2016 Ame Print Version

2016
Annual Mandatory
Education
Directions:
Review the slides
Complete the quiz at the end
Turn in completed answer key to your manager or director if you
DO NOT attend the competency faire
Section 1
1/3/2016
Section 1
Mission and Philosophy

Performance Improvement
Corporate Compliance
Patient Rights
Abuse Reporting
Confidentiality
Diversity
Just Culture
Second Victim Support
Adventist Health
Founded on Seventh-day Adventist

health values which promotes prevention
and whole person care
Entities include 20 hospitals, more than

275 clinics and outpatient centers, 15
home care agencies, 7 hospice
agencies, and 4 joint-venture retirement
centers
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Mission
Simi Valley Hospital
Mission Statement
Demonstrate
God's love by
providing
exceptional
service and quality
care to meet the
physical, mental
and spiritual needs
of our
community.
Mission
We carry out our mission by
providing access to quality health
care in the most appropriate
setting, while working to improve
the health of our community.
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Our Values
Compassion: We demonstrate empathy

and kindness to every person, while
providing medical care to alleviate their
fear, pain and suffering
Integrity: We conduct our business with

integrity, fairness and accountability
Our Values
Excellence: We strive to provide a level

of excellence in service, which meets
our customers expectations
Respect: We appreciate and respect

the diversity of our patients, employees,
physicians, volunteers, business
colleagues, visitors and all who interact
with us
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Our Vision
Simi Valley Hospital will be our
communitys hospital of choice,
providing high-quality care within the
scope of services appropriate to the
needs of the people we serve.
Performance
Improvement (PI)
PI Definition
Performance Improvement is a process that first
measures the current level of performance of the
organization and then generates ideas for modifying
organizational behavior and processes. These changes
are put into place to achieve better outcomes (i.e. less
infections, quicker care, appropriate treatment) and
with time and continual monitoring this change
becomes part of the routine.
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Performance
Improvement (PI)
Purpose of PI
The purpose of a PI model is to provide a collaborative,

planned, systematic, organization-wide approach to
design, measure, assess and improve organizational
performance. The key to PI is that it brings quality to all areas
at all levels.
Performance Improvement is everyones responsibility
Simi Valley Hospital uses the PDSA Model

PDSA is an acronym for plan, do, study, and act.
P
Plan
Plan the improvement.

Plan the implementation.
Plan continued data collection.
Do
Improve the process.

Make the change.
Study
Measure the impact.

Examine data to determine if change led to
expected improvement.
Act
Act to hold the gain and continue to improve the

process.
Develop a strategy for maintaining the
improvements.
Determine whether or not to continue working on
the process.
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Performance Improvement
Project Examples at SVH
Patient Experience-To create a patient centered healing

environment with authentic, intentional interactions at all
touch points, resulting in positive memorable experiences. This
is a regional team that is led by Caroline Esparza, COO.
The team consists of members from Glendale Adventist

Medical Center, White Memorial Medical Center, San Joaquin
Hospital and SVH.
The SVH team members are: Valerie Barrett, Julia Feig, Joanne
Bercier-Gorcey, Jennifer Swenson and Amanda Nigh.
The CLABSI Performance Improvement

Team at SVH worked hard to reduce
the number of infections
CLABSI Is a central IV line

infection that the patient
got in the hospital
In 2014 we had 8
infections that resulted in
a rate of 1.8
In 2015 (Jan-Nov) we had

3 infections that resulted
in a rate of 0.7
Some interventions that were

implemented to help decrease this
rate:
Education to improve the care of the

patient
The nurse wipes the IV pump down

every shift to prevent cross
contamination
Implementation of
Curos caps
Bio-patch
Specific process for dressing change
Infection Prevention daily rounds
Special daily baths for ICU patients and

all patients with an central line
Infection Prevention educated the EVS

staff at monthly meetings and during
rounds
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The CAUTI Performance Improvement

Team at SVH worked hard to reduce
the number of urinary tract infections
CAUTI Is an infection
that the patient got in
the hospital from a
urinary catheter
In 2014 we had 8
infections that resulted in
a rate of 1.5
In 2015 (Jan-Nov) we
had 4 infections that
resulted in a rate of 0.7
Some interventions that were

implemented to help decrease this
rate:
Education of the nurses to improve

the care of the of the urinary
catheter patient
Emergency Department nurses and

physicians use urinary catheters only
when necessary
Encouraging inpatient caregivers to

remove the urinary catheter as soon
as possible
Hand Hygiene Performance

Improvement Team
Did you know that the most common mode of transmission of pathogens is via
hands?
This PI team measures the hand hygiene compliance through monitoring their
own departments, doing surveillance rounds and during their daily activities
The goal is to improve the number of people who use gel or soap to clean
their hands at strategic moments during the patients care to decrease the
incidence of hospital acquired infections
The team members have spoken to the medical staff, volunteers and clinical
staff regarding the importance of using proper hand hygiene
The Hospital Wide 2014 Hand Hygiene Compliance rate

2013 76.70%
2014 - 86.66%
2015 ( Jan- Nov) 86.61%
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Performance Improvement Projects

PUP (pressure ulcer prevention) at SVH
Pressure Ulcer Reduction PI team Is working to

eliminate the number of hospital acquired pressure
ulcers at SVH
Cathy Jimenez has led this team for a few years and
worked with staff educating the clinical staff,
creating protocols and reviewing possible products
that will help us with pressure ulcer reduction
2014 1.05 rate (corp. goal = 1.0)
2015 (Jan-Nov) 0.90 rate (corp. goal = 1.0)
Corporate Compliance Program

Great effort is taken to ensure that as officers, employees,
contractors or volunteers of Adventist Health (AH) and its
affiliates, we conduct ourselves with integrity in accordance
with all applicable laws and ethical business standards. This
means we each must:
Know the rules and policies that pertain to our work areas
Strictly adhere to those rules and policies
Follow applicable laws

and
Immediately report any activity that appears out of line
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The Adventist Health Corporate Compliance

Program is designed to:
Initiated
in 1996
Promote full compliance with all laws and

regulations
Foster and assure ethical conduct
Provide guidance for boards, physicians
and employees for their conduct
Prevent, detect and correct violations
The Compliance
Infrastructure
The discipline of compliance starts at the
highest level of Adventist Health
Adventist Health Chief Compliance Officer
and Compliance Team
Adventist Health Board Compliance
Committee
Local Compliance Officer and Compliance
Team
Local Compliance Committee
Organization Performance Clinical
Compliance
Immediate Supervisor
Administration / Compliance
Officer
Compliance Report Forms
Compliance Hotline
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SVHs Compliance Team
AH Chief Compliance Officer

Local Compliance Officer
HIPAA Facility Privacy Official
Facility Security Official
Facility Safety Officer
Patient Safety Officer
Kevin Longo
Claudia Kanne
Rachel Van Houten
Tim Bundy
Bobby Calderon
Kathleen Percival
AH Compliance Hotline
916-781-4719
805-955-6219
805-955-6901
805-955-6141
805-955-6172
805-955-6892
888-366-3833
Code of Conduct
A set of rules or a protocol
that explains how people
should conduct themselves
and often consists of things
to do in certain situations
and requires certain
behaviors.
CODE of
our values in action
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Ensuring Compliance
We take personal responsibility for our actions

Violators of the Code of Conduct are subject
to disciplinary action
We have many options for reporting ethics or
compliance issues
CODE of
our values in action
We investigate all reports promptly, thoroughly and

confidentially before taking action
We do not retaliate when compliance concerns, issues or
violations are reported
Patient Rights and Responsibilities

Patients have specific rights while they are
hospitalized
California
law says that all patients

(regardless of age, gender, religion, financial
status, etc.) have specific rights while they
are hospitalized. These rights are posted
throughout the hospital and outlined in the
Administration P/P Manual.
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Patient Rights and

Responsibilities
Examples of patient rights
Confidentiality
of protected health information
Informed
consent prior to initiation of tests and

procedures
Participation
The
in the ongoing plan of care
name of the physician delivering medical care
Visitors
A listing of the Patient Rights is located in the Patients

Information Guide along with other important
information.
Patient Rights and

Responsibilities
Patients have visitation rights and may:
Give oral or written consent for visitors or support

persons
Designate a family spokesperson and/or provide

any special instructions or restrictions
Amend the information at any time
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Patient Rights and

Responsibilities
Patients have a right to designate a support person who:
May be whomever the patient chooses to designate
May be changed by the patient as often as they

choose
Does not have to be the patients legal agent or

decision-maker
Patients will be informed of visitation restrictions upon admission to the

hospital (Form 8560-32 Patient Visitation Rights)
Patient Rights and

Responsibilities
Simi Valley Hospital will not restrict, limit, or otherwise deny
visitation privileges on the bases of race, color, national
origin, religion, sex, gender identity or expression, sexual
orientation or disability
If a visitor or support person is denied or given limited

visitation privileges the reason for the limitation or
clinical restriction will be communicated
For patients who lack decision-making abilities, the

support person may make visitation decisions
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Patient Rights and

Responsibilities
Each employee is a patient advocate
Everyone has a responsibility to ensure that the rights of the patients and families are
respected
The hospital has designated administrators who oversee the handling of patient complaints
and grievances
If a patient or family member has a complaint about any aspect of their care
Try to solve the problem and if unable to remedy the problem refer the patient/family to your
supervisor
Patients also have responsibilities
These include responsibility to provide accurate and complete information and comply with
all hospital rules and regulations. Refer to Administration P/P Manual for additional
information
The hospital follows guidelines from the Americans with Disabilities Act (ADA)
Reasonable accommodations can be made for individuals who are covered by the ADA
Refer to the Administration P/P Manual for additional information (e.g., interpreter
services)
Patient Rights and

Responsibilities
The hospital follows guidelines from the Americans with Disabilities Act
(ADA) AND California Health & Safety Code, section 1259
Reasonable accommodations can be made for individuals who are

covered by the ADA. Refer to the Administration P/P Manual for additional
information (e.g., Interpreter Services policy)
Auxiliary aides are available in patient care areas for alternative means
of communication such as dry erase boards, picture boards, bells, etc.
Video Remote Interpretation services are available 24/7 for immediate

access to an American Sign Language Interpreter
The VRI service also provides interpretation services for other languages (i.e.
Spanish, Armenian, etc.)
Live American Sign Language interpreters can be arranged by calling

the nursing house supervisor
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Patient Rights and

Responsibilities
The hospital follows guidelines from the Americans
with Disabilities Act (ADA) AND California Health &
Safety Code, section 1259
CyraCom phones are available in all clinical areas for immediate

access to certified translators for hundreds of languages
A portable TTY machine is available for deaf patients to make

phone calls. Please contact Telecommunications during business
hours or the nursing house supervisor after hours
CLINICAL STAFF: ALWAYS REGULARLY DOCUMENT

COMMUNICATION METHODS IN POWER CHART!
Patient Rights and

Responsibilities
Determine what language the patient prefers to

use for healthcare related discussions
Use CyraCom phone interpreter services for

translation
The patient may designate a family member to

interpret, but if their English is limited use the
CyraCom phone to verify this
Document your efforts in the medical record
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Patient Rights and

Responsibilities
Deaf Patients
Determine which method of communication they prefer (i.e. lip

reading, writing, sign language, etc.)
If a deaf patient uses sign language to communicate, use the Video

Remote Interpreting Service to establish needs and for any ongoing
communication
The patient may ask for an in person interpreter. Please contact the
nursing supervisor to make these arrangements ASAP
Document your efforts in the medical record
Family-Witnessed
Resuscitation
Families/support persons may be present during

resuscitative efforts if they choose to do so. See
(Code Blue & Code White policies for details)
A staff member will be assigned to the family for

support and to answers questions
Guidelines have been written to ensure the safety of

the team members and family members present
CLINICAL STAFF: Always complete a Code Blue Review

