Policy Template1

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PURPOSE: To provide a safe and healthy workplace for all patients, visitors and

employees.

SCOPE: Hospital wide.

POLICY:

1. The hospital shall protect all individuals from preventable occupational injuries

and illnesses. The Hospital will undertake a program of education and

enforcement in safety directed at employees.

2. The primary responsibility for supervision and coordination of the hospital

Safety Program rests with the Hospital Safety Officer. The Hospital Safety

Officer has the authority to deal immediately and directly with any situation that

may be hazardous or potentially hazardous to the environmental health or safetyof the Hospital.

3. The Hospital Safety Officer will issue and maintain safety policies and

procedures which shall be the primary formal medium for communicating

information and instructions to the Hospital as well as through staff training .

These publications will contain rules and regulations and technical information

relating to safety , and is to be enforce by Environmental Health and safety

(EH&S).

The Hospital Safety Program is not limited to passive defense against physical

injury , but shall be an active program to prevent injuries and illnesses by reducing

risk and exposure.

LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.

En ineer II Medical S ecialist II- OIC

e

CAMIGUIN GENERAL

HOSPITAL

POLICY ON SAFETY

DOCUMENT No./ REV. No.

HPTLY-MER-P01-5

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Purpose:

The purpose of this is to describe the safety management structure at Camiguin

General Hospital.

Has established a multi- disciplinary safety management team consisting of

representative from key departments . This management team is committed to

promote safety awareness and practices to evaluate the safety programs

effectiveness.

Policy Statements:

It is the policy of Camiguin General Hospital to provide and environment of

care of Free of recognized hazards.

Application :

This structure is administered through a variety of committees . As applicable ,

the safety programs at Camiguin General Hospital apply to patients , visitors ,

employees, staff, students, vendor And contractors.

Exception:

No exceptions

Procedure:

1. Safety policies , plans, procedures , and programs designs to maintain a safe

healthful environment of care have been develop through the Health and

safety , various departments , and the safety committee . Safety policies are

available , paper copies of emergency preparedness plans are also available

at the command and control are Engineering and Maintenance Section.

2. The safety committee meets monthly to review safety management and

environment of Care activity and to analyze identified safety management

issues and recommended appropriate action.

LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II- OIC

CAMIGUIN GENERAL

HOSPITAL

POLICY ON MANAGEMENT


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3. The safety Committee activity will be communicated quarterly to the trustee

patient care committee . An annual report will be also presented based on

calendar year.

4. The safety committee will review all issues involving safety including

safety ,fire safety , hazardous materials & waste , security , emergency

preparedness , medical equipments , utilities safety education , infection

control quality assurance and risk management , and committee will discuss

the implementation of the various management plans. The committee

implements and monitors the performance improvement indicators and

revises the management plans as necessary.

5. The safety member present the technical aspects of their respective

disciplines as they arise . Safety committee members assists in the

development of resolutions to safety issues and evaluate their effectiveness .

In order majority of the members must be present.

6. The community health center develop , implement and evaluate their own

policies and procedures . Camiguin General Hospital environment care

team member are available for assistance in the development and

maintenance of management plans policies.

LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D. Engineer II Medical Specialist II- OIC

CAMIGUIN GENERAL

HOSPITAL

POLICY ON SAFETY

MANAGEMENT


HPTLY-MER-P01-5

PAGE No.

REVISION DATE


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Responsibility

A collaborative effect between management and staff is needed to maintain the

security program and to efficient manner .Its is the responsibility of the Chief of

Hospital ensure that the program functions in an effective and efficient manner It is

the responsibility of the chief Executive Officer of the facility to ensure that the

security program meets the needs of the facility.

SECURITY MANAGEMENT PROGRAM INCLUDES :

1. Addressing security issues concerning patients , visitors , personnel ,and

property implementation.

a. Monitoring and patrolling designated perimeter , areas , structures and

activities in the hospital.

b. Checking designated areas and building during other when normal working

hours that determine that they are property locked or are otherwise in

order.

c. Responding to protective signal or other hazard indicators.

d. Acting as necessary in the event of situation affecting the safety and

security of the facility including responding to fire and emergency orders.

e. Providing staff information on responding to violence in the work place.



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DOCU

PURPOSE: To provide a plan for Hospital staff to follow in case of fire , outlining

roles and responsibilities.

SCOPE: HOSPITAL only.

I. General

The term Emergency Evacuation has different meanings according to

vulnerability of the building in question. When a building such as the Camiguin

General Hospital affords protection because of its construction and fire

suppression system , evacuation will mean removal of patients , to areas

deemed fire safe for as long it may be necessary to decide further action . The

plan of action for the Hospital is horizontal evacuation to an adjacent fire-safe

area protected by fire \ smoke barriers until the area is deemed safe by fire

department officials and Environmental Health and (EH&S) staff , or until further

evacuation is necessary.

II. Discovery of fire follow R.A.C.E. Procedures:

RRemove endangered persons

AAlarm by activating fire alarm and dialing 321

CConfine fire by closing door

EExtinguish or evacuate

A. The code phrase Code Red shall be used under the following condition:

1. When an Individual discovers a fire and immediately goes to the aid of any

endangered persons , they shall call out Code Red. When someone

hears this phrase, they will activated the nearest fire alarm pull station.

2. During a malfunction of the building fire alarm system

3. During an actual fire and \or smoke condition to alert building staff of the

emergency.

LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO,M.D.

Engineer II Medical Specialist II- OIC

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B. Remove all people from immediate danger. In patient care areas , the room

that has the fire , the adjacent rooms and the rooms directly across the hall

should be evacuated first. Visitors to inpatients will be told to stay in the

room with the person they are visiting, door closed , and await further

instruction.

C. If the fire alarm has not activated automatically, the person discovering a fire

shall either follow Paragraph A.1 above ,or pull the nearest fire alarm pull

station. Dial 321 and announce a Code Red , giving information on the

location, and fire\smoke condition present.

NOTE: A fire alarms can be activated by the following mechanism:

1. Manual pull station

2. Fire suppressions system

3. Heat and\or smoke detection devices

D. Contain the fire by closing the door the fire room. All the patients room shall

be closed to keep smoke out.

E. If the fire is being fed by piped oxygen , the Fire Warden charge nurse, or

respiratory therapists shall direct the oxygen control valve for that room be

shut off. Prior to this , it must be assured that other patients on that oxygenzone are not dependent on the flow of oxygen .

F. As part of the E.D. Full Capacity Protocol ,patients awaiting in-house acute

care bed assignments are allowed to be admitted to acute care unit hall

beds. These patients are most exposed to fire and smoke conditions and

need immediate relocating to either the nearest patient room if ambulatory,

or the adjacent area of refuge if non-ambulatory. All equipment associated

with this patient shall be cleared from the hall.


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G. Corridors shall be cleared of all obstructions. Do not place items in the

patient rooms which could to obstruct the removal of the patients. If allobstructions cannot be removed, they will be place on one side of the

corridor only.

H. Any individual trained to used an extinguisher shall attempt to extinguish the

fire if they can do so without injuring themselves. However, do not delay

turning in the alarm or starting an evacuation simply to extinguish the fire.

