FMS Orientation

1. ‫مستشفى‬
‫الجامعي‬ ‫عبدالعزيز‬ ‫بن‬ ‫عبدهللا‬ ‫الملك‬
FMS Programs Orientation
FMS - Orientation Program emelerqmamalateo

2. Saudi Central Board for
Accreditation of Healthcare
Institutions (CBAHI)
FMS 1: Hospital Leaders establish and
support a facility management
and safety program.
FMS.1.5 : There is an orientation
program conducted for new
hires on the facility
management and safety plans.
Z:KAAUH-PoliciesPROGRAMS
AND PLANSPROGRAMS
Standard Requirements
Joint Commission International
(JCI):
FMS.2 : The hospital develops and
maintains a written program(s)
describing the processes to
manage risks to patients, families, visitors,
and staff.
FMS.11 : The hospital educates, trains, and
tests all staff about their roles in
providing a safe and effective
patient care facility.

3. Facility Management & Safety Chapter
FMS Orientation Program
Programs :
 Fire Safety: To enhance protection of property and occupants from fire and smoke.
 Safety : To which the organization’s buildings, construction areas, grounds & equipment do not pose a
hazard or risk to patients, staff, or visitors.
 Security : Protection from loss, destruction, tampering, or unauthorized access or use in the hospital.
 Hazardous Materials & Waste : Handling, storage, labelling and controlled, and hazardous waste is
safely disposed
 Emergency Preparedness: Internal Disaster & External Disaster : Risks are identified and
response to epidemics, disasters, and emergencies is planned & coordinate
effectively.
 Medical Equipment: Equipment is selected, maintained, and used in a manner to reduce risks.
 Utility Systems: Electrical, Water, HVAC, Medical Gas and other utility systems are properly maintained to minimize
the risks of operating failures.

4. Call 511
Or dial 011-820-0511
KAAUH Hospital Emergency
Codes specification
Fire/ SmokeCODE RED
External Emergency
(Disaster or Mass Casualties)
CODE YELLOW
Adult Medical EmergencyCODE BLUE
Pediatric EmergencyCODE PURPLE
Bomb ThreatCODE BLACK
Radioactive, Biological, Chemical SpillCODE ORANGE
Active ShooterCODE SILVER
Missing Adult Patient or personCODE AMBER
Child AbductionCODE PINK
Utility FailureCODE BROWN
Severe WeatherCODE GREY
Combative AbuseCODE WHITE
Total Building Evacuation will be announce without color coding as ‘’ Evacuation All floors’’
EMERGENCY NUMBER

