Houston Methodist Hospital

SAFTY AND INFECTION CONTROL

GUIDE
For Volunteers (Non- Employees)

Table of Contents
Safety and Infection Control
Back Safety

3-4

Bloodborne Pathogens

4-6

Business Practices

6-10

Equipment and Utilities

10-11

Fire Safety

11-14

General Safety

14-17

Hazard Communications

17-20

Influenza Education

20-22

The Houston Methodist Hospital HIPAA Privacy Rule 22-26

Quick Help Tips for Orientees

SAFETY AND INFECTION CONTROL

The following pages highlight major safety and infection control initiatives at
Houston Methodist Hospital.

Back Safety
Introduction
Back injuries are one of the most common types of reported injury today. They
account for more than 26 billion dollars in medical expenses in the U.S. annually.
At least 80% of the general population experience back pain at some point in
their life. Back injuries are one of the leading causes of disability and career loss
in employees and volunteers (non-employees)
Learning and practicing good body mechanics can mean the difference between a
healthy back and an annoying or even debilitating injury.
Most people assume that a serious back injury is the result of a single accident.
However, it is usually caused by numerous small injuries to the back over time.
Some of the most serious lifting errors are not bending at the knees when lifting
and twisting while carrying a load.

Back Injury Causes

1. Improper body mechanics when lifting is a major cause of back injuries.
Always take time to ensure that proper body mechanics are used.
2. Poor posture can keep the spine out of its normal position and cause stress
on the vertebrae and discs.
3. Poor physical condition is also a contributing factor in many back injuries.
Workers that are required to lift objects should maintain a good physical
condition to help minimize the potential for injury.
4. Workers should always obtain assistance when lifting heavy loads.

Back Injury Prevention

1. Use proper body mechanics.
a. When lifting, remember these tips:
i. EXAMINE the object.
ii. DECIDE how to hold the object.
iii. FACE the object squarely.
iv. MAINTAIN a wide base of support when lifting.
v. CLEAR all obstructions out of your way.
vi. USE proper body mechanics when lifting the object. Bend at the
knees. Use your legs not your back!
vii. KEEP the load close to the body when lifting.
viii. If you have to turn, USE your feet. DO NOT TWIST YOUR BODY!
ix. GET ASSISTANCE when lifting patients or heavy loads.
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x. COORDINATE the lift with the others assisting.

xi. UTILIZE lifting assist devices like transfer stretchers and Gait
Belts and Hoyer Lifts whenever possible.
2.
3.
4.
5.

Eliminate the cause. Break the load up into smaller loads if possible.
Exercise and maintain good physical condition.
Get the proper amount of rest.
Reduce stressful activities.

Some Other Helpful Tips:

1. When standing for long periods of time, keep one foot elevated on a stool
or step.
2. When sitting, adjust our chair as often as necessary to suit your needs.
3. Always stop and stretch when you feel tired.
4. When assisting patients, get their help whenever possible.

Immediate injury treatment

1. See your doctor.
2. First aid: A-I-M: Anti-inflammatories, ice packs and movement.
a. Anti-inflammatories (aspirin or ibuprofen) will decrease the
inflammation present in the nerves.
b. Ice packs decease the pain when experiencing lower back spasms.
c. Gentle movement or stretching immediately after the ice pack will
help stretch the muscles back to their normal limits.
3. Rest.
4. Back support.
5. Medication and physical therapy: Medication should not be relied upon as
the only treatment for a back injury. It needs to be coupled with physical
therapy to allow the back to return to its normal strength.
Remember, YOU are the key person in preventing back injury!

Bloodborne Pathogens
Introduction
OSHA, (the Occupational Safety and Health Administration) issued the Bloodborne
Pathogen Standard effective June 6, 1992, to protect Healthcare Workers (HCW)
from diseases that are transmitted by contact with blood.
Bloodborne pathogens (BBP) are microorganisms present in blood that can cause
disease in humans. Hepatitis B and C and HIV are the most common viruses that
healthcare workers could be exposed to at work. Hepatitis B vaccine is a
vaccination that protects against Hepatitis B. This vaccine is offered at no cost to
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healthcare workers who have the possibility of exposure at work. Currently, there
is no vaccine for Hepatitis C or HIV.
The Bloodborne Pathogen standard is designed to provide you with information on
how to protect yourself from occupational exposure to blood or Other Potentially
Infectious Material (OPIM). Definitions and lists of OPIM are available in the
Houston Methodist Hospital Exposure Control Plan and in the OSHA Bloodborne
Pathogen Standard.

Occupational Exposure
Occupational exposure to blood or OPIM can occur if there is contact with your
eye, mucous membranes, or non-intact skin during your work duties. This could
occur with a splash of bloody material from a patient, a needle stick from a
contaminated needle or a cut from an instrument that has been used on an
infected patient.

Exposure Control Plan (ECP)

Key components and the ECP:
1. Exposure determination (who might be exposed at work).
2. Methods of compliance to prevent exposures.
The Methodist Hospital System Exposure Control Plan is located on the hospital
intranet and in each departments Infection Prevention and Control Manual that
should be located in a central location so that it can be easily reviewed as needed
by all employees and volunteers (non-employees).
Compliance with OSHAs Final Rule
1. Standard Universal Precautions treat all blood and body fluids from any
patient as potentially infectious.
2. Engineering controls Physical devices that isolate or remove the
bloodborne pathogen exposure from the work place. EXAMPLES: Needleless
IV System, sharps safety devices (i.e: self-sheathing needles) and sharps
disposal containers that are puncture resistance.
3. Work practice controls Work practice controls reduce the likelihood of
exposure by altering the way a task is performed. Many times, this means
a change in work habits. For example:
a. Recapping, bending or breaking contaminated needles is prohibited.
The exception is recapping using a recapping device or by onehanded method when no alternative is feasible.
b. Hand-washing facilities must be readily accessible to all hospital
workers.
c. Mouth pipetting of blood or OPIM is prohibited.

d. Disposable gloves will not be washed or decontaminated for reuse.