I. If the fire cannot be immediately extinguish or contained, and\or conditions

warrant relocation rather than stay-in-room protection, the Fire Warden or

charge nurse shall direct that all patients be moved horizontally to an

adjacent fire compartment and area of refuge.

J. All available persons on the unit to include nurse, doctors, and volunteers will

be made available to Fire Warden as necessary to assist in clearing the

corridors, closing doors, and patients relocation .

K. Use any means of transport available to evacuate patients. Ambulatory

patients shall be led to the adjacent smoke compartment.

L. On network levels all visitors and non- critical staff will evacuate the alarm

are to the outside or an adjoining fire safe area located past a set of firedoors.

M. Areas other than alarm floor or area, no action is required other than

checking the fire alarm annunciator to determine the alarm location, and

being aware of a possible fire situation in another area, being evacuees from

that area or to evacuate based on input from the commander. Preparedness

includes clearing corridors.

N. Fire Wardens or charge nurses will direct activities until Fire Marshals,

University Police or Setauket Fire Department arrive.


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III. Fire Notification System

A. The police will immediately notify the Mambajao Fire Department and

Hospital\ Fire Marshals of the alarm. Annunciator panels are located on all

floors of the hospital in the areas listed. The annunciator panels

graphically display the fire alarm zone. This specific display will only show

on the fire floors itself; All other floors will just display the floor in alarm.

B. Bell: Bells sound on the fire floor or area of alarm origin. This indicates thatevacuation, whether actual or preparing for 30 such in that area will

necessary. The bell will alarm initially for 30 seconds . After 30 sec the bell

will resume on the fire floor, and remain on for 2 minutes. The sequence will

begin again if second alarm is activated.

C. Chimes: Chimes indicate that a fire alarm has activated on some other floor

or area . Chime will also sound on the floor. The chimes will sound for 30

seconds. On those floors where chimes sound, follow instructions listed in

paragraph II.M above.

D. Strobe Lights: Strobe lights will activate on the area where a fire condition

exist . They will remain on until manually reset at the fire alarm panel.

E. Public Address System: The Telephone Operators will broadcast a message

over the public address system, notifying where the is located preceded by

the phrase, Code Red . The phrase Code Green over the P A signifies all

clear.

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IV. Responsibilities

A. ADN During an active code red situation, ADN shall proceed to the

fire area and come in contact with the Fire Warden, Fire Marshal, and

other on site command personal. The ADN shall active the Hospital

Emergency Incident Command System (HEICS) as necessary to

support the relocation and evacuation efforts as well as assure

continuity of hospital operation.

B. Environmental Health and Safety

1. The Fire Safety Manager acts as campus emergency response

forces Incident Commander (IC) and coordinate activities with local

fire departments and hospital command structure.

2. Fire Marshals will immediately response to all alarms. They will take

action as appropriate.

C. Hospital Staff

1. Fire Wardens are specially trained staff members , tasked with

taking charge of their areas during fire and fire alarms situations.They will investigate all fire alarms within their area of the Hospital by

first inspecting the annunciator panel located closest to their area.

Fire Wardens take the lead in coordinating an evacuation for their

area, directing where patients will be evacuated to, keeping account

of who has moved.

2. Nurses take lead role under the direction of the Fire Warden or

charge nurse in the evacuation and accountability of patients,.

3. Doctors will assist the nursing staff and be under the direction ofthe Fire Warden or in-charge nurse, clearing halls, closing doors, and

evacuating patients. They will then remain in the evacuation area ,

providing care as appropriate to the evacuated patients.


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4. Volunteers will assist the nursing staff and be under the direction of

the Fire Warden or charge nurse, clearing halls, closing doors, andevacuating patients. If at the time fire alarm activation they are

responsible for the volunteer will stay with those patients and assist

in their evacuation under the guidance of the Fire Warden.

5. All other hospital staff present on the unit will remove any of their

items such as housekeeping, food, and linen carts from the corridors.

They will assist in patient evacuation if necessary, or evacuate the

floor or area if not necessary.

6. Nurses will evacuate the area unless they are specifically tasked by

the Fire Warden or in-charge nurse to assist in patient evacuation.

D. Hospital SSAs

1. Respond to all fires and fire alarm events in the hospital. During

Fires, assist with evacuation as appropriate, as well as keep

unauthorized personnel out of the fire zone.

2. Meet responding fire department personnel at the Fires Command

Room directing them to the fire location.

3. Assist Fire Marshals in finding cause of alarm as well as keeping

unauthorized personnel out of the fire alarm z.


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V. Operating Room \ICU \ Recovery

A. OR Policy, Fire Emergency Guidelines for the OR, Code F:1 , shall be

referenced for full guidance.

B. The Fire Wardens of PACU and OR, OR Nursing and Anesthesia

Coordinators, Nurse Manager of OR and PACU are responsible for

coordination of activities in the event of a fire.

C. No cases will be started after the fire alarm has activated or a fire

announced. Surgeons and Anesthesiologist with cases in progress will be

informed of the situation and advised to complete procedures as quickly

as possible and report the minimum length of time before evacuation ofthe can takes place.

D. The surgical team will stay with their patient in the room until instructed

to evacuate.

E. If evacuation becomes necessary (ie: extreme smoke and fire) from the

OR, the patient will be Stabilized surgically and moved as quickly as

possible to the adjacent OR suites which are separated by fire barriers.

Reference posted the fire evacuation plans for location of barriers and

direction of travel to areas of refuge.

F. For fires in the PACU, patients will be moved to the ORs, or adjacent fire

evacuation zones, per the evacuation plan.

G. For fires in the OR trailer suite, move patients on the adjacent smoke

compartment which is Radiology, and into the main surgical area, per

the evacuation plan.

H. The decision to shut off oxygen flow to the affected OR will depended on

the circumstances of the fire , Emergency shut off valves are located

and clearly marked in the corridor outside each OR. The surgical team

will decide if this measure is necessary immediately, and shut off the

supply valve themselves.

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VI. Vertical Evacuation

The Hospital fire response plans primary method of evacuation is horizontally

to adjacent areas of refuge, protected by fire rated smoke barriers and/or

horizontal exits. Patients and staff are to remain, evacuation in place while the

combination of the facilities fire suppression system and local fire department

extinguish the fire. Should there be a need to conduct an evacuation of an entire

floor, or complete evacuation of the facility due to a fire not being held to a firecompartment, the fallowing evacuation procedures will be fallowed. This plan is

companion plan to the hospitals Emergency Management P&P Manual Total

Evacuation Plan which must be reference for complete emergency planning

details.

A. Patients in imminent danger should be immediately evacuation, with

ambulatory patients moving first. Ambulatory patients should be instructed

to line up outside their rooms, and form a chain by holding hands. An

employee should be at the beginning and end of the chain to guide the

patient to safety. As ambulatory patients are being guided to a safe area, all

available staff should begin assisting non-ambulatory patients with the

evacuation. Due to the extreme effort required to move the amount of

bedridden patients, the hospital IC will, when acting in unison under the

Unified Command with the local fire department, have firefighters provide

manpower for carrying patients down.

