Safety Manual PDF

SATYAMEV HOSPITAL
Opp. CHANDKHEDA GAM BRTS STOP,

CHANDKHEDA, Ahmedabad – 382424 Gujarat, India
ISSUE DATE:
Version No.: 01
Prepared by: NABH Coordinator
Approved by: CEO
Copy Type: Controlled
Publication, reproduction, photocopying, storage, or transmission electronically or otherwise

of all or any part of these documents without the prior written permission from BAPS
YOUGIJI MAHARAJ HOSPITAL, Ahmedabad, India is strictly prohibited. It is illegal to
make copies of all or any part of these documents (whether internally or externally) without
the prior written permission of the owner of the document. For permission regarding the use
of all or any part of the documents, contact BAPS YOUGIJI MAHARAJ HOSPITAL,
Ahmedabad, India
REFERENCE NO. NABH/ FMS / SAFTY / 01
AUTHOR RESPONSIBLE: Sign and Date

NABH Coordinator
REVIEW By NABH Coordinator

Sign and Date
Effective Date Of Manual 01/09/2018
NEXT REVIEW DATE 01/03/2019
Approved by: C E O Sign and Date
Distribution List
Authorized holders of the Controlled copy of Quality Manual
CONTROLLED COPY NO CONTROLLED COPY HOLDER

01 CEO
02 NABH Coordinator
03 MANAGER OPERATION
04 SAFTY OFFICER
04 NURSING ADMINISTRATOR
05 (MASTER COPY ) NABH Coordinator
SATYAMEV Hospital
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Reference NABH standard (4th edition) FMS - 01
Amendment Record Sheet
Sr. Page Clause Date of Amendment Reasons Sign of QM

No No no Amendment Made Of
Amendment
1
2
3
4
5
6
7
8
9
10
Issued By Reviewed By Approved by

NABH Coordinator NABH Coordinator Chief Executive Officer
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TABLE OF CONTENTS
Sr. No. Index Pg. No.

1 Amendment Sheets I & II
2 Policy Statement
3 Emergency Codes
4 Organization for safe working environment
5 Components of Hospital Safety Programme
 Emergency Preparedness, safety aspects & Disaster
Management
 Laboratory Safety
 Radiation Safety
 Occupational health and safety
6 Statutory compliance
7 Steps involved in implementation of hospital safety program are 16

documented
8 Occupational Health Risks in Hospital 20
9 Hazard Identification and Risk Analysis 20

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POLICY STATEMENT:
Our Hospital is committed to safeguarding the health, safety and welfare at work of all its staff,
patients and visitors. We consider safety an essential component of all activities within the
hospital The Hospital safety committee is responsible for ratifying .and implementing policy on
safety matters. The policy will be continually reviewed and developed as we strive for
progressively higher standards of health and safety in the Hospital. .
Although we the hospital and safety committee is ultimately responsible for safety within the
Hospital, it is the responsibility of all staff, patients and visitors to play their own part in the
maintenance of our standards and to act in a responsible manner within the hospital. It is also
expected that anyone with a supervisory role takes on some of the responsibilities of employer
in relation to safety of those in their charge. All who work within the Hospital are encouraged to
have input into safety policy by raising issues with their supervisors or any of the Safety
Committee representative.
In the event of an emergency in the hospital, and when there is a need to make a public
announcement or raise an immediate alert, the staff will dial the telephone operator and
inform the nature of the emergency:
In the event of an emergency in the hospital, and when there is a need to make a public
announcement or raise an immediate alert, the staff will dial the telephone operator and
inform the nature of the emergency:

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Emergency codes are as follows:
EMERGENCY CODES RESPONSE
Name of
Situation To be Contacted Message
Codes
Safety officer, Disaster
management team, Deputy CODE RED - Fire detected at
Code Red Fire Medical Administration, "<Location>". Please activate
Manager Operation and Emergency Response Team
Matron.
Cardiac CODE BLUE at "<Location>".

Code Blue Code Blue / CPR Team
Arrest RESPOND IMMEDIATELY
CMO on duty, CEO Deputy-

Medical Administration, Safety
External Committee chairperson, CODE YELLOW - Activate
Code Yellow
Disaster Assistant Nursing In charge, Central Command center
Manager Administration, Driver
on duty.
CODE BLUE
Cardiac Pulmonary Resuscitation

Policy
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Staff on duty would announce "CODE BLUE", along with the location of the code (which floor)
to telephone operator by Dial 111.This should be announced three times in rapid succession
by telephonic operator & same shall be intimate to Code Blue team.
The following personnel will respond:

CPR Team With crash Cart, Defibrillator & Oxygen
All the nursing staff will be trained in BLS; hence available staff on duty will lead the
resuscitation until the CPR team arrives.
Procedure
Call "CODE BLUE" as indicated earlier and proceed as follows:

• Begin CPR by the available CPR team members in wards with crash cart.
• CPR team on location shall take over when they arrive in the room.
Cardiopulmonary Resuscitation Emergency Procedure
Look for vital signs
• No spontaneous respiration
• No carotid or femoral pulses
• Dilated pupils
• OPEN AIRWAY (tilt head with back), INFLATE LUNGS QUICKLY with two breaths
(mouth-to-mouth breathing or Ambu bag).
• Remove foreign bodies in the upper airway, if necessary.
• Insert airway.
• SOMEONE HELP (call out or send someone for help).
• STAY WITH THE PATIENT!
• Available member of emergency team will start with CPR steps

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• "CODE BLUE" will be called over the intercom by the staff on duty.
• BEGIN EXTERNAL CARDIAC MASSAGE.
• Place patient on flat surface.
• Kneel by the patient's chest and bare the chest.
• Place heel (not palm) of one hand on the lower half of the sternum, while applying
pressure with the other hand on top of the first hand.
• Use only one hand for children and two fingers for babies.
• With hands, thrust vertically downward, displacing the sternum 1 1/2 to 2 inches, at a
rate of 80 thrusts per minute.
• Massage faster and with less force for children and babies.
• Release pressure rapidly and completely between thrusts; however, DO NOT raise hand
off the sternum. Let your back and body weight do the work.
• Check effectiveness of carotid or femoral pulsation with cardiac massage by observing
less constricted pupils, improved body color, etc.
• GIVE MOUTH-TO-MOUTH BREATHING
• Hyperextend neck, pinch patient’s nose, takes a deep breath and place your mouth over
the patient's mouth making a tight seal. Blow air into victim.
• For small children or babies, place your mouth over victim's mouth AND nose.
• Inflate lungs until chest expands. Proceed at a rate of once every 5 seconds or 12 per
minute.
• For infants, once every 3 seconds or 20 per minute.
Cardiopulmonary Resuscitation
• For adults utilize 30 chest compressions at a rate of 100per minute to 2 lung inflations
• For infants, use a 5:1 ratio with 100-120 compressions per minute.
Dual Cardiopulmonary Resuscitation
• For adults, utilize 1: 5 ratios of compressions to inflations. One person administering the
chest massage while the other person inflate the lungs after each fifth compression.
Switching positions is recommended as personnel get tired.

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NEVER STOP CPR FOR MORE THAN 5 SECONDS DURING AN ARREST!
(Refer YMH/COP/04 Policy on Cardio Pulmonary Resuscitation
 CODE RED - FIRE
Fire - Emergency Response Plan

a) Minor Fire
The on duty staff of respective department has to (Dial: 222) to telephone operator.
Telephone Operator to announced code red on intercom by which the indication/information
of fire reaches.
 Inform Safety officer, CEO, Deputy Medical Administration, Manager Operation, ANA.,
 Security Staff has to reached with available fire extinguisher to location.
The individual discovering the fire will take the following actions:
 Dial 222 to inform telephone operator and give his / her name, department, exact
location of fire.
Start immediate action to fight the fire (without panic) & with the assistance of colleagues in
the close vicinity. ‘PICK UP FIRE EXTINGUISHERS FROM THE CLOSEST FIRE POINT’.
 Safety officer and fire officer will immediately.

