Desk Reference Safety - Portland Community College

Legacy Health System

SafetyDesk Reference

Safety Desk Reference 1

IntroductionThe LHS Safety Desk reference is designed

to be utilized by all Legacy Health Systememployees, contract personnel, volunteersand students.

Each employee will be given the LHSSafety Desk reference two months priorto his or her performance appraisal date.Each employee is required to read the deskreference, complete the TB requirements andreturn the completed quiz to their manager.New employees are required to attend newemployee orientation and complete the safetyquiz prior to starting work. The completed quiz will be corrected bythe manager at start of work. Employees must attain a passing scoreof 90% or greater. Employees will be required to review and correctdeficient portions of the quiz.

The LHS Safety Desk reference and quiz should be completed dur-ing the regularly scheduled workday. It should not be necessary tocomplete it on overtime. The LHS Safety Desk reference is availablefrom Safety/Security Department.

Remember to complete the quiz and the TB requirements prior toyour performance appraisal.

Annual Training InformationThe Legacy Health System Annual training information is designed

to provide an alternate method for employees to complete theirmandatory education requirements. You may complete those require-ments by reading this desk reference and completing the test, or byattending a live safety inservice.

SafetyWho is responsible? We all are responsible to make this a safe

environment for ourselves, our visitors and the patients in our care. Be on the look out for unsafe conditions like slippery leaves, icy side-walks, blocked fire exits, damaged electrical cords, biohazards, unsafechemical usage and broken equipment. Report any unsafe conditionto your manager, a safety committee representative or the systemSafety Officer. Legacy Safety Committees meet monthly and are opento anyone who wishes to attend. If conditions persist or you are con-cerned about ongoing unsafe practices, you may call the LHSCompliance HotLine at 415-5555.

Alpha IndexAdverse Drug Reactions & Medication Errors . . . . . . . . . . . . . . . . . . . . . . . . .19Annual Training Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Biohazard Spills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Biomedical Equipment Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Blood and Body Fluid Exposure and Injury Follow-up . . . . . . . . . . . . . . . .25Bloodborne Pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Chemical Spills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Compressed Gas and Oxygen Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Conditions and Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Clinical Device Tracking Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16CQI to Fix Things . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Emergency Phone Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back CoverEmergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Employee Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Equipment Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Ergonomics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Fire Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Hand Washing Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Hazard Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Infection Control Isolation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Infection Control Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Infectious Waste Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Musclo-Skeletal Disorder and Back Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Needlesticks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Patient/Visitor Incident Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Radiation Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Safe Medical Devices Act and Medical Device Tracking Program . . . . . . .16Safety - General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Security Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Smoking Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7TB Surveillance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29The Fleeting Wings of Mercury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Utility Outage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Violence in the Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Waste Disposal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

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2 Legacy Health System Safety Desk Reference 3

Environmental RoundsThe Legacy Safety Committees have a program of safety inspec-

tions called Environmental Rounds. Each year clinical care areas arevisited at least twice to be sure the areas are in compliance with basicsafety requirements. Non-clinical areas are visited at least once. Thestaff working in these areas are quizzed to determine their level ofsafety awareness.

The following is a list of questions that you will be expected to answer:

1.Where is your facility emergency preparedness plan?2.Where is your department emergency preparedness plan?3.Where is your current phone tree?4.Where is your department spill response plan?5.Where are your departments hazmat spill clean up materials?6.Where are your MSDSs for hazardous chemicals?7.What is the acronym to describe our fire response plan?8.Where is the nearest fire extinguisher and pull box?9.What is the acronym to describe how to use a fire extinguisher?

10. Where are the designated smoking areas for your area?11.What would you do if there were a power outage?12.Who is allowed to shut off medical gas zone valves?13.Where are the exposure control plans for TB and Bloodborne Pathogens?14.Where would you locate masks, gloves and eye shields?

Hazard CommunicationLHS 300.11

Employees have the “right to know” what haz-ardous materials they are working with or around. Itis important for each employee to understand howto protect themselves from the potential harmfuleffects of chemicals that they encounter in theirwork area and the hazards of dealing withthese materials.

The selection, use and storing of haz-ardous materials in the workplace is a keysafety issue. Always select the safest chemicalfor the job. Know how to properly handle the chemical. Store it properly.Use the appropriate Personal Protective Equipment when using haz-ardous materials. Remember to dispose of chemicals properly.

Legacy Safety Officer phone 413-4950.

MSDSThe Material Safety Data Sheets is the single most important

source of information in dealing with hazardous chemicals. Eachemployee must know the location of the MSDS for their work area. Ifyou do not know the location of your MSDS, ask your manager now.

MSDSs provide the following information:• Precautionary measures• Emergency First Aid• Physical data• Fire and Explosion information• Reactivity Data• Leak/spill disposal information• Health hazard information• Occupational control measures/personal protective equipment• Storage requirements

Chemical LabelsChemical manufacturers are required by law

to provide chemical hazard information onchemical containers. The label containsimportant information that you need toknow before working with hazardouschemicals. If chemicals are transferred toa secondary container, the same hazardinformation including the name ofthe product, the appropriate hazardwarnings, and the manufacturer’sname and address must be fixed tothat container. If you have anyquestions, ask your manager or supervisor. Chemicals that are notproperly labeled violate OSHA regulations and are a hazard to youand your co-workers. If a container is not labeled, get it labeled ordispose of it (through proper channels).

The appropriate time to read the MSDS is before you beginworking with the hazardous material. This is also the best time todetermine what PERSONAL PROTECTIVE EQUIPMENT isrequired and how to use it. Prior to ordering a chemical, reviewthe hazards to ensure we can safely use and store the mataerial


Emergency ManagementLHS 200.11

All departments are required to have an Emergency ManagementPlan. For an External or Internal Emergency, the operator announcesthis alert via the overhead paging system.

This message will be repeated three times.All staff will then notify their managers/directors and activate

their emergency plans. This includes assessing staffing needs, initiatingcall trees and sending personnel to the personnel pool, if appropriate.At the termination of the Disaster status the operator will announcevia the paging system “Internal (or external) emergency all clear.”Legacy uses the Hospital Emergency Incident Command System(HEICS) as an organizational structure for emergency management.

Fire SafetyLHS 200.09

To respond to a fire in any area of Legacy, remember RACE:RESCUE: Say loudly “Condition Red”, to get attention of co-workers.

Evacuate any individual from immediate danger, to a location beyond the fire doors.

ALERT: Activate the alarm system. Pull the fire alarm Pull Station and call EH 33911, GSH 33911, MP 22222, or MH 44444,LSC 73911.