Sheet to document any feedback from the event
included the presence of family and any issues
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Condition H (HELP)
Families are our partners in care!
Condition H (HELP) allows families/support persons access to

summon the Rapid Response Team if there is a life-threatening
emergency
Calls may also be placed by families/support persons if they notice

a serious change in medical condition that is not being addressed
by the staff
Overhead paging will not change: the operator will page the
Rapid Response Team as per current practice
Condition H calls that are deemed inappropriate are expected

and are an opportunity to determine why the family felt the need
to call for help
Allowing patients and families access to the Rapid Response Team

adds another layer of safety to our patient safety program
The goal of Condition H is to encourage patients and families

become active participants in care
Abuse Reporting
ALL employees are required to report
instances of abuse
California State law requires care
custodians, health practitioners,
and employees of adult protective
service agencies, and local law
enforcement agencies to report
instances of abuse
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Abuse Reporting
Signs and symptoms that may indicate abuse:
Multiple
healing
injuries/fractures in various stages of
Extent
or type of injury inconsistent with

patient/family explanation
Physical
neglect such as unclean appearance,

inadequately dressed, decayed teeth, etc.
Repeated
visits to facility with multiple complaints

or injuries of increasing severity
Malnutrition
in very young and very old
Abuse Reporting
Signs and symptoms that may indicate abuse:
Behavior
abnormalities-avoidance of eye
contact, flinching when approached, etc.
Delay
between injury and medical treatment
Unusual
pattern of injuries
Patient
statement of abuse
Suicide
attempts or self-destructive behavior
Problems
Eating
with pregnancy
disorders
Alcoholism/drug
abuse
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Abuse Reporting
All of the following are forms of abuse:
Physical
Emotional
Financial taking, appropriating or retaining real or

personal property for personal use or with intent to
defraud
Neglect - negligent failure to exercise the degree

of care that a reasonable person in the same
position would exercise
Exploitation - utilization of another person for selfish

purposes or financial gain
Abuse Reporting
Section 11166 of the Penal Code requires reporting of
child abuse
Employees are required to report known or
suspected child abuse to a child protection
agency immediately or as soon as practically
possible, by telephone, and a written report within
36 hours of receiving the information concerning
the incident
Healthcare workers who report in good faith are
protected
California law protects healthcare workers who
reported in good faith, even if the situation is
investigated and turns out to be something else
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Abuse Reporting
California Law requires healthcare
workers to report all cases of
suspected child, dependent adult,
and elder abuse
Abuse Reporting
Guidelines
During business hours contact the Social Service Department if

you need assistance. For In-house patients use extension 6226
For Emergency Department patients use extension 6223
After hours, or if the Social Worker is unavailable, contact the

Nursing Supervisor for questions, help with forms, etc. If further
help is needed the Supervisor can contact the on-call Case
Manager
Do not delay reporting! The person who discovers the alleged

abuse is the ideal person to make the report
Reporting is confidential
In order to protect the identity of the reporter no mention of the

report should be made in the medical record
DO NOT CHART that you filled out an abuse report! Risk

Management will log these reports and maintain the files
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Abuse Reporting
Guidelines
Complete the report by phone and then fax or mail a copy

to the appropriate agency
When the process is completed, attach the abuse report to

an Unusual Occurrence (Incident) report
Be sure to place a patient sticker on the report so the

information can be logged
Send the completed paperwork to your Director
Place an Abuse Reporting Communication Tool in the front

of the chart so that all caregivers are alerted that an abuse
report has been made
This form will be sent to Risk Management when the patient is

discharged
Understanding Elder
Maltreatment
Includes several types of violence against

those 60 and older
Typically occurs at the hands of a caregiver or

other person the individual trusts
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Understanding Elder
Maltreatment
Physical- This occurs when an elder is injured as a result of

hitting, kicking, pushing, slapping, burning, or other show of
force
Sexual- This involves forcing an elder to take part in a sexual act

when the elder does not or cannot consent
Emotional- This refers to behaviors that harm an elders selfworth or emotional well being. Examples include name calling,
scaring, embarrassing, destroying property, or not letting the
elder see friends and family
Understanding Elder
Maltreatment
Neglect- This is the failure to meet an elders basic needs.

These needs include food, housing, clothing, and medical
care
Abandonment- This happens when a caregiver leaves an

elder alone and no longer provides care for him or her
Financial- This is illegally misusing an elders money,

property, or assets
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Understanding Elder
Maltreatment
Why is elder maltreatment a public health problem?
Elder
maltreatment is a serious problem in the United

States. There is a lack of data but what we do know is
that:
In 1996, 551,000 persons ages 60 and older were the victim

of elder abuse, neglect, and/or self-neglect in domestic
settings
Many cases are not reported because elders are afraid to

tell police, friends, or family about the violence. Victims
have to decide: tell someone they are being hurt or
continue being abused by someone they depend upon
or care for deeply
Understanding Elder
Maltreatment
How does elder maltreatment affect health?
Elder maltreatment can have several physical and emotional

effects on an elder
Many victims suffer physical injuries. Some are minor like cuts,
scratches, and welts. Others are more serious and can cause
lasting disabilities. These include head injuries, broken bones,
constant physical pain, and soreness. Physical injuries can
also lead to premature death and make existing health
problems worse
Elder maltreatment can have emotional effects as well.

Victims are often fearful and anxious. They may have
problems with trust and be wary around others
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Understanding Elder
Maltreatment
Who is at risk for elder maltreatment?
Several factors can increase the risk that someone will hurt an
elder. However, having these risk factors does not always mean
violence will occur.
Some of the risk factors for hurting an elder include:
Using drugs or alcohol, especially drinking heavily
High levels of stress
Lack of social support
High emotional or financial dependence on the elder
Lack of training in taking care of elders
Depression
Reference: www.cdc.gov/violenceprevention
Understanding Child
Maltreatment
Child maltreatment includes all types of
abuse and neglect of a child under the
age of 18 by a parent, caregiver, or
another person in a custodial role (e.g.,
clergy, coach, teacher). There are four
common types of abuse.
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Understanding Child
Maltreatment
Physical abuse is the use of physical force, such as hitting, kicking,

shaking, burning or other show of force against a child
Sexual abuse involves engaging a child in sexual acts. It includes

fondling, rape, and exposing a child to other sexual activities
Emotional abuse refers to behaviors that harm a childs self-worth or

emotional well-being. Examples include name calling, shaming,
rejection, withholding love, and threatening
Neglect is the failure to meet a childs basic needs. These needs

include housing, food, clothing, education, and access to medical
care
Understanding Child
Maltreatment
Why is child maltreatment a public health problem?
The few cases of abuse or neglect we see in the news are only
a small part of the problem
Many cases are not reported to police or social services
What we do know is that:
1,740 children died in the United States from abuse and neglect
772,000 children were found to be victims of maltreatment by

child protective services in 2008
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Understanding Child
Maltreatment
How does child maltreatment affect health?
Physical
Stress
Injuries
that disrupts brain development
Increased
risk for health problems
Understanding Child
Maltreatment
Who is at risk for child maltreatment?
Some
factors can increase the risk for abuse or

neglect:
Age
Family
environment
Community
Reference: www.cdc.gov/violenceprevention
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Confidentiality and HIPAA

Confidentiality is extremely important
The acronym HIPAA stands for the

Health Insurance Portability and
Accountability Act of 1996.
46% of Breaches are due to unintentional

employee actions
Penalties for breach of confidentiality are very

severe including disciplinary action, including
termination from employment, civil or even criminal
penalties. INDIVIDUAL employees may also incur
monetary penalties
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Breaches
of confidentiality include:
Accessing YOUR OWN records or those of your

family or coworkers
Using protected health information or patient

financial information for gain
Faxing patient information to the wrong number

by mistake
Handing a patient someone elses discharge

instructions

How to Handle Requests from Patients about Their
Health Information
All
requests for medical records are to be referred
to Health Information Management Department

(formerly Medical Records)
Employees requesting information on themselves

as patients or their family members must also
follow this same protocol and are NOT allowed to
access their own or their family members
information as disciplinary action will result
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Patients have a right to have their information protected from
inappropriate disclosure.
The hospital has a right to decide the type of administrative

information that is shared outside the hospital
If an employee, by virtue of his /her job description, has

access to information about other employees/volunteers,
he/she is not allowed to look up/release that information
unless it is needed to deliver care to the other employee in
the course of assigned work duties
Be mindful of your discussions concerning patients,

move to an area where you will not be overheard
The term minimum necessary describes your

usage of PHI as required to function within you job
description and assigned duties
In other words, dont snoop!
Do not access any records that are not necessary

for you to do your job
Only access PHI on a need to know basis and use

minimum necessary
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Disposal of Paper Protected Health
Information
Patient
sensitive information must be

disposed of in a confidential manner
and must never be placed with regular
trash. At Simi Valley Hospital, we use
shred boxes/bins

Patients also have a right to know about who is
taking care of them.
This means that all personnel are to wear their hospital-approved

identification badges and maintain it in good readable condition.
Failure to do so may result in disciplinary action up to and including
termination
Additional information is available
Refer to the HIPAA policies or talk to your supervisor. You can also
contact the Privacy Officer
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Health Information Security

The HIPAA Security Rule
The
Security Rule is focused on electronic Patient Health
Information or ePHI. We all must do the following:
Ensure the confidentiality, integrity, and availability of

any ePHI we create, receive, maintain, or transmit
Protect against any reasonably anticipated threats to

the security of ePHI
Protect against any reasonably anticipated uses or

disclosures of ePHI that aren't permitted

Information Security Guidelines
Adopt a security awareness mindset:
Understand that someone might want to steal, damage or misuse the

data in your computer system
Protect the confidentiality of sensitive information

Activate password-protected screen savers or log out of your computer
when it is left unattended
Don't send email containing ePHI over the Internet unless you know how
(ask Information Technology Services)
Don't transmit to or store sensitive or confidential information on your

home computer without IT Systems' permission
Make sure your computer monitor isn't legible to the general public
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Information Security Guidelines
You
are responsible for all actions associated with your user
name and password:
Make sure your password is not something others can easily

associate with you
Avoid common words
Your password must be at least seven characters long and

be a combination of numbers and letters. Remember the
longer the password is the harder it is to break
Never
share or reveal your password

Consequences of not protecting ePHI
We take security of our patients information seriously and want you to do so,
too. Adventist Health will not tolerate violations of patient confidentiality.
Employees who don't honor patient confidentiality may be disciplined or
terminated. If you have any questions, please talk to your supervisor.
Reporting Potential Problems
Potential information security violations should be reported to your supervisor,

department director, or the HIPPA Facility Security Official
Anonymous reports can be made by using the Compliance Hotline (888-3663833)
If you know of a problem and dont report it you may be held responsible or
complicit in the violation
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Cultural and Spiritual

Diversity
Cultural and Spiritual Diversity

In a multi-ethnic society this can only be
accomplished if we have some
understanding of the differences and
similarities between cultures and belief
systems
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Cultural and Spiritual Diversity

Cultural and Spiritual awareness becomes central
when interacting with people of different cultures
and backgrounds.
People
see and interpret things differently
An
appropriate type of conduct in one culture may be

inappropriate in another one
Its
important to increase our own self-awareness and crosscultural awareness so that misinterpretations can be
avoided
One
way to increase this knowledge is by showing real

interest in cultures and religions that are different from our
own to learn more about their cultural traits and beliefs
Cultural and Spiritual

