OBJECTIVES:
To reduce hazardous and risky situations for our employees, prevent accidents and injuries, and provide a safe working environment.
To make arrangements and take necessary precautions in the institution to carry out the necessary activities to ensure employee safety,
To provide a safe environment for employee safety,
To identify potential hazards and risks for employees in the healthcare institution and to determine appropriate methods and techniques to eliminate these risks,
To ensure the sustainability of safe service delivery and a safe working environment through in-service training. To ensure that the physical, mental, and social conditions of employees are brought to the highest level. To minimize/eliminate potential harm to the health of employees,
To ensure the suitability of the job to the person.

2. SCOPE: This covers all departments of our hospital. It includes all units/departments within the Service Quality Standards.

3. RESPONSIBILITIES: The Chief Physician and the employee safety committee, as well as all personnel, are responsible for the implementation of this procedure.

4. DEFINITIONS:

Employee: All healthcare professionals providing healthcare services in public or private healthcare institutions, and individuals who, even if not healthcare professionals, participate in and support the provision of healthcare services as responsible personnel.

Employee Safety: Activities related to measures and improvement practices to be taken regarding all procedures and processes that may lead to employees being exposed to physical or verbal violence during the provision of healthcare services,

Employee Rights and Safety Unit: In healthcare institutions and organizations established within the scope of the Ministry of Health's circular no. 2012/23, the unit that accepts requests and complaints regarding the rights and safety of employees, evaluates and reports on applications, forwards reports to relevant units and the ministry, and ensures the initiation and follow-up of necessary corrective and preventive actions.

Violence: Defined as a crime in the Turkish Penal Code, it refers to any form of coercion, assault, force, threat, insult, and harassment, and the intentional use of force that can result in harm to a person's physical, mental, spiritual, moral, or social development.

White Code Application: Established under the Ministry of Health's circular no. 2012/23, this system is closely monitored by the responsible chief physician to ensure its effective operation. In cases of violence against hospital staff, the nearest security personnel and the White Code team are dispatched to the scene to resolve and document the incident.

General Orientation Training: This training is provided to newly hired personnel to introduce them to the institution.

Department Orientation Training: This training is provided to newly hired employees to introduce them to their department.
Blue Code: An emergency management tool that ensures the fastest possible intervention for patients, their relatives, visitors, and all hospital staff who require basic and advanced life support.

Areas Containing Radiation Emitting Devices: These include departments where imaging services are provided, the angiography unit, and areas in the operating room where fluoroscopy procedures are performed. Radiation safety precautions must be taken in all these areas.

Radiation Warning Signs: These are signs used at the entrances to areas containing radiation-emitting devices and in radiation areas, displaying basic radiation symbols and clearly indicating the danger of radiation exposure.

Lead Shields: These are equipment used in radiation areas to protect patients, their relatives, and staff from radiation;

Lead aprons,
Thyroid shields,
Protective screens, etc.

5. IMPLEMENTATION:

Healthcare organizations that strive to protect, improve, or treat people's health must first work to reduce hazardous and risky situations for their employees, prevent accidents and injuries, and provide a safe working environment in order to achieve these goals.

PROTECTION AGAINST INFECTIONS

Measures to be taken against the risk of infection that our hospital personnel may be exposed to are determined by the "Employee Safety Board" and the "Infection Control Committee". Measures to be taken against the risk of infection are specified in our Hospital's "Infection Control and Prevention Program".

Hand hygiene is very important for both patient and employee safety, and the "Hand Hygiene Instruction" specifies appropriate hand cleaning and glove use methods for healthcare personnel to prevent infections and cross-contamination.

Due to our hospital being a tuberculosis hospital, the precautions our employees must take to protect themselves from tuberculosis are determined in the "Tuberculosis Prevention Instructions" and the "Infection Control Instructions in the Multidrug-Resistant Tuberculosis Ward," and the rules and precautions determined by our hospital's Infection Control Committee are listed below.