Non-latex gloves are available through central supply for individuals
who are latex sensitive.
e. Utility gloves may be decontaminated for reuse, but they must be
discarded if they are torn, ripped or punctured.
f. Housekeeping and disinfecting environmental surfaces are cleaned
daily with a hospital approved disinfectant (see ECP).
g. Mouthpieces, resuscitation bags, or other ventilation devices will be
used whenever possible.
h. Regulated waste that requires special handling such as items
contaminated with blood or OPIM is trash. Regulated waste must be
placed in special containers marked with the fluorescent orange/redorange biohazard label and they must be leak proof. At the Houston
Methodist Hospital System, items saturated with blood or body fluids
that contain blood are placed into red bags and special containers for
biohazard waste. The healthcare worker must be sure an absorbent
material is added to these containers to prevent leaking.
i. Blood spills need to be cleaned up promptly and disinfected using a
Hospital approved disinfectant that is effective against HIV and
Hepatitis.
Personal Protective Equipment (PPE)
Examples of Personal Protective Equipment used when exposure to Bloodborne
Pathogens is possible are: gloves, mask/eyewear, impervious gowns, and aprons.
All employees and volunteers (non-employees) who indicate possible
occupational exposure must wear the appropriate PPE prior to performing the
task or procedure. PPE is available on all patient care units and patient testing
departments. It is the employees and volunteers (non-employees) responsibility
to use the PPE properly.
Hepatitis B Vaccination Program
HBV vaccination is offered to all employees and volunteers (non-employees) who
have the potential for occupational exposure. The vaccination must be made
available after the required training and within ten days of initial assignment. The
vaccine is administered in Employee Health free of charge.
Post Exposure Evaluation and Follow-up
All employees and volunteers (non-employees) are required to report all on-thejob injuries and blood/body fluid exposures to their supervisor.
1. All injuries involving a contaminated sharp or other blood or body fluid
exposure are reported to an Infection Control Practitioner (ICP). Call
Employee Health.
2. Following a report of an exposure incident, Employee Health will provide a
confidential medical evaluation and follow-up for the employee.
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3. The source patient will be tested and the results will be made available to
the exposed healthcare worker.

Business Practices
What is the Business Practice Program?
The Business Practice Program is Houston Methodists compliance and
organizational ethics program. This program is designed to:
1. Give employees and volunteers (non-employees) a basic understanding of
how they should conduct business in the name of Houston Methodist.
2. Support your efforts to continue to do the right thing.
3. Address the governments concerns that you understand:
a. Houston Methodist expects you to do the right thing at all times.
b. There can be certain consequences if you do not.
The Business Practices Program Vision is derived in part by the Houston Methodist
Hospital Statement of Values which focuses on the I CARE Values: (Integrity,
Compassion, Accountability, Respect, and Excellence)
The Business Practices Program Vision states that all actions taken in
the name of Houston Methodist are consistent with strong moral values,
high ethical standards, and the law. Simply stated, Houston Methodist strives
to do what is morally and ethically correct and abide by the law. This is what is
expected of each employee of Houston Methodist and is the foundation on which
the Business Practices Program is built.
What are your responsibilities?
As an employee of Houston Methodist, your responsibilities are to:
1. Do the right thing
2. Report questionable practice

Do the Right Thing

Lets focus first on ways to help you continue to do the right thing.
1. Follow the policies and procedures set by Houston Methodist and your
individual departments.
a. Remember that policies and procedures change periodically.
b. Review the department policies either quarterly or as needed to
ensure that you are upholding the standard.
Many times throughout your day, you exercise judgment or make decisions where
there are no written policies or procedures. Here are some tips to help you
determine if you are doing the right thing in those circumstances. Take the tests.
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Headline Test
If the Houston Chronicle or the six oclock news reported on an action you
performed at work, would you feel good about it? If the answer is no, then it is
probably not the right thing to do. Get some clarification before you proceed with
that act.

Pride Test
Could you tell your children or your mother about what you did and feel good
about it? If the answer is no, then it is probably not the right thing to do. Again,
get some clarification before you proceed with that act.

Smell Test
Have you ever said to yourself, This doesnt smell right? Well if it doesnt then it
probably isnt. So dont do it. Use your good instincts to help you determine if
something is right or not. If you are not sure, get clarification from another
source.

Report Questionable Practice

Your other responsibility is to report questionable practices. A questionable
practice is anything that does not appear to comply with the Business Practices
vision, that all action taken in the name of Houston Methodist are consistent with
strong moral values, high ethical standards, and the law.
It is important that you know why it is necessary that you report these things that do not
appear to fit within the vision of the Business Practices Program. Problems or potential
problems that go unreported have the potential to escalate into dangerous or costly
situations. Unless you report them, no one will investigate them and make any
necessary corrections. By reporting questionable practices, you are helping make
Houston Methodist a better place.

Knowing whom to report a questionable practice is just as important as why we

report them. There are several reporting options available to you. You should
report a questionable practice to:

Your supervisor.
Your chain of command.

