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Guide to JCAHO Environment
of Care Standard 3.10.2
© 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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note: this page is under development. Contact
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Introduction Table of Contents Checklist
for 3.10.2
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Environment of Care Standard 3.10: The
organization manages hazardous materials and waste
risks
Element of Performance 2. Hazardous
Materials and Hazardous Waste Inventory
The
organization creates and maintains an inventory that
identifies hazardous materials and waste used, stored
or generated using criteria consistent with applicable
law and regulation. |
This page provides
a set of criteria for evaluating a facility's inventory system
for tracking hazardous materials and waste.
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= Compliance |
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= Environmental Improvement |
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Tools and Resources |
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Hazardous Materials Management
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The facility has instituted a purchasing protocol
that discourages hazardous materials from being
purchased.
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The facility's hazardous
materials inventory contains an accurate list of all hazardous
materials stored or present on site,
including:
- chemicals (laboratory, cleaning, etc.)
- disinfectants and sterilants
- pharmaceuticals and chemotherapeutic agents
- polychlorinated biphenyl (PCB)-containing equipment
- radioactive agents and associated wastes
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The quantity of hazardous materials used over successive time periods
has been tracked and documented. |
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The size of the hazardous materials inventory has been reduced. |
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Inventory records indicate that mercury-containing
equipment, chemicals, lab reagents and pharmaceuticals
are being substituted or eliminated. |
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Inventory records demonstrate the use of
substitutes for hazardous chemicals (e.g. less hazardous
or non-hazardous alternatives to formalin, xylene, and other reagents
and solvents). |
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Inventory records indicate that PCB-containing
equipment such as transformers, elevator oil, light ballasts,
etc. is being replaced or eliminated. |
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Inventory records indicate that petroleum product
storage and use has been minimized. |
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The facility maintains a readily accessible file
of Material Safety Data Sheets (MSDSs)
that are less than five years old. |
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The facility maintains an accurate
list of all asbestos containing building materials.
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Friable asbestos
has been eliminated or is being abated |
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The facility can document that an annual physical hazardous material/waste
review and audit has been performed.
(EC 1.20, 9.10) |
Hazardous Waste Management
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The facility maintains
a record of all hazardous waste generated for each
calendar month (required to determine hazardous waste
generator status).
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The facility maintains
documentation verifying that hazardous
waste storage inspections have been performed.
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Regulated Medical (Infectious) Waste
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The facility maintains a list of all locations where regulated medical (infectious) waste is
generated and stored.
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