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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
REVISION DATE
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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
DOCUMENT No./ REV. No.
HPTLY-MER-P01-5
PAGE No.
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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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D. Engineer II Medical Specialist II- OIC
DOCUMENT No./ REV. No.
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POLICY ON SECURITYMANAGEMENT PROGRAM
REVISION DATE
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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
POLICY ON HOSPITAL FIRE PLAN PAGE No.
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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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D. Engineer II Medical Specialist II- OIC
POLICY ON HOSPITAL FIRE PLAN
REVISION DATE
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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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO,M.D.
POLICY ON HOSPITAL PLAN
REVISION DATE
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Engineer II Medical Specialist II- OIC
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.
CAMIGUIN GENERAL
HOSPITAL
POLICY ON HOSPITAL FIRE PLAN
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D. Engineer II Medical Specialist II- OIC
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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
CAMIGUIN GENERAL
HOSPITAL
POLICY ON HOSPITAL FIRE PLAN
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HPTLY-MER-P01-5
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Engineer II Medical Specialist II- OIC
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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO,M.D.
CAMIGUIN GENERAL
HOSPITAL
POLICY ON HOSPITAL FIRE PLAN
DOCUMENT No./ REV. No.
HPTLY-MER-P01-5
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Engineer II Medical Specialist II- OIC
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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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO,M.D.
Engineer II Medical Specialist II- OIC
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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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D. Engineer II Medical Specialist II- OIC
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.
CAMIGUIN GENERALHOSPITAL
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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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D. Engineer II Medical Specialist II- OIC
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D. Engineer II Medical Specialist II- OIC
CAMIGUIN GENERALHOSPITAL
DOCUMENT No./ REV. No.
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PAGE No.POLICY ON DISPOSAL ANDCONTROL OF HAZARDOUS
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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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO,M.D.
Engineer II Medical Specialist II- OIC
CAMIGUIN GENERAL
HOSPITAL
POLICY ON DISPOSAL ANDCONTROL OF HAZARDOUS
MASTERIALS/BIOLOGIC WASTE
DOCUMENT No./ REV. No.
HPTLY-MER-P01-5
REVISION DATE
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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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II- OIC
CAMIGUIN GENERAL
HOSPITAL
POLICY ON FIRE SAFETYMANAGEMENT PLAN
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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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO,M.D.
Engineer II Medical Specialist II- OIC
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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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO,M.D.
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Engineer II Medical Specialist II- OIC
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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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO,M.D.
Engineer II Medical Specialist II- OIC
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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO,M.D.
Engineer II Medical Specialist II- OIC
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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Engineer II Medical Specialist II- OIC
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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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer II Medical Specialist II- OIC
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.
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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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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer II Medical Specialist II- OIC
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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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer II Medical Specialist II- OIC
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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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer II Medical Specialist II- OIC
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
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer II Medical Specialist II- OIC
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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer II Medical Specialist II- OIC
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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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
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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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II- OIC
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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer II Medical Specialist II- OIC
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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II- OIC
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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer II Medical Specialist II- OIC
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.
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
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.
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer Medical Specialist II- OIC
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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer Medical Specialist II- OIC
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:
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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.
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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.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer Medical Specialist II- OIC
CAMIGUIN GENERALHOSPITAL
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.
CAMIGUIN GENERALHOSPITAL
POLICY ON GENERATOR SET
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II OIC
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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POLICY ON GENERATOR SET
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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
CAMIGUIN GENERALHOSPITAL
POLICY ON SPECIAL PRECAUTION
FOR CLEARING UP SPILLAGE OF
POTENTIAL HAZARDOUS
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II OIC
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.
CAMIGUIN GENERALHOSPITAL
POLICY ON SPECIAL PRECAUTION
FOR CLEARING UP SPILLAGE OF
POTENTIAL HAZARDOUS
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II OIC
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.
CAMIGUIN GENERALHOSPITAL
POLICY PROCEDURES ON RISK
IDENTIFICATION, ASSESSMENT
AND CONTROL, SECURITY RISKS,
USE OF PERSONAL EQUIPMENT
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II OIC
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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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II OIC
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.
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HOSPITAL
POLICY AND PROCEDURE ONMERCURY SPILLAGE
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v. Follow up the instruction supplied with the kit.
vi. Vacuum cleaners must not be used.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II OIC
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.
CAMIGUIN GENERALHOSPITAL
POLICY ANDPROCEDURES ON
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II OIC
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.
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HOSPITAL
POLICY AND PROCEDURES ONMERCURY SPILLAGE
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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.
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POLICY ON PREVENTIVEMAINTENANCE ON EQUIPMENT
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II OIC
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.
CAMIGUIN GENERALHOSPITAL
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MAINTENANCE ON EQUIPMENT
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II OIC
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
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LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.Engineer II Medical Specialist II OIC
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
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HOSPITAL
POLICY ON EQUIPMENTMANAGEMENT PLAN
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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