If this is inappropriate or makes you uncomfortable, you should contact one of the
following:

Human Resources.
Your entitys Business Practices Officer (see list below).
o Methodist Business Practices Officer, Connie Wallace.
o Business Practices Ethics Hotline at 1-800-500-0333.
o Houston Methodist Hospital at 713-383-5124.
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o Houston Methodist Hospitals Physician Organization at 713-3835125.

If you do not want to talk to anyone in person or do not want your identity
revealed, the option is the Business Practices Ethics Hotline at 1-800-500-0333.
This Hotline allows you to report questionable practices while remaining
anonymous. All the calls received are taken seriously and they are all
investigated. The Hotline is answered 7 days a week, 24 hours a day, 365 days a
year. NOTE: The Business Practices Ethics Hotline must not be used to contact
the biomedical ethics consult team. The consult team should be called with any
biomedical ethics issue such as questions/concerns regarding life sustaining
measures. See Official Procedure for your entity.
Retaliation is prohibited against anyone making a report of a suspected violation
in good faith. Use your good judgment about when to call but understand that
you are not limited as far as what you can report.

Conflict of Interest
As employees and volunteers (non-employees), your actions are expected to be
in the best interests of Houston Methodist. A conflict of interest or the
appearance of conflict of interest can exist when your private interests influence
or appear to influence your actions in a way that is not in the best interests of
Houston Methodist. Examples of private interests include personal or family
ownership interests.
So that a conflict of interest can be managed to assure no harm is caused to
Houston Methodist, each employee and volunteer (non-employee) is responsible
for disclosing potential conflicts of interest as they arise. You should disclose a
potential conflict of interest to our volunteer services coordinator, mentor or the
appropriate management member, the Houston Methodist Business Practices
Officer or the chair of any decision-making body you serve. Employees and
volunteers (non-employees) and other associated with Houston Methodist who
have a conflict of interest must not vote on the conflicted matter but, following
proper disclosure and prior approval, may participate in the decision-making
process.

Confidentiality
The definition of confidentiality is safeguarding the privacy or secrecy of sensitive
and private information. It is the responsibility of all of us to protect and preserve
and individuals right to privacy.
Confidential information includes:
Patient information:
Things such as medical records, financial information or personal information

Health plan members information:

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o This could include the name of the insurance company or coverage

information.
Employee Records:
o This could include things such as salary or counseling actions.
Business and trade secret information
o This could include procedures, techniques or cost information that is
unique to Houston Methodist.

Confidentiality Dos and Donts:

Only access information that is needed to perform your job.

o If the information that you are accessing isnt part of your job
function, you should not be accessing it.
Do not discuss or share sensitive information in public places or in
personal conversations with friends or co-workers.
o Avoid talking about sensitive information during casual conversations
others at or away from Houston Methodist.
Do not share your computer password with anyone.
o No one should know your computer password but you. This way,
there is no chance of someone using your password to gain access to
sensitive information.
Do not leave sensitive information displayed on an unattended
computer screen.
o If you have to take a break or attend a meeting, lock your keyboard.
This will prevent someone from walking by and viewing information
that they are not supposed to see.
Keep sensitive paper information in a secure location.
o Dont leave things such as medical records, charts or confidential
memos lying around.
Do not throw away copies of sensitive information in a non-secure
or public area.
o Sensitive information that is not properly disposed can end up being
read by the wrong persons and consequently spread around to others.
Confidentiality of health care information is everyones
responsibility.
o Dont do or say anything with any information that you may have
obtained that is not within the scope of your job.

Equipment and Utilities

Introduction
The Hospital equipment and utility programs are designed to assure the
operational reliability of utility systems that support the patient care environment
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and to control the clinical and physical risks of fixed and portable equipment used
for the care of patients.

Safe Medical Devices Act

Houston Methodist defines a medical device as an instrument, apparatus,
contrivance, implant, in-vitro reagent, or other similar/or related article including
any component, part or accessory, which is used in patient treatment or care.

If you feel that a medical device may have caused or contributed to the
death or serious injury to a patient, you must report the incident
immediately to the department supervisor.
The supervisor or designee is responsible for notifying immediately the
attending physician, and Risk Management.
The three departments that review medical equipment requests prior to
purchase are Biomedical Engineering (technical evaluation), Nursing (user
evaluation) and Purchasing (cost-effective evaluation).

Malfunctioning or Damaged Equipment: Procedure for

handling

Tag equipment, remove from use immediately and inform the department
supervisor.
All equipment should display an inspection sticker with the date of the last
inspection.

Equipment failures are to be reported to:

Clinical:
o Houston Methodist and Corporate Biomedical Engineering,
Radiology Engineering, Respiratory Care, Laboratory Medicine, and
Risk Management
o Non-clinical: Houston Methodist and Corporate Contact Facility
Management Services, I.T. Help Desk, or the vendor issuing the
service contract.

The function of the red wall outlets

In the event of power failure the red outlets will supply electricity from the
emergency power generator.
Electrical equipment that must be used during a power failure must be
plugged into the red outlets.
Critical Life Support equipment should be connected to red wall outlets at
all times.

State the down time between loss of power and the start-up of
emergency power and how utilities will be provided.
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Houston Methodist and Corporate

Houston Methodist has eleven diesel powered generators that turn on 10seconds after the power shuts down.
The telephone system is on emergency power. However, if Southwestern
Bell goes down we will also lose telephone communications.
Water pumps are on the emergency power system. Houston Methodist has
a contract with an outside vendor to deliver water during an emergency
situation.

Fire Detection, Suppression Systems

All hospital buildings are fully equipped with sprinkler systems.
Fire alarm systems are monitored by Facility Management Services and an
outside company. These systems are also on emergency power.
Fire extinguishers are maintained and inspected monthly by Environmental
Safety/Safety Department.

