Guide to JCAHO Environment of
Care Standard 3.10.6
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Introduction
Table of Contents Checklist
for 3.10.6
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Environment of Care Standard 3.10: The
organization manages hazardous materials and waste
risks
Element of Performance 6.
Emergency Procedures
The
organization identifies and implements emergency procedures
that include specific precautions, procedures and protective
equipment used during hazardous materials and waste spills or
exposures. |
This page
provides a set of criteria for evaluating the steps
that a facility takes to prevent emergencies
from occurring, and, when they do occur, to minimize dangers to
employees and patients, and to respond appropriately.
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Compliance |
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Environmental Improvement
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Tools and Resources
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Hazardous Materials Management
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Emergency prevention and preparedness
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Organization
exhibits a preference for non-hazardous materials use to
minimize risk when spills occur. |
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Hazardous materials
locations are identified throughout the facility.
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Appropriate
protective and spill control equipment is readily available in
areas where hazardous materials are used. Spill control equipment is maintained
in usable condition.
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Eyewashes and
showers are available, especially for acid and caustic spills are checked weekly and
documented.
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Employee exposure
incidents are decreased. (Rationale; facilities that
have reduced or eliminated hazardous materials have seen
reduced employee exposure incidents and improved occupational
health). |
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Patient exposure
incidents are decreased. (Rationale: minimizing hazardous
materials use reduces potential of spills and exposures to
patients improving patient safety). |
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Spills |
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Spill
clean up residues are managed as hazardous waste.
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Spills
are reported to local authorities and National Response
Center, if necessary.
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Facility is aware of additional
requirements, that may include
monitoring and medical surveillance,
pertaining to spills or releases of the following
materials:
(Training:
HR2.10.1.9,
29
CFR 1910.1047)
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radioactive materials
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blood
and body fluids
(29
CFR 1910.1020)
-
mold/spore releases from construction, maintenance, or
other activity disturbing mold contaminated materials
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releases of dust contaminated with lead
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Spill incidence is
decreased. (Rationale: facilities that have reduced or
eliminated hazardous materials use such as mercury, have seen
spill incidents decrease remarkably). |
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Costs associated with spill events
decrease. |
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Spill Containment
and Countermeasures plan is in place for aggregate aboveground
tank storage capacity greater than
1320 gallons.
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Facility has procedures in place for permits
and monitoring of aboveground and underground storage
tanks. |
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Tank alarm system
can be heard or otherwise adequately communicated to
operators. Written procedures
are in place for steps to be taken when tank alarm
sounds. |
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Training |
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Staff using
hazardous materials are trained regarding the materials they
use.
(HR 2.10). |
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Staff are trained
on appropriate handling and use of protective equipment.
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TRACER
Staff respond appropriately to spill of hazardous material
used in patient care, e.g. mercury spill from
sphygmomanometer. Spill clean up
procedures are in place.
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Emergency response |
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The hospital has in
place a complete program for handling emergencies involving
victims contaminated with hazardous chemical, radiological, or
biological products. This program includes:
- appropriate protective equipment
- adequate decontamination facilities (fixed or
portable)
- training
- written
program and procedures
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Hazardous Waste
Management
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Emergency prevention and preparedness
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Hazardous waste
locations are identified throughout the facility.
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Precautions are
taken to prevent accidental ignition or reaction of ignitable
or reactive waste, including separation from sources of
ignition or reaction, e.g. open flames, smoking, sparks,
welding and hot surfaces.
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Spills |
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Spills are reported
to local authorities and National Response Center, if
necessary.
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Spill clean up
residues are managed as hazardous waste.
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Training |
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Staff generating
hazardous waste are trained regarding the materials they use.
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All hospital staff
who handle universal waste batteries are trained in proper
handling and emergency response procedures.
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Emergency response |
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An emergency
coordinator is designated and has authority to commit
resources if necessary.
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Emergency
information is posted near the telephone in the hazardous
waste storage area.
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Arrangements are
made with local authorities to respond to a hazardous waste
emergency.
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Contingency plan |
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A contingency plan
is in place if the facility is a Large Quantity Generator.
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The provisions of
the hazardous waste contingency plan are carried out
immediately whenever there is a fire, explosion, or release of
hazardous waste or hazardous waste constituents which could
threaten human health or the environment.
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Regulated Medical (Infectious) Waste
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Emergency prevention and preparedness
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RMW waste
generation locations
are identified throughout the facility.
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Emergency
plans are in place in areas at high risk for
large blood or body fluid spills (such as operating rooms,
trash handling areas, and blood banks). |
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Spills |
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Bloodborne
pathogen spill
clean-up materials are available and accessible, including:
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proper personal protective equipment
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sorbents
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disposal equipment
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Spill
incidents involving a potential exposure to bloodborne pathogens are reported
to the facility's department responsible for employee health and
safety.
[can't find any reference to BBP
reporting requirements]. |
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Blood or body fluid spill incidence is
decreased. |
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Costs associated with spill events
decrease. |
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Training |
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All
hospital staff who may handle blood or body fluid spills are
trained in proper handling and emergency response procedures.
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Staff has
received spill prevention training, and incidence of blood or
body fluid spills has measurably decreased. |
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