Awareness
Cultural awareness helps us remember to honor beliefs

and sensibilities that are not necessarily our own, so that
as we interact with people from other cultures, no
unintended breach of good manners or conversational
blunders occur
Nonverbal communication or body language is an

important part of how people communicate and there
are differences from culture to culture
Hand and arm gestures, touch, and eye contact (or its lack) are
a few of the aspects of nonverbal communication that may vary
significantly depending upon cultural background
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Tips for Providing Culturally and

Spiritually Competent Care
If you dont understand something about a

persons culture, ask them with respect and a
genuine desire to learn
Don't raise your voice when speaking to a

person who appears to have a limited
knowledge of English
Address all people by their last name, unless

specifically told to use the first name
Tips for Providing Culturally and

Spiritually Competent Care
Informed consent documents and regulations can

be extremely upsetting and frightening for patients
that have been taught to believe that talking
about an event may make the event take place
Understand relationships inquire about family

spokesperson
Consider privacy needs may have preferences

about being touched or bathed
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JUST CULTURE
Just Culture
The term, Just Culture, refers to a safetysupportive system of shared accountability
where health care institutions are accountable
for the systems they have designed and for
supporting the safe choices of patients, visitors,
and staff.
Staff, in turn, are accountable for the quality of
their choices knowing that we cannot will
ourselves to be perfect, but we can strive to
make the best possible choices available.
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1. To err is human...
(Human Error)
We all make mistakes when trying to do our

best
Mistakes are opportunities to evaluate our

system
We must recognize that a single failure path

(one human error or one equipment failure)
can be a sign of system vulnerability
2. To drift is human
(At Risk Behavior)
Humans err but they also drift away from safe
behaviors:
1. When perception of risk fades
2. When we try to accomplish more with fewer
resources and less time
A strong patient safety culture is one that
anticipates these at-risk behaviors and designs
barriers and controls to keep staff on the safest
path possible
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3. Occasionally, the reckless act...

(Reckless Behavior)
We should anticipate that sometimes
humans will put their own self-interest ahead
of those they serve
Reckless behavior, where staff know that
they have put patients or the organization in
an unsafe place, must be addressed through
a strong disciplinary or punitive response
Accountability rests wholly with the individual

who chooses the reckless act
Provider and Staff Responsibilities
Look for risks in the systems in which we work
Look for risks in our own behavioral choices
Evaluate the risk versus benefit (look for the risks

that do not provide value to those we serve)
Report hazards and adverse events
Participate in a learning culture and be open

and honest about what happened
Always make safe choices
38
Section 1
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Leadership Responsibilities
Create an open and learning environment

Learn when to console and when to coach staff
Limit use of warnings and punitive actions to the
circumstances where it will benefit system safety
Strive to understand why human errors occur
Strive to understand why at-risk behaviors occur
Learn to see the common threads and to
prioritize risk and interventions
Work with staff to reduce the rate of human error
and at-risk behavior, or mitigate their effects
Second Victim
Support
39
Section 1
1/3/2016

What are second victims?
Second victims are healthcare team members who
are involved in an unanticipated event (patient or
facility), patient injury, medical error, etc. who
become traumatized by the event. The healthcare
team member may feel personally responsible, may
internalize stress and guilt, and may have difficulty
coping.
An event is likely to lead to emotional or

psychological trauma if:
It happened unexpectedly
You were unprepared for it
You felt powerless to prevent it
Emotional and psychological symptoms of trauma:
Shock, denial, or disbelief
Anger, irritability, mood swings
Guilt, shame, self-blame
Feeling sad or hopeless
Confusion, difficulty concentrating
Anxiety and fear
Withdrawing from others
Feeling disconnected or numb
40
Section 1
1/3/2016
Physical symptoms of trauma:
Insomnia or nightmares
Being startled easily
Racing heartbeat
Aches and pains
Fatigue
Difficulty concentrating
Edginess or agitation
Muscle tension
Seek help for emotional or psychological trauma

if youre:
Having trouble functioning at home or work
Suffering from severe fear, anxiety, or depression
Unable to form close, satisfying relationships
Experiencing terrifying memories, nightmares, or

flashbacks
Avoiding more and more things that remind you of

the trauma
Emotionally numb and disconnected from others
Using alcohol or drugs to feel better
41
Section 1
1/3/2016

Employee Assistance Resources
Confidential support through Aetna Resources for Living 24/7:
Contact the Employee Health Nurse at 805-955-6870
Contact Human Resources at 805-955-6860
Self-Help- Visit the Second Victim Support page on Connect

(Quality Corner Staff Resources Second Victim Support)
https://connect.ah.org/site/svh/simi-valley-hospital/departments/risk-management/secondvictim-support-materials/
Now you will take a brief quiz

on the topics in this section.
42
Section 2
1/3/2016
Section 2
Emergency Preparedness
Bioterrorism
Hazardous Materials and Waste Management
Safety Management Program
Codes
Fire, Electrical, Radiation Safety
Compressed Gases
The Emergency Preparedness Program is also
called the Disaster Plan
It is designed to direct how patient care can be

carried out during any type of disaster situation
Simi Valley Hospital has disaster drills on a regular

basis in order to maintain a well-organized
approach to internal and external disasters
All employees are expected to participate in disaster

drills.
Section 2
1/3/2016
We have 4 levels of disaster
Level 1: Notification of a real or potential threat
Level 2: Partial facility support to the incident
Level 3: Full support to the incident
Level 4: Resources are overwhelmed due to the incident
Your role in a disaster can differ based on
whether or not you are on duty when the
incident occurs
If on duty:
Ensure that your patients, your co-workers and you are safe
Contact your supervisor to see if you are needed elsewhere;

otherwise, continue your current work assignment
Stay at your post at the end of your shift until released or

reassigned by your supervisor. This may be done by reporting
to the labor pool
Do not use hospital phones to call home. In-house telephone

lines need to be kept free for emergency calls and hospital
business
Section 2
1/3/2016
Your role in a disaster can differ based on whether or not
you are on duty when the incident occurs
If off duty:
Report for duty when you are next scheduled to work,

unless you are notified otherwise
Do not call the hospital
Listen to television and radio news broadcasts

In case the phones arent working, you may be notified by
radio/TV announcements to report to work
Bioterrorism
Bioterrorism is the deliberate release of disease

causing agents into a community
The best way to decrease anxiety and fear about

bioterrorism is to be informed
The key to rapid identification and control of an

act of bioterrorism is to maintain a high level of
awareness of your surroundings at work and at
home
Section 2
1/3/2016
Bioterrorism
If mail looks suspicious, DO NOT OPEN IT!
The risk of contracting any disease from an envelope or

package is extremely low. Nevertheless, the following
precautions are recommended for personnel who handle large
volumes of mail:
Wash your hands with warm soap and water before and
after handling the mail
Do not eat, drink, or smoke around mail
If you have open cuts or skin lesions on your hands,

disposable latex gloves may be appropriate
Surgical masks, eye protection or gowns are not necessary or

recommended
Bioterrorism
Steps to take if a letter is received that contains a written threat,

powder, or some other biological material
Stay calm!
Do not walk around with the letter, shake it, or empty the
envelope
Place it in a plastic bag and save it so it can be examined

Leave the item where it was discovered and prevent access to
the area
Immediately wash hands with soap and water, being careful

not to touch anything else (e.g., door knobs, telephone)
before washing
Do not allow anyone to leave the office that might have

touched the envelope, but evacuation of the entire workplace
is NOT necessary at this point
Section 2
1/3/2016
Bioterrorism
Steps to take if a letter is received that contains a written threat,

powder, or some other biological material
Notify the Safety Officer, or your Supervisor who will notify law
enforcement
Remove and bag any clothing that might have been

contaminated. When emergency responders arrive, they will
provide further instructions on what to do
Hazardous Materials and

Waste Management
about
You have the right to know

hazardous
substances in your workplace and to receive any
information about them.
Section 2
1/3/2016

Waste Management
Our Hazard Communication Program,
HAZCOM, is the method by which you
receive needed information and training
about the types of materials in the
workplace and their safe handling, storage,
use and disposal.

Waste Management
The Hospital is responsible for providing
training and equipment to allow you to use
hazardous materials safely.
The Written Hazard Communications Program, an

overview of HAZCOM, is available in each
department. Should a hazardous spill occur, a code
ORANGE will be called
Your department manager is your primary source of

information about the proper use and safe handling
of hazardous materials
Section 2
1/3/2016

Waste Management
The hospital has a service to obtain Safety Data Sheets (SDS) on

demand
To obtain a SDS, contact company 24 hours a day at (888) 362-7416.

Each telephone has a sticker with access procedures listed
Information can also be obtained by clicking on

the
link on Connect
Have the following information available when you call:

Product Name
Manufacturers name
Product Number
UPC code
Telephone number of nearest fax machine
Safety Data Sheet Sections
Physical and chemical

properties
Composition/information
on ingredients
Stability and reactivity
Toxicological information
First-aid measures
Ecological information
Fire-fighting measures
Disposal considerations
Accidental release
measures
Transport information
Regulatory information
Handling and storage
Other information
Exposure control and

personal protection
Product identification
Hazard(s) identification
Section 2
1/3/2016

Waste Management
Proposition 65
Designed to reduce problems by making individuals and

organizations more aware of the potential dangers that exist with
a variety of hazardous substances
Created a list of substances known to the State of California to

cause cancer or reproductive toxicity
There are approximately 700 substances on the list but only about 30
of them are of practical concern to most businesses
There is no prohibition against using these substances, but no

business can use or knowingly discharge into the environment any of
the listed substances without warning individuals that they might be
exposed

Waste Management
The hospital complies with Prop 65 provisions
Warnings must be posted when there is reason to believe

that the levels of usage of listed substances will meet or
exceed Prop 65 standards. The hospital has identified
substances used on site that are on the Prop 65 list.
General and specific warnings are posted in departments
as appropriate.
Section 2
1/3/2016
Safety Management
Program
Statement of Intent
It is the intent of Simi Valley Hospital to provide a safe environment for
our patients, visitors, employees, medical staff, and volunteers. To
accomplish this, we must understand the following principles:
Accidents produce human suffering and financial loss; these are

unacceptable by-products of any health care management system
There must never be conflict between operating safely and operating

efficiently
Accidents can be prevented when management and employees work

as a team to create a safe work environment. This occurs when team
members understand and accept their individual responsibilities for safety
and are provided with proper training and equipment
Safety Management
Program
Responsibilities
Management: Managers have the responsibility to manage safety
Employees: It is the responsibility of the individual employee to work safely

and follow safety procedures at all times
Employees need to
Acquire knowledge of the safety hazards to which they are exposed
Follow safety procedures
Report unsafe conditions or practices immediately to their supervisor
Immediately report any injuries they have while on the job
Section 2
1/3/2016
Safety Management
Program
Safety Officer:
Acts whenever necessary to prevent or rectify any conditions

that pose an immediate threat to life, health, or property
Safety Committee:
The Safety Committee acts as an advisory body to the
Medical Committees, Administration and the Safety Officer
Codes
It is the responsibility
of all staff and
volunteers to know
the various codes
used in this
organization for any
emergency situations
that may occur.
10
Section 2
1/3/2016
Emergency Access
Numbers
Main Campus: 3333
All other campuses: 9-911
The next few slides review some of our hospital

codes.
Refer to your badge card for more information.
11
Section 2
1/3/2016
Hospital Codes
Code
Condition/
Description
Staff
Responsibility
RED
Fire
Activate fire alarms,

call 3333*, report
location, close all
fire doors, check all
patient rooms
* Emergency Access numbers may differ depending on your location.
Hospital Codes
Code
Condition/
Description
Staff
Responsibility
PINK
Infant Abduction
Call 3333*, guard all

