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IMPORTANT NOTE on the limitations of this material: This content is not localized to a particular
healthcare environment, system, or entity. Since local system and administrative processes are crucial to
patient safety, it is imperative that the learner be familiar with local, facility/entity practices such as:
policies and procedures, equipment, patient identification and validation procedures, communication
and handoff practices, etc. Adhere to your organizations policies and procedures.
How to Use this Syllabus ............................................................................................................................... 1
Abuse ............................................................................................................................................................ 2
Accident Prevention.................................................................................................................................... 16
Advance Directives...................................................................................................................................... 18
Age Specific Care ......................................................................................................................................... 20
Back Safety .................................................................................................................................................. 32
Bioterrorism ................................................................................................................................................ 39
Blood Products Administration ................................................................................................................... 47
CMS HACs and IHI Care Bundles ................................................................................................................. 55
Consent for Treatment ............................................................................................................................... 60
Corporate Compliance ................................................................................................................................ 62
Cultural Competence .................................................................................................................................. 66
Documenting Patient Care .......................................................................................................................... 69
Drugs in the Workplace............................................................................................................................... 75
Electrical Safety ........................................................................................................................................... 82
Emergency Preparedness ........................................................................................................................... 86
End of Life Care ........................................................................................................................................... 94
Copyright 2015, Cross Country University
Page 1 of 284, Abuse
Abuse
Types of Abuse
Emotional Neglect
Emotional neglect includes not responding to the emotional needs of a child, exposing a child to
domestic violence, allowing a child to use drugs and/or alcohol, and the failure to provide the necessary
psychological care.
Sexual abuse
Sexual abuse is inappropriate sexual behavior with a child. It includes fondling a child's genitals, making
the child fondle the adult's genitals, intercourse, incest, rape, and sexual exploitation. To be considered
child abuse, these acts have to be committed by a person responsible for the care of a child (such as a
parent, baby-sitter, or daycare provider) or related to the child. If a stranger commits these acts, it
would be considered sexual assault and handled solely by the police and criminal courts.
Emotional/psychological abuse
Emotional abuse is an act, by parents or caregivers, which could cause behavioral, cognitive (affecting
the thinking process), emotional, or mental disorders. Examples of this type of abuse include bizarre
forms of punishment such as locking a child in a dark closet, basement, or attic. Emotional abuse is
generally present with most other forms of abuse and is often hard to prove.
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Even after accounting for the larger proportion of women in an aging population, females are
abused more often than men.
Those over 80 are abused at a rate 2-3 times higher than elders between the ages of 60 and 80.
In over 90% of cases where the abused elder knows the abuser, the abuser is a family member.
Two thirds of these abusers are the children of the elder or the children's spouses.
Failure to recognize that the actions are actually abuse (the victim feels that she or he deserves
the abuse)
Social isolation and lack of support for victims and their children
Promises of change from the abuser
Prior lack of intervention or help
Threats of violence.
Injuries in several stages of healing such as old bruises and new bruises, and evidence of old
fractures
Injuries during pregnancy (because pregnancy is a high risk situation for abuse)
Injuries inconsistent with the explanation of the injury.
Examples of situations in which the injuries are inconsistent with the explanation of the injuries:
Someone states that the injuries are caused by a fall, and yet the bruises and cuts, on the hands
and arms, are consistent with self-defense injuries.
Someone states that the injuries are caused by a fall, and yet the injuries are found on both
sides of the body (usually, in a fall, injuries are on one side only).
When abuse is suspected:
Provide privacy and the opportunity for the patient to talk. Privacy also means privacy from
partner, family members, or acquaintances.
Assure the patient of confidentiality.
Be non-judgmental and caring.
Ask if the partner has ever harmed or threatened to harm the patient or his or her children.
Let patient know that there are options. Reinforce the idea that victims do not cause nor
deserve the abuse.
DO NOT ask a patient why he or she does not leave the abuser.
DO NOT change your course of action because a patient does not admit to abuse.
Healthcare workers' responsibilities include:
Screening all patients for signs of abuse
Documenting all findings including the victim's statements
Ensuring domestic violence information is available in waiting areas and rest rooms
Knowing the options and inform the patient of options.
Making referrals, as indicated.
Options for victims include:
Pressing charges to have the abuser arrested
Obtaining an injunction or restraining order against abuser (the purpose of the restraining order
is to prevent the abuser from communicating or associating with the victim)
Going to a safe house or women's shelter for protection and accommodations
Going back home.
Getting help when ready.
BE CAUTIOUS about giving the victim a phone number to call for help. The abuser may find it and respond abusively. Instead,
help the victim memorize the number, tell her how to find the numbers for help, or tell her the names of organizations she
can look up in the phone book when it is safe. If the abuser seeks help, follow the hospital policy on spouse abuse and refer
him or her to treatment centers for help. There is also help for substance abuse.
Accident Prevention
The worker's role in hospital safety
Each worker has a personal responsibility in recognizing safety hazards and preventing accidents in the
hospital.
Actions that help you to be a responsible worker include:
Have your eyes checked regularly. Your sense of sight helps you to be aware of safety hazards.
Come to work well rested. When you are tired, you are more likely to be careless or miss seeing
a hazard.
Don't be in too much of a hurry. Take smaller steps and watch for warning signs such as "WET
FLOORS." If you have to walk on a wet floor, take it easy.
Keeping the hospital safe is everyone's job.
Causes of accidents
When people come to a hospital, they expect to be safe. But accidents can happen.
Possible causes of accidents in the hospital are:
Wet floors or puddles
Standing on an unstable object (such as a rolling chair) to reach something on a high shelf
Burned out lights in stairwells and hallways
Cords stretched across the floor and boxes or carts cluttering walkways.
Accidents can be prevented if workers recognize hazards/causes and respond to them.
How to prevent accidents
Most accidents can be prevented if you do one of two things:
1. REMOVE the problem
2. REPORT the problem
If you REMOVE a problem, it is eliminated or taken away so that it will not cause an accident for you or
anyone else.
If you see a problem that you cannot remove, call or contact the appropriate department about the
problem. Once you REPORT it, someone will remove the problem.
Some examples of how you can prevent accidents are:
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Page 16 of 284, Accident Prevention
If you see a puddle and wipe it up before someone slips, you REMOVE the problem. If the
puddle is too large to easily wipe up, you should REPORT it to your Housekeeping or
Environmental Services Department.
If you see a burned out light, REPORT it. Proper lighting is important in areas such as stairwells,
loading docks and parking areas.
REMOVE or REPORT extended cords and other objects such as boxes, books or equipment to
keep walkways clear and safe.
REPORT any hazard immediately. Do not assume that someone else has reported it.
Advance Directives
What are "advance directives?"
Recent advances in healthcare have resulted in extended life expectancies. However, some people DO
NOT want an extended life if the quality of that life would be severely diminished. To enable people to
indicate their wishes for future healthcare before they become incapacitated, an "advance directive"
may be written.
The Patient Self-Determination Act of 1990 dictates that all patients entering the healthcare system
(including home health, nursing homes, hospitals, etc.) must be given the opportunity to complete an
advance directive document and have it on file. The document defines the patients' preferences in endof-life decisions or at any time that they are unable to convey their own wishes regarding healthcare.
Advance directives are voluntary and are supported by the Patient's Bill of Rights (item 4).
There are two types of advance directives:
Living Wills
Healthcare surrogates
Living Wills
Living Wills give direction about medical care, or limitations to medical care, that patients desire when
there is no hope of recovery and they are unable to make their needs known.
Healthcare surrogates
Healthcare surrogates are persons who have the legal right to direct the care of patients who are unable
to make informed decisions.
Each state has its own laws pertaining to advance directives, but they are similar in all states. An
advance directive signed in one state will be honored in another.
Patients entering hospital should be told about advance directives and, if they do not have one, they
should be provided with the opportunity to complete one. Patients should also be informed that
advance directives may be changed (by the patient) at any time. If patients complete advance directives
or have already prepared advance directives, copies must be placed in their charts and staff must be
made aware of them. Patients must understand the importance of providing copies to families, doctors,
healthcare surrogates and hospitals so their wishes are honored. Advance directives are NOT intended
to be secret documents.
What is a Living Will?
A "Living Will" is a document that gives direction about the medical care, and limitations of medical care,
desired by the patient when he or she is either in a permanent vegetative state with no hope of
recovery or has an imminently terminal condition AND is unable to make his or her needs known (for
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Newborns (0-1 month) display reflex movements and respond to stimulation. One example of a
reflex is the newborn grasping a finger when it touches the palm of his/her hand.
Infants (1-12 months) experience pronounced physical changes and growth. During this time
they triple their birth weight, develop gross motor skills that enable them to walk (with or
without help), and begin to develop fine motor skills such as picking up things using their
forefinger and thumb (pincer grasp).
Toddlers' gross motor skills develop as they become more balanced on their feet. Children at
this age (1-3 years) can walk, jump, catch, and roll a ball. Their fine motor skills increase as they
attempt to balance blocks and draw circles.
The changes in gross and fine motor development experienced by preschoolers (3-6 years)
improve their ability to walk, run, jump, and hop. Their control of a pencil or crayon improves.
In school-age children (6-12 years) athletic abilities and eye-hand coordination are well
developed. They can participate in and enjoy team sports.
The adolescent (12-20 years) experiences greater physical growth than at any other time apart
from infancy. Muscle development increases in both sexes, and puberty begins with the
development of hormones.
Young adults (20-45 years) are generally as fit and healthy as they will ever be. During the
middle adulthood (45-65 years), many people become aware of the gradual changes occurring
in their bodies - signs of the aging process.
Seniors (65 years and older) experience a continuation and acceleration of the body changes
that began during the middle adulthood stage. Thinning and graying of hair, appearance of
wrinkles, and a general decline in the efficiency of some body systems are more pronounced in
seniors.
All of the development stages described in this module refer to typical individuals of each group.
There may be substantial variation between individuals within the "normal" range.
All of the development stages described in this module refers to typical individuals of each
group. There may be substantial variation between individuals within the "normal" range.
Safety Concerns
Safety concerns for newborns, infants, and toddlers
Safety needs are based on physical abilities, judgment and intellectual skills. Parents, or other adults, are
responsible for the safety of newborns, infants, and toddlers.
Safety concerns for newborns, infants, and toddlers fall into the four main areas:
1. Falls
2. Car safety
3. Choking or suffocation
4. Burns and scalds
The newborn (0-1 month)
Falls:
Hold newborn babies firmly and support their heads.
Keep one hand on the baby when on a table, scale, or bed.
Ensure crib rails are up and secured whenever baby is left in crib.
Car safety:
Use a rear-facing car seat designed for newborn babies.
Place the car seat in the middle of the back seat, when possible.
Never place a baby's car seat in a seat fitted with an airbag.
Burns and scalds:
Do NOT use a microwave to heat formula.
Always test bottle temperature on the inside of your wrist.
Always test bath temperature with the inside of your wrist.
Protect babies from sunburn by using shade, suitable hats and clothing, and approved sun
protection.
Choking or suffocating:
Lay babies on their backs or sides to sleep (not stomachs) to reduce the risk of Sudden Infant
Death Syndrome (SIDS).
Hold the bottle when feeding a baby; do not "prop" a bottle.
Keep plastic bags away from babies.
Never tie anything around a baby's neck (pacifiers, etc.).
Avoid clothing with strings or other objects that may get into the mouth.
Do not allow baby to lie on a beanbag seat or cushion.
Do not place stuffed animals or other toys in the baby's crib.
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Ensure crib rails are up and secured, or transfer the toddler to a low bed.
Use gates to block stairs at top AND bottom.
Secure outside doors with locks that are out of reach.
Ensure playground supervision.
Car safety:
Use a forward-facing child's car seat.
Place the car seat in the middle of the back seat, when possible.
Never place a toddler seat in a seat fitted with an airbag.
Burns, scalds, and electrical hazards:
Keep matches, lighters, candles and oil lamps out of reach.
Always test bath temperature with the inside of your wrist.
Keep electrical cords and appliances out of reach.
Install covers on electrical outlets.
Use sunscreen if toddlers will be exposed to sunlight.
Choking, suffocating, and poisoning:
Stay with a toddler in the bath; never leave a toddler unsupervised in the bath.
Keep all small objects out of reach.
Keep plastic bags away from toddlers.
Avoid foods that could cause choking, such as hard candy, nuts and grapes, whole wieners or
hot dogs (cut wieners into small pieces lengthwise), lollipops, etc.
Keep all medicines in a locked cupboard.
Keep all cleaning supplies and other poisonous materials locked up or well out of reach.
Remember, adults are responsible for the safety of newborns, infants and toddlers.
Stranger awareness
Avoiding adverse drug reactions (common when a person has more than one physician and/or
uses over-the-counter medications)
Preventing elder abuse (reporting suspicious situations and providing relief when caregivers
become overwhelmed or frustrated).
Remember, adults are responsible not only for their own safety, but also for the safety of seniors.
Beginning care by performing tasks the toddler will object to the least (for example, examine
fingers or toes before the chest or head)
Allowing the toddler to handle the equipment (such as a stethoscope) whenever possible
Being honest with both the toddler and parents when explaining what is about to happen
Providing the toddler with very simple explanations about what is going to happen, just before
the event
Providing the toddler with choices when possible (for example, showing two pairs of pajamas
and asking which pair the child wants to wear)
Educating the parents that it is normal for a sick child to suffer some developmental regressions,
but that he or she will catch up
Providing stimulating toys and games, such as dolls, musical toys, hide and seek, stacking toys,
balls, push toys and being read to for up to 15 months old; rocking horse, shape sorting, crayons
and paper, running and chasing games for up to 18 months old; modeling clay, finger and brush
paints, tapes and follow along story books, songs and puppets for up to 24 months old; and, play
with other children, building toys, drawing, painting, nurse and doctor kits and imitation
household objects for up to 36 months old.
Being sensitive to concerns about the implications of hospitalization on their jobs and families
Allowing adults to verbalize their fears and worries
Being aware of emerging vision or hearing deficits
Involving adults in their care as much as possible
Providing adults with choices whenever possible
Remembering that competent adults have the right to choose or refuse treatment
Involving family members as much as possible
Including adult patients and their families in instruction and teaching activities
Providing information about healthy nutrition and the importance of regular exercise
Recognizing that physical impairment may be due to various factors including age, illness, or
inappropriate medication
Providing information about risk factors related to chronic diseases, such as preventing
complications of chronic diseases and reducing the risks
Providing information on advance directives.
Back Safety
Anatomy of the back
Your back or spinal column is the main support structure for your body. It carries most of the body's
weight and is the main pathway of the nervous system. The back is composed of 24 moveable bones
called vertebrae. Each vertebra is separated from the next by a cushion-like pad called a disc that
absorbs shock. The vertebrae and discs are supported by ligaments and muscles that keep the back
aligned in three balanced curves. These three natural curves form an S-shape when your posture is
correct.
A healthy back is a balanced back - your neck, chest and lower back curves are all properly aligned. You
know your back is aligned properly when your ears, shoulders, and hips are in a straight line. Anything
that forces the back out of its natural S-shape can strain the muscles and damage the discs. When any
part of the back becomes diseased or injured, back problems and pain are almost certain to follow.
Causes of back injury
Back injuries are one of the most common types of injuries in the workplace and also one of the most
common reasons that people miss work. One study showed that 50-70% of all workers will have some
kind of lower back pain at least once. A single back injury can affect you for the rest of your life. Besides
the pain it causes, the injury can also keep you from doing many of the things you like to do.
Back injuries happen when you:
Lift things that are too heavy - INSTEAD, you should get someone to help or use a cart or dolly to
move heavy objects
Twist back muscles - INSTEAD, you should always turn your body to face the object you want to
lift even if it isn't heavy
Bend at the waist to lift - INSTEAD, you should bend at the knees letting the stronger muscles of
your legs do the lifting
Use back muscles instead of leg muscles to lift - INSTEAD, you should get close to the object you
want to lift using your leg muscles to do the lifting
Pull heavy objects - INSTEAD, you should push objects such as rolling beds or stretchers, using
your leg muscles.
Techniques to protect your back
Many back injuries happen when people lift things incorrectly. Here are some pointers about lifting
safely.
DO:
DO NOT:
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Mouse
Place the mouse at the same height as the keyboard and close to the keyboard to avoid reaching and
shoulder stress. Use the keyboard rather than the mouse when possible. Keyboard shortcuts are
available to replace many mouse actions and thereby reduce the stress on arms and shoulders.
Support for work tasks
There are tools to help prevent injuries in the office and to help you do your job well.
Several support tools are available:
A document holder is used to place documents close to the computer screen and at the same
height and distance as the screen. A holder decreases stretching and reaching.
A wrist rest can be used to rest the palms of your hands when you are not typing.
A cradle that holds the phone and supports it on your shoulder should be used if you often tuck
the phone between your ear and shoulder. The cradle keeps your ear and shoulder in alignment.
Use carts or dollies to carry heavy objects when possible.
End of Back Safety Lesson
Bioterrorism
What is bioterrorism?
Bioterrorism is the intentional use of biological agents to harm or kill civilian populations and cause fear.
Biological agents are bacteria and viruses that produce disease. These diseases are spread through
person to person contact or through other mediums, such as:
Powders
Sprays
Water or food.
Another type of terrorism you should be aware of is chemical warfare. Chemical warfare uses chemical
agents, instead of biological agents, to harm or kill.
There is a real risk of terrorism
Although at least 11 different nations have experimented with biological and chemical weapons, we
have traditionally thought that they would never be used. The reasons for this thinking were:
Countries have seldom used such weapons before
Use of such weapons is morally distasteful
Sophisticated labs are needed to produce and deliver such weapons
The destructive potential is too great.
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The smallpox rash moves from the face and extremities inwards to the trunk.
The smallpox rash is different from the typical chickenpox rash. The chickenpox rash begins on the face,
upper trunk, and shoulders and spreads to the extremities. There may also be different stages in one
area at the same time. For example, an extremity may have some new lesions and some scabbed over.
The smallpox rash starts on the face and extremities and moves inward to the trunk. All lesions in one
area will be at the same stage.
Responding to the Threat of Bioterrorism
Recognizing potential terrorist activity
People who are injured or who become sick as a result of biological or chemical terrorism will come to a
medical facility for treatment. Initially, it might be that no one will know that a terrorist attack has
occurred--even the victim.