5. Authority to announce ‫الطوارئ‬ ‫حالة‬ ‫اعالن‬
Announcement of Emergency
‫الطوارئ‬ ‫حالة‬ ‫وصف‬
Description Of Emergency
‫اللون‬
Color
ED chairman
EDMA
CEO
Drill ‫فرضية‬ Code Yellow Drill ‫خارجية‬ ‫طوارئ‬ ‫تجربة‬/
‫الخارجية‬ ‫الطوارئ‬
External Emergency
(Disaster Or Mass Casualties)
‫األصفر‬
Yellow
Activation ‫تفعيل‬
Code Yellow stand-by ‫خارجية‬ ‫لكارثة‬ ‫استعداد‬/
Code Yellow Activation ‫خارجية‬ ‫كارثة‬ ‫حالة‬ ‫تفعيل‬/
Clear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
Identified bomb location , All staff
Non identified bomb location, Security manager or designee
Activation ‫تفعيل‬ Code Black Activation ‫بالقنبلة‬ ‫التهديد‬ ‫حالة‬ ‫تفعيل‬/ ‫بالقنبلة‬ ‫التهديد‬
Bomb Threat
‫االسود‬
BlackClear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
FMS director or designee
Activation ‫تفعيل‬
Code Gray 22( Stand for server weather watch )
‫مناخية‬ ‫تقلبات‬ ‫وقوع‬ ‫احتمال‬ ‫الى‬ ‫ترمز‬
‫المناخية‬ ‫التقلبات‬
Server Weather
‫الرمادي‬
Gray
Code Gray 44( Stand for server weather Response )
‫مناخية‬ ‫تقلبات‬ ‫وقوع‬ ‫الى‬ ‫ترمز‬
Clear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
All staff
Activation ‫تفعيل‬ Code Red Activation ‫الحريق‬ ‫حالة‬ ‫تفعيل‬/ ‫حريق‬‫دخان‬
Fire Smoke
‫األحمر‬
RedClear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
All staff
Activation ‫تفعيل‬ Cod Purple Activation ‫طفل‬ ‫إسعاف‬ ‫حالة‬ ‫تفعيل‬/ ‫التنفس‬ ‫او‬ ‫القلب‬ ‫توقف‬(‫اطفال‬)
Pediatric Emergency
‫البنفسجي‬
PurpleClear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
All staff
Activation ‫تفعيل‬ Code Amber Activation ‫شخص‬ ‫او‬ ‫مريض‬ ‫فقدان‬ ‫حالة‬ ‫تفعيل‬/ ‫شخص‬ ‫أو‬ ‫مريض‬ ‫فقدان‬
Missing patient & person
‫الكهرماني‬
Amber
Clear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
All staff
Activation ‫تفعيل‬ Code Blue Activation ‫مريض‬ ‫اسعاف‬ ‫حالة‬ ‫تفعيل‬/ ‫التنفس‬ ‫او‬ ‫القلب‬ ‫توقف‬(‫كبار‬)
Adult Medical Emergency
‫االزرق‬
BlueClear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
All staff
Activation ‫تفعيل‬
Code Orange Activation
‫كيميائي‬ ‫تسرب‬ ‫حالة‬ ‫تفعيل‬‫بيولوجي‬‫اشعاعي‬
‫كيميائي‬ ‫تسرب‬‫بيولوجي‬‫اشعاعي‬
Radioactive, Biological, Chemical
Spill
‫البرتقالي‬
Orange
Clear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
All staff
Activation ‫تفعيل‬ Code Silver Activation ‫ناري‬ ‫طلق‬ ‫حالة‬ ‫تفعيل‬/ ‫ناري‬ ‫إطالق‬
Active Shooter
‫الرصاصي‬
SilverClear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
FMS director or designee
Activation ‫تفعيل‬ Code Brown Activation ‫المرافق‬ ‫في‬ ‫عطل‬ ‫حالة‬ ‫تفعيل‬/ ‫المرافق‬ ‫في‬ ‫عطل‬
Utility Failure
‫البني‬
BrownClear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
All staff
Activation ‫تفعيل‬ Code White Activation /‫العدواني‬ ‫السلوك‬ ‫حالة‬ ‫تفعيل‬ ‫العدواني‬ ‫السلوك‬
Combative Abuse
‫األبيض‬
WhiteClear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
All staff
Activation ‫تفعيل‬ Code Pink Activation ‫رضيع‬ ‫طفل‬ ‫اختطاف‬ ‫حالة‬ ‫تفعيل‬/ ‫طفل‬ ‫اختطاف‬
Child abduction
‫الوردي‬
PinkClear ‫انتهاء‬ Code Yellow All Clear ‫الطوارئ‬ ‫حالة‬ ‫انتهاء‬/
CEO or designee
‫بإعالن‬ ‫يتم‬ ‫المبنى‬ ‫اخالء‬"‫األدوار‬ ‫جميع‬ ‫اخالء‬"
Evacuation will be announce without color coding as ‘’ Evacuation All floors’’
‫المبنى‬ ‫اخالء‬
(Hospital Evacuation)
‫لون‬ ‫يوجد‬ ‫ال‬

6. Fire and Life Safety - KAAUH
 Hospital Building is protected by
different types of Fire Protection
Systems
 Fire evacuation plans installed in
hospital hallways
 Fire Exits are signed & illuminated
 Fire Extinguishers are available in
your work place.
 Assembly Points inside and
outside the buildings identified
 Fire drills and training are
performed periodically

7.  All Staff must be familiar with
the location of Emergency Fire
Plan, Manual Pull Stations, Fire
Extinguishers & Nearest Fire
Exits in their Area
 Fire is announced thru the
Hospital Public Address
System as Code “RED”
Fire Safety - Staff
511 - Code RED
FMS - Orientation Program - Fire

8. Each of these three elements must be present at the same time. A
fire will burn until one or more of the elements is removed.
Fuel
Any combustible material solid, liquid or gas
Heat
The energy necessary to increase the
temperature of fuel to where sufficient
vapors are given off for ignition to
occur
Oxygen
The atmospheric air consist of 21% oxygen
& 79 % Nitrogen. However, fire needs
only
16% oxygen to ignite
HEAT
Fire Triangle

9. Class of Fire Type of Fire
Type of
Extinguisher
Extinguisher
Identification
Symbol
Fire Class
Wet
Chemical
Special Agent
: Sodium Chloride or
Copper Power

10. Extinguish

11. In the Event of Fire

12.  Horizontal Where Applicable
 Out of the building
Types of Inpatient Building Evacuations

13. When Do I Evacuate
 Orders for a horizontal
evacuation will be given
by either the Head Nurse,
Nurse in charge, SLO,
Nursing Manager or
Safety Manager
 Orders for a Full
evacuation will be given
by either the Hospital
CEO or designee .