CONFINE: Close all doors and windows in the vicinity of the fire. Do notre-enter the room where the fire is located once door hasbeen closed.

EXTINGUISH: Use a fire extinguisher to extinguish small fires, if safe to do.EVACUATE if you are located in an evacuation area or instructed

to do so by the fire department, Security or Facilities. When evacuatingfrom the fire location, move horizontally, through the first set of firedoors. If you’re then ordered to evacuate you evacuate via the stair-wells (you will never use an elevtor in an alarmed area).

DO NOT open fire doors to enter an area that is in alarm. You mayonly open fire doors to move to a safer area or to rescue patients or

“Attention please. This is an Internal (or External) Alert acti-vate. All available staff report to your unit assignment.Departments implement your Emergency Preparedness Plan.”

4 Legacy Health System

Chemical Spills LHS 200.10

The first thing to do following a spillis access the MSDS for that chemical todetermine the hazards and spill clean upprocedures.

Small spills:If you spill a small amount of a

chemical that you can managewith your spill kit, controlaccess before getting theMSDS. Clean it up accordingto your department “SpillResponse Plan.” Complete an “Incident/Accident/ Exposure Report”to document the spill. The manager of each department using haz-ardous materials is responsible for writing a “Spill Response Plan.” Besure to use the appropriate PERSONALPROTECTIVE EQUIPMENT when cleaning up a spill.

Large spills:If you spill a large amount of a flammable, noxious, corrosive or

otherwise hazardous chemical: evacuate the area, notify the manager,notify security to keep people out of the area and activate the SpillResponse Plan for the area.

Chemical DisposalLegacy Health System has a

“CRADLE TO GRAVE” policy whenit comes to hazardous chemicals.This means a department buys achemical, they are responsible forits proper handling and properdisposal. If you have any surplusor waste chemicals for disposal andare unclear of the disposal process,contact the Legacy Safety Officer at413-4950


• Check local elevators for trapped persons• All Legacy hospitals have emergency power to run essential services

Staff in unaffected areas may be called to assist with life supportsystems, transportation and manual communication.

Telephone Outage: In the event of a total power failureLocate and use PAY PHONES or RED EMERGENCY POWER FAIL-

URE PHONES using alternate phone numbers as listed in the utilitiesoutage plan (200.04) in the LHS General Policy and Procedures Manual.Advise patients of the alternate phone availability.

Water Services or Sewage System Failure:Notify Facilities with the specific location. Notify staff to take con-

servation measures. Toilets will be lined with red bags.

Medical Gas Disruption:Report any disruptions, problems or deficiencies to Facilities, or

Respiratory Therapy. MEDICAL GASES MAY BE SHUT OFF ONLYBY FACILITIES OR RESPIRATORY THERAPISTS.

Smoking PolicyLHS 300.03

Legacy Health System is strongly committed to the health andwell-being of its patients, visitors, volunteers and employees. Smokingis a major cause of cancer, heart and lung disease. In addition, breath-ing second-hand tobacco smoke by nonsmokers may increase a per-son’s risk for those diseases. To provide an optimum healthy environ-ment, Legacy Health System maintains smoke-free campuses exceptfor designated smoking areas.

1.Smoking by employees, medical staff, volunteers, patients and visitors isprohibited in all areas of LHS buildings, including doorways, at all times.

2.Smoking is prohibited in all meetings held in LHS buildings includingmeetings held by outside groups in LHS buildings.

3.All patients and visitors will be informed of the non-smoking policywhen admitted to or upon entering a LHS facility.

4.Physicians orders may not be written allowing patients to smoke.5.All inpatients will adhere to the policy.

Designated Smoking AreasThere are designated smoking areas on each LHS campus. All

smoking on the LHS campuses is restricted to these areas.


visitors. You may not deliberately open fire doors to enter an area thatyou know is in alarm.

If the fire is not in your area:1.Be sure that the fire doors between you and the fire have closed.2.Reassure the patients and families in your area.3.Be prepared to respond or evacuate if the fire is near

your area.4.Continue with your normal duties.

If the fire is in your area: After the alarms have stopped and “Condition RedAll Clear” has been announced, do the following:

• check doors and return them to the open position(ensuring that they stay open)

• reassure patients/visitors that the building is safe

Fire ExtinguishersMost Legacy fire extinguishers are “ABC” rated and are suitable

for almost all fires. To operate a fire extinguisher remember PASS:Pull the pinAim at the base of the fireSqueeze the handleSweep back and forth at the base of the fire

Utility OutageLHS 200.04

Power Outage:• Notify operator with the following:

– name and location – whether lights are on in other areas– what services are affected – phone number for return calls

• Operate life support systems manually• Connect critical electrical equipment to RED OUTLETS

Who Knew:That you must not stack anything closer than 18 inches to the

ceiling to allow automatic sprinklers and fire fighters to pourwater on top of burning material in case of fire.

That you must maintain 8 foot clearance along patient careevacuation routes to allow evacuation of beds along corridorsand around corners.


ConfidentialityLHS.500.501

Maintaining confidentiality of patient information, including ProtectedHealth Information, Employee Information, Proprietary Trade Information,and Quality Information, whether in written, printed, electronic, or oralform is an obligation of all Legacy Health System employees and agents.Information must not be released to any individual, organization, or agencywithout proper authorization. Legacy workforce can only access the mini-mum information necessary to do their work and only the records of thosepatients for whom you are currently providing services. You never accessthe records of friends or family members without signed authorizationfrom the patient. You may access your own records after receiving autho-rization from Health Information Services. Inappropriate access of or indis-criminate release of confidential information will result in immediate disci-plinary action up to and including termination of employment, service orassociation with Legacy Health System. Proprietary trade informationabout Legacy Health System is also protected by this policy. For informa-tion on how to destroy confidential information, please contact theRecycling and Waste Management Specialist.

Violets In The WorkplaceIt would be nice to get flowers but more and more we hear about

“Violence In The Workplace.” You need to know how to handle out-of-control behavior.

Be Alert For The Signs:• Holding a weapon• Acting drunk or under the influence of drugs• Pounding or shouting• Making threats, insults• Pacing or restlessness• Clenched fists

If Someone Loses Control:• Stay calm and alert security• Keep 2–3 arm lengths away• Offer help; actively listen• Use a soft, firm voice• Give them choices


Biohazard SpillsLHS 600.07

To clean up a spill of blood/body fluid or otherpotentially infectious material:

1.Control access to the spill.2.Contain spills with paper towels.3.Physically gather the spill into the towels/rags and discard into a plastic

bag designated or marked as a biohazard bag. Repeat as needed toremove spillage completely.

