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Orientation and Annual Education Part I for RISF Back to Course Index





All employees of the facility are required to participate in annual training upon initial employment, and on an annual basis thereafter. This self-study packet has been developed to provide employees with another medium by which annual refresher requirements can be fulfilled.



Please follow the directions listed below when completing this training:

  1. Read through the self-study booklet carefully.
  2. Complete the written examination at the end of this packet using the separate answer sheet provided.
  3. Return your answer sheet to the person who provided this packet to you.
  4. Keep your study packet as a resource guide for the future.






All employees of the facility are required to participate in annual training upon initial employment, and on an annual basis thereafter. This self-study packet has been developed to provide employees with another medium by which annual refresher requirements can be fulfilled.


Table of Contents


Safety Philosophy
National Patient Safety Goals
Accident Prevention
Emergency Codes
Disaster Preparedness
Electrical Safety
Equipment Management
Fire Safety
Hazard Communication
Material Safety Data Sheets
Personal Protective Equipment
Security Management
Infection Control
Driver Safety
Bloodborne Diseases
Airborne Diseases
Standard Precautions
Patient Rights
Reporting Abuse/Neglect
Patient/Family Concern System
Incident Reporting
Drug-Free Workplace
Performance Improvement
Sexual Harassment-Q&A’s
Workplace Violence
Ethical Behavior


An effective organizational safety program cannot exist without optimal reporting of medical/health errors and occurrences. Therefore, it is the intent of the facility to adopt a non-punitive approach in its management of errors and occurrences. All personnel are required to report suspected and identified medical/health care errors, and should do so without the fear of reprisal in relationship to their employment. This organization supports the concept that errors occur due to a breakdown in systems and processes, and will focus on improving systems and processes, rather than disciplining those responsible for errors and occurrences. A focus will be placed on remedial actions and individual development to assist rather than punish staff members.



All employees need to be aware of the:

  1. The Joint Commission National Patient Safety Goals
  2. Need for accurate and timely reporting of incidents
  3. The RCA (root cause analysis) process
  4. Culture of “no blame


2013 National Patient Safety Goals

  1. Improve the accuracy of patient identification.
    1. Use at least two patient identifiers (neither to be the patient’s room number) whenever taking blood samples or administering medications.


  1. Improve the effectiveness of communication among caregivers.
    1. Implement a process for taking verbal or telephone orders or critical test results that require a verification “read-back” of the complete order or test results by the person receiving the order or test result.
    2. Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use.
    3. Measure and assess, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by critical test results and values.
    4. Standardize an approach to “HAND OFF” communications, including an opportunity to ask and respond to questions and determine what is critical information.

  2. Improve the safety of using high-alert medications.
          1.  Develop list of “look alike – sound alike” medication.
          2.  Store medication safely.



  1. Reduce the risk of health care-acquired infections.
    1. Comply with current CDC hand hygiene guidelines.
    2. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection.


  1. Medication Reconciliation – Accurately and completely reconcile medications across the continuum of care.

  2. a) Obtain and document a complete list of the patient’s current medications upon the patient’s entry to the facility and with the involvement of the patient. This process includes a comparison of the medications the facility provides to those on the list.

  3. A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.


  1. Patient Falls – Assess and decrease the patient’s risk of falling.


  1. Encourage patients’ active involvement in their care as a patient safety strategy.
    1. Educate patient and families on methods to report concerns related to care, treatment, services, and patient safety issues.


  1. Identifies safety risks inherent to patient population.
    1. Identify patients at risk for suicide.




There are various potential hazards associated with the workplace environment. Many of these hazards can probably be found in your workplace and can lead to accidents, injuries, or illnesses. This training is designed to provide you with information to help you recognize and eliminate such hazards.


Identification of Hazards

Our first goal should always be to identify hazards before they lead to an adverse effect. To make this easier, we place hazards into the following hazard categories:

  • Kinetic/Mechanical – crushing, cutting, lifting, slips, trips, and falls, ergonomics,…..
  • Thermal – burns, frost bite, heat exhaustion or stroke, …..
  • Electrical – shock, burns, …..
  • Acoustic – noise induced hearing loss, …..
  • Biological – bloodborne pathogens, airborne pathogens, …..
  • Chemical Hazards – acids, bases, flammable, reactive, …..

