Hospital Safety Manual

FOREWORD
This policy is intended to enhance safety awareness in all employees,

and to motivate them to perform their work safely, in accordance with
the established safety rules, procedures, and instructions.
This policy also features the rules and guidelines for administering
disciplinary action to Davao Doctors Hospital employees who violate
safety rules and procedures or who, by their record or actions indicate
a disregard for health and safety.
Safety related disciplinary actions will be administered through the

concerted collaboration of the Hospital Health and Safety Committee
and Human Resource Department.
Thus, this policy must be followed by all employees of the hospital.

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PART I
I. MISSION STATEMENT
The Hospital Health and Safety Committee is mandated by Davao Doctors Hospital to design
and implement a safety process. The employees of Davao Doctors Hospital have a right to a
place of employment that is safe from all hazards that are likely to cause death or serious
harm. Our goal is to provide an environment where all employees will work safely, all the time,
everywhere, in all circumstances.
In achieving our goals, we will endeavor to have:
1. All supervisors, managers, and employees accept their responsibilities and actively participate in the
process.
2. Each department performs all activities in a manner which will ensure the safety of all involved.
3. The safety message communicated throughout the facility in such a way that it will build self esteem,
pride, enthusiasm and innovation.
II. INRODUCTION TO MANUAL
It is important for Davao Doctors Hospital to establish a written safety and health policy. This policy should be specific,
comprehensive, and fully implemented. A comprehensive safety and health policy can be an effective mechanism for
reducing and preventing accidents resulting from:
 Employees exposure to unsafe or unhealthy work conditions or

 Employees’ performing unsafe acts
The basic elements of an occupational safety and health program meet several goals:
 To prevent accidents
 To reduce workers compensation costs
 To reduce project downtime due to accidents
 To reduce the costs associated with the accident related property damage claims
 To meet the state’s legal responsibilities
 To provide employees with a safe and healthful workplace, free from recognized hazards
 To help reduce the financial losses which result from accidents
118 E. Quirino Ave., Davao City | Tel. Nos. +6382 222-8000, +6382 221-2101 | Fax No. +6382 226-4770
Email: info@davaodoctorshospital.net | Website: www.davaodoctorshospital.net
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To be successful, the Hospital Health and Safety Committee must encourage the support and compliance of all
employees. They can be made aware of their responsibilities regarding workplace safety through the use of notices,
rules, regulations and guidelines, which appear in this manual.
This manual is not intended to take place of any government regulations or necessary legal or professional assistance.
If expert assistance is required with regard to a specific issue confronting the hospital, then the service of a competent
professional will be sought accordingly.
1. Worksite Analysis
In an effort to identify all safety and health hazards, the Hospital Health and Safety Committee will:
 Perform regular and unannounced site safety inspections
 Provide reliable systems for employees to report safety and health hazards or concerns
 Report all accidents immediately and perform a timely accident investigation
 Perform an analysis of the patterns of injuries and occupational illnesses
2. Hazard Prevention and Control
In an effort to prevent accidents and injuries, managers must:
 Utilize engineering controls, work practice controls, personal protective equipment (PPE), and administrative
controls as appropriate to reduce safety and health hazards
 Perform preventive maintenance as required or recommended
 Establish a plan to prepare for emergencies
3. Safety and Health Training
 Educate employees regarding workplace safety, health, infection control and how to prevent harm to
themselves and others
 Educate supervisors regarding their safety and health responsibilities in identifying potential hazards and
reinforcing employee training through feedback on performance
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II.1 Supervisors
The Line Supervisor / Hospital Supervisor is the key person in the safety program. The broad responsibilities of
management can be clearly identified for the administration and department heads, but the implementation of these
procedures and day-to-day operation of the safety program are dependent upon each employee’s supervisor.
All supervisors must:
1. Know the safety rules and work practices that apply to the areas they supervised
2. Take action to confirm that all employees under them understand the safety rules and proper materials handling
procedures that apply to them. Let them know that unsafe acts or procedures will not be tolerated.
3. Prevent bad work habits from developing. Be responsible to make daily observations of employees to ensure that
they perform their work safely and continue this observation regularly once safe working habits are established
4. Take action to correct or control hazardous conditions, which are present in their assigned work location
5. Encourage employees to report unsafe conditions. Seek advice when necessary from the senior manager or to the
top management
6. Set a good example by demonstrating safety in their own habits and personal conduct. Always utilize appropriate
personal protective equipment and materials handling equipment
7. Train the employees on the proper safety procedures to follow for the job
8. Investigate and analyze every accident or near miss, no matter how slight
9. Never assume that workers will automatically select the proper work procedures to prevent injury since simple
experience is frequently their first choice
10. Make safety suggestions
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II.2 Employees
Those employees who are in non-supervisory positions have a responsibility – “to perform their work in a safe
manner”. Any rules and regulations exist for specific situations, but they all have as a common factor this
same rule – to avoid accidents by performing the work in a safe manner.