14.  Personnel in immediate danger
 Ambulatory –Walking
 Semi-Ambulatory- Chair assist
 Non-Ambulatory- Full assist
Evacuation Order (inpatient) – Who’s First

15. Safety Management
 Multidisciplinary safety committee that
provides oversight of the facility management
and safety program.
 The Enviromental Safety Round Team conducts
facility safety tours to identify risks and hazards
related to the facility and physical plants as well
as evaluation of staff knowledge.
 Safety measures and equipment are applied
where needed in the hospital to ensure safety
of patients and staff.

16. Safety Management
 Ensures and implements a policy for safety of
patients, staff and visitors during
construction, renovation, or demolition in the
hospital.
 Ensure all its occupants are safe from
radiation hazards are protected from
unnecessary exposure to laser beams in areas
where it is used.
 Report any Safety Related Issue at Extension
Hotline #2784

17. Security Management
 KAAUH Security Staff responsibilities are to protect
staff, patients, visitors & properties.
 KAAUH staff has a role in keeping the hospital a secure
and safe place.
 KAAUH Identification badges shall be obtained at the
security section in the ground floor and it must be worn
by all staff inside the KAAUH facilities.
 All admitted patients must have an Identification
Wristband
 It is important to report any suspicious activity or
threats.
 Keep valuables out of sight and limit the amount of
cash you carry.
Call 2800

18. Chemicals may be used:
 To clean and disinfect
 To sterilize
 To treat certain diseases
 For research and testing in the
lab
Hazardous Materials

19. What is “Hazardous Material”?
A hazardous material is any item or agent (biological,
chemical, physical) which has the potential to cause harm to
human, animal, or the environment, either by itself or
through interaction with other factors.
19 19

20. Types Of Hazardous Materials
Infectious Substances
Some infectious substances (such as some viruses) can be transmitted by
blood and other body fluids, equipment, containers, paper goods,
glassware,
linens and by people.
Radioactive Materials
These require special handling techniques to prevent exposure to
personnel and visitors.
Flammable Liquids And Gases
For example, chemicals, such as ether or alcohol, can burn or explode.
Toxic Chemicals
A person may be exposed over a long period of time before effects are
noticed.
20

21. How to get information about the HAZMAT in
your work place?
21
Product Label Safety Data Sheet
(SDS)
NFPA Label

22.  Product Identifier: The commercial name and chemical name of the product
should match the SDS.
 Signal Word: An alert to the severity of the hazard for example “Danger” or
“Warning”.
 Pictograms: The GHS Pictograms are intended to quickly convey specific hazard
information visually.
 Hazard & Precautionary Statement: Describes the nature of the hazard and
advises measures to prevent adverse effects.
 First Aid Statement: Emergency care information.
 Supplier Information: Name, address and phone number of the manufacturer or
supplier.
22

23. Hazard Identification
 Adopted the NFPA
Labeling System
for Hazardous
Materials

24. Globally Harmonized System
(GHS) Pictograms
24

25. Read the SDS before working with
a chemical. The SDS:
 Provides a written
description of a hazardous
chemical
 Describes the risks,
precautions
 Must be readily available to
you
Hazardous Materials Data Sheets

26. 26
Safety Data Sheet
What information is on the SDS?
These are chemical fact sheets that contain all the information an employee would
need to know about a hazardous chemical..
26

27.  Inhalation
 Ingestion
 Skin absorption and eye contact
 Injection (cut, puncture, or
injection)
How Chemicals Enter the Body

28. Commonly required PPE includes:
 Safety goggles
 Face shields
 Gloves
 Other skin protection
 Respiratory protection
Personal Protective Equipment

29.  Eyes: Flush with water for 15
minutes
 Skin: Wash with soap and
water, remove contaminated
clothing
 Inhalation: Move to fresh air
 Swallowing: Follow the MSDS
 Contact the Emergency
Department
General Precautions First Aid

30.  If its major spill call 511.
 If minor spill call your housekeeper or
dial 3666.
 Alert others in the area
 Evacuate if necessary to the internal
assembly point and Stay away until told
it’s safe to return
Major Chemical Spills or Leaks

31. General Waste
 This waste is generally
harmless and needs no
special handling
 Bags for general
healthcare waste are
black.
Waste Management

32. Human and Animal Body Parts
and Organs:
Plastic Red Bag with the
phrase “hazardous waste”
(Arabic & English) with Bio-
Hazard logo
Infectious Waste
Plastic Yellow Bag with the
phrase” hazardous waste”
(Arabic & English) with Bio-
Hazard” logo
Waste Management

33. Chemical Waste
Plastic Yellow Bag with the
Phrase Chemical Waste (Arabic
& English) with “Bio-Hazard”
logo
Pharmaceutical Waste
Plastic Yellow Bag with the
Phrase Chemical Waste (Arabic
& English) with “Bio-Hazard”
logo Waste”.

