Q. What can be stored
under the sink?
A. According to JCAHO
requirements, the area under a sink should
be considered a soiled environment. Therefore, anything that a
patient or staff member wears, ingests, or is treated with should
not be stored under a sink. Anything durable that is contaminated anyway, like a toilet bowl
brush, toilet bowl cleaner, or trash can liners, could be kept under
a sink.
Please be advised that the storage area under the sink needs to be cleaned on a regular
schedule. If you are working in a pediatric or psych area please
assess whether the storage area under the sink (because of contents)
needs to be locked.
Q. Who should be contacted
with questions about Environmental Monitoring Rounds?
A. Lois Scarborough at
lscarbo2@jhmi.edu.
Questions that pertain to multiple areas of the hospital and/or OPDs
will be posted on the web site with the answer.
Q. Why do I need an
eyewash station?
A. Accidental exposure of the eyes
to chemical substances in any form can result in irritation,
temporary or permanent vision impairment, or blindness. Under the
Workplace Safety and Health Act an employer is required to provide
approved emergency eyewash equipment.
Q. Why do I have to run
the eyewash for three minutes each week? Three minutes is an awful
long time. (HSE037)
A. Because it is recommended by
APIC (Associated Professionals in Infection Control and
Epidemiology) and OSHA. View
OSHA's response to the DOE Hazardous Information Bulletin:
Q.
Why can’t we run a central class to train employees on how to use the eyewash? I don’t know how to train them.
A.
Hopkins has more than twenty (20) different models of eyewashes. Employees have to know how to use the eyewash in the area where they
work. This is best accomplished by teaching them to use the eyewash in their own area and then have them do a return demonstration so
you – as the supervisor – know they actually understood what you taught.
Pathology has put together a teaching plan for their supervisors who have to teach the use of the eyewash. They are willing to share
this with other departments. If you go to their web site: http://pathology2.jhu.edu/cqi/ and look under “Forms and templates” you can
use this as your teaching guide. The actual guide is called “Emergency Equipment Training Guide”.
The form you use to document the training is found on this web site under “Forms”. It is called “Eye Wash Training Log”.
Q.
Why do I have to send HSE a copy of my training log?
A.
HSE maintains a data base of employee safety training. Often this training is mandated by OSHA and/or JCAHO. HR can call HSE to obtain
these records when they need to present the records to inspectors – such as JCAHO and OSHA. It is much easier and quicker for HR to call
one location (HSE) than it is to call each Nurse Manager or Administrator for each employee in order to obtain proof of mandatory
training. Inspectors are not willing to wait for long periods of time while these records are located.
Q. There is
'wasted' space at the end of our floor in our building. We often
have visitors who are waiting to enter a patient room. I would like
to place a sofa in those areas (Green areas on diagram) to provide
comfortable seating area for the visitors. That way they can see
when the doctor and/or nurse finish with the patient they are
visiting. Can I do this?
A. No. Even though you are not
blocking an egress fire route with the sofa, you are providing fuel
(combustible sofa) to the hallway. Even plastic is a combustible.
So plastic chairs in the hallway are not acceptable either.
Q.
What is wrong with these pictures?
A.
Unsecured compressed gas cylinders can fall over and start a fire. The strap that would secure the oxygen cylinder to the stretcher
or wall is missing.
This stretcher should not be used until this is replaced.
|
CGC Poster 1
|
|
|
|
|
CGC Poster 2
|
Q.
What are you talking about when you
say "expiration date" for the Oxygen?
A. An expiration date was added
a few years ago for all compressed gas cylinders. Compressed gas
cylinders are only good for five years. So Oxygen compressed
gas cylinders which were changed out in 2004 will expire in 2009.
Recently, we have found several expired compressed gas tanks –
including an oxygen tank on an emergency cart that expired in 1998.
The expiration sticker looks like a white price
sticker that you would see in a store. If you have oxygen tanks on your emergency cart, an ‘H"
reserve tank or any compressed gas tanks, please check to see that
they are in date.
As of today 9/23/04, Marty Palen is making rounds on all the JHH units. He is checking
volume of compressed gases present in each unit, storage conditions of the compressed
gas cylinders, expiration date and whether the compressed gas cylinder is full. He is
currently finding a lot of empty tanks. His recommendations:
-
DO NOT
open the tank to see if it still has gas. It is very difficult to shut off these
valves so the tanks will continue to leak until they are empty.
Don’t turn on a tank unless it is being used on a patient.
-
As he makes round, he is checking the expiration dates on all of the compressed
gas cylinders he finds and replacing those tanks which are expired. So the only
thing you need to do
now
if you find a compressed gas cylinder that is expired is
make sure no one uses it
.
-
Exception:
If the expired tank is your
only
tank of oxygen, do call him immediately
-
Starting 11/15/04
– if you find an expired tank or a missing expiration label, contact Marty Palen at
(410) 955-6530 or
mpalen@jhmi.edu
Q.
Why can't I prop (wedge) open the door?
A.
Door Stoppers endanger the lives of both patients and staff. They help smoke and fire to
spread around the building trapping and possibly killing the occupants.
|
|
DoorStop Poster
|
Q.