CONTROL AND PREVENTION OF INFECTIONS
Measures to address the risk of infection that our employees may be exposed to while in the hospital are determined by the Employee Safety Committee and the Infection Control Committee. Some of the measures to prevent infection are taken by the institution, and some by the employee themselves.
Employees should be provided with personal protective equipment to protect themselves from infection.
Health screenings should be conducted regularly according to the Personal Health Card Form. Employees should be included in the vaccination program according to the screening results. Employee accidents are reported and monitored.
The cleaning of hospital departments according to their risk levels is carried out in accordance with the Hospital Cleaning Plans and Hospital Cleaning Instructions.
To prevent injuries from sharp or pointed instruments, the Personnel Injury Prevention and Monitoring Instructions are followed. Personal Protective Equipment should be used to prevent dripping/splashing of blood or body fluids.
Infection control is carried out according to the Infection Control and Prevention Procedure.
Isolation is carried out according to the Isolation Precautions Instructions.

STAFF HEALTH SCREENINGS

The frequency and method of health screenings for our hospital staff working in high-risk areas are determined in the "Personnel Health Follow-up Instructions" prepared by our Hospital's Infection Control Committee. Staff health screenings are conducted by the staff physician. The results of these examinations must be recorded by the staff physician on the "Personnel Health Screening and Follow-up Card".

Personnel injured by sharp or pointed instruments in our wards must be followed up according to the "Personnel Injury Follow-up Instructions". The injured personnel must fill out an "Accident Notification Form" to ensure follow-up.

EMPLOYEE HEALTH SCREENINGS

The aim is to ensure that health screenings, necessary for the safety of personnel working in high-risk units of the hospital, are conducted regularly at specified intervals.
Health screenings are performed according to the Personal Health Card Form.
Following the health screenings, the results are evaluated by relevant specialists. Employees are informed about the results by the evaluating physician, with information security ensured.
Health screening records are kept securely by the relevant department heads.
X-RAY LABORATORIES

In our hospital's X-ray laboratories, dosimeter monitoring of our personnel is carried out under the responsibility of the Head of Radiology, and the results are followed up and recorded by the Head of Radiology. For personnel found to have been exposed to high doses of radiation, the procedures to be followed are determined by the Head of Radiology and the staff physician.

Personnel working in the X-ray laboratories are required to wear lead vests, and a sufficient number of lead vests have been provided.

Maintenance of all imaging equipment is carried out according to a specific plan by the Head of Radiology, and records are kept in the X-ray laboratory.

ENSURING RADIATION SAFETY

Employees exposed to radiation should receive training on radiation protection and radiation safety.
Radiological imaging devices should be regularly maintained and calibrated.
The radiation hazard symbol and other warning signs should be displayed in relevant areas.
Employees should be ensured to work in accordance with radiation safety rules and use personal protective equipment (Personal Protective Equipment Inventory).
Health screenings should be conducted regularly according to the Personal Health Card Form.
Dosimeter monitoring should be performed, and measures should be taken to protect employee health when results are negative.
The Radiation Protective Material Control Instruction should be followed.

SECURITY MEASURES

The security of the hospital building, both inside and outside, is provided by the hospital's security company personnel and supervised by an assistant chief physician.

To prevent incidents such as theft, the security company personnel will continuously monitor the area. In case of theft, the police will be notified, and the incident will be documented. Visiting hours at our hospital are weekdays and weekends between 13:30-14:30 and 18:30-19:30. Since visits outside these hours disrupt hospital order, the reception and security personnel will be vigilant.

FIRE SAFETY

Fire is a constant risk in a healthcare facility. Therefore, our hospital plans to protect building occupants from fire and smoke. Our hospital's Civil Defense Specialist takes fire safety measures (fire extinguishing systems, precautions for the transportation and storage of flammable materials, fire extinguishers, fire prevention and extinguishing guidelines, etc.) considering the characteristics of our buildings.

The measures to be taken against fire and the responsible parties in our hospital are defined in the "Fire Prevention and Extinguishing Guidelines".

In accordance with these guidelines, training is provided at least once a year under the responsibility of the Civil Defense Specialist, fire drills are conducted after the training, and records are kept.

A fire alarm system (4444) has been installed in our hospital, and precautions have been taken for possible fires.

