Shared on behalf of Wayne Taylor, Code Yellow Executive Sponsor
The Hospital’s Code Yellow (EMER-70) policy has been revised.
Actions required:
- Read this memo and review the updated Code Yellow: Missing or Wandering Patient (EMER-70) policy to familiarize yourself with important process changes.
- Managers to ensure that the updated policy is added to their area’s emergency binder and that all workers review the attached safety huddles and policy.
- Areas are to update their sub plans (see templates attached) by February 29; please submit a copy to TBRHSC.EmergencyPreparedness@tbh.net
Policy changes:
- Clarified that in all instances of a missing patient: a preliminary area search is required; we must attempt to call them using the contact information provided; and we must page them to return to the unit.
- Additional clarification that only if a high-risk patient is missing, a Code Yellow-Search is initiated.
- Use of eObservation to report area search results within 10 minutes of an overhead announcement versus previous process of notification to Admitting.
- ILS reports must include a rationale for categorizing a patient as high risk when a Search has been called.
- All Code Yellow Searches will desist at the 60 minute mark if not cleared before.· Incorporated police feedback regarding their preferred contacts.
- External buildings response edited to match other recent policy updates.
- Updated response algorithms.
Process Reminders:
- All departments are required to maintain up-to-date Code Yellow sub-plans.
- Code Yellow – Search is a Hospital-wide response to search for a high-risk patient (age 16 years or older) that is missing from within the Hospital and there is reason to believe they are still on Hospital grounds.
- Code Yellow – Check is initiated to support the identification of a wandering patient (age 16 or older) who appears to be high risk and unaccompanied, found on or nearby Hospital property.
Education:
- Safety Huddles (see attached)
- Code Yellow – Search drills. More details to come!
If you have any questions, please reach out to Mēsha Richard, Lead, Emergency Preparedness (ext. 6552 or mesha.richard@tbh.net)
Thank you,
Wayne Taylor, Code Yellow Executive Sponsor & Director, Cardiovascular, Medicine & Renal Program (ext. 6677 or Wayne.Taylor@tbh.net.