4.Disinfect surface with hospital approved disinfectant or 10% bleach.Allow adequate contact time with wet disinfectant.

5.Be sure disinfected blood spill area is dry after procedure.

To Clean Up Sharps:1.Wear gloves and additional barriers, if necessary. Do not handle spilled,

broken glass or dropped sharps. Sharps must be picked up using for-ceps, broom and dustpan or other mechanical device.

2.Place sharps in a sharps container.3.Clean up any spilled blood/body fluids or other

potentially infectious materials as described above.

NeedlesticksDon’t be stuck with a bad situation!DO: • Dispose of used needles

in a sharps containerimmediately after use

• Dispose of all syringesthat could hold needlesin a sharps container

• Know where every needle is at all times• Use extra caution when cleaning up after procedures• Immediately report any unsafe work practices!

DO • Recap used needlesNOT: • Remove syringes from needles by hand

• Cut, bend, or break needles• Place needles, syringes, or sharps in the waste/trash containers• Leave needles or sharps in bed linens, on bedside tables or food

trays

DO NOT GIVE OUT COMPUTER PASSWORDS


The Fleeting Wings of MercuryLegacy Health System is committed to eliminate all use of mer-

cury and mercury devises. Mercury is found in thermometers, bloodpressure devices, fluorescent light tubes, batteries and some labchemicals. Do not order any devices containing mercury unlessabsolutely required. If you find a device or instrument with mercury,please contact the Recycling and Waste Management Specialist forproper disposal.

Compressed Gas and Oxygen SafetyCompressed gases and oxygen tanks constitute several

hazards. A gas cylinder with a broken valve head maybecome a missile capable of penetrating walls. Somegases may be toxic or flammable.

Only employees who have received proper trainingin compressed gas safety should be allowed to handlecompressed gas and oxygen tanks.

• Patients using oxygen must be informed that smoking is not allowed.• Compressed gas and oxygen tanks must not be left free standing or

leaning against a wall. All cylinders must be secure in a supportingcart or rack.

• When trasnporting a patient on oxygen in a bed or stretcher, makesure the oxygen cylinders are secure to prevent dropping. Wheneverpossible, use stretcher cylinder holders to secure cylinders.

• Always use both hands when handling cylinders and never grasp thecylinder by the stem.

• Gas cylinders are colored and labeled for each type of gas. Alwayscheck labels and tank before using.

• Never use an adapter on a regulator or a regulator that is broken orhas a pin missing.

• Compressed gas or oxygen cylinders must “NEVER” be handledwith oily or greasy hands, gloves or clothing.

• Always make sure you are using the proper regulator for thecylinder type and size.


Security Services How To Be Safe at Legacy

1.Always wear your ID badge.2.Question unknown people entering or exiting patient rooms or other

work areas.3.Report suspicious people or suspicious incidents to Security Services

(LEHHC/LGSMC 413-7911, LMPH 692-2222, LMHMC 674-4444, LSC 360-487-1911). Tell your coworkers about the person or their activities. Asuspicious person is anyone who cannot or will not tell you the reasonthey are in the area or are doing something that arouses your suspi-cions.

4.Be observant of your surroundings when entering or exiting the work-place. Keep your keys in your hand. Walk with purpose and chooselighted areas.

5.Enforce Legacy’s “Zero Tolerance” for workplace violence by reportinginappropriate or dangerous behavior.

6.Ask Security for an escort if you are concerned for your safety whenarriving early or leaving late.

7.Know where your coworkers are, watch out for each other.8.Lock your car every time you leave it. Use supplemental locking devices.

If storing valuables in the vehicle, keep them in the trunk, out of sight.9.Lock desks, lockers and offices when unattended. Keep keys in a

secure place.10.Keep your wallet or purse in a secured area. Lock it up.11.Do not share keys or key pad codes with others.12.Report all minor incidents to Security.

Security Services are available at all Legacy Hospitals and theHolladay Park site. We have officers on duty 24 hours/day, locks,alarm systems and closed circuit camera surveillance to assist you inproviding a safe and secure workplace.

12 Legacy Health System Safety Desk Reference 13

Medical Waste InformationThere are 4 types of medical wasteWet waste-saturated materials such as gauze, full liquid containers

(such as suction canisters, hemovacs, pleuro-vacs).These items go into a red bag and are sent to a treatment facilitySoft waste- materials contaminated with blood or bodily fluids

that are not bulk liquids or saturated (such as gowns, gauze, bandages).These items go into a clear bag and go to Emanuel or Good

Samaritan for treatment in steam sterilizers.Sharps-needles, syringes, scalpels, broken glass, pipettesPathological, Biological and culture/stocks waste must be treated

or disposed of within 7 days.Medical waste is removed from areas of collection regularly.

Containers must never be over-filled so container lids cannot seal.Containers must be kept within the weight limits for the type of container.

All employees are trained about specific needs, definitions andrequirements concerning the proper disposal of medical waste duringtheir department orientation and on an annual basis through appro-priate inservice arrangements by the department.

Medical waste placed in the trash is an issue of public health andsafety. All Legacy community members are responsible for the safedisposal of the waste. The consequences to Legacy of mistakes couldinclude penalties and a loss of our special waste permits. Anyemployee/department that has caused such a mistake will beincluded in the clean up at the transfer station.

Recycling InformationLegacy has one of the leading recycling programs in the country. We

have a recycling collection program throughout our system as well as col-lecting or accepting materials from other sites in the greater Portland area.

In addition to recycling, we encourage reuse of materials throughdonation to non-profits, schools and other organizations. This is a partial list of all items that can be recycled:

Items that can be Recycled (clean/uncontaminated)

Guidelines for Disposal of WasteTYPE OF WASTE BIOHAZARD BIOHAZARD BIOHAZARD SOLID WASTE RECYCLING DOCUMENT

RED BAG CLEAR BAG SHARPS DESTRUCTIONCONTAINER

Any items saturated with blood or bodily fluids X

Any containers of liquid containing or contaminated with bodily fluids X

Isolation patient waste X X

Chemo sharps X

Chemo contaminated-trace Chemocontainer

Paper containing PHI or confidential information X

Needle/syringe units, needles,scalpels, suture needles, etc X

Pathology waste Pathologic(placenta’s, etc) container/

red bag

Unsaturated but contaminated bandages, diapers, cotton swaps,gowns, etc X

Glass slides, pipettes, specimen tubes, vials of blood X

IV bags/tubing-no contamination X

Materials used to clean up blood spills X X

Used gloves, gowns, etc not contaminated X

Food Waste X

Plastics (1-6+) X

Paper and cardboard (non PHI) X

Batteries/Electronics (no TVs or microwaves) X

Other recycling call recycling specialist X

Unwanted office supplies X

Toner cartridges X

Cell Phones

For detailed recycling guidelines call the Recycling Hotline or Recycling Specialist at 413-6066

BatteriesBlue wrap and plastic bagsBooksCardboard and paperElectronics (computers, printers,stereo’s, peripherals)

Foam (Styrofoam, peanuts)Glass

Metals (tin, aluminum, steel, iron,etc)

Plastics 1-6 (solution bottles,trays, etc.)