Fire exit signs are placed in visible locations throughout the hospital, and the opening of fire exit doors is ensured by the block's deputy chief physicians.

Fire extinguishers are placed in appropriate locations by the Civil Defense Specialist and are regularly inspected.

To eliminate the causes of fires in our hospital, the electrical system is routinely checked by the technical service. Smoking by staff and patients/patient relatives is strictly prohibited.

To protect our hospital buildings against lightning strikes, lightning protection systems have been installed at necessary points and are regularly inspected by our technical service.

MEDICAL WASTE

In our hospital, waste is collected, transported, temporarily stored, and delivered to the relevant units in accordance with the Medical Waste Control Regulation. The procedures, principles, and responsibilities related to this are defined in the "Medical Waste Management Procedure," and the aim is to ensure that medical waste is disposed of without harming our hospital's healthcare personnel or the environment.

HAZARDOUS MATERIALS

The hazardous drugs and materials found in our hospital are as follows:

Chemotherapeutic agents, while in the pharmacy, are transported and stored by warehouse managers according to the information on their packaging and in accordance with storage instructions. While in the relevant unit, they are kept in the same manner by the relevant unit managers until use. These medications must absolutely be used under the supervision and direction of a doctor. Work must comply with the Ministry of Health General Directorate of Treatment Services' "Instructions regarding the Chemotherapy Unit and the Presentation of Chemotherapy Drugs". Special drug preparation cabinets are used during the preparation of medications, and the nurse preparing them must wear gloves, a mask, and a gown. Records of use are kept in the pharmacy information system and in patient files. If there are expired or unsuitable medications, the chief pharmacist is contacted for replacement or disposal, and general regulations are applied.

Anesthetic agents, while in the pharmacy, are transported and stored by warehouse managers according to the information on their packaging and storage instructions. While in the operating room, they are kept in the same manner by the relevant unit managers until use. These drugs must absolutely be used under the supervision of an anesthesiologist. Personnel preparing the drugs must wear gloves and masks. Records of use are kept in the pharmacy information system and the anesthesia department. If expired or unsuitable drugs are found, the chief pharmacist is contacted for replacement or disposal, and general regulations are applied.
Preion drugs (both green and red) are transported by warehouse staff according to the storage instructions on their packaging and kept in locked, special cabinets while in the pharmacy. Records of who received these drugs are kept in the pharmacy. While in the relevant unit, they are kept in the same manner by the unit's supervisors until use. If there are expired or unsuitable drugs, the chief pharmacist is contacted for replacement or disposal, and general regulations are applied.

Chemicals: Alcohol, Formaldehyde, Xylene, Acetone, X-ray developing solutions, etc.

Irritant and flammable chemical substances used in our hospital are handled and stored by warehouse managers according to the storage instructions and the information on their packaging. Once in the usage area, they are kept in the same manner by the relevant unit managers until use.

When using these substances, gloves and, if necessary, masks should be worn; fire should be avoided; adequate ventilation should be provided; and necessary fire extinguishing equipment should be readily available.

Medical and Infectious Waste

The procedures, principles, and responsibilities related to this subject are defined in the "Medical Waste Management Procedure," and in accordance with this procedure, the appropriate collection, transportation, temporary storage, and delivery of medical waste to the relevant units are ensured.

TRAINING

Our hospital staff receive training on reducing hazardous and risky situations, controlling and preventing infections, and preventing accidents and injuries. The methods of conducting these trainings are determined by our hospital's Training Board, Infection Committee, and Employee Safety Board, and are announced to employees through annual training programs.