Total power failure

In a total power failure, employees should follow the department specific plan for
tasks and/or evacuations.

Fire Safety
Introduction
The purpose of fire safety is to inform all employees and volunteers (nonemployees) regarding fire prevention, detection and the proper procedures
to follow in case of a fire or a fire drill.
We have an obligation to the Hospital and each other to follow an organized
plan. The Hospital fire and emergency evacuation plan is outlined in detail
in the Fire Safety and Disaster Manual, Chapter 3.
You must act quickly if you discover a fire since they generally can double in size
in about 2 minutes.
Many people die in fires every year and the biggest killer in a fire is smoke. Fires
can produce deadly gases that are odorless, colorless and hard to detect. One
such gas is carbon monoxide.
Until smoking and the use of tobacco was banned in healthcare facilities, the
leading cause of fires was the careless use and disposal of smoking materials.
Now electrical related fires are the leading cause.
The acronym R.A.C.E. is an easy reminder of the appropriate response to a fire.
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R.A.C.E. stands for RESCUE, ALARM, CONTAIN, EXTINGUISH.

RRESCUE: Rescue patients, visitors, and anyone else in danger from the fire and
go to a safe place.
AALARM: There are two steps to take in alerting the Hospital to a fire.
The first is to sound the alarm by pulling the lever on the PULL STATION.
The alarm sounds on the floor of activation, one floor, Annex, Dunn Town
The second step is calling in a fire report:
Houston Methodist Hospital and Corporate
713-790-3300 Main Building, Annex, Dunn Tower, Fondren-Brown,
Alkek and Neurosensory Buildings or West Pavilion
9- 9-1-1 Scurlock Tower, Smith Tower, Warehouse, Greenbriar, El
Rio, and Holly Hall
CCONTAIN: Close all doors and clear hallways of people and equipment. The
doors to the fire exit stairway must ALWAYS remain closed unless you are moving
through them.
EEXTINGUISH: If you can do so safely, and you feel comfortable using the fire
extinguisher, use it. If not, dont put yourself at risk.
Sometimes RACE may be taken out of order if the situation permits (Example: If a
persons clothing is on fire, you should try to extinguish their clothing first. If
there is a fire in a storage closet, you should try to close the door to the closet.
If the fire is in a patients room, remove the person if possible and sound the
alarm. REMEMBER, the unit should work together as a team.
AFTER PULLING THE FIRE ALRAM, ALWAYS NOTIFY THE FIRE OPERATOR
so the fire department will upgrade its response. Once the pull station is
activated it sounds the alarm on the floor of activation, one floor above and one
floor below. It also notifies the fire department, closes the fire doors on the floor of
alarm, shuts down the HVAC (A/C) system on the floor of alarm and notifies our
Emergency Response Team. Notifying the fire department is important whenever
any fire is suspected in your facility.
Each employee and volunteer (non-employee) should know their specific roles
and responsibilities when they are away from a fires point of origin
(Departmental specific fire plans should reflect this information.)
Each department has a specific evacuation plan in case of fire.

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EVACUATION PROCEDURES:

IF:

THEN:

The fire/smoke is confined to a small

area.

Remove all patients, visitors, and

personnel from the immediate area.

The fire/smoke is not confined to a

small area,
OR
Progresses to a point where
evacuation becomes necessary.

Move all patients, visitors, and

personnel HORIZONTALLY beyond the
fire/smoke doors. This is the primary
direction of evacuation.
NOTE: The fire/smoke doors must be
kept closed when people are not being
evacuated through them to contain the
smoke or fire to the point of origin and
isolate patients and visitors from the
fire.

The Houston Fire Department or

Administrator On Call tell you to
evacuate the floor.

Move all patients, visitors, and

personnel VERTICALLY by stairwells
using the route and destination
identified in our department specific
fire evacuation plan (DO NOT USE
ELEVATORS except under the direction
of the fire department).

Total evacuation out of a building is a last resort and ONLY under the direction of
the fire department.

Methods of Patient Movement:

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1. BLANKET/SHEETS CAN BE USED TO SMOTHER FLAMES, DRAG PATIENTS, OR

SHIELD A PATIENT FROM FIRE.
2. WHEELCHAIR.
3. FIXED CHAIR OR STAIR CHAIR.
4. STRETCHERS.
5. MOVEMENT OF PATIENT BEDS.
6. FIRE DEPARTMENT SUPERVISED USE OF ELEVATORS.
OXYGEN ZONE VALVE SHUTOFF will occur only under the direction of the Head
Nurse or Charge Nurse of the affected unit. Shutting off oxygen zone valves could
affect many patients.
If oxygen is contributing to a fire, shut it off at the source if possible, or shut off
the zone valve if necessary.

Identify classification of fires

The 3 most common classifications of fires:

o Class A: Common combustibles (trash, paper, linen, wood, plastics)
o Class B: Flammable liquids (gasoline, alcohol, paint)
o Class C: Live electrical equipment

It is possible to have a fire with a combination of A, B or C classes (Ex: Laser

printer: paper and printer are an A, yet while the printer itself is connected to
electricity it is a C class.)

Types of fire extinguishers:

Pressurized water A class fires only.

Water Mist A and C class fires (MRIs, ORs)
Carbon Dioxide B and C class fires only.
Dry Chemical A, B or C class fires.

When using the dry chemical extinguisher, remember that it contains a

compressed powder that is corrosive and can cause difficulty to the respiratory
system.

