1. Management of Environment of Care

2. Overview Safety Fire Safety Security Management Hazardous Materials and Waste Management Emergency Preparedness Medical Equipment Management Utilities Management

3. The Essential Functions of the Safety Program:  Accident and incident analysis, safety inspections and hazard surveillance and safety training utilized as proactive means of preventing conditions and activity which cause injury, illness or loss.  A multidisciplinary Environment of Care Committee with the collection, analysis, and evaluation of information necessary to create a safe environment.  A system for evaluating the effectiveness of the program and identifying opportunities for improvement.

4. Your responsibility with regard to the Safety Program :  Learn and follow job/task specific safety procedures as specified in your department;  Report incidents, accidents, and unsafe conditions when they occur;  Know your department’s role in the event of an incident or emergency; and  Utilize personal protective clothing, supplies and equipments as appropriate for job/task.

5. Fire Safety Locate your department fire plan on the EOC board. Familiarize yourself with the location of the Fire Alarm Pulls and Fire Extinguishers in your department.  If you smell smoke or see flames initiate PACT.  P – Remove Patient to safety  A – Alarm activated  C – Close doors  T – Telephone 75330 Prevent fires by taking appropriate precautions in your department.  Do not plug in unauthorized devices (space heaters, extension cords, holiday lights)

6. How to report incidents or accidents:  All injuries or accidents are recorded in Quantros, the Hospital on-line incident reporting tool. To enter an event (injury or accident), go to the St. Patrick Hospital Intranet. Click on Clinical Resources then Event Reports. This will send you to the Quantros website.

7. What to do when Dealing with an unruly or violent patient or visitor:  Request Security assistance by dialing “75330” from any phone. Report if a weapon is involved  The Call Systems Operator will notify Missoula City Police Department as required.

8. Identification badges for Employees, Volunteers, Vendors/Contractors and patients are required at all times.  Employee and Volunteer identification badges are issued by Safety Management in the HR Office.  Vendor identification badges are issued by Purchasing using REPTRAX.  Contractor & Subcontractor identification badges are issued by Facilities Engineering.

9. Six areas have been designated as security sensitive and have controlled access from 2130 – 0600 daily. These areas are: 1. Safety Management Office 2. Emergency Department 3. Medical Records 4. Neurobehavioral Unit 5. Pediatrics 6. Pharmacy During these hours, all visitors must pass through a security checkpoint and be prepared to show identification.

10. St. Patrick Hospital has a “NO WEAPONS POLICY”. Firearms and other weapons are prohibited on hospital property. Exception: Law Enforcement Personnel are allowed to carry weapons as part of their duties. If a weapon is found on a visitor or patient, request Security assistance by dialing “75330” or “72620”.

11. Infant/pediatric abduction policy includes the following provisions  Approved visitors list at nurses station  Staff awareness training in Pediatric Unit  Response protocol: “Dr. Steal go to main entrance” is the over head page Department exit monitoring assignments Security lock down of the facility, initiate search procedures, notify law enforcement

12. Hazardous Materials and Waste Management Hazardous material or waste spills are reported to the Safety Management Department by dialing “75330”. The Safety Management Department will complete required reports.

13. The Hazard Communication Program consists of five elements 1. Department identification of chemical hazards present in the department. 2. Material Safety Data Sheets (MSDS) provide specific information regarding the properties of a chemical including the hazards associated with the chemical and the level of personal protection required to work safely with the chemical. MSDS may be accessed online at the Safety Corner on the intranet website by clicking on “MSDS Vault” or the MAXCOM icon. 3. Chemical labels are required on all chemicals in the hospital. In most cases these are provided by the manufacturer. 4. Department training on the chemicals used in that department is conducted in the department orientation, annually and each time a new chemical is added to the inventory. 5. MAXCOM manuals, including the online MAXCOM User Guide, are located in the Department’s Environment of Care Board.

14. The Waste Management Program consists of three elements: 1. Department identification of hazardous waste generated or handled in the department 2. Waste segregation at the point of generation. Waste segregation as general, biohazardous, antineoplastic, chemical, radiological or gaseous: Biohazardous waste is red bagged and transported to a storage area Antineoplastic waste is yellow bagged and transported to a storage area Chemical waste is disposed of in accordance to MSDA instructions Radiological waste is held in the hospitals hot lab for decay and return to vendor Gaseous waste is recaptured utilizing gas scavenging system 3. Department training on waste generated or handled in that department is conducted in that department orientation, annually and each time a new chemical is added to the inventory.

15. Your responsibilities regarding Emergency Preparedness  The Environment of Care (EOC) Board in your department contains specific information for you to use during an emergency or disaster.  Familiarize yourself with the location of the EOC Board and it’s contents.  Know your role and your department’s role in the event of a disaster.

16. The Emergency Preparedness Program consists of five elements: 1. An external all-hazards disaster plan that includes provisions for mass casualties and biohazard/chemical/radiological contamination 2. An internal disaster plan that includes provisions for evacuation, fire, bomb threat, hazardous material spill, telephone outage, power loss, portable water loss, sanitary, sewer loss, and oxygen failure 3. Department plans supporting the objectives outlined in the external and internal plans 4. Department training with regard to departmental/job specific role and responsibilities 5. Regularly scheduled disaster drills

17. Employees on site are notified of a disaster by the overhead page: Code 99 Phase I or II Code 99 Phase I – there is a potential for a disaster Code 99 Phase II – a disaster is imminent  Employees off site are notified of a disaster via Group Cast and departmental telephone trees.  Employees responding to a disaster must have their Identification Badges to enter the area/building.

18. The initial response to a Code 99 involves the manager or the manager’s designee responding to the Command Post located in the location as paged overhead.  The Incident Commander will brief the staff on the nature of the disaster and the level of response anticipated.  The staff will be instructed to implement the appropriate departmental disaster plans. Departmental disaster plans may be found on the Environment of Care Information Center bulletin board located in each department.

19.  Requests for additional personnel will be directed to the Manpower/Nursing Pool at extension 72098.  Requests for additional supplies and equipment will be directed to the Command at extension 72080.  Disaster drills are conducted twice each year. All on-site staff and selected call-in staff are required to participate.

20. Your responsibilities regarding the Medical Equipment Program  Learn and follow job/task specific equipment procedures as specified in your department  Attend annual medical equipment management education  Report medical equipment failures when they occur  Report injuries as the result of medical equipment failures  Report unsafe conditions or equipment to your Supervisor, the Director of Biomedical Equipment or Safety Officer

21.  Medical equipment failures will be reported to the Director of Biomedical Engineering. The employee reporting the failure will remove the equipment from service by: placing it in the soiled utility area; affixing an out of service tag to the cord plug of the equipment in a manner that will prevent operation; and filing a work order on the St. Patrick Intranet

22.  Medical equipment operator errors will be reported to the employee’s supervisor. If injury occurs as a result of the incident, a report will be filed on Quantros.  Unsafe conditions or equipment will reported to the Director of Biomedical Engineering and the equipment will be removed from service until repaired.

23. Your responsibilities regarding the Utilities Management Plan  Learn and follow job/task specific utility operating procedures as specified in your department.  Report utility failures when they occur.  Report injures as the result of utility failures.  Report unsafe conditions to your Supervisor, the Director of Facilities Engineering or the Safety Officer.

24.  Utility failures will be reported to the Director of Facilities Engineering. The employee reporting the failure will refer to the appropriate utility failure plan found in the internal disaster plan located on the Environment of Care Information Center bulletin board.  If injury occurs as a result of the failure, an incident report will be filed on Quantros.  Unsafe conditions will be reported to the Director of Facilities Engineering.