The hospital, especially the emergency department, may be the first place to identify that an attack has
occurred.
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Because a WBC infusion induces fever and chills, administer an antipyretic if fever occurs. Don't
discontinue the transfusion; instead, reduce the flow rate, as ordered, for patient comfort.
Agitate the WBC container to prevent settling, thus preventing the delivery of a bolus infusion of
WBCs.
Platelets
Use component drip administration set to infuse 100 mL over 15 minutes. As prescribed, premedicate
with an antipyretic and an antihistamine if the patient's history includes a platelet transfusion reaction.
If the patient has a fever before administration, notify the practitioner for probable delay of the
transfusion.
FFP
Use a straight-line I.V. set, and administer the infusion rapidly.
Albumin
Use a straight-line I.V. set with rate and volume dictated by the patient's condition and response.
Albumin is contraindicated in severe anemia. Keep in mind that albumin is contraindicated in patients
with severe anemia. Use caution when administering to patients with cardiac or pulmonary disease due
to potential circulatory overload.
Factor VIII
Use the administration set supplied by the manufacturer. Administer with a filter; the standard dose
recommended for the treatment of acute bleeding episodes in patients with hemophilia is 15 to 20
units/kg.
Factors II, VII, IX, and X complex
Use a straight-line I.V. set, basing the dose on the desired factor level and the patient's weight.
Coagulation assays are drawn prior to administration and at intervals throughout treatment.
Post-treatment Care
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Change the blood or blood administration set and filter after each unit or as needed to ensure
sterility and/or system integrity.
If evidence of bleeding or reactivity develops at the I.V. site, discontinue the transfusion and the
IV and notify the prescriber. Follow your facility's policy for treatment of the reaction site.
Monitor I&O, and signs of fluid overload such as lung status and edema.
After completing the transfusion, adhere to standard precautions and remove and discard the
used infusion equipment in the biohazard material receptacle. Reconnect the original I.V. fluid, if
necessary, or discontinue the I.V. infusion.
Return the empty component bag to the blood bank, if facility policy dictates.
Prepare to draw blood for a platelet count, as ordered, 1 hour after platelet administration to
determine platelet transfusion increments.
Keep in mind that large-volume transfusions of FFP may require correction for hypocalcemia
because citric acid in FFP binds calcium.
The half-life of factor VII is 8 to10 hours, which necessitates repeated transfusions at specified
intervals to maintain normal levels.
Patient Teaching
Teach the patient to immediately report the following complaints to the nurse:
o Flushing, feverish feeling, chills, nausea, headache (transfusion reaction)
o Palpitations (with hypotension, arrhythmia, and shaking chills; may be sign of
hypothermia)
o Difficulty swallowing or breathing (possible anaphylaxis)
o Tingling in the fingers, muscle cramps, nausea and vomiting, faintness (with
hypotension, arrhythmia, and seizures; may signal hypocalcemia from citrate toxicity or
liver impairment)
o Intestinal colic, diarrhea, muscle weakness (with irritability, oliguria, T-wave changes on
the electrocardiogram, and bradycardia; may signal hyperkalemia from large-volume
transfusions).
Inform the patient that specimens may be drawn to evaluate the effectiveness of therapy.
Hypoxemia
Rales
Orthopnea
Tachycardia
Jugular venous distention
Crackles at lung bases
Dependent edema
Bacterial contamination
Though blood products are tested carefully, infections cannot always be detected, especially where the
donor was infected shortly before giving blood. Treatment is as for any sepsis.
Symptoms
High fever
Chills
Vomiting
Diarrhea
Marked hypotension
Weak pulse
Hemolytic reaction
Subtle mismatches between host and donor blood (as well as occasional treatment errors) can result in
the destruction of the donors red blood cells during or after the transfusion. Along with TRALI, this type
of reaction has the highest death rate.
The patient may experience vague anxiety or discomfort, dyspnea, flushing, back pain, or chest pressure.
Usually, this reaction starts as general discomfort or anxiety during or immediately after the transfusion.
Severe shock can result, and this reaction can be fatal. As soon as this reaction is detected, the
transfusion is stopped and the patient is supported according to the symptoms. A delayed hemolytic
reaction can occur up to a month after transfusion, though these are usually mild.
Symptoms
Fever
Hypotension
Flushing
Wheezing
Anxiety
Red-colored urine
Disseminated intravascular coagulation (late)
The elements are all based on randomized controlled trials, what we call Level 1 evidence. Theyve
been proven in scientific tests and are accepted, well-established.
The elements in a bundle involve all-or-nothing measurement. Successfully completing each step is a
simple and straightforward process. Its a yes or no answer: Yes, I did this step and that one; no, I
did not yet do this last one. Successfully implementing a bundle is clear-cut: Yes, I completed the
ENTIRE bundle, or no, I did not complete the ENTIRE bundle. There is no in between; no partial credit
for doing some of the steps some of the time.
Bundle changes also occur in the same time and space continuum: at a specific time and in a specific
place, no matter what. This might be during morning rounds every day or every six hours at the patients
bedside, for instance.
Example 1: Central Line Bundle:
This is a set of five steps to help prevent catheter-related blood stream infections, deadly bacterial
infections that can be introduced through an IV in a patients vein supplying food, medications, blood or
fluid. The steps are simple, common sense tasks: using proper hygiene and sterile contact barriers;
properly cleaning the patients skin; finding the best vein possible for the IV; checking every day for
infection; and removing or changing the line only when needed.
Example 2, Ventilator Bundle:
Ventilator-associated pneumonia (VAP) is a serious lung infection that can happen to patients on a
ventilator. The Ventilator Bundle has four care steps: raising the head of the patients bed between 30
and 40 degrees; giving the patient medication to prevent stomach ulcers; preventing blood clots when
patients are inactive; and seeing if patients can breathe on their own without a ventilator.
Whats the difference between a bundle and a checklist?
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The physician, nurse practitioner, physician assistant, or other designated person must explain the
procedure, expected benefits, alternatives to the procedure and the risks. The treatment or procedure is
fully discussed, and the patient is given the opportunity to ask questions and make decisions.
Signing a consent form must be a voluntary process. After signing the consent, patients still have the
right to refuse a treatment or procedure.
Health care workers must know their responsibilities in the consent process and must support the
Patients' Bill of Rights and the ethical principles in healthcare. Their responsibilities in the consent
process are crucial to the patient's treatment, procedures, and healthcare services.
The physician, nurse practitioner, physician assistant, or designated person is responsible for explaining
the procedure, its implications, expected benefits and risks, and alternatives to the procedure. The
treatment or procedure must be discussed fully to satisfy the patient's or guardian's needs. The patient
must be given the opportunity to ask questions and make decisions.
The witness should ask questions to verify that the patient or guardian understands the procedure. The
witness is NOT responsible for explaining the procedure or treatment. If the witness determines that the
person signing the consent does not understand the form or the procedure, the witness MUST NOT
allow the form to be signed and must notify the person who will be doing the procedure. If the patient
or guardian signs the form with an "x", the witness must document the reason why the signature is an
"x".
End of Consent for Treatment Lesson
Corporate Compliance
Ethical Business Practice
What is corporate compliance?
Corporate compliance refers to comprehensive programs of internal control designed to prevent and
detect fraud and abuse within healthcare facilities. The goal of compliance programs is to create an
atmosphere within the facility that promotes ethical conduct according to State and Federal laws and
operational standards required by insurance companies. Fraud and abuse are prosecuted under the
False Claims Act with heavy fines attached to each offense.
The Department of Justice has made healthcare fraud a high priority, second only to violent crime.
Increased resources have been allotted and efforts are ongoing to detect fraud and abuse within
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Standards of conduct
A facility should have comprehensive written standards of conduct and other policies that promote the
group's commitment to compliance.
Responsibility
It is essential that a facility designates a compliance officer or have a particular person responsible for
implementing and monitoring the compliance process.
Internal reporting mechanism
A facility should have an internal reporting system for receiving complaints and suspected problems.
Employees should feel comfortable about making a report when necessary and not fear retaliation for
doing so.
Education and training
A facility must provide education and training for all staff that is tailored to the demands of the
compliance process and meets current federal requirements. Priority should be given to risk areas that
have been identified. Training materials should be continuously updated as federal requirements
change.
Internal policing
A facility must have auditing systems to monitor the effectiveness of the compliance process. The
auditing system should include employee interviews, chart reviews, and prospective billing audits.
Discipline
A facility must have mechanisms for enforcing compliance programs and disciplining employees. Finding
problems does not indicate ineffectiveness, but failing to correct problems and failing to take action to
prevent further occurrences will severely weaken a compliance program.
Evaluation and modification
A facility should implement a program of modifications to prevent future offenses. Self-evaluation is
necessary to determine weaknesses and correct processes.
Each element of a compliance program should be documented. Written reports are important and
should include all policies, minutes of compliance committee meetings, meeting attendance sheets,
training sessions, copies of training materials, employee screening reports, disciplinary reports,
enforcement measures, and evaluation and modification of procedures.
Discovery of Fraud
What is fraud?
Fraud is an intentional deceptive act done for unfair or unlawful gain. Examples of healthcare fraud
include:
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Deliberate overcharging
Unnecessary home health visits to obtain reimbursement
Unnecessary procedures done for financial gain.
Giving false information for gain is also fraud. Examples of false information for gain include:
Duplicate billing
False codes on healthcare visits or procedures to obtain a higher reimbursement
Claims for reimbursement of home health visits that were not made
False reports.
Fraud does not include acts that are honest mistakes. Mistakes can occur in billing and there can be
reimbursement discrepancies but neither is fraud.
What to do if you suspect fraud
The federal Child Abuse and Prevention Treatment Act (CAPTA) defines child abuse and all employees
have a duty to report cases of fraud. It is also important that you alert your organization to cases that
could look like fraud. After being alerted, the organization can solve the problems, and avoid legal
accusations of fraud.
To be able to report fraud, you should know that:
Your organization has a policy and procedure for reporting suspected fraud
You may need to contact a specific person, and/or dial a hotline number
You cannot be penalized by your organization for reporting suspected fraud.
How to prevent fraud and suspicions of fraud
Mistakes such as simple billing errors and reimbursement discrepancies occur and, although not fraud,
must be investigated to prevent future errors and to ensure that fraud is not intended. Prevent all errors
that could possibly appear as fraud or raise the suspicion of fraud.
If your job involves billing, charging, or coding:
Learn the policies and procedures, and then follow them
Document your work accurately
Seek training if you do not understand how to do tasks
Take advantage of training opportunities that will help you do your job better
Be thorough and ask for help if needed
Treat all customers and patients courteously
Always give customers and patients accurate information
Cooperate in internal audits - they are in place to discover and then correct problems.
End of Corporate Compliance Lesson
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Cultural Competence
What is cultural competence
Cultural competence is the ability to effectively communicate with people of different cultures, and to
embrace cultural diversity among those with whom you interact. Understanding the terms culture and
diversity are key to an understanding of cultural competence.
Culture
Culture is a way of life. It is the knowledge, beliefs, and values of an ethnic or religious group, nationality
group, or social group. Culture guides the groups' thoughts, decisions, and actions. The customs of each
culture are learned and passed from one generation to another.
Diversity
Diversity is variety. It is the human qualities that are different from our own and the groups to which we
belong but are present in other individuals and groups. Diversity can be divided into two sub-categories:
The primary category includes things that we cannot change such as age, ethnicity, physical
abilities, race, and sexual orientation.
The secondary category includes things that can be changed such as educational background,
geographic location, income, marital status, military experience, parental status, religious
beliefs, and work experiences.
Cultural diversity
Cultural diversity refers to the differences between cultural groups and within cultural groups. For
example, diversity within the Asian-American culture includes Korean Americans and Japanese
Americans.
Cultural differences can be found throughout our country. For example: the popular sandwich made
from a small bread roll and filled with a variety of meat, cheeses, and vegetables might be called a sub,
submarine, poor boy, hoagie, grinder or foot-long depending on which area of the country you are in.
The influence of culture on behavior
All cultural groups have certain customs, normal behaviors, beliefs, superstitions, and language that
guide how they:
Live
Make decisions
Face a crisis
Communicate
Structure their society
Prepare food and eat
Celebrate holidays
Dress.
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The extent to which someone's cultural background influences their behavior is dependent on factors
such as:
Gender
Sexual orientation
Class
Education
Status within the family
Immigrant status.
Examples of how culture influences behavior are:
A Russian woman who has only been in the United States for a month and does not yet
understand English will behave differently than a Russian woman who was born and raised in
the United States even if she were raised learning Russian customs and language.
People of all cultures have a "comfort zone" that determines how close they allow someone
they don't know well to stand next to them. If someone gets too close, they feel uncomfortable.
Cultures such as those in South American countries have a "small" comfort zone. If someone
whose culture has a "wide" comfort zone meets with someone from South America who stands
too close, the behavior of the South American may be incorrectly interpreted as being
aggressive.
Prejudice and stereotyping
The United States is a country of very diverse cultures. Its citizens come from 120 different countries
with many different languages, religions, and customs. Not understanding how culture affects the way
people act often results in prejudice and stereotyping.
Prejudice is a premature judgment; a positive or negative attitude or opinion about a person or group
that is not based on facts. Prejudices may also result from an emotional experience with a person from a
similar culture or group. A person who thinks or says, "I don't want Hispanics living in my
neighborhood," is expressing a prejudice.
Prejudices are usually based on stereotypes which are over-simplified and over-generalized views about
individuals or groups of people who belong to a different religion, race, nationality, or other group. They
involve strong feelings that are difficult to change. Stereotypes also provide us with role expectations
such as how we expect the other person or group to relate to us and other people. It is important NOT
to over-generalize the characteristics of a culture and use them to label an individual within that cultural
group.
Examples of stereotypes in our culture are:
"Leaders are dominant, arrogant men"
"Housewives are nice but empty-headed"
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There may be some articles of clothing, religious medals, holy pictures, icons or other objects
that are important to a patient. Whenever possible, allow him or her to keep these at the
bedside.
If litigation is brought about, it is the patient's chart that is used to "tell the story." Therefore, it must
reflect accurately the patient situation. A patient's record is generally admissible as evidence. And
again, "If it isn't charted, it wasn't done."
State hospital licensing laws and regulations and The Joint Commission standards specify required
documentation. Other accrediting bodies may have documentation guidelines for other settings, such as
long term care, home health, clinics, etc. Most of the guidelines are applicable to all settings.
Documentation should be as quantitative, i.e., measurable, and as factual as possible. Don't chart, "Pt.
fell out of bed," unless you actually witnessed the event. Instead describe what you observed when you
arrived on the scene. If staff or visitors provide information, chart the source of information as well.
Avoid stating personal feelings about the patient. Don't say, "Mr. Jones is bullheaded, obnoxious, and a
pain in the rear end. Instead describe Mr. Jones' behaviors as factually as possible.
Documentation should be as timely as possible. Facts are less likely to be omitted when charting is done
throughout the shift. This is of particular importance when recording changes in condition, medications,
calls to physicians, procedures, etc.
Your documentation should be legible and accurate. Handwriting that is difficult to read creates a
negative impression. It is necessary that the author be able to read what she has written years later.
Reflect on what you really mean. Be sure that you use abbreviations that are approved by your
institution.
Ultimately, rigorous documentation is for the benefit and protection of your patient, you, and your
employer.
Documentation Guidelines
The 5 C's of documentation are to be Correct, Complete, Concise, Consistent, and Cautious. Here are
some specific guidelines to follow:
Use military time. This eliminates guesswork - is it 7:00 p.m. or a.m.?
Write legibly.
Use black permanent ink for entries.
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Though this is an amazingly large list of guidelines, you can remember them easily with the following
mnemonic: DOCUMENT CORRECT COMPLETE CONCISE CONSISTENT AND CAUTIOUS. (Just kidding. Even
Shakespeare couldnt come up with a mnemonic for that mess. There are no shortcuts to good
documentation. It takes practice and fastidious attention to detail.)
Flow sheets are designed to streamline the documentation process. However, flow sheets are only as
good as the information that is listed on the flow sheet. Flow sheets should be developed with the
staff's involvement and be periodically reviewed to assure that they represent the needs of the unit.
Come to work free of alcohol or other drugs that could affect judgment or performance.
Do not use drugs or alcohol on the job.
If you suspect you have a problem, get help.
If you suspect a co-worker has a problem, speak to your supervisor.
Drug or alcohol abuse can be detected if you are aware of the signs.
Signs of drug or alcohol abuse include:
Frequent absenteeism or lateness
Changes in work habits (for example, an organized person becomes disorganized)
Mood changes (for example, a person suddenly becomes difficult to work with)
A decrease in productivity (for example, not getting things done)
An increase in workplace accidents
Mistakes on the job.
Substance abuse self-test
Do you have a problem with substance abuse? How would you know? Take the self-assessment test.
Although this type of test is not 100% reliable, it may be useful in indicating whether you should get
help.
Self-assessment test
Has anyone ever questioned you about your alcohol or other drug use?
Have you ever used alcohol or other drugs alone?
Have you ever missed work because you were sick from using too much alcohol or other drugs?
Have you ever had trouble stopping once you started using alcohol or other drugs?
Have you ever had legal problems because of your alcohol or other drug use?
If you can't use alcohol or other drugs, do you get jumpy, shaky, cranky, nervous, or have
cravings?
Are you in debt because of your alcohol or other drug use?
Does it now take more alcohol or other drugs to get the same effect?
Have you ever used alcohol or other drugs in the morning?
Have you ever been in the hospital as a result of your drinking or drug use?
Have you ever used alcohol or other drugs at work?
If you answered "Yes" to one or more of these questions, you might have a problem with abuse or
addiction.
If you have never taken drugs, don't start.
If you think you may have a problem with drug or alcohol abuse or addiction, get help. The earlier you
get help, the better. Addiction is a disease that can be controlled with treatment, but you will need help.
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Electrical Safety
Electrical conductors and insulators
Understanding the difference between conductors and insulators helps to explain how people can safely
touch an electrical cord while equipment is turned on and why damaged cords are dangerous.
Materials that allow electricity to move through them are known as conductors. Conductors include:
Metals such as copper, silver, gold, aluminum, and iron
Liquids such as water, saline, blood, and urine
The human body.
Insulators are materials that do not let electricity move through them. Examples of insulators are:
Rubber
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Glass
Dry cloth
Paper
The ground
Wood.