 Security supervisor or all security on duty will immediately reach the location
 Inform to CEO, Deputy Medical Administrator, Manager Operation and Fire brigade after
confirmation by safety officer.
 Fire officer and Security staff will fight the fire with the assistance of others in the vicinity,
including members available on the floor till fire brigades arrival.
PROCEDURE TO BE FOLLOWED DURING FIRE EMERGENCY:

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The following procedures are observed to prevent / minimize the effects of Fire Accidents in the
hospital:
• In the event of a fire, or smoke, quick action is imperative. The code word for the event
is “CODE RED”; the same is passed on mobile so that the safety officer, authorities and
security staff in the hospital can be informed about the fire without creating any panic
among patients etc.
• The R.A.C.E. Procedure is followed:

RESCUE: Remove patients or others from immediate danger without panic.
ALARM: Break open Alarm system that are placed in different locations of the hospital which
can be activated at the time of fire by breaking the glass panel. The alarm will be indicated in
the fire indication panel placed in the in-house telephone exchange where the floor in which the
alarm has been activated will be indicated. In case any facilities is not available or not working
than immediately informed authority of department.
CONTAIN
Contain the fire by closing doors and windows.
EXTINGUISH/EVACUATE
Extinguish fire if possible. Use correct extinguisher for the type of fire. Evacuate all persons to
a safe area, if necessary. Follow directions of Safety Officer or code red team
Fire plan is placed in every floor which indicates the exact location of the fire exits and fire
extinguishers hence in case of any fire accidents; the nearest fire exit in the floors can be
easily traced.
The procedure for use of any fire extinguisher is:

1. Pull Pin (from handles)
2. Aim at base of fire
3. Squeeze handles
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4. Sweep nozzle or hose from side to side.

Types of fires and extinguishers:
There are different categories of fire
A. Ordinary combustibles (paper, cloth, mattress, etc.)
B. Flammable liquids (alcohol, grease, etc)
C. Electrical short circuit at any place (motors, computers, etc)
Fire extinguishers of the type ABC which can be used for controlling all types of fire are placed
in different parts of the hospital.
In case of small fire which cannot be extinguished with the help of fire extinguishers the
telephone operator immediately notifies the Fire Fighting Department for help. Incase of large
fire it should be immediately conveyed to fire brigade without waiting.
Fire Safety Training and Drills:
Fire Safety Training and Fire drills are held at periodic intervals .All employees are provided
adequate fire training, they are informed about the fire evacuation procedures including fire
exits located in their work places.
The following special precautions are also undertaken:

Exits:
No obstructions may be placed in front of or upon any exit door. No exit access, or stairway
may be obstructed with furniture or other obstructions so as to reduce the required width of the
exit.
Railings, Steps and Walks:

The area immediately outside of building exits will be maintained free of material at all times.
Vehicles are not permitted on sidewalks immediately adjacent to an exit.
Duties of Staff Involved In Fire

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Person Discovering the Fire
 Dial telephone operator by No. 222 and gives his/her name, department, exact location
of fire & try to fight fire without panic with the assistance of colleagues in the close
vicinity.
 Pick up fire extinguishers from the nearest fire point.
Safety Officer:
• Immediately inform fire brigade & rush to the location.
• As per instruction of safety officer informed the code red team
• . Inform CEO/Deputy Medical Administrator about the fire situation
Hospital Staff on Duty:

 Concerned authorities will immediately assist in beating the fire.
 Rest of the members will immediately rush to location of fire once they receive a
message.
 Pick up fire extinguishers from the nearest fire point.
 Fight the fire.
 Assist fire officer in any other task assigned to them.
Assistant Nursing In charge on duty:

 Suppress panic & supervise the on duty staff to fight fire effectively.
 Control off or isolate power, gas or machines as required (Electrician).
 Under guidance of Deputy Med admin, will instruct evacuation of patients/staff, if
required.
Security Staff on duty:

 To take part in fighting the fire with fire extinguisher.
 Keep fire officer informed about the situation.
 Suppress panic and active member of fire-fighting team to fight the fire effectively.
 Clear parking areas of all vehicles to facilitate easy movement for fire fighters vehicle.
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 Arrange to remove trapped person from the place of fire.

 Provide all assistance in the evacuation operation to help customers to reach
designated assembly area.
 Depute / deploy security staff to prohibit unauthorized persons entry into the hospital.
 Prevent pilferage & guard all floors to prevent thefts of customer’s Baggage & hospital
property.
 Keep attendance details for the hospital staff on duty. This will be required to take a roll
call of the employees at safe assembly point.
 Guide Fire brigade vehicle near to location of fire.
Maintenance Services (Electrical & Water):

 Switch off power to the affective area.
 Cut off A/C supply.
 Maintenance department will ensure water availability to the concerned floor
 Take part in fighting the fire.
 All AHU’S, fresh air units, exhaust fans should be switched off immediately.
 Shut off main LPG line.
 Other/ rest of electrical staff should reach the site of fire with fire fighting equipment &
tools.
 Switch off electricity in affected area, Activate generator if need arise.
 Coordinate with Fire Brigade Authority, Ahmadabad to effectively fight the fire.
 Ensure water & emergency power is in ready state to cater for emergency.
 On receiving the directions for evacuation, telephone operator will inform everyone in
Gujarati, Hindi & English.
Information Counter:
 Keep visitors or attendants calm and answer queries.
 Do not create panic.
 Information regarding patients, staffs, visitors, security, fire brigade team, any morbidity
or mortality. Press conference or Talk with Media or Police Department will be done by
Deputy Medical Administrator
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 Responsibility: In charge Front Office , Front office administrative Officer,


Administrative Activities: To be done by Front office executive and manager operation.
 Take a list of staff on duty for roll call.(Class 4 – Housekeeping Supervisor’s Office and
for other staff from respective department locations)
 Be present in the safe area for roll call.
 Keep CEO/Deputy Medical Administrator informed about the progress of evacuation and
details of missing employees.
Nursing:
 Assist in the evacuation of patients.
 Wake-up patients and attendants and ensure that the rooms are vacated. This has to be
done carefully.
 Direct patients or attendants to the safe area.
 Provide first aid to the staff, patients, attendants gathered in safe area if required.
Other Staff Members

 Keep away unauthorized persons from entering areas.
 Do not spread panic but suppress it.
 Reach the safe area via shortest possible route using fire escape
Duties of all other staff:

 All others staff not specifically asked should report to CEO/Deputy Medical administrator
for any assignment he may wish to delegate.
Doctors:
 Attend to employees / customers with injuries and provide First aid, if required.
Make arrangements for Medical Ambulance if required.
CODE YELLOW – EXTERNAL DISASTER

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Purpose -The Hospital provides a policy for disaster planning for external disaster and plan for
that. The Emergency Department of hospital will take care of the Disaster. External disasters
are like earthquake, flood, riots, and major accidents & like chemical disaster, major
Earthquake Response Procedure
General:
The actual movement of the ground in an earthquake is seldom the direct cause of death or
injury. Most casualties result from falling objects and debris because the shocks can shake,
damage or demolish buildings and generate huge ocean waves (seismic sea waves), each of
which can cause great damage. Earthquakes usually strike without warning. In most cases
the shock occurs and ends in seconds, which precludes any personal protective action during
the tremor. If the seismic action is a prolonged shaking and rolling, it is sometimes prudent to
take protective measures. These might include taking cover in a doorway or under a table. In
any event, if you have time, cover your head and shoulders and try to protect yourself from
Falling objects or shattered glass. The scope of this procedure covers response to all types of
earthquakes.
Injuries are commonly caused by:

 Partial building collapse, collapsing walls, falling ceiling plaster, light fixtures and
pictures
 Flying glass from broken windows and mirrors
 Overturned bookcases, fixtures and other furniture and appliances
 Fires, broken gas lines and similar causes; the danger may be aggravated by the lack of
water due to broken mains.
 Fallen power lines
 Drastic human actions resulting from panic
Immediate Response Measures - All Personnel:

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 Upon detection of shock - remain in place.