When you are in your workplace you should always be on the lookout for hazardous conditions or situations. If you recognize such conditions or situations, you should take immediate action to eliminate them.



Since many of the hazards categories listed above are addressed in other training sessions, they will not be covered in this training module. In this training session, special emphasis will be placed on ergonomics. Fundamentally speaking, ergonomics is the manner in which the human body interacts with the workplace. It is the body mechanics of how work is done, and how these mechanics can cause trauma to the body. Several key points to remember which will help protect you from ergonomic hazards are as follows:



The facility has numerous methods to protect its employees from accidents, injuries and illnesses.   Many policies and procedures have been developed to help educate employees and help them work more safely and can be found in the policy and procedure manuals.

The facility has other informational resources available to help keep you safe such as chemical safety sheets or Material Safety Data Sheets (MSDSs), training programs, labels, and warning signs.

Control / Elimination of Hazards

Once hazards have been identified, steps should be taken to minimize the affect on you or your co-workers. This can be done with engineering controls, administrative controls, and/or personal protective equipment.


Employee Accident/Injury Response

If you were to have any type of an accident, injury or hurt yourself in type of way while at work at the facility you should make sure that you take appropriate actions and contact your supervisor immediately who will determine if you need emergency care. If you are in need of emergency care, go immediately to the Emergency Room. If you are not in need of immediate care contact your supervisor will have you contact Human Resources Department and initiate the completion of required paperwork.

An Incident Report is to be completed by the employee’s supervisor any time there is an occurrence of work-related injury or illness. These reports should be completed prior to the end of the work shift and forwarded to Human Resources.

Employee Personal Safety

Your personal safety in the workplace is important.

  1. Never walk to your car alone after dark. Ask a co-worker to go with you.
  1. Never deal with an agitated patient alone. Always be sure another staff member is aware of the situation. Never let a patient place themselves between you and your exit.
  1. Jewelry can be dangerous in the workplace. Bracelets, earrings and chains can get caught in machinery or grabbed by a patient. Be aware of what you wear to work.
  1. Do not bring valuables or large sums of money to work. Keep your valuables on your person or locked up.
  1. Utilize proper body mechanic principles when lifting, moving or when engaged in physical activity.


Emergency Codes – An alert may be announced during certain emergencies. Your supervisor will instruct you in your duties or actions during the following alerts.


This indicates a Disaster Emergency. There is a comprehensive plan of operation to be implemented in the event of a major disaster within our community. In addition to closing the facility to all unauthorized persons, this plan is designated to insure that sufficient personnel and medical supplies can be made available on short notice to handle such emergency situations. For purpose of disaster preparedness, the facility conducts disaster drills periodically. Instructions concerning your responsibility in the event of a disaster will be given during the orientation program. Further instructions will be provided by your supervisor.

The Emergency Preparedness/Disaster Plan will be activated to deal with any internal/external emergency, such as: weather (hurricane, tornado, flood, etc.), civil disturbance, explosion, terrorism, etc.).


  1. Communication will announce via overhead page: “The External Disaster Plan is now in effect.”
  2. All personnel are to report to their assigned duties as outlined in the Plan.
  3. Follow your departmental plan and await further instructions.



When the disaster is complete, communication will announce via the overhead page:

“The Disaster Plan is now secured.”

For more detailed information about the Emergency Preparedness / Disaster Plan, refer to the specific manual addressing these issues.


CODE RED: This indicates a Fire Emergency. Fire safety is of critical importance. During a fire alarm, all employees have specific assignments and responsibilities as outlined in the Fire

Plan applicable to their departments. The Fire Plan provides a complete explanation of the departmental fire drill and evacuation procedures. Instructions concerning your responsibilities in the event of a fire will be given during your orientation program. Further instructions will be provided by your supervisor.



R = Rescue / Remove endangered persons – move patients, visitors, etc. to safety  -reassure them.

