Risk Management Safety Information Handbook For Non-Hospital Personnel







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Risk Management

Safety Information Handbook

For Non-Hospital Personnel



Mission Statement ... 1

Vision Statement ... 1

CORE Values ... 1

Introduction/Purpose ... 2


... 2

Reporting of Injuries or Accidents ... 3

Smoking/Tobacco Free Environment ... 3

Personal Protective Equipment ... 3

Waste Disposal ... 4

Confidentiality... 4

Electrical Devices ... 5

Hospital Infection Control ... 5

Infection Control in Surgery ... 6-8

Law Enforcement/Forensic Staff. ... 8-10

Responsibility of Law Enforcement

In a Disaster Occurrence ... 10

Communication Lines for Law Enforcement... 11

Restraint of Prisoners ... 11 & 12

Signature Page ... 13

Confidentiality Agreement ... 14

Emergency Notification ... 14

If you have questions regarding the contents of

the “Risk Management Safety Information

Handbook for Non-Hospital Personnel”, call the

Director of Patient Safety and Risk at extension




Provide excellent health care and promote

healing through trusting relationships.


To be recognized as the regional center

of excellence for health care.














The “Risk Management Safety Information Handbook for Non-Hospital Personnel” (“Handbook”) will be used by personnel who are not employed by Good Samaritan Hospital (GSH) but are present within the facility for the purposes of facility maintenance, business, shadowing/observing and law enforcement. A review of the “Handbook” will be provided by the appropriate hospital staff (can also be viewed on RepTrax). The following will receive a copy of the “Handbook” and an explanation at their level of understanding: Consultants, Contractors, Physicians/Interns/Residents, Service Vendors, Sales Representatives, Shadowing/Observing Students, and Law Enforcement Personnel.

Vendors and contractors having business at GSH will be on file in the RepTrax system. All vendors will visit a RepTrax kiosk immediately upon entrance to GSH, and register their visit for the day. Vendor representatives will possess either a base or premium membership. The difference in membership denotes a difference in access to specific areas within the hospital. The vendor must register at a RepTrax kiosk and receive either a base or premium name/access badge and display that badge prominently on their person while in the hospital or on hospital grounds. If the kiosk does not produce a badge for the vendor, they must immediately proceed to the materials Management Department to register.

Security staff will be notified when non-hospital personnel are not wearing badges. Non-hospital personnel who are not wearing badges will be escorted by security staff to the Materials Management Department. Repeat offenders may be limited access to Good Samaritan Hospital.


Non-hospital personnel are required to comply with Good Samaritan Hospital’s policies and procedures that apply to their job responsibilities.

Needle/Sharp safety is of extreme importance. Never recap needles, always dispose of needles/sharps in proper containers, and report all actual and potential needle/sharp exposures.




Non-hospital personnel should immediately report hospital-related injuries, accidents, or unusual occurrences to the Department Director or Manager. This includes patient incidents and non-hospital personnel incidents. The Department Director or Manager will ensure that appropriate documentation and reporting are completed.



Good Samaritan Hospital promotes a smoking/tobacco free environment. Smoking and tobacco use is prohibited on all Good Samaritan Hospital campuses.



Personal Protective Equipment (PPE) provides an essential barrier between workers and hazards they may face at the hospital.

Examples of PPE include: Eye/Face Shield, Mask, Goggles, Gloves, Gowns, and Respiratory Equipment.

Notify the Department Director or Manager if you need PPE or if you are unclear as to when to use PPE or where PPE is located.



Waste Type Bag Color

1. Infectious Red 2. Confidential items Green 3. Recyclable items White 4. Regular trash Black 5. Laundry Yellow

Needles and sharp objects will NOT be placed in plastic

bags or trash cans.


Honoring patient and hospital confidentiality is essential while at Good Samaritan Hospital. Any information regarding a patient’s condition, care, treatment, demographics, personal affairs or medical record is confidential and must not be discussed with anyone other than those directly responsible for the care and treatment.

Examples of violating a patient’s confidentiality include, but are not limited to the following:

1. Discussing a patient in a public area such as an elevator or the cafeteria where others may inadvertently hear the confidential information.

2. Discussing a patient’s medical condition and/or care with a friend, family member, or any hospital or non-hospital personnel who is not directly involved with his/her care. 3. Reviewing the surgery schedule for non-work related reasons. 4. Accessing patient information on yourself or others when it is



All electrical devices brought into the hospital MUST be checked by Biomedical staff prior to use.


