Safety Infection Control Committee Meeting For September 20, 2006

Members: Present- X, Absent-O, Excused-E: Safety Infection Control Committee Meeting For September 20, 2006 Brown, Lisa Research Support X Nasits, Alan Risk Management X Camacho, Debra Custodial Support Services E Pacheco, Hector M.D. PI Committee Rep. X Garcia, Manuel Facilities Operation X Quintela, Tony Campus Police (Co-Chair) X Chenoweth, David - Thomason Hospital Representative X Ramirez, Maria Faculty/Staff/Student Safety X Gutierrez, Dan Administrative Support Services X Reyes, Najera IT Support Services X Holguin, Donna Patient Safety X Salinas, Sonia Patient Representative X Levine, Johanan, M.D. Clinic Oper. Committee Rep X Snelling, John Educational Support Services X McCarty, Jovita Clinical Support Services X Taylor, Sabrina M.D. Representative Resident X Melchor, Jose Chem/Fire/Rad/Electrical/Biological Safety X Terreros, Daniel M.D. Committee Facilitator X Meza, Armando Infection Control Committee Rep X Torres, Rito Human Resources X The meeting was called to order by Dr. Daniel Terreros at 12:05 p.m. ISSUE DISCUSSION ACTION/RESPONSIBLE PARTY 1. Review of Minutes from June 16, 2006. Since the Safety/Infection Control Committee was reorganized and most of the members present at this meeting are new, Mr. Jose Melchor, Safety Manger, asked members who were active at the previous committee meeting to review the past minutes and proceed for approval. 2. Fiscal 2007 Opening Business: a. Introduction of new Committee Members. b. Introduction of new Committee Chairperson Minutes were reviewed and corrected to read: The X-ray technician was lifting a patient from the wheelchair to the exam table and the employee (employee instead of patient) sustained lower back strain. Mr. Melchor asked the reorganized Safety/Infection Control Committee asked members to introduce themselves. With the exception of Mrs. D. Camacho excused- committee members were introduced. Mr. Melchor introduced Dr. Daniel Terreros as the new Chairman of the committee. Minutes were approved. c. Committee s Mission and Vision and Expected Outcomes Dr. Terreros shared with the committee a power point presentation stating the Vision/Mission, Roles and responsibilities, and ground rule of the new reorganized Safety/Infection Control Committee. Copies of the presentation were provided to all members; it is attached to this minutes as (Attachment 1). Page 1 of 8

d. Chair Ground rules for Meetings e. Committee s membership f. Safety/Infection Control Committee Webpage g. Review and Sign Commitment letters: Attendance Commitment, Commitment to Representation, and Confidentiality Reminder Dr. Terreros stated that he sees himself as a facilitator of the committee, not as a chair. He will not vote on any issue except if there is a deadlock, or when his presence is needed to reach committee s quorum (half plus one members). Membership was selected based on operational functions needed to be represented. Committee membership was kept at a maximum; some additional stakeholders may need to be added at a later date. The committee was informed that IT department is designing a Safety/Infection Control Web Page. This web page will be available to the employees. Employees will be able to use this page to communicate with the members, note any safety issues, read meeting minutes, and learn about committee s activities and accomplishments. There will be a section where only committee members will be able to login. In that restricted space, members could review any confidential reports, report cards and diagrams for all committees supported initiatives, and vote on any issue that needs to be approved before the next scheduled meeting. Members will dispense of as many issues as possible through this mechanism so that the committee could concentrate on most critical issues during face to face regular and emergency meetings. The members will be notified whenever an important issue is placed on the web for review and vote. A picture of each member, and e-mail, will be placed on this web page to facilitate internal and external communication with the supporting/interacting stakeholders and organizations. Dr. Pacheco questioned the Resident s commitment for 1-year. It was explained that if the resident or any other member of the committee were not able to attend for a whole year the committee would understand. All members signed Commitment letters. A sample is attached as (Attachment 2). Members agreed, Mr. Melchor will take the pictures if not available at medical media. Page 2 of 8

