Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

Service Name : Date Created :

Safety Manual
15-01-2008 Chief Medical Superintendent

Approved By :

Name

Signature : Head of Hospital Safety Committee Reviewed By : Name : Signature : Director Issued By : Name : Signature : Head of the Department Responsibility of Updating : Name : Signature :

Page of Contents

Sl.Order Particulars
A

Purpose
1

Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

B C

Scope Policy 1.Care Environment 2.Safety Management 3.Disaster 4.Bomb Threat 5.Diagnostic Services Safety Manual 6.Risk Management 7.Communcable Disease 8.Regulation and Standard 9.Hospital Safety Committee 10.Hospital Safety Officer 11.Safety Inspection and Records 12.Hazard Communication and Reporting of Event

A.

Purpose: This Safety Management Plan serves to describe the policies and processes in place to minimize safety risks to patients and staff through a comprehensive hazard surveillance program and analysis of aggregate information. Scope: The Safety Management Plan defines the mechanisms for controlling hazards, promoting and implementing safety measures for the patients, staff in particular and the hospital in general.

B.

Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

C. 1.

Policy: Care Environment (CE): is made up of three components: building(s), equipment, and people. The following are identified as elements and issues that can contribute to positively or negatively influencing patient outcomes, satisfaction, patient and staff safety that are appropriate and consistent with the clinical philosophy, security, orientation and access to the outside environment, ease in traversing both the inside and outside of facilities , efficient layouts that support staffing and overall function. To effectively manage the CE the following should be done: Reduce and control environmental hazards and risks Prevent accidents and injuries Maintain safe conditions for patients, staff, students and visitors Maintain CE that is sensitive to patient needs for comfort, social interaction, and positive distraction Maintain CE that minimizes unnecessary environmental stresses for patients, staff and visitors.

2.

Safety Management: a. Hazard Recognition:

Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

Hazard identification is the process used to identify all possible situations in the hospital where people (patient, staff, visitors etc) may be exposed to injury, infections or disease. The risk management authorities undertakes periodic evaluation of safety precautions to be followed by each department. For hazard recognition the following steps will be undertaken: 1. Both Clinical and Non-clinical audits will be undertaken on a periodical basis to identify the measures taken to prevent/reduce the impact of the potential hazards. 2. All the staff of the hospital will be encouraged to routinely assess all activities to identify potential hazards. 3. Departmental Heads and Managers will identify hazards within their specific area of control. The same should be notified to the appropriate hospital authorities for immediate corrective actions. b. ELECTRICAL SAFETY: The following measures are undertaken to ensure Electrical safety: 1. Routine Inspection of the power outlets through out the hospital by the electrician. 2. Trip Switches are located in different parts of the hospital to prevent short circuits. 3. Periodic inspection of wires to ensures that they are in appropriate conditions. 4. Before any electrical appliance is brought into RML Hospital, a safety inspection is provided. 5. Electrical equipment not required during night are switched off. 6. Areas around electrical switchboards must be kept clear for a distance of at least 1 meter. 7. ABC type fire extinguisher will be located adjacent to electrical switchboards. c. Power Loss: The Hospital may experience temporary power losses due to 1. 2. Storms Power company disruptions, or damage to the service lines entering the hospital.

Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

3.

Malfunctioning of the internal electrical wire system of the hospital.

d. Immediate Action: In the event of power loss, every effort should be made to immediately turn off all electrical equipment (if required) within an employees work area before power is restored to protect the equipment. e. Reporting Power Losses: In general, the loss of power or the disruption in normal electrical service should be reported immediately to the Electrician. Maintenance staff will investigate the scope and condition of power loss and proceed to correct the matter accordingly. f. Biological Hazard: Two primary sources for biological hazards has been identified which are: 1. Infectious Sharp objects. 2. Blood and Body fluid spills. g. Infectious Sharp Objects:

Sharps are any medical or non-medical equipment that is capable of cutting and/or puncturing the skin. Sharps' injuries represent the major occupational cause of accidents involving potential exposure to blood borne illnesses.

i. The Hospitals policy on Sharps Handling is:

Any equipment designated as a sharp must be handled and disposed of safely

Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow

Document No : RML/SM/01 Date of Issue : 15/1/2008

Safety Policy

Sharps are to be handled carefully at all times. Sharps are designated as clinical waste .

ii. PROCEDURE

Sharps must be disposed of at point of use. Used needles:

o o o o

must not be recapped after use unless using an appropriate device. must not be removed from syringes by hand. must not be bent, broken or otherwise manipulated by hand. must be destroyed immediately after its use.

