2016 Safety and Risk Management

Course Overview

The Patient Safety and Quality Management Plan and Risk Management Program are both designed to protect the life and welfare of patients, visitors, employees and healthcare providers. Additionally, the Risk Management Program provides a framework to prevent adverse incidents by providing an environment in which potential risks to safety can be identified and managed.

Teamwork and participation among leadership, providers, and employees is essential. Improvement processes are based on the belief that risk reduction, patient safety, and process improvement can be achieved when everyone strives to improve their personal performance and the performance of the surgery center.

Employees, allied health professionals and physicians are responsible for actively participating in the functions of the Risk Management Program, working safely according to applicable standards of care within his/her licensure and position, reporting incidents and near misses, and identifying, recommending, and implementing corrective action(s) if needed.

In this course, we will review key updates to the Patient Safety and Qualiy Management Plan and Risk Management Plan and corresponding policies and procedures. 


  • Define a Fire Watch and when it it would be initiated.
  • Review fire safety responsibilities and location of fire safety equipment and protection systems.
  • Outline medication labeling requirements and changes to policies and procedures for multi-dose vials and controlled substance chain of custody.
  • Review Verbal Orders, Verbal Test Results procedure
  • Review specimen collection, labeling, transport, tracking and reporting requirements in the OR and outside the OR.

Fire Safety

  1. Fire Protection Systems Out of Service

A fire watch will be initiated by the Administrator or designee if required fire protection systems (fire alarm and/or sprinkler system) are out of service for four or more hours in a 24 hour period and will continue until all patients have been discharged or evacuated from the facility or the impaired system(s) have been restored to normal working order.

No new surgical procedures will be started if a fire watch is initiated.

Fire watch duties will be assigned by the Administrator or designee. The individual(s) serving as a fire watch may have no other duties assigned to them while the affected fire protection system is out of service and carry a cell phone with them for fire department notification. The individual will perform continuous tours of area(s) affected by the impairment at not less than 30 minutes intervals, watching for and promptly reporting any incidents of fire, visible smoke, or strong smell of smoke or other unwanted odor. While on tour, the individual assigned to fire watch should ensure:

  • Portable fire extinguishers are in place and unobstructed
  • Corridors and exits are free and clear of storage and all other obstructions
  • Exit and stairwell doors are clear and fully operational
  • EXIT signs are visible and properly illuminated
  • Fire doors, smoke barrier doors and hazardous area doors are kept closed and latched (not wedged or blocked open)
  • Oxygen cylinders/containers not in use are properly stored
  • Electrical hazards are promptly reported and remedied

Tours will be documented in a log. Any problems found during the fire watch should be documented and reported to the Administrator or designee and/or builidng management for immediate corrective action.

Click on the following button to read the OISC Fire Watch Policy.

Fire Watch Policy

2. Pull Stations and Fire Extinguishers

Every employee and provider is responsible for knowing the location of fire alarm pull stations, fire extinguishers, evacuation routes and the fire safety plan (RACE).

New fire pull stations have been installed at OISC. There is now a fire pull located at each exit door from the facility.

An additional ABC fire extinguisher was mounted on the wall across from Bay 5 in PACU.

Medication Administration

Always follow the Five Rights (plus one) for medication administration: Right Patient, Right Drug, Right Dose, Right Route, Right Time, and Right Reason.

Multi-dose vials accessed in the immediate patient care area (i.e., operating room) must be dedicated to that patient and discarded immediately after use.

Multi-dose vials accessed outside of the immediate patient care area must be dated with the expiration/beyond use date when they are first opened and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for the opened vial (i.e., Succinylcholine is stable for up to 14 days at room temperature without significant loss of potency). There are stickers available in the medication preparation to document the beyond use date. 

All multi-dose vials/medications found opened without a beyond-use date must be discarded according to facility policy. 

The individual retrieving a controlled substance from locked storage is responsible for the administration of the medication. Parenteral medications should be administered by the individual who prepared  the medication, except when necessary in the management of an emergency (i.e., LAST, seizures, etc.).

Specimen Management and Tracking

Specimens will be rejected when the results are compromised due to submission in an improper container, improper anticoagulant ration, inadequate volume, improper timing, transport or storage, or the presence of interfering substances.

The following is a PARTIAL guideline to assess the appropriateness of laboratory specimens. Complete specimen requirement criteria include but are not limited to:

  • Patients must be wearing an armband
  • Correct container, anticoagulant or solution
  • Correct blood/anticoagulant ratio
  • Adequate quantity for testing
  • Must meet testing procedure integrity requirements (i.e., clotting, hemolysis, contamination)
  • Timely transport and proper storage of specimen
  • Container sealed to prevent leakage and specimen contamination as applicable
  • Accurate timing of collection
  • Adequate preparation of the patient to avoid interfering substances
  • Appropriate fixative as applicable

Non-Surgical Specimens

Lab Collection (Blood Samples)

  1. Notify the Allina Health Laboratory via telephone for blood specimens ordered.
  2. Complete a Clinical Lab Requisition form and make a copy of the patient’s Face Sheet (registration form). Give both the requisition form and Face Sheet to lab staff on arrival to OISC.

The following information needs to be completed on the requisition form:

  • Ordering Provider (first and last name)
  • Diagnosis/Reason for testing (for ICD 10 coding)
  • If stat, check the STAT box and complete “Call to” information
  • Affix patient label
  • Test(s) ordered (check appropriate boxes)

Only one requisition form is required if multiple blood tests are ordered.