ACTIVITY FLOW:

EMPLOYEE SAFETY COMMITTEE AND ITS RESPONSIBILITIES

The Employee Safety Committee consists of: At least one representative each from Medical, Administrative, and Nursing Services Managers, the Quality Management Director, a Physician, an Infection Control Nurse, a Security Chief, a Psychiatrist or Psychologist or Social Worker, and one representative from other professional groups (Laboratory Technician, Anesthesia Technician, Radiology Technician). Employee Safety Committee meetings: Two days before the meeting, the meeting place, time, duration, and agenda items are determined, and relevant individuals are notified in writing, by email, or by phone. The Employee Safety Committee meets at least every four months, and the decisions made are recorded in the meeting minutes. Emergency meetings are also held when necessary. The decisions made are recorded in the meeting minutes. Meeting decisions are reported to the Quality Management Unit. The committee's job deion includes, at a minimum:

The Employee Safety Committee covers the following topics:
Reducing the risk of harm to employees,
Taking necessary precautions for employees working in risky areas,
Reducing the risk of exposure to physical and psychological violence,
Reducing the risk of injuries from sharp or pointed instruments,
Reducing the risk of transmission through blood and body fluids,
Conducting health screenings,
Control and prevention of infections,
Waste management,
Basic life support safety,
Safety reporting system and incident notifications.
The Employee Safety Committee should meet at regular intervals.
It should initiate corrective and preventive actions when necessary. It should organize training for employees on the subject.
It conducts root cause analysis for incident reports submitted by the Quality Management Unit and initiates corrective and preventive actions when necessary. It sends the analysis results and activities carried out regarding the incident report to the Quality Management Unit. It organizes training for employees on the subject.

REDUCING THE RISK OF HARM TO EMPLOYEES

Regulations should be implemented regarding employee safety. Measures should be taken according to the identified potential hazards and risks in each department. In our hospital, risk assessments are conducted on a departmental basis; risks are identified as radiation, noise, hazardous materials, carcinogenic/mutagenic substances, medical waste, infection, allergens, ergonomics, violence, and communication conflicts. Risk analysis studies have been conducted on a departmental basis and according to the employee's title.
In the Department Employee Risk Analysis Tables, hazards and risks, as well as necessary precautions, have been identified. Activities are initiated and continued to prevent potential risks that employees may face (infection, radiation, sharp instrument injuries, exposure to blood and body fluid splashes, violence, ergonomic issues, etc.), including ensuring the provision and use of personal protective equipment, conducting health screenings, carrying out vaccination activities, improving physical working conditions, establishing a safety reporting system, initiating the White Code procedure, and organizing employee safety training.

Incidents experienced by employees are reported using the following forms, depending on the nature of the incident:
Safety Reporting System Notification Form
White Code Incident Notification Form,
Sharp and Pointed Instrument Injuries Notification Form (on the Hospital Information System)
Blood and Body Fluid Splash Exposure Notification Form (on the Hospital Information System)
Notifications are submitted to the Quality Management Unit, and corrective and preventive actions are initiated by the Employee Safety Committee following the evaluation by the Quality Management Director.

WHITE CODE OPERATION

Regulations should be made for white code management.
The White Code is an emergency management tool to prevent violence against employees in hospitals.(1111)
In order to ensure that at least one drill is conducted every period for the application of the white code, to initiate corrective and preventive actions when necessary, to provide the necessary support to employees exposed to the incident, and to provide training to employees on the white code, white code management officers have been determined. (White Code Application Instruction)
White Code Management Team Officers:
White Code Management Team Responsible Persons:
The White Code Management Team consists of at least one representative each from the Medical, Administrative, and Nursing Services Managers, a Psychologist or Social Worker, and a Security Supervisor. Two (2) days before the meeting, the meeting place, time, duration, and agenda items are determined, and relevant individuals are invited in writing, verbally, or via email. The team meets at least 3 times a year, and the decisions made are recorded in the meeting minutes. If necessary, emergency meetings are held, and the decisions made are recorded in the meeting minutes. Meeting decisions are reported to the Quality Management Unit.
The White Code Management Team organizes drills and training related to the White Code.
White Code application forms sent by the Quality Management Unit are forwarded to the White Code Management Team. Records are kept by the White Code Management Team, and corrective and preventive actions are initiated when necessary.
Following an incident triggered by a White Code call, a White Code Incident Notification Form is completed by the security personnel who implemented the White Code. This form includes the date and time of the incident, the location of the incident, the action taken at the time, the cause of the incident, the manner in which the incident occurred, any objects used, any negative consequences in the surrounding area, the age and gender of those involved, their personal information (if any), and the personal and contact information of those who witnessed the incident. This form is then sent to the Quality Management Unit. The Employee Safety Committee initiates activities to provide the necessary support to the employee who has been subjected to violence. Psychological support is provided to the employee through the team's psychologist.