exits, check all
rooms
12
Section 2
1/3/2016
Hospital Codes
Code
Condition/
Description
Staff
Responsibility
PURPLE
Child Abduction
Call 3333*, guard all

exits, check all
rooms
Hospital Codes
Code
Condition/
Description
Staff
Responsibility
GRAY
Combative/
Disruptive person
Call 3333*, report

location, remove
patients and visitors
from area
13
Section 2
1/3/2016
Hospital Codes
Code
Condition/
Description
Staff
Responsibility
SILVER
Person with
weapon
Call 3333*, report

location, remove
patients and visitors
from area
Hospital Codes
Code
Condition/
Description
Staff
Responsibility
SILVER: Active
Shooter
Person with a gun
Call 9-911 & report

location, then notify
PBX at 3333*
14
Section 2
1/3/2016
Hospital Codes
Code
Condition/
Description
Staff
Responsibility
Bomb Threat
Call 3333*, keep

caller on the line to
obtain more
information,
evacuate involved
area
Hospital Codes
Code
Condition/
Description
Staff
Responsibility
ORANGE
Hazardous Material
Spill
Call 3333*, report

location, evacuate
the spill area
15
Section 2
1/3/2016
Fire Safety
What you need to know in case of fire:
Know the location of the nearest fire alarm
Know the emergency numbers to dial
Dial 3333 for the Main Campus
Dial 9-911 for all other areas, then call 3333
Know the location of fire extinguishers in

your area and how to use them
Know where the fire doors are located
Fire Safety
When a fire happens:
Remain calm
DO NOT panic
Act quickly
NEVER shout FIRE!
Remove all patients and personnel from the immediate fire area
and tape the door
Activate nearest fire alarm, and call the appropriate number to

report location
Contain the fire and smoke by closing all doors, etc.
Extinguish the fire if it is safe to do so
16
Section 2
1/3/2016
Fire Safety
Using a fire extinguisher:
Pull the pin
Aim the extinguisher
Squeeze the trigger
Sweep the extinguishers contents back and

forth across the base of the fire
Fire Safety
Important points to remember
Keep telephone lines clear for fire control
Do not use elevators
Make sure all fire, corridor and room doors are

closed
Clear all corridors and exits of unnecessary traffic

and obstructions
17
Section 2
1/3/2016
Fire Safety
Important points to remember
All nursing personnel shall report to their areas and remain

there for instructions
All other personnel shall report to their areas and await

emergency assignment as needed
Reassure patients. Inform them why the alarm has been

turned on, the emergency plan is in effect and that there is an
abundance of help to assist as needed
Electrical Safety
Electricity is distributed throughout
our facility. It can be a hazard in
the workplace if not properly used.
18
Section 2
1/3/2016
Electrical Safety
Do not overload electrical circuits
Electrical panels should only be accessed by authorized

personnel
All electrical appliances and patient care electrical

equipment must be safety checked and approved by
the Plant Operations or Clinical Engineering Departments
prior to use in the hospital
Any equipment with frayed or damaged electrical cords

must be removed from service and tagged as defective.
Notify Plant Operations or Clinical Engineering
Electrical Safety
If you feel a tingle or electric shock while using any

electrical equipment, contact 6160 or 6240 immediately
Isolate it until Plant Operations or Clinical Engineering has

removed it
If Plant Ops or Clinical Engineering are not available,

contact the House Supervisor to contact the appropriate
on call personal
Ensure patient and employee safety.
Arrange equipment cords and cables away from

passageways to avoid trip hazards and accidental
electrical shock
19
Section 2
1/3/2016
Electrical Safety
Avoid damaging cords by not walking on them, closing

them in doorways, or rolling over them with wheelchairs
or beds
Grasp the plug to disconnect electrical equipment

rather than pulling on the power cord
Only use approved power strips. Starting in late 2014,

only power strips that have UL 1363A approval will be
allowed to be used in the patient care areas
Radiation Safety
The use of radiation is a common element of patient care. Every
aspect of its use is carefully monitored at Simi Valley Hospital.
Radiation exposure is decreased by limiting time around the source,

increasing distance from the source, and shielding by using lead aprons,
closing doors, etc.
Patients who have received X-rays or CT scans pose no radioactive

hazards
Employees who work directly with radioactive materials or radiation

emitting machines will receive special safety training and must follow
special safety procedures that do not apply to all employees
The Radiation Safety Committee monitors:
Patients at Simi Valley Hospital who receive doses of radioactive materials

for diagnostic or therapeutic purposes
20
Section 2
1/3/2016
Compressed Gases
Oxygen, air, nitrous and all other gas cylinders must be placed in
storage racks or stored in a secure fashion
Nitrous Oxide should only be used in a vertical position with the

valve end up
Compressed medical gases should be transported in approved

devices
All oxygen, nitrous or any other gas cylinders must be kept free of
oil or grease
They should not be hand carried down the halls
Always check to make sure that the index pins on the regulator are
intact to avoid attaching the regulator to the wrong gas
Use compressed gases only for the jobs for which they are
intended
Compressed Gases
Know the location of the gas shut off

valves in your area in case of fire
The incident commander or the highest

ranking authority or designee at the scene
(which may be the caregiver) may shut off
utilities in an emergency
For more information refer to policy D07004

under Environment of Care
21
Section 2
1/3/2016
MRI Safety
MRI stands for Magnetic Resonance Imaging. MRI

combines the use of strong magnets with radio waves to
form images
Due to the use of powerful magnets, there are special

safety precautions, as the magnet is always ON
MRI Safety
Equipment or devices containing metal (ferromagnetic)

components cannot enter the MRI area unless they are
labeled as MR safe
This includes patient-care equipment such as wheelchairs

and oxygen tanks
Do not bring ID badges or credit cards into the MRI area

as the magnetic strip information can be erased
Do not enter the MRI area if you have an implantable

device or object (such as a pacemaker or metal clips)
22
Section 2
1/3/2016
MRI Safety
NEVER enter the MRI suite

without checking with the
MRI technologist!
MRI Safety
Do not bypass safety measures.
Access to the magnet room is
strictly prohibited and limited to
those who have been screened.
23
Section 2
1/3/2016

24
Section 3
1/3/2016
Section 3
Equipment, Furnishings and Machines
Good Housekeeping
Office Safety
Employee Health
Preventing Injuries
Workplace Violence
Security
Equipment, Furnishings and

Machines
Each of us uses electrical and mechanical equipment every day.
Do not operate a machine or piece of equipment until properly trained and refer
to equipment manuals for specific information and instructions
Many manuals can be found on Connect in the Department section under Bio
med services
Conduct checks to ensure safety of equipment prior to starting
Use personal protective equipment such as gloves, safety glasses or goggles,

ear protection, safety clothing, etc. as required by the specific job task you
perform
Do not operate equipment or machines without the proper safety guards
The equipment will be supplied by the hospital
All machine guards must be in place and used when operating a piece of
equipment
Missing guards should be reported to your supervisor
Section 3
1/3/2016
Equipment, Furnishings and

Machines
You have the responsibility for tagging every piece of

malfunctioning equipment, medical and non-medical and
taking it out of service as soon as you discover it is not
working properly
After tagging Out of Order, call Plant Operations @ 6160 (pick option
1) for non-medical devices or Clinical Engineering/Biomed at 6240 for
medical/patient care equipment
If an accident or injuries occurred, the equipment involved must be

sequestered and proper documentation filled out
All accessories should stay with the equipment and all the settings on
equipment should be left where they were whenever possible
For construction or renovation refer to the Construction &

Renovation policy in the Hospital Wide: Environment of Care
Manual
Vehicles
When driving on hospital property you are expected to

observe all traffic rules and normal rules of the road
Do not enter restricted areas with flashing red lights, and do not
leave main roads or enter areas not specifically required for the
accomplishment of your job
Park only in approved areas
Do not block roadways, accesses, fire lanes or fire hydrants
If you are required to drive a hospital vehicle, your drivers

license number will be reported to the Adventist Health
Insurance Company
Fill out a form at the Plant Operations Department
Proper sign-in and sign-out procedures must be followed
Section 3
1/3/2016
Good Housekeeping
Slips, falls, and other injuries often result from poor

housekeeping habits; you can make a difference by
following these simple housekeeping guidelines:
Keep all doorways and hallways clear of obstruction
Keep work areas clear and clean
Approach hallway intersections and elevators with caution
Observe Wet Floor signs and proceed carefully
Good Housekeeping
Do not overfill trash bags and containers or push down contents by hand
It is the responsibility of all employees to prevent slip/fall hazards
Pick up or clean up spills, trash, or other unsuitable materials immediately or

secure the areas and call Housekeeping staff for assistance
When you store material, make sure to arrange it so that it will not fall
Access must be maintained to emergency devices, such as fire hydrants,

extinguishers, gurneys, control valves or electrical switch boxes
Doors, exits, and aisles must not be blocked
A minimum of 18 inches clearance must be maintained between the

top of storage and ceiling sprinkler deflectors
Remember:
Protect yourself and others with good housekeeping skills
Section 3
1/3/2016
Office Safety
Employees may not perceive the office setting as containing work
hazards. You should be alert to the hazards that exist in your
office.
General principles
Do not leave desk and file drawers open when unattended
File cabinets are a tip hazard
Do not open more than one file drawer at a time or overload upper
drawers
Use a stepladder or step stool to reach items above shoulder

height
Do not use a chair, desk or other improper device
Keep electric phone and video display terminal cords neat and
out of the flow of traffic as they are trip hazards
There are two adjustments on every chair, chair height and lower
back support
Sit properly with both feet on the floor with knees level with the hips.
Office Safety
Video Display Terminals (VDTs) can be a source of eye strain, fatigue and repetitive motion injuries
Use these safety tips to prevent VDT associated problems
Use non-reflecting screens or filters and eliminate glare from windows or

lights
Lower background lighting in the area
Keep any copy work as close to the screen as possible and at the same
level; also, illuminate it with the same light intensity as the screen
Keep the screen 10-15 degrees below the straight-ahead eye position
If you wear corrective lenses, you may need a special prescription for
screen work at the recommended arms length distance from video
screens
Bifocals should be avoided for VDT work; eye and neck strain can result from
their use
Have your eyes checked annually and be sure to tell your eye-care
professional that you work with VDTs
Section 3
1/3/2016
Office Safety
More safety tips to prevent VDT associated problems.
Take frequent eye breaks by looking away from the screen and
focusing on an object 20 feet away
Take time for stretch breaks to exercise back, neck, and hand muscles
Vary your tasks throughout the day
Perform 10 minutes of non-VDT work every hour
Arrange your workstation to allow for good body mechanics
Make sure you are sitting comfortably with your head over your shoulders,
your arms and knees flexed at a 90-degree angle, and your wrist in a
neutral position rather than flexed or extended
Check that your monitor and keyboard are directly in front of you and that
your arms and wrists are in a neutral position
Contact your supervisor and Employee Health for help with your
workstation design
Take breaks every 30

minutes changing to noncomputer tasks for 5
minutes
Section 3
1/3/2016
Employee Health
Ergonomics
Ergonomics is the study of how humans work with machines,

equipment, or patients in a work environment
It is possible to become injured by working at repetitive tasks

for long periods of time if you dont pay attention to the
correct positioning of your body and/or equipment
Undue fatigue may increase your injury rate
Lack of physical fitness, or repetitively placing the body in

unnatural postures should be avoided
If you are uncomfortable at your work station, notify your

supervisor and Employee Health
Employee Health
Some symptoms of repetitive motion injury are:
Numbness, tingling of extremities

