.
4. If the person threatens you, one of the physicians, another employee, a patient or their family
member with violence or indicates they are armed or have a weapon with them, the situation
becomes an emergency. Notify the police immediately.
5. If you receive a phone call threatening any of the above-mentioned people, immediately notify
your supervisor. A police report will be filed for all significant threats. The physician will be
notified of all threats to their person and may file a police report at his discretion.
6. You should avoid leaving or entering the building alone. If you are accosted for drugs,
money, equipment, etc., give them whatever they ask for. Remember there is nothing that can’t
be replaced and nothing that is worth risking your life for. See attached sheet to be used in case
of robbery to help describe the assailant.
CULTURAL DIVERSITY
As the country continues to become more ethnically and racially diverse, healthcare workers
may encounter numerous languages, beliefs, and practices during a normal workday.
It is important to learn about the different cultures and values. It is the difference that can
make or break good patient relations. By understanding these differences, healthcare workers
have the opportunity to meet and exceed patient expectations. If patients feel they are being
misunderstood, ignored, or treated poorly, they may take their business elsewhere.
Cultural Factors to be Aware Of:
1. Country of Origin- most people who live in the United States have roots in other
countries. How long a person has lived here may affect his or her view toward health.
2. Preferred Language- patients who are encouraged to talk or read about care in their
own language may feel more at ease and understand their care better.
3. Views of Health- the patient may see illness as having a supernatural cause, such as
punishment for sins, needing a certain traditional care, such as herbal remedy or
specific diet.
4. Community Style-verbal and non-verbal styles may differ. For example, culture may
affect how, or whether a patient expresses pain.
5. Family and Community Relations- a patient may expect certain people to be involved
in his or her care, or allowed to remain with them.
6. Food Preferences- religious, healing, and other cultural practices all affect what foods
a patient may eat or avoid.
7. Religion- a patient’s religion may affect his or her consent to treatment, schedule of
care (because of certain prayer practices), birth and death practices.
Understanding patterns of cultural behavior and valuing differences are important to
healthcare workers because they provide explanations for behaviors related to life
events. Significant life events are birth, death, puberty, child bearing, child rearing,
and illness. The Center complies with Patient’s Rights, which specifically state that
patients are allowed to exercise cultural and spiritual beliefs that do not interfere with
well-being of others or themselves. Doing a good job as a healthcare worker means
acknowledging, understanding, and supporting the many cultural, social and religious,
etc differences in our patients, their families, and customers with whom the Center
comes into contact.
CULTURAL COMPETENCE
Cultural competence refers to the knowledge, attitudes, and skills that enable individuals
and organizations to render services to all cultures in an effective and respectful manner.
There are many determinants of culture. One determinant is ethnicity, which refers to an
individual’s country of origin, race, and religion. However, even in the same ethnic groups,
cultural practices and beliefs can vary greatly. Age, education, length of time in the United
States, and personality differences can cause great variance in how one’s culture is expressed.
Other important factors are gender, socioeconomic status, sexual orientation, physical or mental
status, and geographic differences within the United States.
Language itself is the most obvious barrier to communication, especially when slang,
technical jargon, and abbreviations are used. Non-verbal communication may also present
barriers. Smiles, silence, gestures, nodding, eye contact, and body language can all cause
misunderstandings.
Another barrier is stereotyping, which is judging individuals on their perceived culture.
This is not only unfair, but also often inaccurate. Stereotypes are inflexible assumptions about an
individual based on group membership. Our stereotypes are often formed while we are growing
up through information and misinformation given to us from our families and friends.
In contrast to stereotyping is generalizing, which can be useful. This begins with an initial
assumption, but then leads to getting more complete information to determine if the assumption
actually fits the individual in question.
Here are some ways to improve cross-cultural understanding:
• Begin by being more formal with patients who were born in another culture. The
American custom of using first names is often seen as disrespectful.
• Looking a person in the eye is not done in many cultures. Many Americans
interpret lack of eye contact as dishonesty; to some cultures it is a sign of respect.
• Some cultures will not ask questions if they do not understand. Be sure the
individual understands you by asking open-ended questions, such as “Tell me
how you are going to do this”, or asking for a return demonstration.
• Never laugh at or belittle another person’s cultural beliefs or practices. Besides
being very rude, this will certainly end any open and honest communication.
• Speak slowly, not loudly. Remember the problem is usually comprehension, not
hearing ability. A loud voice implies anger in many cultures.
• Avoid difficult or uncommon words or idioms. An example of an idiom would be
“in the nick of time”. These expressions are often misunderstood.
• Avoid questions that can be answered by a “yes” or “no”. In some cultures, “yes”
can merely mean the patient heard the question. Try to begin questions with
what, where, why, how, and when so you can be sure the question was
understood.
• Face the individual when talking. Use gestures, pictures, or facial expressions. If
the individual’s face indicates a lack of understanding, try restating the
information in a different way.
• Be patient and avoid interruption. It may take longer for a person of another
culture to express his/her thoughts.
Remember, the first Core Standard of the Accreditation Association for Ambulatory
Healthcare is “Rights of Patients”. And item A under this standard states “Patients are
treated with respect, consideration, and dignity”.
Cultural competence is an integral part of this standard.
REVIEW AND REVISE LOOK-ALIKE/SOUND-ALIKE DRUG LIST ANNUALLY
POLICY: LOOK-ALIKE/SOUND-ALIKE DRUGS
OBJECTIVE:
• To make every effort to avoid medication errors.
• To prevent errors involving the interchange of look-alike/sound-alike drugs used.
Procedure:
• The Center will annually review a list of look-alike/sound-alike drugs used in the Center.
• The list will be posted at the medication station to alert the nursing staff and physicians of
medications most likely to be confused.
• All medications that are deemed as medications at risk of being confused will not be
stored in the same bin.
Problematic Drug List
Potential Problematic Drugs Generic Name Trade Name
Sound-alike
Anzemet/Aldomet Dolasetron mesylate Anzemet
Aldomet Methyldopa
Aminophylline/Ampicillin Aminophylline
Ampicillin Alpen, Amcil, Omnipen
Celebrex/Cerebryx Celeoxib Celebrex
Fosphenytoin Sodium Cerebryx
Injection
Diltiazem/Digoxin Diltiazem Hydrochloride Cardizem
Digoxin Lanoxin
Diprivan/Ditropan Propofol Diprivan
Oxybutynin chloride Ditropan
Dobutamine/Dopamine Dobutamine Hydrochloride Dobutrex
Dopamine Intropin
Ephedrine/Epinephrine Ephedrine I-Sedrin Plan
Epinephrine Asmolin, Asthma-meter,
Primatene Mist, Sus-phrine
Toradol/Foradol Toradol Ketoralac Tromethamine
Formoterol fumarate Foradil
Morphine/Hydromorphone Morphine
Hydromorphone Sulfate Dilaudid Sulfate
Hydromorphone Dilaudid Hydrochloride
Hydrochloride
Nitroglycerine/Nitroprusside Nitroglycerine Cardabid, Gly-Trate
Nitro-bid, Nitrol, Nitroprn,
Nitrospam, Nitrotest
Sodium Nitroprusside Nipride
Norepinephrine/Epinephrine Levarterenol Bitartrate Levophed Bitartrate,
Norepinephrine Bitartrate
Epinephrine Asmolin, Asthma-meter,
Primatene Mist, Sus-phrine
Solumedrol/Depomedrol Methylpredinisolone Solumedrol
Sodium Succinate
Methylprednisolone Depo Medrol
Acetate
Diltiazem/Digoxin Diltiazem Hydrochloride Dobutrex
Digoxin Lanoxin
Historical Perspective
The French surgeon Daetigus wrote: “Were we to imagine ourselves suspended in timeless
space over an abyss out of which the sounds of revolving earth rose to our ears, we would
hear naught but an elemental roar of pain uttered as with one voice by suffering mankind”
(Bonica, 1990, pg2)
The evolution of pain began with primitive societies in B.C.
By A.D., the Mesopotamians developed the first multidisciplinary approach to pain
management- members may have included a shaman, a priest, a physician, and an exorcist!
The Egyptians introduced a type of electrotherapy application that involved placing an
electric fish from the Nile over the wound- a very early prototype to the TENS
(transcutaneous electric nerve stimulator)!
Ancient China contributed a current modality for pain management during 2800-2600 B.C.
Huang Ti developed acupuncture therapy and practice based on Yin
(negative/feminine/passive) and Yang (positive/masculine/active).
Ancient Greeks such as Aristotle and Hippocrates studied the senses relative to the origin
and nature of sensory data.
The Middle Ages brought religious beliefs rather than reason as the influencing factor for
the practice of medicine.
Then the Renaissance produced a physician during the early to mid-1500s by the name of
Paracelsus. He advocated physical therapies such as massage, exercise, and electrotherapy.
The 16th-19th Centuries showed slow progress relative to pain management. Then in the
mid-19th Century major advances took place in 3 fields:
• Administration of opiates and hypnotics
• Inhalation of analgesic and anesthetic gases
• Administration of local anesthetics by various means
In addition, physical therapies re-emerged in pain management, including such things as
light therapy, hydrotherapy, and thermotherapy.
Key contributors to the surgical approach to pain management during this period include:
• Abbe- introduced posterior rhizotomy
• Spiller and Frazier- performed neurectomy and cordotomy
The 20th Century produced the first studies on chronic pain. Pain centers began to evolve,
as did the organization of pain societies.