 Remain calm. Think through the consequences of any action you take. Try to calm and
reassure others.
 If indoors, watch for falling plaster, light fixtures and other objects. Watch out for high
storage areas, shelves and tall equipment, which might slide or topple. Stay away from
windows and mirrors. If in danger, get under a table, desk, or in a corner away from
windows; or in a strong doorway. Encourage others to follow your example. Usually it is
best not to run outdoors.
 After the initial shock has ended, and a reasonable interval has passed with no further
shock, survey immediate surroundings to determine injuries and damage.
 Do not attempt to move seriously injured persons unless they are in immediate danger
of further injury.
 If telephones are operating, call the switchboard for the head of department and report
condition of patients and estimated damage in your area.
 If you are in a patient care area and are not seriously injured, your first responsibility is
to the patients in the vicinity. If possible, reassure them and attempt to calm those who
may be hysterical or panic stricken. If there are obvious injuries from falling objects,
shattered glass or if patients or personnel are trapped under debris, you must request
assistance and perform first aid within your capability where possible until additional
medical personnel arrive to assist in treatment or rescue.
 Check for fire or fire hazards from broken electrical lines or short circuits and follow the
Fire Response Procedure if a fire is discovered or reasonably expected.
 Do not attempt to lead or assist any patients to leave the facility until you are directed to
do so by the Manager/designee. If the facility has not been rendered untenable by the
earthquake, it is advisable to keep the patients inside.
 Make sure all ambulatory patients wear shoes in areas near debris and glass.
 Immediately clean up spilled medications, drugs and other potentially harmful materials.
 Check to see that sewage lines are intact before permitting continued flushing of toilets.
 Check closets and storage shelve areas. Open closet and cupboard doors carefully and
watch for objects falling from shelves.

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 Be prepared for additional "aftershocks". Although most of these are smaller than the
main shock, some may be large enough to cause additional damage.
Responsibilities:
 After receiving damage assessment reports from all departments, determine the
advisability of partial or complete evacuation of the facility.
 If evacuation is deemed advisable, determine condition of exit areas and avoid those
that are obstructed or otherwise hazardous.
 Conduct an immediate check of all communications systems including the telephones.
 Direct implementation of evacuation procedures as per the instruction of safety officer.
 Ensure that all local emergency service authorities are informed of the degree of
damage and extent of injuries sustained by the facility, its patients and personnel.
Riot or Civil Disturbance Response Plan

A civil disorder may escalate a minor disturbance to a major riot, through the actions of one or
a group of individuals who are well organized. The first ingredient is a ‘cause’ or reason for
upsetting the normal routine or committing aggressive action against the healthcare facility, its
personnel or one or more of its patients.
A healthcare facility is particularly susceptible to incursions by malcontents or individuals with a

"cause," because of its lack of security and open admissibility to the public. An individual
determined to enter the healthcare facility to start trouble will pay no attention to signs
restricting entrance, such as "RESTRICTED ENTRY," and other similarly restrictive notices. In
fact, such an individual will probably go to the rear or side entrance where he/she is not likely to
be observed and probably won't be challenged if he/she is seen entering the building.
General:
 As soon as it is determined or suspected that a person with no official business or
medically-related reason for being in the facility is, in fact, circulating within the
premises, he/she shall be challenged, preferably by an official of the facility and
escorted out of the building as discreetly as possible, on the basis that he/she has no

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reason for being in any part of the facility except the reception area, and that it is a
private institution. If he/she objects, the facility official shall notify the police department,
and the challenged individual shall be allowed to speak to the police department on the
telephone. In most cases, the person will not avail himself/herself of the opportunity, but
the facility will have protected itself from any charges of unfair treatment or
discrimination.
 When it has been determined that a group of individuals are in the facility on other than
official or medically-related business, all entrances shall be secured and, where
possible, the group shall be isolated, by activating the fire doors, and prevented from
circulating through the rest of the facility. The police shall be summoned by the
Concerned HODs/ Supervisors or designee who shall brief the police over the
telephone.

Responsibilities - Potentially Violent Situation:
Security:
Maintain contact with the police and fire departments.
 Familiarize personnel with the procedures used by the police department for handling
unrest, civil disorders or riots. Since security personnel are often the first contact with
participants in any type of civil disturbance, it is most important that they correctly
estimate the situation and avoid aggravation of the existing situation. These personnel
will be the first and most reliable sources of information needed by the police to properly
respond to a potentially violent situation. Information regarding the circumstances
surrounding the situation of unrest shall help facility officials in dealing with the group or
individual ringleader in the early stages of the controversy. In the case of an organized
group attempting to reach a patient or a member of the facility staff with intent to harm,
the Safety Officer's only recourse is to prevent entry to the area where the target
individual is located.

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 Be prepared to call the police if a trouble situation appears to be developing. If there is

any doubt, it is better to inform them too early rather than too late, as the situation can
often be resolved before violence occurs.
 All non-public entrances to the facility shall be posted with restrictive notices to establish
legal basis for possible subsequent recourse measures against illegal entrants.
 Special precautions shall be taken to protect the manifold room oxygen storage area; a
supply of auxiliary cylinders shall be maintained in the facility as back-up to the main
storage and supply source and for use in an emergency situation. The generator shall
also be guarded against actions by intruders.
Disruption of Services: Electric
Policy:
To make necessary arrangements in case of disrupted power supply
Procedure
 The hospital is having semi automated diesel operated generator set which is sufficient
to supply power to whole hospital working as soon as the commercial supply is
interrupted.
 Generator operator will be informed immediately to start generator.
 In case of failure of the generator set the staff on duty will shift to the alternative supply
of electricity (UPS).
 The electrician will determine how long the service will be out.
 Notify all departments and tell personnel that service will be out and approximately how
long.
After electric service is restored, check for proper operation: (to be done by wireman
along with biomedical engineer)
• Ventilating Systems.
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• Electrical Equipments – Generator etc.

• Air Conditioning.
• Vacuum Pumps, etc.
• Elevators
• Notify all departments when service has been restored.
Disruption of Services: Medical Gas
Policy:
To define the steps this shall be taken in the event of a medical gas system failure.
Hospital has medical gas supply in Wards, ICU & OT pipe line supplies Oxygen, Nitrous oxide
and Suction.
Procedure:
For Oxygen Supply failure:
 Use Extreme Caution! The risk and severity of a fire are much greater in an oxygen rich
environment.
 Absolutely no smoking or open flames. Try to avoid making sparks.
 If the problem is a leak, shutoff supply to the affected zone using the appropriate shutoff
valve.
 Notify the affected area first and receive permission from medical personnel before
shutting off supply.
 If oxygen supply is not working and the problem cannot be corrected immediately, notify
the affected areas and deliver portable cylinders. If necessary, order emergency
delivery of additional cylinders until the system can be repaired.
 Call and request emergency delivery of oxygen, as needed.
 Make necessary repairs. Request outside assistance if necessary.
Disruption of Service: Compressed Air
Definition

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A central system for delivery of compressed air and vacuum to area of use through pipe
Procedure
 Call Bio Medical Engineer
 The Bio Medical Engineer will respond to failures in the compressed air.
 If there is a failure of a vacuum pump or air compressor: Shut off faulty pump or
compressor.
 To be advised for use of electrically operated suction if necessary
Disruption of Service: Failure of Elevators
Policy:
To define the responsibilities and actions to be taken during the failure of an elevator to
function properly
Procedure:
 Electrician / wireman shall be responsible for responding to any call concerning elevator
malfunction, electrical department is to be informed for repairing.
 Wireman shall place the malfunctioning elevator out of service on the ground floor and
identify it as out of service. Call for repairs as above. Notice is to be placed every floor
to use of another lift.
 Security and Wireman shall be responsible for freeing trapped patients, passengers,
employee, liftman from stuck elevators.
 Establish communication with lift mechanic/engineer if not already done.
 Gain access, enter the elevator and attempt to clear the problem.
 Operate elevator to the next lowest floor and allow passengers to exit.
 Place elevator out of service and call appropriate service contractor.
Failure of Operating Room Air Conditioning

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Policy:
Action to be taken in the event of failure of operating room air conditioning system
Procedure:
• If a unit fails for any reason, such as faulty motor, dirty filters, grounded compressor,
frozen unit, etc., the AC contractor is to be notified to determine the ability of the staff to
make appropriate.
• If AC fail in between operation then the operation is to be finished or with the help of
fans or otherwise postponed till repair has done.
SECTION – B
SAFETY ASPECTS
Clinical Storage Guidelines
Purpose
To establish guidelines for clinical storage.
Policy
Hospital staff shall use the following procedures for the safe storage of equipment, supplies
and medications.
Specific Information:
Supplies/Equipment
• Store all supplies at least 18 inches below the ceiling.