The principles of Standard Precautions will be carried out with every patient interaction and are intended to protect both the patient and the workers from transmission of infectious diseases. Signs are posted throughout the hospital to remind you that all blood and body fluids are considered potentially infectious material. It is important for you to know the location of the personal protective equipment in the area that you are working and to follow the departmental policies regarding gowns, masks, eye/face shields, goggles, and respiratory equipment. These devices are used to protect mucous membrane (eye, mouth) or non-intact skin (open area, cut) from being exposed to potentially infectious material and blood and body fluids.

Wash Hands thoroughly

Wear Gloves when you anticipate contact with body fluids.

Wear Apron or Gown to protect clothing – never take soiled clothing home.

Wear Mask and Eye Protection when splashing might be likely.

Wear Respirator Mask when in a TB patient’s room.

Some patients are placed in isolation due to the nature of their illness. Those patients are identified with an Isolation Precautions sign on the door to their room. It is important that you do not enter these rooms without first consulting with the nurse to learn the appropriate precautions necessary to protect you and other patients or workers.

Hand hygiene is very important in the hospital environment. Bacteria and diseases may be spread from the hands of healthcare workers. Hand washing facilities and alcohol hand gel dispensers are located in every department. It is extremely important for you to wash your hands after using the restroom, wearing and removing gloves, and before and after contact with a patient or a piece of critical equipment. Please note that direct patient caregivers will not wear artificial nails.



Infection Control in Surgery is based on the following premise:

1. Every surgical procedure is considered to be contaminated and is to be managed in a consistent manner utilizing a “confine and contain” technique.

2. All patients, personnel, and materials are considered to be a potential source of cross contamination.

3. Infection control is the shared responsibility of all Surgery personnel.

Traffic Control

Rationale – the number of airborne microorganisms is directly related to the number of people and their activity in a given area. The Surgery Department is divided into three zones of restriction according to the degree of desired microbial reduction and patient’s increasing vulnerability to infection.

Unrestricted Zone – Street clothes are permitted.

Zone includes: Front desk, holding area, lounges, department offices, locker rooms, restrooms, scheduling office, unsterile equipment room.

Semi-restricted Zone – Scrub attire, including hair cover, is required.

Zone includes: Anesthesia work room, all department corridors, instrument room, cystoscopy room, sterile supply room, storage areas, and pack room.

Restricted Zone – Scrub attire, hair cover required. Face Mask required if procedures in process. Before case begins, instruments are opened. Zone includes: All Surgery rooms.

Doors to Surgery are to be kept closed except during passage of personnel, equipment, or supplies. Movement in and out of Surgery room during a procedure is to be kept to a minimum.

Observers are limited to students of health care disciplines, visiting physicians, hospital employees, and instrumentation/equipment company representatives as indicated. All observers are to be properly attired and assignment of students shall be at the discretion of Surgery management, charge nurses, and department educators. Activity within Surgery during a surgical procedure is to be conducted with consideration for airborne contamination potential. All persons in Surgery room during a surgical procedure are to be documented on surgery record.




 Surgery attire is to be worn by all persons entering semi-restricted or semi-restricted zones.

 Maintenance personnel, etc. may wear single use coveralls over their clothing, hair, and shoe covers.

 Scrubs must be changed before re-entering a restricted area when any soiling, spillage, coming in contact with body substances or dirty surfaces occurs.

 When there is any question of possible contamination, personnel will consider the scrubs contaminated and change them accordingly.

 Cover gowns or lab coats are not required to be worn over scrub attire when the wearer is out of the surgery department.

 A cover gown is required outside of the building on campus.

 If anyone wearing scrub attire exits the building, scrub attire will be changed prior to entering a restricted zone.

 Head hair is to be covered completely.

 Disposable caps or hoods are provided.

 Shoes that are worn out of the hospital should not be worn in restricted zones unless shoe covers are also worn.

 Disposable shoe covers are provided.

 Disposable, string-tied high filtration facemasks are to be worn in surgery in restricted areas.

 Cysto Room is excluded except during spinal/epidural anesthesia insertion for a procedure for which a facemask is normally worn.

 Masks are to be changed after each surgical procedure and as needed after becoming wet or soiled.

 Hospital owned attire is not to be removed from the premises. Warm-up jackets are encouraged as a deterrent for shedding of skin. Artificial nails will not be worn by patient care providers. Nail polish is discouraged but can be worn as long as polish is not cracking and peeling.