Some of the other general rules with which all employees must be familiar are as follows:
1. Report to the supervisor immediately any condition or practice they think might cause injury or property
damage. Also advise fellow workers if they may be exposed to the hazard.
2. All prescribed safety equipment and personal protective equipment must be used when required and
must be maintained in good condition. It is their responsibility to use such equipment properly after
appropriate training.
3. Obey all safety rules, government regulations, signs, markings and instructions.
4. Never engage in horseplay. Avoid distracting others.
5. Always use the right tools and equipment for the job. Use them safely and only when authorized. If they
are not familiar with the safe way to use a particular tool or piece of equipment, ask the supervisor.
6. Good housekeeping must always be practiced. Return all tools and equipment to the proper storage
locations when they are finished with them. Take the time to remove tripping hazards and keep floors
clean and passageways clear.
7. Do not handle chemicals unless trained in the safe handling procedures.
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III. GENERAL SAFETY RULES FOR ALL AREAS
The typical workplace today is part of a very complex mixture of people, processes, equipment, regulatory procedures
and policies, etc. It is a location in which many people may be performing different functions with the same work area, it
is impossible to develop a list of all applicable safety rules. The following is intended to highlight the most common
safety rules applicable to the different operations. These or a similar list should be part of the documented information
provided to all employees.
1. The use of extension cords and multiple-outlet adapters is prohibited throughout the hospital except for temporary
installations.
2. The person who created the spill must take appropriate action to expedite the safe clean up of all liquid spills.
Material Safety Data Sheet is to be consulted prior to clean-up.
3. Open doors slowly – there may be somebody on the other side.
4. Promptly notify the supervisor of defective equipment and other safety hazards.
5. All aisles and corridors are to be kept clear of obstructions in order to provide clear and safe exits in case of an
emergency.
6. All hospital staff is responsible for knowledge of their responsibility in the event of a fire or disaster alert.
7. All fires and/or smoke must be immediately reported.
8. All employees, regardless of position, will be held strictly accountable for maintaining the knowledge of, and
following, the requirements established by the hospital’s safety and health program. This includes adherence with
all of the safety responsibilities provided to all.
9. Never expose oneself, the coworkers, or the public to safety or health hazards or unsafe conditions.
10. Report all safety concerns or questions to the supervisor, the Health and Safety Committee Chairperson or other
management representative for corrective action.
11. Immediately correct those safety or health hazards or conditions for which they are authorized to do so.
12. Always properly use and maintain all assigned personal protective equipment.
13. Wear uniforms as specified.
14. Drugs and alcohol are prohibited from all hospital premises.
15. Use only prescribed lifting and materials handling policies. Never attempt to lift excessively heavy or awkward
objects without getting help.
III.1 Administrative and Office Areas
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III.1.1 Do not lift or move typewriters or any other heavy piece of equipment without help. Call Facilities and Planning
Management / Engineering Department to request the moving of file cabinets, desks, and similar large and/or
heavy items of furniture.
III.1.2 Do not stand on chairs with wheels, or on folding chairs, at any time.
III.1.3 Keep all drawers and chairs pushed in under the desks and tables so as not to create stumbling hazards.
III.1.4 All electrical power cords should be taped out of the way and not allowed to lie in the aisles.
III.1.5 Drawers should be kept closed at all times when not actually in use.
III.1.6 Keep aisles clear of debris – papers, paper clips, pencils, and other tripping hazards.
III.1.7 Keep stored items orderly. Nothing should be permitted within 18 inches of a ceiling in order to insure proper
operation of the fire sprinkler heads.
III.1.8 Notify the supervisor of all safety hazards so that they can be corrected.
III.1.9 Report to the supervisors all equipment that once thought as may be defective.
III.2 Nursing Services
III.2.1 All new employees are oriented to fire safety, disaster protocol, the use of extinguishers, ergonomics in the
workplace, fall prevention, patient safety, the use of oxygen, pharmaceutical management of hazardous drugs,
Occupational Safety and Health Standards, the “Right to Know” laws, the Heimlich Maneuver and violence in
the workplace. Annual training is provided for nursing employees on these subjects as well.
III.2.2 New employees are oriented to the use of patient care equipment and must demonstrate knowledge of the
correct use of such. Annual skill assessments include evaluation of continued competency.