OISC Staff Collection (Blood samples)

  1. Confirm the patient using name and date of birth.
  2. Complete the requisition form as described above and make a copy of the patient’s Face Sheet.
  3. Collect blood specimen in appropriate collection tube and affix patient label to each tube.
  4. Write the time of collection and your employee (a or D) number on the patient label and on the requisition form under DATE & TIME COLLECTED and DRAWN BY.
  5. Place tubes in a biohazard bag. Place the requisition form and copy of Face Sheet in the outer sleeve of the bag and deliver to lab.
  6. Notify lab employee of delivery. It is recommended to have a lab employee review the specimen (i.e., label) and requisition form for completeness to reduce the risk of specimen rejection, etc.


Lab will promptly report all stat results using a Verbal Order Read Back method during operating hours and include the patient’s name, test, and results.

Report all results to the ordering provider and document the test, results and time of provider notification in the patient’s medical record.

Lab will submit dated reports of tests performed via fax. Reports will be filed in the patient’s medical record.

After hours results that require action (critical results) will be reported to the Administrator.

Surgical Specimen Management

All specimens obtained during a surgical procedure shall be labeled, packaged, visually and verbally confirmed as to its identity and testing ordered with the surgical team and delivered to the Allina Health Laboratory with completed requisition form(s).

The expiration date on all supplies, when applicable, must be verified prior to use (i.e., Eswab, formalin containers, etc.). The circulating RN and the scrub must perform a visual and verbal confirmation of the expiration date of collection containers, devices, swabs, etc. as applicable prior to use.

Containers and collection devices of appropriate size and type with correct preservative should be determined  and obtained before the procedure.

Communication with the surgeon will be Read Back verification by the RN for specimens that are sent during the procedure.

If a specimen must be kept on the surgical field before transfer, it must be labeled appropriately to prevent loss, damage or mishandling, which may include keeping the tissue moistened with sterile saline. Confirm with the surgeon.

Caution should be used when handling formalin. It can be absorbed through the skin and nasal passages, splashed in the eyes and ingested. Exposure can result in irritation, burns, and allergic reactions.

Tissue, swab, and syringe specimens may be obtained. Specimens will be passed off the sterile field by the scrub to the circulating RN.

Circulating RN, scrub tech and the surgeon will verbally agree to the visualization of the specimen in container if applicable and  the circulating RN will verify the correct labs and completeness of the requisition form(s) with the ordering surgeon prior to transport.

Contamination of outside of container will be avoided and not overfilled. If the outside of the container is visibly contaminated with blood or other potentially infectious material, it should be placed in a second, leak-proof container.

All specimens must be placed in a clean transport bag with the completed requisition form and a copy of the patient’s Face Sheet.

The patient label should include:

  • Specimen ID number, if applicable
  • Name of specimen and source
  • Collection time
  • Circulating RN’s initials

The laboratory request form should include:

Clinical Request

  • Ordering provider (first and last name) and signature
  • Diagnosis
  • Date and time collected
  • Patient label
  • Check box of clinical test(s) ordered


  • Ordering provider (first and last name) and signature
  • Patient label
  • Specimen removal time and date; placed in formalin time and date, if applicable
  • Exact specimen source(s) by number and name
  • Clinical information (reason for biopsy)





Specimen/Pathology tracking and reporting is completed to ensure that the ordering provider or another privileged provider receives and reviews the results. The provider must acknowledge in writing (date and sign the report) that the results were reviewed.

Surgical specimens need to be documented in Vision when sent to the Allina laboratory.

Document the following:

  • Status – Pending
  • Number of specimens
  • Select the lab (there is only one to select)
  • Specimen type
  • Additional comments as necessary

Allina laboratory will send dated reports via fax when complete. These will include preliminary and final results.

Office Coordinator staff will provide reports to the provider or designee for review/signature, file FINAL results in the patient’s medical record and update the status in Vision.

Document the following:

  • Status
  • Lab (there is only one to choose from)
  • Pathology Comments to include that the results were given to and reviewed/signed by the physician or designee

Verbal Orders, Verbal Test Results

Verbal Orders

Medications, treatments, and diagnotic testing ordered by a physician or allied health professional that are not on preprinted or standing orders require a written order.

Verbal orders given by a physician or allied health professional must be documented in the patient’s medical record as a Verbal Order.

The following information needs to be documented:

  1. Date and time of order
  2. Order designated as a Verbal Order with abbreviation VORB
  3. Specifics of the order such as:
  • Medications: name of medication, dosage, route and frequency
  • Diagnostic testing: what, when, where, why
  • Other orders such as treatment, frequency, duration and provider of service

4. Verbal orders given are verified by “read back” procedures, where ALL information regarding the order is read back to the prescriber.

5. Name of provider giving order followed by the name and credential of person receiving order.

6. Provider must co-sign the order at earliest opportunity.

Example: 3/30/2016 0850 Dilaudid 0.5 mg IV x 1, pain, VORB Dr. Jones/Jane Doe, RN

Test Results

All test results received by telephone should be documented and provided to the provider with the following:

  • Date and time of test result(s) received and caller
  • Test ordered and results
  • Test result received to be designated as a Test Result Read Back with abbreviation TRRB
  • Test results given are verified by “read back” procedures, where ALL information is read back to the caller, including patient identification information.
  • Name and credentials of person receiving test results
  • A notation should also be made for provider notification and include: date and time of notification and the provider.

Example: 3/30/2016 0820 Allina Health Lab called, K 4.0. TRRB Jane Doe, RN. Dr. Jones notified 3/20/2016 0822.

Patient Safety and Risk Management Education Attestation

Please complete the following attestation form and submit to verify completion of the Patient Safety and Risk Management Education objectives.
  • Date Format: MM slash DD slash YYYY