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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. |
Please
note: this page is under development. Contact
(734) 995-7989,
if you have questions or suggestions.
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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= 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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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). |
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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)
-
radioactive materials
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blood
and body fluids
(29
CFR 1910.1020)
-
mold/spore releases from construction, maintenance, or
other activity disturbing mold contaminated materials
-
releases of dust contaminated with lead
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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. |
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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:
- appropriate protective equipment
- adequate decontamination facilities (fixed or portable)
- training
- written
program and procedures
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Hazardous Waste Management
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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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Training |
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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
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Emergency
prevention and preparedness |
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RMW
waste generation locations are
identified throughout the facility.
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Emergency
plans are in place in areas at high
risk for large blood or body fluid spills (such as operating
rooms, trash handling areas, and blood
banks). |
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Spills |
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Bloodborne
pathogen spill
clean-up materials are available and accessible, including:
- proper
personal protective equipment
- sorbents
- disposal
equipment
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Spill
incidents involving a potential exposure to bloodborne
pathogens are reported to the facility's department
responsible for employee health and safety. [can't
find any reference to BBP reporting requirements]. |
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Blood
or body fluid spill incidence is decreased. |
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Costs associated with spill events decrease. |
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Training |
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All hospital
staff who may handle blood or body fluid spills are
trained in proper handling and emergency response procedures.
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Staff
has received spill prevention training, and incidence
of blood or body fluid spills has measurably decreased. |
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