Changes to skin color/temperature
Pain with joint movement
Extreme fatigue or weakness
Tightness in your shoulders
Report ergonomic concerns and/or symptoms of

repetitive motion injury to your supervisor and
Employee Health at ext. 6870
Section 3
1/3/2016
Employee Health
Body Mechanics
Body mechanics is the way you move your body and back
By using good body mechanics you may be able to

prevent problems and prevent back injury
Using good posture whether you are sitting, lifting, bending,

pushing or pulling is one of the first principles of good body
mechanics
Remember, the back you save may be your own!
Employee Health
Body Mechanics
Utilize lifting, transport and other supportive

devices as indicated for staff and patient
safety
Patient care staff are to follow safe lifting nurse

judgment & assessment regarding the use of
repositioning linens and assist devices
Section 3
1/3/2016
Employee Health
Studies show that people in poor physical condition are more apt to
injure their lower backs
Even if your back feels fine right now, you may be straining it if you:
Are not using lift assist devices as indicated
Have poor posture
Are out of shape or overweight
Move your body incorrectly
Strains can be cumulative. That is, simple strains can add

up until one day a simple act like bending over can bring
on sudden chronic back pain.
Employee Health
Back injuries hurt you, your family

and your job
Many
times they can be prevented
Use good body mechanics and lift

assist devices as indicated at work,
recreation, and at home
Section 3
1/3/2016
Employee Health
Sitting can be twice as hard on your back
as standing
Here are a few tips that might help:
Keep your head over your shoulders, your arms

and legs flexed at 90 degrees and your wrists
neutral
Use a chair that supports your lower back
Sit close to your work
Avoid leaning over and slumping
When sitting for long periods of time, take

frequent back breaks
Get up, move around, and stretch
Employee Health
Push, dont pull whenever possible. This allows you to
move twice as much without back strain.
Repetitive motions (e.g., data entry, stacking laundry or
food trays or supplies) can add up to back pain unless
you:
Keep loads as small as possible
Tighten stomach muscles before lifting
Change position frequently
Turn your whole body by taking little steps, avoiding any

twisting
Use mechanical devices and carts for heavy items
Section 3
1/3/2016
Preventing Strains and Back

Injuries
Prevention tips when working with patients
Nursing staff evaluates the
physical and mental status
of the patient prior to
transfer/lifting and
recommends safe lifting
techniques or devices
Get help from additional

people or equipment, if
needed
Keep the patient close to

you during the transfer
Use a mechanical lift

device whenever possible
Use your leg muscles instead

of back muscles
If feasible, give patient

specific instructions on
how they are to help
during the transfer
Avoid bending over and

keep your back straight
Turn/pivot with your feet and

avoid twisting
Tell the patient what you

are going to do and how it
will be done
Clear extra equipment and

furniture out of the way
before transfer
Employees who work

together as a team have
fewer back injuries
10
Section 3
1/3/2016

Injuries
Prevention tips when working with
objects:
Evaluate the size and shape of

the object you will be lifting or
moving
Get help from additional people

and tell them what you want to
do and how you will do it
Keep the object close to you

during the lift or move
Use your leg muscles instead of

your back muscles
Dont bend over keep

your back straight
Dont twist your body

pivot with your feet
instead
Use hand trucks, carts,

and other assistive
devices as much as
possible

Injuries
Report all injuries and
symptoms of strain and/or
other ergonomic concerns to
Employee Health @ extension 6870
11
Section 3
1/3/2016
Accident Reporting
If you experience a work related injury/illness/event you are required to
report the incident to your supervisor and complete a RADAR report.
If your supervisor is unavailable, contact the House Supervisor on duty
Complete a RADAR report of Employee Report of Occupational

Injury/Illness/Event as soon as possible and no later than the end of the
shift in which the event occurred
Additional RADAR entries must be completed: Director/Manager

Investigation Report of Employee Accident
Injuries or exposures are to be seen by Employee Health or the SVH

Emergency Department on the date of injury
Follow-up will occur with Employee Health
Accident Reporting:
Needlestick
If an exposure to blood or body fluids has occurred,

complete a RADAR report and include the source patients
name and MR#
Report all injuries and exposures to your manager/director,

the house supervisor and Employee Health as soon as
possible on the day of event
You are to be seen by Employee Health or the Emergency

Department on the date of occurrence
Complete a sharps injury form with Employee Health or

Human Resources by the next business day
12
Section 3
1/3/2016
Bloodborne Pathogens
A blood borne pathogen is any pathogenic
microorganism that is present in human blood and
can infect and cause disease in persons who are
exposed to blood containing the pathogen.
Some of the most common are HIV, Hepatitis B, and
Hepatitis C.
Bloodborne Pathogens
Follow needlestick and body fluid exposure guidelines
Containers for storage, transport and/or shipping must be

appropriately labeled with a florescent red-orange
Biohazard label
All equipment and work surfaces need to be cleaned and

decontaminated when contact with blood or other
potentially infectious material occurs
In the event of a larger spill, contact Housekeeping at ext.

6190
The law that requires these actions are designed to protect
health care providers
13
Section 3
1/3/2016
Safe Injection Practices
If available, use safety needles
The safety devices on needles and other sharps should be

activated immediately after use
Place used syringes immediately in the closest

designated sharps container
If a safety needle is unavailable, DO NOT recap or

manipulate the needle in any way
Do not overfill sharps containers
Discard after 2/3 full or when the contents are at the full
line
Report improperly disposed sharps and near misses

immediately to Employee Health (ext. 6870)
Exposures
Immediate Steps:
Wash the wound(s) with soap and water or irrigate

the mucous membranes for 3 5 minutes
Notify your manager immediately or notify the

House Supervisor
Report all exposures to the Employee Health Nurse,

if available - If Employee Health is unavailable,
report to the Emergency Department
Bring the name and MR# of the source patient to

assist with proper follow-up
14
Section 3
1/3/2016
Exposures
The hospital is committed to help you remain
healthy on the job and to obtain appropriate
follow-up if you experience any unprotected
exposures to blood / body fluids (BBF).
Some exposures may be unavoidable but most
can be prevented.
Exposures
An unprotected exposure may occur when the BBF of

another individual (potentially carrying pathogenic
organisms) are able to gain entrance to your body.
This might happen because:
You neglected to use appropriate personal protective

equipment (PPE) such as gloves, face shield, or mask
The equipment failed (e.g., hole in a glove)
You neglected to follow recommended procedural

guidelines (e.g., tried to recap a needle, performed
unprotected CPR or cardiopulmonary resuscitation)
You neglected to use needleless or safety-engineered

options that were available
15
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Unanticipated Exposures
The event was unanticipated and so

reasonably could not been avoided
Examples include
when a patient suddenly vomits and you were not

wearing gloves or goggles
a unit of blood you are carrying has a leak in the plastic
a sharp instrument falls onto your foot and cuts it
Employee Health
The Hospital has an Employee Health

Department to help you:
Obtain immunizations
Follow appropriate procedures when you must be off

work due to illness or injury
Obtain additional information about unprotected

exposure
Evaluate the ergonomics of your work station
Review mechanical lift devices
16
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Employee Health
Report all injuries, exposures and

near miss events to Employee
Health.
Workplace Violence
Simi Valley Hospital maintains a

strict policy that prohibits acts of
violence, harassment or
intimidation in any form.
17
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Workplace Violence
Examples include
Verbal, written, or physical threats

Stalking
Destroying property
Robbery
Physical acts such as slapping, punching,
kicking
Using weapons
Assault and battery
Workplace Violence
What can you do to prevent
workplace violence?
Remember that violence can happen

anywhere
Be aware of warning signs
Treat co-workers, patients, and visitors
appropriately and with respect
Recognize signs of trouble early
18
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Workplace Violence
What can you do to prevent
workplace violence?
Trust your feelings and instincts

Take threats seriously
Dont try to handle situations alone
Learn the correct actions to take when
faced with a violent situation
Workplace Violence
Recognize the warning signs of
violence
Use of an angry or threatening tone

Nervous pacing and/or restlessness
Shouting, screaming or cursing
Clenched fist or jaw, tightly gripping objects
Staggering, slurred speech, irrational speech
or other signs of being under the influence of
alcohol or drugs
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Workplace Violence
Recognize the warning signs of
violence
Verbal threats
Unreasonable demands
Violent gestures, pounding on or breaking
objects
Angry looks or stares
Workplace Violence
What should you do when confronted
with a violent person?
Report immediately any

acts or threats of violence
to your supervisor, Security
personnel or Human
Resources
Take immediate action to

protect yourself. Keep
your distance
Leave yourself an escape

path
Stay calm and alert,

talk calmly and slowly
Listen to the person.

Meet the persons
demands if possible
Do not try to restrain

or disarm the person
Your goal is to
prevent harm to
yourself and others
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Security
Every employee has the responsibility to help make

the hospital secure
If something is stolen, damaged, or tagged

(graffiti), report it immediately to Security and
complete an Occurrence Report Form
It is important that each of us keeps our eyes open to

any unusual situations and report them

21
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Topic: Patient
Safety
SECTION 4
Patient Falls
At Simi Valley Hospital it is our goal to provide a

safe environment for all patients
Upon admission adult patients are evaluated for

their potential risk for falls using the Morse Fall
Scale or the Pediatric fall risk scale
Patients at risk for falling will have a sign posted

on their room door to alert all members of the
healthcare team that the patient is at risk
At SVH we use a falling star as our symbol in

order to alert staff while also protecting the
patients privacy
Section 4
1/3/2016
Patient Falls
Interventions that may be used to help prevent patient falls
Bed is in low position; brakes are

locked
Fall risk patient identification armband
Upper side rails are raised
Moved to a room visible from the

nursing station
Call light is within reach
Sitter or family attendant at bedside
Adequate lighting during the day;

nightlight in the evening
Frequent toileting
Patient care articles are within reach
Non-skid socks or slippers
Fall mats
Physical/Occupational therapy
evaluation and intervention
Bed alarms
Fall risk sign posted
Assistive devices such as walkers,

canes, and grab bars
Frequent patient rounds
Patient Falls
If you see a fall risk patient
attempting to get out of bed stop
and assist, and then call for help!
Patient Safety is EVERYONES
responsibility!
For policy details please see Fall Prevention Program policy

Patient Care Manual located on Connect.
Section 4
1/3/2016
Hand-Off
Communication
Hand-off communication is used

whenever there is a change in the
patients caregivers and when
communicating amongst members
of the interdisciplinary care team
We use the SBAR format
Hand-Off
Communication
S Situation
B Background
A Assessment
R Recommendation
SBAR is a clear, concise method for
communication.
Section 4
1/3/2016
Unapproved Abbreviations
The Joint Commission Information
Management Standard: IM.02.02.01
EP#3 prohibits the use of the following
abbreviations, acronyms, symbols,
and dose designations.
These abbreviations are prohibited from
all entries in the medical record, such
as orders and progress notes, and
includes BOTH handwritten and
electronic entries!
Unapproved Abbreviations
NEVER USE
WRITE OUT AS
MSO4
Morphine
MS
Morphine
MgSO4
Magnesium
U or u
Unit
IU
International Unit
Zero after decimal point (1.0 mg)
Do not use terminal zeros for dose

expressed in whole numbers 1 mg
No zero before decimal point (.5mg)
Always use zero before a decimal

when the dose is less than a whole
unit 0.5 mg
Q.D., QD, q.d., qd
Daily
Q.O.D., QOD, q.o.d., qod
Every other day
Section 4
1/3/2016
Look Alike- Sound Alike Medications

