Staff Questions

EOP - Staff must be able to locate the Emergency Operations Plan. Every clinic must have a copy in a red binder.

Staff knew
Staff did not know

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

Flashlights - Staff must be able to locate a working flashlight. Your clinic should also have a supply of extra batteries in case of power outage. All employees should know where these are kept. Unless in use, batteries should not be kept in the flashlight as they may leak and damage the flashlight so that it will not be of use in an emergency.

Staff knew
Staff did not know

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

R.A.C.E - Staff must understand what to do in a fire. When asked what the "R" in RACE stands for, staff must identify the need to rescue and remove anyone from immediate danger

Staff knew
Staff did not know

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

R.A.C.E - Staff must understand what to do in a fire. When asked what the "A" in RACE stands for, staff should identify the closest fire alarm pull station and know who to call (9-911 and/or 4-4444) in the event they discover a fire or smoke.

Staff knew
Staff did not know

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

R.A.C.E - Staff must understand what to do in a fire. When asked what the "C" in RACE stands for, staff should identify the need to close all doors and windows in the area and clear the corridors of ALL items (including items otherwise allowed as well as "rogue" items).

Staff knew
Staff did not know

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

Staff must understand what to do in a fire. When asked what the "E" in RACE stands for, staff should be able to identify which doors are fire doors, if applicable. They must know whether they should defend in place or evacuate where their muster site is.

Staff knew
Staff did not know

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

Electrical Appliances - Workforce Members must know that only approved commercial appliances (e.g. coffee makers, microwave ovens, toasters) are allowed in hospital buildings. Personal Use or Household appliances are not allowed, even for temporary functions (e.g. staff potlucks).

Staff knew
Staff did not know

Use of Small Electrical Cooking Appliances in I Occupancy Areas Policy

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

SDS – Staff were asked to locate the SDS (Safety Data Sheet, formerly known as the MSDS) of a chemical on your unit. Each unit must have an indexed binder for all chemicals found on the unit.

Staff knew
Staff did not know

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

PEDs - IF your clinic has infusion pumps or other sensitive medical equipment, staff need to know that personal electronic devices (PEDs) have the potential to produce electromagnetic interference. They should not be used within three feet (roughly arm's length) of medical one laboratory devices. Staff need to know that PEDs include cell phones, electronic readers, laptops, etc.

Staff could identify at least two PEDs
Staff could NOT identify at least two PEDs

CTS: 503.494.8420. Policy: Safe Use of Cell Phones and Personal Electronic Devices in the Healthcare Environment ,

EC Highlights on safe use of PEDs

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

Active shooter - staff must know what to do if they are involved in an active shooter situation, understanding that there is no one correct answer. They must know where the exits are if they decide to run. They must know what to do to hide (lock doors, turn off lights, etc). They must know that it is a personal decision to fight back.

Staff knew what their choices are
Staff did not know what choices they might have.

Resources available on the Department of Public Safety O2 web site:
Run, Hide, Fight video
Active Shooter on Campus: Safety Guide
Active Shooter Event Quick Reference Guide.

Active Shooter on Campus: Safety Guide

Active Shooter Event Quick Reference Guide

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

Disclosing medical information - staff must know that they cannot give out patient information, including discharge or appointment dates and times, even to those who appear official, such as law enforcement officers or surveyors. Staff we're asked what they would do if a law enforcement officer asked for information about a patient.

Staff knew not to give information
Staff did not know to withhold information

Law Enforcement Relations Policy

Safety and HIPAA Orientation for Criminal Justice Personnel

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

Dr. Strong - Staff must understand that the code phrase "Dr. Strong" is to be used to communicate to Public Safety or a co-worker that they feel threatened or are at risk of violence AND that they are not free to discuss the situation without risking further escalation of the potential violence. Please note Dispatch will treat the use of this phrase as an emergency and send officers immediately. This is an important tool for the OHSU community, but when used inappropriately, the use of this code may divert critical resources from other situations.

Staff understood when to use the code phrase "Dr. Strong"
Staff did not know understand the proper use of the code phrase "Dr. Strong".

Here are three examples:

Patient approaches the reception desk and slams their fist on the counter, demanding to speak to the doctor. The action caused you to jump and in fear. The patient is clearly agitated, fists clinched, and loud. You do not have the ability to step away to call public safety. You pick up the phone and dial 4-4444 and ask to speak to Dr. Strong. Is this appropriate to use ‘Dr. Strong’ in this scenario? Answer: Yes and I should stay on the line and answer yes and no questions if I am still unable to talk and give more details.