By 1992, policies and legislature were enacted to address various types and aspects of pain.
As we entered the 21st Century, pain was recognized by JCAHO as the “Fifth Vital Sign”,
and organizations began focusing on institutional management of pain as well as standard
for pain assessment and management.
Cultural and Communication Considerations
Two factors having a major influence on pain are culture and communication.
Culture as defined by Weber, is the beliefs, values, and practices shared by a group or
community of people. This learned behavior is passed down from one generation to the
next.
Communication as defined by Nance is a transactional process whereby two or more
people engage in the creation of meaning. It involves generating and receiving messages.
In an effort to prevent these two major influences from resulting in ineffective pain
management, the following 8 areas should be considered: *
PACU Nurse:
The PACU nurse will manage the patient’s pain postoperatively as ordered by the physician
and/or anesthesiologist. The use of alternative pain management techniques should be
made part of the patient’s pain management plan.
The nurse will evaluate the patient’s pain level postoperatively and prior to discharge. This
will be documented in the chart record. Patients scaling their pain level above tolerable
levels prior to discharge will be reevaluated by the anesthesiologist.
Medication will be prescribed to try to bring the patient’s level of pain to a tolerable level
whenever the physician feels this is appropriate.
The patient will only be discharged when pain is at a tolerable level. If pain is not tolerable
the patient will be admitted to the hospital for appropriate follow up care.
Patients will be instructed during discharge instruction to call the Center if pain is unrelieved
by the medication prescribed by their physician.
When the patient makes a complaint of pain unrelieved by medication prescribed the nurse
taking the call will instruct the patient to call his/her physician. If the patient is unable to
contact his/her physician he/she will be instructed to call the Surgery Center back for
assistance.
All complaints of pain not relieved by medication prescribed will be documented on the
patient complaint log and followed up to ensure that this process is being followed.
Pain management continuous quality improvement
• The facility’s continuous quality improvement program shall include a systematic review
and evaluation of pain assessment, management and documentation practices. The
Center will collect and analyze data in order to evaluate outcomes or performance. Data
analysis shall focus on recommendations for implementing corrective actions and
improving performance.
Please:
Wear your glasses and or your hearing aid
Use your walker, cane or wheelchair
A contingency plan is a routinely updated plan for responding to a system emergency that
includes performing backups, preparing critical facilities that can be used to facilitate continuity
of operations in the event of an emergency, and recovering from a disaster.
A contingency plan should address the potential interruption of claims processing and claims
payment due to problems with transmission using the new HIPAA transaction standards. Just as
each covered entity is different, there is no single contingency approach that would be
appropriate for all situations. Regardless, HIPAA requires that all contingency plans include:
• An application and data-criticality analysis
• Data-backup plan
• Disaster-recovery plan
• Emergency-mode operation plan
• Testing and revisions procedure
Procedure:
The receptionist will make copies of all paperwork needed to continue patient care in the Center.
In the event that a disaster occurs and there is no electricity, hard copies will be available to
continue working. No further patient care will be started. The case in progress will be
completed and all patients sent home or to the transfer facility for follow-up care. If the power is
returned to normal the Administrator/Director of Nursing in coordination with the Medical
Director or designee may give the order to continue patient care in the Center. In the event of a
community disaster, fire or evacuation the fire official and police shall be contacted to approve
the order to reenter the building and continue patient care.
Disaster-recovery plan
This is the actual process through which facilities restore lost data in the event of fire, theft,
vandalism, natural disaster, or system failure.
How will systems be brought back online both electronically and physically in the event of a
disaster?
Back up generators are on site to automatically transfer the building to normal power.
In the case of an emergency, the case in progress will be completed and all patients sent home or
to the transfer hospital.
Ventilation
oxygen saturation
heart rate and
blood pressure
Monitoring for the presence of exhaled carbon dioxide should be utilized when possible, since
movement of the chest will not dependably identify airway obstruction or apnea.
Age-appropriate equipment:
Age-appropriate equipment must be immediately available for the maintenance of a patent
airway, oxygen enrichment and artificial ventilation in addition to circulatory resuscitation.
The warnings section of the drug’s package insert for Diprivan states that propofol used for
sedation or anesthesia should be administered only by persons trained in the administration of
general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.
Definition: a drug that has a high risk of causing injury to patients when misused. Errors with the
drugs are not necessarily more common than with other drugs, but their consequences can be
more devastating.
Identification of these drugs and initiating safeguards may reduce the risk of errors. These
safeguards may include such things as limiting access, auxiliary labels, and standardization of
how these drugs are ordered, prepared, and administered.
Specific medications:
• Amiodarone, IV
• Colchicine injection
• Heparin injection (low molecular weight)
• Heparin, IV (unfractionated)
• Insulin, subcutaneous and IV
• Lidocaine, IV
• Magnesium sulfate injection
• Methotrexate, oral, non-oncologic use
• Nesiritide
• Nitroprusside sodium, injection
• Concentrated Potassium chloride injection
• Potassium phosphates injection
• Sodium chloride, hypertonic (greater than 0.9% concentration)
• Warfarin
REVIEW AND REVISE POLICY: ABBREVIATIONS NOT TO USE
REVIEW FORMULARY AND REVISE AS NECESSARY
REVIEW AND REVISE EMERGENCY CART INVENTORY AND HAVE APPROVED BY
THE MEDICAL DIRECTOR
REVIEW AND INSERVICE EVENT RELATED STERILITY POLICY
SIGN OFF POLICY AND PROCEDURE MANUAL ANNUALLY BEFORE IT IS
OUTDATED
Administration - Incident Report
Nosocomial Infections
Infections require:
• A germ
• A carrier
• A way into the body
• A person without resistance who becomes infected
Chart Review:
A. Look for S&S of infection
• Culture Reports
• Colonization vs infection
• X-rays
• Scans
• WBC’s
• ABG’s
• Diagnosis by surgeon
S&S are:
• Pus
• Cough
• Temp Elevation
• Redness
• Swelling
• Pain
B. Review all reports:
o Endoscopy
o Bronchoscopy
o CT Scan
o Ultrasound
o MRI
If it is documented by a physician it is an infection according the CDC.
Wash Hands
Practice Standards:
• Infection Prevention and Control Practice
• Epidemiology
• Surveillance
• Education Consultation
• Performance Improvement
• Program Management and Evaluation
• Fiscal Responsibility
• Research
Director of Nursing
Download form HCQ-1 Report of Serious Preventable Adverse Event In a new Jersey Licensed
Health Care Facility
www.NJ.gov/health/ps
Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care Facility:
Submit a Root Cause Analysis (RCA)
Identify the contributing causes of adverse events
Ensure that it is a focused review
Identifying prevention strategies
(What happened? why? and how to prevent it from reoccurring?)
RCA Team should include:
Staff knowledgeable about processes involved in the event
Effect on pt
Environment/Equipment
Rules/Policies/Procedures
Barriers
5 Rules of Causation:
Clearly show “cause and effect
Causality Statement
__________increased the likelihood of _____________happening which led to the adverse
event.
Action Plan
• Address the root causes
• Doable
Action plan
1. Create action plan for each causal statement
Actions/Prevention strategies
Monitoring
Root Cause Analysis Grid
Causality Statement Action or Prevention Monitoring
Strategy
Cause and Effect Specific, measurable Includes specific time
Relationship actions, implemented frames and
No negative within 45 days of responsible staff
descriptions incident, or are Need to confirm
Human Errors/Policy currently being actions have taken
Violation-must have implemented place
a preceding cause Include time frames,
Procedures responsible staff
deviations
Failure to act only
causal if there is pre-
existing duty to act
Administration - Incident Report
Causality Statement Action or Prevention Monitoring
Strategy
Rationale:
Multidrug-resistant organisms (MDRO), including methicillin-resistant Staphylococcus aureus
(MRSA), vancomycin-resistant enterococci (VRE) and certain gram-negative bacilli (GNB) have
important infection control implications and affect all healthcare settings.
Administration - Incident Report
Patients colonized or infected with these organisms can safely be cared for and managed in the
ambulatory setting by following appropriate infection control practices. CDC does not have
recommendations for pre-admission screening in non-hospital settings. In general, healthy
people are at low risk of getting infected with MRSA or VRE.
Hand Sanitizing: Hand sanitizing and hand washing compliance by staff and each person,
including visitors in the patient care units can NOT be overemphasized since DIRECT
CONTACT is the primary method of cross contamination with MRSA and other MDRO. It is
the single most important Infection Control and Prevention method.
Standard Precautions: These Infection Control Precautions should be used for all patient
care.
Hand hygiene: After touching blood, body fluids, secretions, excretions, contaminated
items; immediately after removing gloves; between patient contacts;
Gloves: For touching blood, body fluids, secretions, excretions, contaminated items; for
touching mucous membranes and non-intact skin;
Gown: During procedures and patient-care activities when contact of clothing/exposed
skin with blood/body fluids, secretions, and excretions is anticipated;
Mask, eye protection (goggles), face shield: During procedures and patient-care
activities likely to generate splashes or sprays of blood, body fluids, secretions, especially
suctioning, endotracheal intubation;
Notify other healthcare personnel and/or facilities that provide care for the patient that the patient
is colonized/infected with a multidrug-resistant organism.