(LASA)
See policy Look-Alike, Sound Alike Medication Management
LASA- Medication names that when written or verbally

communicated have a high potential for causing erroneous
interchange (they are easily mistaken for something else)
Some examples of safe medication practices:
Clarify illegible or unclear orders (i.e. repeat back, spell out

names, etc.)
Telephone/Verbal Order read-back policy for EVERY order
Organizing pharmacy stock with purposeful separation of supplies
Use of Tallman letters on our MARs (to visually clue the reader that
the drug has a potential for confusion with another)
Look Alike- Sound Alike Medications

(LASA)
Examples of Look-Alike, Sound Alike Medications
diphenhydrAMINE (Bendaryl) can be confused with

dimenhyDRINATE (Dramamine)
amLODIPine (Norvasc) can be confused with

aMILoride (Midamor)
ALPRAZolam (Xanax) can be confused with

LORazepam (Ativan)
hydrOXYzine (Vistaril) can be confused with

hydrALAZINE (no trade name- used for BP)
Section 4
1/3/2016
Advanced Directives
Simi Valley Hospital (SVH) recognizes the right of each

individual adult to assert their rights in determining the
course of their healthcare decisions
This is done with the assistance of their Advance

Directive
An advance directive is written or verbal statements

made by the patient indicating treatment wishes in the
event the patient becomes incapacitated
Advance directives may include living wills, durable

power of attorney, or similar documents or
documentation conveying the patients preferences
Organ and Tissue Donation
SVH supports the concept of death with dignity while also

supporting the rights of individuals to donate their organs and
tissues after death
Hospital staff works to implement state regulations which

allow the patient and/or their legally authorized surrogates to
give informed consent allowing organ and tissue
transplantation after death
SVH works with One Legacy, our Organ Procurement

Organization (OPO)
The death of a loved one can be a very emotional time for

the patients family and friends, and the decision to donate
organs may add to their emotional burden
Staff will make every effort to provide comfort and support to

the patient and their families, being especially sensitive to their
personal, cultural and religious beliefs
Section 4
1/3/2016
Tubing Misconnections
What is a Tubing Misconnection?
Misconnection of tubing, used to link patients to medical

devices or medical devices to each other, have the
potential to result in serious injury or death
It is believed that these types of mistakes are underreported
Although errors involving various types of tubing and

catheters have been reported for over 20 years, there has
been a recent increase in awareness of this issue and a call
from governmental agencies, professional organizations,
and patient safety groups to put mechanisms in place to
prevent this type of incident
What is a Tubing Misconnection?
A patient, for example, may be connected to

several devices used to administer fluids through
a vein; administer medication through an
epidural catheter; deliver feedings via a tube to
the stomach; monitor blood pressure; and
administer oxygen
This collection of devices poses a risk of tubing

misconnection especially in a busy clinical
environment where stress, fatigue and
distractions are common
Section 4
1/3/2016
What can be done to prevent this type of error?
One of the most important prevention strategies is staff awareness.

Nursing staff should always take their time whenever dealing with
any tubing and connections
Tubing must be labeled and tubes must be traced from their source
to the patient whenever the line is manipulated: This is called
reconciling the tube or line
High-risk catheter tubing must be labeled with cloth tape
Other safety actions include turning the light on in a darkened room

before connecting or reconnecting tubes or devices
Tubing Misconnection
It is important to remember if you are NOT a nurse and you

find a disconnected tube, DO NOT TRY TO RECONNECT IT
Tell the nurse caring for the patient to avoid making a tragic
mistake
It is important to emphasize with the patient and their family

the importance of contacting the nurse if any tube becomes
disconnected
These practices can save a life!
Section 4
1/3/2016
Clinical Staff: Line Reconciliation

See policy Line Reconciliation and Tubing Misconnections
Perform a line reconciliation (trace from the

origin/source to the patient)
At the beginning of each shift
At patient hand-off
Prior to the addition/removal/manipulation of any

equipment attached to the patient
Prior to the administration of any medication, diagnostic

preparation, or contrast media
Clinical Staff: Tubing

Misconnections
Never force connections
Only use adapters that are clearly indicated
Do not modify or adapt devices
Review identification labels before administering

solutions to ensure intended delivery route is
correct
Section 4
1/3/2016
Clinical Staff: Line

Reconciliation & Tubing
Misconnections
IF IT DOESNT FIT
THEN QUIT!
If something appears out of the
ordinary, doesnt fit, makes you
uncomfortable, or is unclear
always stop and ask questions!
National Patient Safety

Goals (NPSGs) 2016
The purpose of the Joint Commissions National Patient Safety
Goals is to promote specific improvements in patient safety.
The goals highlight problematic areas in health care and
describe evidence-based and expert-based consensus as
solutions to these problems. Because sound-system design is
intrinsic to the delivery of safe, high-quality care, the goals
generally focus on system-wide solutions, whenever possible
(CAMH Refreshed Course, January 2009).
You will notice that there are missing goals. Those that are
not listed are either not applicable to hospitals or are no
longer applicable as a safety goal.
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Goals (NPSGs) 2016
Goal 1
Improve the Accuracy of Patient Identification
NPSG 01.01.01- Use at least two patient identifiers when providing care,
treatment, and services
At SVH we use the patients name and date of birth (DOB). In the absence of
one of the identifiers, the medical record number is an alternate patient
identifier
The patients room or location is NEVER used as an identifier
Containers used for blood or other specimens are ALWAYS labeled in the
presence of the patient
NPSG 01.03.01- Eliminate transfusion errors related to patient

misidentification
During blood transfusions the blood is matched to the order and to the
patient using a two-person verification process

Goals (NPSGs) 2016
Goal 2
Improve the Effectiveness of

Communication Among Caregivers
NPSG 02.03.01- Report critical results of tests and diagnostic

procedures on a timely basis
Critical test results are communicated to the physician within

60 minutes
DOCUMENT the notification under Physician
Communication in Power Chart
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Goals (NPSGs) 2016
Goal 3
Improve the Safety of Using Medications
NPSG 03.04.01- Label all medications, medication containers, and

other solutions on and off the sterile field
Label if not immediately administered even if only one

medication is used
Label when a medication or solution is transferred from the

original packaging to another container
Verify all medications and solution labels both verbally and

visually
A 2 person verification process is used when the person

preparing the medication or solution is not the person who will be
administering it

Goals (NPSGs) 2016
Goal 3

NPSG 03.05.01- Reduce the likelihood of patient harm
associated with the use of anticoagulant therapy
Before starting a patient on warfarin assess the patients baseline

coagulation status
Manage food and drug interactions for patients receiving warfarin
Use programmable pumps to administer continuous intravenous

heparin
12
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Goals (NPSGs) 2016
Goal 3

NPSG 03.06.01- Maintain and communicate accurate
patient medication information
Obtain a medication list of what the patient is currently taking at home
Identify and resolve discrepancies between home meds and those ordered
in the hospital
Provide written information on medications at discharge
Educate to the importance of managing medication information when

discharged (i.e. give list to primary MD, update it frequently, etc.)

Goals (NPSGs) 2016
Goal 6
Reduce the Harm Associated with Clinical Alarm Systems

NPSG 06.01.01- Improve the safety of clinical alarm systems
Establish alarm safety as a hospital priority
Clinical Alarms is a part of our Patient Safety Plan
New corporate policy and procedure was approved and adopted
Our site specific policy was linked as a supplement to detail our

processes
Identify the most important alarm signals to manage based on input

from staff, physicians, incidents, and best practices
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Goals (NPSGs) 2016
Goal 7
Reduce the Risk of Health-Care Associated Infections
NPSG 07.01.01- Comply with the CDC hand hygiene guidelines

Clean your hands- Rememberalways
gel in and gel out!

Goals (NPSGs) 2016
Goal 7 Reduce the Risk of Health-Care Associated
Infections
NPSG 07.03.01- Implement evidence-based practices to

prevent health care-associated infections due to multi
drug- resistant organisms (MDROs)
MRSA
VRE
C. Difficile
14
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Goals (NPSGs) 2016
Goal 7 Reduce the Risk of Health-Care Associated Infections
NPSG 07.04.01- Implement evidence-based BUNDLES to prevent

central line-associated bloodstream infections (CLABSI)
Central Line Insertion Bundle
Hand hygiene prior to starting procedure
Use maximal sterile barriers (hat, masks, gloves, gown for inserter, head-to-toe drape
for the patient)
Use CHG applicator for recommended length of time, allow to dry
Avoid femoral site
Remove central line as soon as possible
Document daily line necessity

Goals (NPSGs) 2016
Goal 7 Reduce the Risk of Health-Care Associated
Infections
NPSG 07.05.01- Use evidence-based BUNDLES for

preventing surgical site infections
Surgical bundle
Prophylactic antibiotic timing, selection, and discontinuation
Hair removal with clippers (no razors!)
Normothermia
Administration of beta blockers during peri-operative period for those

patients already on beta-blockers
VTE prophylaxis ordered and given
Removal of Foley no later than post op day two (unless a reason is given)
15
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Goals (NPSGs) 2016
Goal 7 Reduce the Risk of Health-Care Associated Infections
NPSG 07.06.01- Implement evidence-based BUNDLES to prevent

indwelling catheter-associated urinary tract infections (CAUTI)
(excludes pediatric populations)
Urinary Catheter Bundle
Insertion of a Foley requires an indication
Foleys should be discontinued within 48 hours unless there is an indication

to continue

Goals (NPSGs) 2016
Goal 15 The Organization Identifies Safety Risks Inherent in Its
Patient Population
NPSG 15.01.01- Identify patients at risk for suicide
Address immediate safety needs
Provide patient and family with information/resources during discharge

planning
16
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Universal Protocol for Preventing Wrong

Site, Wrong Procedure, and Wrong
Person Surgery
UP 01.01.01- Conduct a pre-procedure verification process
Missing information or discrepancies are addressed before starting the

procedure
UP 01.02.01- Mark the procedure site
The site is marked before the procedure is performed and with the patient, if
possible
The site is marked by the licensed independent practitioner who is accountable

for the procedure and who will be present when it is performed
Method of marking is unambiguous and used consistently throughout the

hospital
Universal Protocol for Preventing Wrong

Site, Wrong Procedure, and Wrong
Person Surgery
UP 01.03.01- A time-out is performed before the procedure
The time-out is standardized, initiated by a designated member of

the team, and involves the immediate members of the procedure
team
At minimum, a time out includes correct patient identity, the

correct site, and the procedure to be done
Completion of a time-out is documented
17
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Clinical
Alarms
Clinical Alarms:
Licensed Staff
Ensure alarm settings are appropriate
Default alarm parameters may be adjusted by the RN or

RCP to meet patient needs
Alarm parameters should not be set in such a manner that

prevents the equipment from alarming
Alarms are to be in the ON position while in use
Alarms may be suspended or temporarily silences when

staff is in attendance
Alarms should never be disabled
18
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Clinical Alarms:
Licensed Staff
Alarms will be assessed and resolved by the primary

nurse or respiratory therapist
Life-support equipment alarms will be resolved by any

immediately available licensed staff
Investigate alarms that continue to sound despite

intervention
If unable to resolve, remove from service, tag equipment

with the issue, and notify Clinical Engineering (e.g. Biomed)
Clinical Alarms:
Licensed Staff
Use the ALARMS acronym for patient safety:
A lways physically enter the room during an alarm

L ook at the patient
A larms should be audible over competing noises
R eason: evaluate the reason for the alarm
M ake sure to check the alarm before and during a
procedure
S top turn-off capabilities: do not deactivate an alarm
19
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Clinical Alarms:
ALL Staff
Non-licensed clinical staff should never silence or

disable an alarm
Immediately report clinical alarms to the patients

nurse or unit charge nurse
Bed exit alarms should be addressed by all

members of the clinical care team as part of the
Fall Prevention Program
Take steps to reduce ambient noise such as :
adjust the volume of the television
minimize overhead paging
be mindful of noise levels at the nursing station
take malfunctioning equipment out of service
Infant and Pediatric