3. Operational Reports: a. Review Quarterly Health and Safety Reports i) Reported Occurrences ii) Infectious Exposures iii) Non infectious Exposures Reported Occurrences Donna Holguin, RN, presented the 21 patient falls report (Attachements 3a and 3b). Falls are #1 occurrence reported on our campus. The bottom line presented is that all staff must be more vigilant in assuring that patients can step down from exam tables or chairs and that they are not sitting in the rolling seats and be aware when anyone may need extra help. Mr. Nasits requested that copies of occurrences be sent to him also. Dr. Levine stated that there should be a policy on rolling stools/chairs since these are also causing falls. In addition, Dr. Levine questioned if a seizures followed as a fall should be reported as an incidental fall occurrence. A seizure is medical condition and not an operational safety issue. Neurosurgery Department does not report seizures as occurrences because these are classified as a medical condition treated at the clinic. Mr. Quintela stated that his department treats every incident the same way as they can sort them out. From a legal perspective, every fall should be reported and properly documented. Members agreed that there is a missing analytic issue in the root-cause reporting on the falls; a medical condition-related column is missing. A motion to improve the patient fall report to include all falls including those related to medical condition was entertained. Dr. Levin suggested check boxes i.e. syncope/seizure, other medical condition. Dr. Pacheco- suggested adding an analytical category of preventable or not preventable and deleting other. The motion was unanimously approved. Infectious Exposures Ms. Maria Ramirez explained that this report contains body fluid exposures sustained by employees disregard if they are from infected patients/employees or not. There were total of 37-reported incidents in Fiscal Year 2005-2006. There doesn t seem to be a clear trend or pattern (Attachment 4) Page 3 of 8 Donna Holguin RN will modify occurrence report format and approved modifications will reflect on next quarterly report. Neurosurgery and other clinical departments need to ensure that all falls disregard cause are reported.

b. Safety Managers Activity Report Non-Infectious Exposure Ms. Ramirez indicated that non-exposure report consists of work related injuries such as falls, struck, strains, etc. There were 51 work-related injuries reported in Fiscal Year 2005-2006. There doesn t seem to be a clear pattern or trend (attachment 5) Mr. Melchor stated that the safety office investigates all work-related injuries, that are not-infectious in nature as reflected on attachment 5. His office also evaluates any hazardous conditions reported by departments or individuals. Mr. Melchor stated that he has developed a hazard report form. This form is unique to the El Paso campus. (A copy was provided to the committee members and is attached as (Attachment 6). If they use this form, they can give it to any Unit Safety Officer, Safety team member or Safety/Infection Control committee member and they will forward it to the Safety Dept. In addition, there is a form online that employees can use as well, however the information goes directly to Lubbock and then Lubbock notifies El Paso about the hazard. In fulfilling the safety office preventive component: Mr. Melchor recently developed a presentation entitled - Safety is everyone s responsibility that was initially given to housekeeping as it relates to falls etc. In addition, the same group received targeted chemical safety training by the supplier. Mr. Melchor stated that he and Mrs. Holguin attended Radiation Safety Officer Training in June and in August, in addition he attended Instrumentation calibration training. Drs. Pacheco and Levine indicated that Mr. Melchor should provide the committee complete report on planned use of radioactive materials in the campus.. The committee members should be informed about which departments would be affected, who is approved to use radioactive materials etc. Dr. Page 4 of 8 Mr. Melchor will report to the committee as to number of incidents, cause, actions, etc. Mr. Melchor will report also on the number of incidents detected through the online mechanisms Mr. Melchor will report if number of incidents related to housekeeping changes following this intervention. Mr. Melchor will report on radioactive materials usage, policies and procedures at the next meeting. Policies and procedures will be e- mailed to members prior to the meeting.

4. Operational Issues: a. Eyewash/Drench Hose Policy b. Patient fall in OB Clinic with Potential for litigation. 5. Improved Departmental Reporting: a. All Departments need to report to the committee Terreros stated this issue was complex, some policies and procedures are generated in Lubbock and it needed to be discussed in full would at the next meeting once the members could be familiarized with it. This is a new program in the campus. Mr. Melchor informed that 09/21/2006, he will start providing Manual Aerial Lift Platform Training to the maintenance and housekeeping department; plans are to train all pertinent employees within 2 weeks. The eyewash/drench hose policy has been modified (Attachment 7). The committee needs to review and approve this policy for implementation. This policy is to be utilized mainly in the research areas. Ms. Donna Holguin informed that a young person fell in the OB clinic and was transported to an Emergency Room by ambulance because of the possible injuries she might have sustained. Since this event, the patient has requested portions of her medical record possibly to initiate litigation. Ms. Holguin also informed that she notified the Chairman of the Department about the incident. She indicated that potential for serious falls can involve patients and non-patients and faculty and staff need to be aware/ reminded that not just elderly patients can fall we must be alert and offer assistance to any person in the campus who may need assistance. Mr. Jose Melchor stated that the following departments have been requested to provide monthly reports of Activities. Maintenance Fire alarms equipment failures/activations, elevator problems, electrical power outages, etc. TT Police documented occurrences, security concerns and actions. Housekeeping - Biohazard waste cost and amount produced. Page 5 of 8 Mr. Melchor will report on progress on this activity. Committee members need to read the policy, make suggestions and approve it for implementation. Ms. Holguin will keep the Committee informed as pertinent. Maintenance, TT Police, Housekeeping, Health and Safety and Ms. Salinas will report at next meeting.