Occasionally, healthcare workers can become persistently colonized with an MDRO, but these
healthcare workers have a limited role in transmission, unless other factors are present.
Additional risk factors that can facilitate transmission, include chronic sinusitis, upper
respiratory infection and dermatitis.
Administration - Incident Report
Healthcare worker decolonization is indicated only as a prevention and control intervention when
a health care worker is chronically colonized with MRSA and has been epidemiologically
implicated in ongoing transmission of MRSA to patients.
References:
Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006
Healthcare Infection Control Practices Advisory Committee, CDC
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare
Settings 2007
Healthcare Infection Control Practices Advisory Committee, CDC
Multidrug-Resistant Organisms in Non-Hospital Healthcare Settings, December 2000; CDC
Procedure:
Detection (Red Flags)
The Surgery Center adopts the following red flags to detect potential fraud. These are not
intended to be all-inclusive and other suspicious activity may be investigated as necessary.
• Identification documents appear to be altered
• Signature on photo ID does not match the signature on the chart record.
Response
Any employee that may suspect fraud or detect a red flag will implement the following response
as applicable. All detections or suspicious red flags shall be reported to the Administrator.
• Ask the patient for additional documentation.
• Notify the Administrator or designee when any staff person becomes aware
of a suspected or actual fraudulent use of a customer identity.
• Do not attempt to collect against the account and notify the Administrator or
designee, who will be responsible to contact the proper authorities.
Security Procedures:
• Paper documents, files and electronic media containing secure information
will be stored in a locked file cabinets.
Administration - Incident Report
• Only specially identified employees with a legitimate need will have access to
the cabinet.
• Employees shall not leave sensitive papers out on their desks when they are
away from their workstations.
• Employees shall log off their computers when leaving their work areas
• Employees shall lock file cabinets when leaving their work areas
• Employees shall lock the file room doors when leaving their work areas
• Visitors who must enter areas where sensitive files are kept must be escorted
by an employee of the surgery center.
• No visitor will be given any entry codes or allowed unescorted access to the
office.
• The use of laptops shall be restricted to those employees who need them to
perform their jobs.
• The computer network will have a firewall where the network connects to the
internet.
• Every effort will be made to ensure that workers who leave employment no
longer have access to sensitive information.
• Employee training will be performed annually with all other required in-
services.
• Employees who violate security policy are subjected to discipline, up to, and
including , dismissal.
• Service providers will be trained to notify the Center of any security incidents
they experience, even if the incidents may not have led to an actual
compromise of data.
• Paper records will be shredded before being placed into the trash.
• Any data storage media will be disposed of by shredding, punching holes in,
or incineration.
INCIDENT REPORTING
Administration - Incident Report
POLICY:
All occurrences in the Center that are not consistent with the desired operation of the facility or
the care of the patient shall be considered as incidents. All incidents shall be reported,
documented, and reviewed and action taken appropriate to the incident. All incident reports shall
be submitted to the Quality Improvement Committee and Risk Management for review.
RESPONSIBILITY:
The Nursing Director is responsible for administering the incident reporting program. All
employees and staff members are responsible for reporting incidents.
FUNCTION:
Provide a formal means of identification and review of incidents which may constitute a threat to
the health and safety to patients, visitors, staff, and employees as well as a process for
determining appropriate corrective action. As such, the program serves as a basis for Quality
Improvement activities and loss control for risk management.
PROCEDURES:
A. Any employee or staff member who observes or is aware of any occurrence which
is perceived, either prospectively or retrospectively, to constitute a threat to the
health and safety of patients, visitors, staff, and/or employees shall report the
incident to the Nursing Director or designee. The report may be made verbally or
in writing. If in writing, it shall contain the basic information required for the
incident report as described below.
B. The person receiving the report of the incident shall prepare a formal incident
report. NOTE: any occurrence reported as an incident shall be processed as such.
The Incident Report shall be prepared using the appropriate form and containing
the following information.
1. Incident
3. Persons Involved
c. Visitors.
d. Others.
4. Location
5. Description
6. Recommendations/Action Taken
The name of the person and the date the incident was reported
along with the signature of the person.
The name of the person preparing the report and the date it was
prepared.
9. Incident Investigated By
C. All incidents require at least minimal investigation as soon as possible after they
are reported. The investigation process will assist to determine contributing
factors and ascertain facts versus opinion. The investigation may include, but not
be limited to:
3. Testing equipment
4. Testing environment
8. Obtaining photographs
D. All incident reports shall be reviewed by the Nursing Director and Medical
Director/Risk Manager. The Nursing Director may approve or change
recommendations included in the report and take whatever action is deemed
appropriate to avoid repetition of the incident unless such action requires the
approval of some other entity: i.e., Managers.
E. All incidents, unless judged to be inappropriate or invalid by the Nursing
Director, shall be reviewed by the Quality Improvement Committee and
Risk Management Committee of the Center at its next regular meeting.
All Events are to be reported to the Nursing Director who will be responsible for
coordinating the intensive assessment process.
BODY MECHANICS/ERGONOMICS:
If your work in not high enough, you should lean down to it in order to lift it.
True False
Good posture and body mechanics should be used in the presence of acute injuries
only.
True False
Workstation ergonomics include such things as chair comfort, arm and keyboard
position, foot position, and lighting.
True False
If you must recap a needle you should do this only if absolutely necessary,
And then, use a resheathing device or one-handed scoop method? T F
HANDS OFF:
The most highly recommended technique for preventing sharps injuries in the OR is to
create a neutral or safe zone for no-hands passing of all sharps.
True
False
When deciding alternate methods for the safe zone the key is to focus on communication,
patient safety, and staff safety when deciding what practices you will use.
True
False
When there is a lapse in behavior staff are expected to report it to their manager. The
manager is obligated to report this to the Medical Advisory Committee.
All employees are empowered to speak up and retaliation is an offense.
True
False
RADIATION SAFETY :
SEXUAL HARASSMENT:
1.Any employee who feels that he or she has been the subject of sexual
harassment from a coworker, manager, patient,
or any other person in connection with employment at the Center should
immediately report the behavior in question to the Nurse Manager or
designee. The Nursing Manager or designee will obtain from the employee
a signed statement describing the harassment.
True/False
F
2.The Nursing Manager or designee will investigate the report promptly and
as confidentially as possible.
True/False
True/False
True/False
5.In the event that the offending individual is not an employee, the Nursing
Manager in consultation with the Administrator will take action necessary to
prevent a recurrence of the incident in the workplace.
True/False
True/False
True/False
CORPORATE COMPLIANCE:
1. Only Billing Staff must comply with the Corporate Compliance Program.
True
False
2. All Center staff must comply with the Corporate Compliance Program.
True
False
True
False
Call the Compliance Officer and the Center’s legal council immediately
Answer all questions asked and hand over all information available
Not ask for a copy of the search warrant
Never ask the agent to give you an inventory of items taken and sign for it
8. The Center will not tolerate retaliation against staff that report violations of the
Center’s policies
True
False
9. Gifts to referral sources are prohibited. The Staff will not accept gifts from vendors,
suppliers or other providers in exchange for patient referrals
True
False
True
False
11. If the reporting person would prefer anonymity they may leave a letter in the
complaint box located in the waiting area.
True
False
True
False
CUSTOMER SERVICE:
1. It is important to create a positive first impression.
True False
2. A customer forms impressions about you and your organization within seconds of
contact.
True False
3. Your attitude is the key to customer satisfaction
True False
4. What will please customers most? (Circle all that apply)
• No hassle
• Someone who listens
• Verbal feedback
• Immediate action
• Using his/her name
5. Irritating words to avoid using when speaking with customers include: (Circle all that
apply)
• Can’t
• Can’t help you
• You should have
• All we can do
• It is company policy
• You have to
• What would you like for us to do?
• What will work best for you?
6. Listeners should: (Circle all that apply)
Judge others before listening
Pay attention to content and facts
Listen completely first, this makes people feel valued
Listen for the main idea
Try to change the subject
Avoid eye contact
Listen carefully, give feedback, ask confirmation
Make negative statements
Maintain patience while listening
Maintain eye contact
7. The Surgical Center employees and personnel should avoid: (Circle all that apply)
o Arguing
o Rationalizing
o Defending
o Complaining
o Reacting
o Emotionalizing
o Promising
8. You should explain to the customer how he or she may make a complaint.
True False
Who is responsible for identifying quality and safety concerns at the Center?
Fire Safety:
The best way to stop fire and smoke from spreading is to:
A. Type A
B. Type B
C. Type C
D. Type ABC
A. Dial 911
B. Dial “0” for the operator
Electrical Safety:
HAZARDOUS MATERIALS:
The most reliable way to find out if a product is hazardous is to:
A. Smell it
B. Look for warnings on the label
C. Ask other employees
First aid and more detailed information about cleaners used in the Center are available in
the:
A. AAAHC Manual
B. State Standards
C. MSDS (Material Safety Data Sheets)
A. Nurse’s station
B. In the Business Office
C. In the staff lounge
EMERGENCY PREPAREDNESS:
The emergency preparedness plan includes directives for:
A. Fire
B. Respiratory Arrest
C. Electrical Outage
A. A Tornado
B. A Hurricane
A. A Hurricane
B. A Tornado
C. A state of high humidity in the O.R.
BIOTERRORISM:
A respirator mask is necessary to enter a patient’s room that has which of the following:
A. Anthrax
B. Smallpox
C. Botulism
Disposable gown, respirator mask (N95) and gloves are required before entering an
isolation room for:
A. Tuberculosis
B. Smallpox
C. Anthrax
A. Contact
B. Droplet
C. Airborne
HIPAA Policies and procedures are intended to ensure that the practice complies with the
Privacy Standards established by the Health Insurance Portability and Accountability Act
of 1996, as well as other applicable state and federal laws, when maintaining, using and
disclosing protected health information.