Safety:
Preventing Abductions
20
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Abductions
128 infants were abducted from healthcare

facilities between 1983 and April 2010.
Infant abductions from home are a large area of

concern and are on the rise as it becomes more
difficult to steal infants and children from hospitals.
While these occurrences are rare,
EVERYONE has a responsibility to protect
these vulnerable patients!
Infant and Pediatric Abductions

Whats your role?
Be familiar with:
Code Pink (Infant Abduction)
Code Purple (Pediatric Abduction) policies
and know your role!
When a code is called all non-essential work

is to stop and all exits are to be covered
Question/stop suspicious persons/activities
Notify Security of any concerns immediately
21
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Abductions
Whats your role?
Pediatric patients are also at risk especially

when there are custody issues/disputes in the
family
An abductor can be ANYONE
Be polite and professional to our visitors, but do

not allow that to cloud your judgment, stop you
from asking questions, or prevent you from calling
for help
Know the profile of a typical abductor!
Profile of a Typical Abductor

Remember this is typical but an abductor
can be anyone!
The offender is:
Almost always female
Is frequently overweight
Of childbearing age (12-53) but in general is in her 20s
Usually lives in the community
Frequently impersonates a nurse, doctor, or other health care

professional
Often asks detailed questions about policies and procedures, and the
maternity floor layout
Abducted infant almost always matches race/skin tone of the

abductor or the abductors significant other
Often becomes friendly with staff and victims parents
Generally has a plan, but looks for opportunities (seizes the moment)
22
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Infant Abduction- Local Case

Santa Barbara Cottage
Hospital 2009
Surveillance camera photo of an
abduction suspect
Woman
Wearing Scrubs
Carrying a large bag
(the baby is in the bag)
The baby was found unharmed hours later in nearby home and
reunited with his biological mother
NEVER LET THIS HAPPEN HERE! BE A PART OF THE

SOLUTION!
SAFE SURRENDER
23
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Safe Surrender
On January 1, 2001 the Safely Surrendered Baby Law was
implemented in California for the purpose of preventing harm
and possible death to newborns
If you are approached by a person looking to surrender their

baby, immediately escort them to the Emergency Department
All Emergency Department nurses are trained in Safe

Surrender and are authorized to accept the infant
This will ensure that we have our best opportunity to get critical
information to care for the infant
Call the Nursing House Supervisor if you need help!
Safe Surrender
Did You Know?
A parent or person with lawful custody can safely surrender a

newborn within 72 hours of birth without fear of prosecution
The hospital places a special identification bracelet on the

baby and gives the parent or guardian a matching one in
case the baby is reclaimed
The parent or lawful guardian has up to 14 days from the time

of the surrender to reclaim their baby
We attempt to get medical information from the

parent/guardian critical to the health and survival of the infant
Policy details can be found in the Emergency Department

policy manual- Safe Surrender available in Lucidoc
24
Section 4
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Now
you will take a brief

quiz on the topics in this
section.
25
Section 4
1/3/2016
Section 5
INFECTION PREVENTION
Standard
Isolation
Aerosol
Precautions
/ Transmission Based Precautions
Transmissible Diseases
Respiratory
Protection
Standard Precautions
Standard Precautions include a group of

infection prevention practices that apply to
ALL patients, regardless of suspected or
confirmed infection status, in any setting in
which healthcare is delivered. These include
Hand hygiene
Use of personal protective equipment (PPE)
Respiratory hygiene/cough etiquette
Safe injection practices
Section 4
1/3/2016
Standard Precautions must be observed with

ALL patients at ALL times
Regardless of age, gender, diagnosis, or

isolation precautions
The type of personal protective equipment is

based on the patients symptoms or condition
(i.e. mask for coughing, gloves for bleeding)
Standard precautions are mandatory work practices

that help keep you safe
Hand Hygiene
Hand Hygiene is the single most effective way to
stop the spread of infection!
Wash hands with soap and water in the following

situations
Before eating
After using the restroom
When hands are visibly dirty
If exposure to Clostridium difficile

(or any other spore forming organism)
is suspected or proven
Section 4
1/3/2016
Hand Hygiene
How
to Wash
Wet hands under running water
Apply soap and thoroughly distribute over

hands
Vigorously rub hands together for at least

15 seconds, generating friction on all
surfaces of the hands and fingers
Rinse hands with running water and dry

with a disposable towel
Turn off faucet with a clean, dry paper

towel
Hand Hygiene
When to Rub
If hands are not visibly soiled, use an alcohol-based

hand rub for routine decontamination of hands
Hands must be decontaminated in the following

situations
Upon entering and exiting patient room or care

area
Before and after direct patient contact
Before and after wearing gloves
Before performing any invasive procedure
When moving from a contaminated body site to a

clean body site during patient care
After contact with inanimate objects in the

immediate vicinity of the patient
Alcohol based hand rub is not effective in killing the spores of

Clostridium difficile (C. Diff)
Section 4
1/3/2016
Five Moments for

Hand Hygiene
Personal Protective
Equipment (PPE)
PPE includes items such as gloves, gowns, masks,

respirators, and eyewear used to create barriers that
protect skin, clothing, mucous membranes, and the
respiratory tract from infectious agents
Wear gloves when touching blood, body fluids, nonintact skin, mucous membranes, and contaminated
items
Gloves must always be worn during activities

involving vascular access, such as performing
phlebotomies
Section 4
1/3/2016
Personal Protective
Equipment (PPE)
Wear a surgical mask and goggles or face shield if

there is a reasonable chance that a splash or spray of
blood or body fluids may occur to the eyes, mouth, or
nose
Wear a gown if skin or clothing is likely to be exposed to

blood or body fluids
Remove PPE immediately after use and wash hands. It

is important to remove PPE in the proper order to
prevent contamination of skin or clothing
Respiratory Hygiene/
Cough Etiquette
The following measures to contain respiratory secretions are recommended

for all individuals with signs and symptoms of a respiratory infection
Cover the nose/mouth with a tissue when coughing or sneezing or using

the crook of the elbow to contain respiratory droplets
Use the nearest waste receptacle to dispose of the tissue after use
Perform hand hygiene after having contact with respiratory secretions

and contaminated objects/materials
Ask patients with signs and symptoms of respiratory illness to wear a surgical
mask while waiting in common areas or placing them immediately in
examination rooms or areas away from others
If they are unable to wear a mask you should wear a surgical mask to
protect yourself
Supplies such as tissues, waste baskets, alcohol gel, and surgical masks
should be available
Section 4
1/3/2016
Isolation / Transmission
Based Precautions
Designed for patients documented or suspected to be

infected or colonized with highly transmissible or
epidemiologically important pathogens for which
additional precautions beyond Standard Precautions
are needed to interrupt transmission in hospitals
Transmission Based Precautions consist of four

additional categories of precautions
Contact
Contact Plus (formerly Modified Contact)
Droplet Precautions
Airborne
Based Precautions
Contact Precautions Wear a gown and gloves when
entering the room
Contact Plus Precautions Wear a gown and gloves when
entering the room and wash hands with soap and water after
caring for the patient
Use of alcohol rub is not recommended
Droplet Precautions Wear a surgical mask when entering the
room
Airborne Precautions The patient must be placed in a
negative airflow room
Wear a PAPR/N95 mask when entering the room
Remove the PAPR/N95 mask after leaving the room
Section 4
1/3/2016
Based Precautions
Follow directions on isolation signs on doors to isolation

rooms. Wear the necessary personal protective
equipment (gown, gloves, and mask), per instructions on
sign. This includes all employees, volunteers, and visitors
If you have questions about the necessary protective

equipment, ask the patients nurse or your supervisor
before entering the isolation room
Discard personal protective equipment in the designated

receptacle, before leaving the room, unless it is dripping
with blood (if dripping with blood, dispose of the PPE in
the Biohazard bin)
Hand Hygiene is required before and after caring for all

patients
Aerosol Transmissible
Diseases
Communicable diseases that
are transmitted by the
release of small droplets that
are often breathed into the
respiratory tract.
Section 4
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Diseases
Diseases
Section 4
1/3/2016
Diseases
Diseases
Tuberculosis
Signs and Symptoms of TB
Unexplained weight loss
Fatigue
Fever
Night sweats
Chills
Loss of appetite
Cough
Coughing up blood
Chest pain or pain with breathing or coughing
Section 4
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TB Exposure Prevention
TB Exposure Prevention consists of
Prompt identification of suspect patients
Placing mask on patients with TB symptoms
Place patient suspected of infection in

airborne isolation
Teach respiratory etiquette to patient
Staff uses PPE
Healthcare staff undergo annual TB screenings
SVH primarily uses PAPRs

PAPR
is a positive pressure respirator powered by a

portable battery pack which pumps air through a
filter unit and then distributes the filtered air into the
hood of the respirator
PAPRs
offer a higher level of protection and may

be used at anytime in place of the N95 mask
10
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PAPR/N95 Masks are to be

worn:
When entering a room with airborne

isolation
When performing high-risk medical

procedures
When changing filters from air filtration

devices or ventilation ducts when those
filters were used to remove TB bacteria
PAPR/N95 Masks are to be

worn:
11
Section 4
1/3/2016
Now
you will take a brief

quiz on the topics in this
section.
12
Annual Mandatory Education Quiz

Put answers on answer sheet
Section 1
1.
a.
b.
c.
d.
Simi Valley Hospital achieves its mission by:

Entering into business relationships with staff physicians
Following The Joint Commission, CDPH and CMS rules
Demonstrating Gods love by providing exceptional service and quality care
Providing high-quality medical care in terms of outcome, process, and community
perception
2. The following are examples of current SVH Performance Improvement (PI)

projects EXCEPT:
a.
b.
c.
d.
Elimination of Catheter Associated Urinary Tract Infections

Pressure Ulcer Reduction
Patient Experience
Preparation and Planning of the Hospitals 50th year anniversary
3. You and your co-workers would like to pick a performance improvement (PI)
project to work on. After careful consideration you decide to focus on patient
experience. The main reason to do PI is:
a.
b.
c.
d.
To
To
To
To
help improve the quality within your department and possibly hospital-wide
save money
meet the CMS coding requirements for payment
help your manager/director complete the annual job requirements
4. In order to conduct ourselves with integrity in accordance with the applicable laws
and ethical business standards every employee and volunteer must do all of the
following EXCEPT:
a. Follow all applicable laws
b. Make a face to face report with the Corporate Compliance Officer, since this is
the only way to submit a report
c. Immediately report any activity that appears out of line
d. Know the rules and policies that pertain to our work areas and follow them
Patient rights include all of the following EXCEPT:
5.
a.
b.
c.
d.
Keeping their medical and personal information confidential

Picking their nurse each day
Having informed consent prior to initiation of tests and procedures
Actively participate in their care
6.
Patient advocates are only the patients family and friends.
7.
Signs and symptoms of abuse include:
True or False
a. Malnutrition in the very young and very old

b. Repeated visits to the facility with multiple complaints or injuries of increasing
severity
c. The person states they are abused
d. All of the above
8.
Only the Risk Manager or Social Worker completes abuse reports.