III.2.3 All patient care equipment is to be used according to the manufacturer’s instruction. Staff members are
provided with in-service orientation to learn the correct use and maintenance of patient care equipment. Any
equipment recalled by a manufacturer is immediately removed from patient care use upon recall. All defective
equipment is immediately removed patient use as well.
III.2.4 When an incident occurs involving the misuse of patient care equipment by an employee, the employee is re-in
serviced on its correct use and is forbidden to use the equipment independently again until they further
demonstrate correct and safe use of the equipment.
III.2.5 Employees injured during working hours are evaluated by the Hospital Supervisor and are triaged according to
their injury.
III.2.6 Annual in-service is also provided in Infection Control, which covers basic hand washing, standard precautions,
isolation techniques, infectious disease management, TB precautions, and blood-borne pathogens. The
Infection Control Committee meets monthly or quarterly to review and revise policies and procedures regarding
Infection Control. Policies and procedures are strictly enforced.
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III.2.7 Volunteers/ trainees and private duty staff/nurses are oriented to hand washing, fire training, the “Right to
Know” laws, and Infection Control procedures.
III.2.8 Employees are not permitted to smoke in the workplace.
III.2.9 Patients are assessed for their level of awareness. Safety measures are instituted for patients found to be at
high risk for injury from falls, wandering, elopement or choking (i.e. presence of responsible watchers at all
times, and bed rails rose).
III.3 Housekeeping Services
III.3.1 Check for and report all unsafe conditions, such as:
7.3.1.1 Defective equipment

7.3.1.2 Sharp edges
7.3.1.3 Loose floor coverings
7.3.1.4 Loose light fixtures
7.3.1.5 Defective carts
7.3.1.6 Damaged light switch and power outlet covers
III.3.2 Do not attempt to fix any equipment by oneself, at any time. Report it to the supervisor or to the head who will
arrange for repairs to be made.
III.3.3 Safe floor cleaning and finishing procedures are important in reducing the number of slips and falls in the
hospital.
7.3.3.1 Use a dry mop before using a wet mop.
7.3.3.2 Mop only one side of a corridor at a time. Use the same procedure with floor finish.
7.3.3.3 Post wet floor signs near the wet areas.
7.3.3.4 Stay in the area until the entire floor is dry. Be sure to ask people to walk on the dry side.
7.3.3.5 When possible, avoid leaving hoses and cords lying across halls.
7.3.3.6 Do not block doorways or elevator entrances with equipment.
7.3.3.7 Insure that all wet mops and equipment are removed from rooms and public areas when they are done.
III.3.4 Do not place articles on top of stepladders, cabinets, lockers or other high places.
III.3.5 Use rubber gloves when cleaning with strong chemicals. The department will provide these gloves. If there are
none when they are working, ask the supervisor or head for them.
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III.3.6 Do not mix or use unauthorized chemicals or chemicals they are unfamiliar with. Ask the supervisor or head to
show how to safely mix and use them.
III.3.7 CART SAFETY
7.3.7.1 Park carts against walls, away from fire doors and fire extinguishers.
7.3.7.2 Always stay to the center of corridors, so as not to run into people leaving rooms. Pass oncoming
traffic on the right.
7.3.7.3 Pull carts through swinging doors. Do not ram them through the door.
7.3.7.4 Store materials in the carts in an orderly manner.
7.3.7.5 Approach all intersections, doorways and elevators SLOWLY so that it will not run into anyone.
7.3.8 DO NOT PICK UP BROKEN GLASS WITH THE HANDS. Sweep it up with a brush and dustpan. Pick up
small splinters and chips with a wet or damp cloth (and dispose of the cloth after doing this).
7.3.9 Be sure to unplug electric cords before wiping the cord with a damp or wet cloth.
7.3.10 ALWAYS handle electrical equipment with dry hands.
7.3.11 ALWAYS unplug electrical cords by holding onto the plug. NEVER pull on the cord. Also, be sure to turn off
machines before plugging them in or removing the plug from the wall.
7.3.12 DO NOT PUT THE HANDS INTO WASTEBASKETS TO EMPTY THEM. Remove the plastic bag by the
edges. Do not swing bags against the legs as the bags may contain sharp objects.
7.3.13 Do not stand on the top step of any ladder. Make sure that the ladder’s safety lock is in place and that the
ladder is secure before putting one’s weight on it.
7.3.14 Mark all containers to indicate what they contain. All unmarked containers must be promptly discarded.
7.3.15 Report slipping and tripping hazards to the supervisor immediately.
7.3.16 Keep janitor closets and other storage spaces clean and organized. Keep janitor closets locked on the
area provided for them.
7.3.17 Do not plug in an unattended or upright buffing machine. Make sure that the buffer is in a lying-down
position.