Toner cartridgesUnused office supplies and equipment

Wood


Your job as an employee is to be ableto Recognize the radiation symbol

And

to keep your own and everyone else’sexposure ALARA.

Biomedical Equipment Management is aTeam Effort

What is the purpose of the Biomedical Equipment department?They provide assistance to Legacy Health System in technology

management and medical equipment maintenance management. Theareas we provide assistance include:

• Service and Support of your medical equipment. Through our equip-ment management program and our trained technical staff, we willassure that your equipment is serviced to provide you with the high-est degree of reliability.

• Determine feasibility of replacement equipment through accuraterecord keeping and suggesting the replacement of equipment whichexceeds repair cost expectations, equipment which is not reliable andequipment which has reached the end of its useful life.

• We help in the evaluation and acquisition of new equipment.• We help coordinate the installation and training of staff on new equip-

ment and identify training needs on existing equipment.• We help find outlets for selling and disposing of your equipment

which is no longer needed.

How do I contact the Biomedical Department?Normal working hours are between 8:00 am and 4:30 pm, Monday

through Friday. The staff is available during these hours for routineand/or emergency repairs as follows; 413-7221

• Call the listed extension for any facility.


Cannot recycle (at this time)IV bags MicrowavesIV tubing TelevisionsIf there are any questions, please contact the LHS Recycling

Specialist.

Radiation SafetyKeeping radiation exposure As Low As Reasonably Achievable

(ALARA) is a team effort. We call this the ALARA policy. Our man-agement and even our radiation license from the State of Oregonrequires us to have an ALARA policy.

Radiation Safety at Legacy is a priority to minimize radiation expo-sure to staff and visitors. Legacy Hospitals follow the principles ofALARA. These principles involve the recognition of the radiationsymbol (posted wherever radiation is present) and the application ofthe Three “R’s” of radiation safety:

1.Time - limit your time near radiation2.Distance - keep the greatest distance between yourself and radiation3.Shielding - use of lead aprons or walls to stop radiation

If you have any questions or concerns about radiation safety,please contact the Legacy Radiation Safety Officer at 692-2593. If notavailable, please contact Radiation Administration at your facility.

The radiation warning symbol shown below is often encounteredin the nuclear medicine, radiology and oncologydepartments.However, it may be found anywhere in the hospital suchas the Adult Short Stay unit at Legacy Emanuel Hospital. Anytimethis symbol is seen, your job as an employee is to check with yoursupervisor before going into the room with this symbol. If it is foundon a trash container, immediately notify the person in charge.Radioactive materials should NEVER be left unattended in the hall-way of the hospital or in an unlocked room or laboratory.

Employees at Legacy have done an excellent job in the past of noti-fying the Radiation Safety Officer whenever they have questions or concerns about radioactive materials. At Legacy, radiation safety iseveryone’s concern.

Radiation serves us in many ways at Legacy Hospitals. It is benefi-cial in the diagnosis of diseases and in finding disease sites such asbone scans in nuclear medicine. It is used to treat cancer in the radia-tion therapy departments and can even be implanted permanently inthe form of radioactive “seeds” for curing prostate cancer in men.

MRI Safety is everyone’s job. Keep in mind that the magnetwithin a MRI scanner is NEVER turned off. Never enter the scan-ner room without being authorized/accompanied by MRI per-sonnel and NEVER with any form of metal on your person. Infact, now that I think about it, JUST DON’T GO IN!


What Is A Serious Illness Or Injury?A serious illness or injury is life threatening, results in permanent

impairment of a body function or permanent damage to a body struc-ture, or necessitates immediate medical or surgical intervention to pre-clude permanent impairment of a body function, or permanent dam-age to a body structure.

Requirement For ReportingIt is a mandatory requirement of the FDA to report any occurrence

when a medical device potentially caused or contributed to the death,serious injury or illness of a patient.

The medical devices involved in a potentially reportable occur-rence will be secured and removed from the service by the reportingdepartment and the Risk Management Department will be notifiedimmediately. Packaging inserts and labels must be included whenapplicable.

Medical Device TrackingMedical device tracking requires that records be reported and/or

maintained for certain permanently implantable devices, and for life-supporting/sustaining devices that are distributed outside of thehealthcare facilities.

It is a mandatory requirement that if the healthcare facility is deter-mined to be the final or multiple distributor of a FDA designatedmedical device, receipt of the device, specific implantation informa-tion, distribution to another facility and/or explanation must bereported to the manufacturer.

Patient/Visitor Incident ReportingOOPS! What Do I Do Now?

You have just discovered you gave your patient the wrong medica-tion or the wrong dose, or your patient just fell out of bed. What doyou do now? First, care for your patient, do what is necessary to makesure your patient is safe, then fill out an incident report and make sureit gets to your manager. An incident report is filed whenever an eventoccurs that is not consistent with the normal operating procedure ofthe facility or routine patient care. The report is filed whether or notan injury was sustained. Unusual occurrences can happen to visitorsalso and must be reported. Unusual occurrences should be reportedby the person or persons most directly involved, or by those whoobserved or discovered the occurrence.


• Provide the equipment repair information to the individual or leave amessage on the voice mail. Instructions for emergency repairs areincluded in the voicemail message.

• Always attach a work request or a note with the repair request infor-mation to the device.

For calls after normal working hours (Saturday, Sunday, Holidays)the biomedical equipment department can be contacted as follows:

Routine Repairs• Call the extension listed above and leave the equipment repair

request information on the voicemail.• Always attach a work request or a note with the repair request infor-

mation to the device.