What is wrong with storing things on the top shelf?
A.
The distance from the bottom of the sprinkler to the top edge of the shelf is 18.5 inches.
Nothing can be within 18 inches of the bottom of the sprinkler - so nothing can be stored
on the top shelf. Things may only be stored on the top shelf if there is more than
18 inches of space between the bottom of the sprinkler and the top of what is stored on
the shelf.
Q.
What is wrong with this picture?
A.
If linen is stored in a closet with other items, it must be covered.
Q.
What is wrong with this picture?
A.
Water (in yellow bucket) sitting in a closet. Infection control problem.
Q.
What is wrong with this picture?
A.
Clean paper towels sitting on a dirty closet floor - Infection Control problem.
Q.
What is wrong with this picture?
A.
Linen Chute door is blocked. There is no yellow sign on the linen chute door explaining
that this is a confined space and that you need a permit and confined space training in
order to enter the linen chute.
Q.
What is wrong with these pictures?
A.
Nothing should be stored in these mechanical spaces. The temperature in mechanical spaces
which house autoclaves is high enough that some of the chemicals might catch on fire. The
combustible (mop head) - lying against the autoclave insulation would provide additional
fuel for such a fire. The scrubs and the trash also could be fuel for a fire.
Q.
What is wrong with this picture?
A.
There are two things:
-
Unable to reach eyewash because of cart blocking it.
-
Cart contains plastic container where dirty instruments are soaked waiting to be
transported to sterile processing area but no Blood borne pathogen sign was on the
container.
Can you imagine being half blind from a chemical in the eye, crashing into this cart and
then having disinfectant with dirty instruments fall onto you before you could start the
eye wash?
Q.
What is wrong with this picture?
A.
The fire marshal says that we need three (3) feet clearance on all sides of the blanket warmer. In
fact any electrical equipment that heats - including such items as toaster ovens and microwaves -
also need three feet clearance from combustibles. Examples of combustibles are linen, cardboard,
etc. Make sure your compressed gases are not stored near a blanket warmer.
Q.
What is wrong with this picture?
A.
All chemicals have to be labeled and the label has to be readable. If you look at the bottle to the
right, you will notice that the label is no longer readable - so a new label needs to be applied if
you want to keep using this chemical.
Q.
What is wrong with this picture?
A.
The main reason why wet ceiling tiles are a problem is because they are breading grounds for mold.
If a stained ceiling tile is noticed please call Facilities immediately to place a work order.
Q.
What is wrong with this picture?
A.
Integrity of Patient items (ie. mattress, chair cover, stretch, wheel chair...): tears in the outer
covering of patient care items prevent the adequate cleaning from occurring. The torn surface can
harbor bacteria and other microorganisms, which the cleaning solution cannot get to.
Q.
What is wrong with this picture?
A.
JCAHO is enforcing NFPA 99 (2002 edition) regarding compressed gas storage. This is found on page 128 of
the Health Care Facilities Handbook 2002. This is a NFPA publication that explains how NFPA 99 pertains
to healthcare facilities. A copy of this book is available for viewing at 2024 E. Monument ST, B-200 -
Department of Health, Safety and Environment.
"Chapter 5.1.3.3.2 Design and Construction. Locations for central supply systems and the storage of medical
gases shall meet the following requirements:... (7)Be provided with racks, chains, or other fastenings to
individually secure all cylinders, whether connected, unconnected, full, or empty, from falling."
Back to Top
JCAHO INSPECTIONS
Q.
What is JCAHO and why is it important?
A.
JCAHO
JCAHO stands for The Joint Commission on Accreditation of Healthcare Organizations. By asking for accreditation, an organization agrees to be measured against national standards set by health care professionals. An accredited organization substantially complies with Joint Commission standards and continuously makes efforts to improve the care and services it provides.
Health care organizations seek Joint Commission accreditation because it:
-
Enhances community confidence.
-
Provides a report card for the public.
-
Offers an objective evaluation of the organization's performance.
-
Stimulates the organization's quality improvement efforts.
-
Aids in professional staff recruitment.
-
Provides a staff education tool.
-
May be used to meet certain Medicare certification requirements.
-
Expedites third-party payment.
-
Often fulfills state licensure requirements.
-
May favorably influence liability insurance premiums.
-
Favorably influences managed care contract decisions.
For more information visit:
www.jcaho.org
Q.
How does JCAHO benefit Johns Hopkins?
A.
JCAHO
is the Joint Commission on Accreditation of Healthcare Organizations. The Centers for Medicare and
Medicaid Services (CMS) is a Federal agency within the U.S.
Department of Health and Human Services which pays many of the medical bills for Medicare and Medicaid;
but, does not do their own inspections. Instead they delegate to JCAHO to inspect. If a healthcare
institution does not pass the JCAHO inspection, they will not receive payment from CMS for the bills of
Medicare and Medicaid patients who use that healthcare institution's services. The bottom line is that
it is possible that the healthcare institution could be shut down if it does not pass the JCAHO
inspection.
Q.
How often are the JCAHO surveys?
A.