6. Committee Members Safety Issues/Concerns (Roundtable): a. Unit Safety Officers Conference October 12, 2006, 9:00-12:00 at room A3500 b. Hazard Alarms: c. Availability of wheel chairs: Volunteer services- Patient complaints and occurrences. Employee Health Immunizations, training. Mr. Melchor invited all Safety/Infection Control committee members to the Unit Safety Officers Conference. Lieutenant Quintela stated that all employees in the Medical Science Building, despite the multiple false alarms, should evacuate every time the alarm is activated. Mr. Reyes Najera-Nothing to comment Mr. John Snelling-Nothing to comment Mr. Rito Torres-Nothing to comment Dr. Ruben Ramirez-Nothing to comment (Not committee member) Ms. Lisa Brown-Nothing to comment Ms. Sonia Salinas stated that there is a need for wheelchairs. For example, recently, a patient who had an appointment in the Ophthalmology clinic had to wait 1 ½ hours to get to his appointment because he did not have access to a wheelchair. A motion to create a bank of available chairs (presently locked in some clinics) was entertained. Dr. Levin stated that in order to reduce the number of falls, we should have available a system of checkouts of wheelchairs through Central Registration and the front desk lobby. This bank of wheelchairs should be made available to all patients disregard of clinic. Ms. Lisa Brown asked if there was a liability of employees operating a wheelchair. Ms. Salinas stated that administration was concerned about liability. Apparently employees are not allow employees to push wheelchairs but patient can borrow them if available. Mr. Manuel Garcia indicated that there is also an issue with lost wheel chairs if patients leave them unattended. The committee unanimously approved the motion of having and improved availability of wheel chairs at the entrance of the clinical building. Page 6 of 8 Members support for this activity is needed Recommendation will be sent to the Dean for approval (Appendix A)

d. Hand antiseptic: e. Emergency Call Boxes f. What will happen with new committee recommendations? g. Interfacing with 911: h. Traffic Issue: Ms. Maria Ramirez-nothing to comment Dr. Levin stated that there is a need for rapid hand antiseptic in areas where patients are seen in order to reduce the risk of infection. Dr. Meza and Dr. Pacheco agreed. The committee entertained a motion to provide hand wash products at the clinical areas. It was unanimously adopted. Dr. Pacheco-positively commented on wheelchair and hand antiseptic issues. Also, he stated that there was an issue in reference to call boxes. Dr. Meza-positively commented on antiseptic issues. Mr. Gutierrez asked, When this committee makes a recommendation on anything, who makes the decision that the suggestion will be implemented, the chairperson of the committee or the Dean? Dr. Terreros explained that all operational committees are advisory to the Dean. The Deans office is finally responsible for safety and health in the campus, this committee has no budget or authority to fund corrective actions. Minutes of all meetings will be forwarded to the Dean and the Chief Financial Officer in order to assist them to make decisions about viability of recommendations made by the committee. Dr. Taylor questioned how soon or how the committee would be notified the Dean s decision. Dr. Meza stated that an item in the next meeting agenda should be set for follow-up on this issue. Mr. Gutierrez stated that; as a result of a problem the Surgery Clinic had with a suicidal patient, there should be guidance provided to employees on how to treat patients who want to harm themselves. Mr. David Chenoweth, Thomason representative informed that there was a Public Auction scheduled on Saturday, Sept 23 rd at the first floor of Thomason Employees parking garage. Due to this event the main entrance to the garage would temporarily be closed on Sept 21 & 22. In order to access the parking facilities, employees will need to use the exit gates, which are located on the west Page 7 of 8 Recommendation will be sent to the Dean for approval (Appendix A) Committee will discuss call boxes issue at the October meeting.

i. New employee Safety Orientation to Department: j. Hand wash stations and other safety issues at Thomason General Hospital: k. Work place violence: 7. Adjournment The meeting was adjourned at 1:45 p.m. end of the garage. Ms. Jovita McCarty inquired about eye wash stations and safety showers in the medical bldg. She stated that as a Safety Officer, she provides this information to new employees in her department as requested by the New Employee Safety Orientation to Department Level 2 Form. Dr. Taylor stated that residents have complains about some infection control issues at TGH: It happens very often that some stations where alcohol based hand wash products are to be available the dispensers are empty. Often, soap dispensers are empty and doctors have to walk with their hands wet to find another sink where soap is available. Boxes that contain face shields are empty and doctors have to do procedures without using protection for their face. Many female staff have to use medium or large size gloves because the small sizes are not available and this might cause needle sticks because they do not have the appropriate grip whenever they are using the wrong size glove. Dr. Taylor stated that someone in the hospital should be responsible to check the availability of all these products. Mr. Manuel Carcia-nothing to comment Mr. Melchor stated that at the November meeting, Ms. Holguin would review with the committee Policy 76.10- Workplace Violence. Regular future meetings will be one hour, lunch will be provided. Dr. Meza will serve as bridge of these issues with Thomason Infection Control. Dr. Taylor will give follow up to the committee. Ms. Holguin will review policy 76.10 with the committee members at the November meeting. Next meeting: October 18, 2006 at 12 noon in the QI Conference Room. Page 8 of 8