True False
Whenever Practice personnel are presented with an issue regarding the release of patient
information which is not addressed by this Manual or further guidance is needed, such
personnel should contact the Privacy Officer. The Privacy Officer in turn should consult
legal counsel where appropriate.
True False
The practice Privacy Officer is the Administrator/Director of Nursing, who will be
responsible for developing, implementing, and supervising the Practice’s privacy policies
and procedures.
True False
Privacy Contact is the Administrator/Director of Nursing.
True False
Any violation of these policies and procedures by any physician, employee, independent
contractor, volunteer, or other member of the Practice’s workforce may result in
disciplinary action, up to and including suspension and/or termination from the Center.
True False
The Center will not intimidate, threaten, coerce, discriminate against, or take other
retaliatory action against any individual for the exercise of any right, participation in any
process, or opposition to any unlawful act or practice, set forth in the Center’s policies
and procedures.
True False
Protected health information (PHI) is any health information transmitted or maintained
in any form that:
A. Is created or received by the Practice
B. Relates to the past, present or future physical or mental health or condition of an
individual, the provision of health care to an individual, or the payment for the provision
of health care to an individual;
C. and identifies the individual or offers a reasonable basis for identification.
D. All of the above
When using or disclosing PHI, or when requesting PHI form another covered entity, the
Center will make reasonable efforts to limit PHI to the minimum necessary to accomplish
the intended purpose of the use, disclosure, or request.
True False
The “Minimum Necessary” Standard will not apply in the following circumstances;
• Disclosures for purposes of treatment
• Disclosures made to the individual
• Disclosures made pursuant to a valid authorization
• Disclosures made to the Secretary of the Department of Health and Human
Services (“HHS”) for purposes of compliance
• Disclosures required by law or
• Disclosures necessary for compliance with the HIPAA Privacy Rules
True False
The Center may use or disclose an individual’s PHI for purposes of treatment, payment,
or health care operations (“TPO”) without the individual’s consent or authorization.
This includes the use of information:
• For the Center’s TPO, as set forth in the Notice of Privacy Practices
• For treatment activities for another health care provider
• For the payment activities of another covered entity, so long as the recipient is
that covered entity; and
• For purposes of health care operations between covered entities participation in a
group health plan or other joint arrangement
Exception to this rule is:
Pursuant to Federal and State law, the Center will not use or disclose, for any purpose,
PHI related genetic testing or received from Federal funded Drug or Alcohol Treatment
Program, without a patient’s authorization. The Practice will not use or disclose PHI
related to HIV/AIDS without a patient’s authorization except for treatment purposes.
Furthermore, the Practice will not release Psychotherapy Notes for purposes of treatment,
payment, or healthcare operations unless permitted under the HIPAA Regulations.
True False
The patient has the right to:
Request limits on uses and disclosures of PHI
Choose How their PHI is sent
See and get copies of their PHI
Get a list of the disclosures that the Center has made
To correct or update their PHI
A copy of the Notice
To get notice via E-Mail
True False
Every patient will be offered a Notice of Privacy Practices for Physician Practices when
they come to the Center for treatment.
True False
ADVANCE DIRECTIVES:
A Proxy Directive or “durable power of attorney” identifies the person who will:
The patient has the right to information regarding advance directives prior to admission
True
False
A. Sexual exploitation
B. Mental retardation
C. Accidental injury
Who is required to report suspected child abuse and neglect in the State of New Jersey?
A. All citizens of NJ
B. Law enforcement officers only
C. Physicians and nurses only
A. They believe the authorities will not be able to stop the abuse
B. They are ashamed of having a child who abuses them
C. All of the above
LATEX ALLERGY:
The medical product most often associated with latex allergy is:
A. IV tubing
B. B/P cuffs
C. Latex gloves
A. Children
B. Healthcare workers
C. The elderly
Which of the following items would need to be removed from the room of a patient with
a latex allergy?
A. Plastic utensils
B. Latex gloves
C. Pillows
CHAIN OF INFECTION/ BLOODBORNE PATHOGENS/TUBERCULOSIS:
The most effective way to prevent the spread of infection is by:
A. Wearing gloves
B. Doing a 15 second hand wash or using waterless soap
C. Enforcing contact isolation
The Hepatitis B and C virus may cause permanent damage to which of these organs?
A. Stomach
B. Heart
C. Liver
Workplace Violence
The code to call for help is:
A. Code Red
B. Code Blue
C. Code 5
6. Using the first name when addressing a patient from another culture may be
interpreted as disrespect.
True False (Circle one)
10. “Patients are treated with respect, consideration, and dignity” is a statement
contained in the AAAHC First Core Standard which confirms the
commitment to cultural competence.
True False (Circle one)
Culture and communication are two major influences of pain management efficacy.
T F
Cultural differences between the patient and the health provider may lead to
misunderstanding or mistrust.
T F
While a patient is at the Center, the only obligation the nursing staff has is to provide
medication for pain and document its effectiveness.
T F
Groups of patients that may not be able to communicate their pain management needs
are:
infants/children
speech impaired patients
hearing impaired patients
intubated patients
patients with a language barrier
all of the above
The patient will be asked to scale their pain from 1 to 10. 1 being the least amount of
pain and 10 being the most severe pain. The non verbal pain scale will be used to
demonstrate this concept to the patient.
a. True
b. False
The preoperative nurse will assess the patient’s level of pain on admission and
interview the patient to determine methods that work best for pain relief for the
patient. This assessment will be documented in the chart record.
a. True
b. False
The nurse will evaluate the patient’s pain level postoperatively and prior to discharge.
This will be documented in the chart record.
a. True
b. False
The patient will only be discharged when pain is at a tolerable level. If pain is not
tolerable the patient will be admitted to the hospital for appropriate follow up care.
a. True
b. False
The Center will collect and analyze data in order to evaluate outcomes or
performance. Data analysis shall focus on recommendations for implementing
corrective actions and improving performance
True
False
Present:
Objectives:
To test how quickly and effectively how well
The Center staff can retrieve data
The Center staff can react during an emergency
The business office functions without a computer using only paper
The business office functions with no outside power
The shared systems involving vendors and business associates continue to operate
The Manager announced that the contingency plan was in place. All computers were
shut down for 3 hours during patient care hours.
Evaluation:
A drug that has a high risk of causing injury to patients when misused and that has
consequences that can be more devastating is a high alert medication.
True False
Identification of these drugs and initiating safeguards may reduce the risk of errors.
True False
Rescue:
Rescue of a patient from a deeper level of sedation than intended is an intervention by a
practitioner proficient in airway management and advanced life support. It is not
appropriate to continue the procedure at an unintended level of sedation.
True False
Physician present:
The physician should be physically present throughout the sedation and remain
immediately available until the patient is medically discharged form the post-procedure
recovery area.
True False
Education/training:
The practitioner administering propofol for sedation/anesthesia should, at a minimum,
have the education and training to identify and manage the airway and cardiovascular
changes which occur in a patient who enters a state of general anesthesia, as well as the
ability to assist in the management of complications.
The practitioner monitoring the patient should be present throughout the procedure and
be completely dedicated to that task.
True False
Nosocomial Infections: Test Questions:
Please answer either true or false by circling the correct response.
1. In order to have a nosocomial infection you need a germ, a carrier –and a person
without resistance who becomes infected
True False
7. If a physician documents his/her patient has a surgical site infection you should
not document the patient as having a surgical site infection until you have more data.
True False
Address:
Phone #:
Address:
Phone#
_____________________________________________ ____________
Employee signature Date
True False
True False
True False
True False
Director of Nursing
True False
There are protections for facility deliberations under the Patient Safety
Act.
True False
Event/RCA Reporting
Time frame is 5 business days
True False
Download form HCQ-1 Report of Serious Preventable Adverse Event in a New Jersey
Licensed Health Care Facility at:
www.NJ.gov/health/ps
True False
Report of Serious Preventable Adverse Event in a New Jersey Licensed Health Care
Facility:
Submit a Root Cause Analysis (RCA)
Identify the contributing causes of adverse events
Ensure that it is a focused review
Identifying prevention strategies
(What happened? why did it happen? and how can the Center prevent it from
reoccurring?)
RCA Team should include:
Staff knowledgeable about processes involved in the event
Effect on pt
Environment/Equipment
Rules/Policies/Procedures
Barriers
True False
True False
True False
• Be doable
True False
True False
When trying to resolve a problem you should:
1. Include an action plan for each causal statement
True False
True False
TEST QUESTIONS: Infection Control Plan for Managing High Risk Infections
Care of Patients with Resistant Organisms – MRSA and other MDRO
in Ambulatory Care Settings
In general, healthy people are at low risk of getting infected with MRSA or VRE.