Emergency Repairs• The Charge Nurse or department designee is to call Biomed

(emergency number in phone directory)

Safe Medical Devices Act and MedicalDevice Tracking ProgramLHS 100.29

What Is A Medical Device?A medical device is any instrument, apparatus or other article that

is used to prevent, diagnose, mitigate or treat a disease or to affect thestructure or function of the body, with the exception of drugs. A med-ical device includes, but it not limited to the following: ventilators,monitors, dialyzers, any electronic equipment, implants, thermometer,patient restraints, syringes, catheters, diagnostic kits and reagents, dis-posables, hospital beds, suture materials, wheelchairs and relatedcomputer software.

Equipment FailureWHEN CLINICAL EQUIPMENT FAILS1. Remove the device from service.2. Place a “defective” note on it.3. Contact Biomed.


Reporting Adverse Drug Reactions andMedication Errors

To help ensure patient safety and improve the medication useprocess, it is important that all medication related incidents are report-ed. Adverse drug reactions are any reaction to a drug that results inany of the following:a. discontinuation of drugb. hospitalization or increased length of stayc. use of supportive cared. treatment with a prescription druge. temporary or permanent disability or toxicity to the patientf. death

Reporting adverse drug reactions is a JCAHO mandate, additional-ly information from serious idiosyncratic ADR’s are reported to theFDA and this information may result in a drug being pulled from themarket. ADR information should also be documented in the patientchart to prevent future reactions. It is important to report ADR’s so thedata may be used to uncover and correct underlying problems in themedication use system.

An ADR or Medication Error can be reported to pharmacy byeither reporting to on-line reporting system, or by calling the ADRHotline.

ADR HOTLINE 833-3336

Reporting of medication errors is equally important. Like thereporting of ADR’s, medication error reporting is also a JCAHO focus.Studies have found that medication errors are often repetitive innature and are a result of system or process failures. Legacy hasfocused on aggregating medication error data and comparing it tonational data to identify opportunities to improve the medication useprocess. Medication error reporting should not be viewed as punitivebut as an opportunity to improve patient safety.


Patient/Visitor Incident Reporting is done via the Legacy electronicreporting system. Call your manager and Risk Management if there issignificant injury to the patient or visitor.

If the event involves injury to a visitor, they should be encouragedto be seen in the emergency room or by medical personnel. Refusal tobe seen should be documented on the Patient/Visitor Incident Report.Do not state that the hospital will absorb the charges. This decision ismade on an individual basis by Risk Management.

What Is An Unusual Occurrence?• Actual patient/visitor injury• Potential patient/visitor injury• Medication errors• Falls• Accidents (such as being struck by falling objects; caught, crushed,

jammed or pinched between moving or stationary objects)• Equipment related incidents• Dermal Ulcers acquired at LHS• Failure to follow policy and procedures• Dissatisfaction with care• Confidentiality issues• Loss/theft/patient/visitor• Physician issues

What Kind Of Information Should Be Included On ThePatient/Visitor Incident Report?

• Who was involved, who witnessed the event and who was notified.• What happened, when did it happen (date and time), what was seen, heard

and said about the event.“Direct quotes are good whenever possible”.• What action was taken or patient outcome.• Document extenuating circumstances, non-compliance or refusal of care.• If medical device was involved, document model, lot number or LHS ID

number.

Is This Event Documented In The Medical Record? • The patient’s medical record should reflect the objective facts regard-

ing the event.• DO NOT reference the Patient/Visitor Incident Report in the medical

record or to the patient or visitor.• DO NOT make copies of the Patient/Visitor Incident Report.

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Static posturesRemaining in one position for long periods

Contact StressDirect pressure from tools or equipmentagainst soft tissues like the palm, wrist orforearm

VibrationContact with vibrating tools or equipment (such as power tools)

Cold TemperaturesContact with cold materials or equipment

Although one risk factor may be able to cause an MSD, most often,ergonomic risk factors act in combination to create a hazard.

Symptoms of an MSD may include:• Pain • Tingling• Numbness• SwellingMild episodes of symptoms that come and go can be the “early

warning signs” of a developing MSD. Early identification and reduc-tion in ergonomic risk factors can often prevent the MSD from devel-oping!

What should you do if you experience any symptoms of anMSD:

Discuss your symptoms with your Employee Health Nurse as soonas possible. The Ergonomic Specialist may be contacted by your man-ager or Employee Health for additional assistance or you may callLegacy Ergonomics directly at 413-2204.


Musculo-Skeletal Disorders (MSD’s) andBack Safety

We are all designed to move, but the human body is subject towear and tear. Doing the same motion over a period of time can causeproblems, especially when working in anawkward position or using a lot offorce. After a time, muscles, tendonsand joints can be damaged result-ing in a Musclo-Skeletal Disorder(MSD).

MSD’s are injuries or disordersof the muscle, tendon, joints,spinal discs, nerves, ligaments orcartilage. MSD’s develop as a resultof repeated exposure to ergonomicrisk factors. Back injury is the num-ber one MSD occupational hazard inour nation. Eighty pecent ofAmerican adults suffer from low backpain or injury at some time in their life.These statistics are reflected within Legacy as well: Back injuryaccounts for the largest number of lost work days and compensationcosts within our Health System.

Ergonomic Risk Factors that put you at risk for MSD

Forceful exertions The greater the muscle force involved in doing a task, the greater therisk

RepetitionThe higher the number of wrist or arm repetitions, the greater the risk

Awkward posturesThe more awkward the posture or position the greater the risk

• Bent wrist• Outstretched arms• Elbows away from the body• Slumped shoulders• Bent or twisted back• Poor Sitting posture

Spine Neutral

Squat to Lift

bend atknees

head upback neutralbend at hipsbottom outfeet shoulderwidth apart

• Inflammation• Burning• Stiffness• Skin discoloration


Bloodborne Pathogens LHS 600

Bloodborne Pathogens (BBP) refers to those infectious diseases thatare present in blood, and certain body fluids. Other PotentiallyInfectious Materials (OPIM) include: semen, vaginal secretions, cere-brospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peri-toneal fluid, amniotic fluid, saliva in dental procedures, any bodyfluid that is visibly contaminated with blood, and all body fluids insituations where it is difficult or impossible to differentiate betweenbody fluids. Also any unfixed tissue or organ (other than intact skin)from a human (living or dead).