• Store all equipment and supplies at least 6 inches off the floor.
• Store items containing liquid below other supplies.
• Store only cleaning supplies under sink. (If pediatric area, secure cabinet with lock.)
• Place linens in a covered cart with a solid bottom or a cabinet.
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• Store appropriate personal protective equipment (PPE) such as, gloves, gowns,
eyewear, masks, goggles, gumboot, heavy duty gloves and face shields at the work site.
• Keep all corridors free and unobstructed by equipment, furniture, and storage.
• For temporary placement, items with wheels are permissible in corridors (e.g., crash
carts, wheelchairs). Items are all on one side of the corridor and cannot block fire
prevention equipment, electrical panels, and/or exit doors.
Sharps Container
• Place Sharps containers in an easily accessible area out of children's reach.

• Close and lock Sharps containers when contents reach the fill line and place in a
separate area.
• Secure Sharps containers in a manner to avoid spillage.
Medications
• Store medications in a clean dry area.

• Store all medications (including sample medicines), sharps, and prescription pads in a
locked area away from patient view.
• Separate internal medications from external medications.
• Double lock controlled of narcotics medications.
Radiology Equipment/Supplies
• Store x-ray films in a clean, dry area.

• Hang lead aprons and gloves crease free on rack.
• Store sandbags off floor.
Medical Records:
• Store medical records including medico legal case in a location not easily accessible to
patients/visitors.

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Damaged or Leaking Cylinder
• If the cylinder is in a designated gas storage room, do not enter the room. Many
compressed gases are simple asphyxiates. If a cylinder is leaking, the storage room
may have insufficient oxygen.
• Notify the Medical Stores & Biomedical Engineer as soon as possible.
Electrical Equipment
Purpose
To establish guidelines concerning electrical equipment used within SAL
Policy
Electrical equipment used within BAPS YOGIJI MAHARAJ HOSPITAL for direct patient care
will be tested prior to initial use and at scheduled intervals as determined by the Biomedical
Engineer. Equipment not specifically addressed will be covered under the following Specific
Instructions.
Specific Instructions:
Authorized extension cords are in good repair. These devices are checked for signs of
deterioration and defect at an interval of not less than annually. It is the responsibility of the
department head or designee to perform these checks.
• All electric cords are properly grounded. No more than one extension cord may be used
per piece of equipment.
• Electrical outlets have safety plug covers or safety outlets in the pediatric areas or
waiting areas where children might visit.
• To promote compliance with this policy, the member of hospital safety committee checks
all areas for the unauthorized use of extension cords and adapters.
• There are anti skid shock proof mat used at all electrical panel box for safety of
employee.
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• All electrical panel boxes have closed with insulated wire & open only by authorized
electrician
Staff Personal and department-owned Non-Biomedical Electrical Equipment:
• In general, staff’s personal electrical devices should be discouraged from use in BAPS
YOGIJI MAHARAJ HOSPITAL.
• If there is a question about the safe use of an item, contact electrician / biomedical
engineer.
Specific Information:
Chemical Spill Protocol:
The range and quantity of hazardous substances used in work areas require preplanning to
respond safely to spills
Blood and Body Fluid Spills:
 Blood and body fluid spills must be cleaned up immediately or as soon as possible &
disposed as per bio medical waste management rule.
 Standard precautions must be used when cleaning up spills of blood or body fluids.
 Gloves and other personal protective equipment appropriate for the task must be worn.
Hands must be washed properly after the spill has been cleaned up.
Procedure:
Take into account the following points when cleaning up body fluid spills:
Type of body fluid
Size of spill
Surface type area involved
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Impervious Surfaces
• Wipe the spill up using absorbent paper toweling.
• Wash the area with water and detergent.
• If there is a likelihood of bare skin contact with the surface, the area is disinfected with
sodium hypochlorite solution.
Microorganism Spill:
Procedure:
Biological spills outside biological safety cabinets will generate aerosols that can be dispersed
in the air throughout the laboratory. To reduce the risk of inhalation exposure from spill
occupants should:
 Leave the laboratory immediately.

 The laboratory should not be reentered to decontaminate and cleanup the spill for at
least 30 minutes. During this time the aerosol will be removed from the laboratory by
the exhaust air ventilation system.
 Appropriate protective equipment is particularly important in decontaminating spills.
 This equipment includes:
1. Disposable gloves
2. Particulate mask with safety goggles.
Use of these equipment prevents contact with contaminated surfaces
and protects eyes and mucous membranes from exposure to splattered
materials.
Small Spill Involving a Microorganism:

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Procedure:
o Wear disposable gloves

o Soak paper towels in disinfectant and place over spill area.
o Place towels in plastic bag for disposal.
o Clean spill area with fresh towels soaked in disinfectant.
Major Spill Involving a Microorganism
Procedure:
 Alert people in immediate areas of the spill.

 Wear appropriate protective equipment
 Cover the spill with paper towels or other absorbent materials.
 Carefully pour a freshly prepared sodium hypochlorite solution around the edges of the
spill and into the spill. Avoid splashing. Allow a 20 minute contact period.
 Use paper towels to wipe up the spill, working from the edges into the center.
 Clean spill area with fresh paper towels soaked in disinfectant.
 Place paper towels into a red biohazard bag.
* File an Adverse Event report for any hazardous material-related exposure or injury.
Hazardous Bio Waste Management: Handling and Disposal

(Refer to YMH/HIC Manual)
Radiology safety
(Refer to YMH/AAC/ Radiology Manual)
Laboratory safety
(Refer to YMH/AAC/ Laboratory Manual)
Personal Protective Equipment used in the lab as follows -

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 Mask to reduce splash, splatter etc.

 Goggles/ protective eye wear to protect eyes from particulate matter & flying debris.
 Fluid resistant gown as needed
 Heavy duty heat resistant gloves while handling hot devices.
 All Bunsen burners, torches, flame torches used in the lab should be cleaned, inspected
& stored safely
 Any source of oxygen/gases used in the lab should be shut off at the end of the day
 During periods of extended non use, such as vacation periods, the hoses should be
disconnected & the lids screwed back on the containers
 All gas cylinders should be harnessed securely to avoid tipping over or falling
 As torches, burners, open flame is used in the lab, fire extinguishers should be installed
& the technicians/ staff trained in its proper use.
Standard precaution and Hand washing

(Refer YMH/HIC/ Infection Control Manual)
Needle Stick Injury

(Refer YMH/HIC/ Policy on Needle Stick Injury)
Patient Safety
Policy
All Patient Care Services staff shall use every reasonable precaution to provide a safe
environment.
Specific Information
The precautions listed herein should not be considered to be all inclusive, as safe practice
requires sound judgment in individual situations and constant awareness of the environment
Safety from fall

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 Patients are to be placed in a bed/trolley that has functional side rails.