PPE should be used as indicated when there is reasonable anticipation of exposure to blood, body fluids, and other potentially infectious material. Available components include: scrub attire, gloves, hair cover, shoe covers, eye/face protection, warm-up jackets, cover gowns, and waterproof aprons. PPE is to be discarded (if disposable) or cleaned with a tuberculocidal disinfectant (if reusable).


Handling of stock should be conducted so that items are available for use in a clean or aseptic condition. Cardboard shipping boxes are not to be taken into semi-restricted or restricted zones.


All observers, vendors, and sales representatives will be identified by name tags.


Vendors will not have direct patient contact. They will sign in and out on the Vendor Log Book.


Good Samaritan Hospital recognizes the basic rights of all patients and is committed to caring for the whole person, physically, emotionally, and spiritually while treating all with dignity, compassion, courtesy, and respect.

1. The physician and hospital staff will coordinate care with the law enforcement officer to ensure and/or maintain appropriate care to the patient.

2. Good Samaritan Hospital requires that all outpatient/inpatient prisoners be guarded at all times by an officer of the law enforcement agency responsible for the prisoner. In some cases it may not be possible to segregate prisoners, but at all times the officer responsible will be present.

3. A nurse will orient the law enforcement officer(s) to hospital policy and operation to facilitate the care of the prisoner using a “Risk Management Safety Information Handbook for Non-Hospital Personnel”.



4. The law enforcement officer will communicate disciplinary restriction, necessary for the prisoner, to the physician and hospital staff so they may be incorporated into the patient’s care, i.e., limiting visitors and phone calls, gifts, and access to personal property.

5. The usual Patient’s Rights may be suspended when the patient is a prisoner due to law enforcement protocols and procedures. 6. A law enforcement officer must be assigned and remain with the prisoner at all times. In critical care units (especially if the patient is in critical condition), the officer may sit outside the door of the prisoner’s room.

7. Officers are to leave the patient only when relieved by another guard, however, at anytime the medical staff, nursing, or approved visitor enter the room the officer must be in the room to ensure their safety.

8. If the prisoner goes into the operating room, the officer must remain in the room until the patient is anesthetized. Then the officer must leave and wait outside the room. When the prisoner is transferred to the recovery room, the officer will accompany and remain with the prisoner.

9. It may be requested that the officer not be present in the prisoner’s room due to infection control considerations. This exception must be approved by the Nursing Supervisor and Security.

10. Officers will comply with all hospital policies.

11. The Security Department will assist police or correctional officers as appropriate when requested. The Security Department will not assume responsibility for the custody of the prisoner.

a. In the event of an extreme emergency that incapacitates the assigned officer, Security will be responsible for assigning personnel to protect staff, patients, and visitors pending arrival of appropriate relief coverage.

b. The Security Department will not provide relief coverage for officers for purposes such as meals or personal breaks.

c. In the event that a patient prisoner expires while at the hospital, the orderlies will assist the officers, either getting access to the morgue or transfer of the body to the coroner.


12. Prisoners who must leave their beds and room for any purpose, such as visits to ancillary treatment areas, must be accompanied by the assigned officer. Bedside tests will be done when feasible.

13. Law enforcement and corrections officials will not interrogate or conduct office proceedings involving a prisoner unless the attending physician is informed and grants consent. This provision is to ensure that the prisoner is medically able to participate in such activity.

14. No visitors will be allowed in the room of the prisoner except those authorized by the law enforcement agency. The law enforcement agency is responsible for screening all visitors. Admission of any representative from the press requires explicit approval from hospital administration.

15. The Public Relations Department or Administration will respond to the press should that become necessary.

16. The prisoner will be assigned to a private room whenever possible. If a private room is not available, the prisoner will then be assigned to a semi-private room. No other patient is to share the room.

17. If the prisoner is assigned to a semi-private room and has bathroom privileges, the door to the bathroom must remain open in order to ensure the safety of the patients sharing the bathroom and for the prisoner’s own safety.

18. Discharge planning and instructions will be communicated to and coordinated with the law enforcement officer and law enforcement facility to ensure prisoner security and continuity of care.




In the event of a disaster (fire, bomb threat, etc.) the law enforcement officer in charge of the prisoner will take directions from the nurse in charge of the unit. Should evacuation become necessary; the officer will be responsible for assisting with the patient/prisoner.




The law enforcement officer should direct clinical questions or concerns to the nurse in charge of the unit.

In the event of a medical emergency, the law enforcement officer may call 3911 and state CODE 99 and give the exact location.

Should a security emergency arise, the law enforcement officer may call 3911 and ask for security assistance and give the exact location.