JCAHO surveys occur approximately every three years. In an in-service Kathy Norins - a JCAHO surveyor - said a year ago that healthcare organizations that passed with low marks on their last JCAHO survey and when JCAHO's assessment of their eighteen month self-assessment/corrective action plan - the assessment raised concerns - might see JCAHO as soon as two years. Healthcare institutions that passed with a good score and whose self assessment is realistic might not see JCAHO until four years. If a patient incident makes the newspaper or an institution reports a sentinel event, JCAHO can come back in at any time
Q.
When is the next survey for Johns Hopkins Hospital?
A.
The next survey is scheduled for the 15th through 19th of November 2004 (the week before Thanksgiving). This is the last time we will know when JCAHO is coming before they arrive at the JHH door.
Q.
Are surveys always announced?
A.
Presently they are announced ahead of time. However, starting January 2005 surveys will not be announced.
Q.
How long is the JCAHO survey?
A.
It depends on the size of the institution. At JHH it is usually a week long.
Q.
What happens during the survey?
A.
JCAHO inspects everything from doors/floors/walls/ceilings to patient records. They will talk to staff and patients.
Q.
What areas are surveyed?
A.
Any patient care (clinical) area or clinical support area (such as linen distribution, facilities workshops, power plants, etc).
Q.
Who makes up the group conducting the JCAHO survey?
A.
The survey team can include one, two, three or more health care professionals, including a physician, nurse or hospital administrator who has senior management level experience. The surveyors are selected from the Joint Commission's cadre of more than 350 surveyors. JCAHO will be adding an engineer starting January 2005.
Back to Top
Safety Training
Q.
What training do I need to have? How often do I need to have them? Why do I have to have them?
A.
HSE offers many different training classes. Depending on where you work and what your
responsibilities
are influences what trainings you are required to have.
-
All new Hopkins employees must attend new employee orientation. At this orientation you will
receive fire safety, hazard communication, and bloodborne pathogen training.
-
Any employee who may have a potential to be exposed to blood or body fluids...i.e. they work with
or around patient blood/body fluids and/or non-human primate blood/body fluids must attend annual
bloodborne pathogens training. This is an OSHA regulation.
-
Any employee who has to wear a respirator of any type (N95, PAPR, etc) must have annual fit testing
on the respirator. This is an OSHA regulation.
-
It is required that every employee receive fire safety and hazard communication training at least
once every three years.
-
It is recommended that employees who work in a biosafety lab take the Biosafety Training Class at
least once.
-
Before an employee operates a power industrial truck, the employee must be trained in the operation
of that equipment and is then recertified every three years. This is an OSHA regulation.
-
Any employee who has the responsibility for repairing powered equipment that must be locked and/or
tagged out prior to repairing must receive lockout/tagout training. This is an OSHA regulation.
-
DOT/IATA Dangerous Goods Shipping Certification course for individuals who ship hazardous materials
(including biological samples)
-
All laboraotry employees should take the Laboratory Safety course which reviews the items covered by
the annual laboratory research safety inspections.
-
All employees who work with radioactive matieral must attend the Radiation Safety course. The
Primary Investigator is responsible for assuring that individuals who handle radioactive materials
under their authorization are trained in radiation safety. This training may be done in-house or
through the Radiation Safety course.
Back to Top
Biosafety Cabinets (BSCs) and Clean Air Benches (CABs)
Q.
How often do HEPA-filter containing devices need to be certified?
A.
At least annually. Biosafety cabinets used by the Pharmacy and certain non-exhausted units need to be
certified every six (6) months.
Q.
How do I initiate an annual certification service request?
A.
Contact the Biosafety Office with the following information: serial number, contact information, and method
of payment. JHU departments should identify an SAP budget account number that can be charged for the service.
JHH departments should complete a check request for the full amount made payable to Johns Hopkins University.
Be sure to include the serial number, room number, and contact person for the BSC or CAB to be certified.
Q.
Why is annual certification required?
A.
To ensure the BSC is operating according to Original Manufacturer's Specifications. Regulatory agencies such as
the FDA, USDA, CDC, Public Health Service and funding agencies such as the NIH, NCI, and American Heart
Association require compliance with this standard. Certification includes tests for proper air flow through the
equipment as well as HEPA filter integrity. Your safety and the sterility of the work environment within the
equipment are not assured if the unit has not been certified.
Q.
How do I enroll my equipment in this program?
A.
Provide Biosafety, HSE with the following information:
-
Owner name & office address
-
Cabinet location building and room number
-
Laboratory contact person name and phone number
-
Cabinet manufacturer, unit model and serial number
Q.
How will I know when my equipment is due for certification?
A.
It is the Principle Investigator's responsibility to maintain compliance with the annual
certification. The Biosafety Office suggests the PI or Dept Administrator maintain a
tickle file to remind themselves to schedule routine services on an annual basis. The
Biosafety Office does send out reminders approximately 30 days prior to certification
expiration, but this system is not 100% accurate due to changes in contact information
(names, phone and addresses) that may have occurred since the previous certification,
but have not been submitted to the Biosafety Office.
Q.
Who pays for this service?
A.
Payment is made by the PI or, in some instances, the department covers these costs.
Back to Top