True False
Hand sanitizing and hand washing compliance by staff and each person, including
visitors in the patient care units can NOT be overemphasized since DIRECT CONTACT
is the primary method of cross contamination with MRSA and other MDRO. It is the
single most important Infection Control and Prevention method.
True False
Standard Precautions should be used for all patient care.
True False
Standard Precautions include:
• Hand hygiene: After touching blood, body fluids, secretions, excretions,
contaminated items; immediately after removing gloves; between patient contacts;
• Gloves: For touching blood, body fluids, secretions, excretions, contaminated
items; for touching mucous membranes and non-intact skin;
• Gown: During procedures and patient-care activities when contact of
clothing/exposed skin with blood/body fluids, secretions, and excretions is
anticipated;
• Mask, eye protection (goggles), face shield: During procedures and patient-care
activities likely to generate splashes or sprays of blood, body fluids, secretions,
especially suctioning, endotracheal intubation;
True False
When a private room is not available, place the patient in a room with a patient who is
colonized or infected with the same organism, but does not have any other infection
(cohorting). Another option is to place an infected patient with a patient who does not
have risk factors for infection. At minimum, place patient at a station with as few
adjacent stations as possible (e.g. at the end or corner of the unit) and pull privacy
curtains on both sides to create a visual barrier which will serve as a reminder to staff that
extra precautions are required.
True False
When transport or movement of the patient within the facility is required, ensure that
infected or colonized areas of the patient’s body are contained and covered.
True False
Gloves should be worn whenever touching the patient’s intact skin or surfaces and
articles in close proximity to the patient (e.g. medical equipment, bed rails). You should
put on new gloves upon entry into the room or cubicle.
True False
You should wear a gown whenever anticipating that clothing will have direct contact
with the patient or potentially contaminated environmental surfaces or equipment in close
proximity to the patient. Put on the gown upon entry into the room or cubicle. Remove
gown and wash / sanitize hands before leaving the patient care environment. After gown
removal, ensure that clothing and skin do not contact potentially contaminated
environmental surfaces that could result in possible transfer of microorganisms to other
patients or environmental surfaces.
True False
You should notify other healthcare personnel and/or facilities that provide care for the
patient that the patient is colonized/infected with a multidrug-resistant organism.
True False
EPA registered disinfectants or detergents/disinfectants that best meet the overall needs
of the healthcare facility for routine cleaning and disinfection should be selected. In
general, use of the existing facility detergent/disinfectant according to the manufacturer’s
recommendations for amount, dilution and contact time is sufficient to remove pathogens
from surfaces of rooms where colonized or infected individuals were located. This
includes those pathogens that are resistant to multiple classes of antimicrobial agents
(MRSA, VRE, etc.).
True False
You should focus on frequent and between case sanitizing and disinfecting the high touch
areas in close proximity to the patient and the frequently touched surface areas (e.g. bed
rails, bedside tables, commodes, bathroom fixtures, and doorknobs).
True False
Disposable disinfectant equipment and surface wipes are readily available in accessible
locations in the patient care areas to allow staff to perform rapid equipment and surface
disinfection during the care hours of operation.
True False
Occasionally, healthcare workers can become persistently colonized with an MDRO, but
these healthcare workers have a limited role in transmission, unless other factors are
present. Additional risk factors that can facilitate transmission, include chronic sinusitis,
upper respiratory infection and dermatitis. Healthcare worker decolonization is indicated
only as a prevention and control intervention when a health care worker is chronically
colonized with MRSA and has been epidemiologically implicated in ongoing
transmission of MRSA to patients.
True False
Drug Competency
1 teaspoon = cc
1 tablespoon = cc
1ml = cc
1ounce = cc
10cc = teaspoons
1kg = lbs
If you were giving a child Versed po syrup (Versed Syrup 2mg/ml), using the maximum
dosage of 0.5mg/kg. What is the maximum allowable dose for a 22lb child?
If you were ordered to give Demerol 50mg IV and Demerol 100mg/ml was the only
dosage available how many ml would you administer?
How would you prepare Ancef IVPB? Can you give this medication to someone who is
allergic to sulfa?
Penicillin?
What is the maximum dose of Demerol that can be administered to a 70kg man?
What is the maximum dose of Demerol that may be administered to a 30kg child?
What is the maximum dose of Morphine that can be given to a 70kg man?
What is the first action you would take for an episode of narcotic induced respiratory
depression?
What is the protocol for a patient who faints in the Center?
Can Toradol be given to a patient with a history of Renal Disease, GI problems, Ulcers,
Bleeding, currently taking ASA or non-steroidal anti inflammatory drugs (ASAIDs)?
What complication should you continue to look for following Narcan administration?
POLICY: Urine pregnancy can be done in the Center by appropriately trained personnel.
PROCEDURE:
1. Gather supplies:
1. Quick-Vue urine pregnancy kit
2. Procedure Gloves
3. Dropper
4. Specimen Cup
2. Obtain urine sample from patient (First morning specimens generally contain the
highest concentrations of hCG; however, any urine is suitable for testing).
1. Remove Quick-Vue test cassette from foil pouch just before use and place
on dry, level surface.
2. Using one of the disposable pipettes supplied, collect sample and add 3
drops of urine to the Round Sample Well on the test cassette. The test
cassette should not be handled or moved until the test is complete and
ready for reading.
3. Wait three (3) minutes and read.
4. Interpret results
i. Positive: Any pink-to-red test line (T) along with a blue control
line (C)
ii. Negative: A blue control line (C) and no pink test line (T)
iii. Invalid: no blue control line visible at three (3) minutes. If this
happens, retest using a new sample and a new test cassette, or
contact Quidel Technical Support at 800-874-1517.
4. Dispose of kit contents per Center procedure and record results on patient chart
and in POS Test Log.
5. Monthly, results will be reviewed and signed off by the Medical Director.
6. Whenever a new lot number or fresh supplies are obtained, a control must be run
using the hCG Control Set. Documentation of the control is entered on the Log
sheet.
POLICY: CLIA WAIVED TESTING:
Purpose/Objective:
To make every effort to ensure safe practices are used when performing CLIA
waived testing in the center.
To make every effort to ensure the staff performing CLIA waived testing are
properly in-serviced annually.
To make every effort to ensure that the Medical Director oversees the use of
CLIA waived tests.
Procedure:
• The Medical Director shall review the logbook and oversee the use of CLIA
waived tests performed in the Center at least three times a year.
• All Staff members that will be performing CLIA waived tests shall be in-serviced
on CLIA waived tests used in the Center annually.
• An annual in-service will include CLIA waived testing. A list of CLIA waived
employees will be kept in the Control testing book.
The use of the Accu-Vue Urine Pregnancy Kit was explained. Use of the hCG Control
Kit-to be used each time a new lot or shipment of test materials is received- was
explained.
Demonstration of the Test Kit and the Control Kit were also performed.
The Procedure Card was reviewed, including how positive, negative, and invalid test
results are displayed on the cassette.
Discussion re: inability to obtain a urine specimen and appropriate actions was presented.
Objectives:
1. The learner will demonstrate how to use all the components of the urine
pregnancy kit.
2. The learner will demonstrate proper use and documentation of the hCG Control
Kit.
3. The learner will verbalize the rationale for performing a urine pregnancy test per
Center policy.
4. The learner will verbalize appropriate actions to take, per Center policy, in the
event that a patient refuses the test, or inability on the patient’s part to provide a
urine specimen.
Objectives:
1. The learner will demonstrate how to turn on the glucometer.
2. The learner will demonstrate how to run controls and document them properly.
3. The learner will explain why it is necessary to take a blood glucose on a patient in the
Center.
4. The learner will explain why only U-100 syringes are used to give insulin to a patient
subcultaneously.
5. The learner will explain why it is necessary to run appropriate fluids on diabetic
patients having surgery.
6. The learner will explain why it is necessary to check the patient’s blood sugar
following surgery if ordered.
Narrow Complex:
12 lead EKG
Clinical information
Vagal maneuvers
Adenosine
Wide Complex
12 lead EKG
Clinical information
DC cardioversion
Procainamide
Amiodarone
CPR-Drug-Shock-CPR-Drug-Shock-etc
DO 5 CYCLES OF CPR
DO NOT INTERRUPT FOR PULSE CHECKS UNLESS FOR GOOD CAUSE
HAVE SOMEONE SWITCH DOING COMPRESSIONS IF AVAILABLE
ABCD Survey
Assess ABC’s
Secure airway noninvasively
Ensure monitor/defibrillator is available
Secondary Survey
Assess secondary ABC’s is invasive airway needed?
Oxygen-IV-Monitor-Fluids
VS, pulse oximeter, monitor B/P
12 lead EKG
Problem focused history
Problem focused physical exam
Consider Causes
Type II second-degree AV block? 3rd degree block?
Observe
Serious Signs or Symptoms?
Atropine 0.5 to 1.0mg
Transcutaneous pacing if available
Dopamine 5 to 20ug/kg per minute
Epinephrine 2-10 ug/min
Isoproterenol 2-10ug/min
Hospital:
• Obtain A-ABG’s; B- Body temperature (core)- avoid hyper/hypothermia; C-End-
tidal CO2, CK, Coagulation tests, myoglobin levels; D- Diuresis (urine output
and color); E- Electrolytes
• Admit to intensive care unit for at least 24 hours
Review MH Video- video clip available on MHAUS website; full video available with
purchase of MH Kit for Ambulatory Surgery (See MHAUS website for purchase
information)
Practice Mixing:
Dantrolene Sodium is difficult to mix. If your supply expires, use the out-of-date supply
for training. Mix the drug in an assembly-line fashion where several people take the
responsibility for just one small step in the process.