B. Stretchers, wheelchairs and Paraslyde evacuation sleds can be used to

move non- ambulatory patients. Never use an elevator unless it is under thecontrol of the fire Department personnel or Fire Marshals. The Emergency

Management Total Evacuation Plan details evacuation equipment and

methods to include Respiratory Cares portable vents. Alternate care sites

and transportation methods are also outline in the same plan.




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Management Plan which includes policies, procedure and programs, risk

assessment hazard surveillance among others that address the following:

How the risk is determined

In the estimation of the risks, three or steps are involved, requiring the inputs of

different discipline:

1. Hazard Identification, aims to determine the qualitative nature of the

potential adverse consequences of the contaminant (chemical, radiation,

noise, etc.) and the strength of the evidence it can have that effect. This is

done, for chemical hazards, by drawing from the result of the sciences of

TOXICOLOGY and epidemiology. For other kinds of hazards, engineering or

other disciplines are involved.

2. Dose-Response Analysis, is determining the relationship between dose

and the probability or the incidence of effect (dose- response assessment).

The complexity of this step in manycontexts derives mainly from the needto exportable results from experimental animals (e.g. mouse, rat) to humans,

and\or from high to lower doses. In addition, the differences between

individuals due to genetics or other factors mean that the hazard may be

higher from particular groups, called susceptible populations. An alternative

to dose-response estimation is to determine an effect unlikely to yield

observable effects, that is a no effect concentration. In developing such a

dose, to account for the largely unknown effects of an animal to human

extrapolations, increase variability in humans, or missing data, a prudent

approach is often adopted by including safely factor in the estimate of the

safe dose, typically a factor 10 of each unknown step.



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POLICY ON DISPOSAL AND

CONTROL OF HAZARDOUS

MATERIALS/BIOLOGICAL WASTE

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3. Exposure Quantification, aims to determine the amount of a

contaminant (dose) that individuals and population will receive. This is done

by examining the results of the discipline of exposure assessment. As

different location, lifestyle and other factors likely influence the amount of

containment that received, a range or distribution of possible values is

generated in this step. Particular care is taken to determine the exposure of

the susceptible population (S).

Finally, the results of the steps above are then combined to procedure an

estimate of risk.

Because of the different susceptibilities and exposures, this risk will vary

within a population.

Hazards Material and Hazards Wasted Management Program

This program description provides information on requirements for the

management of hazardous materials, including the disposal of hazardous

waste, Camiguin General Hospital (CGH). Failure to comply with these

requirements may subject CGH and\or individual to fines, and civil or criminal

prosecution. In the additional, the management of hazardous materials is

necessary to reduce disposal cost. While the disposal of all material as

hazardous wasted is expensive, there are certain materials that require special

attention to minimize the difficulty and expense of their disposal.





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HAZAROUS WASTED INDENTIFICATION

.Wasted Identification Classification

. All wasted streams generated throughout the CGH must be identified and

then classified as hazardous or non-hazardous according to EPA and state

definition. If you need assistance in determining whether wasted is

hazardous, you should contact the Environmental Health and Safety Office at

CGH for assistance.



CAMIGUIN GENERAL

HOSPITAL

POLICY ON DISPOSAL ANDCONTROL OF HAZARDOUS

MASTERIALS/BIOLOGIC WASTE


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FIRE SAFETY MANAGEMENT PLAN

Reasons for the plan

This plan been written to ensure that school:

. observes fire related legislation

. has an effective Fire Safety Management System in place

. identifies the roles and responsibilities of all who use the hospital.

How the plan was developed

The plan was developed by the hospital after consultation with the Fire and

Rescue Service and written in accordance with the hospital policies.

Fire safety Specification

The hospital consists of main single/double-storey building used for patients

and administration purpose . All are covered by a common fire alarm system

and served by 19 fire extinguishers strategically placed around the building.

Risk assessment

The risk assessment will be carried out by the Fire Safety Coordinator (FSC),

using the county format. It should identify risks and controlling measures

together with dates for controls measures to established plus identification of

who responsible for bringing these into effect.

These assessments will be monitored by doctors/nurses and reviewed

annually or sooner if significant changes occur. Copies will be kept in the FireSafety Manual stored in reception.


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An Evacuation Plan

This will be produced by the FSC and should catalogue everything planned to

happen during the evacuation plus pre-planned control measures and actions. This

will include a Fire Brigade Reception Pack which will be kept in reception alongside

the Fire Safety Manual. The plan which be monitored by the chief of hospital and

reviewed annually or sooner if significant changes occur. A copy will be kept in the

Fire Safety Manual.

Tackling Fires

In the event of a fire, the hospital will generally adopt a flight not fight policy.

However dealing with small fires can prevent them developing into a more serious,larger fire.

If a small fire is blocking an escape route then staff will be expected to use a fire

extinguisher to put out the fire. Larger fires should only be tackled by staff that

have undergone enhanced training on how to use fire extinguishers. Staff should

always deal with such fires in twos and if visibility becomes a problem or the

flames reach ceiling height then they should withdraw immediately. The safety of

staff and patient is always the firsts priority.

Effective Records.

Records form an important part of fire management system. They should be kept

in the fire Safety Manual and demonstrate the following:

Fire alarms checks, tests and maintenance weekly tests by site supervisor,

six monthly maintenance by approved contractors monitored by the site

supervisor.

Equipment connected to the fired alarms- checks, tests and maintenance;

weekly by site supervisor, six monthly maintenance by approved contractors

monitored by the site supervisor.



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Emergency lighting checks, tests and maintenance- monthly tests by site

supervisor, six monthly maintenance by approved contractors monitored bythe site supervisor.

Fire fighting equipment- monthly checks by site supervisor, annual

maintenance by approved contractors monitored by site supervisor.

Fire doors quarterly conditions checks by site supervisor of fire resisting

doors and final exist to ensure effective operation and maintenance as

necessary.

Management Structure: Roles and Responsibilities.

The governing body has overall responsibilities to ensure that the hospital

complies with fire safety regulations and has an adequate Fire Safety Management

Plan.

The Chief of Hospital is responsible for the day to day implementation of the

management Plan.

The Fire Safety Coordinator (FSC) is responsible for:

Complementing the Fire Risks Assessment

Producing the Evacuation Plan.

Organizing fire drills(FSC) is responsible for:

Complementing the Fire Risks Assessment

Producing the Evacuation Plan.

Organizing fire drills.


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Fire Drills

A fire drill will be carried at least one each term. These will be organized and

monitored by the FSC. A record sheet will be completed on each occasion and

should include the narrative, problems noted, remedial actions undertaken

together with completion dates and who had been tasked with the actions. These

records should be field in relevant section of the Fire Safety Manual.

Training

The FSC will receive appropriate training.

All staff will undertake basic training on safety to include:

General Fire Safety Issues housekeeping and fire prevention measures and

use of extinguishers.

Issues specific to the evacuation plan.

Issues arising from the risks assessment.

Issues relating Fire Drills.