An electrical cord is made of wires that are conductors (usually copper), which are covered with an
insulator, such as rubber. People can safely touch an electrical cord while equipment is turned on
because the insulator stops electricity from traveling outside the cord.
If the wires are not covered or the insulator is damaged, and the equipment is turned on, you can
receive a shock or injury.
Electricity follows a path
Electricity travels down wires from an electrical source (the wall outlet) to the electrical equipment and
back again to the electrical source. This path that the electricity follows from the outlet to the
equipment and back to the outlet is called a circuit. If there is damage at any place in the circuit,
electricity can leak out.
Three wires make up the circuit.
The first wire, called the lead wire or the hot wire, conducts the electricity from the outlet to the
equipment.
A second wire conducts the electricity from the equipment back to the outlet.
Cords that have a third pin on the plug, have a third wire that conducts any stray electricity from
the equipment to that pin. The third pin is called the ground pin and it is a safety feature. It
allows excess electricity to return to the earth, which is an insulator.
The three wires in an electric cable are the hot wire, the return wire, and the ground wire
Electricity leaking from a broken electrical cord can cause a fire if it is near flammable material. The
leaking electricity can also cause electrical shock or injury to people.
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DO NOT roll beds, wheelchairs, or other equipment, over an electrical cord. This can break the wires and
damage the cord.
Safe electrical plugs
All electrical plugs should have three pins or prongs. The third pin, called the ground pin, is a safety
feature. It allows excess current or leaking electricity to return to the earth. The ground pin is shaped
differently from the other two.
Cheaters are plug adaptors that have two pins to plug into the wall outlet. A plug with three pins fits into
the other end of the adaptor. The adaptor therefore cheats the three-pinned plug (by making it twopinned) and cheats people of the ground pin safety feature. Never use cheaters.
Rules about electrical plugs to protect you, other employees, patients, and visitors from harm:
DO:
DO NOT:
Use plugs with broken pins or with only two pins.
Pull on an electrical cord to unplug equipment. Pulling can damage the cord.
Use cheaters. Cheaters are adaptors that convert three-pin plugs into two-pin plugs.
Emergency Preparedness
Emergency Codes
Though healthcare organizations universally use emergency codes, there is no universally accepted
standard for those codes. The Hospital Association of Southern California has made the following
recommendations for standard coding. These may or not be the case at the organization at which you
work, but all of most of these are commonly employed at most healthcare entities. Know the codes for
your organization.
RED for fire
BLUE for adult medical emergency
WHITE for pediatric medical emergency
PINK for infant abduction
PURPLE for child abduction
GREEN for patient elopement
YELLOW for bomb threat
GRAY for a combative person
SILVER for a person with a weapon and/or hostage situation
ORANGE for a hazardous material spill/release
TRIAGE INTERNAL for internal disaster
TRIAGE EXTERNAL for external disaster
Types of Emergencies
Be prepared!
The hospital has specific plans to be followed for different types of disasters. When casualties begin
arriving, do you know what your role is? What procedures should you be following during this crisis? The
time to prepare is before a disaster occurs.
In order to be able to properly care for injured people while continuing to care for the patients already
in hospital when a disaster strikes, the hospital needs to be prepared for any type of emergency or
disaster.
A disaster is any type of situation (event) that involves large numbers of injured people being
admitted for emergency treatment.
To prepare for a disaster, THE JOINT COMMISSION standards require health care facilities to
conduct two disaster drills each year.
At least one of these drills has to be an "external disaster" drill that includes patients coming
into the facility from outside.
While participating in a drill, everyone should treat it as if it were "real".
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Types of disasters
Emergencies or disasters can be classified as either "internal" or "external."
An internal emergency is one that directly involves the facility and is a threat to the staff and patients,
such as an in-house fire, a toxic chemical spill, or a natural disaster such as a tornado, earthquake, or
hurricane that causes damage to the facility.
An external emergency is one that occurs outside of the facility and does not directly threaten the staff,
patients and others inside the building(s). The indirect effect on the facility is the possibility of large
numbers of casualties arriving for treatment. External disasters include such things as:
Accidents involving buses, trains, airplanes or multiple vehicles
Explosions
Chemical spills
Large fires
Violent incidents involving a large group of people
Natural disasters occurring outside the facility such as tornadoes or floods.
Weather watches and weather warnings
Staff can plan for potential emergencies by responding to weather service forecasts of severe weather.
The weather service uses the terms WATCH and WARNING to describe the chance for a particular type
of weather hazard to occur in the area. A weather WATCH is a forecast that weather conditions are
favorable for a particular type of weather hazard to form. For example, a tornado watch means that the
environmental conditions are favorable for the formation of tornados.
The term "WATCH" may also be used to describe severe thunderstorms, winter storms, heavy snow, and
flash floods. When used to describe a hurricane or tropical storm, it means that there is a chance that a
hurricane or tropical storm could strike the area within 24-36 hours. A tropical storm indicates a storm
with sustained winds between 39 and 73 mph and hurricanes involve even stronger sustained winds:
Tropical storm: sustained winds between 39 and 73 mph
Category 1 hurricane: sustained winds between 74 and 95 mph
Category 2 hurricane: sustained winds between 96 and 110 mph
Category 3 hurricane: sustained winds between 111 and 130 mph
Category 4 hurricane: sustained winds between 131 and 155 mph
Category 5 hurricane: sustained winds over 155 mph
A weather WARNING is more serious than a weather WATCH. It means that a particular weather hazard
has actually been observed and threatens the area over which the warning is issued. For example, a
tornado WARNING means that a funnel cloud has actually been spotted. Warnings are used to describe
hazards such as tornadoes, severe thunderstorms, winter storms, heavy snow, and flash floods.
Click here if you'd like to explore more maps and information from the USGS.
The seriousness of an earthquake is dependent upon its magnitude and intensity.
The magnitude of an earthquake is a measure of the size of the earthquake and is not dependent on the
location or the amount of shaking caused. Seismographs measure magnitude.
The intensity of an earthquake is a measure of the amount of shaking caused and is dependent on the
location. The effects on people and property determine an earthquake's intensity.
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Most earthquakes go unnoticed. However, depending on magnitude and intensity, damage can range
from slight to devastating. As a worst case scenario example, it is estimated that an 8.3 magnitude
earthquake in Southern California would:
Cause severe damage as far as hundreds of miles from the center
Collapse buildings, including tall and modern buildings, and buildings of importance such as
schools, hospitals, and municipal services centers (though newer structures are built to
withstand earthquakes, many are vulnerable to an earthquake reaching a magnitude of 8 or
more)
Disrupt communication, water, power, and transportation for more than 24 hours
Cause landslides in vulnerable areas
Cause tsunamis (tidal waves)
Injure and kill thousands of people as a result of structural collapses (buildings, bridges, tunnels,
homes)
Before the Earthquake
A disaster such as an earthquake, for which there is no early warning system, often causes more
casualties because the victims have no time to prepare or to leave the area.
As a result, healthcare workers must know their facility's disaster plan. What will you do if an
earthquake occurs while you are at work or at home? Disruption of utilities and communications will
likely prevent you from using a phone to find out what to do. You must know and prepare in advance.
Healthcare workers in a high-risk earthquake area must also be aware of, and try to correct, any of the
following potential hazards in the work area:
Unanchored furniture and wall fixtures more than 42 inches high
Stacked furniture
Tall bookcases
Unanchored computers and equipment
Heavy items that are stored above floor level
During the Earthquake (until shaking stops)
Stay Calm
If you know what to do, you will find it easier to stay calm.
Stay Put
If inside, STAY inside.
If outside, STAY outside. Most people injured in earthquakes moved more than 10 feet once the
earthquake started.
Take Cover
If inside
o Move the shortest distance possible to a place of safety
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Rising water
If rising water is a problem, move patients to higher floor levels, if possible. Depending on the situation,
patients may need to be evacuated.
Emergency Response
Examples of disasters/emergencies
There are many different types of disasters and emergency situations. Examples include:
Meteorological disasters such as cyclones, typhoons, hurricanes, tornados, hailstorms,
snowstorms, and droughts
Topological disasters such as landslides, avalanches, mudflows, and floods
Disasters that originate underground such as earthquakes, volcanic eruptions, and seismic sea
waves
Biological disasters such as communicable disease epidemics and insect swarms.
Accidents involving transportation (planes, trucks, automobiles, trains and ships), structural
collapse (buildings, dams, bridges, mines and other structures), explosions, fires, chemicals
(toxic waste and pollution), and sanitation.
Civil disasters such as riots, demonstrations, and strikes
Criminal/terrorist action such as bomb threats or incidents, nuclear, chemical or biological
attacks, and hostage incidents
Conventional warfare, including bombardment, blockade, and siege
Non-conventional warfare such as the use of nuclear, chemical, and biological weapons.
Hospital preparation for disasters/emergencies
All organizations must have an emergency management plan or disaster plan so that patient care can
continue if a disaster occurs.
Hospital disaster/emergency management plans must:
Address both external and internal disasters
Include general activities that will occur no matter what the emergency situation
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Allow specific responses to the types of disasters the facility might face
Include a plan for evacuation of the hospital if all or part of the facility is damaged or nonfunctional.
If you hear a disaster announced over the hospital intercom or otherwise, activate the disaster
plan and follow your role.
If phone lines are down, your hospital may use the local radio station to notify employees.
Ethical Care
The Ethics Committee
A dilemma is usually an instance in which an undesirable or unpleasant choice must be made. An ethical
dilemma occurs when two principles of ethics "collide."
For example, an ethical dilemma may arise if a patient refuses chemotherapy against physician's advice.
Does the physician continue to care for the patient when he believes that continuing on this course will
lead to harm for that patient? The conflict arises between the patient's right of autonomy and the
physician's duty of beneficence - always to do what is best for the health of the patient.
An ethics committee deals with conflicts on principles of ethics. Your organization will have a policy or
procedure for convening the Ethics Committee to discuss ethical dilemmas. The committee will listen to
and discuss the problem, and provide recommendations. In most facilities, anyone can ask for an ethics
consultation.
Ethical Principals
Ethical care is care that helps preserve your patient's rights and well being. Accrediting bodies such as
The Joint Commission and CHAP require organizations to establish guidelines for patient, staff, and
physician involvement in ethical education and decision making.
Ethical Principals
The following ethical care principles are values and virtues that guide the behavior of healthcare
providers.
Autonomy: Derived from the Greek word autos (self) and nomos (rule or law), autonomy refers
to self-rule. In modern use, it has broad meanings, including individual rights, privacy, and
choice. It entails the ability to make a choice free from external constraints.
Beneficence: The duty to do good and the active promotion of benevolent acts (for example,
goodness, kindness, and charity.) May also include the injunction not to inflict harm.
Confidentiality: This principle relates to the concept of privacy. Information obtained from an
individual will not be disclosed to another unless it will benefit the person or there is a direct
threat to the social good.
Double Effect: The principle that may morally justify some actions that may produce both good
and evil effect. All four of the following criteria must be filled:
o The action itself is good or morally neutral
o The agent sincerely intends the good and not the evil effect (the evil effect may be
foreseen but not intended)
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Individuals provide ethical care according to their personal and professional codes of conduct and their
employer guidelines. Ethical issues and problems can occur during the provision of patient care. These
issues may involve:
Abuse and neglect
Advance directives
Pain management
Do Not Resuscitate (DNR) status
Patient competency
Noncompliance
Refusal of care
Abandonment
Privacy and confidentiality.
Ethical Decision-making
Ethical decisions are needed when there is a conflict involving a patient's request or behavior, and the
caregiver and organization's standard of care.
These conflicts result from the different points-of-view of the patient, the caregiver, and the
organization. These points-of-view incorporate each participant's sense of justice, moral development,
socialization, professional standards, and clinical experience. Organization's points-of-view are also
influenced by policies and procedures, regulations and legislation, and budget constraints.
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Fall Prevention
In every facility, accidents and problems sometimes occur. They are called "variances," and they can be
very minor or very serious. A large number of health care variances are related to injuries. In fact,
injuries are a much bigger problem than many people realize.
There are several different ways that patients can be injured, but the most common cause of injury is a
patient fall.
Facts about patient falls:
In one study, patient falls accounted for 70-80% of all hospital variances.
The majority of falls occur in patients aged 60-80.
10% of falls occur in patients who have fallen before.
The average cost of fall-related injuries is $29,800 per patient.
Total costs of fall-related fractures in the U.S. are more than $30 billion per year.
The effects of a patient fall can be very serious. Patients who fall are more likely to be admitted to a
nursing home and those who do return to their own homes are more likely to need home-care services.
A patient fall may also result in:
Longer hospital stays
Permanent injury
Disability
Death
Causes of falls
Most falls occur as a result of:
Poor communication among:
o Care team members,
o Patient and care team member,
o Patient friends and family and care team members
Patient changing position
Patient going to the bathroom
Call bell or equipment out of reach
Improper footwear
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Unsafe environment, e.g., obstacles on the floor between bed and bathroom
Fall risk
You can also learn to recognize patients who are at risk for falls. These include:
Infants and young children
Older adults
Sedated patients.
Infants and young children
These patients are immature, and they often do not understand what they should or should not do.
Their motor skills are still developing, so they can fall easily. They are also full of curiosity.
Older adults
The majority of falls occur in patients over 65 with the highest number in the 80-89 age group. These
patients may be unsteady on their feet. They may also have problems with hearing and eyesight.
Patients with altered awareness or level of consciousness
Either from dementia or medications, these patients are at high risk of falling. They often cannot
recognize dangers and may become confused.
Patient education can also help prevent falls. Teach patients and their families about:
The hospital environment
Potential hazards
Equipment being used.
Preventing falls
In light of the above causes, there are things you can do to help prevent patient falls:
Maintain a safe environment
Communicate patient fall risk to teammates and at change of shift
Orient patients and families to their surroundings
Show them how to use the call light and explain how and when to get assistance.
Ensure good lighting in rooms and bathrooms
Keep call bell in reach
Keep beds at a low height.
Make sure path to bathroom is clear
Bedrails
You should be careful to use bedrails only as stated in the policy of your facility. Research shows that the
improper use of bedrails increases the chance of patient falls because patients climb over them.
Restraint
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Fire Safety
Fire Hazards
Components of a fire
Fire is one of the biggest dangers in a hospital because of the large number of people who must be
evacuated. Before you can recognize fire hazards in a hospital, you must understand how a fire starts.
Three things are needed to start a fire:
Fuel
Heat
Oxygen
Fuel is anything that can burn. Examples of fuel are:
Paper
Rubber
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Cloth
Patients' personal care items (deodorant, hairspray, etc.)
When fuel becomes hot enough, it can ignite and burn. In the hospital, this heat can come from:
A cigarette butt
A hot electrical wire
A spark
Oxygen, the third ingredient needed to start a fire, makes up about 20% of the air.
A fire will keep burning as long as the fuel, heat, and oxygen are present. If you remove one of the
components, the fire will go out. It is usually easier to remove the heat or the oxygen than to remove
the fuel.
Potential fire hazards
Fire hazards are found in many areas of the hospital including:
Patients' rooms
Storage areas
The kitchen
Machinery and equipment areas.
Here are some specific examples of potential fire hazards:
Although smoking is not permitted in hospitals, patients or visitors sometimes ignore this rule
and smoke in the washroom, for example, cigarette butts may still be hot and if carelessly
tossed into a wastebasket may start a fire.
Misused or faulty electrical equipment (paper jammed in a printer or a coffee machines left
unattended for a long period, for example) can cause a fire and so can broken electrical cords or
any electrical equipment that is not working properly.
Flammable substances, such as hairspray and deodorant in aerosol containers can explode and
cause a fire if left too close to a source of extreme heat.
Fires can occur where a patient is receiving oxygen, if there is a spark or static electricity.
Cylinders that contain compressed gases such as oxygen, anesthetic, and ammonia are fire
hazards and must be handled properly and stored in well-ventilated, fireproof, dry areas with
controlled temperature.
How to respond to fire hazards
There are several ways you can respond to or prevent fire hazards:
Eliminate the hazard if you can do it safely. For example, store or dispose of flammable liquids,
such as paint thinner, properly. Unplug electrical appliances from overloaded sockets.
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Report hazards you cannot eliminate to your supervisor immediately. If you notice a leaking
sprinkler or a beeping smoke detector, report it.
Any spark in an oxygen-rich space can cause a fire to ignite. Be careful when using or working
around oxygen, especially if using electrical equipment.
Be sure that patients and visitors understand that smoking is not permitted in medical facilities.
Provide information on the smoking policy of the hospital to patients as soon as they are
admitted. If the hospital has designated outside smoking areas, make sure directions to those
areas are posted.
Learn and follow the fire safety policies of your hospital. Know the location of fire exits and pulldown fire alarms in each area where you work.
Environmental Controls
The purpose of environmental controls
Environmental controls are the built-in features of your facility that warn of fires, help to control fires,
and contain smoke. All of these features are included in the hospital fire protection plan and should be
inspected and updated regularly. Specific staff is responsible for maintaining these features but it is
important that you understand how the systems work and what you can do to keep them working.
There are two types of built-in fire safety controls:
Passive measures
Active measures
Passive built-in fire measures are part of the framework of the hospital. They do not require input or
action from anyone to work and most of the staff is unaware of their presence. However, passive fire
safety measures should be checked regularly for damage.
Active built-in fire measures include systems that act in a specific way to fire conditions. These systems
work automatically to sound an alarm warning of fire or react to fire or smoke. Staff can activate some
of these systems.
Passive fire safety measures
Passive fire safety measures slow down and help contain the fire. They are part of the structure of the
building.
Examples of passive fire safety measures are:
Firewalls
Fireproofing materials.
Firewalls should be inspected and checked regularly. They may be damaged if:
They are drilled to allow the installation of cables and wires
If changes are made to the structure of the building.
Structural steel or other elements of the building that have been fireproofed should be checked
regularly for cracks or chipping.
Active fire safety measures
Active fire safety measures are automatic systems that respond to heat, smoke or fire. Regular checks
are required to make sure that they are in proper working order at all times.
Examples of active fire safety measures are:
Smoke detectors
Overhead sprinklers
Smoke doors
Fire alarm systems
Smoke detectors
Smoke detectors are located in all areas and will set off the fire alarm if they detect smoke. They need to
be kept in good working order. Report any damaged smoke detectors to your supervisor.