A = Alarm / Alert – Activate Fire Alarm nearest you or page overhead Code Red.

       Repeat Code Red and location of fire clearly three (3) times.

C = Confine / Contain the fire by closing all doors and windows.

E = Extinguish if small fire and it is safe to do so.

       Evacuate all patients, visitors, employees, etc. from the building to designated safe area.



P = Place fire extinguisher on the floor and pull the pin.

A = aim at the base of the fire; stand 8-10 feet away from the fire.

S = Squeeze the handle.

S = Sweep from side to side at the base of the fire.

***Know the location of pull stations, emergency exits, fire extinguishers and your departmental fire plan***



This indicates a Medical Emergency requiring prompt and immediate attention. All nursing staff and physicians if present will respond to the site to evaluate situation and determine necessary action.

Code Blue is the code used in the event of a medical emergency such as: cardiac / respiratory arrest, seizure activity, etc.


  1. Overhead page “Code Blue” clearly three (3) times including exact location.
  2. Institute emergency measures (i.e.: CPR).
  3. Call 911.


CODE GREEN:           

This indicates a Bomb Threat has been received and requires specific activities to be      followed to ensure the safety of all those in the building and on the premises. In addition          to specific activities required by the person receiving the threat, evacuation of the                building will take place

If you receive a call / information about a bomb threat, listen carefully and record           answers to the following questions (use Bomb Threat Report Form if readily available):            

  1. When is it going to explode?
  2. Where is it right now?
  3. What does it look like?
  4. What kind of a bomb is it?
  5. Why did you place it here?
  6. Time called:_________________
  7. Male or Female caller: M____   F____
  8. Adult or Child: Adult____   Child____
  9. Background noises:______________________________________________________
  10. Other clues:____________________________________________________________


Page Code Green overhead and begin following procedures:

  1. Begin a search of your immediate area for any “package or device” that does not belong there or appears suspicious.
  2. If such a “package or device” is found, DO NOT TOUCH OR MOVE IT. Call 911.
  3. Safely evacuate building and do not cause panic in patients or others.

For further information on the procedures for responding to a Bomb Threat, refer to the Bomb Threat policy and procedure in the Environment of Care P&P manual in your program.



This indicates a Hazardous Material Spill or Leak and requiring prompt and immediate attention. Maintenance staff will respond to the site to evaluate situation and determine necessary action.


  1. Know the location of spill kits for small spills.
  2. Know location of MSDS (Material Safety Data Sheets) manual.
  3. Persons exposed to the chemical are to be directed to the Emergency Department at closest hospital with a copy of the applicable Material Safety Data Sheet. 


For HAZMAT incidents that present a significant or unknown hazard to the patient and staff and cannot be safely handled, please follow the steps below:

  1. Remove patients from danger and notify staff in the area to leave and assemble in a safe place.
  2. Notify the receptionist of a “CODE YELLOW”; identify yourself, report the exact location and type of spill, if known.
  3. Persons exposed to the chemicals are to be directed to the Emergency Department of the closest hospital with a COPY of the applicable Material Safety Data Sheet.
  4. Notify the Emergency Department of the person/s to be evaluated. E.D. staff may need to isolate and decontaminate to prevent potential exposures to staff / patients.

For further information on the procedures for handling hazardous materials refer to Safety Manual in your program.


CODE GREY                       

This indicates a Security Assistance / Tech in Trouble and requiring prompt and  immediate attention. All staff will respond to the site to evaluate situation and determine  necessary action.


Code Grey summons Staff / Security assistance immediately in the event of a  physically combative person or a Tech in Trouble. This code enables assistance to arrive at the area of the problem without disclosing Security response.

Follow the procedures outlined below in the event of a potential risk of  aggressive behavior:   

  1. Page Code Grey clearly three (3) times to include the exact location of the incident.
  2. All employees available are to report immediately to the location involved.
  3. De-escalation techniques are to be utilized to dissipate the situation.
  4. Call 911 if indicated by danger risk and/or if a weapon is present.

The facility has a zero tolerance for violence in the workplace. If a patient, visitor or             employee becomes physically abusive or violent, implement the Code Grey procedures             immediately.