Proper use of a fire extinguisher:

To remember the steps, use the acronym: PASS

P Pull the pin

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A Aim the extinguisher at the base of the flames (start back 3-5 ft. from
the fire).
S Squeeze the handle
S Sweep: sweeping motion to completely cover fire area with extinguisher.

General Safety
Introduction
A safe work environment is no accident. Houston Methodist Hospital strives to
keep its premises free from all hazards and is committed to providing the safest
possible physical environment to avoid illness and injury to those on its premises.
Some factors that increase your safety awareness are:
Posted warning signs
Container labels
Material safety data sheets
Safety meetings / in-services

SAFETY, WHEN IT IS A FACTOR, HAS THE HIGHEST PRIORITY

IN ALL DECISIONS
The Safety Management Program
The Safety Management Program pertains to all departments and everyone
(employee and non-employee). It consists of policies and guidelines for the
management of all safety issues in the hospital, some of which include:

Hazardous material and waste.

Fire safety.
Disaster/Server weather preparedness.
Infection control.
Radiation safety.
Public safety.
Safety training and education.
Routine safety inspections to monitor compliance with the program.
Equipment and utilities.
General safety.
Accident prevention/reduction.

Departmental Safety Plan

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In addition to the hospital-wide procedures, each department is required to have

written departmental specific safety procedures. These departmental plans
should cover the specific safety issues within every area relating to the above
topics. The departmental plans should support and make reference to t related
chapter within the Fire, Safety and Disaster Manual and should be kept in the
department-specific area within the FS&DM.

Safety Inspections
These inspections are physical checks of the work area for safety hazards.
Inspections are performed at least twice a year by a representative of each
department using the Departmental Safety Inspection Checklist. Once each year
Environmental Safety performs an inspection.
To report safety hazards, contact the department supervisor or call the Central
Dispatch at 713-790-2274.

Accidents
ALL VOLUNTEER ACCIDENTS (even those that do not result in serious
injury) SHOULD BE REPORTED TO THE VOLUNTEER SERVICES
DEPARTMENT DIRECTOR OR VOLUNTEER COORDINATOR IMMEDIATELY.

Occurrence Report
If a patient (or visitor) is injured on the property, it SHOULD BE REPORTED TO
THE DEPARTMENT DIRECTOR OR SUPERVIOR IMMEDIATELY.

Patient Fall Prevention

Houston Methodist Hospital has a process in place to identify patients who might
be at a high risk for falling during their stay in the Hospital. Patients who are
assessed and have been determined to be at risk for falls are identified by a
yellow plastic arm band, a yellow dot or diamond on their chart, and yellow socks.
These patients should be assisted when ambulating and should be observed by
staff more frequently than other patients.

Emergency Announcements-Overhead Paging Codes

You must be familiar with the Hospital code announcements: Code 99 Disaster
plan is being activated. The three disaster alert levels are:

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Code 99 Triage
Code 99 Management Standby
Code 99 STAT

Code Orange Bomb Threat

Code Blue Cardiac/Respiratory
Arrest
Dr. Pyro Fire
Code Pink Infant Abduction

Environment of Care Committee

The Environment of Care (EOC) Committee is charged with the responsibility for
policy/procedure development, routine review, monitoring of compliance, and
enforcement related to hospital-wide safety issues. The EOC Committee is
chaired by a vice president or designee and is composed of standing and ad hoc
working groups from various departments and divisions.

Safety Officer
In addition to the Safety Committees there are also Safety Officers at each entity.
The Safety Officer is responsible for assisting in the development, implementation
and enforcement of departmental and system-wide safety procedures to keep the
institution in compliance with regulatory agencies. He/she also serves as a
resource to departmental safety committees and acts as a consultant to
management and executives on safety related issues.

Public Safety Awareness

One component of safety that we often take for granted in the Hospital setting is
public safety or security. Public safety involves protecting patients, visitors,
employees and (non-employees) from the threat of crime and physical harm.
Public Safety consists of a combination of Public Safety Representatives, off-duty
uniformed Houston Police Officers, surveillance cameras, 24-hour Services
Communications (central dispatch) office, and controlled access points. To report
a security related incident at Houston Methodist, please call Service
Communications at 713-441-4246.
Infant Abduction (Code Pink)
In order to minimize the risk of an infant abduction in the Hospital, special
security measures are in place in the Labor and Delivery areas, as well as the
Nurseries. In the event of a reported infant abduction, a Code Pink
announcement will be made over the public address system. Security and other
radio dispatched Hospital personnel will respond to apprehend the abductor.
Everyone is requested to be on the lookout for someone attempting to flee the
Hospital with an infant.
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Any suspicious persons or activities should immediately be reported to the

Security Department at 281-274-7112.

Access Control
Houston Methodist has a standing access control procedure which is in effect
between the hours of 9:00p and 5:30a. During these hours, entry to the Hospital
can be made at various monitored entry points upon providing valid identification.
Individual departments may have their own access control procedures.

Workplace and Domestic Violence

Violence in the workplace and at home is becoming much more commonplace
today. To report known or suspected incidents of domestic or workplace violence,
call 713-441-4246.
It is every employees and volunteers (non-employees) responsibility to increase
their knowledge and awareness concerning the Hospital-wide safety plans, their
own departmental safety plans and the safety issues related to their work area.
Remember: YOU ARE RESPONSIBLE FOR YOUR OWN SAFETY!