Fire sprinkler systems
Overhead fire sprinklers are set off when they sense high temperatures from a fire. When set off, they
pour water under pressure onto the fire. Never hang anything from the sprinklers and be sure that
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The blue symbols below indicate which type or types of fire (A, B, C, or some combination) a particular
fire extinguisher is rated for.
Water extinguisher
A water extinguisher (also known as a Type A extinguisher) can be used on a Type A fire. High
pressure water or foam can soak deeply into the fire to cool it down and put it out. Never use a water
extinguisher on a Type B or Type C fire.
Carbon dioxide extinguisher
"P" stands for "PULL" or "PIN." The first step is to pull out the locking pin at the top of the extinguisher.
"A" stands for "AIM." The second step is to aim the nozzle of the extinguisher at the base of the flames.
It is important to aim at the base of the flames, because spraying water, foam, or powder at the middle
or top of the flames may actually spread the fire.
"S" stands for "SQUEEZE." The next step is to squeeze the handles together to expel the contents of the
fire extinguisher. Do not touch the nozzle of the extinguisher because it may be very cold and could
cause a "freeze" burn.
"S" stands for "SWEEP." The final step is to sweep the contents of the fire extinguisher across the fire.
The nozzle should still be aimed at the base of the fire, but a side-to-side sweeping motion should be
used so the water, foam, or powder rolls over the fire, forming a thick blanket that cools and smothers
the fire.
Crouch low (between 24 and 36 inches from the floor) when the room is full of smoke.
Harassment
Workplace Harassment
What is workplace harassment?
Workplace harassment is unwelcome or unsolicited speech or conduct based upon race, sex, creed,
religion, national origin, age, color, or handicapping condition that creates a hostile work environment
or circumstances involving quid pro quo. Workplace harassment is a form of discrimination, which is
prohibited by law.
Examples of behavior that can constitute unlawful workplace harassment and/or create a hostile work
environment include, but are not limited to:
Making jokes about individuals based on race, sex, creed, religion, national origin, age, color, or
handicapping condition
Making racial or ethnic slurs
Forcing employees to segregate based on race, sex, creed, religion, national origin, age, color, or
handicapping condition
Giving a subordinate a degrading or humiliating assignment on the basis of race, sex, creed,
religion, national origin, age, color, or handicapping condition
Displaying offensive literature or posters
Repeatedly proselytizing fellow employees on the correctness of a particular religion
Types of workplace harassment
Workplace harassment may take many forms. Any harassing activity based on one of the categories
listed below that creates a hostile work environment or impairs a person's ability to do their job may be
considered workplace harassment. See the previous page for some common examples.
The following categories are known as "Protected Classes." These are categories to which people belong
that are specifically protected from discrimination by federal and state laws.
Everyone is a member of at least one of these categories, and therefore anyone can be a victim of
workplace harassment based on:
Age - A person 40 years of age or older
Color - The complexion or shades of a person's skin
Creed - A system of beliefs, principles or opinions
Disability - Any person who has a physical or mental impairment which substantially limits one
or more major life activities; one who has a record of such impairment; or one who is regarded
as having such an impairment
National Origin - Characteristic of, or peculiar to, the people of a nation; of or relating to
ancestral beginnings, physical, cultural, or linguistic characteristics of a particular national group
Race - A local geographic or global human population distinguished as a more or less distinct
group by certain characteristics such as skin color, hair texture, and facial features. A race may
also be any group of people united or classified together on the basis of common history,
nationality, or geographical distribution
Religion - All aspects of religious observance, practice and belief which include moral or ethical
beliefs as to what is right and wrong which are sincerely held with the strength of traditional
religious views
Gender and Sexual Orientation - The condition or character of being male or female as well as
sexual orientation or preference
The harasser may be a person, group of persons, or even an employer or organization that is responsible
for creating a hostile work environment for any member of one or more of the above groups.
Response to workplace harassment
If you feel that are the victim of workplace harassment, take the following steps:
1. Collect and preserve evidence
Take notes as soon as you feel you are being harassed. Record dates, names, and a description
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3. Take a stand.
When you see harassment take place even when it is not directed at you, point it out and
object.
4. Respect the differences between people.
We're all unique. Cherish and respect those differences.
If you are a supervisor or manager, you can further help to prevent harassment by doing the following:
Treat employees fairly and consistently,
Display zero tolerance for harassing behaviors.
Discuss your organization's harassment policies with your employees.
Ensure that your employees know what to do if they feel they have been harassed.
Persistent letters.
Hazardous Materials
Safety Data SheetsSDS Effective June 1, 2015 (Formerly Material Safety Data Sheets)
What is a Safety Data Sheet?
The Hazard Communication Standard (HCS) requires chemical manufacturers, distributors, or importers
to provide Safety Data Sheets (SDSs) (formerly known as Material Safety Data Sheets or MSDSs) to
communicate information about the hazards of chemicals contained in their products. As of June 1,
2015, the HCS will require new SDSs to be in a uniform format, and include the section numbers, the
headings, and associated information under the headings below:
When on the job, workers may be required to work with different chemicals that could cause injury if
not used properly.
These are examples of products that contain harmful chemicals:
Paint
Cleaners
Disinfectants
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Pesticides
Printer cartridges
Bleach
Toners
You have the right to know about the different chemicals you come in contact with and how to handle
them safely. All of this "right to know" information is available on the Safety Data Sheet, or "SDS."
SDS is a separate document that comes with every chemical-containing product that you use on the job.
The SDS lists information about the chemical, like how to handle the chemical safely and what to do if it
spills. The SDS gives more detailed information than would fit on the label of the product.
The SDS for each chemical solution that you might use on the job has to be easily available to you while
you are working. If you do not know where the Safety Data Sheets are kept, ask your supervisor.
Information on an SDS
While the SDS format for different products may differ, they all must contain the following information:
Section 1: Identification
This section identifies the chemical on the SDS as well as the recommended uses. It also provides the
essential contact information of the supplier. The required information consists of:
Product identifier used on the label and any other common names or synonyms by which the
substance is known.
Name, address, phone number of the manufacturer, importer, or other responsible party, and
emergency phone number.
Recommended use of the chemical (e.g., a brief description of what it actually does, such as
flame retardant) and any restrictions on use (including recommendations given by the supplier).
Section 2: Hazard(s) Identification
This section identifies the hazards of the chemical presented on the SDS and the appropriate warning
information associated with those hazards. The required information consists of:
The hazard classification of the chemical (e.g., flammable liquid, category1).
Signal word.
Hazard statement(s).
Pictograms (the pictograms or hazard symbols may be presented as graphical reproductions of
the symbols in black and white or be a description of the name of the symbol (e.g., skull and
crossbones, flame).
Precautionary statement(s).
Description of any hazards not otherwise classified.
For a mixture that contains an ingredient(s) with unknown toxicity, a statement describing how
much (percentage) of the mixture consists of ingredient(s) with unknown acute toxicity. Please
note that this is a total percentage of the mixture and not tied to the individual ingredient(s).
Recommendations for personal protective measures to prevent illness or injury from exposure
to chemicals, such as personal protective equipment (PPE) (e.g., appropriate types of eye, face,
skin or respiratory protection needed based on hazards and potential exposure).
Any special requirements for PPE, protective clothing or respirators (e.g., type of glove material,
such as PVC or nitrile rubber gloves; and breakthrough time of the glove material).
This section identifies the safety, health, and environmental regulations specific for the product
that is not indicated anywhere else on the SDS. The information may include:
Any national and/or regional regulatory information of the chemical or mixtures (including any
OSHA, Department of Transportation, Environmental Protection Agency, or Consumer Product
Safety Commission regulations)Sometimes the PPE listed are needed only when the worker is
exposed to large quantities of the substance and not during normal use. This section needs to be
read carefully.
When dealing with products that contain chemicals, read through the SDS to be sure you are
appropriately handling them.
Biohazardous waste materials present a risk of death, injury, or illness to individuals who handle them.
HCAHPS
Background and rationale for this presentation
The Centers for Medicare and Medicaid Services (CMS) has developed and mandated a standardized
patient satisfaction survey in which recently discharged patients can assess their hospital experience.
This survey is titled Hospital Consumer Assessment of Healthcare Providers and Systems and
pronounced h-caps.
The survey was developed over several years with input from a broad representation of consumers,
stakeholders, and scientists. The survey was extensively analyzed and piloted before implementation.
CMS says that they went to great lengths to assure that the survey is credible, useful, and practical.
(HCAHPS Fact Sheet, July 2010)
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As of July 2007, hospitals receiving Medicare and Medicaid funding must report HCAHPS results or lose
up to 2% of that funding. As of October 2012, those hospitals may receive additional, incentive funding
as a result of HCAHPS performance.
Intent
Ultimately, the goal of HCAHPS is to incentivize hospitals to improve patient satisfaction, and, indirectly,
the quality of care. A standardized survey enables between-hospital comparisons of patient experiences.
In effect, survey results will be used to compare and rate hospitals according to how well they meet
their patients expectations. The results are publicly reported.
Hospitals have a dual incentive to address barriers to patient satisfaction: 1. Reimbursement will
depend, to some extent, on survey performance, and 2. Knowledgeable consumers will make utilization
decisions based on publicly available survey information.
Methodology
Hospitals may use one or more of the following survey technologies: mail, telephone, mail with
telephone followup, or active voice recognition (automated phone survey technology). Official
language versions include Chinese, English, Russian, Spanish, and Vietnamese. All are available to the
public.
Patients are surveyed between 48 hours and six weeks after discharge. A random sample of all adult
patients, not just those receiving Medicare, is chosen from a variety of diagnoses.
Content
The survey focuses primarily on (emphasis is the authors):
. . . critical aspects of patients hospital experiences (communication with nurses and doctors, the
responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain
management, communication about medicines, discharge information, overall rating of hospital, and
would they recommend the hospital). -HCAHPS Fact Sheet
Additional survey questions are intended to adjust for differences between patients and hospitals, assist
patients in answering the survey questions, and support mandated reporting.
Measuring and reporting
Each hospitals survey is summarized for public reporting into ten HCAHPS measures. The following table
has been copied directly from the HCAHPS Hospital Comparison website. After entering a zip code, the site
allows selection of up to 3 hospitals for comparison. Below, two hospitals in the 65203 zip are
compared.
1600 E BROADWAY
COLUMBIA,MO 65201
(573) 815-8000
UNIVERSITY OF MISSOURI
HEALTH CARE
10.6 miles
Measure Description
Add To My Favorites
Add To My Favorites
83%
72%
87%
74%
67%
60%
71%
66%
72%
56%
73%
69%
57%
52%
89%
85%
76%
64%
82%
70%
Meeting patient requests, especially bathroom requests, and answering call lights
Maintaining room and bathroom cleanliness
Managing pain
Providing information about medications
Providing information about post discharge activities and medications
Maintaining a comfortable and quiet (especially at night) environment
The challenge, therefore, is to assure that your patient answers Always as often as possible. Keep in
mind that these surveys take place well after the hospital stay. The patients recollection of details of
nursing care will likely be incomplete, and survey responses will be heavily influenced by only a few
incidents that may stand out in the patients memory. The following behavioral techniques will help
your patient to remember the good care you provide.
Make your good care explicit.
Making your care explicit may be the most powerful behavioral technique you can use to reinforce your
patients memory of good care. When performing any care that falls into one of the seven Always
categories, announce what you are doing to the patient. In other words, explicitly state to the patient
that you are providing care in one of those seven categories. For example:
When entering a room to answer a call light, say to the patient, I am answering your
call light, Mrs. Brown. And when leaving the room, make a statement that again
reminds the patient of what youve done, such as, Ive answered your call light; is there
anything else I can do for you? If possible, incorporate your announcement into the
first and last things you say to the patient.
If you have to keep your patient waiting, tell them what to expect. Never leave your patients
hanging in limbo.
Give the patient your full attention.
Don't interrupt. Listen carefully to what your patients have to say, especially when you're in a
hurry.
Respect your patients' privacy.
Treat patients as people, not medical conditions. A patient with potential breast cancer won't
appreciate being referred to as 'the breast mass'
Involve patients in decision making. Don't be a 'care dictator'!
Don't be critical of other care the patient has received. Nurse's criticism of other nurses who
have taken care of the patient can give rise to highly unnecessary game-playing and is in very
poor taste. It can also give rise to law suits!
Make sure your fellow nurses show your patients the same consideration that you do. This is
also a part of your role as the patient's advocate
The following table is based on the information presented at the above site:
Survey Order
Rank Order
Patients who
reported that
their nurses
"Always"
communicated
well.
77
Patients who
reported that
their doctors
"Always"
communicated
well.
Patients who
reported that
they "Always"
received help as
soon as they
wanted.
Patients who
reported that
their pain was
"Always" well
controlled.
Patients who
reported that
staff "Always"
explained about
medicines
before giving it
to them.
Patients who
reported that
their room and
bathroom were
"Always" clean.
81
65
70
62
72
Patients at each
hospital who
reported that
YES, they were
given information
about what to do
during their
recovery at
home.
Patients who
reported that
their doctors
"Always"
communicated
well.
Patients who
reported that
their nurses
"Always"
communicated
well.
Patients who
reported that
their room and
bathroom were
"Always" clean.
Patients who
reported that
their pain was
"Always" well
controlled.
83
Patients who
reported YES,
they would
definitely
recommend the
hospital.
70
81
77
72
70
59
Patients who
gave their
hospital a rating
of 9 or 10 on a
scale from 0
(lowest) to 10
(highest).
Patients who
reported that
they "Always"
received help as
soon as they
wanted.
68
Patients at each
hospital who
reported that
YES, they were
given
information
about what to
do during their
recovery at
home.
Patients who
gave their
hospital a rating
of 9 or 10 on a
scale from 0
(lowest) to 10
(highest).
Patients who
reported YES,
they would
definitely
recommend the
hospital.
83
68
Patients who
reported that
staff "Always"
explained about
medicines before
giving it to them.
62
70
Patients who
reported that the
area around their
room was
"Always" quiet at
night.
59
65
Be aware of the trends displayed in the right hand columns above. From this information, you can
assume, for example, that patients consider hospitals noisy at night, are puzzled about their
medications, and dont feel they can reliable get help quickly. Visit your own employers HCAHPS results
and compare those with the national trends above.
Bottom line, by focusing on the problem areas, and utilizing the behavioral techniques youve learned,
you can strongly influence your patients recall of the care you provide, and impact your organizations
survey results.
Conclusion
The HCAHPS rating depends, to a large extent, on the patients relationship with their professional
healthcare provider. Hospital reimbursement and consumer choice are dependent upon those ratings.
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To law enforcement agencies when needed for legal purposes. This includes coroners and
medical examiners
to public health officials
If needed for Workmen's Compensation
If needed to stop serious threats to health and/or safety
If needed for charges of fraud or abuse
With a valid authorization by the individual patient
When providing PHI, use the Minimum Necessary Rule. That is, provide only the least amount of
information that is needed.
This Minimum Necessary Rule does NOT apply to:
Information shared with other health care providers for treatment purposes; healthcare
providers may require the entire record for treatment
Information requested by the individual
Information required by law
With an oral or written authorization from the patient, PHI can be disclosed to family members and to
friends identified by the patient, and it can be included in a facility directory (for example, Patient
Information may provide the patient's room number to callers). The patient also has the right to place
restrictions on the amount of information to be given out.
A written patient authorization is required to use or disclose PHI for any other purpose, such as
marketing or research.
Protected Health Information that can be disclosed does NOT include psychotherapy notes. The patient
must give specific authorization for psychotherapy notes to be disclosed except:
To carry out treatment, payment, or healthcare operations
To the originator of the notes so that treatment can be provided
To students who are training within the facility, to improve counseling skills
To use as a defense if the individual has brought a suit against the agency
A Note about Psychotherapy Notes:
The first bullet item above seems to indicate that psychotherapy notes may be addressed the same as
any other PHI. However, in practical application, psychotherapy notes are held to a higher standard of
privacy and employees must be aware of their organization's specific policies regarding the privacy of
these notes. As a rule of thumb, without the patient's written authorization, the notes cannot be used
by, or shared with, anyone other than the attending physician.
Healthcare organizations inform patients about the Privacy Rule
HIPAA requires that a notice of the organization's privacy practices be given to each individual receiving
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Social Media
Patients enter the healthcare system with the right and the expectation of privacy. The HIPPA Privacy
rule holds you to an extremely high standard in protecting patient privacy. Please ensure that you
adhere to this high standard in your use of blogs and social media. It is just as easy, and just as
wrong, to violate patient privacy in a blog or Facebook post, as it is in a casual discussion in the
cafeteria or an elevator.
Infant Abduction
The standard hospital emergency code for Infant Abduction is Code Pink. Yours may differ, so know your
emergency codes.
One of the most serious incidents that can occur in a healthcare facility is the abduction of an infant or
child. There are criteria that can be used to identify a potential abductor.
The typical kidnapper:
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Is female
Is between the ages of 16 and 45
May hang around the nursery and ask to hold or feed the babies
May ask questions about when babies are fed and other nursery routines, such as shift changes
and number of staff.
One common profile of an infant abductor is a woman aged 16 to 45 who hangs around the nursery.
Engineering controls.
Teach mothers how to identify nursery and other staff and inform them about usual routines. This is an
important step in the protection of newborn and infant children. Your facility may also have visiting
procedures stating who can visit and providing methods of identifying visitors. Engineering controls,
such as closed-circuit TV cameras, exit-door and wrist-band alarms, and other security devices may also
be in place.
One of the most important components in the prevention of infant and child abduction is an alert staff.
It is important that staff involved with care of infants and children are aware of security issues and
suspicious of anyone who does not belong in the area.
If you discover that an infant is missing, follow your institution's infant abduction procedures. These
usually include:
Securing all exits from the facility
Inspecting all stairwells, rooms, and other areas where someone might hide.
THE TYPICAL ABDUCTOR
(Developed from an analysis of 256 cases occurring 1983-2008.)
Female of childbearing age (range now 12 to 53), often overweight.
Most likely compulsive; most often relies on manipulation, lying, and deception.
Frequently indicates she has lost a baby or is incapable of having one.
Often married or cohabitating; companions desire for a child or the abductors desire to provide
her companion with his child may be the motivation for the abduction.