MH cart should include:
Dantrolene Sodium kits, which include 1,000 cc sterile water for injection, a 60cc luer-
lok syringe, a 3-way stopcock and a fluid path
Needles
Syringes
IV catheters
IV tubing
Blood collection tubes and sets including ABG Kit
60 cc Toomey syringe
Nasogastric tube
Esophageal stethoscope
Foley catheter with urimeter
Drugs should include:
Dantrolene Sodium (36 vials) Every ASC should have 36 vials of Dantrolene Sodium
on hand at all times. This enables a 70 kg pt to receive 4 doses of the drug.
Sterile water for injection (preservative free)- advise 100ml vials if available
Calcium chloride (10%)- 10ml vials x2
Insulin- Regular 100units/ml (refrigerated)
Mannitol
50% dextrose- 50mlvials x2
Digoxin
Physostigmine
Furosemide 40mg/amp x 4 ampules
Heparin lock
Dexamethasone
Lidocaine 2%- 100mg/5ml or 100mg/10ml in pre-loaded syringes x3
Sodium bicarbonate 8.4%- 50ml x5
0.9% saline for injection, cold sterile saline for lavage, regular insulin (refrigerate) and
ice.
Make certain your MH ice supply is available at all times.
Keep a conversion chart for pounds to kg available in your MH cart
TEAM RESPONSE/EFFICIENCY:
EXCELLENT GOOD FAIR POOR
Additional Comments:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
________
___________________________________
______________________________
__________________, RN- Admin/DON Anesthesia Department
Date:
Present:
Instructor:
Case scenario:
A patient is on the O.R. table. Suddenly the patient’s heart rate is 180. The
anesthesiologist shows concern and begins to look for likely causes. Other symptoms
noted are tachypnea, spontaneous ventilation, unstable blood pressure, arrhythmias, dark
blood in the surgical field despite adequate inspired oxygen, cyanotic mottling of the
skin, profuse sweating, fever: rapid rise in temperature (1 degrees Fahrenheit/15min)
sustained rise 108 degrees or more, and fasciculation and/or rigidity (sometimes
involving total body); trismus (lockjaw is an early sign.)
1. Stop anesthesia and surgery immediately. Change all rubber goods on the anesthesia
machine.
Anesthetic agents are absorbed into the rubber, which will exude those agents, providing
a continuous trigger mechanism.
2. Hyperventilate the patient with 100% of oxygen ( 8-10 liters)
3. Administer Dantrium IV as ordered by the anesthesiologist/physician. 36 vials are
obtained with sterile water for injection to reconstitute the vials. One nurse is
assigned this job alone since it is very difficult to mix.
4. RECOMMENED DOSAGE: 1mg-10mg/kg of body weight. For a patient weighing
70kg the initial dose would be 3 ½ vials. If the full dosage should be required
(10mg/kg) ten times the initial dose would be needed or 35 vials.
5. If necessary Pronestyl IV bolus and then continuous drip as ordered by
anesthesiologist/physician.
6. DO NOT USE LIDOCAINE in treating arrhythmia in malignant hyperthermia, as a
local amide anesthetic agent is felt to be a triggering agent.
7. Initiate cooling: Administer IV iced saline solution-100ml/10min for 30min.
8. Do not use lactated ringers solution. IV fluids should be administered through a large
gauge peripheral line. Ideally the patient will require two good peripheral IV sites as
well as a central line. Two liters of iced saline are always available.
9. Surface cooling is done using ice. A nasogastric tube and urinary catheter with 3-way
adapter are placed. The patient may also be lavaged rectally
10. Administer sodium bicarbonate as directed by the anesthesiologist/physician.
11. EKG, temperature, urinary catheter, must all be monitored closely.
12. Administer diuretics as ordered by the Anesthesiologist. Maintain urine output of at
least 2ml/kg/hr.
13. If necessary, administer regular insulin 10/50-50W IV push as ordered by the
Anesthesiologist/physician. To provide energy to the cells.
14. TRANSFER THE PATIENT TO THE HOSPITAL IMMEDIATELY.
15. * FOLLOW THE PROTOCOL AS STATED BY THE MALIGNANT
HYPERTHERMIA ASSOCIATION OF THE UNITED STATES.
Date:
Reviewer:
Objectives:
1. To be able to recognize the different alarm sounds in the surgical center and respond
in an appropriate manner.
Disaster Drill was explained and then performed with the staff members.
The evacuation protocol was explained and simulated with the staff members.
The use of the snow ball list was explained.
Objectives:
1. To ensure all staff members are aware of the procedure to follow in a Disaster and
Evacuation.
4. To demonstrate how items are to be inspected for loss of integrity and the proper
procedures to use when items compromised are found.
The Policy on Event related sterilization was handed out to all staff members involved in
sterilization processes. The Policy was read and a question and answer period took place.
The Policy on Sterilization Procedures/Clean Utility Room Procedure was presented for
review. The Policy was read and a question and answer period took place. The Policy on
Record Keeping of loads was read and reviewed with the staff members. The
documentation of the loads was demonstrated and questions were answered. The Policy
on Single Use Devices was reviewed. This was done to ensure that only proper devices
continue to be sterilized in the Center. The Policy on Recall of In-House Sterilized Items
was reviewed and a demonstration of how this policy works was demonstrated by
pretending that a load was bad. Questions were answered. The monthly Instrument
Packaging Integrity Check was explained and a hands on demonstration took place
implementing the procedure to ensure that the staff understood the procedure.
The Nurse Call System is located in the Recovery Room. This serves as the emergency
notification system for the Center. It is always staffed when a patient is in the Center.
This device monitors all necessary areas of the Surgical Center. If a patient or a staff
member is in need of assistance, this system serves to notify another staff member of
their need.
Objectives:
1. The staff member will demonstrate how to answer an incoming call on the system.
2. The staff member will demonstrate how to answer a code situation.
3. The staff member will demonstrate how to answer a bathroom page.
4. The staff member will demonstrate how to speak through the call system.
5. The staff member will explain the importance of staffing this call system at all times
when a patient is present in the Center.
The Welch Allyn monitors were in-serviced including the functions, how to change
parameters, how to hook up the patient properly, how to set alarms, when a patient should
remain on a monitor, how to detach the monitor from the stand to use for patient for
patient transport. A demonstration was given on how to record necessary rhythm strips
and how to properly change the paper in the machine.
Objectives:
4. Artificial fingernails or extenders should not be worn when providing patient care.
True False
6. Gloves should be worn when it can be reasonably anticipated that contact with
blood or other potentially infectious materials, mucous membranes, and non-
intact skin will occur. This is required and mandated by Federal and/or state
regulation or standards.
True False
7. If hands are not visibly soiled you may: (Please circle the correct answer.)
A. Use an alcohol-based waterless antiseptic agent for routinely decontaminating
hands.
B. Wait to wash your hands until they become visibly soiled.
8. It is recommended that employees decontaminate hands after contact with a
patient’s intact skin (as in taking a pulse or blood pressure, or lifting a patient.
True False
Competency for PPE
Employee name: ________________________________________________
Observation/Demonstration Competency met Competency not Comments
met
Verbalizes understanding
of Standard Precautions
Wears scrub attire in semi
restricted and restricted
areas.
Wears bouffant cap or hair
covering in designated
areas.
Wears shoe covers if
soiling of shoes is likely.
Wears goggles or face
mask when splashing is
possible.
Wears mask in restricted
areas.
Changes mask after use.
Does not leave mask tied
around neck for reuse.
Wears gown when
applicable
Wears gloves when
touching body fluids/ Uses
standard precautions.
Dons gown appropriately
Dons gloves appropriately
Dons mask appropriately
Removes PPE in correct
order and disposes of
properly.
Washes hands between all
patient encounters.
Washes hands after taking
off gloves.
Washes hands when gloves
are removed following
contact with body fluids.
Supervisor’s signature: ________________________________________
AORN provided a Medication Tool Kit which is a summary of the new regulations.
Patient safety issues are on the rise with medication errors comprising a large portion of
medical accidents. Recent studies have received the attention of health care providers,
health care organizations, experts in safety, and federal and state lawmakers.
A study from the institute of Medicine reported that 44,000 to 98,000 people die each
year from medical accidents costing from 17 billion to 29 billion for preventable adverse
medical events.
In 1999 the Institute of Medicine reported that adverse events in surgery account for 20%
of the errors in health care, while medication errors make up about 16% of all medical
adverse events.
According to the U.S. Food and Drug Administration, more than 777,000 patients are
injured by medication errors each year.
The AORN offered a tool kit to help implement safe medication administration practices
in their facility to ensure safe patient outcomes. The tool kit was developed by the
Association of Preoperative Registered Nurses, under an educational grant from Sandel
Medical Industries. This tool provides resources to enhance perioperative medication
competencies and creates awareness of safe medication administration among the
surgical team.
The plan includes identifying and learning from errors by developing a nationwide public
mandatory reporting system and encouraging health care organizations and practitioners
to develop and participate in voluntary reporting systems.
