Information

  • Clinic

  • Conducted on

  • Surveyor

Staff Questions

  • 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

  • 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

  • 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

  • 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 for R.A.C.E. - please respond with your plan within two weeks unless otherwise indicated.

  • 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.

  • 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.

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 on 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

  • 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.

  • 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.

  • 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.

  • 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. Pleas report these to your building management.

  • 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.

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