Usually lives in the community where the abduction takes place.
Frequently initially visits nursery and maternity units at more than one healthcare facility prior
to the abduction; asks detailed questions about procedures and the maternity floor layout;
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frequently uses a fire-exit stairwell for her escape; and may also try to abduct from the home
setting.
Usually plans the abduction, but does not necessarily target a specific infant; frequently seizes
any opportunity present.
Frequently impersonates a nurse or other allied healthcare personnel.
Often becomes familiar with healthcare staff members, staff members work routines, and victim
parents.
Demonstrates a capability to provide good care to the baby once the abduction occurs. In
addition an abductor who abducts from the home setting is more likely to be single while
claiming to have a partner.
Often targets a mother whom she may find by visiting healthcare facilities and tries to meet the
target family.
Often both plans the abduction and brings a weapon, although the weapon may not be used.
Often impersonates a healthcare or social-services professional when visiting the home.
Close questioning about healthcare-facility procedures, security devices, and layout of the floor
such as, When is feeding time? When are the babies taken to the mothers? Where are the
emergency exits? Where do the stairwells lead? How late are visitors allowed on the floor?
Do babies stay with their mothers at all times?
Taking uniforms or other means of identification within that facility.
Physically carrying an infant in the facilitys corridor instead of using the bassinet to transport
the infant, or leaving the facility with an infant while on foot rather than in a wheelchair.
Carrying large packages off the maternity unit (e.g., gym bags, suitcases, backpacks), particularly
if the person carrying the bag is cradling or talking to it.
aware that a disturbance may occur in another area of the healthcare facility creating a diversion to
facilitate an infant abduction (e.g., fire in a closet near the nursery or loud, threatening argument in the
waiting area). Healthcare facilities need to be mindful of the fact that infants can stay in or need to be
taken to many areas within the facility. Thus vigilance for infant safety must be maintained in all areas of
the facility when infants are present.
Be
General Guidelines (You MUST review your facility guidelines; these are non-specific and lack the details
necessary for full compliance with your local facility and regional standards.)
Persons exhibiting the behaviors described above should be immediately asked why they are in
that area of the facility. Immediately report the persons behavior and response to the nurse
manager/supervisor, security, and administration. The person needs to be positively identified,
kept under close observation, and interviewed by the nursing manager/supervisor
and security. Remember, caution needs to be exercised when interacting with people who
exhibit these behaviors.
Report and interview records on the incident should be preserved in accordance with the
organizations internal procedures. (Many suggest records should be kept from a minimum of
seven years up to the child reaching adulthood.)
Each facility should designate a staff person in their critical-incident response plan who will have
the responsibility to alert other birthing facilities in the area when there is an attempted
abduction or someone is identified whom demonstrates the behaviors described above, but
who has not yet made an attempt to abduct an infant.
Proactive Practices (Again, these are general. Know your facilities standards.)
As part of contingency planning, the backbone of prevention, every healthcare facility must develop,
test, and critique a written proactive-prevention plan for infant abductions that includes all of the
elements listed in this section. In addition measures must be taken to inform new or rotating
(temporary) employees of these procedures as they join the staff. This plan needs to be tested,
documented, and critiqued at least annually.
Require all healthcare-facility personnel to wear, above the waist and face-side out, up-todate, conspicuous, color-photo ID badges. The persons name and title need to be easily
identifiable, and the persons photograph needs to be large enough so that he or she is
recognizable.
Update the photograph as the persons appearance changes. These badges need to be returned
to Human Resources or the issuing department immediately upon termination of employment.
Personnel who are permitted to transport infants from the mothers room or nursery, including
physicians, should wear a form of unique identification used only by them and known to the
parents (e.g., a distinctive and prominent color or marking to designate personnel authorized to
transport infants). IDs should be worn above the waist, face-side out, on attire that will not be
removed or hidden in any way. Paraphernalia should not be worn on name badges (i.e., pins,
stickers, and advertisements) that hide name, face, or position. ID systems should include
provisions for all personnel, who are permitted to transport infants from the mothers room or
nursery including students, transporters, and temporary staff members, such as the issuance
of unique temporary badges that are controlled and assigned each shift (e.g., strict control
should be similar to narcotics control). This unique form of identification should be periodically
changed.
Limit infant transportation to an authorized staff member wearing the authorized infanttransportation ID badge.
Ensure the mother or father/significant other with an identical ID band for that infant are the
only others allowed to transport that infant, and educate the mother and father/significant
other about the importance of this precaution.
Require infants to be taken to mothers one at a time. Prohibit grouping infants while
transporting them to the mothers room, nursery, or any other location.
Prohibit arm carrying infants, and require all transports to be via a bassinet. Require family
members transporting the infant outside the mothers room, including the mother, father, or
significant other, to wear an ID wristband.
Always place infants in direct, line-of-sight supervision either by a responsible staff member, the
mother, or other family member/close friend so designated by the mother, and address the
procedure to be followed when the infant is with the mother and she needs to go to sleep/the
bathroom and/or is sedated. If the mother is asleep when the infant is returned to the room,
staff members should be careful to fully awaken her before leaving the room. In rooming-in
situations, place the bassinet so the mothers bed is between the exit door(s) to the room and
the bassinet.
Do not post the mothers or infants full name where it will be visible to visitors. If necessary,
use surnames only. Do not publish the mothers or infants full name on bassinet cards, rooms,
status or white boards. Do not leave charts, patient index cards, or any other medical
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Conform with an access-control policy for the nursing unit, nursery, maternity, neonatalintensive care, and pediatrics to maximize safety.
Require a show of the ID wristband for the person taking the infant home from the healthcare
facility and be sure to match the numbers on the infants bands, as worn on the wrist and ankle,
with the bands worn by the mother and father/significant other.
Know and conform with your facilitys critical-incident-response plan to respond to an infant abduction.
Alcohol hand rubs (See below) are approved in some hospitals as an alternative to washing with soap
and running water.
If you wish, you may use a hospital-approved hand lotion, to protect your hands and prevent damage
from over washing. Lotions with a water-based, greaseless formula are best. They should also be
silicone-free and petroleum-free to prevent damage to latex gloves.
Alcohol hand rubs
Healthcare workers use alcohol-based hand rubs as a convenient and effective method to maintain
prevent the spread of germs.
Alcohol hand rubs are waterless; healthcare workers pour the solution directly from the bottle onto
their hands. In busy areas or in situations in which handwashing stations are not available, alcohol hand
rubs are a convenient alternative.
As a result, the Centers for Disease Control (CDC) issued recommendations on long natural nails and
artificial nails:
Do not wear artificial fingernails or extenders when having direct contact with patients at high
risk (e.g., those in intensive-care units or operating rooms)
Keep natural nail tips less than inch long.
Your organization may already have put in place specific requirements for nail type and length. Know
your healthcare organization's policy regarding this important issue.
Presented here, as an example, are typical elements of a fingernail policy for workers providing direct
patient care:
No artificial fingernails (may be limited to specific high-risk areas)
Fingernails will not extend more than inch beyond fingertips
Fingernail polish must not be chipped
Standard Precautions
Two levels of precautions
Healthcare workers are often exposed to the body fluids of patients, including blood. Because serious
diseases can be transmitted not only through blood, but also by other means, the Center of Disease
Control (CDC) has recommended a two-level or "two-tier" system of precautions to prevent the spread
of infections.
The two tiers of precautions are:
Standard Precautions
Special Precautions
Standard Precautions
The CDC has recommended that ALL patients be treated according to Standard Precautions which
provide protection against the spread of diseases through contact with blood or other body fluids.
Follow Standard Precautions with ALL patients at ALL times.
Special Precautions
The CDC has also recommended that certain Special Precautions be added to the Standard Precautions
for diseases that spread in ways other than through infected blood.
The meaning of Standard Precautions
Standard Precautions are practices designed to help prevent the spread of diseases carried by the blood.
They are called standard because they apply to everyone. Nobody, not even you, can tell by looking at a
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Dispose of all sharps (needles, blades, IV catheters) in the proper disposal box.
Wash your hands after removing gloves.
Do not eat, drink, put on make-up or put in contact lenses in areas where exposure to body
fluids is possible.
Devices are available, such as safety syringes and special IV catheters that help protect health care
workers. The Occupational Safety and Health Administration (OSHA) directs medical agencies to use
recommended safety devices. Although they take a little time to learn, the effort could save a life maybe yours.
Know and follow your facility's procedures for reporting injury and/or exposure to body fluids. Your
facility has an Employee Exposure Control Plan that lists all areas where precautions are needed and
also has procedure to follow if you are exposed to blood or other body fluids. It is important to know
what the plan is and to follow it if you are exposed. Report ANY needlestick-type injury or ANY other
exposure to blood or body fluids. You will need to be evaluated and may also need follow-up care.
If you have any questions about how to follow Standard Precautions in your organization, ask your
supervisor.
Special Precautions
Two levels of precautions
Health care workers are exposed to the body fluids of patients, including blood. Because serious
diseases can be transmitted not only through blood, but also by other means, the Center of Disease
Control (CDC) has recommended a two-level or "two-tier" system of precautions to prevent the spread
of infections.
The two tiers of precautions are:
Standard Precautions
Special Precautions.
Standard Precautions
The CDC has recommended that ALL patients be treated according to Standard Precautions. Follow the
procedures outlined by your particular facility. Anyone could have a disease that is spread through the
blood or other body fluids. Many people are unaware they have a disease, and many do not tell others
they have a disease. Due to confidentiality laws, workers are sometimes told only on a need to know
basis, and you may not need to know. To protect yourself and others from infection, follow Standard
Precautions with ALL patients at ALL times.
Special Precautions
Special Precautions are practices used in health care to help prevent the spread of diseases that can be
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Disseminated Intravascular
Coagulation (DIC)
Index patient
Infectivity
Natural reservoir
Secondary
infection/secondary
outbreak
Virulence
Ebolavirus is now the preferred term to refer to the Ebolavirus genus, the family of closely related
viruses. There are five subtypes, or species, of the Ebolavirus:
Ebola virus (EBOV)
Sudan virus
Tai Forest virus
Bundibugyo virus
Ebola-Reston
The Ebola virus (EBOV) is responsible for most outbreaks and is the pathogen responsible for the current
outbreak that originated in West Africa. All but the Reston variety were first identified in Central or West
(sub-Saharan) Africa. The Reston variety originates in the Philippines and is not infectious to humans.
EVD in humans is a zoonosis, a disease transmitted from animals to humansrabies is another example.
Humans are exposed to the virus when they come in contact with an infected animal, killing, butchering,
drying, eating, and selling wild animals for food (bushmeat) is a common practice and has been
associated with EVD. Monkeys and bats are common sources of bushmeat.
Ebolavirus has been documented only in mammals, especially bats, monkeys, and apes. There is no
current evidence that insects can be infected with or transmit Ebolavirus.
Sporadic epidemics of disease caused by Ebolavirus kill non-human primates, monkeys, and antelope (an
animal epidemic is more correctly termed an epizootic). These epizootics may be related to human
outbreaks. Some research suggests that fruit bats may be a natural reservoir, but this is not yet
confirmed. As with rabies, there may be several animal reservoirs.
Summary of etiology
Ebola is both a virus, e.g. EBOV, and a disease, e.g., EVD
The natural reservoir of Ebola is an animal or animals living in Western and Central Africa. The
disease is transmitted to humans when they have close contact with an infected animal.
EBOV is a highly infective and virulent pathogen
Hepatitis B and, to a lesser extent, Hepatitis C can also be transmitted as a result of:
Close household contact with an infected person
Unprotected sex with multiple partners
Childbirth (from mother to baby).
About one third of Hepatitis C patients never find out how they contracted the virus.
Accurate detection techniques were developed for Hepatitis B in 1972, and for Hepatitis C in 1992.
Before these dates, the virus could not be detected reliably, so some people received infected blood in
blood transfusions. If you had a blood transfusion or organ transplant before these dates, ask a doctor
to test you for the appropriate virus or viruses.
Who is at high risk for hepatitis?
Any time the skin is broken, there is the opportunity to contact another person's blood or body fluids
and the risk of hepatitis infection increases. People who routinely come into contact with other people's
blood are at high risk. These include:
Healthcare workers
Tattoo artists, people doing body piercing
People with multiple sex partners.
Drug users
Healthcare workers
People who are exposed to blood and body fluids are at high risk for hepatitis. This includes people who:
Work in the lab and handle specimens
Work directly with patients and come in contact with body fluids
Change the diapers of infected babies
Work in housekeeping and come in direct contact with garbage or laundry.
All healthcare workers are at a greater risk because of their job.
Tattoo artists and people doing body piercing
Equipment that has not been properly sterilized and shared ink may contain the hepatitis virus. The
following people are at risk:
The person receiving the tattoo or piercing
The tattoo artist or the person doing the piercing.
People with multiple sex partners
The risk of getting hepatitis is high for people having unprotected sex with multiple partners.
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Latex Allergy
Background to Latex Allergy
What is latex?
Latex is a rubber compound found in many products that you use on your job. It is produced from
rubber trees in the Tropics.
If you or someone nearby begins to experience any of these symptoms of latex allergy, get medical
attention immediately.
Prevention and Treatment of Latex Allergy
Reducing reactions to latex
Latex contains proteins that can cause mild to severe allergic reactions. Chemicals that are combined
with the latex during processing, and powder that is added to the gloves to make them easier to put on
may also cause allergic reactions.
People who are frequently exposed to latex are the most at risk for developing an allergy. As with any
allergy, the more the exposure to the substance, the greater the chance of developing an allergy. If you
show any signs of latex allergy, it is important to limit your exposure to latex and to other agents to
which you may be allergic.
Use the following methods if you need to limit your exposure to latex:
Use non-latex utility gloves for non-clinical work.
When there is NO potential risk of contact with infectious material (when you are NOT working with
patients or with clinical material), it is NOT necessary to wear latex gloves. For example, a housekeeper
cleaning an oven does not need to wear latex gloves - non-latex utility gloves are adequate for these
tasks.
Wear a medical alert bracelet. A medical alert bracelet is a wrist band with written information
about any medical conditions you have and what someone should do if you are experiencing a
medical problem.
Use latex-free "crash carts" and procedure trays.
Carry an epinephrine injection kit (similar to the allergy kits carried by people who are allergic to
bee stings) in case of a reaction to latex. Injection of epinephrine is an emergency treatment for
an allergic reaction.
Also, protect other people who have a latex allergy. For example, screen patients for latex allergy.
Clearly identify those patients with allergies to ensure that only latex-free equipment is used.
What to do if someone has an allergic reaction to latex
Reactions to latex can range from mild contact dermatitis to a severe allergic reaction.
If the reaction is mild (itching or redness):
Remove the latex product
Wash and thoroughly dry the skin area.
If someone is experiencing a severe allergic reaction (difficult breathing, coughing spells, or shock):
Remove any sources of latex
Get immediate emergency medical help.
Reactions usually begin within minutes of exposure to latex, but they can occur hours later and can
produce various symptoms.
It is best for anyone who experiences symptoms to be evaluated by a physician, since further exposure
could result in a serious allergic reaction. A diagnosis is made by using the results of a medical history,
physical examination, and tests.
Report allergic events related to latex medical devices to the Food and Drug Administration MedWatch
Program, 1-800-FDA-1088.
End of Latex Allergy Lesson
Violence is any act that causes physical or emotional harm, and includes the threat of being
harmed.
Workplace violence is any act or threat that causes physical or emotional harm in a place where
an employee performs job duties.
Private
Sector
Overall
Health
Services
Overall
Nursing &
Social
Personal
Services
Care
Facilities
85% of non-fatal workplace injuries occurred in healthcare facilities. (Occupational Safety and
Health Administration, OSHA)
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One million healthcare workers are injured in violent incidents every year.
A nationwide survey of emergency nurses between May 2009 and February 2010 found that in
hospitals:
97.1% of physical violence was perpetrated by patients and their relatives.
80.6% of physical violence occurred in patients' rooms; 23.2% in corridors, hallways, stairs and
elevators; and 14.7% at nurses' stations.
38.2% of physical violence against emergency nurses occurred while they were triaging patients,
33.8% while restraining or subduing patients, and 30.9% while they were performing invasive
procedures.
15% of male nurses reported having been victims of physical violence compared with 10.3% of
female nurses.
13.4% of violent acts occurred in large urban areas compared with 8.3% in rural areas.
Risk factors
Your facility has policies for handling violence in the workplace. Do you know what the policies are? Are
you aware of risk factors associated with employment in the healthcare field?
Many factors contribute to the risk of violence in a hospital.
Hospitals are open 24 hours a day.
Employees and patients enter and leave at all times of the day and night.
There is no way of knowing a person's purpose for being in the hospital.
There are usually fewer working staff visible or available during times of increased activity, such
as meal times and visiting hours.
At certain hours, especially at night, there are only small numbers of staff working in isolated
areas of the building.
There are a lot of people who are under emotional stress as a result of their illness and/or a long
wait to be treated.
Patients and staff bring money and valuables into the hospital.
Hospitals are known to have a large supply of drugs, which attracts substance abusers.
Many hospitals have poorly lighted parking areas.
Gang members and other violent individuals are treated in the emergency room for injuries
sustained in gang violence.
Weapons, especially handguns, are brought into hospitals by gang members and by other
patients who carry weapons for self-defense.
Prevention of Violent Incidents
Types and effectiveness of security
Your facility has security devices you should use and security practices you should follow to help reduce
the risk of violence.
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Security devices include entrance controls, lighting, surveillance equipment, motion detectors, and
other equipment used to monitor traffic in and around the hospital. Be aware of these devices in your
facility and learn how to use them correctly. For example, a door may be designed to limit access to a
particular area. If you prop that door open, you will be providing an opportunity for an unauthorized
person to enter and violence to occur.
Security policies and procedures of your facility are in place for your safety. Keep safety in mind and
develop security practices that will help you to reduce the risk of violence. For example, identification
(ID) badges may be required for entry to a particular lab. Do not hold the door open to allow someone
to enter with you, and question any person who does not have an ID badge, even if that person is
wearing the proper uniform or lab coat.
Security personnel and equipment
Security equipment may include bright lighting, cell phones, automatic locks, alarms, video cameras, and
ID badges
Your facility has security personnel, equipment, and devices intended to reduce violence in the
workplace. Do you know what they are? Do you know where they are? Do you know how to use them?