The general training will be provide for new staff as part of their induction and will

be updated annually for all staff. This is the responsibility of the FSC. Staff will be

updated on any issues regarding fire safety at staff briefing meetings. Records will

be kept of who gave the training, what is related to and its duration. These will be

kept in Fire Safety Manual.

Housekeeping and Fire Prevention.

Waste bins will be emptied at least daily.

External bins are housed in a locked compound and emptied weekly. The

school will arrange for additional collections as required.

All escape routes and Fire exists must be kept clear and classrooms and

work areas kept tidy.

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Any flammable materials are stored in caretaker room which is kept locked.

Matches and candles are only use when necessary and always in the

presence of an adults.

Fire prevention is include within the curriculum as part of the hospital. It is

the responsibility of all the staff to give clear fire safety message including

when using emergency lights.

Special Needs

The hospital is mindful that staff and patient with special needs will need to have

fire safety procedures explained them and if necessary provided with a Personal

Emergency Evacuation Plan.

The Site Supervisor is responsible for:

Carrying out safety checks

Providing information for the risks assessment.

Implementing arson prevention measures.

Helping with fire drills

The Assistant Administration Officer is responsible for checking that:

All appropriate checks and procedures are completed as stated in the

management plan.

Any actions identified to improved fire safety are completed within the

specified timescale.

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All Staff has a legal Responsibility to:

Report any concerns regarding fire safety to the FSC or supervisor.

Implementing the aspects of this policy which refer to them.

Undertake training as required.



Arson Prevention

The hospital recognizes that hospital sites are particularly vulnerable to arson

attacks. The following prevention measures will adhered to:

Daily checks of the hospital building, grounds and woodlands to detect

any signs of intruders, vandalism and fire lighting. Any incident will be

reported to the police.

Care will be taken not to live, anywhere on the hospital site, easily

combustible materials e.g. wood a paper that could be used to start a fire.

Rubbish waiting for collection will be housed in the locked bin store.

The hospital has no letter box and good outdoor lighting.

Monitoring and Review

The Governing Body has delegated the responsibility for reviewing the Fire Safety

Management Plan. The Plan will reviewed annually and the committee will received

regular updates from the supervisor on any matters relating to Fire Safety.

Staff who has specific responsibilities for implementing the Fire Safety

Management Plan should inform the Chief of Hospital of any concerns relating to

fire safety.



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The Management of Health and safety all to effective plan, organize, control,

monitor and review their health and safety systems and procedures. For your

health and safety policies and procedures to be effectively implemented, they

need to be:

up - to date

relevant

practical

comprehensible.

We can draft health and safety policies and procedures from scratch or simply

review and update existing material. Whichever route you choose, we work closely

with you to ensure legal compliance and workable procedures.

Benefits

Efficient use of time our health and safety consultants know what

legislation is relevant to your business and the best way to implement it

Keep up to date we can let you know when policies need to reviewed due

to new legislation or best practice.

Dont reinvent the wheel model policies and procedures are available for

you to adapt.

Practical approach our policies and procedures are written to be used, notto be filed and forgotten.

Our approach

We can manage and deliver a full health and safety policy, plan and

procedures


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Project stages often include:

review of current health and safety procedures.

Development of plans and policies for areas not already covered

Recommendation for change and revision of existing policies

Making the revisions

Regular review of documents for this is legal requirement.

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HOSPITAL

POLICY ON HEALTH AND SAFETY

PROCEDURE


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Purpose : To ensure that staff have relevant information regarding the procedures

to be followed when dealing with spillage of Metallic mercury.

Policy Statement : IT is the policy of the Camiguin General Hospital To ensure the

health and Safety of the Staff in relation to potential Exposure to metallic mercury

and its vapours.

Policy Application : Trust wide

Author: Health and Safety Advisor

MERCURY SPILLAGE POLICY AND PROCEDURES

1. Introduction

1.1. The aim of this policy is to provide information regarding health and

safety issues when the spillage or mercury occurs,

1.2. Mercury is the silver liquids metal contained in thermometers and

sphygmomanometers. It is toxic. The principle hazard is by inhalation

of vapour . Skin and eye absorption add to the danger. It may also be

ingested. All staff should Therefore be familiar with basic safetyprecaution and the action to be taken in the event of a mercury spillage.

1.3. Mercury and its compounds are listed substances which must not be

put down drains, Incinerated or and taken both trust and the individual

liable to criminal prosecution.

2. Responsibilities / Accountabilities

a. Responsibility for Spillage Clearance

b. Department Wards the person in charge of the department ofward at the time the spillage is responsible for arrange the safe

clearance of the spillage and for ensuring that the medical

attention is sought for any injured person. An incident form via Trust

internet must also be completed by the person in charge.

c. Public Areas - A mercury spillage must be reported immediately

to the person in charge.

POLICY ON MERCURY SPILLAGE

AND PROCEDURE

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Refers to range of activities designated to maintain control over disaster and

emergency situation and to provide a framework for helping persons at risks, to

avoid or recover from the impact of disaster.

Policies :

1. Formulation of a Disaster Management Plan considering the following

elements of disaster :

. Identify threats ( hazards likely to occur )

. Determine their probability of occurrence

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Policies :

1. Formulation of a fire Disaster Management Plan

2. Conduct of Fire Drill at least once a year to be conducted By Bureau of

Fire Protection.

The following should be considered :

1. Building and equipment should be as close to fire resistant and fire proof as

possible.

2. Written report of any deficiency.

3. All fire codes are observe and carried out

4. Fire regulation and signages are prominently posted (ex. No smoking).

5. Fire detection equipment should be checked every six months.

6. Fire Extinguisher installation should be checked annually.

7. ALL fire exits should not be locked

8. Driveways to building should be free for access by big fire trucks.

PROCEDURE:

Identify Exits:

identify the different exits

identify the different stairs

identify the different evacuation areas

identify the war and corresponding rooms

Plan an escape Route

Make an escape route according to ward room number thru the

nearest exit into nearest stairs leading to the nearest evacuation area

but which are safer and father from the fire and which are accessible in

case of earthquake.


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Prepare a Directory

Make a ready Directory to emergency numbers t be called like:

o Fire stations

o Fire rescue units

o Emergency light service provider

Designate Rule and Roles


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Procedure

Emergency Procedures for Utility System : Disruption

The power Plant Directive and its associated manuals manual provide

specific procedures in the event of a utility system malfunction,

identifies alternative sources of essential utilities, location and shut off

procedures, emergency numbers and notification procedure , repair

services and emergency clinical inventions when utility system fail.

POLICY AND PROCEDURE OF

UTILITY SYSTEM

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INTRODUCTION

This program established minimum standards to prevent hazardous electrical

exposure to personnel and ensure compliance with regulatory requirements

applicable to electrical systems. The program is intended to protect employees

against electrical shock, burns and other shock, burns and other potential electrical

safety hazards as well as comply regulatory requirements.

ELECTRICAL HAZARDS

Electrical related hazards include electrical shock and buns, arc- flash burns blast

impacts, and falls.

Electric shock and burns. An electric shock occurs when electric currentpasses though the body. This can happen touching and energized part. If

the electric current passes across the chest or head, death can result. At

high voltage, severe burns can result.