Used disposable sharps are disposed of in a designated, clearly marked, puncture resistant container. Reusable sharps are disposed of in a clearly labeled, puncture resistant container for transport to the reprocessing area (CSSD). Sharp sections on intravenous giving sets are cut off and disposed of in the sharp's container. The remainder is disposed of in the general waste. This only applies to giving sets that have no visible blood in the line. This does not apply to IV sets that have been used for cytotoxic drugs. Sharps containers must be sealed and replaced.

h. Blood and Body Fluid Spills: i. The Hospitals policy on Blood and Body Spills is:

Blood and body fluid spills must be cleaned up immediately or as soon as possible. Standard precautions must be used when cleaning up spills of blood or body fluids. Gloves and other personal protective equipment appropriate for the task must be worn.

ii. Hands must be washed properly after the spill has been cleaned up. iii. Procedure The following points should be taken into account while cleaning up body fluids:

Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

Type of body fluid Size of spill Surface type area involved iv. Impervious Surfaces: a. Wipe the spill up using absorbent paper towel. b. Wash the area with water and detergent. c. If there is a likelihood of bare skin contact with the surface, the area is disinfected with sodium hypochlorite solution. v. Operating theatres a. Spills should be attended to as soon as it is safe to do so. b. Area to be disinfected with sodium hypochlorite. vi. Bathrooms and toilets a. Spill are hosed off into sewerage system and are flushed with water and detergent. b. The area is disinfected with sodium hypochlorite. A detailed inference to the preventive measures undertaken to control biological hazards can be drawn from the following manual: 1. Hospital Infection Control Manual. 2. Biomedical Waste Management Policy. The Infection Control Manual can be referred for instruction guidelines regarding management of hazardous waste.

I. Fire protection: Incidents of fire has been termed as CODE RED. In an incident of fire the staff has been instructed not to shout the word FIRE instead of that the word CODE RED to be used for informing the other staff about the incidence of fire. 7

Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

The two-fold objectives of the Fire Safety Plan are : i. Fire Prevention: To prevent the incidence of fire by implementing appropriate measure to control fire hazards in the building and by the maintenance of the building facilities provided for the safety of the occupants.(patients, staff ,visitors etc) a. The hospital has been declared No Smoking zone. b. Smoke Detection Devices are placed in different parts of the hospital, incase of the fire, on detecting smoke the devices are activated and an hooter is alarmed in the security office. c. Fire Extinguisher: Fire extinguishers, in appropriate sizes and types (ABC), are provided throughout the hospital in every floor of the hospital. Extinguishers are inspected as required by a qualified contractor. The theft of or tampering with an extinguisher should be reported immediately to the Maintenance Incharge. ii. Emergency Evacuation: To establish a systematic method of safe and orderly evacuation of an area or building, by and of its occupants, in case of fire or other emergency. The following procedures are observed to minimize the effects of Fire Accidents in the hospital: iii. The R.A.C.E. Procedure is followed: a. RESCUE Remove patients or others in immediate danger, and the door behind is closed .If the person is busy in rescue effort, he should shout CODE RED so that other employees can pull the alarm. b. Alarm : Break open Alarm system are placed in different parts of the hospital which can be activated at the time of fire by breaking the glass panel. Smoke detectors are also located in different parts of the hospital which in the event of detecting smoke will activate the alarm system in the in house telephone exchange. c. Contain: Contain the fire by closing doors and windows so that it does not spread to other parts of the hospital. d. Extinguish/evacuate i. Extinguish fire if possible.

Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

ii. Use correct extinguisher for the type of fire. iii Evacuate all persons to a safe area, if necessary. iv. Follow directions of Safety Officer, Fire Department or Nursing Supervisor. Fire plan is placed in every floor which indicates the exact location of the fire exits and fire extinguishers hence in case of any fire accidents; the nearest fire exit in the floors can be easily traced. The procedure for use of any fire extinguisher is : 1. Pull Pin (from handles) 2. Aim at base of fire 3. Squeeze handles 4. Sweep nozzle or hose from side to side: e. Fire Training and Drills: Fire Training and Fire drills are held at periodic intervals .All employees are provided adequate fire training, they are informed about the fire evacuation procedures including fire exits located in their work places.

The following special precautions are also undertaken: f. Exits: No obstructions may be placed in front of or upon any exit door. No aisle, exit access, or stairway may be obstructed with furniture or other obstructions so as to reduce the required width of the exit unless it is required for some maintenance purpose or during night hours when the main entrance is closed.

Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

g. Railings, Steps and Walks: The area immediately outside of building exits will be maintained free of material at all times. Vehicles are not permitted on sidewalks immediately adjacent to an exit. 3. Disaster: The Hospitals Disasters Management Manual (Ref no : ) identifies the various kind of internal and external disaster and specifies the measures to be undertaken for ensuring appropriate prevention and management of disasters. 4. Bomb Threat Bomb threats are delivered in a variety of ways with the majority of threats being called in to the target. In the event of a bomb threat, all personnel will follow the following procedures: i. The staff member receiving the call should make reasonable efforts to gain as much information as possible. Keep the caller on the line as long as possible. Ask who is calling, and have the caller repeat the message. Write down every word spoken by the person making the call. If the caller does not indicate the location of the bomb or the time of the possible detonation, the person receiving the call should ask the caller to provide this information. Inform the caller that the building is occupied and the detonation of a bomb could result in death or serious injury to many innocent people. Pay close attention to any strange or peculiar background noises such as motors running, background music, or other noises that might give some clue concerning the origin of the call. Listen closely to the callers voice, voice quality, accents, and speech impediments. Immediately after the caller hangs up, the person receiving the local Police Department. Evacuation notification procedures will be activated to evacuate the buildings. The staff should direct and assist patients to exit the buildings consistent with fire evacuation procedures All staff should exit the buildings the buildings. The police and assigned staff (security Personal) will conduct an extensive search of the buildings.

ii. iii. iv.

v. vi. vii. viii. ix.

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Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

x.

The Director or authorized representative will approve re-entry into the building after a search is completed and after consultation with the police.

5. The Laboratory Safety Manual, Radiation Safety Manual can be referred for laboratory and radiation safety procedures observed by the department in particular and the hospital n general. 6. Risk Management: Dr.Ram Manohar Lohiya Hospital recognizes and attaches greatest importance to and concern for, the safety of all its patients, hospital staff and the users of the premises under its control .Consequently the hospital strives to ensure that accidents, incidents and near misses are identified, reported and action taken to help ensure the safety and security of all staff, patients, visitors and other users of the hospital. The hospitals Risk Management Manual (Ref No : RML/RM/01.) describes in the details the methods adopted to eliminate and or control of all risks. 7. COMMUNICABLE DISEASE a. Dr. Ram Manohar Lohiya Hospital is committed to assure, to the extent possible, that each employee enjoys safe and healthful work conditions. The Hospital, in its effort to control communicable diseases on the hospital, has adopted this provision. Persons infected or reasonably believed to be infected with communicable diseases will not be restricted in their access to Hospital services or facilities unless medically-based judgments in individual cases establish restriction is necessary to the welfare of the individual, patients and other members of the institution, or others associated with the institution through clinical, cooperative, intern, or other such experience, involving the general public.

i.