Physical security measures at your facility could include:
Security personnel at entrances, to patrol inside and outside buildings, to monitor sensitive
areas, and to provide escorts to and from parking lots
Access controls such as ID badges, key codes, and automatic door locks (after hours, people are
normally escorted by security personnel) to restricted-access areas such as the pharmacy,
laboratories, obstetrics, and pediatrics
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Security equipment such as effective lighting (in isolated areas, parking garages and lots,
doorways, hallways, and stairways), alarms and emergency call buttons, video cameras (their
presence alone is a deterrent), metal detectors, bullet-proof windows, cellular phones, and
curved mirrors in hallways (for visibility around corners)
Structural planning such as safe rooms (containing at least two exits) and minimal furniture and
objects that could be used as weapons in counseling rooms.
Be sure you know about the physical security that is available at your facility. Determine where they are
located and learn how to use them properly.
Security practices
Your facility has security policies and procedures intended to reduce violence in the workplace. Do you
know what they are? Do you use security practices to help prevent workplace violence?
Security practices at your facility could include:
Access control policies such as using ID badges for entry, questioning anyone without ID badges,
and signing-in all visitors
Awareness issues such as being especially sensitive to patients and families during stressful
situations, keeping people informed during long waits to reduce stress and frustration,
monitoring gang activity and reporting interference with duties, and developing awareness of
items that could be used as weapons (pens, syringes, lamps, books, IV poles, etc.)
Sensitivity issues such as separating persons angry with each other and keeping patients in
states of psychiatric crises separated from other patients
Personal practices including wearing minimal jewelry (so it cannot be grabbed), wearing hair
short or close to the head (so it cannot be grabbed), avoiding stairways at night or when fewer
staff are around, using a buddy system to avoid being alone in areas of potential risk, and
withholding personal information (concerning yourself or others) from patients and their
families, such as address, phone number, names of family members, etc.
Hospital policies including prosecuting to the full extent of the law for acts of violence, reporting
all threats and incidents to supervisors for investigation, providing security and/or escorts when
travelling to and from parking areas (especially at night), and using code words to alert others of
a problem or when discussing sensitive topics such as drugs or money.
Be sure you know the security policies and procedures of your facility. Use security practices properly to
help prevent violence in your workplace.
Diffusion of Violent Incidents
Signs of anger
Violent incidents are often the result of someone's anger.
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A red face, clenched fists, and swearing are signs that indicate a person is angry.
When people get angry, their heart rate, blood pressure, and adrenaline levels rise. These signs are not
visible, but there are other signs that will help you recognize that a person is angry or getting angry.
Signs of anger include:
Reddening of the face
Staring eyes
Rapid breathing
Shouting (although some people may become quieter)
Clenching fists
Swearing
Pacing
Challenging behavior.
Causes of anger
Anger can lead to loss of control, which may result in violence. Understanding the causes of anger will
prepare you to respond to anger and diffuse a potentially violent incident before it happens.
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If you feel that a person is getting out of control and may attack you, take the following precautions to
protect yourself:
Don't try to be a hero. ... Get out!
Loosen or take off items of clothing such as a scarf or necktie that the angry person could grab.
Remove high heels if you feel you may need to run.
Move to a place where the furniture in the room is not blocking the exit or the pathway to the
door.
Stay at least six to seven feet away from the angry person.
If the person comes toward you, hold your arms up with the palms facing outward.
Trust your instinct; get out if you feel it is necessary.
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Wrong patient
Wrong medication
Wrong dosage or concentration
Medication given incorrectly
Medication prescribed to which patient is allergic.
Sometimes, these errors involve drugs that have similar names or that come in similar packages. In all,
the wrong medication being given accounts for 15% of medication errors. In many cases, the drugs
involved in medication errors are those kept on floor stock. These are less likely to have gone through a
pharmacy check or to have been checked by another person before being given.
Other reasons that errors are made include:
Lack of knowledge about the drug
Lack of information about the patient
Violations of rules and procedures
Lapses and slips in memory
Transcription errors when copying names or dosages
Faulty patient identity checking
Miscommunications between different services in the facility
Improper dose checking
Problems with delivery equipment (such as an infusion pump).
Many of these factors can also contribute to procedure or treatment errors:
Faulty patient identity checking could result in lab tests being performed on the wrong patient.
Miscommunications between services could result in breakfast being served to someone who is
scheduled to have surgery or a diagnostic test and is classified as NPO (not allowed to take
anything by mouth).
Violations of rules and procedures, such as not following the surgical checklist, could result in
performing the wrong surgery or other serious consequences.
Identifying system problems
If you know that you have made an error, or if you discover an error made by someone else, it is
important to report it. Your facility has a procedure that you should follow for reporting medication or
treatment errors.
Most errors are not the fault of one person. There is a combination of factors in the process of delivering
a treatment, procedure, or medication. It is important to find out what went wrong, so that the system
can be corrected and future errors of the same type can be avoided.
Here is an example of how an error can occur:
A doctor writes an order for Chlorpromazine.
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Result: The patient receives an incorrect medication and also does not receive the prescribed
medication.
What went wrong? The mistake is not the fault of one person. The error is a result of a combination of
factors. Correcting this problem would involve investigating:
Why the pharmacy technician was distracted
Why the drugs are stored so that they could be confused
Why the nurse did not notice the error.
The goal of reporting and investigating is not to blame someone. The goal is to fix problems in the
system so that the same error will not happen again.
Preventing medication errors, the Five Rights
There are things that you can do to help prevent medication errors. One of these is to follow the "Five
Rights":
Right patient: Always check patient identification.
Right medication: Read the labels. Follow the system that your facility uses to make sure that
you have the right medication and concentrations.
Right dosage: Check the concentrations and amounts.
Right time: Give medications according to the patient's treatment schedule.
Right route: Administer the medication via the right route (orally, intramuscular injection,
intravenously, etc.)
Some facilities have automated systems for delivering medications. This can greatly reduce errors, but
will not eliminate them. Your common sense is also important. If something doesn't seem right, stop
and INVESTIGATE.
For example:
If the patient says that the medication is different or not right, INVESTIGATE.
DOUBLE-CHECK any order you are unsure of.
Error
Sentinel Event
Near Miss
Hazardous Condition
Error
An Error is an unintended act of either omission or commission, or an act that does not achieve its
intended outcome. In other words, an Error is:
Something done by accident
Something that should have been done but was not
Something that was done that did not have the expected result.
An example of an Error is a patient's blood pressure not being measured when it should have been.
Sentinel Event
A Sentinel Event is an unexpected occurrence which actually happened and which either resulted in
death or serious physical or psychological injury, or carried a significant risk thereof. Serious injury
specifically includes loss of limb or function.
An example of a Sentinel Event is the wrong dose of medication being given to an infant, causing death.
Certain types of events are reported to The Joint Commission under their Sentinel Event policy, whether
they actually or potentially resulted in death or serious injury. These events are:
Rape
Patient suicide
Infant abduction or discharge to the wrong family
Hemolytic transfusion reaction involving administration of blood or blood products
Surgery on the wrong patient or wrong body part.
Near Miss
This term is used to describe any process variation which could have led to a Sentinel Event, but the
Sentinel Event did not actually happen because of some kind of intervention. A recurrence of the
process variation carries a significant chance of a serious adverse outcome.
Here is an example of a Near Miss. By mistake, a patient is handed a medication to which she is allergic,
and which could lead to death or serious illness. Fortunately, she recognizes the medication is different
from what she is usually given, questions staff about it, and ultimately receives the correct medication,
instead. In this case, the process variation is that the patient is not wearing a wrist band listing her
allergies, and that the information about her allergies is not available to staff anywhere else.
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Patient suicide
Operative/post operative complications
Wrong site surgery
Medication errors
Delays in treatment
In 2002, TJC began implementation of the National Patient Safety Goals program. Each year, experts
recommend, emphasize, or de-emphasize certain patient safety goals based on analysis of the sentinel
event program.
The National Patient Safety Goals promote and improve patient safety in certain identified problem
areas. Where possible, the goals will focus on system-wide solutions. TJC monitors accredited
organizations' compliance with those goals, and expects organizations to be in compliance.
*A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury,
or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk
thereof" includes any process variation for which a recurrence would carry a significant chance of a
serious adverse outcome. . . Such events are called "sentinel" because they signal the need for immediate
investigation and response.
(TJCs Sentinel Event Policy and Procedures Revised: July 2002)
Patients who meet appropriate criteria (see your local standards) are referred to the appropriate
referral network affiliated with your healthcare facility. Most organ donors are patients who have been
declared brain dead.
A typical process for the determination of brain death is a clinical exam by an LIP with an apnea test,
then confirmatory tests of cerebral brain flow, and/or an additional exam with an apnea test 6 hours
after the initial exam and test.
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Referral process
Know your local standards. Typically, a healthcare professional contacts a representative of the referral
network which then conducts a phone evaluation that includes demographics, cause of death, neuro
status, medical history, family information, hospitalization and current medical status. Based on the
phone assessment, a transplant coordinator conducts an onsite evaluation.
Approaching the family about organ donation
Know your local standards. Generally, an approach is only made in collaboration with the state referral
network. And that approach is typically not made until after medical suitability for referral has been
determined by the network. Local standards will determine who can authorize the donation.
Donor management
Maintain organ function, oxygenation, and hemodynamic stability. Key parameters include urine output,
CVP, systolic BP, pH, electrolytes, and O2 saturation. In addition, there are organ and tissue-specific
procedures depending on what will be donated.
Nurses role in organ and tissue donation
Refer appropriate patients (know your local standards) to state referral network
Ensure that discussions take place only with participation of the referral network
Assist in maintaining organ viability
End of Organ and Tissue Donation Lesson
Pain Management
Pain Facts; Pain Myths
What is pain?
Pain is the most common reason that people in the United States seek medical care. Every year, painrelated complaints result in:
Approximately 140 million physician visits
More than $100 billion in healthcare costs and lost work time.
More than 2.6 million people routinely take prescription medication for pain. But what is pain?
Pain can be defined as "an unpleasant sensory and emotional experience associated with actual or
potential tissue damage."
It is important to remember that pain is very subjective. Pain is whatever the patient says it is. It is
experienced differently by different people.
A number of factors can influence the way that different people experience pain:
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Family and social expectations can also play a role. The experience of pain may be influenced by the way
that the patient was brought up to view and deal with pain, and by the expectations of the patient's
culture or society. Finally, some people are physically more or less sensitive than others to actual or
anticipated injury.
Acute and chronic pain
Pain is often described as either acute or chronic. These terms describe the duration of the pain and the
way it may respond to treatment. They do not describe how severe the pain is.
Acute pain
Acute pain is caused by a specific physical condition. It includes such things as:
Pain following surgery
Pain of a sore throat
Pain of an injury.
Acute pain has a well-defined onset, is temporary, is predictable, and is treatable. Once the condition
causing the pain no longer exists, the pain will go away.
Chronic pain
Chronic pain is different because it may not have a specific onset or timecourse. Chronic pain:
Lasts more than a month
May not respond predictably to treatment
May not result from a particular injury or event.
Pain resulting from an injury or surgery may also be classified as chronic pain, if the pain continues much
longer than the normal healing period.
Cancer Pain
Cancer pain is sometimes considered as a separate type of pain. Cancer pain can be acute or chronic. If
the cancer is not curable, the pain may get worse and worse as the disease progresses. Cancer pain may
be caused by:
The disease itself
Treatments (such as surgery, chemotherapy, and radiation)
Infections.
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Like the other vital signs, pain needs to be assessed at certain times during treatment. This should begin
when the patient is first admitted. After admission, follow-up pain assessments should take place:
At regular intervals
After any intervention to decrease pain (to find out if the intervention helped)
At discharge.
The Joint Commission (TJC) has standards for the assessment and management of pain. Under TJC
standards:
All patients are screened for pain when admitted
Patients are re-assessed regularly for pain
Patients are taught about pain control
Patients are given discharge instructions about pain management.
Physical signs of pain
There are a number of physical signs that can show that someone may be in pain. Physical signs include:
Grimacing
Crying
Moaning
Tension
Withdrawal
Restlessness
Guarded movements
Rubbing area of pain.
Increased pulse, respirations, and blood pressure may also be signs of pain. These may not be accurate
signs, however, so they should only be used when the patient is not able to report pain verbally.
Record any physical signs you see, as well as the patient's report of any pain. This will help you and other
staff to be alert for the signs later. Remember that every patient experiences pain differently. Any signs
you observe apply only to that patient.
How to assess pain
Even though there may be some physical signs, the best indication of pain is what the patient says.
To assess pain, your facility has a pain assessment tool. The tool will have some kind of a rating scale.
For example, it might ask patients to rate their pain on a scale from 1 to 10, with 1 being no pain and 10
being the worst pain imaginable. Some facilities use a graphic scale with faces that range from a smiley
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Pharmacological interventions
Non-pharmacological interventions
Pharmacological interventions are pain control methods that use medications. These include:
1. Opioids, such as morphine and codeine
2. Non-opioids, such as acetaminophen
3. Adjuvants, a variety of drug types that are usually used to supplement opioids or non-opioids.
Non-pharmacological interventions are alternative measures that do not use drugs. The methods that
are selected will depend on the needs of the patient. Non-pharmacological pain management methods
include:
Relaxation and distraction techniques
Physical interventions.
Relaxation and distraction techniques
These techniques work best if they are practiced before they are needed for pain relief. They include:
Deep breathing (with focus on breathing techniques)
Listening to music
Guided imagery
Biofeedback
Hypnosis.
Physical Interventions
Physical interventions that can help in the treatment of pain include:
Massage
Exercise (especially for chronic pain)
Application of heat or cold (not longer than 20 minutes; be careful of extremes of heat or cold
that could damage tissue)
Acupuncture
Position change
TENS unit (trans-electrical nerve stimulation therapy).
A TENS unit controls pain by stimulating the nerves at the pain location and helping to block pain signals.
A mechanism of action of acupuncture has not been determined. There is no evidence for the energy
fields mechanism commonly described, and much evidence against its existence. The effect may simply
be placebo, but in any case, many patients report pain relief with acupuncture and it is widely accepted
as a legitimate physical intervention for pain.
Non-opioid medications
When using drugs to control pain, the best strategy is to use the least strong drug which still gives
adequate pain relief. If the intervention does not relieve the pain, it may require:
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An increase in dosage
An increase in frequency
An increase to the next level of drug.
Usually, pain control measures begin with non-opioid (non-narcotic) drugs. Non-opioids, such as
acetaminophen (Tylenol) are generally available in both over-the-counter and prescription strengths.
Non-opioids are usually taken orally or by suppository. The most common side effect of acetaminophen
is hepatotoxicity (liver involvement). This is most common with an overdose.
Non-opioids also include NSAIDS (non-steroidal anti-inflammatories), such as Advil and Motrin. These
may also be used in combination with opioids. The most common side effects of NSAIDS are:
Gastric irritation
Prolonged bleeding time.
Opioids and adjuvants
The name, opioids, refers to drugs that are based on opium. They can be either natural or synthetic.
Opioids are used for moderate to severe pain.
Pure agonists
One class of opioids, known as "pure agonists", which refers to their specific mechanism for pain relief,
includes:
Morphine
Hydromorphone (Dilaudid)
Fentanyl
Codeine.
Increased dosage of pure agonists provides increased analgesia (pain relief) and increased side effects.
Side effects include:
Euphoria
Sedation
Constipation
Nausea
Vomiting
Itching
Urinary retention
Hypotension
Respiratory distress.
Over time, patients may develop a tolerance for opioids, meaning they require higher dosages to
achieve the same pain relief. However, the usual reason for increasing dose is because of disease
progression. Patients who have received opioids for a long period of time may experience withdrawal
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You must provide patients with full explanations of recommended treatments, reasons for
giving treatments, potential benefits of receiving treatments, and risks of refusing treatments.
For example, if cancer patients refuse to accept chemotherapy treatments, they must be made
to realize that although there are risks associated with treatment, there are also risks associated
with not accepting treatment and the disease may progress without it.
You must let patients know that they have to provide accurate information about insurance
coverage and determine if they understand the limits of their policies. They must be made
aware that they are responsible for procedures not covered by their insurance company.
You may not only have to inform patients and their visitors of hospital rules and regulations, but
you may also have to enforce the rules and regulations. For example, visitors may have to be
told that visiting hours are over and they must leave the hospital.
You may have to tell patients that they must respect the rights of other patients. For example, if
they are playing music too loudly and it is disturbing others, you may have to tell them to lower
the volume.
Transfer belts enable employees to grip patients more firmly and control their movement during transfer.
Studies show that using a transfer belt increases patient satisfaction. Lifting patients manually without a
transfer belt may cause the patient discomfort under the arms. Patients also prefer the transfer belt
because they feel more secure. The belt gives the employee the ability to better control the patient's
movement during a transfer.
A transfer belt should not be used with some patients. These include:
Pregnant patients
Patients who have undergone recent abdominal surgery
Patients who are experiencing pain in the abdomen
Patients who have ostomies (such as a colostomy, ureterostomy, iliostomy)
Patients who are unable to tolerate the pressure of the belt.
Remember that a transfer belt is to assist in the transfer of a patient. It is NOT intended to lift a patient.
When performing this transfer, if patients wish to hold on to you for support, ask them to hold on to
your upper arms, forearms, or waist. Never allow a patient to hold on to your neck. If you are concerned
that a patient may grab your neck, you may grip the transfer belt by placing your arms around the
patient's arms.
If a second employee is available to help with the transfer, a similar process is used. The second
employee should be behind the patient with one knee on the bed. The second employee grips the
transfer belt from the back. The first employee uses a gentle rocking motion to stand the patient up. As
soon as the patient clears the bed, the second employee shifts the patient to the chair.
Bed to Stretcher Transfer
Safe practice when performing lateral transfers
Healthcare is a physically demanding occupation. In fact, the nursing profession has one of the highest
rates of work-related back injuries. Many of these injuries occur during patient transfers.
The most hazardous types of patient transfers are:
Bed to chair
Bed to stretcher
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Reposition in bed.
It is important to follow proper transfer techniques to reduce the chance of injury. In addition,
whenever you move a patient or lift, push, or pull an object, it is important to use good body mechanics.
Even a light load can cause lower back strain if poor body mechanics are used.