PURPOSE

This program has been established in order to:

Ensure the safety of employees who may work on or near electrical

equipment.

Ensure that employees understand and comply with safety standards related

to electrical work.

Ensure that campuses, agencies and employees follow uniform practice

during progress of electrical

work.

Comply with Standards and procedures according to the following six

points:

1. Provide and demonstrate a safety program with defined responsibilities.

2. Determine the degree of arc flash hazard by qualified personnel.

3. Affix warning labels on equipment.

4. Provide personal protective equipment (PPE) for workers.

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SCOPE

This is program applies to all State of Wisconsin properties and work performed by its

employees regardless of job site location.

ELECTRICAL SAFETY PRINCIPLES ENERGIZED CONDITION

De-energized whenever possible.

Plan every job. The approach and step by step procedures to complete

the work at hand must be discussed and agreed upon between all involvedemployees before beginning. Write down first- time procedures. Discuss

hazards and procedures in a job briefing with supervisors and other workers

before starting any job. It is the employers responsibility to have or develop a

checklist system for working on live circuits, if such a scenario arises.

Identify the hazard .Conduct a job hazard analysis. Identify steps that could

create electric shock or arc- flash hazards.

Minimize the hazards. De energized any equipment, and insulate, or

isolate exposed live parts so contact cannot be made. If this impossible, obtainand wear proper personal protective equipment (PPE) and tools.

Anticipate problems. If it can go wrong, it might. Make sure the proper PPE

and tools are immediately available for worst case scenario.

5. Provide documented training to workers on Lockout.

6. Provide appropriate tools for safe work.



Obtain training. Make sure all involved employees are qualified electrical

worker with appropriate training for the job.

RESPONSIBILITIES

Each agency must determine the assignment of the following responsibilities

based on staff expertise, resources and agency specific considerations:



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Safety Precaution

Evaluate work being performed and determine compliance with this

program.

Provide or assist in the task of specific training for electrical work

qualifications.

Training recordkeeping.

Periodically review and update this written program.

Provide or coordinate general training for work units on the content of this

program.

Evaluate the overall effectiveness of the electrical safety program on aperiodic basis.

Assist work units in the implementation of this program.

Supervisors

Promote electrical safety awareness to all employees.

Ensure employees comply with ALL provisions of the electrical safetyprogram.

Ensure employees receive training appropriate to their assigned electrical

tasks and maintain documentation of such training.

Develop and maintain a listing of all qualified employees under their

supervision.




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Ensure employees are provided with and use appropriate protective

equipment.


Employees

Follow the work practice describe in this document, including the use of

appropriate protective equipment and tools.

Attend all training required relative to this program.

Immediately report any concerns related to electrical safety supervision.

DEFINATIONS

Authorized Maintenance personnel- A person who has completed the

required hazardous energy control training and authorized to maintain

specific machine or equipment to perform service maintenance. A Person

must be certified as Authorized Technical Employee in order to apply her/his

knowledge to control dangerous equipment. All Authorized Maintenance

personnel must be trained in:

Electrical Safety / Maintenance Equipment

Equipment specific procedures in their individual works units

Confined space An enclosed space which has limited egress and access,

and has an atmospheric hazard (e.g., electrical hazard).

Damp location Particularly protected location subject to moderate

degrees of moisture, such as some basements.

De- energized electrical work- Electrical work that is performed on

equipment that has been previously energized and is now free from any

electrical connection to a source of potential difference and from electrical

charges.




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Disconnecting (or Isolating ) work- A device designed to close and / or

open an electrical circuits.

Dry location Locations not normally subject to dampness or wetness, as in

the case of a building under contraction.



Energized source Any source of electrical, mechanical, hydraulic,

pneumatic, chemical, thermal, 2nd Generator.

Exposed electrical parts Energized parts that can be inadvertently

touched or approach nearer than a safe distance by person. Parts not

suitably guarded, isolated, or insulated. Examples include terminal contactsor lugs, and bare wiring.

Flash Protection Boundary- An approach limit distance from exposed live

parts within which a person could receive a second degree burn if an

electrical arc flash were to occur.

Ground Fault Circuit Interrupt (GFCI)- A device whose function is to

interrupt the electrical circuit to the load when a fault current to ground

exceeds a predetermined value that is less than that required to operate the

over- current protective device of the supply circuit.

Ground A conducting connection, whether international or accidental,

between an electrical circuit or equipment and the earth or to some

conducting body that serves in place of the earth.

Hazardous Location- An area in which an Toxic wasted, Laboratory wasted.

Interlock- An electrical, mechanical, or key-locked device intended to

prevent an undesired sequence of operations.

Isolating Switch- A switch intended for isolating an electric circuit fromsource of the power. It has no interrupting rating, and intended to operate

only after the circuit has been opened by some other means.

Life Safety Equipment Equipment that provides critical protection for

safety in the event of an emergency or other serious hazard. Life safety

equipment, which is electrically energized, should be worked on using




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Energized Electrical Equipment (EEW) procedures to ensure that the

protection provided by the equipments is not lost.

Limited Approach Boundary An approach limit is a distance from an

exposed live part within a shock hazards exists.

Lockout The placement of a lock on an energy isolating device according

to procedure, ensuring that the energy isolating device and equipment being

controlled cannot be operated until the lockout device is removed.

Lockout / tagout A standard that covers the servicing and maintenance of

machines and equipment in which the unexpected re energization of the

equipment or release of stored energy could cause injury to employees. It

establishes performance requirements for the control of such hazardous

energy.

Prohibited Approach Boundary An approach limit distance from an

exposed live part within which work is considered the same as making

contact with the live part.

Qualified Electrical Worker - A qualified person trained and

knowledgeable of construction and operation of equipment or specific work

method and is trained to recognized and avoid the electrical hazards that

might be present with respect to that equipment or work method.

Qualified electrical workers shall be familiar with the proper use of the

special precautionary techniques, personal protective equipment (PPE) ,

including arc, flash insulating and shielding materials, and insulated tools

and tests equipment. A person can be considered qualified with respect to

certain equipment and methods but is unqualified for others.

An employee who is undergoing on-the-job-training, and who is the course

of such training, has performed duties safety at his or her level training

and who under the direct supervision of a qualified person shall be

considered to be qualified.

Qualified electrical workers shall not be assigned to work alone, except

for replacing fuses, operating switches, or other operations that do not

require the employee to contact energized high voltage conductors or

energized parts of equipment, clearing trouble, or emergencies involving

hazard to life or property.




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Note One : Whether a person is considered to be qualified person will depend

upon various circumstances in the workplace. It is possible and, in fact, likely for

an individual to be considered qualified with regard to certain equipment in the

workplace, but unqualified as to other equipment.


Note Two : An employee who is undergoing on-the-job training and who, on the

course of such training, has demonstrated an ability to perform duties safely at his/

her level of training and who is under the direct supervision of a qualified person is

considered to be a qualified person of the performance of those duties.

Restricted Approach Boundary An approach limit distance from an

exposed live part within which there is an increase risk of shock, dueelectrical arc-over combined with inadvertent movement, for personnel

working in close proximity to the live part.