34. Sharps Bins
Sharps waste must be
collected in
appropriate sharp
container as soon as
possible at the place
where it is generated

35. Equipment Engineering
Services is a team of
Biomedical & Clinical
engineering professionals
working in a clinical
environment to resolve
technology issues related to
patient care, improvement in
outcomes and cost
effectiveness.
 New technology need
assessment and planning.
 Pre-purchase Evaluations/
Consulting.
 Selection and acquisition of
medical technologies.
 Equipment
Recommendations.
 Incoming Inspections
 Arrange for new technology
demonstration.
 User (In-service) Training.
 Regular Planned Preventive
Maintenance / Safety /
Performance Testing /
Calibrations.
 Equipment Installations.
 Review of hazard alerts and
product recalls
FDA/ECRI/SFDA.
 Medical equipment incident
investigations.
 Obsolescence Notifications.
 Replacement
Recommendations.
 Documentation of equipment
History for every medical
device.
 Construction projects –
Medical equipment aspects.
How to request
medical
equipment
maintenance?
Through computerized maintenance
management system (Asset Plus)
 Through department 24/7
hotline at: 2727.
Medical Equipment

36.  Any event (disaster) occurring inside the hospital facility that
threatens to overwhelm the hospital’s functions.
 In KAAUH it is an emergency event called “Code Evacuation”.
 Activation by Safety Manager or designee on duty, approval from
CEO or designee.
 When there is announcement of code white ,you should evacuate
thru the emergency exit to the external assembly points.
Internal Disaster
Emergency Preparedness

37. Hospital Evacuation Tools &
Equipment
Evacuation Chair for Adult
EVACU – B for babies & infant
Evacuation Med Sled

38. Hospital Evacuation Tools &
Equipment
Baby Apron
Ski Pad
Ski Sheet
Baby Apron for
Intensive Care
Area

39. ASSEMBLY
POINT #5
ASSEMBLY
POINT #6
ASSEMBLY
POINT #1
ASSEMBLY
POINT #2
ASSEMBLY
POINT #3
ASSEMBLY
POINT #4
MAIN ENTRANCE
ERENTRANCE
OPD ENTRANCE EMPLOYEE ENTRANCE
MAINTENANCE
ENTRANCE
TRANSPORTATION
ENTRANCE

40.  Any event (disaster) occurring outside the hospital that threatens to overwhelm the hospital’s function and
normal response capacity in KAAUH it is an emergency event called .
Activation by ED consultant on duty, after approval of Executive medical director, and CEO.
There are three categories of Code Yellow Announcement:
First Category:
The threat is received and confirmed; casualties are still on their way to
the hospital.
2nd Category:
The threat is confirmed with an estimated number of critical cases.
3rd Category:
The threat is confirmed with an estimated number of casualties
more than 15 critical cases.
Activation of Drill
:status whereby the disaster is declared over.
External Disaster

41. Triage Area: is an area in KAAUH used to sort out or prioritize patients for medical
attention and intervention. It is located in front of the Emergency Department
Ambulance Bay.
Red Zone : Cases with immediate life threatening conditions that
demand urgent and aggressive resuscitation.
Yellow zone : cases with injuries that have no immediate threat of life and
are usually stable.
Green zone : All other emergency cases with minor or superficial wounds.
Black zone : All casualties pronounced dead. will be moved to the
morgue.
Disaster Zones

42. Utility Systems
The Utility System Management
Covers:
 Electrical Distribution Systems
 Water Supply Systems
 HVAC Systems
 Plumbing System
 Medical Gas Systems
 Pneumatic Tube System
 Boilers & Steam Delivery Systems
 Elevators & Escalators
 Fire Protection System
 Civil Works

43. Reporting Systems
Ext. 2777
Maintenace@Kauuh.edu.sa
511 - CODE BROWN- FOR UTILITY FAILURE
Maximo System for Job Order

44. Thank You