Using good body mechanics includes keeping your back in proper alignment. To maintain the back's
natural S-shape, keep the ears, shoulders, and hips in a straight line. When bending forward, this
straight line is maintained by bending at the hips, not the waist.
In addition to back injuries, there are other risks to both patients and employees from improper transfer
techniques. These risks might include falls, dislocation, and shoulder strain to name a few.
Types of lateral sliding aids
A lateral transfer is the movement of a patient, who is in a lying down position, from one flat surface to
another. One example of a lateral transfer is a transfer from bed to stretcher.
There are many types of aids available to make the process of a manual lateral transfer easier. A sliding
aid should always be used when performing a lateral transfer. Lateral sliding aids include draw sheets,
transfer pads, and transfer boards.
Draw sheets
A draw sheet or any short sheet can be used as a sliding aid. There are also specially designed roller
sheets. These are made of special fabrics that have low-friction inner surfaces. The layers of fabric roll or
slide over one another during the patient transfer.
Transfer pads
Various types of pads are also available. These may be quilted pads with pull straps and a roller sheet
underneath. The pads may also come with slats that can be used to bridge small gaps between surfaces.
Transfer boards
Transfer boards are also used. These may use various low-friction or roller technologies so that the
patient can be pulled across easily.
Other sliding aids can also be used to transfer a patient from a bed to stretcher. Whatever type of aid is
used, always remember to:
Follow any procedures established by your facility
Become familiar with the type of sliding aids available
Make sure there is enough space to perform the transfer
Remove any obstacles
Keep your center of gravity as near the patient as possible
Eliminate reaching and twisting
Raise the bed to a comfortable height whenever possible
Apply brakes on both bed and stretcher
Clean the sliding aid between uses to prevent infection.
Ambulating with the Patient
Safe practice when ambulating with the patient|
Your back is very important. It provides balance and support to your whole body. Suffering a back injury
can have a serious impact on the way you live and on the things you can do.
When ambulating with a patient, you walk beside the patient and provide assistance. If you are
ambulating with a patient, performing a transfer, or doing any other job that requires lifting, follow
these guidelines to help maintain a healthy back:
Maintain the back's natural curves by keeping the ears, shoulders, and hips aligned.
Lift and lower with your legs, not your back.
Keep the weight close to your body.
Bend at the hips, not the waist.
Avoid twisting or turning the upper body when carrying or lifting.
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Explain what you are doing to patients and other employees who are participating.
Make sure that both you and the patient are wearing non-slip footwear.
Be sure the floor is dry and obstacles are removed.
Get assistance whenever possible.
If patients are not used to getting up, allow them to sit on the side of the bed for a few minutes before
standing. This can help to prevent dizziness.
If the patient begins to fall, DO NOT try to stop the fall. Instead, ease the patient down gently. Provide
support, bending your knees not using your back, and guide the patient to the floor. Do not try to get
the patient up off the floor by yourself.
A transfer belt is not intended to lift a patient. You are also not in a position to maintain good body
mechanics and support the patient's entire weight. Trying to hold the patient up could cause serious
injury to both the caregiver and the patient.
End of Patient Transfers and Body Mechanics Lesson
Population Served
Becoming Knowledgeable about the Patients You Care for
Background
This module is intended to raise awareness of The Joint Commissions (TJC) requirement that training
and orientation for healthcare professionals (HCPs) be relevant to the populations they served, and to
place the Caregiver Safety Series in that context.
This terminology, population served, can be seen as a maturation of the TJCs earlier campaign to
integrate age-specific care into facilities orientation programming. HCPs care for people all across the
lifespan, and quality care and the assurance of patient safety depend on that knowledge. It is obvious
that many other issues are as vital as age and developmental stage to quality care and patient safety.
In addition to age and transcultural issues, the concept of population served incorporates broader
demographic data, morbidity, socioeconomic status, and access (and barriers) to care. Population served
is a concept that encompasses the nature of the people and families and even of the region served by
the healthcare facility.
Naturally, as a program intended for Cross Country travelers and per diems (or HCPs employed by Cross
Country allies), our orientation materials must necessarily be from a high-altitude, national, and generic
point of view. As a result, there are two primary aims of this module:
1. Provide the knowledge and point of view you will utilize in your study of the Caregiver Safety
Series.
As you complete the various components of the training, please focus on, and look for, the
special relevance of those components to the patients for whom you will be caring at your next
assignment.
2. Provide the knowledge and tools you will utilize in your own investigations and discussions
about population served prior to, and after, arrival at your assignment.
In preparation for your assignment, please try out some of the suggested methods below that
will enable you to gain as much information as possible about the demographics and health
issues of the population for whom you will be caring.
Regional differences in populations
Each healthcare facility serves a unique population that differs from the population served by other
facilities in a variety of ways.
Social Explorer at http://www.socialexplorer.com/pub/home/home.aspx displays graphic versions of US Census
Data that demonstrate how populations trend in different regions.
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The map below shows the median age for different areas of the country; darker areas have a higher
median age than lighter areas.
The following map shows concentrations of members of the Muslim religion in the United States. Darker
areas have higher concentrations.
Health data is a bit harder to find than census data, but the Centers for Disease Control provides a
wealth of data to the public on national and regional health issues and trends.
One excellent publication is the Health United States publication:
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The following section will provide some tools and suggestions for identifying local and regional
demographic and health information.
Identifying the Population Served
Sample investigation: Broward County
While it may be difficult to research a particular facilitys population prior to an assignment, the nature
of that facilitys population can be easily investigated. For example, if your next assignment was at a
hospital in Broward County, Florida, here are some of the steps you might take to get a feel for the
population served by your facility.
Regional demographic data
The US Census Bureau provides an excellent summary of state and county statistics at the following
address:
http://quickfacts.census.gov/qfd/
Further information
Broward
County
People QuickFacts
Florida
1,759,591
18,251,243
8.4%
14.2%
1,623,018
15,982,378
6.5%
6.3%
23.6%
22.2%
14.3%
17.0%
51.4%
50.9%
69.6%
80.0%
25.3%
15.9%
0.4%
0.5%
3.0%
2.3%
0.2%
0.1%
1.4%
1.3%
23.4%
20.6%
48.1%
60.8%
Living in same house in 1995 and 2000, pct 5 yrs old & over
47.1%
48.9%
25.3%
16.7%
Language other than English spoken at home, pct age 5+, 2000
28.8%
23.1%
82.0%
79.9%
24.5%
22.3%
310,454
3,274,566
27.4
26.2
803,064
8,718,385
69.5%
70.1%
47.5%
29.9%
$128,600
$105,500
654,445
6,337,929
2.45
2.46
$52,504
$47,804
$23,170
$21,557
11.4%
12.1%
Note the link at the top of the page to Browse data sets for Broward County. Clicking that link will
produce, among many interesting tables, a Profile of General Demographic Characteristics: 2000.
SEX AND AGE
Male
Female
783,232
839,786
48.3
51.7
Under 5 years
5 to 9 years
10 to 14 years
15 to 19 years
20 to 24 years
25 to 34 years
35 to 44 years
45 to 54 years
55 to 59 years
60 to 64 years
65 to 74 years
75 to 84 years
85 years and over
103,041
110,142
109,132
95,161
82,834
230,864
278,547
215,086
76,548
60,554
116,641
101,417
43,051
6.3
6.8
6.7
5.9
5.1
14.2
17.2
13.3
4.7
3.7
7.2
6.2
2.7
37.8
(X)
1,240,089
586,807
653,282
1,189,386
296,169
261,109
105,784
155,325
76.4
36.2
40.3
73.3
18.2
16.1
6.5
9.6
RACE
One race
White
Black or African American
American Indian and Alaska Native
Asian
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian 1
Native Hawaiian and Other Pacific Islander
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander 2
Some other race
Two or more races
1,568,597
1,145,287
333,304
3,867
36,581
14,217
8,230
4,314
989
2,256
2,697
3,878
916
202
154
130
430
48,642
54,421
96.6
70.6
20.5
0.2
2.3
0.9
0.5
0.3
0.1
0.1
0.2
0.2
0.1
0.0
0.0
0.0
0.0
3.0
3.4
1,175,608
360,611
8,140
45,601
3,086
86,944
1,623,018 100.0
271,652 16.7
19,451
1.2
54,938
3.4
50,911
3.1
146,352
9.0
1,351,366 83.3
941,674 58.0
RELATIONSHIP
Total population
In households
Householder
Spouse
Child
Own child under 18 years
Other relatives
Under 18 years
Nonrelatives
Unmarried partner
In group quarters
Institutionalized population
Noninstitutionalized population
1,623,018 100.0
1,603,094 98.8
654,445 40.3
301,745 18.6
445,172 27.4
341,255 21.0
103,814
6.4
33,751
2.1
97,918
6.0
41,638
2.6
19,924
1.2
13,063
0.8
6,861
0.4
72.4
22.2
0.5
2.8
0.2
5.4
HOUSEHOLDS BY TYPE
Total households
Family households (families)
With own children under 18 years
Married-couple family
With own children under 18 years
Female householder, no husband present
With own children under 18 years
Nonfamily households
Householder living alone
Householder 65 years and over
654,445 100.0
411,403 62.9
191,804 29.3
301,745 46.1
131,559 20.1
81,818 12.5
47,190
7.2
243,042 37.1
193,701 29.6
81,408 12.4
210,779
188,789
32.2
28.8
With just a few clicks, it is possible to view age, ethnicity, income, income, disability status, health
insurance coverage, and many other key demographics that help develop a picture of the population
served by Broward County hospitals.
Regional health data
The Centers for Disease Control is an excellent source of health date. Their DATA2010 website is easy to
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Though not county specific, heres a screenshot of the tiny portion of the data set that was displayed by
selecting the years 1999 through 2005 for people 65 and older:
Data shown include diabetes-related deaths for that age group as well as rates of flu and pneumonia
vaccinations.
Numerous diseases, conditions, and healthcare structural issues (such as access to care) can all be
investigated at this site.
In looking for closely at local health concerns, it is usually possible to find that information at the local
health department. A few minutes browsing the Broward County Health Department website gives a
nice appreciation for that areas health issues and concerns. Here is a site map from that website,
http://browardchd.org/Services/Administration/SiteMap.htm#Disease :
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Children
Chicken Pox
Diarrhea
Drowning Prevention
Head Lice
Immunization Schedule
Fort Lauderdale
Hollywood
Plantation
Pompano
Dental
Family Planning
Flu
Hepatitis
HIV
Immunization
Northwest Health Center
Pregnancy Prevention
Refugee
Sexually Transmitted Disease
Teen
Travel
Tuberculosis
Women Infants Children: WIC
Chlamydia
Cold or Flu?
Encephalitis
Gonorrhea
Hepatitis A
Hepatitis B
Hepatitis C
Influenza: the Flu
Meningitis
Pneumonia
Rabies
Salmonellosis
Scombroid
Shingellosis
Clinics
Disease
Emergency
Health
Breast Cancer
Hurricane
Other
Safety
Lead Poisoning
Seniors
Reporting Abuse
Retiring to Florida
Services
Birth Certificates
Cancer
Communicable Diseases/Events
Death Certificates
Dental
Environmental Health
Health Education
Immunization
KidCare
Medical
Nursing
Pharmacy
Social Services
Vital Statistics
Teens
Services
Facility and department specific data
Naturally, facility and department information will be hard to investigate prior to assignment. However,
the process for identifying the population served is an easy one at this point. Though healthcare facilities
collect these data in a formal way, you do not need to ask administration or Risk Management for these
studies.
Instead, discuss with your colleagues supervisors and department manager(s) the following issues
related to your assigned facility and department(s):
Facility specific training and orientation materials addressing population served
Prevalence of various age groups
Types and prevalence of various ethnicities and languages
Types and prevalence of the diseases, admission diagnoses, and nursing diagnoses
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The above is just a short list of examples. Start the conversation and see where it leads. Because you
have researched the region, youll be prepared to hear and understand how local health issues are
framed, and already have come armed with a good idea about the major sources of concern for staff,
patients, and families.
Hopefully this presentation has demonstrated what is meant by population served and has pointed the
way to several sources of data on that population that can be accessed even before arriving at your
assignment.
End of Population Served Lesson
Procedural Sedation
Procedural Sedation is defined here as the use of minimal and/or moderate sedation for the purpose of
diagnostic and therapeutic interventions (e.g., minor surgery). Minimal and moderate sedation occupy a
middle ground in the depth of sedation continuum, and are both safer than anesthesia:
Purposes of procedural sedation
Mild Sedation reduces patient anxiety, and as a result, reduces discomfort and enhances compliance. A
common example of mild sedation is the preoperative administration of a benzodiazepine for the relief
of anxiety.
Moderate sedation reduces anxiety and pain, enhances compliance, maintains stable vital signs,
produces amnesia, and speeds recovery when compared to anesthesia.
Deep Sedation produces a decreased level of consciousness to the extent that it enables the patient
to experience a painful procedure, but is relatively safer than anesthesia and speeds recovery when
compared to anesthesia.
Unaffected
Adequate
Unaffected
Usually adequate
Deep Sedation
Purposeful response to
repeated or painful
stimulation
May require
intervention
May require
intervention
Usually adequate
Anesthesia
Unarousable
Intervention required
Intervention required
Intervention may be
required
Mallampati Scoring
Courtesy of Creative Commons Attribution-ShareAlike 3.0 Unported
Any Class greater than Class I could be cause for concern and for notifying the physician/LIP in
responsible for the procedure.
Universal Protocol
Rather than duplicate content in the UP module in this same course, please refer to that module for
ensuring patient safety in regards, to proper site and procedure.
Equipment requirements
IV
Oxygen
Suction
Code cart
Medications (drug antagonists and reversal agents, and emergency medications)
Monitoring Protocols
Generally accepted protocols for assessment which also conform to broader Joint Commission
guidelines for care include:
A pre-sedation assessment is conducted for each patient
Each patients sedation care is planned
Sedation options and risks are discussed with the patient and family prior to administration
The patients physiological status is monitored during sedation. Generally accepted guidelines
include a minimum of q5 (Deep Sedation) and q15 minutes (Moderate Sedation) to include, at
minimum, vital signs, pulse oximetry, pulses, Sedation level, and cardiac monitoring if indicated.
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The RN monitoring the patient must have no other responsibilities (that could impede that monitoring)
from the time the 1st dose of sedative is administered until the procedure is complete the patient has
returned to baseline.
With geriatric patients, special attention is paid to dosages, evidence of sedation and respiratory
depression, and probable increased circulatory time and decreased metabolism of medications.
All healthcare professionals caring for patients during procedural sedation must be appropriately
trained/credentialed as required by state law and relevant practice acts.
Pharmacology
Drugs used in procedural sedation ideally meet the requirements that they decrease anxiety and/or
reduce pain with minimal side effects, as well as have a fast onset and short duration of action. The
most common agents are propofol, bendiazepenes, ketamine, opioids, and etomidate. These drugs are
most commonly administered as a bolus plus continuous infusion. Patient monitoring during
administration is primarily focused on minimizing/managing the adverse hemodynamic and respiratory
effects of these drugs.
Propofol
Propofol is an effective sedative and amnesiac agent. Because it is not an analgesic, it is given in
combination with other drugs when pain control is needed. Hypotension and respiratory depression are
common side effects, and cardiopulmonary side effects are sometimes seen when coadministered with
sedatives and/or analgesics. The drug is usually administered in an initial IV bolus and additional boluses
if needed. To minimize hypotension, the bolus is administered in small increments.
Benzodiazepenes
Midazolam is the most commonly administered benzodiazepine in procedural sedation due to its fast
onset and short duration. Benzodiazepenes reduce anxiety and can cause sedation and retrograde
amnesia. As with propofol, midazolam is given in combination with other drugs when pain control is
needed. Hypotension and respiratory depression are common side effects, and cardiopulmonary side
effects are sometimes seen when coadministered with sedatives and/or analgesics. In as many as 15% of
patientsmost commonly children and older adults, the drug can cause symptoms of paradoxical
excitement including agitation, anxiety, and aggression. Flumazenil is an effective reversing agent
recommended for acute benzodiazepine overdose, but is contraindicated in patients who are chronic
users of benzodiazepines because reversal can lead to withdrawal symptoms and seizures in that
population.
Etomidate
Primarily a sedative, this drug is often coadministered with analgesics. It is generally used for shorter
procedures due to its rapid onset and short duration of action. Unlike many sedatives, etomidate has
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Quality Improvement
The concept of quality improvement
An organization is a system made up of many parts, and each part has a specific role to play within the
organization. Processes, such as admitting patients or providing meals to patients, are things that help
the organization accomplish its goals.
A Process is all of the steps involved in doing a particular procedure or task, and it may involve more
than one department. For example, the process of admitting a patient is all of the steps that go into
admitting the patient.
1. The patient gets the admission order from the physician office and walks into an Admitting
Department.
2. The volunteer has them sign in and wait.
3. An admitting clerk calls them into the admitting area and has them answer questions and sign
papers.
4. Someone from Transportation takes them up to their room and gives the paperwork to a staff
person.
Quality improvement ensures that an organization's processes are designed to fulfil its goals. It entails
looking at the mission, values and goals of the organization to determine whether its processes could be
improved.
The focus of quality improvement is not on the people, but on the process. It is designed to determine
what areas of service must be improved. Quality improvement involves gathering and analyzing data to
see if outcomes are consistent with the mission, values and goals of the organization. It also determines
whether outcomes are in line with established benchmarks for the industry. Benchmarks are industry
standards by which an organization's outcomes are measured.
For example:
"Are waiting times in the emergency department of your organization comparable to the
waiting times set as standards within the healthcare system?"
Implementation of Quality Improvement
The Joint Commission mandate to healthcare organizations
The Joint Commission mandates that healthcare organizations systematically:
Monitor and evaluate the quality and appropriateness of care
Pursue opportunities to improve patient care
Resolve identified problems.
Organizations must have a written plan that describes the program's objectives, organization, scope,
and mechanisms for overseeing the effectiveness of monitoring, evaluating, and problem-solving
activities.
Organizations have adopted various methods and plans to monitor processes, improve processes, and
solve problems. Terms referring to these plans include Continuous Quality Improvement (CQI), Total
Quality Management (TQM), and Performance Improvement (PI).
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Quality improvement should entail a constant cycle of continuous improvement. One model is PDCA:
Plan, Do, Check and Act.