CODE PURPLE:            

This indicates a Weapons On Premises and requiring prompt and immediate attention. Maintenance staff will respond to the site to evaluate situation and determine necessary action.


Code Purple is the code to be utilized in the event of a weapon (i.e.: gun, knife, etc.) is on the premises and posing a potential deadly threat to patients, employees, visitors, etc.

The following procedures are to be employed in the event of a threat posed by a weapon:

  1. Page Code Purple overhead clearly three (3) times with exact location.
  2. Call 911.
  3. Employees not in immediate area of danger are to calmly evacuate everyone not involved in situation from the building.
  4. Do not attempt to physically remove weapon from threatening party.
  5. Utilize verbal de-escalation techniques if appropriate.





Be aware of any program specific safety risks that you may encounter; look around your area.

Report all safety / security hazards to your Supervisor immediately.


                                    Poison Control:                   1-800-282-3171

                                    Fire Department:                 911                  

                                    Emergency:                         911                 



Finally, it should always be remembered that the most important element in the prevention of workplace injuries, illnesses, and accidents/incidents is you the worker. Make sure that you are constantly aware of your surroundings and the hazards therein. Once you have recognized a hazardous situation or condition, make sure that you take all actions necessary to control or eliminate these hazards.




There is an ever-present possibility that a disaster will strike the facility or one of the surrounding communities. It is imperative that we, as a healthcare organization, are prepared to respond to any disaster scenario that could present itself.

Goal and Responsibilities

The purpose of our Disaster Plan is to outline how we will respond in the event of a disaster. The goal of the response will be to save lives, limit casualties, limit damage, and restore normalcy ASAP.

We, the facility community have the responsibility to respond to disaster by organizing all available resources to be deployed in the most efficient and effective manner. Each department and employee has a responsibility to cooperate and extend their services to prevent, minimize and repair damage/injuries resulting from disasters.


Disaster Types

There are numerous types of natural and man-made disasters that could occur in our area to which we must be prepared to respond. Some of them are listed in the table below:



Technology and Man Made

·       Tornadoes

·       Damaging winds

·       Storms (Hurricanes)

·       Floods

·       Fires

·       Public Health Emergencies

·       Utility failure and loss of communication

·       Structural collapse

·       Industrial accidents involving toxic, caustic, radioactive, explosive,

         and/or biological hazards

·       Civil disturbance

·       Major accidents of land, sea, and air

·       Bomb threat


In the event of a disaster, the facility will probably be notified through the County Emergency Warning System, which is a countywide alert or “emergency broadcast” system. Individual receiving disaster call/warning will identify:

  1. Type of disaster
  2. Number of victims and acuity
  3. Types of assistance required
  4. Contact for continuing information
  5. Verify call

The Director and administrative staff will be called immediately if the disaster is on the premises. Administrative staff or designee will determine if and when a disaster should be declared.   If indicated the directive for treatment site closure either complete or partial, will come from the Director or designee. In the event of a disaster, Switchboard will make an overhead announcement the disaster.

All facility employees will come to the facility if an alert stage is reached. Employee’s will make themselves accessible by phone or respond and receive communication from the facility.

In the event a hurricane or other emergencies, an Employee Hot Line toll-free number is operational 24/7 for employee to check status and to listen to the recorded instructions. The recording will be updated as needed as needed. The number is 1-888-558-237.

It is very important that all responding departments maintain up to date callback lists, and that all employees who are on this list have adequate training. When callback lists change it is very important that all lists are updated. Employees who are on a callback list must always be prepared to return to the facility to assist in response. Those employees, who are off duty and are not on a call list, can remain available if needed.


Communications during disaster response could be handled through any of the following methods: telephone, fax, pager, radio, person to person, news media, etc.

Employees should not communicate with the media during a disaster response except to instruct them to contact the Director who will brief them. This will ensure patient privacy and prevent the communication of inaccurate information.



Severe weather such as a tornado or hurricane could threaten the safety of staff, patients and visitors.