For administrative questions during day hours, the law enforcement officer may call the switchboard and ask for the Administration Office. During evening and night hours the Nursing Supervisor should be contacted through the switchboard.


Hospital staff will abide by the requirements for safety as dictated by the law enforcement officers. Staff will assess the patient and document the presence of restraints and presence of the correction officers in constant attendance.

To provide protection for physicians, nurses, hospital personnel, visitors, and other patients and to prevent the escape of the prisoner, the law enforcement officer shall use physical restraints (which may include handcuffs, and/or leg irons) unless these directly interfere with required medical care. These are considered forensic restrictions. The length of restraint and device necessary will be determined by law enforcement officers. Forensic restrictions differ from clinical seclusion and restraints which are defined below:

Clinical Seclusion – Refers to the involuntary confinement of a person in a locked room.



Clinical Restraint – Refers to the direct application of physical force to an individual, without the individual’s permission, to restrict his or her freedom of movement. The physical force may be human, mechanical devices, or a combination thereof. Types of restrain may include roll belt, jacket, limb, mitten, seclusion, and chemicals. Excluded from this definition area:

1. Body restraint during medical, surgical, or diagnostic procedures.

2. Arm restraint by use of an arm board for intravenous insertion. 3. Mechanism used for adaptive support to permit the patient to

maintain or achieve normal bodily functions. 4. Seat belts for postural maintenance.

Revised 3/6/13

MyDocuments\Risk Management\Safety Information Handbook kb



I hereby confirm that I have received a copy of the “Risk Management Safety Information Handbook for Non-Hospital Personnel”.

I agree to adhere to the expectations set forth in the “Risk Management Safety Information Handbook for Non-Hospital Personnel”.

I also agree to adhere to Good Samaritan Hospital’s policies/procedures and emergency alert responses. Policies/procedures will be available to each department.

I hereby confirm that I am a bona fide authorized agent of the business or agency that I am representing.

I have previously received the training/instruction needed to perform the work assigned by my company/agency while at Good Samaritan Hospital.

I agree to provide Good Samaritan Hospital with written training and safety records upon request.

I agree to contact the Infection Control Nurse at Good Samaritan Hospital prior to assuming work activities if I have had recent contact with an individual with active tuberculosis or diseases such as chickenpox or rubella. I will contact the Infection Control Nurse prior to assuming work activities if I have had a persistent productive cough of two weeks or longer, night sweats, fever, or open skin lesions.

I understand that if I have questions regarding the “Risk Management Safety Information Handbook for Non-Hospital Personnel” I may contact the Director of Patient Safety and Risk. Other contacts are the Department Director or Manager, and the Nursing Supervisor.

Payment for Products:

I understand that any invoices submitted for products that have not been properly presented to GSH, as described in GSH policy #P16.05, will not be paid.

Signature: ______________________________________ Phone #: ________________ Please Print Name: ________________________________________________________ Company/Agency: ________________________________ Date: ___________________ (All lines must be completed)

The SIGNATURE PAGE is to be signed during the safety education process prior to assuming work activities.

The original SIGNATURE PAGE will be sent to the Education and Training Department where it will be placed on file.

A copy of the SIGNATURE PAGE will be retained and filed by the Department Director.







I understand that in the course of my work I may come in contact with confidential information, including clinical, employee-related, financial, and administrative. Such information may be acquired from written records, documents, ledgers, internal verbal correspondence and communication and computer programs and applications.

I understand that unauthorized use of computer terminals/workstations for any purpose is prohibited and that any non-hospital person who accesses or attempts to access computer information that is not within his/her scope of responsibility will be subject to termination from the hospital.

I understand that all information obtained by virtue of my work in the hospital must be held in the strictest confidence. I agree not to divulge or disclose to anyone other than those persons in the hospital who have the “need to know” directly or indirectly, any confidential information acquired during the course of my work at Good Samaritan Hospital. I understand that my obligations under this Agreement will continue after termination of my non-hospital personnel status.

I understand and acknowledge that in the event I breached any provision of this Agreement. Good Samaritan Hospital has the right to terminate my non-hospital personnel status. Signature: _____________________________________________________________ Print Name: ___________________________________________________________ Date: _________________________________________________________________ In an emergency notify: Name: ________________________________ Phone #: ( )____________________ Address: _______________________________________________________________ Relationship: ____________________________________________________________

Consultant Vendor (Sales/Service) Contractor Student (Other)

Physician Law Enforcement Intern/Resident Other






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