Hazard Communications
Introduction
Hazard Communication is important to us because it protects us by providing
information about materials that are hazardous to us and our rights under the law.
Hazardous Communication is also known as the Workers Right-To-Know Law. It is
based on the simple concept that Hospital workers have both the need and the
Right-To-Know of the hazards of the chemicals they may be exposed to during
their normal work operations. Hospital workers and non-Hospital workers also
have the Right-To-Know where to find information concerning the hazardous
materials they work with or around. Hazardous chemicals can be found in every
department in the Hospital.
Elements of the OSHA Hazard Communication Standard
The Occupational Safety and Health Administration (OSHA) administers the
standard which requires the following:
Identifying and listing all hazardous chemicals in the workplace (WPCL).
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Obtaining Material safety Data Sheets (MPCL).

Ensuring proper labeling of containers.
Training everyone working in the Hospital.
Establishing a written program describing how the standard will be met.

Workplace Chemical Lists (WPCL)

OSHA requires a listing of all hazardous materials in the workplace and refers to
this as the Workplace Chemical List (WPCL). The Hazard Communication Standard
includes chemicals in all physical forms, (solids, liquids, gases, vapors, mists)
whether or not they are contained.
Every department is required to maintain their WPCL on the intranet. Each
department must review and update their WPCL at least once per year. New
chemicals should be added to the list throughout the year.

Material Safety Data Sheet (MSDS)

The MSDS is supplied by the manufacturer or distributor of the chemical land
must contain specific information concerning the properties and safe use of the
product - MSDS must be available to employees and volunteers (non-employees)
at all times.
All MSDSs do not look alike, but they should contain the necessary information.
The information contained in the MSDS is grouped into the following categories:

Identification Information: Basic reference information; chemical name.

Hazardous Ingredient Data: Describes the percentage of hazardous
materials in a product.
Physical and Chemical Characteristics: Flash point, volatility, density.
Fire and Explosion Data: What might cause explosions and how to fight fires
involving this material.
Reactivity Hazards: Chemicals which might have a hazardous reaction with
this chemical.
Health Effects/Hazards/Ingestion methods: Short-term and long-term health
hazards and the most likely way to be poisoned, (potential routes for
exposure include: skin and eye absorption, inhalation, ingestion, injection)
Emergency Information and First Aid.
Storage and Disposal: How to store/dispose of the chemical to avoid water
or ground pollution.
Spill and Leak Procedures: What to do in case of a spill.
Protective Equipment/Control Measures: (PPE: gloves, goggles, boots,
gowns, etc.)
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Each department is responsible for obtaining and reviewing the MSDS before a
new chemical enters the work place. All MSDS can be obtained directly from the
manufacturer or from the Hospitals off-site MSDS faxback retrieval service at 9100-451-8346.
Be prepared to tell the MSDS retrieval service:

The product name.

The product manufacturer.
Your fax number.

Questions about information on MSDS can be referred to the department

supervisor, the manufacturer or the Safety Department.

Labels
The label is another place to find more immediate hazard information about a
chemical as well as directions for its proper use.

All hazardous material must have a label that identifies the material as well
as the hazard associated with the material.
Hazards are listed on labels based on words, colors or numbers. Words used
to indicate a hazard are: Danger, caution, waning, corrosive, flammable,
toxic, poison, etc. (carcinogens are chemicals that can cause cancer)
The name on the label identifying the material must be the same name
found on the MSDS.
The label must be in legible English.
Labels may give more than the required information, such as first-aid
information, personal protective equipment selection, emergency telephone
numbers, and other pertinent data concerning the material.

If you use a secondary container for hazardous chemicals, you must label the
container with the name of the product and appropriate hazards. Labels must be
legible and in English.

Written Hazard Communication Program

The Hospitals Hazard Communication Program can be found in the Fire, Safety
and Disaster Manual. The departmental hazardous material procedures and Work
Place Chemical List should be kept in a place that is accessible to all Hospital
workers.

21

Reporting and Managing Chemical Spills or Exposures

Report to the supervisor immediately any of the following:

Spills of known or suspected hazardous chemicals;

Accidents involving known or suspected hazardous chemicals;
Malfunctioning equipment, and
New and potentially hazardous chemicals.

Take immediate action in the event of a spill known, or suspected to be, a

hazardous chemical. Handle the spill as follows:

If the chemical is spilled on you, wash it off immediately.

Isolate the area of the spill and warn others in the area.
For Houston Methodist and Corporate Hospital workers call 713-441-4246 to
report the spill.
OR, CALL THE NUMBER FOR SPILLS PRINTED ON YOUR PHONE STICKER.
If the department has procedures for cleaning up small spills, follow the
procedure. DO NOT attempt to clean even small spills yourself unless you
have been trained on clean-up procedures. DO NOT ask Housekeeping to
clean a hazardous material spill.
Report to the supervisor.

INFLUENZA EDUCATION
What is influenza (Also Called Flu)?
The flu is a contagious respiratory illness caused by influenza viruses. It can
cause mild to severe illness, and at times can lead to death. The best way to
prevent the flu is by getting a flu vaccination each year.
Every year in the United States, on average:
5% to 20% of the population gets the flu;
More than 2000,000 people are hospitalized from flu complications, and;
About 36,000 people die from flu.

What is influenza (Also Called Flu)?

Symptom of the Flu Cold, Fever (usually high), Sudden Gradual Cough, Nonproductive, Severe Hacking, Headache, Prominent Rare Fatigue lasting 2-3 weeks;
Very Mild Myalgia - Common; Severe Slight Chest Discomfort - Common;
Mild/Moderate Extreme Exhaustion, Early and Prominent Very Rare Stuffy Nose 22

Sometimes Common, Sneezing, Sometimes Usual Sore Throat - Sometimes

Common

Complications of the Flu

Complications of the flu can include bacterial pneumonia, ear infections, sinus
infections, dehydration, and worsening of chronic medical conditions, such as
congestive heart failure, asthma or diabetes.