Remote- control Circuit- Any electric circuit that controls any other circuit

though a relay on an equivalent device.

Service- The conductors and equipment for delivering energy from the

electricity supply system to the wiring system of the promises served.

Service Equipment The necessary equipment, usually consisting of a

circuit breaker or switch and fuses, and their accessories, located near theentrance of supply conductors to the building and intended to constitute the

main control and means of cutoff the supply.

Setting Up Any work performed to prepare a machine or equipment to

perform its normal production operation.

Switching Devices Devices designed to close and / or open one more

electric circuits. Included in this category are circuit breakers, cutouts,

disconnecting (or isolating) switches, disconnecting means, interrupter

switches, and oil (field) cutouts.

Voltage (of a circuit ) The greatest root-mean square (effective)

difference of potential between any two conductors of the circuit concerned.

Voltage, high Circuits with a nominal voltage more than 50 volts.

Voltage, low Circuits with nominal voltage less than or equal to 50 volts.




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1. PURPOSE and APPLICABILITY

1.1 This policy is designed to ensure that all Hospital and institution activities

and operation involving the use of radioactive materials /x rays/ ct scan are

performed in such a way as to protection users, staff patients and generalpublic from exposure. The operating procedure is to main all radiation

exposures as Low As Reasonably Achievable (ALARA).

1.2 This policy to all Hospital and institution Doctors and Nurses who receive,

possess, use, transfer, own, or acquire any source of ionizing radiation or

radioactive material.

2. DEFINATION and SCOPE

2.1 Radioactive materials include any material that spontaneously emitsionizing radiation.

2.2 Ionizing Radiation is electromagnetic radiation ( x ray and gamma ray

photons ) or particulate radiation ( beta particles, electrons, positrons,

neutrons, and alpha particles) capable of producing ions by secondary

processes.

2.3 ALARA is an acronym for as low as reasonably achievable a level to

which radiation protection aims to reduce occupational exposures. ALARA is

achieved though good radiation protection planning and practice, backed bymanagement commitment.

Voltage, nominal An approximate value assigned to a circuit or system

for the purpose of conveniently designating its voltage class, e.g., 120/ 240,

480/277, and 600.



3. ROLES and RESPONSIBILITIES

3.1 The Radiation Safety Committee (RSC) is a committee responsible for

development and administration of radiation safety program at the Hospital

affiliated institutions. It establishes policies and enforce compliance with

program.


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3.2 The Radiation Safety Officer (RSO) is responsible for the daily

implementation of the radiation safety program in accordance with directives

from the RSC, license provisions, and regulatory requirements. As the

authorized representative of the Radiation Safety Committee, the RSO

supervises all radiation control activities. The RSO is responsible for ensuring

the safe use of radiation and radioactive materials and for meeting ALARA

levels.

3.3 The Office of Environmental Health and Radiation Safety (EHRS) is the

lead office for radiation safety at the Hospital and affiliated institutions.

Details of these duties and responsibilities are described I the appropriate

radiation safety manuals (radioisotopes an x rays).

3.4 A License is an individual authorized in writing by the RSC to use

radioactive materials in laboratory research or class instruction. The official

document providing the defined scope of authorization is known as license. A

licensee is responsible for the radiation control activities under his/her

license.

3.5 A radiation Worker us an individual who works with ionizing radiation

and receives radiation safety training She/he is responsible for following allapplicable regulations pertaining to the use of x rays and / or radioactive

materials as presented in the Radiation Safety Manual, in the license, and in

notices issued by the RSO.

1. PROCEDURES

License to Use Radioactive Material

All individuals who wish to independently use radioactive material mustapply to the RSC for a license. The license evacuation take into consideration

the adequacy of facilities and equipment, training and experience of the

user, and the operating of equipment.


POLICY ON RADIATION SAFETY


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Engineer Medical Specialist II- OIC

Water safety is critically important and essential in the operation and services in

the hospital. In fact, water is defined as LIFE.

POLICIES:

1. Water sample analysis should be done at least 2x a year.

2. Regular check of water lines, pipes and fitting and immediate replacement of

defective faucets and other plumbing fixtures.


POLICY ON WATER SAFETY


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Make Hospital Fire Safe

Smoke alarms save lives. Install a smoke outside each sleeping area and on

each additional level of your hospital.

If people sleep with doors closed, install smoke alarms inside sleeping area,

too. Immediately

Use the test button to check each smoke alarm once a month. When

necessary, replace batteries immediately. Replace all batteries at least once

a year.

Vacuum away cobwebs and dust from your smoke alarms monthly.

Smoke alarms become less sensitive overtime. Replace your smoke alarms

every ten years.

Consider having one or more working fire extinguisher at hospital. Get

training from the fire department in how to use them.

Consider installing an automatic fire sprinkler system in hospital.

Plan Your Escape Routes

Determine at least two ways to escape from every room of the hospital

Consider escape ladders for sleeping areas on the second or third floor.

Learn how to use them and store them near the window.

Select a location outside the hospital where everyone would meet after

escaping.



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Practice your escape plan at least twice a year.



ESCAPE SAFELY

Once you are out, stay out! Call the fire department from a neighborsphone.

If you see smoke or fire in your first escape route, use your second way

out. If you must exit through smoke, crawl low under the smoke to

your exit.

If you are escaping through a closed door, feel the door be3fore

opening it. If it is warm, use your second way out.

If smoke, heat, or flames block your exit routes, stay in the room with

the door closed. Signal for help using a bright-colored cloth at the

window. If there is a telephone in the room, call the fire department

and tell them where you are.

Be Smart, Be Responsible, Be Prepared. Get Ready

Get involved, Volunteer, Bear Responsibility

10 ways YOU can be Disaster Prepared

1. Identify Your Risk.

2. Create a Family Disaster Plan

3. Practice Your Disaster Plan

4. Build a Disaster Supply Kit For Your Home and Car


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5. Prepare Your Children

6. Dont Forget Those With Special Needs

7. Learn CPR and First Aide

8. Eliminate Hazards in Your Home and the Workplace

9. Understand Post 9/11 Risks

10. Get Involved, Volunteer, Bear Responsibility

The place to be cleared must be secured and cordoned. Only

authorized personnel or the pollution control officer should be allowed

in the area.

In clearing-up spillage of the body fluids or other potentially hazardous

substances, particularly if there is a risk of splashing, eye protectors

and face masks should be worn in addition to gloves and overalls.

The need for respirators/gas mask is also necessary if an activity is

particularly dangerous,, for example, if it involves toxic dust, chemicalreagents, the clearance or incinerator residues, or the cleaning of

contaminated equipment.

It is especially important also to recover spilled droplets of metallic

mercury, if leakage or spillage involves material; the floor should be

cleaned and disinfected after most of the waste has been recovered.

RESPONSE TO INJURY AND EXPOSURE

All staff that handles health care waste must be trained to deal with injuriesand exposures.

Health care establishment should develop a program that would prescribe

the actions taken in the event of injury or exposure to a hazardous

substance.

