Guide to JCAHO Environment of Care Standard 3.10.5
© 2005
Joint Commission on Accreditation of Healthcare Organizations.
Any use of any or all of the Joint Commission standards
and elements of performance beyond this particular tool
is strictly forbidden without the written permission
of the Joint Commission. Citations from JCAHO standards are ©2005 Joint Commission on Accreditation of Healthcare Organizations. Any use of any or all of the Joint Commission standards and elements of performance beyond this particular tool is strictly forbidden without the written permission of the Joint Commission. These pages do not reflect any changes in the standards made after 2005. |
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Introduction Table of Contents Checklist for 3.10.5
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Environment of Care Standard 3.10: The organization manages hazardous materials and waste risks Element of Performance 5. Hazardous Gas and Vapor Management The organization monitors and disposes of hazardous gases and vapors. |
This page provides a set of criteria for evaluating a facility's system for tracking and disposing of hazardous gases and vapors
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Hazardous Materials Management
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Hazardous gases
are inventoried throughout facility including:
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Use of hazardous gases and materials that emit hazardous vapors is eliminated to the extent possible. | |||
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Hazardous gas tanks are managed appropriately. | |||
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All waste anesthetic gases are scavenged using active scavenging methods such as a dedicated vacuum line. | |||
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Management and exposure control plans implemented for all hazardous gases and vapors in facility. | |||
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Documentation of monitoring program for employees exposed to hazardous gases and vapors is maintained. | |||
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Employees are trained
and competency tested regarding hazardous gas and vapors
use and disposal, if necessary.
(Emergency: EC3.10.6, 29 CFR 1910.1200). |
| Ethylene oxide | ||||
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A management plan describes actions in the event of an accidental release of ethylene oxide. | |||
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Ethylene oxide sterilizer has valid operating permit if required. | |||
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Emission controls for ethylene oxide sterilizers are in place and well maintained. | |||
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Wherever
employee exposure to ethylene oxide may exceed 1 ppm
(8 hour time weighted average) or 5 ppm (15 minute
average), exposure levels must be monitored periodically,
or testing must indicate exposure is consistently below
those levels.
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Ethylene oxide is replaced with safer alternative sterile processing technology such as hydrogen peroxide plasma or ozone. | |||
| Formaldehyde, glutaraldehyde | ||||
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Employee
exposure to formaldehyde is monitored in all appropriate
areas, or statistically representative tests establish
that employee exposure is consistently below 0.5 ppm,
time weighted average.
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Formalin use is minimized to the extent possible. | |||
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Formalin is recycled. | |||
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Glutaraldehyde is replaced with a less hazardous high-level disinfectant such as ortho-pthalaldehyde (e.g. Cidex OPA) | |||
| Xylene and other solvents | ||||
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Xylene use is limited to the extent possible and/or terpene-based clearing agents are used. | |||
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Solvents are recycled. | |||
| Other air contaminants | ||||
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Use of aerosols, e.g. room deodorizers, cleaners, hand sanitizers is reduced or eliminated. (Rationale: aerosols add hazardous chemicals to breathing zone potentially diminishing patient safety. Waste aerosols may be considered hazardous waste increasing management and disposal costs.) | |||
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