ii. Persons known to have, or have a reasonable basis for believing, that they have been infected or have a communicable disease which may pose a threat to others are expected to seek expert advice about their health circumstances and are obligated, ethically and legally, to conduct themselves so as to protect themselves and others. iii. Employees or Applicants Currently Infected Any applicant or currently enrolled employee who is known to have a communicable disease (including human immunodeficiency virus (HIV), hepatitis B, and other blood borne disease) will be individually evaluated and all enrollment decisions concerning the individual will be based upon a consideration of the following factors: a) The potential harm that the individual poses to other people, 11

Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

b) The ability of the individual to accomplish the objectives of the assignment, and c) Whether or not a reasonable accommodation can be made that will enable the individual to safely and efficiently accomplish the objectives and specific tasks for the assignment without significantly exposing the individual or other persons to the safety of infection. All employees who have a known communicable disease will be assessed as needed by appropriate medical staff. The evaluation of an applicant or currently enrolled employee with a known communicable disease will include a physician's statement of the individual's health status as it relates to the individual's ability to adequately and safely accomplish the essential objectives of the applicant's or employee's assignment. The physician's statement must also indicate the nature and extent of the individual's susceptibility to infectious diseases often encountered when accomplishing the objectives of the individual's assignment. Each new employee is required to undergo pre employment medical examination prior to their reporting to duty and all the existing employees of the organization have to undergo annual medical check on a regular basis. The Food Handlers are required to under medical check up once every six month. 8. Regulations and Standards : The Hospital ensures strict adherence to the required standards and performs its operations within the purview of the law of the land so as ensure utmost safety for its patients ,staff ,visitors etc. The required licenses and other regulatory requirements are duely satisfied. The Chief Medical Superintendent of the hospital is the custodian of all the statutory documents/licenses.

9. Hospital Safety Committee: The Hospital Safety Committee is a multidisciplinary committee consisting of five members. It meets at least six times in a year to evaluate the various safety aspects of the hospital .The Committee undertakes detail analysis of the ongoing monitoring activities and gives its feedback on the same .The Committee submits its report to the Chief Medical Superintendent of the hospital. i. The Hospital Safety Committee evaluates the ongoing monitoring activities on various aspects of the following problems: Injuries to patients/ visitors

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Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

ii.

Property damage. Occupational illnesses and injuries to staff Hazardous materials and waste spills, exposures, and other related incidents Security incidents involving patients, staff, students and visitors at Dr.Ram Manohr Lohiya Hospital. Fire-safety management problems, deficiencies, and failures. Medical equipment-management problems, failures, and user errors Utility systems management problems, failures, or user errors. Staff Unavailability (such as Weather Emergencies, natural disasters) Mass Casualty Patient Influx (such as Infectious Disease Outbreaks).

Role of the Hospital Safety Committee : A. Provide guidance and direction in all phases of the Safety Management Program. B. Pro-active safety risk assessments of the clinical and clinical support areas of hospital. C. Facilitates the Environmental Monitoring Rounds. D. Advising management of unsafe conditions or of non-compliance with regulations and standards. E. Conducts on-going safety education classes. F. Responsible for proposing/revising safety policies.

iii.

Records and Reports: 1. Both the quarterly and annual reports are to evaluate the objectives, scope, performance and effectiveness of each of the CE management plans. 2. Both quarterly and annual reports are compiled, trended and presented to the Hospital Safety Committee. 3. The Hospital Safety Committee submits the reports to the Chief Medical Superintendent. 4. The annual evaluation includes recommendations for Performance Improvement during the following year.

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Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

x.

Hospital Safety Officer

i. Authority

Appointed by the Chief Medical Superintendent. Reports to the Chief Medical Superintendent/ designated authorities on all matters pertaining to safety matters Has the authority to shut down any process that is considered to be in violation of policy until the issue is resolved by Head of Department or Officer Has the authority to enter all areas of the Hospital, assess safety practices

ii. Responsibilities

Administer safety policies of the hospital and department Liaise with hospital authorities and other regulatory authorities Inspect laboratories and other areas to ensure safety practices are being observed Advise Head of Department of the various department on new and proposed legislation, together with safe work practices needed for compliance Ensure suitable personnel are appointed to positions to oversee biohazards, chemicals and radiation matters within the respective department Prepare Departmental procedures dealing with health and safety issue within the Department Identify training needs and arrange for Departmental staff and student training in consultation with Hospital Officers Must ensure that all tasks associated with and required for the position of Chairperson of the Hospital Safety Committee are undertaken.