Essential elements of the program should include the following:


POLICY ON SPECIAL PRECAUTION

FOR CLEANING-UP SPILLAGE OF

POTENTIALLY HAZARDOUS


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Immediate first aid measures, such as cleaning of wounds and skin,

and irrigation (splashing) of eyes with clean water .

An immediate report of the incident to designated responsible person.

Retention, if possible, of the item involved in the incident, details of its

source for identification of possible infection

Additional medical attention in an accident and emergency or

occupational health department, as soon as possible

Medical surveillance

Blood or other test if indicated

Recording of the incident

Investigation of the incident, and identification and implementation of

remedial action to prevent similar incident in the future.



FOR CLEANING-UP SPILLAGE OF

POTENTIALLY HAZARDOUS


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The generating set is designed to be safe in correct manner.

Responsibility for safe however rests with the personnel who use the set.

Policies:

1. The generating set should only be operated by authorized and trained

personnel.

2. A logbook on preventive maintenance should be maintained.

(sample of safety precaution contained in the generator manual)

Warning:

Read and understand al safety precaution and warning before operating the

generating set.

Never start the generating set unless it is safe to do so.

Do not attempt to operate the generating set unless it is safe to do so.

If the generating set unsafe, fit danger notices and disconnect the battery (-)lead so that it cannot be started until the condition is corrected.

Disconnect the battery (-) lead prior to attempting any repairs or cleaning

inside the ensure, if equipped.




POLICY ON GENERATOR SET


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Never store flammable liquids near the engine.

Store oily rags in covered metal containers

Do not smoke or allow sparks, flames or other sources of ignition around fuel

or batteries. Fuel vapor are explosives.

Avoid refilling the fuel tank while the engine is running.

Do not attempt to operate the generating set with any known leaks in the fuel

system.

Mechanical:

The generating is design with guards for protection from moving parts.

Warning:

Do not attempt to operate the set with safety guards removed. While the

generating set is running do not attempt to reach under or around the

guards for any reason.

Keep hands, arms, long hair, loose clothing and jewelry away from pulleys,

belts and other moving parts.

Attention:

Some moving parts ca not be seen clearly when the set is running.

Keep access doors on enclosures, if equipped closed and locked when not

required to be open.

Avoid contact with hot oil, hot coolant, hot exhaust gases, hot surface andsharp edges and corner.

Wear protective clothing including gloves and hat when working around.

LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II OIC

Install only in full compliance with relevant national, local, or federal codes,

standards or other req

uirements.

Fire and explosion:

Ensure the generating set room is property ventilated.

Keep the room, floor and generating set clean. When spills of fuel, oil,

battery electrolyte or coolant occur, they should be cleaned up immediately.




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Chemical

Fuels, oils, coolants, lubricants and battery electrolyte used typically of theindustry.

Warning:

Do not swallow or have skin contact with fuel, oil, coolant, lubricants

or battery electrolyte, if swallowed, seek medical treatment

immediately. Do not induce vomiting if fuel is swallowed. For skin

contact wash with soap and water.

Do not wear clothing that has been contaminated by fuel or lube oil.

Electrical Safety

Safe and efficient operation of electrical equipment can be achieved only if

the equipment is correctly operated and maintained.

Warning:

Ensure that generating set effectively ground/earthed prior to operating.

Do not touche electrically energized parts of the set or interconnecting

cables or conductor with any part of the body or with any non insulated

conductive object

Use only class BC or class ABC extinguishers on electrical fires.




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The place to be cleared must be secured and cordoned. Only authorized

personnel or the pollution control officer should be allowed in the area.

In clearing- up spillage of body fluids or other potentially hazardous

substance, particularly if there is a risk of splashing eye protectors and face

masks should be worn in addition to gloves and overalls.

The need for respirators / gas mask is also necessary if an activity is

particularly dangerous, for example, if it involves toxic dust, chemical

reagents, the clearance or incinerator residues, or the cleaning of

contaminated equipment.

It is especially important also to recover spilled droplets of metallic mercury,if leakage or spillage involves material; the floor should be cleaned and

disinfected after most of the waste has been recovered.

RESPONSIBLE TO INJURY AND EXPOSURE

All staff that handles health care waste must be trained to deal with injuries

and exposures.

Health care establish should develop a program that would prescribe the

action taken in the event of injury or exposure to a hazardous substance.

Essential elements of the program should include the following.

o Immediate first aid measures, such as cleaning of wounds and

skin, and irrigation (splashing) of eye with clean water



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o An immediate report of the incident to designated responsible person.

o Retention, if possible, of the item involved in the incident, details of its

source for identification of possible infection.

o Additional medical attention in an accident and emergency or

occupation health department, as soon as possible

o Medical surveillance

Blood or other test if indicated

Recording of the incident

Investigation of the incident, and identification and implementation of

remedial action to prevent similar incident in the future.



FOR CLEARING UP SPILLAGE OF

POTENTIAL HAZARDOUS


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Introduction

Risk assessment is the process of quantifying of a harmful effect to individual or

population from certain human activities, In most hospital the use of specific

chemicals, or the operation of specific facilities is not allowed unless it can be

shown that they do not increase the risk of death or illness above a specific

threshold.

The process of managing risk to identify potential risks. Are about events that,

when triggered, cause problem. Hence, risk identification can start with the source

of problems, or with the problem itself.

Policy

1. Camiguin General Hospital should identify, assess the risk and manage the

risk before any harmful effects would come to the patients, family, and staff

2. If there is presence of security risk, control should be established

immediately in order to prevent harm to the patients, family, and staff.

3. Risk is identified assessed and appropriately controlled. Where elimination or

substitution is not possible, adequate warning and protection devices are

used.


POLICY PROCEDURES ON RISK

IDENTIFICATION, ASSESSMENT

AND CONTROL, SECURITY RISKS,

USE OF PERSONAL EQUIPMENT


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4. A coordinated security arrangement in the organization assures protection of

patients, staff, and visitors.

1.DOT NOT use the EQUIPMENT if there is an

intermittent audio alarm.

2.DO NOT plug the unit if the power lines/ outlet is

overloaded.

3.DO NOT plug MEDICAL EQUIPMENT if the voltage

regular is under wattage.4. ALWAYS USE voltage regular or UPS when using

the MEDICAL EQUIPMENT.

5.ALWAYS USE power time delay when using the

MEDICAL EQUIPMENT.

CAMIGUIN GENERAL

HOSPITAL

POLICY ON MEDICAL EQUIPMENT

AND PROCEDURE


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CAMIGUIN GENERAL HOSPITAL

Title: Mercury Spillage and Procedures

Purpose: To ensure that staff have relevant information

regarding the procedures to be followed when

dealing with spillages of metallic mercury.

Policy Statement; It is the policy of the Camiguin General Hospitalto ensure the Health and safety of staff in

relation to potential exposure to metallic

mercury and its vapours.

Policy Application: Trust-wide

Author: Health and Safety Advisor

MERCURY SPILLAGE POLICY AND PROCEDURES

1. Introduction.

1.1 The aim of this policy is to provide information regarding health and safety

issues when the spillage of mercury occurs.

