Guide to JCAHO Environment of Care Standard 3.10.6
© 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 3.10.6
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Environment of Care Standard 3.10: The organization manages hazardous materials and waste risks Element of Performance 6. Emergency Procedures The organization identifies and implements emergency procedures that include specific precautions, procedures and protective equipment used during hazardous materials and waste spills or exposures. |
This page provides
a set of criteria for evaluating the steps that a facility
takes to prevent emergencies from occurring, and, when they
do occur, to minimize dangers to employees and patients, and
to respond appropriately.
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Hazardous Materials Management
| Emergency prevention and preparedness | ||||||||||||||||
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Organization exhibits a preference for non-hazardous materials use to minimize risk when spills occur. | |||||||||||||||
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Hazardous materials
locations are identified throughout the facility.
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Appropriate protective
and spill control equipment is readily available in areas
where hazardous materials are used. Spill control equipment is maintained
in usable condition.
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Eyewashes and showers
are available, especially for acid and caustic spills
are checked weekly and documented.
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Employee exposure incidents are decreased. (Rationale; facilities that have reduced or eliminated hazardous materials have seen reduced employee exposure incidents and improved occupational health). | |||||||||||||||
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Patient exposure incidents are decreased. (Rationale: minimizing hazardous materials use reduces potential of spills and exposures to patients improving patient safety). | |||||||||||||||
| Spills | ||||||||||||||||
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Spill
clean up residues are managed as hazardous waste.
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Spills
are reported to local authorities and National Response
Center, if necessary.
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Facility is aware of additional requirements, that
may include monitoring and medical surveillance,
pertaining to spills or releases of the following
materials:
(Training: HR2.10.1.9, 29 CFR 1910.1047)
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Spill incidence is decreased. (Rationale: facilities that have reduced or eliminated hazardous materials use such as mercury, have seen spill incidents decrease remarkably). | |||||||||||||||
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Costs associated with spill events decrease. | |||||||||||||||
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Spill Containment
and Countermeasures plan is in place for aggregate aboveground
tank storage capacity greater
than 1320 gallons.
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Facility has procedures in place for permits and monitoring of aboveground and underground storage tanks. | |||||||||||||||
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Tank alarm system can be heard or otherwise adequately communicated to operators. Written procedures are in place for steps to be taken when tank alarm sounds. | |||||||||||||||
| Training | ||||||||||||||||
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Staff using hazardous
materials are trained regarding the materials they use.
(HR 2.10). |
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Staff are trained on appropriate handling and use of protective equipment. | |||||||||||||||
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TRACER Staff
respond appropriately to spill of hazardous material
used in patient care, e.g. mercury spill from sphygmomanometer. Spill
clean up procedures are in place.
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| Emergency response | ||||||||||||||||
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The hospital has
in place a complete program for handling emergencies
involving victims contaminated with hazardous chemical,
radiological, or biological products. This program includes:
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| Emergency prevention and preparedness | ||||
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Hazardous waste
locations are identified throughout the facility.
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Precautions are
taken to prevent accidental ignition or reaction of ignitable
or reactive waste, including separation from sources
of ignition or reaction, e.g. open flames, smoking, sparks,
welding and hot surfaces.
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| Spills | ||||
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Spills are reported
to local authorities and National Response Center, if
necessary.
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Spill clean up residues
are managed as hazardous waste.
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Staff generating
hazardous waste are trained regarding the materials they
use.
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All hospital staff
who handle universal waste batteries are trained in proper
handling and emergency response procedures.
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| Emergency response | ||||
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An emergency coordinator
is designated and has authority to commit resources if
necessary.
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Emergency information
is posted near the telephone in the hazardous waste storage
area.
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Arrangements are
made with local authorities to respond to a hazardous
waste emergency.
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| Contingency plan | ||||
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A contingency plan
is in place if the facility is a Large Quantity Generator.
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The provisions of
the hazardous waste contingency plan are carried out
immediately whenever there is a fire, explosion, or release
of hazardous waste or hazardous waste constituents which
could threaten human health or the environment.
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Regulated Medical (Infectious) Waste