How Flu Spreads

Flu viruses spread mainly from person to person through coughing or sneezing of
people with influenza. Sometimes people may become infected by touching
something with flu viruses on it and then touching their mouth or nose. Most
healthy adults may be able to infect others beginning one day before symptoms
develop and up to five days after becoming sick. That means that you may be
able to pass on the flu to someone else before you know you are sick, as well as
while you are sick.

Prevention
Non-vaccine prevention
Cover your face when you cough or sneeze
Wash your hands frequently
Stay at home while you are sick
Avoid crowded areas during flu season
Preventing the Flu: Get Vaccinated
The single best way to prevent the flu is to get a flu vaccination each year. There
are two types of vaccines:
The flu shot an inactivated vaccine (containing killed virus) that is given
with a needle. The flu shot is approved for us in people 6 months of age
and older, including healthy people and people with chronic medical
conditions.
The nasal-spray flu vaccine a vaccine made with live, weakened flu
viruses that do not cause the flu (sometimes called LAIV for Live
Attenuated Influenza Vaccine). LAIV is approved for use in healthy people 5
years of age to 49 years of age who are not pregnant. The one exception is
healthy persons who care for persons with severely weakened immune
systems who require a protected environment; these healthy persons
should get the inactivated vaccine. The Houston Methodist Hospital System
23

is not currently offering nasal-spray flu vaccine to its employees and

volunteers (non-employees).
About two weeks after vaccination, antibodies develop that protect against
influenza virus infection. Flu vaccines will not protect against flu-like illnesses
caused by non-influenza viruses.

When to Get Vaccinated

October to November is the best time to get vaccinated, but getting
vaccinated in December or even later can still be beneficial since most influenza
activity occurs in January or later in most years. Thought it varies, flu seasons
can last as late as May.

Who Should Get Vaccinated?

Children aged 6 months until their 5th birthday.

Pregnant women.
People 50 years of age and older.
People of any age with certain chronic medical conditions.
People who live in nursing homes and other long-term care facilities.
Household contacts of persons at high risk for complications from the flu.
Household contacts and out of home caregivers of children less than 6
months of age.
Health care workers.

Who Should Not Be Vaccinated

People who have a severe allergy to chicken eggs.

People who have had a severe reaction to an influenza vaccination in the
past.
People who developed Guillain-Barre syndrome (GBS) within 6 weeks of
getting an influenza vaccine previously (www.cdc.gov/flu/about/qa/gbs.htm).
Children less than 6 months of age (influenza vaccine is not approved for
use n this age group).
People who have a moderate or severe illness with a fever should wait to
get vaccinated until their symptoms lessen.

THE METHODIST HOSPITAL HIPAA PRIVACY RULE

QUICK HELP TIPS FOR HOUSTON METHODIST
HOSPITAL ORIENTEES
Notice
of
Privacy
Practices
(Notice) - A patient has questions

24

See the Notice Quick Tips.

The answer will likely appear on

about
the
Notice
or
the
Acknowledgment form of receipt of the
Notice.

Patient Inquiries Someone calls or

a visitor comes to the Orientees desk
to ask about a patient.

25

that sheet.
If you cannot determine the
answer from the Notice Quick
tips, refer the patient to your
Entity Business Practices Officer
for handling.
Do not release any information if
a visitor or caller does not
provide the patients name.
If you are given the patients
name, unless the patient is a
No
Information
/
Confidential
Patient,
you
may:
o Indicate that the patient is inhouse
and
provide
the
patients room number, and
transfer a call to a patients
room.
o Never give out a patients
room telephone number.
Questions regarding a patients
general
condition
must
be
referred to the nursing unit.
If
the
patient
is
a
No
Information/
Confidential
patient,
o Do
not
release
any
information.
o You may tell the caller or
visitor I am sorry, we do
not have any information
on that person.
If the caller or visitor is insistent,
you may say, We understand
you are concerned. We would
suggest you contact a family
member for any information
about the person to whom you
are referring.
If the caller or visitor is
unsatisfied that you cannot
release any information, and is
insistent about speaking to or

Patients of the same name The

visitor or caller provides the patients
names, but there is more than one
patient with the same name.

Media inquiries A member of the

media calls asking about a patient.

Clergy requests A member of the

community clergy wants a religion
census list.

Talking to patients A patient wants

to talk about his health condition,
however, others are nearby.

Filing complaints A patient wants

to file a complaint about the handling
of his health information.

26

seeing
a
No
information/Confidential
Patient, then refer the caller
or visitor to a supervisor in
admitting services.
Ask the visitor or caller to
confirm the town or city in which
the patient resides, or the
patients age.
Do not give information to an
individual inquiring about the
patient.
Do not release any information
directly to the media, even if the
media provides the patients
name when calling.
Refer all media inquiries to the
Houston
Methodist
Strategic
Planning,
Marketing
and
Corporate Communications for
handling.
Refer community clergy
members who want religion
census lists to the Spiritual Care
and Values Integration
Department.
Tell him that you are not a health
professional and should not be
discussing his care.
If he insists on talking to you, do
not repeat any of the
conversation to others who are
not involved in his care and use
reasonable precautions such as
lowering your voice so the
conversation cannot be
overheard.
A patient has the right to file a
complaint about his health
information.
Refer the patient to your Ethics
Business Practices Officer.