True or False
9.
Signs of Elder abuse or maltreatment include:

a.
b.
c.
d.
10.
Financial assets that are being misused by someone else

Refusing to let the elderly person see friends or family
Abandoning the elderly person
All of the above
Breaches of confidentiality include which of the following:
a. An employee or volunteer accessing information not required in the course of

his/her assigned job duties
b. An employee looking up information that is needed in the course of assigned
work duties
c. Discussing the previous years holiday party with a co-worker
d. Requesting the HIM (Health Information Management) Department to speak
to a visitor regarding their request for medical record copies
11.
by:
You had lab work drawn at the SVH lab. You are allowed to access the results
a. Looking directly in Power Chart if you have access

b. Calling the lab and asking for a copy of the results
c. Requesting the results from the HIM Department (Medical Records) or by
accessing them through the My Adventist Health portal
d. Asking your director to look them up for you
12.
Faxing information to the wrong number by mistake is a breach of
confidentiality.
True or False
13. You are talking to a person who is from a culture different from your own. It
is important to remember that:
a. Its essential to increase our own self-awareness and cross-cultural awareness
so that misinterpretations can be avoided
b. If they arent fluent in our language it is helpful to speak louder
c. A way to start the conversation is by referring to them by their first name
d. If you are confused by something they are doing or saying just pretend that
you understand and nod your head
Section 2
1.
What does Simi Valley Hospital do to assure we are ready to handle disasters
of any kind?
a.
b.
c.
d.
Follows the Hospital Earthquake Plan (HEP)

Works with local restaurants to ensure they can help feed the patients and
employees
Studies fault lines and damage reports from previous earthquakes
Participates in disaster drills on a regular basis in order to maintain a wellorganized approach to disasters
2.
While at work you hear a Code Triage called. Which action is NOT
correct?
a.
b.
c.
d.
Make sure you, your patients and your co-workers are safe
Report to the labor pool, if directed by your supervisor
Report to your supervisor for direction
Call Plant Ops to see what needs to be done
3.
You are going through your departments mail and you come across a
suspicious letter. What should you do?
a.
b.
c.
d.
Send the letter to the lab for testing

Stay calm, place the item in a plastic bag and leave it where you found it,
wash your hands, and do not touch anything else
Call 9-911 so the fire department can investigate
Call 3333 for a Code Triage
4.
The best way for an employee or volunteer to obtain information on
hazardous materials is to obtain a safety data sheet (SDS) from the toll-free
number located on a unit phone or by clicking the MSDS link on Connect.
True or False
5.
a.
b.
c.
d.
When calling a code in the main hospital you should dial

3333
9-911
8888
HELP (4357)
6. You see someone acting strangely near the elevators. They have a large bag with
them and you suspect an infant has been taken. What code do you call?
a.
b.
c.
d.
Code
Code
Code
Code
Purple
Pink
White
Yellow
7.
You walk into a patients room and you find an unresponsive adult patient. The
emergency number to call is 0 and ask the operator to call a Code Blue.
True or False
8.
You call Code Red for a fire.
True or False
9. Code Purple is what you would call when you need help from others to respond
to a situation where patients or visitors have become combative. True or False
10. The acronym PASS helps you remember how to use a fire extinguisher. PASS
stands for:
Pull the pin, Aim the extinguisher, Squeeze the trigger and Sweep the
extinguisher contents back and forth across the fires base
True or False
11. We follow the acronym RACE to prevent loss of life from a fire. RACE stands for:
Remove all patients and personnel from the fire area, Activate the nearest fire alarm,
Contain the fire and smoke by closing doors, and extinguish the fire if it is safe to do
so
True or False
12.
To disconnect electrical equipment from an outlet or receptacle you should
grasp the plug rather than pulling on the power cord.
True or False
13.
The following statements reflect safe practice when using power cords
EXCEPT:
a. Covering fraying or exposed wires with tape
b. Avoid damaging cords by not walking on them, closing them in doorways or
rolling over them with wheelchairs or beds
c. Using only approved power strips
d. Taping power cords to the floor to reduce the tripping hazard
14.
You can reduce your exposure to radiation by wearing shielding, increasing
your distance from the source and decreasing the amount of time you spend near
the source.
True or False
15.
Gas cylinders should be stored in a secure and approved storage device.

True or False
16.
The hospital complies with Proposition 65 by identifying the substances used
at the hospital and posting warnings in the appropriate departments.
True or False
17.
In regards to MRI (Magnetic Resonance Imaging) safety, the most important
item to remember is
a.
b.
c.
d.
Its safe to go into the MRI as long as the magnet is turned off
NEVER enter the MRI suite without checking with the MRI technologist
Its OK to go into the suite as long as you leave your cell phone outside of the room
The MRI magnet isnt very strong so there no concern with most metal objects
Section 3
1.
You discover a piece of equipment that is not working properly. You should:
a. Tag the equipment as Out of Order and then notify Plant Operations for nonmedical equipment and Clinical Engineering (Bio-Med) for patient-care devices
b. Continue to use it as long as it is not involved in patient care
c. Email your supervisor and place the item in the utility room
d. Review the instruction manual and try to repair the device
2. The floor has just been mopped. You notice the wet-floor sign is hard to see due to
a gurney blocking it. You should:
a.
b.
c.
d.
Move the sign so everyone can easily see it before entering the wet area
Tell the housekeeper
Complete a RADAR report for this safety hazard
Stand guard and warn people about the wet floor
3. Using good posture whether you are sitting, lifting, bending, pushing or pulling is one
of the first principles of good body mechanics. True or False
4. Office safety principles include keeping cords neat and out of the flow of traffic and
adjusting your chair to keep your body in alignment. True or False
5. When storing supplies you must ensure proper clearance (18 inches) between the
top of the stored items and the fire sprinklers.
True or False
6. If you experience a work-related injury or illness you should complete a RADAR

report, report the incident to your supervisor or the house supervisor on duty and
follow-up with Employee Health Nurse or the Emergency Department.
True or False
7. Bloodborne pathogens are best described as a pathogenic microorganism that is

present in blood which can infect and cause disease.
True or False
8. If you come into contact with blood or body fluids from a patient either by
needlestick or by a splash you should:
a. Wash the affected area, immediately notify your manager or the house
supervisor and report all exposures to the employee health nurse. Then,
complete a RADAR report including the source patients name and medical
record number
b. Report the exposure only if you think the patient has a transmissible disease
c. Report the exposure if you begin to experience flu-like symptoms
d. Report directly to the lab for testing
9. When confronted with a violent person you should keep a safe distance between
you and the individual while speaking calmly and slowly. True or False
Section 4
1. Simi Valley Hospital uses the Falling Star symbol to identify patients at risk of
falling.
True or False
2. You walk into a patients room to deliver flowers. You notice that the patients IV
is disconnected and dripping fluid on the floor. What should you do?
a.
b.
c.
d.
Turn off the clamp and put a towel on the floor to absorb the spill
Do not touch the line. Notify the patients nurse immediately
Ask the patient to reconnect it and then notify the nurse
Reconnect it to the nearest port and notify the nurse
3.
When a Code Pink is paged all non-essential work is to stop and staff are to
cover all exits.
True or False
4.
The National Patient Safety Goals (NPSGs) are standards to promote specific
improvements in patient safety by highlighting problematic areas in healthcare as
well as promoting evidence-based solutions.
True or False
5.
If a person approaches you and wants to surrender their newborn, your next
step would be to:
a.
b.
c.
d.
Call 911
Immediately escort them to the Emergency Department
Immediately escort them to Labor and Delivery
Call security
Section 5
1. Standard precautions are meant to reduce the risk of transmission of
bloodborne and other pathogens from both recognized and unrecognized
sources. They are:
a. To be used when you are infectious
b. The basic level of infection control precautions which are to be used, as a
minimum, in the care of ALL patients
c. When caring for patients with infectious diseases
d. Only by employees that provide direct patient care
2. Standard precautions require hospital staff to
a. Use proper hand hygiene technique
b. Always recap used needles
c. Wear personal protective equipment (PPE) when exposure to blood,
body fluids or respiratory secretions is possible
d. Both A and C
3. You are providing hands-on care for a patient who is continually coughing
from bronchitis. You should:
a.
b.
c.
d.
Ask the patient to wear a PAPR Hood

Not wear protection as it is only bronchitis and not contagious
Wear a PAPR hood
Wear a surgical mask to protect yourself
4. Unexplained weight loss, night sweats and cough are signs and symptoms of
TB (Tuberculosis).
True or False
5. Which of the following is a way to prevent transmission of TB?
a.
b.
c.
d.
Prompt identification of suspect patients

Placing all suspect patients in DROPLET Isolation
Have suspect patients wear gloves when outside of his/her room
Placing patients in a positive-pressure isolation room
6. The best way to prevent the spread of infection is

a.
b.
c.
d.
Wear a surgical mask when you are sick

Perform hand hygiene (wash your hands/use alcohol based hand gel)
Keep your office door closed at all times
Avoid travel during the flu season
END OF TEST
Name______________________
Date__________________2016
Dept.______________________
ANSWER SHEET
2016 Annual Mandatory Education Answer Sheet
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Section 1 Questions
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
TRUE
FALSE
A
B
C
TRUE
FALSE
A
B
C
A
B
C
A
B
C
TRUE
FALSE
A
B
C
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Section 2 Questions
A
B
C
A
B
C
A
B
C
TRUE
FALSE
A
B
C
A
B
C
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
A
B
C
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
A
B
C
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
1.
2.
3.
4.
5.
6.
7.
8.
9.
Section 3 Questions
A
B
C
D
A
B
C
D
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
TRUE
FALSE
A
B
C
D
TRUE
FALSE
1.
2.
3.
4.
5.
Section 4 Questions
TRUE
FALSE
A
B
C
D
TRUE
FALSE
TRUE
FALSE
A
B
C
D
1.
2.
3.
4.
5.
6.
Section 5 Questions
A
B
C
A
B
C
A
B
C
TRUE
FALSE
A
B
C
A
B
C
Pass / Needs Remediation
D
D
D
D
D
Needs 80% to pass
Remediated by: __________________ Date: _______________
Employee Signature: __________________Date: __________

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2016

Mission and Philosophy

Founded on Seventh-day Adventist

Entities include 20 hospitals, more than

Compassion: We demonstrate empathy

Integrity: We conduct our business with

Excellence: We strive to provide a level

Respect: We appreciate and respect

The purpose of a PI model is to provide a collaborative,

Performance Improvement is everyones responsibility

Simi Valley Hospital uses the PDSA Model

Plan the improvement.

Improve the process.

Measure the impact.

Act to hold the gain and continue to improve the

Patient Experience-To create a patient centered healing

The team consists of members from Glendale Adventist

The CLABSI Performance Improvement

CLABSI Is a central IV line

In 2015 (Jan-Nov) we had

Some interventions that were

Education to improve the care of the

The nurse wipes the IV pump down

Specific process for dressing change

Infection Prevention daily rounds

Special daily baths for ICU patients and

Infection Prevention educated the EVS

The CAUTI Performance Improvement

Some interventions that were

Education of the nurses to improve

Emergency Department nurses and

Encouraging inpatient caregivers to

Hand Hygiene Performance

The Hospital Wide 2014 Hand Hygiene Compliance rate

Performance Improvement Projects

Pressure Ulcer Reduction PI team Is working to

2014 1.05 rate (corp. goal = 1.0)

2015 (Jan-Nov) 0.90 rate (corp. goal = 1.0)

Corporate Compliance Program

Strictly adhere to those rules and policies

Follow applicable laws

Immediately report any activity that appears out of line

The Adventist Health Corporate Compliance

Promote full compliance with all laws and

SVHs Compliance Team

AH Chief Compliance Officer

our values in action

We take personal responsibility for our actions

We investigate all reports promptly, thoroughly and

Patient Rights and Responsibilities

law says that all patients

Patient Rights and

of protected health information

consent prior to initiation of tests and

in the ongoing plan of care

name of the physician delivering medical care

A listing of the Patient Rights is located in the Patients

Patient Rights and

Patients have visitation rights and may:

Give oral or written consent for visitors or support

Designate a family spokesperson and/or provide

Amend the information at any time