CAMIGUIN GENERAL

HOSPITAL

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v. Follow up the instruction supplied with the kit.

vi. Vacuum cleaners must not be used.


1.2Mercury is the silver liquids metal contained in thermometers and

sphygmomanometers. It is toxic. The principle hazard is by inhalation of

vapour. Skin and eye absorption add to the danger. It may also be ingested.

All staff should Therefore be familiar with basic safety precautions and the

action to be taken in the event of s mercury spillage.

1.3 Mercury and its compounds are listed substance which must not be putdown drains, Incinerated or put in general wasted. To do so would be illegal

and taken both the trust and the individual liable to criminal prosecution.

2. Responsible for Spillage Clearance

i. Department and Wards the person in charge of the

department or ward at the time the spilla is responsible for

arrange the safe clearance of the spillage and for ensuring that

medical attention Is sought for any injured person. An incident

form via Trust internet must also be complicated by the person in

charge.

ii. Public Areas A mercury spillage must be reported immediately to

the person in Charge of the nearest ward or department. The

spillage area must be supervised.

3. Clearance Procedure

3.1 In the event of mercury spillage (e.g. a broken sphygnomameter), the

spillage must be cleaned up Immediately by taking the following steps:

I. Open doors and window to improve ventilation

II. Keep unnecessary personnel, patient and visitors away from the

spillage area.

III. Disposable gloves and aprons must be worn.


POLICY ANDPROCEDURES ON


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IV. Contact Bleep Holder or out of hours Pharmacist on call for a mercury

spillage kit, if one if one is not available in the Department or on the

Ward.

vii. Wash hands when the procedure is complete

viii. Seek first aid/ medical attention for any injured persons, including

individuals who have had skin contact with the spillage mercury and

remove them from the contaminated atmosphere.

ix. Contact Engineering / Maintenance Department regarding

disposal waste.

4. Equipment for Repair ( e.g. broken Sphygomomanometer )

4.1Using gloves, broken equipment contaminated with mercury should be

sealed in two strong yellow Plastic sacks and declaration of contamination

status label should be completed and fixed to the Bag stating Broken

Equipment for Repair Contaminated with mercury and taken to the

Engineering / Maintenance Department having first alerted Department by

Telephone.

4.2 For disposal out of hours, the container should be stored in a safe place

until removal to the Engineering / Maintenance Department.

4.3 The Engineering / Maintenance Department will recycle mercury and

arrange for Associate contaminated waste to be sent to the hazardous

Waste Management of the Government.

CAMIGUIN GENERAL

HOSPITAL

POLICY AND PROCEDURES ONMERCURY SPILLAGE


HPTLY-MER-P01-5

REVISION DATE

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Performance of preventive maintenance procedure of each machine /

equipment should be daily, weekly and monthly in accordance with the

operators manual. Proper filing up of the form provided for, must be made.

All authorized equipment users should know the basic limitations and

precaution in handling every machine.

All authorized equipment users must familiarize themselves with the

mechanical, physical, and electrical safety features of each machine.

Strictly follow manufactures instruction for installing / operating all

equipment and instruments:

Only those personnel who properly trained can operate the machine.

Use only the prescribed input voltage of the equipment / instrument.

Never remove ground plug.

Never operate the instruments with their cover off.

Do not attempt to make repairs or adjustments to the circuitry.

Storage temperatures should be followed.

Do not install any unspecified parts.

Adequate clearance and ventilation should be provided as well as vibration

free surfaces.

Connection to main pumps with large pumps, compressors or refrigeration

should be avoided.

To enhance trouble free operation of all equipment, it is imperative to follow

the maintenance schedule outline for individual equipment.

5. Equality and Diversity

5.1 The Camiguin General Hospital is committed to an environment that

promotes equality and embraces diversity both within our workplace and in

service delivery. This policy (procedure/ guideline) should be implemented

with due regard to this commitment .

6. Review

6.1 This document will be review by safety & waste Management Committee

every two years.


POLICY ON PREVENTIVEMAINTENANCE ON EQUIPMENT


HPTLY-MER-P01-5

REVISION DATE

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Perform maintenance procedure either on a time schedule or on an

instrument cycle schedule.

Keep a calendar marked with dates for maintenance and calibration

schedule.

Keep a logbook of visits of technician or engineers for quick reference.

Service reports on all equipment should be field and documented.

Prior to running temperature controlled assays, and periodically while

running temperature controlled assays, monitor the temperature on the

display ( Block and Cell temperature for chemistry analyzers ) to assure that

37c is being properly maintained.

Periodically check the calibration and linearity of the instrument against

standard reference.

Appropriate control should be run with each assay or indicated in the

package inserts to check the performance of the equipment.

Clearing should be done when necessary.

Read instrument instruction manuals before performing testing.

Keep them handy as reference.

Excessive humidity should be avoided and storage condition must be

followed.

Do not place, eat or drink foods and liquids near instrument / equipment to

avoid accidental spillage.

Do not smoke or allow sparks, flames or other sources of ignition around fuel

or batteries. Fuel vapor are explosives.

Judicious use of AVR and USP for all machines.



HPTLY-MER-P01-5

REVISION DATE

PAGE No.POLICY ON PREVENTIVE

MAINTENANCE ON EQUIPMENT


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To train a pool of medical equipment technician who will be responsible to do

the corrective maintenance of hospital equipment.

CONTINGENCY PLAN ON EQUIPMENT BREAKDOWN

Do not continue to operate malfunction equipment to avoid further damage

to the equipment.

Back up equipment should always be available in case of machine

malfunction.

Manual technical procedures and reagents must be available in case the

automated bogs down.

Inform the Supervisors immediately to facilitate arrangements with the

technicians.

If the appropriate trouble shooting procedures do not correct the observed

errors, contact the authorized technician or the local distributor of the

equipment.

CAMIGUIN GENERAL

HOSPITAL

POLICY ON CORRECTIVEMAINTENANCE EQUIPMENT


HPTLY-MER-P01-5

REVISION DATE

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CAMIGUIN GENERAL HOSPITAL

Maintenance Section

EQUIPMENT MANAGEMENT PLAN

1. JOEL CUTAB Medical Equipment Technician

- Electrician II

Scope of Work

a. Maintain all Medical Equipment

b. Maintain all Electrical works at Hospital

2. ANACLITO INFATE - Air Condition Technician I

Scope of Work

a. Maintenance all air condition unit at Hospital

b. Quarterly cleaning of air condition

CAMIGUIN GENERAL

HOSPITAL

POLICY ON EQUIPMENTMANAGEMENT PLAN


HPTLY-MER-P01-5

REVISION DATE

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1. Infection Control Doctor / Infection Disease Specialist

2. Infection Control Nurse

3. Microbiologist

The Infection Control Team;

The Infection Control Team shall be responsible for the day to day infection

control activities.

There shall be least 1 full time infection Control Nurse(ICN) who is registered

nurse who has been trained or is receiving training in infection control provided by

an accredited training organization like PHICS, PHICNA, PSMID. The ICN coordinates

with the ICP as well as with other senior hospital staff.

There shall be sufficient number of trained ICNs to facilitate and ensure the

effective implementation of infection control program in the health c

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