For more information, go to the Privacy Practices Office Home Page at

http://www.tmh.tmc.edu/dept/privacypractices/ppo _home_page.htm
HIPAA Privacy Rule Quick Help Tips for Orientees
What is PHI?

What is the Notice

Practices (Notice)?

of

Privacy

Where can I find the Notice?

When does the patient receive the

Notice?

How do you document that the

patient received the Notice?

Protected health information

(PHI) is patient identifiable
information, such as
demographics and financial
information.
The Notice of Privacy Practices
(Notice) describes individuals
health information rights at HM;
how individuals can act upon
these rights; HMs legal duty and
responsibilities to protect health
information; and how HM is
permitted or required by law to
use and disclose health
information.
The Notice is publicly posted
(such as at the patient
registration sites) and is posted
electronically on the Houston
Methodist Internet website.
The Notice must be given to the
patient at the time of first
service at HM.
The patient must sign an
Acknowledgment of receipt of
the Notice.
A good faith effort must be made
to obtain an acknowledgement
of receipt of the notice but if the
patient refuses to sign the
acknowledgement you may
continue with treatment.

Permission to Use or Give out PHI

When do I have to get the
patients permission to use his her
protected
health
information
(PHI)?

27

A patients authorization is
required for any use or
disclosure of PHI that is not for

treatment, payment or health

care operations, and permitted
or required by law.
Using and Giving out PHI
What is use?

What is meant by disclosure of

information?
What does minimum necessary
mean?

Who is a qualified
representative (QPR)?

personal

Use refers to what HM does with

PHI internally.
Disclosure refers to how PHI is
released to outside entities.
Limit access to the minimum
amount of information necessary
to accomplish your duties as a
student when using or disclosing
PHI.
A QPR is a person who has the
legal authority to act on behalf
of the patient (for example,
parent of a minor or legal
guardian, etc.).

Who is responsible for HIPAA compliance?

Who is responsible for HIPAA Compliance at Houston Methodist?

Who handles complaints?

What
government
enforcing HIPAA?

agency

is

What
happens
if
Houston
Methodist or its employees dont
comply with HIPAA?

Dont Repeat

28

The HM Business Practices

Officer (BPO) is the contact
person to handle
communications and complaints
related to privacy.
The U.S. Department of Health
and Human Services Office of
Civil Rights (OCR) is responsible
for enforcement of the Privacy
Rule.
There are civil and criminal
penalties for failure to comply
and for wrongful use and
disclosure of PHI.
Anything that you observed or
learned about a patient to
family, friends or others.
Anything heard during the

Dont Copy

Dont Take

Dont Share

treatment of a patient when you

are away from the patient
treatment area. If you are
discussing the treatment of a
patient in the treatment area,
always lower your voice and
never discuss a patient in the
hallways or elevators.
Any documents containing
Houston Methodists patient
information.
Any documents pertaining to any
Houston Methodist patients.
Any documents containing
Houston Methodist patient
information.
Any user IDs or Passwords with
anyone.
Any documents containing
Houston Methodist patient
information.

METHODIST HIPAS PRIVACY RULE QUICK TIPS

Research / Studies
Can I use patient information to
write a paper? Can I get patient
information to see if I have
enough of a population for a
study?
Can
I
use
patient
information
for
a
class
assignment? Can I use aggregate
data for my paper? Can I use
dates relating to the patient (e.g.,
DOB, admitting and discharge
dates) in my paper?

29

If the paper is for research, (i.e.,

study designed to develop or
contribute to generalizable
knowledge) or for publication,
the protocol must be approved
by the IRB and patient
authorization or waiver of
patient authorization must be
obtained. Follow Houston
Methodist policies on research.
Houston Methodist policy
requires record reviews
preparatory to research to be

approved by the IRB. Patient

authorization is not necessary.
Follow Houston Methodist polices
on research.
If the purpose is not for research,
as describe above, IRB approval
and patient authorization is not
necessary. However, you may
not disclose any patient
identifiers (see below) in your
assignment.
Health information that does not
contain any patient identifiers
(see below) may be used without
may be used without IRB
approval or patient
authorization. Follow Houston
Methodist policy on deidentification of patient
information.
This information may be used
without IRB approval or patient
authorization by using a Limited
Data Set. Follow Houston
Methodist policy on limited data
sets.

Patient Identifiers: Names of the individual, and relatives, employers or household members of the
individual; Geographic identifiers: Geographic identifiers of the individual, including: Subdivisions
smaller than a state; Street addresses; City; County, and Precinct; Zip Code at any level less than the
initial three digits (e.g., NNNxx-xxxx). However, if the initial digits cover a geographical area of 20,000 or
less people, then it has to be reported as 000; All elements of dates (except year) directly related to an
individual, including: Birth date; Admission date; Discharge date; Date of death, and all ages over 89 and
all elements of dates (including year) indicative of such age, except that such ages and elements may be
aggregated into a single category of age 90 or older; Telephone numbers; Fax numbers; E-mail addresses;
Social Security numbers; Medial record numbers; Health plan beneficiary numbers; Account numbers;
Certificate/license numbers. Vehicle identifiers and serial numbers: Vehicle identifier and serial
numbers including license plate numbers; Device identifiers and serial numbers; Web Universal Resource
Locators (URLs); Internet Protocol (IO) address numbers; Biometric identifiers, including finger and voice
prints; Full-face photographic images and any comparable images, and any other unique identifying
number, characteristic, or code. For further information, visit the Privacy Practices Office Home Page at:
http://www.tmh.tmc.edu/dept/privacypractices/ppo_home_page.htm

30