You are busy and a patient comes up and keeps demanding to speak to the doctor. The patient does not have an appointment. The patient is not appearing to be violent or out of control, just demanding to see the doctor. You have asked the patient to have a seat and you will see what you can do. Is it appropriate to call 4-4444 and use ‘Dr. Strong’ in this scenario because you are busy and want DPS to get there quickly? Answer: No, however you could call the 4-7744 number and relay that you have a patient that does not have an appointment and you need assistance in explaining that no one is available to treat the patient today.

You have a man approach the reception desk who is holding a knife and makes a statement he wants to kill someone today. Is it ok to call 4-4444 and use ‘Dr. Strong’ in this scenario. Answer: yes, absolutely.

EH Highlights - Decoding the Codes

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

Special Air Flow Rooms - Staff in areas where there are special air flow rooms (for infection control purposes) must know how to verify that the air flow is in the proper direction.

Staff understood how to verify
Staff did not understand how to verify

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

Bathroom Rescue

Bathroom Rescue - Staff must know how to quickly access a locked restroom door in order to rescue someone in distress. In order to pass, they must be able to unlock and open the bathroom door within three minutes.

Seconds to first response, such as knocking and asking if the occupant is alright (if 3 minutes or less)
Seconds to "rescue" (if 3 minutes or less)

EC Highlights - Emergency Pull Cords

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

Pull Cords - In bathrooms where there is an alarm to pull, the fort must be accessible to someone lying on the floor. This means the cord cannot be wrapped around anything and must hang free to about six inches from the floor.

Plan of Action - please respond with your plan within two weeks unless otherwise indicated.

Observations

Door Props - Doors may not be propped, wedged or otherwise blocked open. This means there can be NO doorstops, wedges, kick down door stops, equipment, chairs, or other items preventing doors from closing. Doors must also be able to latch - latches cannot be taped over or otherwise disabled.

EC Highlights on door propping

Action Plan - please respond with your plan within two weeks unless otherwise indicated.

Combustibles must be compliant. If at all possible, keep bins behind closed doors and certainly out of the path of egress.

Action Plan

Corridor Clutter - There must be unobstructed access to the egress route. Keep corridors as clear as possible, limit any items to one side.

Action Plan - please respond with your plan within two weeks unless otherwise indicated.

Eyewash stations - if your area uses high-level disinfectant (Cidex, Cidex OPA, Sporlox, etc), you must have eyelash capabilities. Plumbed eyewash stations must be activated weekly and the log must be kept up to date.

EC Highlights - Emergency Eyewash Stations

Action Plan - please respond with your plan within two weeks unless otherwise indicated.

All chemicals must be in labeled containers. This includes any chemicals moved to secondary containers such as spray bottles, smaller containers and open containers such as soaking bins.

Action Plan - please respond with your plan within two weeks unless otherwise indicated.

Medical equipment - All patient care electrical equipment shall be safety tested by Clinical Technology Services before first use, no meter who purchased or rented it. Users can tell this has been done by the presence of a Medical Equipment Sticker. Stickers are either green (no preventative maintenance required), yellow (approved for use but owner is responsible for maintenance) or orange (dated with next required maintenance).

Action Plan - please respond with your plan within two weeks unless otherwise indicated.

ID Badges - All OHSU employees must always display their official photo ID badge. Effective May 1, 2014, the badge must be on a clip or pull (NOT a lanyard), above the heart with all text and photo visible. Having it in their pocket, desk or purse does not count. Everyone should be given permission to " poke" others who are not properly displaying their ID.

Employees properly displaying ID
Employees displaying ID, but not properly per 2014 policy
Employees not displaying official ID

Professional Appearance policy effective May 1, 2014

University policy on Identification Cards

Action Plan - please respond with your plan within two weeks unless otherwise indicated.

Electrical Panels - the area around and in front of electrical panels must be kept clear of obstructions

Action Plan - please respond with your plan within two weeks unless otherwise indicated.

Fire Sprinklers must have an escutcheon or "skirt" to seal the gap in the ceiling where they come through.

Escutcheons present and intact
Escutcheons in need of repair or replace. EHRS will report these to OHSU Facilities on your behalf.
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.