11. SAFETY INSPECTION AND RECORDS: The hospital undertakes periodic inspection of the safety precautions undertaken either internally or with the help of an appropriate external agency. The reports of the safety inspections are reviewed by the hospitals safety committee and the same is submitted to appropriate Government Department/Agency as and when required .The safety Inspection records are maintained with respective departmental authorities. The Safety Management Officer or Committee may require periodic assessment of the following inventory:

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Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

a. Environmental (lighting, dusts, gases, sprays, noises). b. Hazardous materials (flammable and caustic). c. Equipment (biomedical equipments etc.). d. Power equipment (boilers, motors, etc.). e. Electrical equipment (switches, breakers, fuses, outlets, connections). f. Hand tools. g. Personal protective equipment (safety glasses, ventilators, radiation safety aprons etc). h. Personal service/first aid supplies (Medical Check Up). i. Fire protection equipment (alarms and extinguishers). j. Walkways/roadways (sidewalks, roadways). k. Transportation equipment (Ambulances, lifts). l. Containers (hazardous waste bags). m. Structural openings (windows, doors, stairways). n. Buildings/structures (floors, roofs, planter walls, fences). o. Miscellaneous (any items not covered above). Each inspection report will record pertinent safety management violations, noncompliance items, and observe deficiencies. Employees directly involved in the use or operation of the facilities or function being inspected is to participate in the inspection process.

12. HAZARD COMMUNICATION: a. General Any incident in the hospital which effects the safety policies of the hospital will be investigated by the Hospital Safety Committee and the report would be forwarded to the appropriate higher authority for further action .The following incidents should be immediately informed to the Safety Officer of the hospital: 1. Serious injury to patients. 2. Serious injury to employees. 2. Serious injury, caused by Hospital operations, to another party. 15

Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

3. Major loss of Hospital equipment or property. 4. Major loss of equipment or property belonging to another party caused by hospital operations. b. Reporting Accidents i. Any accident should be immediately investigated by the employees supervisor or appropriate staff member. ii. A Supervisors Accident Report Form should be completed and filed as soon as possible with the Safety Management Officer for reporting purposes and for further investigation and resolution. iii. Upon learning of a serious accident involving employees, employees, or equipment, an employee must notify the Hospital Safety Officer immediately. Serious accidents will be investigated by the Hospital Safety Officer. Reports for any such incident is to be forwarded to the Safety Management committee of the hospital. c. Release of Information In the case of accidents, supervisors and employees must not release information to the news media so as to avoid creation of unwanted panic among the people. Information to the media is to be provided by the top management authorities not less than the designation of Vice President. If contacted by the media please refer these individuals to the appropriate persons

d. Safety education: The Hospital requires all new employees to attend new employee safety orientation programme. This orientation is intended to provide new employees with an awareness of safety importance and their responsibility for maintaining a safe and healthy work environment, and to give an overview of workplace safety basics. The results should be more safety conscious employees who are receptive to learning and practicing the specifics of a safe, healthy workplace. Safety Orientation for New Employees

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Quality Operating Process

Dr. Ram Manohar Lohia Combined Hospital , Lucknow Safety Policy

Document No : RML/SM/01 Date of Issue : 15/1/2008

All new employees receive safety orientation. The orientation will consist of the following information: The Safety Management Officer or external instructors will present the general safety policies of the Hospital, and the new employees supervisor will present: 1. Procedures and policies specific to the new employees position 2. Fire reporting procedures 3. Fire extinguisher location and use 4. Fire prevention 5. Safe lifting techniques 6. Any information the supervisor feels will provide the new employee with a safe environment.

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