Know Thine EnemyIn the healthcare industry the principal bloodborne pathogens of

concern are: Hepatitis B (HBV), Hepatitis C (HCV), and HumanImmunodeficiency Virus (HIV). Only HBV has a vaccine availablewhich is offered free of charge to employees with risk of exposure.Contact your Employee Health nurse for more information. All threeof these viruses are transmitted by the same methods: entering thebody through percutaneous means (most commonly needlesticks),through splashes to the mucous membranes (eyes, nose, or mouth), orthrough contact with non-intact skin (skin that has a cut or a scratch).

Each virus varies in its ability to infect a person given a singleexposure incident. For example, HBV is the most communicable witha one in three chance of infecting after a single needlestick exposure.HCV has a one in thirty risk, and HIV is a one in three hundred. Earlysymptoms of all three of these bloodborne diseases are similar with aflu-like illness. Hepatitis will also cause abdominal pain, joint aches,and can go on to cause jaundice (a yellowing of the skin and whites ofthe eyes). HIV early symptoms include a chest rash and swollenlymph nodes. Further symptoms of HIV usually don’t appear untilyears after the initial infection.

Control the RisksThe risk of exposure to BBP can be reduced by using engineering

controls appropriately such as: needleless IV systems, safety syringes,needles and devices, proper disposal of sharps in sharps containers,overfilling sharps containers. Risk can also be reduced by good workpractices such as: not eating in work areas that may be contaminated,not putting on make-up or lipstick in work areas, handwashing afterremoving gloves and at other crucial times, and proper handling of


Prevention of MSD, including back injury is our own individualresponsibility. Here are some important points to remember:

• Keep everything in easy reach• Work at proper heights• Reduce excessive force• Work in good posture• Reduce excessive repetition• Minimize fatigue• Minimize direct pressure• Provide adjustability and change of posture• Provide clearance and access• Maintain a comfortable environment• Improve work organization

Use CQI to Fix ThingsWhenever we find a safety problem or a

process that needs to be improved upon, we can use what we’ve learned about CQI to fix things!

Plan...Do...Check...Act

THE PROBLEM SOLVING MODEL:

PLAN the changes you wish to make, DO the changes, CHECK tosee if the changes fixed the problem, and ACT upon your findings.

We have CQI to make major changes in our Legacy SafetyProgram; Here are only a few examples of our best CQI outcomes:

• Environmental Rounds Program• “Violence Free Zones”• New Employee Orientation and Safety Training curriculum


Questions concerning vaccine and exposure follow up should bedirected to your Employee Health Nurse.

Blood and Body Fluid Exposure & InjuryFollow-up

REDUCE YOUR RISK!!!If you have been exposed to blood or body fluids, you must do

the following to reduce your risk of infection:• FIRST AID FIRST!!! Clean the wound with soap and water. Flush mucous

membranes with water or saline for five (5) minutes.• INFORM YOUR MANAGER OR SUPERVISOR so you can be relieved of

duty for medical evaluation.• Call your site employee health nurse or RAIL Hotline (503 415-5717)

for evaluation and treatment.• For after hours treatment, go to a Legacy Emergency Department.The best way to reduce your risk is to prevent the exposure. Here

are some guidelines:

Always Use Standard Precautions:• Use gloves, goggles, aprons, face shields and other PERSONAL PRO-

TECTIVE EQUIPMENT.• Dispose of needles, lancets, and other sharps in sharps containers. DO

NOT RECAP NEEDLES!!!• Wash hands before and after procedures, when removing gloves and

when there is contact with blood or body fluids.

INJURY/ACCIDENT/EXPOSURE REPORTING and FOLLOW UPCARE

• Notify your Manager or Supervisor immediately of any accident, injuryor exposure

• Call RAIL or your site Employee Health nurse for evaluation, treatmentand possible referral.

• If after hours, and your injury requires emergency care, or is a blood orbody fluid exposure, go to the emergency department.

• Document your injury on a Legacy Incident/Accident/Exposure Reportwithin 24 hours and give to your manager.

• To file a Worker Compensation Claim contact RAIL at 503-415-5717.

!!! Immediate Evaluation Required !!!


specimens and other materials to avoid spills. HBV can survive dry ona surface for up to two weeks.

PPEPersonal Protective Equipment (PPE) are used to

avoid contact with blood and OPIM (other poten-tially infectious material). Under normal conditionsof use PPE must not allow blood or OPIM topass through to your clothing or body. Youare relied upon to anticipate when a splashor other exposure might occur, and wear thenecessary PPE to avoid contact withblood or body fluids. If a garment is pene-trated with blood or OPIM, you shouldchange it out as soon as possible.Depending on the activity, gloves may beall that is needed, or gloves, face shield, andgown may be necessary. Even though gloves cannot prevent a needlestick exposure, they cangreatly reduce the amount of blood you areexposed to, and thereby greatly reduce your riskof infection with a BBP. If you are unsure whatPPE you should wear, contact your supervisor,Infection Control, or Employee Health.

Clean UpHousekeeping practices are important to maintain a clean and safe

work area. All equipment, environmental and working surfaces mustbe cleaned and decontaminated after contact with blood or OPIM. If aspill of blood or OPIM occurs, put on the appropriate PPE, contain thespill with paper towels, and then pick up the spill. Dispose of thematerials in the infectious waste. The final step is to disinfect the cont-aminated surface with the hospital disinfectant. Remember that disin-fectants are rapidly inactivated by the presence of organic material, sobe sure to apply to a clean surface for maximum effect. After the spillis cleaned up and the area disinfected, remove gloves and wash yourhands.

Legacy’s written exposure control plan is found in the section 600of the General Policies and Procedures Manual. This article has greatlycondensed the information in the exposure plan. If you have ques-tions, please contact the Infection Control person at your facility.


The three types of Transmission Based Precautions are:

Airborne ^^^^^^^^Droplet ..........

Contact - - - - -

Depending on the individual patient diagnosis, you may use oneor more of the Transmission Based Precautions. Transmission BasedPrecautions provide guidelines for ensuring the appropriate environ-ment and barriers to prevent transmission of specific diseases. A pri-vate room is required for Airborne Precautions and preferred forDroplet and Contact Precautions.

Airborne PrecautionsAirborne Precautions are used for diseases like Tuberculosis,

Measles and Chickenpox. Very small droplet nuclei are aerosolized bythe coughing patient. These droplet nuclei remain suspended in theair for long periods or until the air-handling system removes them.For Airborne Precautions, a private room is always used and the doorto the room must be closed at all times to ensure effective ventilation.Each facility has designated rooms with proper air-handling and neg-ative pressure to control and contain airborne diseases. All peopleentering the room of a patient in Airborne Precautions must wear res-piratory protection. For TB, orange tecnol particulate respirator mustbe worn (including visitors). For other airborne diseases, a surgical orisolation mask may be worn. If the patient must be transported out-side the room for required procedures, put a surgical mask on thepatient and notify the receiving department.