Act: If process works, implement overall change. If process does not work, begin again with a
modified "Plan."
Radiation Safety
Dangers of Radiation
Radiation is energy traveling through space. Sunshine is one form of radiation. It provides heat, light,
and tans our bodies. Too much sunshine may be harmful so we control our exposure to it with
sunglasses, sunscreen, clothing, and shade.
Other types of radiation are infrared and ultraviolet. Some kinds of radiation are known as ionizing
radiation and they can be harmful to living tissues. Just as we protect ourselves from sunshine, we also
must protect ourselves from ionizing radiation.
Controlled amounts of ionizing radiation are used in health care to visualize organs, bones, teeth, etc.
These types of ionizing radiation include X-rays, gamma rays, and radiation emitted by radioactive
materials. Different types allow us to either see body structures and diagnose disease. Some ionizing
radiation is used to treat disease by destroying damaged tissues.
Naturally occurring ionizing radiation provides light and heat and supports life. Artificially produced and
controlled radiation can be used to promote health and save lives. Radiation of any kind can cause
damage to living tissue so, it is necessary to control the amount of exposure.
Warning signs should be visible in all areas of the hospital where exposure to radiation is possible.
Ionizing radiation in hospitals is used for diagnosing and treating patients. Warning signs should be
visible in all areas of the hospital where exposure to radiation is possible. Major uses are of ionizing
radiation include:
Medical and dental x-rays
Nuclear medicine testing
Radiation treatments.
Medical and dental x-rays
Medical and dental x-rays are used to diagnose patient's conditions. X-rays enable specialists to
distinguish bones and dense organs like the lungs and heart, from less dense parts of the body such as
skin, muscle, and fat. X-rays, along with a "contrast medium" such as a "barium meal," is used to see
organs that cannot be seen by x-ray alone, and to see the shape, action, and state of disease or wellness
of these organs.
Nuclear medicine
Nuclear medicine may be used to diagnose patients' conditions. In nuclear medicine, radioactive
materials are inserted into the body. The radioactive materials emit radiation and a pattern outside the
body is captured as an image on a computer screen. The image along with mathematical imaging
techniques, is used to detect disease very early on in the disease.
Radiation treatment
Radiation treatment, or radiation therapy, is used to kill certain types of cancer cells. Radiation is most
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Spend as little time as possible close to the patient, but be careful not to make the patient feel
isolated. Talk to the patient from a safe distance.
Organize your patient care tasks so you minimize the time spent in close proximity with the
patient.
Distance
The further away you are from the radiation source, the less exposure you have.
Leave the room, or stand behind a shielded wall, when x-rays are being taken (including
portable x-ray equipment).
If you must stay in the room, wear a lead apron if one is available.
If you must stay in the room, stand at least 6 feet away.
If distance is not possible try to minimize the length of time you are in contact.
Shielding
Shielding refers to a barrier between the radiation source and yourself or others. Shielding can be
furniture, a wall, or even other people who have not been exposed as much as you have.
The purpose of lead walls in x-ray rooms is to separate the technician from the patient being xrayed.
Technicians and others who need to be close to the patient being x-rayed wear lead aprons.
Patients should wear lead aprons or other clothing to protect certain areas of the body when
another area is being x-rayed.
Safety features, such as built in lead, are used in the walls of rooms where radioactive implants
are given.
Pause for review
Identify potential risk situations and be alert and responsive to signs and directions in radiology
and nuclear medicine areas so you can minimize your exposure to radiation.
Exposure to radiation does occur if you have an x-ray, are close to others when they have an xray, if you receive radiation treatment, or if you are close to people who have radiation
implants.
Exposure to radiation does NOT occur just because you are in a radiology or nuclear medicine
department, near an x-ray machine that is off or not being used, or because you are near people
after they have had diagnostic radiation tests.
To keep exposure to radiation As Low As Reasonably Achievable (ALARA), remember three
things: the less time you are in an area where radiation is present, the less your exposure you
have; the greater your distance from the radiation source, the less exposure you have; and lead
shielding (between the radiation source and yourself or others) minimizes exposure.
Restraints/Restrictive Practices
A Philosophy for Using Restraints
What are restraints?
A restraint can be any mechanical device (physical restraint) or drug (chemical restraint) used to limit
the normal movements of a patient.
Physical restraints
Physical restraints include any device used for the purpose of restricting the movement of a patient or
denying the patient access to parts of the body. Examples of physical restraints:
Mittens
Vests
Limb restraints
Chest restraints
Roll belts
A siderail, when used for the SOLE PURPOSE of keeping a patient in bed, is also a restraint. However,
half-rails that still allow a patient to get out of bed, or that are raised to assist a patient in turning or for
some other purpose are NOT considered restraints. Similarly, supportive devices, such as a sling for a
sprained wrist, are not restraints even though they may restrict movement.
Soft (cloth) restraints may have to be replaced by stronger restraints (4-point leather) for extremely
agitated or combative patients. Leather restraints, used to secure ankles and/or wrists, are buckled into
place and may be locked.
A restraint is a physical device or a drug used to restrict or limit the normal movements of a patient.
Chemical restraints
Chemical restraints include any drug given for the sole purpose of restricting the movements of a
patient. Examples of chemical restraints:
Sedatives
Tranquilizers
Dangers of using restraints
There is always danger involved in restraining patients. In the US, approximately 100 deaths every year
are blamed on the use of patient restraints.
The use of restraints has been shown to:
Increase the number of falls (rails used to keep patients from falling sometimes cause more
injury because of patients crawling over them and falling from a greater height)
Increase the patient's length of stay in hospital (this can happen as a result of injuries acquired
when patients try to free themselves from restraints)
Increase mortality rates (patients are occasionally strangled by ties used to secure them to the
bedrail, or they may die from cardiac arrest due to the increased agitation of being restrained).
The use of restraints increases the number of patient falls, the length of stays in hospital, and mortality
rates.
Patients escaping physical injury from restraints may still suffer emotional injury. Patients have
reported:
Feeling humiliation and shame
Being increasingly confused
Not understanding why they were being restrained
Restraints are to be used ONLY as a last resort. They are used when other measures are not effective
and the patient could injure himself or others if his movement is not restricted. At times, combative and
confused patients who are potentially violent need to be restrained during an acute outburst. Patients
who are simply confused, but not violent, should ONLY to be restrained if they are endangering
themselves or others AND other methods are not working. The least restrictive type of restraint must
always be chosen.
Your facility may have policies that determine when restraints can be applied. Follow all policies of your
facility. Before taking any action, you must document (in writing) the reasons why restraints are
necessary (for example, "the patient is not able to understand the reason for having an IV line and
persists in removing it") and the reasons for choosing the particular type(s) of restraints (for example, "a
soft wrist restraint is being used to prevent the patient from pulling out the IV line").
In the above example, a patient, unable to understand the reason for using an IV line, may try to remove
it. That patient would have to be placed in a soft wrist restraint for ONLY as long as he or she is still not
able to understand the reason for the IV being in place. The restraint would be removed immediately
once it has been determined that the patient is able to understand the necessity of having the IV line in
place.
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Installing a bed alarm that detects patient movement and alerts staff.
Keeping the path to the bathroom free of obstacles such as tables or chairs
Using a nightlight or lamp so the patient is able to see where he or she is going
Keeping lights lowered if they are too stimulating or disturb the patient
Making sure the emergency call button or light is within reach of the patient and that the
patient knows how to use it
Placing a commode near the patient so trips to the bathroom won't be necessary
Reducing noise level wherever possible so as not to disturb the patient (for example, by keeping
voices down, turning down ringers on phones or lowering volumes on nearby TVs)
Drawing the curtains (around the bed or on the windows) to eliminate distractions.
Psychosocial interventions
Patients' fears, as well as other feelings, play a large part in determining how they behave. The
psychosocial aspect involved in providing patient care cannot be overlooked when trying to avoid the
use of restraints.
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DO NOT:
Secure restraint too tightly
Leave the patient unsupervised for any length of time.
Chest and vest restraints
There are times when patients must be immobilized in a bed or chair. However, chest and vest restraints
should ONLY be used as a last resort. They not only restrict patient movement, but they also pose a
safety hazard to the patient.
The guidelines listed below may be helpful when using chest and vest restraints.
DO:
Reposition the patient at least every 2 hours and adjust pillows for comfort
Check the patient, frequently
Follow the policies of your facility
Document the use of all restraints.
DO NOT:
Attach a chest/vest restraint to the bedrail
Use a chest/vest restraint if a less restricting device would be adequate.
Restraint Orders
What are restraint orders?
An order to restrain a patient MUST come through the proper authorities. It is usually issued by a
licensed independent practitioner (LIP) such as a medical doctor (MD), a doctor of osteopathy (DO), or
nurse practitioner (NP). Some hospitals might allow a physician assistant (PA) to give a restraint order,
but this is not common and depends on privileges granted by the hospital.
A restraint order must contain:
The type of restraint ordered
The reason for the restraint (based on the behavior of the patient - NOT on a diagnosis)
The time limit or duration of the restraint (NOT more than 24 hours)
The signature of the practitioner who issued the restraint order.
Summary of Joint Commission Standards
When to use restraint
Restraint is used only when clinically justified or when warranted by patient behavior that
threatens the physical safety of the patient, staff, or others.
The least restrictive method of restraint should be used.
Restraint is employed for the shortest time necessary.
Safe use
Restraints are applied according to written policies and procedures and are in regulatory
compliance
Restraints are pain-free.
Restraints are applied by trained staff.
Individualized use
A prescriber (LIP) responsible for the patients ongoing care orders the restraint
Within one hour of restraint initiation, an authorized licensed professional responsible for the
patients care will evaluate the patient in person, and, as soon as possible, consults with the
attending physician or LIP.
No standing or PRN orders
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Renewal orders may be made (unless state laws are more restrictive):
Q4 hours for adults at least 18 years old
Q2 hours for children 9 to 17
Q1 hour for children less than 9 years old
Every 24 hours (unless state law is more restrictive), an authorized prescriber may write a
new order.
Patients are continuously monitored for vital signs, circulation, and comfort by staff trained in
restraint application and use.
Documentation
Monitoring activities that must be documented include:
Releasing the restraints at least every two hours
Repositioning the patient
Checking circulation and performing range-of-motion exercises
Checking the patient's skin condition and noting skin care procedures
Offering nutrition/fluids at least hourly, unless sleeping (note times and patient's responses)
Providing toileting opportunities at least hourly, unless sleeping (note times and patient's
responses)
Assessing patient behavior at least hourly (to clarify the reason for continuing the restraint)
Assessing patient response to being restrained
Removing the restraints (when the criteria for the restraints no longer exist).
End of Restraints/Restrictive Practices Lesson
To meet the requirement for annual reporting of incident reports to specific national regulatory
associations
Depending on specific state law, the incident report is a confidential document that is protected from
discovery in a lawsuit at all cost. The incident report should never be copied and never be placed in the
patient chart. It should also never be referred to within the patient chart. Three examples that require
an incident report are patient falls, medication errors, and wrong site surgery.
Regulatory and contract compliance
The Risk Management department will assist in the compliance of current laws and regulations as well
maintenance of current certifications of regulatory organizations such as Joint Commission. The Risk
Manager will support human resources in their role of medical staff credentialing and reappointment as
well as maintaining representation on several facility committees including Quality Improvement. The
Risk Manager will additionally review all facility contracts and advertising for possible risk and
appropriate verbiage.
Education
Education of the staff is extremely important as a method of risk control because an educated staff will
be more apt to follow policies and understand how to decrease liability in their daily practice.
Risk Financing
This includes the selection of insurance coverage, the type of insurance, and the review of specific
insurance carriers. The Risk Manager will assist executive management in these critical decisions as a
vital member of the team.
Litigation and claims management
Another crucial responsibility of the Risk Management department is litigation or claims management.
When a lawsuit has been filed, the Risk Manager will be involved in all stages of this process from the
initial notification of a claim, or formal "notice of intent" to the final settlement or jury award. This
process may take years to proceed to completion. The Risk Manager will cooperate with the defense
attorney and the insurance consultant, to determine case strategy, aid in the investigation, discuss
reserving of monetary funds for expenses and indemnity, and manage the file to conclusion.
The Risk Management Process
Risk Identification is the first step in the Risk Management process. Potential problems prior to a patient
injury or actual problems that can result in a loss to the organization are identified through the use of
many different systems.
Some of the risk identification systems will include occurrence or incident reports, patient complaints,
performance improvement indicators, satisfaction survey reports, personal inspections, infection
control, sentinel event tracking, failure mode and effect analysis (FEMA). In failure mode and effect
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Do not be defensive or argumentative in the record. If you are not going to take an action, do
not write that you are going to take action.
Make sure all of your notes are legible. It can be construed as negligence if the record is not
legible. Do not use unauthorized abbreviations.
Use ink
Never erase an entry; cross out the incorrect entry with a single line and initial it, provide the
date and time for all entries,
Do not leave blank lines on the medical record,
Use a "late note" for matters charted out of sequence.
Document what is seen, heard, felt and smelled, thought processes, and non-compliant
behavior.
With the current nursing shortage, more hospitals may ask nurses to take assignments outside of their
scope. The hospital will then share a portion of the principal responsibility for sending the nurse to this
unfamiliar area.
When an incident occurs
When an incident occurs, there are several things that may happen.
Initially, an incident report should be written. This should be a confidential document from Risk
Management. As previously stated, it should never be copied, never be placed in the patient chart, and
never be referred to within the patient chart.
After this, you should not write any statements, give any formal statements, or sign any statements.
Your charting should be appropriate and complete as per the listed guidelines stated above.
You should no longer discuss this situation with anyone without the expert guidance of your employer's
Risk Management department. If you are ever contacted by an attorney or investigator in relation to any
past or present incident, please contact your employer's Risk Management department immediately.
End of Risk Management Lesson
Security
General Security Precautions
Protecting property
In every facility, it is important to follow security procedures. By taking simple security precautions, you
can help to:
Protect personal, patient, and institutional property
Maintain a safe environment.
Personal Property
There are a number of security precautions that you can take at your facility to help protect your own
personal property:
Lock car doors.
Secure all valuables.
Keep purses and wallets in a locked area or locker.
Remember that a locker is not secure unless it is locked.
Patient Property
Patients should be encouraged to leave their valuables at home. If patients choose to bring their
valuables into the facility with them, you can help to keep them safe by:
Securing patient valuables
Educating patients about security.
Follow your facility policy for securing patient valuables. For example, valuables may be placed in the
facility safe according to policy. You can educate patients by explaining the visitor policy, including who
can visit, visiting hours, and any restrictions. You should also explain how patients can identify staff.
Institutional Property
There are also things you can do to protect institutional property:
Keep restricted areas locked
Report missing or damaged equipment.
Following policy
Some areas in your facility may be restricted or "security-sensitive." This means that only people who
need to be in these areas should be there.
Security-sensitive areas may include the following:
Pharmacy
Operating rooms
Obstetrics (especially the Nursery)
Pediatrics
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If you work in a security-sensitive area, follow facility policies and procedures to keep them secure.
Procedures that should be followed all the time, especially in security-sensitive areas may include:
Wearing your ID badge
Keeping doors locked
Reporting missing or damaged equipment.
You should wear your ID badge according to facility policy. If you lose your badge, you should report it
and have it replaced immediately. It is important for you to be properly identified. It is also important to
insure no-one else uses your badge.
In addition to wearing your own ID badge, you should be suspicious of people who are not wearing
proper identification. Remember, wearing a lab coat or scrubs does not mean someone is an employee.
You should also be sure to keep doors to security-sensitive areas locked. Do not prop doors open that
are supposed to be secure. If you do see someone acting suspiciously, report it to your security
personnel.
There are good reasons that some areas need to be secure. For example, the pharmacy must restrict
access to drugs. In Obstetrics (particularly the Nursery), it is important to guard against infant abduction.
Medical Records contains sensitive personal information. By following procedures, you can help keep
these areas secure.
Ensuring personal safety
In addition to protecting personal, patient, and institutional property, it is important to ensure your
personal safety. Take the following simple precautions:
Do not walk alone to your car at night.
Park in well-lit areas.
Do not keep valuables in your car.
Report any potential security hazards.
Park in a well lit area and keep your car locked. If you have to leave after dark, ask someone to
accompany you to your car.
For your own safety, do not walk alone to your car at night or any time you feel uncomfortable. Follow
your facility procedure to get an escort. Park in well-lit areas and do not keep valuables in your car,
especially in plain sight. If you do have valuables in your car, lock them in the trunk.
Report anything that you feel might be a security hazard. This includes such things as burned out lights
in a stairwell or garage. If you feel someone is acting suspiciously, notify security personnel immediately.
Special Security Precautions
Security-sensitive areas
Some areas in your facility are "security-sensitive areas." These are areas with limited or restricted
access.
Security-sensitive areas may include the following:
Pediatrics and Obstetrics (especially the Nursery), because of the risk of infant or child
abduction
Pharmacy, because of access to drugs
Medical Information Systems and Medical Records, because of access to confidential
information.
Billing
Only people who need have access to security-sensitive areas are given access.
Your facility may have policies restricting access to these areas. There may also be security devices, such
as alarms and video cameras. Restricted access to security areas applies to everyone, even staff. Only
people who need to be in a restricted area should be there.
End of Security Lesson
Recommendation vignette (continued): I believe it would reassure Mr. Kelly if you would examine him.
When can we expect you to come?
Here is another yet more concise example
Dr. White, this is Sue Black, RN, I am calling from ABC Hospital about your patient Sophie Brown.
Situation: Here's the situation: Mrs. Brown is having increasing dyspnea and is complaining of chest pain.
Background: The supporting background information is that she had a total knee replacement two days
ago. About two hours ago she began complaining of chest pain. Her pulse is 120 and her blood pressure
is 128/54. She is restless and short of breath.
Assessment: My assessment of the situation is that she may be having a cardiac event or a pulmonary
embolism.
Recommendation: I recommend that you see her immediately and that we start her on 02 stat.
The safe and effective care of patients depends on consistent, flawless communication between
caregivers. End of shift report, hand-offs or the process of passing on specific information about patients
from one caregiver team to another, is an area where the breakdown of communication between
caregivers often leads to episodes of avoidable harm to a patient.
End of Team Communication about Serious Events, the SBAR Model Lesson
End of Environment of Care Professional Direct Care Course