A severe Weather Watch means conditions are favorable to the development of severe weather. A Severe Weather Warning indicates that there has been an actual sighting of severe weather in the immediate area.

If the National Weather Service announces a Severe Weather Watch, the Safety Officer or the highest level of authority in the facility will implement the Plan.

  1. Staff will secure or remove all objects on the facilities grounds such as umbrellas, trashcans, etc.
  2. All work areas should locate and check their flashlights for use in the event of a power shortage.
  3. Patients, visitors and staff should stay inside with all doors and windows closed.

If the Safety Officer/Supervisor feels that the facility is in the path of a tornado, a Code ‘White’ will be called and all patients, staff, and visitors will go immediately to the designated safe area away from all doors and windows.

When the Weather Service discontinues the warning, the Safety Officer will page an “all clear” and normal operation will resume.


It is imperative that we are prepared to respond to any disaster scenario that could present itself. It is the responsibility of each employee to understand their role during a disaster response, and that they be ready to assist in such response when called upon to do so.



Electricity makes our lives much easier. It is all around us, running our air conditioners, heaters, lights, stereos, and much more. Electricity is easy to use and convenient, but it must also be remembered that electricity can be very DANGEROUS. Electricity can cause electrical burns or electrocution, and overheated electrical equipment can cause fires. Also, electrical sparks can cause explosions.

Electrical Shock

imagesElectrical current is brought into the organization by two wires which we see as electrical receptacles.  One slit is “hot”, the other neutral.  The “round” opening is the ground or safety wire.  Electricity always tries to reach the ground and if you remove the third prong from a plug it is possible that if electricity “leaks”, it will reach the ground through you.  It is also very important that you always keep an insulator between you and electricity.  This could be the plastic covering to a wire, dry wood, rubber or glass.  

electroElectrical current that “leaks” from a broken cord or piece of equipment can produce electrical shock known as macroshock. The effects of macroshock can range from a slight tingling sensation to stopping the heart. Individuals experiencing macroshock must be removed from the electricity source quickly and safely. This can be accomplished by performing the following:

  1.  Eliminating the power source by pulling the plug if possible or shutting off the power supply to the building or room.
  2. Knocking the chord away or pushing the person away from the power source using something non conductive (Never use hands or metal objects)
  3. After the victim and power source have been separated, immediately check for a pulse and initiate emergency care and activate the emergency medical system.

If you think a piece of equipment has the potential to or has caused macroshock, contact Maintenance immediately.


One specific safety measure found throughout the hospital to prevent shock is the use of ground fault circuit interrupters (GFCIs). These are special outlets use near sinks or wet areas which will discontinue the flow of electricity if it starts free flowing into you or another conductor. 

Extension Cords/Multiple Receptacle Adapters

Extension cords are PROHIBITED. You can obtain approved grade extension cords from Maintenance personnel.

In non-patient care areas like lounges and offices, in some instances there are not enough electrical outlets. Many multiple receptacle adapters are available for purchase. The only acceptable adapter for use is a multiple receptacle surge protector with an in line circuit breaker. All other adapters are unacceptable including 3 in 1 extension cords and prong adapters.

Safe Work Practices

The following are some of the Do’s and Don’ts of electrical safety.


·       Treat all wires as “live” or “hot “

·       Use properly insulated tools

·       Unplug appliances before cleaning Always use surge protectors

·       Keep all areas dry when working

·       Pull plug with plug not cord

·       Report all frayed cords or damaged equipment  

·       Inspect cords and equipment frequently


·       Never overload electrical circuits

·       Never place electrical equipment near flammable

·       Never use electrical equipment while touching metal or other conductors

·       Never use extension chords unless they are 1 to 1 hospital grade

·       Never remove the third prong from plugs

·       Never string electrical cords together

·       Never run over cords



It is critical that safe work practices be utilized when working with, or in close proximity to, sources of electricity.   It is the responsibility of each the facility employee to understand the possible electrical hazards associated with their jobs, and to ensure that all necessary steps are taken to ensure that electricity does not cause death, injury or illness.


Please move on to lesson 3:  RISF Orientation and Annual Education Part II.