The goal is to provide a system allowing for open disclosure of medical errors while
providing for legal protection for physicians. None of the health technology legislation
introduced to date has addressed issues of medical liability until now.
The National Medical Error Disclosure and Compensation Act of 2005, also known as
the Medic Act is an extension of the recently passed Patient Safety and Quality
Improvement Act of 2005, which was signed into law by president George W. Bush in
June 2005, and is aimed at providing liability protections for physicians who disclose
medical errors to patients and participate in a national error reporting system. According
to the language in the bill, the Medic Act’s purpose is to promote a culture of safety
within hospitals, health system, clinics and other sites of health care, through the
establishment of a national medical program. The Medic Act would establish an Office
of Patient Safety and Health care Quality to implement and oversee a national patient
safety database, as well as the Medic Program.
http://www.aorn.org/EDUCATION/SAFEMEDTOOLKIT.HTM
Patient Safety First:
Improving specimen practices to reduce errors.
In 2005 the AORN approved the AORN guidance statement: Safe specimen
identification, collection and handling in the preoperative practice settings. The
statement provides guidance regarding quality improvement issues of reducing medical
errors specific to preventing misidentification, mislabeling, loss of identifiers, and actual
loss of surgical specimens.
The AORN guidance statement recommends that managers develop separate policies and
procedures that address processes for specimen handling. The policies should include.
• Specimen containment
• Identification, including patient identification that uses at least two identifiers
• Tissue and specimen identification and Source identification
• Transferring specimens from the sterile field
• Transferring specimens to the point of use (e.g. sterile field, person implanting)
• Labeling specimen container(s) on and off the sterile field.
• Documentation:
o On the laboratory requisition(s)
o In the patient’s record
• Chain of custody
• Verbal/written communication;
• Verifying correct information
• E.g., specimen type, patient information)before transferring the specimen
• Storing and maintaining specimens until transfer
• Transferring or facilitating transfer of the specimen for examination and
• Using risk reduction strategies.
Specimen errors are preventable. Each institution is responsible to help evaluate quality
improvement to prevent specimen error that could have a significant effect on a patient,
nursing staff members, medical providers, a facility, and a community.
Errors that have been reported include:
• Lost specimens
• Mislabeling, mix-ups
• Retrieving specimens that have been misplaced in garbage bins, sent to the wrong
laboratory
• Specimens being stored in towels and lost in the laundry
• Multiple specimens being handled simultaneously cause difficulty organizing and
identifying tissues on the field before they are transferred to the circulating nurse
• Loss of lymph node biopsy resulting in patient receiving radiation therapy
Such errors can lead to delayed diagnoses, the necessity of repeating surgical procedures
resulting in decreased patient satisfaction, and potential legal action. Loss of a specimen
tissue could result in the lack of ability to diagnose and treat a critical condition.
1. Increase Stimulation
• Begin procedure if not already in progress
• Jaw thrust (combined noxious stimulus and airway maneuver)
2. Withhold further sedation until protective reflexes return
3. Supplement oxygen if indicated by falling oxygen saturation; airway support if
indicated by falling oxygen saturation or airway obstruction
• Jaw thrust
• Head tilt/Chin lift
• Nasal/Oral airway
• Positive pressure ventilation- call for help
• Suction if indicated
4. Pharmacological reversal
• Narcan (Naloxone)
• Romazicon (Flumazenil)- for Versed (Midazolam)
Purpose/Objective:
To make every effort to prevent identity theft from occurring in the Center.
Procedure:
Detection (Red Flags)
The Surgery Center adopts the following red flags to detect potential fraud. These are not
intended to be all-inclusive and other suspicious activity may be investigated as
necessary.
• Identification documents appear to be altered
Response
Any employee that may suspect fraud or detect a red flag will implement the following
response as applicable. All detections or suspicious red flags shall be reported to the
Administrator.
• Ask the patient for additional documentation.
Security Procedures:
• Paper documents, files and electronic media containing secure
information will be stored in locked file cabinets.
• Employees shall not leave sensitive papers out on their desks when
they are away from their workstations.
• Employees shall log off their computers when leaving their work areas
• Employees shall lock file cabinets when leaving their work areas
• Employees shall lock the file room doors when leaving their work areas
• Access to offsite storage facilities is limited to employees with a
legitimate business need (if archiving is in place)
• Visitors who must enter areas where sensitive files are kept must be
escorted by an employee of the surgery center.
• The computer network will have a firewall where the network connects
to the internet.
• Procedures exist for to make every effort to ensure that workers who
leave your employ no longer have access to sensitive information.
• Employee training will be performed annually with all other required in-
services.
• Paper records will be shredded before being placed into the trash.
Preventive Strategies:
• Utilize encryption system
Post-breach Response:
If you suspect your information system has been targeted and patient or client
information is exposed, a rapid assessment and mitigation of damage is imperative, as
outlined below:
o Board certification
o Education
o Licensing requirements
o Professional experience
o References
o Training
• How can your facility best protect patients against these possible
complications?
• Does the procedure fit within your practice’s current mission and
future plans?
The most effective way to reduce your exposure related to negligent credentialing claims is to
implement protocols that clarify administrative responsibilities and ensure conformity with
Federal and State licensure laws, regulations and standards.
Your protocols should reinforce the following fundamental principles:
• Clinical assignments are granted or denied based upon objective
carefully documented institutional criteria.
• Practice rules and regulations and standards are applied equally to all
applicants.
• Quality outcome data and patient information used in the process are
treated with utmost confidentiality.
Note: Healthcare entities must report professional review actions taken against physicians and
dentists and may report such actions against other healthcare practitioners to the NPDB.
References: 2009 HPSO Risk advisor Vol. 1
IN-SERVICE: RED FLAGS
The Federal Trade Commission has enacted a new rule requiring all creditors to
implement written policies aimed at curbing identity theft.
Any Medical practice that extends, renews, or continues credit for a patient-i.e, one that
bills patients for services rendered- is subject to the Red Flags Rule, regardless of
whether the Center first bills an insurance carrier.
A written program has therefore been developed that allows the Center to:
identify relevant red flags
detect flags as they occur and
prevent and mitigate identity theft
A red flag is anything that could alert the Center to suspicious activity that may indicate
identity theft.
The Federal Trade Commission’s guidelines identify four warning-sign categories:
1. Alerts, notifications, or warnings from a consumer reporting agency
2. Suspicious documents
Red flags may be detected when you verify a patient’s identity, review medical records,
verify insurance forms, or receive alerts or information of suspicious activity from
outside agencies.
This must also be done if there has been a breach or attempted breach of the Center’s data
base.
The Center’s program will be updated when the methods of identity- theft threats change
or new risks and trends develop.
Drlaw.com/publications/Red_Flag_Rules_Template1.pdf.
Reference: Medica Economics April 17, 2009, page 23
INFLUENZA VACCINE DECLINATION FORM
2009
If you work in a patient care area, and did not receive a flu vaccine at the Center, please
complete all applicable sections and return to the Admin/DON by June 1, 2009.
This acknowledges that the following influenza information is understood, as well as the
ability to receive the flu vaccine at the Center with no charge.
• Influenza can be spread for 24-48 hours before symptoms appear
• Yearly vaccination is required, as the flu strains vary year to year
• I cannot get the flu from the flu vaccine
• CDC Recommendations include the receipt of flu vaccine by all
healthcare workers in order to protect patients, visitors, and co-
workers
Vaccinated Elsewhere:
I received vaccine at _______________________________________
(Facility )
I received it on this date: ________________ (INCLUDE MONTH)
Contraindications to Vaccine:
Persons with severe egg allergy should not get the vaccine. If you have a history
of Guillain-Barre Syndrome, please consult your physician as to whether or not
the vaccine is appropriate to receive.
I have been advised by my physician not to receive the vaccine.
Declination Statement:
Despite review of all the above, and the recommendation by the facility based on
current CDC literature, I choose not to receive the vaccine at this time.
As of June 24, 92 countries had officially reported 52,160 cases of novel influenza A
(H1N1) infection, including 31 deaths. This includes 21,449 cases in the U.S. with 87
deaths. New Jersey is reporting 609 confirmed cases with another 290 probable.
At the beginning of what is now the influenza pandemic, back in April, the CDC found
that half of flu cases were attributable to regular seasonal flu and the other half to the new
H1N1 novel influenza virus. Today that is no longer the case. Any patients presenting
with flu-like symptoms and testing positive for Influenza A by normal lab/office methods
are considered to have novel H1N1; other (seasonal) flu strains have disappeared by now.
Despite low numbers of confirmed cases, due largely to limited testing, disease is
widespread in our communities. The State Lab is accepting only those specimens from
patients who require hospitalization, or patients involved in institutional outbreaks. There
is no reason to test patients unless doing so will alter treatment, or unless they are a
member of an institutional outbreak.
If a patient presents complaining of fever and cough, reception staff should hand the
patient a mask when they arrive; the patient should be brought back to an exam room as
soon as possible. If the reception staff hears a patient coughing in the Waiting Area, they
should give the patient a mask and ask them to put it on. Check Waiting Areas regularly
to make sure tissues, waste cans, and hand cleaning agents are available.
People with flu-like illness (fever, cough, and/or sore throat) and no other specifically
identified cause ( i.e. Strep throat should stay home for 7 days from work or school). This
applies to employees! If employees come to work sick, the chance of other employees
becoming ill as well is highly likely. Please recognize that dealing with an outbreak next
week, with many people sick, would be far worse than having a few people out now.