Droplet PrecautionsRespiratory droplets are large, moist particles that do not remain

suspended in the air. Droplets can only travel short distances of 3-5feet since they are so heavy. Because of this, disease transmissionrequires fairly close contact with the patient. Examples of these dis-eases include Meningococcal Disease, Pertussis and Influenza. ForDroplet Precautions, use a private room and put Droplet Precautionssign on door. If you will have close contact with the patient, wear asurgical mask. For transporting the patient outside the room, place asurgical mask on the patient and notify the receiving department.

Contact PrecautionsContact Precautions are used to prevent transmission of diseases

which are spread by direct or indirect contact. Drug resistant organ-isms such as Methicillin Resistant Staph Aureus and VancomycinResistant Enterococcus and Clostridium Difficile are good examples of


Legacy Infection Control IsolationGuidelines

PROTECT YOURSELF

PROTECT YOUR PATIENTSUniversal Precautions (UP) and Body Substance Isolation (BSI)

have been replaced by Standard Precautions. Standard Precautions arethe guidelines for using appropriate barriers to protect yourself whencoming into contact with all secretions, excretions, and discharges(except sweat). Assume all patients are infected and all secretionsare infectious.

Familiar Elements of Standard Precautions• Use Personal Protective Equipment (PPE) appropriately. Wear a mask,

eye protection, cover gown or fluid resistant gown if there is potentialfor blood or body fluids to splash, saturate or spray.

• Wear gloves for anticipated contact with the patient’s body fluids, bro-ken skin or mucous membranes.

• Change gloves after contact with each patient and between proce-dures for the same patient.

• Wash your hands every time you remove your gloves, gloves may leakor tear.

• Legacy provides a wide range of personal protective equipment forstaff to use. For example, there are several varieties of gloves availableincluding hypoallergenic and latex free products. PPE needs to bereadily accessible to you in your work area. It is your responsibility toensure you have the equipment you need to do your job safely. Thisincludes using PPE that is appropriate to the task.

Transmission Based PrecautionsThere are three (3) types of additional precautions you may need to

stop the transmission of infections. Each of these types of isolationshould be used in addition to Standard Precautions.

Did You Know:Did you know in order to help prevent transmission of

vaccine preventable diseases in the healthcare setting and thecommunity, Legacy requires all new employees to be immune toMeasles, Rubella, and Chickenpox and offers vaccines for thesediseases as well as Hepatitis B and the Influenza vaccine.


• Use of antiseptic waterless hand cleanser is acceptale hand washwhen hands are not visibly soiled.

• Use only hospital approved hand lotion so that the integrity of yourgloves are maintained. (Lotions containing petroleum may affect theintegrity of your gloves)

• Short nails make it easier to keep the area under the nails clean.• Healthcare workers with patient care duties should not have artificial

nails.

Legacy Health System Infection Controland Employee Health Information* INFECTION CONTROL RESOURCES ** EMPLOYEE HEALTH NURSE RESOURCESLEHHC . . . . . . . . . . . . . . . . . . . . . . . .413-4919 LEHHC . . . . . . . . . . . . . . . . . . . . . . . . . .413-4282LGSH . . . . . . . . . . . . . . . . . . . . . . . . .413-7053 LGSH . . . . . . . . . . . . . . . . . . . . . . . . . . .413-7487LMHMC . . . . . . . . . . . . . . . . . . . . . . .674-1584 LMHMC . . . . . . . . . . . . . . . . . . . . . . . . .674-1260LMPH . . . . . . . . . . . . . . . . . . . . . . . .692-2215 MPH/KCLM Labs . . . . . . . . . . . . . . . . . .692-2118Clinical Research. .. . . . . . . . . . . . . . . . . 413-5116 LHP/Research . . . . . . . . . . . . . . . . . . . .413-5116LSC . . . . . . . . . . . . . . . . . . . . . .360-487-1225 LSC . . . . . . . . . . . . . . . . . . . . . . . . .360-487-1070LHS . . . . . . . . . . . . . . . . . . . . . . . . . .413-2597 New Hire/ System Office . . . . . . . . . . .415-5298* Each Legacy Operating Unit has a designated Infection Control expert and Employee Health Nurse.** Employee Health is open M-F, except holidays, hours of operation vary by site.

TB Surveillance ProgramEmployee Health Service works together with Infection Control to

monitor communicable diseases within our environment. One wayyou can help is by getting your required annual TB skin test.Employee Health staff provides this service at your operating unit.Your manager will be notified if you are overdue for your annual test.

In addition to the annual screening, Employee Health team alsooffers Interval TB skin testing for those employees who may havebeen exposed to TB. If you think that you may have been exposed toTB or another communicable disease, please notify Employee Healthimmediately. In the event of a communicable disease exposure, theInfection Control and Employee Health teams collaborate in the man-agement of the exposure. You or your manager may be contacted ifthere is a suspicion of a communicable disease exposure. In the eventthat your exposure is confirmed, Employee Health will help you toget the appropriate prophylactic medication as needed. Having a posi-tive TB skin test or PPD, does not necessarily mean you are infectious.It is an indication for further investigation.


organisms that can be spread this way. Major components of ContactPrecautions are:

• Put Contact Precautions sign on door.• Use a private room, if possible, to isolate the disease.• Always wear gloves when entering the room.• Always remove gloves before leaving the room and wash your hands.• Wear additional barriers (gowns, masks, etc.) if you anticipate substan-

tial contact with the patient, their immediate environment, or especial-ly any secretions or excretions.

• Remove all protective equipment before leaving the room of a patientin Contact Precautions or wash your hands with an antibacterial handsoap; or use the alcohol hand rinse. If patient has C Difficule, you mustuse soap and water.

• If patient transport is necessary, notify the receiving department.Additional precautions (i.e. re-enforcement, place a clean sheet over patientbedding) may be needed to protect the environment from contamination.

Hand Washing Facts• The purpose of hand washing is to remove

dirt, organic material and transientmicroorganisms. Transient microorgan-isms such as E. coli and staph can causehospital acquired infections in sus-ceptible hosts. Transient microorgan-isms survive on skin for short periods oftime, usually less than several days, and canbe readily removed by hand washing.

