TITLE: Safety Committee Meeting
Date: January 19, 2011
ATTENDANCE: Kris Bombard, Bill Kellogg, Cindy Teichroew, Mark Visenor, Ellen Ryan, Karen Renaud, Kim Carlson, Diane Bankers
GOVERNING BOARD RESPONSE: Documentation reflects the Governing Board indicates a concurrence to the action of the Safety Committee with no additions or information required for the meeting of October 20, 2010.
MINUTES: The Minutes of the October 20, 2010 meeting were accepted as written.
GENERAL SAFETY Employee incidents for the fourth quarter were reviewed. There were a total of 11 employee injuries reported. Five needle sticks in fourth quarter for a total of 10 for the year.
Patient incidents (inpatient and outpatient) for the fourth quarter of 2010 were reviewed.
| Incident | 4th quarter | 2010 YTD Totals |
| Total | 7 | 34 |
| Falls | 2 | 19 |
| Other | 5 | 15 |
| Burns |   | 0 |
| Cuts/contusions |   | 0 |
| Visitor Incidents | 5 | 8 |
| FALLS | 0 | 3 |
| Other | 5 | 6 |
Clinic staff will be in attendance at April safety meeting. The clinic safety committee will continue to meet for 6 – 9 months after transition.
PERFORMANCE IMPROVEMENT PLAN: Bill Kellogg reviewed the fire drill critiques. Information is entered into a data base that Facility Operations updates. Opportunities for improvement are being reviewed.
INFECTION PREVENTION & CONTROL: Bill Kellogg reported that a hand dryer has been installed and is operational in Imaging. Pine City Clinic will also receive hand dryers. Cindy Teichroew reported that OSHA is looking at departments having a core group of employees that are fit tested. We are a low risk facility. This will be looked at in 2011.
Secret shopper hand hygiene observations have shown a noticeable improvement. Results are posted on the intranet. We will continue to benchmark amounts.
Flu shots – 87% of employees have received vaccine.
HAZARDOUS MATERIALS AND WASTE A waste stream profile has been posted in our energy star portfolio. Clinic hazardous waste will be incorporated into our existing contracts.
We will be starting to collect Public Health’s hazardous waste every other month. The law states that the hospital is able to help with Public Health hazardous waste.
HAZARD SURVEILLANCE: Discussion on tie wraps used in various departments – can be harmful if not sanded or filed down.
SECURITY: There were not any security incidents reported fourth quarter and data is being tracked on spreadsheet. There were 12 in 2010. Lock down buttons for exterior doors in ED are being installed. There are many different types of doors and lockdowns. FROM PREVIOUS MEETING:Discussion on Sentinel Event Alert on preventing violence in the health care setting.
PLAN: A policy and procedure will be developed.
PLAN: Bill and Ellen will work on enhancing the policy on violence in the workplace using Joint Commission recommended actions.
EMERGENCY PREPAREDNESS
FROM PREVIOUS MEETING: Ellen is gathering information on the requirement of the NIMS 100, 200 and 700 courses that employees will have to take if they have a role on a disaster leadership response team. More information to follow. Emergency Disaster plan is being reviewed. Working on a type of kardex for the color codes such as code red, code pink, code blue, etc. The cards would summarize essential information and be user friendly. More information to follow at next safety meeting.
A code pink drill was held in December. There was a dead amplifier, so some areas did not hear the drill. Amplifier has been fixed and a summary of drill has been written up.
FOLLOW UP: No action is needed.
FOLLOW UP: Departments are reviewing various codes and when completed, it will be brought to safety meeting for final review.
EDUCATION: Clinic employees will have orientation and will meet individually with human resources. They will be assigned education for 2011. Online education for employees for 2010 resulted in 93% compliance. Employees have been notified if they still need to complete annual education.
EQUIPMENT MANAGEMENT TLC has reviewed the Preventative maintenance report:
- 100% of Preventative Maintenance has been completed on Class 1 and Class II
- 1 patient incidents reported to TLC No recalls
- Patient incident – 12 lead monitor was not reading properly, spare cable – rectified machine and confirmed correction.
Installing AMC temp traks at remote clinics – completed the last of February. Management plans are to be reviewed. Physicist was here in November to inspect imaging equipment.
FIRE SAFETY
FROM PREVIOUS MEETING: Bill has developed a fire drill data spreadsheet to be completed after each fire drill. He will bring to the next safety meeting. Discussion was held on life safety code regarding number of fire drills for clinic per year. Bill contacted Jeff Juntunen regarding number of fire drills for clinic – his response was one per year. (See Attachment)
FOLLOW UP: Safety committee reviewed data sheet.
UTILITY MANAGEMENT Bill is checking into estimates for generators at remote clinics for refrigeration.
PLAN: Bill to report at next meeting.
NEXT MEETING:Next meeting, Wednesday, April 20th at 9:00 a.m in Administration Small Conference Room.