 The following patients have side rails raised when unattended by staff:
Transportation
 Wheels of stretchers, wheelchairs, scales, and beds are locked when a patient is lifted
from or assisted onto them.
 Side rails are raised on stretchers, when present. Where no side rails exist, safety belts
are fastened.
 The nurse responsible for the patient determines the safest and most reasonable means
of transporting for tests/procedures or transfer to another room or unit.
Patient's Role in Promoting Safe Health Care
Patients are encouraged to become an active, involved, and informed member of their health
care team. Listed below are ways that the patients are to be encouraged to promote their own
safety.
 Patients are instructed to ask if they have questions about their health or safety.
 If the patient is having an operation, the patient is asked to verify prior to the procedure,
the site/side of the body that is to be operated on.
 If the patient's ID band is not checked before medications are given, blood/blood
products are administered; blood samples are obtained or prior to an invasive
procedure, the patient are asked to remind the staff.
 The patient is taught to know what medications they take and why they take them.
 Patients are instructed to adhere to the hospitals No Smoking Policy
 Patients are instructed to follow the ‘patient’s rights & responsibilities.
 Any restarin if required to be done as per policy.
ORGANIZATION OF SAFE WORKING ENVIRONMENT

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Hospital safety committee: Hospital has constituted a safety committee to look after the
safety aspects of the hospital. The committee meets regularly at defined interval to discuss the
matter related to safety and take appropriate decisions to improve the level of safety within the
hospital. Following is the list of Hospital Committee member’s alongwith their scope of work:
Scope of Work:
 Develop and issue policy on patient, staff and visitor safety and security.
 Develop and issue policy on prevention, management and control of emergency
situations within hospital and outside hospital.
 Develop plans for handling fire and non fire emergencies.
 Conduct training on all aspects of safety to hospital employees and maintain a record of
the same.
 Conduct mock drills and maintain record of the same.
 Monitor occupational health and safety of employees.
 Ensure safe water supply and maintain records of regular water checks carried out in
the hospital.
NABH Chapter Ref: FMS – 04, 05, 06, 08
Safety officer: From within the committee a safety officer has been appointed to look after the
day to day safety aspects and .bring the safety issues in committee for deliberation and
decision. Roles and responsibilities of safety officer includes
1. Conduct periodic walkthrough inspection of the facility
2. Identify potential hazards and hazardous material in the hospital
3. Obtain MSDS and other information on potential hazards
4. Maintain a record of hazardous chemicals and materials that are used and stored in
hospital.
5. Identify training needs of staff on safety aspects

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6. Develop training schedule in coordination with HR dept. and begin a training program
for workers, based on respective department’s job responsibilities
7. Bring issues and agenda for discussion and decision to hospital safety committee.
Policy and procedure documents: All policies and procedural documents in the hospital have
safety practices included in it. The work practices has been laid down and standardized by
taking safety aspects as one of the important components. These standardized policies and
procedures are followed by all staff of the hospital and monitored by Departmental in charges /
Chairpersons of various committees, Quality Improvement Committee and hospital
management.
COMPONENTS OF HOSPITAL SAFETY PROGRAMME
The hospital safety programme is focused in to entire hospital, staff, patients and visitors in
general and in specific to .
1. Infection control
2. Emergency preparedness, safety aspects & Disaster Management.
3. Laboratory safety
4. Radiation safety
5. Occupational health and safety
6. Chemicals/hazardous materials
1. Infection control: Infection control is an important component of hospital safety program

and is focused and dealt separately. Hospital infection control committee, Infection control

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team, infection control manual and infection control program are the sub-component of
Infection control safety of the hospital. (Refer: Infection Control Manual – YMH/ICM/05
2. Emergency preparedness, safety aspects & Disaster Management: This component

focuses on fire, non-fire emergencies, emergency codes, employee safety protocols and
external disaster situations. The hospital safety committee caters to emergency & safety
preparedness aspect and the hospital disaster management committee looks after the
development and implementation disaster management manual
(Refer: Disaster Manual –YMH/FMS/DM/07)
3. Laboratory Safety: laboratory safety is looked after by HOD laboratory. Laboratory safety
practices is documented and implemented to ensure safety of employees in laboratory.
Hospital safety committee alongwith Pathologist oversees the laboratory safety practices and
ensures its proper implementation. However, Laboratory Services are outsourced to NABL
Accreditated Lab.
(Refer: Laboratory Documents)
4. Radiation Safety: Radiation safety is looked after by Radiologist. The safety level as
described by AERB is followed. Hospital safety committee alongwith radiologist oversees the
radiation safety practices and ensures its proper implementation.
(Refer: Imaging Services)
5. Occupational health and safety: Hospital has identified Occupational risks within the
hospital and orients all the staff on precautions to be taken from occupational hazards. Hospital
safety committee ensures that occupational health and safety is properly addressed. These
occupational health risks are documented in this document.
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STEPS INVOLVED IN IMPLEMENTATION OF HOSPITAL SAFETY PROGRAMME
Sr. Item Component tasks

No.
1. Administrative  Formulation of hospital safety committee
support  Adherence to committee meeting schedules and time for
surveys
 Funding to evaluate and monitor hazards implement
controls, and conduct health examinations
 Provision of safety devices and personal protective
equipments
 Fulfilling necessary infrastructural requirement to increase
safety within the hospital building
2. Hazard  Conduct periodic walk-through inspections.
identification  Maintain a log of hazardous chemicals and materials that
are used or stored in each department.
3. Hazard evaluation  Conduct safety inspections and hygiene monitoring of
potential hazards and determine needs for hazard controls.
 Conduct medical evaluations where necessary.
 Select appropriate medical surveillance programs.
4. Training  Identify training needs for health and safety
 Develop training schedule and begin a training program for
workers, based on department / job responsibilities.

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5. Program review  Preview results of periodic safety. Inspections to find

patterns of hazards, to measure the success of the safety
and health program, and to determine the effectiveness of
controls.
 Modify the safety and health program as new materials or
procedures are introduced or as new hazards are identified
in the review process.
6. Recordkeeping  Maintain records of results for all surveys, evaluations,
monitoring, corrective actions and medical health check up.
OCCUPATIONAL HEALTH RISKS IN HOSPITAL
The staff working in hospital setting possesses risks of facing many kinds of hazards. It is
important for staff to determine which hazards can affect him/her and what can be done to
prevent illness and injuries.
Following Occupational health risks have been identified as general hazard applicable
throughout the organization. Staff shall keep him / her aware of these health hazards and
follow the recommendation given by hospital, to avoid the occurrence of these hazards.
Sr. Occupational health risks that you Prevention strategies

No. should know
1. Infectious Diseases: Get all your immunization done.
Infectious diseases can be caused by Wash hands frequently (proper hand
coming into contact with bacteria, washing is the best way to prevent

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viruses, fungi or parasites when handling communicable diseases)

patients, contaminated objects, body Follow "Routine Practices" at all times for
secretions, tissue or fluids. all patients.
Hepatitis B, Hepatitis C and Human Follow post needle stick injury protocol
Immunodeficiency Virus (HIV) can be Adhere to standard precautions
spread by infected blood and body fluids
when they come into direct contact with
broken, scraped, chopped or inflamed
skin or when skin is punctured by a sharp
object such as a needle
2. Back injuries Use available lifts
Back injuries are the most frequent injury Get help to lift if mechanical device is not
in hospitals. Heavy lifting and frequent appropriate or not available
bending or twisting when moving objects Use proper lifting technique
or patients increases the risk of back
injury.
3. Repetitive Strain Injuries Organize your work day so repetitive
A repetitive strain injury (RSI) is an injury tasks are done for short periods
that' occurs' over time as a result of throughout the day
repetitive, forceful or awkward body Take regular breaks
movements. The injury usually affects the
wrist, hand, shoulder, elbow, back, knee
or ankle. It can cause pain, weakness,
numbness or difficulty in grasping

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objects.
4. Shift work Ask your doctor's advice before becoming
Changing shifts and working at night a shift worker if you have diabetes,
disrupts your body's natural rhythms. It asthma, epilepsy or mental health
can contribute to digestion problems, problems
heart disease, and sleep problems. It Improve your sleep by practicing a regular
also makes participation in social bedtime ritual and avoid caffeine,
activities and family life difficult. smoking and sleeping pills.
5. Violence Report incidents to your health and safety
Health care workers are at risk from representative and/or committee.
violence when dealing with angry and
stressed patients and their families.
Workplace violence can result in loss of
sleep, fear or depression, post traumatic
stress disorder, and sometimes even
death. It is, therefore, very important for.
workplaces to develop strategies to
prevent violence
6. Radiation Follow procedures and use PPE.
Radiation is used in diagnostic Use TLD badges appropriately and follow
procedures such as x-ray, fluoroscopy recommendation of AERB
and angiography. It is also used in Take all safety concerns to your health
treatments using radioactive material. and safety representative and/or
Other forms of radiation are used in committee.