Remind parents that Aspirin should not be used for symptom management in
children under 18 due to risk of Reye syndrome, a rare but potentially serious
illness seen in children following viral illnesses and linked to Aspirin use for
symptom management.
H1N1 Novel Influenza Update
June 25, 2009
As of June 24, 92 countries had officially reported 52,160 cases of novel influenza A
(H1N1) infection, including 31 deaths. This includes 21,449 cases in the U.S. with 87
deaths. New Jersey is reporting 609 confirmed cases with another 290 probable.
At the beginning of what is now the influenza pandemic, back in April, the CDC found
that half of flu cases were attributable to regular seasonal flu and the other half to the new
H1N1 novel influenza virus. Today that is no longer the case. Any patients presenting
with flu-like symptoms and testing positive for Influenza A by normal lab/office methods
are considered to have novel H1N1; other (seasonal) flu strains have disappeared by now.
Despite low numbers of confirmed cases, due largely to limited testing, disease is
widespread in our communities. The State Lab is accepting only those specimens from
patients who require hospitalization, or patients involved in institutional outbreaks. There
is no reason to test patients unless doing so will alter treatment, or unless they are a
member of an institutional outbreak.
If a patient presents complaining of fever and cough, reception staff should hand the
patient a mask when they arrive; the patient should be brought back to an exam room as
soon as possible. If reception staff hears a patient coughing in the Waiting Area, they
should give the patient a mask and ask them to put it on. Check Waiting Areas regularly
to make sure tissues, waste cans, and hand cleaning agents are available.
People with flu-like illness (fever, cough, and/or sore throat) and no other specifically
identified cause ( i.e. Strep throat should stay home for 7 days from work or school). This
applies to employees! If employees come to work sick, the chance of other employees
becoming ill as well is highly likely. Please recognize that dealing with an outbreak next
week, with many people sick, would be far worse than having a few people out now.
Remind parents that Aspirin should not be used for symptom management in
children under 18 due to risk of Reye syndrome, a rare but potentially serious
illness seen in children following viral illnesses and linked to Aspirin use for
symptom management.
Disaster Drill: Novel H1N1 Influenza (Swine Flu).
Purpose/Objective:
To make every effort to ensure that the staff is aware of the steps to take if a case of the
Swine Flu is present in the Center.
Present:
Scenario #1:
Patient arrives at the front desk with fever and cold symptoms. The patient is sent into
the exam room and is interviewed by a nurse.
Actions:
Patient is asked to wait in the exam room
Nurse is called to the exam room
Patient is asked to wear a mask
Patient responds that he/she is ill with cold symptoms
The patient is instructed to contact primary care physician and stay home until symptoms
resolve
Wash hands frequently especially after coughing and sneezing
Cough into a tissue (not into bare hands or onto another person
Dispose of tissues in the trash
If the patient experiences a high fever >37.8 degrees C (100 degrees F and cough and/or
sore throat (in the absence of another known cause)
Instruct the patient to go to the hospital.
Scenario #2:
The Center is informed that a patient that was in the Center came down with the Novel
H1N1 Influenza (Swine Flu).
Actions:
Inform the Administrator
Call local health department
Call the infection control nurse for direction
Contact individuals that came in direct contact with the patient
Ask contacts to call the Center if they develop symptoms and are diagnosed with
influenza H1N1.
(Http://nj.gov/health/lh/directory/lhdselectcounty.shtml) If local health department is not
available, please call NJDHSS during normal business hours (M-F 8 a.m. to 5 p.m.) at
609-588-7500 or after hours at 609-392-2020.
All suspect clusters are immediately reportable to the local health department
(Http://j.gov/health/lh/directory/lhdselectcounty.shtml) or when not available
NJDHSS.NJDHSS can be reached during business hours (M-F 8 a.m. to 5 p.m. ) at 609-
588-7500 or after hours at 609-392-2020.
Clusters are defined as:
Two or more individuals with symptom onset within 7 days of each other residing in the
same household or are associated with the same institution/activity/event (i.e., work,
school, travel)
Scenario #3:
Patient is called preoperatively at home and is screened for illnesses, contact with anyone
with a communicable disease or travel outside the US.
The patient responds that he/she is ill with cold symptoms
The patient is instructed to stay home until symptoms resolve
Wash hands frequently especially after coughing and sneezing
Cough into a tissue (not into bare hands or onto another person)
Dispose of tissues in the trash
If the patient has a high fever >37.8 degrees C (100 degrees F and cough and/or sore
throat (in the absence of another known cause)
Instruct the patient to contact his/her primary care physician.
(Http://nj.gov/health/lh/directory/lhdselectcounty.shtml) If local health department is not
available, please call NJDHSS during normal business hours (M-F 8 a.m. to 5 p.m.) at
609-588-7500 or after hours at 609-392-2020.
All suspect clusters are immediately reportable to the local health department
(Http://j.gov/health/lh/directory/lhdselectcounty.shtml) or when not available
NJDHSS.NJDHSS can be reached during business hours (M-F 8 a.m. to 5 p.m.) at 609-
588-7500 or after hours at 609-392-2020.
Clusters are defined as:
Two or more individuals with symptom onset within 7 days of each other residing in the
same household or are associated with the same institution/activity/event (i.e., work,
school, travel)
POLICY: INFLUENZA
Purpose/Objective:
To make every effort to ensure the staff is aware of the procedures to follow if a patient
or visitor is suspected to have influenza like illness.
IF YES:
IF YES ADMIT VIA EMERGENCY DEPARTMENT
IF NO:
CALL THE PATIENT’S/VISITOR’S PRIMARY CARE DOCTOR OR URGENT
CARE CENTER AND INQUIRE WHETHER THE PATIENT SHOULD BE
EVALUATED AND/OR SENT FOR A RAPID INFLUENZA TEST.
Preoperative call:
The patient responds that he/she is ill with cold symptoms and fever
The patient is instructed to stay home for 7 days after onset of symptoms or until 24 hours
after symptoms resolve-whichever is longer
Wash hands frequently especially after coughing and sneezing
Cough into a tissue (not into bare hands or onto another person)
Dispose of tissues in the trash
If the patient has a high fever >37.8 degrees C (100 degrees F and cough and/or sore
throat (in the absence of another known cause)
Instruct the patient to contact primary care physician or go to the emergency room if
warranted.
IF PATIENT WAS CANCELLED DUE TO INFLUENZA TYPE ILLNESS, OBTAIN
CLEARANCE FROM PRIMARY MEDICAL DOCTOR PRIOR TO RESCHEDULING
THE PATIENT
INFLUENZA TRIAGE QUESTIONS
2009
1. Recent travel outside the country; visits from anyone residing
outside the country? Y N
Date of onset:
Procedure;
Besides the technical concepts and skills required by those performing phlebotomy, the
following areas must also be incorporated to provide a quality experience for patients/
those receiving phlebotomy services:
• Roles and Responsibilities per job description
• Only RN’s that have been trained in phlebotomy will perform
phlebotomy in the Center.
Patient identification
• Roll easily
o Gauze Pads
o Adhesive Bandage or Tape- patients should be advised to
hold the arm straight, apply pressure for 3-5 minutes, and
remove the bandage in 15-20 minutes.
o Sharps Container
Gold or Red/Black
Green
Light Green or Green/Gray
Pink or Lavender
Gray
• Roll easily
o Gauze Pads
o Sharps Container
Gold or Red/Black
Green
Pink or Lavender
Gray
• Risk Management
• Breach of confidentiality
References:
Booth,Wallace, Fitzgerald; Phlebotomy for Healthcare Personnel,
2nd Edition, 2009
True False
2. RNs automatically may perform phlebotomy base on their core nursing education
True False
3. Specimen tubes must be labeled before the RN leaves the patient; never before the
specimen is drawn
True False
4. Performing correct hand hygiene is critical to prevention of infection during
phlebotomy
True False
5. Name the 3 most common veins, located in the antecubital fossa, that are used for
phlebotomy:
a. ____________________________________________________
b. ____________________________________________________
c. ____________________________________________________
6. An important thing to remember if using the basilic vein for phlebotomy is a)it
lies close to the median nerve and b) it lies close to the brachial artery.
True False
7. Factors that may limit access to veins include dermatitis, existing IV infusions,
patient history of mastectomy or stroke
True False
8. Choosing an evacuated tube color is based on: lab manual from contracted
institution, manufacturer’s instructions for technical products
True False
9. If multiple tubes of different colors are required, it doesn’t matter which tube is
used first.
True False
10. If the RN has difficulty locating a vein and/or performing the venipuncture,
attempts should be limited to 2; at this point a physician/Anesthesiologist should
be called to perform.
True False
11. Hematoma formation may result from leaving the tourniquet in place after the
needle is withdrawn
True False
12. Care for an accidental arterial puncture should include: immediate withdrawal of
the needle; application of firm pressure for at least 5 minutes followed by
application of a gauze pressure dressing; notification of the physician; notification
of DON and completion of appropriate QI documents
True False
13. Common causes for liability in the area of phlebotomy include: misidentification
of the patient, breach of confidentiality, acting outside the scope of practice,
improperly labeled/mishandling of specimens, injury to blood vessels or nerves,
poor sterile technique resulting in infection, permanent scarring or disfigurement
True False