• Hand washing is the most important way to prevent person to persontransmission of microorganisms. The indications for hand washing arethe following:

• Between patients• Before eating• After using the bathroom• After removing gloves

• Hand washing technique should include: wetting your hands prior toapplying soap; apply soap and wash vigorously for at least 15 seconds;pay particular attention to all surfaces, especially between fingers,dominant hand, under nails, around your wrist and thumbs. Dry handscompletely with a disposable paper towel or warm air dryer. Clothtowels are not recommended. Avoid recontamination of hands on sinkor faucet after drying by using the paper towel to turn the water off.


Associated risk factors include the following:• Recent exposure to someone with active TB, or tuberculin skin test

conversion from negative to positive• Reduced immunity due to chronic illness or advanced age• Lack of access to medical care• IV drug or alcohol abuse• Recent stay in correctional facility• Foreign born and recent immigration from areas of the world where

TB is endemic or epidemic• Homelessness• Untreated latent TB infection (occurred in the past) with activation to

acute disease state

Key Points to protecting yourself from TB:• Instruct ANY coughing patient to use a tissue to cough into• Suspect TB if symptoms and risk factors start adding up, and report

this to patient’s physician• Admit suspected TB patients to airborne precautions isolation room• Follow Legacy Airborne Precautions (based on CDC recommendations):

• Put Airborne Precautions sign on isolation room door• Put appropriately marked STOP sign on isolation room door• Be fit-tested for and wear fitted respiratory protection any time you

enter a suspected TB patient’s room (we currently use the orangeTecnol N95 mask). YOU MUST BE FIT-TESTED FOR AND INSTRUCTED INTHE USE OF THIS RESPIRATOR, OTHERWISE YOU ARE NOT APPROPRI-ATELY PROTECTED!

• Keep the door to the airborne precautions room closed• Limit any movement of the suspected TB patient outside the airborne

precautions room to essential trips to diagnostic or treatment depart-ments only

• Have patient wear a surgical mask when they must be outside the air-borne precautions room

• When the patient is discharged from the hospital, they may still be con-tagious, have the patient wear a surgical mask to the outside of thehospital, and keep the airborne precautions room door closed for anhour to allow the air exchange mechanism to clear the room ofremaining infectious droplet nuclei.

TB containment is everybody’s business. If you have any questionsregarding TB (or any other infection control subject), please contactyour Infection Control Practitioner listed under Infection Control ateach hospital.


As always, using proper isolation techniques and standard precau-tions will reduce your risk of exposure to communicable disease.

TuberculosisTuberculosis is one of the leading causes of death from infectious

disease in the world, nearly three million deaths per year (100,000 ofthese are children).

Estimates are that approximately 1/3 of the world’s population isinfected with some form of the disease. How fast is the problem grow-ing? Studies show that worldwide about eight million new cases occureach year.

Tuberculosis (MTB or TB) is caused by bacteria which are carriedby airborne droplet nuclei, produced when a person with pulmonaryor laryngeal TB coughs, sneezes, or sings; even just talking can pro-duce them. These droplet nuclei are so small (1 to 5 microns) that youcould fit a hundred of them on the end of a human hair. They canremain suspended in the air currents for hours after they are pro-duced.

Multidrug resistant TB (MDR TB) is of particular concern. Thisform of TB is difficult to treat as it is resistant to several of the avail-able drugs normally used to treat TB. Many areas of the world havehigh levels of endemic TB, as well as high levels of MDR TB. With air-line travel being what it is today, we could see a patient with MDR TBat any time, in any of our facilities.

In Oregon, over the past 15 years, there has been an average of 160new cases identified each year, with the majority of these coming fromMultnomah, Clackamas and Washington Counties (that’s where mostof us reside or work).

At Legacy, we have seen dramatic swings in the number of activepulmonary TB cases showing up in our hospitals over the past coupleof years. For example, some facilities that rarely see any TB have hadas many as four cases in a year, and others that normally see an aver-age of 4 cases in a year have numbers as high as 12 in a year.

The classic symptoms of TB include a cough that lasts more thanthree weeks, associated with the following:

• Abnormal chest x-ray (cavitary lesion or diffuse infiltrate)• Coughing up blood• Unexplained weight loss or anorexia• Recurrent night sweats or low grade fever• Unexplained fatigue


Conditions and Codes at LegacyLHS.300.05

Codes and conditions at LHS were developed to provide uniformand timely response to defined emergency situations. A conditioninvolves a response by everyone in the operating unit. A codeinvolves a response by a team of specific employees. The followingcodes/conditions are in use in the Legacy system.

CODE 22 . . . . . . . . . . . . . . .Combative Patient RestraintResponse

CODE 55 . . . . . . . . . . . . . . .Psych. Unit Combative patientCODE 77 . . . . . . . . . . . . . . .Bomb ThreatCODE 99 . . . . . . . . . . . . . . .Cardiac ArrestCODE GREEN . . . . . . . . . .Visitor down (in house)CODE ORANGE . . . . . . . . .Harzardous Material Spill

ResponseCONDITION 33 . . . . . . . . .Security Incident MessageCONDITION EXTERNAL .External EmergencyCONDITION INTERNAL . .Internal EmergencyCONDITION PINK ABC . .Infant or child abductionCONDITION RED . . . . . . .Fire AlarmDR. STRONG . . . . . . . . . . .Security ResponseCONDITION SILVER . . . . .Campus Lock-Down


Leadership Commitment to a Cultureof Safety

Legacy Health System is committed to providing a safe envi-ronment for our patients, physicians and staff. We will accomplishthis with a focus on medical error reduction by:

• Simplifying our processes,• Standardizing our processes and equipment,• Building accountable, blame-free teams that work together, train

together and communicate frequently with• The support and direction from Leadership to achieve the out-

comes of high reliability, and• Continuously monitoring our processes to identify opportunities

for improvement.

Emergency Phone NumbersFire Condition RedEmanuel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33911Clinical Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-911Good Samaritan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33911Meridian Park . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22222Mount Hood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44444 System Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33911Salmon Creek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73911

Cardiac Arrest Code 99Emanuel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32911Clinical Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-911Good Samaritan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32911Meridian Park . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22222Mount Hood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44444 System Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-911Salmon Creek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72911

Security Emergency Code 22Emanuel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37911Clinical Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37911Good Samaritan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37911Meridian Park . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22222Mount Hood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44444 System Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37911Salmon Creek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71911

Child or Infant Abduction Condition Pink

Emanuel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37911Good Samaritan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37911Meridian Park . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22222Mount Hood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44444Salmon Creek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71911

8/05

Documents

Desk Reference Safety - Portland Community College