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microwaves magnetic fields and lasers.

Long term and repeated exposure to
radiation can cause genetic damage and
reproductive health problems. Light
beams from lasers can harm the eyes
and skin.
7. Chemicals Take concerns to your workplace health &
Chemicals found in hospitals can be in safety
the form of dusts, vapors, gases or Representative and/or committee
liquids. A chemical can enter your body in Read labels of all chemicals used and if
three main ways more information is required, go to the
 It can be breathed in MSDS
 it can go through your skin Use PPE
 it can be swallowed
Many chemicals can cause serious
illness and in some cases, death. Often
the effects are not noticeable right away.
Staff shall contact Hospital Safety Committee to seek further information, or recommendation
to include additional health risks in safety program .
HAZARD IDENTIFICATION AND RISK ANALYSIS
Hospital has identified the potentially hazardous materials in the hospital. These materials are
analyzed for their potential risks and measures to minimize the risk and action to take in case
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of emergency has been documented in 'Material Safety Data Sheet' of the hazardous material.
This Material Safety Data Sheet contains vital information regarding safety from these
hazardous materials. The MSDS are pasted at the location where these hazardous materials
are kept.
List of Hazardous Materials
1. Asbestos
2. Acryl amide solution
3. Diesel
4. Propylene LPG
5. Ethylene Oxide
6. Formaldehyde
7. Gluteraldehyde.
8. Mercury
9. Phenol
10. Sodium Hypochlorite
11. Compressed gases
12. Laser
13. Radiation rays
14. Waste Anesthetic gases
15. Latex
16. Cytotoxic agents
The hazardous materials are continually identified and their risk is analyzed. If found to be of
substantial risk it is included in the above list of hazardous material and its Safety instruction is
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Material Safety Data Sheet (MSDS)
MSDS of some of the hazardous material are given below:
Acryl Amide
Synonyms- Acrylic Amide, Ethylene Carboxamide, 2- Propenamide, Propenoic Acid Amide,
Vinyl amide, Propenamide, Acrylamide Monomer
Hazards Identification
 Appearance: White crystalline chunks, Melting point: 84 - 86 C, Boiling point: 125C at
25 mm Hg, Specific gravity: 1.12
 Toxicology and Hazard
Toxic: possible human carcinogen. Possible teratogen. May because heritable
genetic damage, readily absorbed through skin, Inhalation may be fatal, May cause
CNS damage, May cause damage the effects of which become apparent only after a
delay of several months or years, Skin, eye and respiratory irritant, OEL 0.3 mg/m3
 Personal protection
Safety glasses and gloves, Effective ventilation. Handle as a carcinogen
First Aid Measures

Eye Contact: Check for and remove any contact lenses. In case of contact, immediately flush
eyes with plenty of water for at least 15 minutes. Cold water may be used. Get medical
attention.
Skin Contact: In case of contact, immediately flush skin with plenty of water for at least 15
minutes while removing contaminated clothing and shoes. Cover the irritated skin with an
emollient. Cold water may be used. Wash clothing before reuse. Thoroughly clean shoes
before reuse. Get medical attention immediately.
Serious Skin Contact: Wash with a disinfectant soap and cover the contaminated skin
with an anti-bacterial cream. Seek immediate medical attention.
Inhalation: If inhaled, remove to fresh air. If not breathing, give artificial respiration. If breathing
is difficult, give oxygen. Get medical attention.
Serious Inhalation: Evacuate the victim to a safe area as soon as possible. Loosen tight
clothing such as a collar, tie, belt or waistband. If breathing is difficult, administer oxygen. If the
victim is not breathing, perform mouth-to-mouth resuscitation. Seek medical attention.

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Ingestion: If swallowed, do not induce vomiting unless directed to do so by medical personnel.

Never give anything by mouth to an unconscious person. Loosen tight clothing such as a collar,
tie, belt or waistband. Get medical attention immediately.
Accidental Release Measures

Small Spill: Use appropriate tools to put the spilled solid in a convenient waste disposal
container.
Large Spill: Poisonous solid. Stop leak if without risk. Do not get water inside container. Do
not touch spilled material. Use water spray to reduce vapors. Prevent entry into sewers,
basements or confined areas; dike if needed. Eliminate all ignition sources. Call for assistance
on disposal.
. Handling and Storage
Precautions: Keep locked up. Keep away from heat. Keep away from sources of ignition.
Empty containers pose a fire risk, evaporate the residue under a fume hood. Ground all
equipment containing material. Do not ingest. Do not breathe dust. Wear suitable protective
clothing. In case of insufficient ventilation, wear suitable respiratory equipment. If ingested,
seek medical advice immediately and show the container or the label. Avoid contact with skin
and eyes. Keep away from incompatibles such as oxidizing agents, acids, alkalis, moisture.
Storage: Light Sensitive. Store in light-resistant containers, Keep container tightly closed.
Keep container in a cool, well-ventilated area. Do not store above 23°C (73.4°F). Preferably
store in a refrigerator
Formaldehyde
Common
Formalin, paraform, methylene glycol, methyl aldehyde
synonyms
Formula CH2O
Physical Form: normally supplied as a colorless solution in water, (at a strength of

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properties around 37%); becomes cloudy at temperatures lower than 21 C

Stability: Stable
Melting point: depends upon the concentration of the solution; close to 0 C
Boiling point: depends upon the concentration of the solution; a little below 100
C
Specific gravity: around 1.1
Formaldehyde presents a range of hazards to health. It is toxic if you swallow

or inhale it and is also toxic if absorbed through the skin.
Chronic (long-term) exposure to formaldehyde, particularly through inhalation,
Principal is dangerous since there is some possibility that it may act as a carcinogen in
hazards humans. Chronic exposure may also damage the kidneys.
Formaldehyde solutions are corrosive and can cause burns to the skin or eyes
and damage to the upper respiratory tract.
Susceptible people may develop an allergic reaction to formaldehyde.
Safe Wear safety glasses. Good ventilation is essential. Do not work in conditions
handling where you are exposed to high levels of vapor for prolonged periods.
Eye contact: Immediately flush the eye with water and continue for several
minutes. Call for medical help.
Skin contact: Wash off with soap and water. If there are signs of burns or the
Emergency
skin reddens, seek medical help.
If swallowed: Wash out the mouth with water if the person is conscious. Call for
medical help.
Store in a clearly-labeled container for later disposal as liquid waste. Do not

Disposal
pour into sinks.
Protective
Safety glasses, butyl or nitrile rubber gloves.
equipment
Mercury
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Appearance: Silver Liquid.
Danger! Corrosive Harmful if inhaled. May be absorbed through intact skin Causes eye and
skin irritation and possible burns May cause severe respiratory tract irritation, GI irritation, liver
and kidney damage and CNS effect
Target Organs: Blood, kidneys, central nervous system, liver, brain
Potential Health Effects

