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Fire Safety Plan

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A.To define program responsibilities and functions for an effective Fire Safety program for Memorial Hospital of Sheridan County.

A.It is the policy of Memorial Hospital of Sheridan County to provide a safe environment for patients, visitors and staff and to ensure that staff is familiar with the actions necessary during a fire/smoke incident.

B.The fire plan is based on organizational experience, applicable laws, accepted practice codes, standards from the regulatory agencies concerned with hospital operations, e.g., JCAHO, OSHA, NFPA, etc., and consultation with the local Fire Department.

C.Key aspects of the plan will be monitored utilizing data collection.  Effectiveness of the plan will be evaluated annually.

1.All new hospital employees will receive fire safety training upon employment.  New employees may not assume their normal staff duties until this training has been completed.  Students using MHSC as a clinical training site and faculty who supervise them must attend fire safety training at the beginning of their hospital experience.

2.All continuing employees will receive fire safety training during their attendance at the mandatory in-service day program.

3.In case of an actual fire/smoke incident, action will be taken to defend (the facility) in place by maintaining a closed compartment, i.e., by closing all doors to contain the fire/smoke.

D.Fire chimes will sound with activation of a pull station, smoke detector or sprinkler head.  The code phrase used to announce a fire drill or actual fire/smoke incident will be CODE RED, repeated with the location of the activated smoke detector, sprinkler, etc.

E.In the event of a fire or drill or actual fire/smoke incident at the Welch Outpatient Clinic, Saunders and MAC the receptionist will phone 911 and the hospital switchboard operator with the CODE RED information.  The receptionist will notify all staff in the Welch Building of the fire emergency.

F.In the event of an alarm system failure, electrical system and/or telephone failure that prevents paging CODE RED or interrupt the automatic communication with the Fire Department, administration will designate staff to go to each department to announce the fire emergency.  The Fire Department (911) will be notified by use of the pay phones in the lobby, cell phones, or other phones off site, e.g., from Mental Health Center.  Two-way radios are available in the Facilities Services Department to aid in communications.

G.The Hospital Safety Officer is responsible for coordinating and supervising the Fire Safety Program.


A.At the direction of the Hospital Safety Officer, the Facilities Services Department will: 

1.Conduct and monitor fire drills, one per shift per calendar quarter and sites will rotate throughout the facility.  Separate drills will be conducted at the Welch Outpatient Clinic, Saunders and MAC.  More frequent drills will be conducted if circumstances warrant, e.g., during construction projects.

2.Inventory and maintain all fire protection equipment, alarm systems, lists of pull stations, extinguishers, smoke detectors, sprinkler heads and automatic fire/smoke doors.  

3.Provide, post, and update hospital-wide egress maps.  

4.Respond to all fire drills and actual fire/smoke incidents.  They will bring fire extinguishers, will be prepared to assist with immediate rescue efforts, and fight the fire if safely possible, until the arrival of the Sheridan Fire Department.

B.All hospital employees will be responsible for:

1.Knowing the location of all fire pull stations, extinguishers, automatic fire/smoke doors and designated exits from their department and the building.

2.Knowing the fire plan specific to their department.

3.Participating in hands-on training in the use of fire extinguishers when presented.

4.If not involved in patient care, taking the nearest fire extinguisher and responding to the drill or actual fire/smoke incident, using the acronyms RACE and PASS.  See Attachment A.

a.R:  Rescue/Remove anyone, e.g., patient, visitor, coworker, etc., in immediate danger from the fire.

b.A:  Sound and Alarm.  Shout CODE RED to attract the attention of coworkers in the immediate area.  While rescue of those in immediate danger is taking place, the alarm will be sounded by pulling the nearest pull station.  Call the switchboard with the exact location of the fire emergency and notify the Fire Department of the exact location of the fire emergency.  In the case of electrical system failure, staff will be assigned to go to each hospital department/area to notify staff of the fire emergency.

c.C:  Confine the Fire by closing all the doors.  Check that the automatic fire doors have closed and latched.  DO NOT violate the integrity of the closed compartment by unnecessarily passing through the closed fire doors.  This action would allow smoke and/or fire to penetrate the closed compartment.  DO NOT USE THE ELEVATORS.

d.E. Evacuate the area if directed to do so.  Administration and/or the Safety Officer of Facilities Services may direct patient, visitors and staff be moved away from immediate danger.  Larger evacuation will be directed by the fire official in charge of the scene.    Stand by to move patients and visitors to a safe area, or to evacuate the building if necessary.  Reassure patients and visitors.  Patients would be evacuated to the VA Medical Center, if necessary.  Transportation of the patients will be done by local ambulances, VA vehicles, and/or the National Guard Unit, if they have been accounted for. Memorial Hospital of Sheridan County employees will assist with staffing for patient care at the VAMC as necessary. Extinguish a small fire ONLY IF THERE IS A CLEAR ESCAPE ROUTE. Use the PASS procedure.

e.Take the nearest fire extinguisher and;

1)P: Pull the locking pin to enable the handle.
2)A: Aim at the base of the fire.
3)S: Squeeze the handle to activate the stream of powder.
4)S: Sweep from side to side at the base of the fire to blanket it.

C.Employees in the Welch Outpatient Clinic, Saunders and MAC will not respond to fire drills or actual fire/smoke emergencies in the hospital building.  In drills or fire/smoke emergencies in the Welch Building, they will respond to the situation as described above.

D.Staff in the Dialysis Unit will not be a part of the fire drill emergency response team. They will be responsible for:

1.Knowing the fire plan for their department, incorporating both PASS and RACE procedures as above.

2.Being prepared to initiate the clamp and cut procedure with patients in case of the need to evacuate the dialysis area.

A.RACE and PASS Handout
B.Code Red Announcement

A.All Departments

A.Joint Commission Standards
B.NFPA Standards


A.All Departments