Records of the work carried out are kept by the Employee Safety Committee.

EVALUATION OF EMPLOYEE OPINIONS AND SUGGESTIONS

Employee opinions should be collected and evaluated. Employees can submit their opinions through suggestion boxes in visible locations and via the intranet. Opinion and suggestion forms are available in all units. All submitted opinions are evaluated monthly by a team consisting of the quality management director, a representative from the employee safety committee, and a member of senior management. Improvement efforts are undertaken after the evaluations. Employees can also submit these forms in person to the Quality Management Unit. In these cases, the Quality Management Director determines the urgency of the issues daily and, if necessary, contacts the relevant parties for evaluation. Except for emergencies, evaluations are conducted monthly. Improvement requests are made to the relevant units based on the evaluation results. There is no obligation to respond to opinions and suggestions placed in the boxes.

DISABLED EMPLOYEES

Functional accommodations should be provided for disabled individuals. The needs of disabled employees should be met and they should be employed in areas that accommodate their disabilities.
Arrangements should be made in the departments where disabled employees work to provide a suitable working environment and meet their needs (e.g., toilets, sinks, grab bars, elevators, etc.).

EMPLOYEE INFORMATION

Employees are informed through various methods including notice boards, announcements, written notices, telephone, notifications via unit supervisors, and signed acknowledgments. INFORMATION SECURITY

The accurate collection, transmission, storage, and use of information belonging to all institution employees is ensured. Employee information is kept and transmitted under appropriate conditions, and employee information is not shared with any third party, institution, or organization without the employee's consent or unless legally obligated to do so. Employees must adhere to security, data integrity, access, and confidentiality principles regarding the collection and protection of their information. The Bozkurt District State Hospital Information Security Procedure is followed regarding the disclosure of information collected from patients and employees only within the framework of necessary authorizations and legal regulations, etc.

BASIC LIFE SUPPORT SAFETY

Regulations should be made for Blue Code management.
Blue Code: An emergency management tool that ensures the quickest possible intervention for patients, their relatives, visitors, and all hospital staff who need basic and advanced life support. (2222)
Blue Code management officers, consisting of one representative each from medical, administrative, and nursing services, have been appointed to organize drills and training related to the Blue Code and to initiate corrective and preventive actions when necessary. CPR training is provided to employees assigned to the Blue Code implementation team. Employees have been trained on making Blue Code calls.
Making Blue Code calls, telephone numbers, and the teams' access to the patient are determined in the Blue Code Procedure.
The Blue Code team must reach the scene within 3 minutes.
The Blue Code team must carry an emergency response kit for use during interventions. The expiration dates and critical stock levels of the emergency response kit are monitored by the anesthesia technician in the main building and by the emergency nurse in charge in the annex building. In the Blue Code procedure, records are kept using a Blue Code Incident Notification Form that includes information about the person being treated, the procedure performed, the location of the intervention, the time the call was made, the team's arrival time, the outcome of the intervention, and information about the members of the intervention team.
After each blue code call, the Blue Code Incident Notification Form is completed in duplicate by the blue code responsible person. One copy is submitted to the Quality Management Unit, and the second copy is placed in the patient's file. At least one drill is conducted each period as part of blue code management.
The emergency response kit includes, at a minimum, a laryngoscope set and spare batteries (separate for children and adults), a balloon-valve-mask system, masks of various sizes, oxygen tubing and masks, endotracheal tubes in child and adult sizes, laryngeal masks, airway or combi tubes, syringes, and personal protective equipment. In operating rooms, intensive care units, and dialysis units, a defibrillator is also included in the emergency response kit.
SAFETY REPORTING SYSTEM

To ensure that incidents threatening employee safety are reported using the Safety Reporting System Notification Form. This is done in accordance with the Safety Reporting Instructions.

How to Get There?

The Employee Rights Unit is located on the upper floor of our hospital's dialysis unit.