Eye: May cause discoloration on the front surface of the lens, eye irritation and ulceration of
the conjunctiva and cornea.
Skin: May cause skin sensitization, skin irritation, skin rash and possible burns.
Ingestion: May cause severe and permanent damage to the digestive tract.
Inhalation: Causes chemical burns to the respiratory tract.
Chronic: May cause liver and kidney damage and CNS effect
First Aid Measures
Eyes: Get medical aid immediately. Do NOT allow victim to rub eyes or keep eyes closed.
Extensive irrigation with water is required (at least 30 minutes).
Skin: Get medical aid immediately. Immediately flush skin with plenty of water for at least 15
minutes while removing contaminated clothing and shoes. Wash clothing before reuse. Destroy
contaminated shoes.
Ingestion: Do not induce vomiting. If victim is conscious and alert, give 2-4 cupfuls of milk or
water. Never give anything by mouth to an unconscious person. Get medical aid immediately.
Wash mouth out with water.
Inhalation: Get medical aid immediately. Remove from exposure and move to fresh air
immediately. If breathing is difficult, give oxygen. Do NOT use mouth-to-mouth resuscitation. If
breathing has ceased apply artificial respiration using oxygen and a suitable mechanical device
such as a bag and a mask.
Notes to Physician: The concentration of mercury in whole blood is a reasonable measure of
the body-burden of mercury and thus is used for monitoring purposes. Treat symptomatically
and supportively. Persons with kidney disease, chronic respiratory disease, liver disease, or
skin disease may be at increased risk from exposure to this substance.
Antidote: The use of d-Penicillamine as a chelating agent should be determined by qualified

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medical personnel. The use of Dimercaprol or BAL (British anti-lewisite) as a chelating agent
should be determined by qualified medical personnel.

General Information: Use proper personal protective equipment
Spills/Leaks: Absorb spill with inert material (e.g. vermiculite, sand or earth), then place in
suitable container. Avoid runoff into storm sewers and ditches which lead to waterways. Clean
up spills immediately, observing precautions in the Protective Equipment section. Provide
ventilation.
Handling and Storage
Handling: Wash thoroughly after handling. Remove contaminated clothing and wash before
reuse. Minimize dust generation and accumulation. Keep container tightly closed. Do not get
on skin or in eyes. Do not ingest or inhale. Use only in a chemical fume hood. Discard
contaminated shoes. Do not breathe vapor.
Storage: Keep container closed when not in use. Store in a tightly closed container. Store in a
cool, dry, well-ventilated area away from incompatible substances. Keep away from metals.
Store protected from azides.
Asbestos
Form: fibrous solid which may be white, grey, brown or blueish

Physical
Stability: Stable
properties
Specific gravity: varies, depending upon form
*** Asbestos is a known human carcinogen when inhaled. The different

Principal
varieties pose different levels of hazard, but all are harmful.
hazards
*** Asbestos acts as a severe eye irritant.
There is nowadays almost never a need for asbestos in the laboratory; good
Safe handling
alternatives exist for all the applications to which asbestos used to be put. If

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it is present at all, asbestos will probably be in the form of asbestos cement,

used perhaps as an oven lining.
It is essential that asbestos is not cut, drilled or machined, since these
actions release fibers into the air which are then readily inhaled.
Eye contact: Immediately flush the eye with water. If irritation persists, call
for medical help.
Emergency
Skin contact: Wash off with soap and water.
If inhaled: Call for medical help.
Removal of asbestos must be handled by specialist contractors. If you

Disposal discover asbestos in the laboratory, leave it undisturbed and contact a
suitable waste disposal company qualified to deal with asbestos.
Protective Protective equipment should not be necessary, since you should not be in
equipment contact with asbestos!
Glutaraldehyde Solutions
Appearance: clear, colorless liquid.
Danger! Causes eye and skin burns. Causes digestive and respiratory tract burns. May cause
allergic respiratory and skin reaction, Harmful if swallowed, inhaled, or absorbed through the
skin. Aspiration hazard if swallowed. Can enter lungs and cause damage. Dangerous for the
environment
Target Organs: Central nervous system, lungs, respiratory system, eyes, skin
Potential Health Effects

Eye: Causes eye irritation and burns. May cause permanent visual impairment. Skin: May
cause skin sensitization, hives, skin irritation and burns
Ingestion: Harmful if swallowed. Causes gastrointestinal tract burns.

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Inhalation: Harmful if inhaled. Causes chemical burns to the respiratory tract..
First Aid Measures

Eyes: Immediately flush eyes with plenty of water for at least 15 minutes, occasionally lifting
the upper and lower eyelids. Get medical aid immediately.
Skin: Get medical aid immediately. Immediately flush skin with plenty of water for at least 15
minutes while removing contaminated clothing and shoes. Wash clothing before reuse. Destroy
contaminated shoes.
Ingestion: Do not induce vomiting. Get medical aid immediately. Call a poison control center.
Do not give anything by mouth. Oral toxicity of Glutaraldehyde increases with dilution. Drinking
water following ingestion of concentrated Glutaraldehyde solutions can enhance the toxicity.
Inhalation: Get medical aid immediately. Remove from exposure and move to fresh air
immediately. If breathing is difficult, give oxygen. Do NOT use mouth-to-mouth resuscitation. If
breathing has ceased apply artificial respiration using oxygen and a suitable mechanical device
such as a bag and a mask.
Notes to Physician: Treat symptomatically and supportively.
General Information: Use proper personal protective equipment

Spills/Leaks: Avoid runoff into storm sewers and ditches which lead to waterways. Clean up
spills immediately, observing precautions in the Protective Equipment section. Absorb spill
using an absorbent, non-combustible material such as earth, sand, or vermiculite. Do not use
combustible materials such as sawdust. Provide ventilation.
Handling: Wash thoroughly after handling. Remove contaminated clothing and wash before
reuse. Do not get in eyes, on skin, or on clothing. Use only with adequate ventilation. Avoid
breathing vapor.

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Storage: Keep container closed when not in use. Store in a cool, dry, well-ventilated area
away from incompatible substances, Refrigeration has been recommended.
Ethylene Oxide
General
Synonyms: amprolene, anprolene, anproline, dihydrooxirene, dimethylene oxide, ENT-26263,
EO, epoxyethane, 1,2-epoxyethane, ethene oxide, ethox, merpol, oxane, oxacyclopropane,
oxidoethane,oxiran, oxirane, oxirene, oxyfume, T-gas
Physical data
Appearance: colourless gas, Melting point: -111 C, Boiling point: 10.7 C,
Vapour density: 1.52 g/l, Specific gravity: 0.882, Flash point: -20 C
Explosion limits: no upper limit - burns in its own atmosphere
Autoignition temperature:
Stability
Stable when isolated, but reacts violently with water, bases, oxidizing metals, acids, alcohols,
alkali metals, ammonia, chemically active metals and their salts. Highly flammable. Forms
explosive mixtures with air which may be ignited by rapid compression
Toxicology
Carcinogen, mutagen, reproductive hazard, toxic. Severe irritant. Sensitizer Toxic by inhalation,
ingestion and through skin contact. Moderate levels (0.1% or less) may rapidly be fatal if
inhaled. Typical OEL 1-5 ppm.
Personal protection
Safety glasses, gloves, high quality ventilation. Avoid sparks and any form of ignition.
Phenol
Hazard Identification
May be fatal if inhaled, swallowed or absorbed thru the skin Avoid all contact. Use with
adequate ventilation. Wash thoroughly after use. Keep container closed.
First Aid Measures

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May be fatal if inhaled, swallowed or absorbed thru the skin Avoid all contact. Use with
adequate ventilation. Wash thoroughly after use. Keep container closed.
FIRST AID: CALL A PHYSICIAN.

SKIN: In case of contact, immediately flush skin with water for at least 15 minutes while
removing contaminated clothing and shoes. Thoroughly clean clothing and shoes before reuse.
EYES: Wash eyes with plenty of water for at least 15 minutes, lifting lids occasionally. Seek
Medical Aid. INHALATION: Remove to fresh air. If not breathing, give artificial respiration. If
breathing is difficult, give oxygen
INGESTION: Give several glasses of milk or water. Vomiting may occur spontaneously, but DO
NOT INDUCE! Never give anything by mouth to an unconscious person.
Evacuate area. Wear self-contained breathing apparatus and protective clothing(rubber boots
and heavy rubber gloves). Cover with lime or soda. Keep in closed container and hold for
disposal.
Store in a cool dry well ventilated area. Keep away from heat and flame. Do not get in eyes, on
skin, or on clothing.
Propylene LPG
APPEARANCE: Clear
PHYSICAL STATE: Flammable Liquid and Gas under pressure
ODOR: Natural Gas odor
EMERGENCY OVERVIEW: Flammable liquid and gas under pressure. Can form explosive
mixtures with air. May cause frostbite. Can cause rapid suffocation. May cause dizziness and
drowsiness. Self-contained breathing apparatus may be required by rescue workers.
POTENTIAL HEALTH EFFECTS:

INHALATION: Asphyxiant. Effects are due to lack of oxygen. Moderate concentrations may

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cause headaches, drowsiness, dizziness, excitation, excess salivation, vomiting and

unconsciousness. Lack of oxygen can kill.
EYE CONTACT: Liquid may cause frostbite.
SKIN CONTACT: Liquid may cause frostbite.
INGESTION: Not expected, this product is a gas
First Aid Measures

INHALATION: If inhaled, remove to fresh air. Get medical attention if breathing becomes
difficult or respiratory irritation persists. Give oxygen.
EYE CONTACT: For contact with the liquid, flush immediately with warm water for at least 15
minutes. Seek medical attention.
SKIN CONTACT: For Exposure to liquid, IMMEDIATELY WARM FROSTBITE AREA WITH
WARM WATER. Remove contaminated clothing. Call a physician.
INGESTION:NA

Shut off ignition sources; no flames, smoking or flares in hazard area. Do not touch spilled
material; stop leaks if you can do it without risk. Use water spray to reduce vapors; isolate area
until gas has disappeared. Report spills to appropriate authorities. Dispose of in accordance
with Federal, State and Local regulations.
HANDLING / STORAGE: Ground and bond all transfer and storage equipment. Must be
handled and stored under pressure to maintain liquid form. Use non-sparking tools and
equipment. Avoid ignition sources. Avoid contact with eyes, skin or clothing. Avoid breathing the
vapor.
FIRE FIGHTING MEASURES
FLASH POINT (°F): -162 ºF
AUTOIGNITION TEMPERATURE: 842 ºF
FLAMMABILTY CLASSIFICATION: Flammable Gas
GENERAL HAZARD: Incomplete burning can produce carbon monoxide. Vapors are heavier
than air and may travel considerable distance to source of ignition and flashback. Stay away

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from ends of storage tanks. Prevent runoff from fire control dilution from entering streams or
drinking water supplies. Extremely flammable. Will vaporize violently if depressured. Flame
contact with the storage vessel above the liquid level could result in a Boiling Liquid Expanding
Vapor Explosion
FIRE FIGHTING INSTRUCTIONS: stop flow of gas. For fires involving flammable gases, the
best procedure is to stop the flow of gas before attempting extinguishment of the fire. To
extinguish the fire, while allowing continued flow of gas, is extremely dangerous; an explosive
cloud of gas/air mixture may be created that, if ignited, may cause far more damage than the
original fire. Extinguishing the flame using carbon dioxide or dry chemical may be desirable to
allow immediate access to valves to shut off the flow of gas, but this must be done carefully. In
many cases, it will be preferable to allow continued burning, while protecting exposures with
water spray, until the flow of gas can be stopped.
FIRE FIGHTING EQUIPMENT: HAZARDOUS COMBUSTION PRODUCTS:
Hazardous Decomposition Products: May produce carbon monoxide
Sodium Hypochlorite
EmergencyOverview
WARNING! HARMFUL IF SWALLOWED OR INHALED. CAUSES IRRITATION TO EYES
AND RESPIRATORY TRACT. CAUSES SUBSTANTIAL BUT TEMPORARY EYE INJURY.
PotentialHealthEffects: -
Inhalation: May cause irritation to the respiratory tract, (nose and throat); symptoms may
include coughing and sore throat. Ingestion: May cause nausea, vomiting.
Skin Contact: May irritate skin.
Eye Contact: Contact may cause severe irritation and damage, especially at higher
concentration.
Chronic Exposure: A constant irritant to the eyes and throat. Low potential for sensitization
after exaggerated exposure to damaged skin.
Aggravation of Pre-existing Conditions: Persons with impaired respiratory function, or heart
disorders (or disease) may be more susceptible to the effects of the substance
First Aid Measures

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Inhalation: Remove to fresh air. If not breathing, give artificial respiration. If breathing is
difficult, give oxygen. Get medical attention immediately.
Ingestion: If swallowed, DO NOT INDUCE VOMITING. Give large quantities of water. Never
give anything by mouth to an unconscious person. Get medical attention immediately.
Skin Contact: Immediately flush skin with plenty of water for at least 15 minutes while
removing contaminated clothing and shoes. Get medical attention immediately. Wash clothing
before reuse. Thoroughly clean shoes before reuse.
Eye Contact: Immediately flush eyes with plenty of water for at least 15 minutes, lifting lower
and upper eyelids occasionally. Get medical attention immediately.
Note to Physician: Consider oral administration of sodium thiosulfate solutions if sodium
hypochlorite is ingested. Do not administer neutralizing substances since the resultant
exothermic reaction could further damage tissue. Endotracheal intubation could be needed if
glottic edema compromises the airway. For individuals with significant inhalation exposure,
monitor arterial blood gases and chest x-ray
Ventilate area of leak or spill. Wear appropriate personal protective equipment. Isolate hazard
area. Keep unnecessary and unprotected personnel from entering. Contain and recover liquid
when possible. Collect liquid in an appropriate container or absorb with an inert material (e. g.,
dry sand, earth), and place in a chemical waste container. Do not use combustible materials,
such as saw dust. Do not flush to sewer.
HANDLING / STORAGE: Keep in a tightly closed container, stored in a cool, dry, ventilated
area. Protect against physical damage. Isolate from incompatible substances. Containers of
this material may be hazardous when empty since they retain product residues (vapors, liquid);
observe all warnings and precautions listed for the product

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SATYAMEV HOSPITAL

Opp. CHANDKHEDA GAM BRTS STOP,

Copy Type: Controlled

Publication, reproduction, photocopying, storage, or transmission electronically or otherwise

AUTHOR RESPONSIBLE: Sign and Date

REVIEW By NABH Coordinator

Authorized holders of the Controlled copy of Quality Manual

CONTROLLED COPY NO CONTROLLED COPY HOLDER

Reference NABH standard (4th edition) FMS - 01

Amendment Record Sheet

Sr. Page Clause Date of Amendment Reasons Sign of QM

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Sr. No. Index Pg. No.

7 Steps involved in implementation of hospital safety program are 16

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Emergency codes are as follows:

EMERGENCY CODES RESPONSE

Cardiac CODE BLUE at "<Location>".

CMO on duty, CEO Deputy-

Cardiac Pulmonary Resuscitation

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Reference NABH standard (4th edition) FMS - 01

The following personnel will respond:

Call "CODE BLUE" as indicated earlier and proceed as follows:

Cardiopulmonary Resuscitation Emergency Procedure

Look for vital signs

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NEVER STOP CPR FOR MORE THAN 5 SECONDS DURING AN ARREST!

(Refer YMH/COP/04 Policy on Cardio Pulmonary Resuscitation

 CODE RED - FIRE

Fire - Emergency Response Plan

 Safety officer and fire officer will immediately.

PROCEDURE TO BE FOLLOWED DURING FIRE EMERGENCY:

Issued By Reviewed By Approved by

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Reference NABH standard (4th edition) FMS - 01

• The R.A.C.E. Procedure is followed:

The procedure for use of any fire extinguisher is:

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4. Sweep nozzle or hose from side to side.

Fire Safety Training and Drills:

The following special precautions are also undertaken:

Railings, Steps and Walks:

Duties of Staff Involved In Fire

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Reference NABH standard (4th edition) FMS - 01