7.3.18 Notify the head or supervisor of any wastes that may be hazardous, as the may need special disposal.
7.3.19 Use the proper handling procedure when removing and handling linen and trash.
7.3.20 Notify the head or supervisor of any broken fixtures, machines (e.g. leaking faucets, faulty elevator doors)
holes in walls, baseboards, broken windows, broken floor tiles, frayed electric cords, etc.
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7.4 Laboratory
7.4.1 Smoking and consumption of food/beverages is prohibited in the laboratory work area.
7.4.2 Flammable and toxic materials shall be worked with inside of an explosion-proof exhaust hood.
7.4.3 Keep floors and aisles clear of obstructions.
7.4.4 When working with hazardous substances:
7.4.1 Do not wear contact lenses.
7.4.2 Always wear safety glasses.
7.4.3 Wear appropriate protective apparel, such as gloves, lab apron, etc.
7.4.4 Know the properties of the substances you are working with. Read their Material Safety Data
Sheet.
7.4.5 Know the locations of emergency showers and eye wash stations and how to operate these devices.
7.4.6 Irrigate eyes continuously for at least 15 minutes whenever a substance is splashed into them. Unless
there is also trauma, it is generally not advisable to go to the Emergency Room first, as this will delay
irrigation of the eye and more serious injury may result. Call for medical assistance to the scene where felt
necessary.
7.4.7 Use only equipment that has been safety checked by the Facility Planning and Management and/or
Engineering Department or other authorized personnel. Do not use equipment which is past the due date
for re-inspection and/or calibration.
7.4.8 Do not place flammables into refrigerators unless they are designed as explosion-proof and so marked.
7.4.9 Dispose glass, needles, and other sharp objects only into the marked containers that are provided.
7.4.10 Dispose of hazardous waste properly. Contact the Hospital’s Waste Management Officer (Housekeeping
Head) when in doubt about a substance. The following is a listing of some common lab chemicals that
must be disposed of as hazardous waste:
7.4.10.1 Xylene
7.4.10.2 Acetone
7.4.10.3 Formalin / Formaldehyde
7.4.10.4 Methanol
7.4.10.5 Anything containing mercury in any form. Most commonly this is HgCl in fixatives used in
Bacteriology
7.4.10.6 Glutaraldehyde (Cidex)
7.4.10.7 All NiCad and other rechargeable batteries
7.4.10.8 Anything containing lead
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7.4.10.9 Picric acid
7.4.11 Some flammables in safety cans and safety cabinets.
7.4.12 Strong acids, strong bass and flammables should always be stored separately. Do not place acids or
bases into safety cabinets, which are only for the storage of flammables.
7.4.13 Store acids and bases on the lowest level possible; to minimize damage should the container break.
7.4.14 All containers must be labeled to indicate the contents as to whether it is flammable, toxic, corrosive,
highly reactive or infectious. Unlabeled containers must be promptly discarded, even if a person
“knows” what is in it.
7.4.15 Read and observe all applicable safety policies and procedures in this manual, including those for
flammables and compressed gases.
7.5 Pharmacy
7.5.1 Keep poisons and external substances stored separately from internal substances.
7.5.2 Permit no unidentified substances to remain in the pharmacy.
7.5.3 Check labels twice; first when the order is filled and then again as the stock bottle is put away.
7.5.4 Pour away from the label so that it will not be obscured by spillage.
7.5.5 Pour corrosive substances below eye level and avoid splashing. Handle corrosive chemicals with great
care. If chemicals contact the skin, wash immediately.
7.5.6 Give close attention to materials being heated. Do not leave any such process unattended.
7.5.7 Return drugs and equipment to their proper places and clean the work area immediately after
compounding.
7.5.8 Use special care in filling prescriptions involving the handling of a number of tablets which are available in
different sizes, yet which look much the same.
7.5.9 When pouring acetic, phenolic, and other substances with hazardous vapors, do not stand over them.
7.5.10 All items must be dated and discarded when determined to be deteriorated.
7.5.11 Do not combine partial bottles of drugs under any circumstances.
7.5.12 Measure out drugs on clean papers to avoid contamination.
7.5.13 Keep drawers closed at all times when not actually using them.
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7.5.14 Neutralize and clean up all spills immediately. Notify the Waste Management Officer / Pollution Control
Officer (Engineering Head) of all clean ups which may require disposal as hazardous wastes.
7.5.15 Use step stools for obtaining items on higher shelves. Do not use boxes, drawers, or chairs.
7.5.16 Break ampules with care, following established procedure to protect your hands.
7.5.17 Store cytotoxic medications separately on a bottom shelf. Wear gloves to handle.
7.6 Dietary Services
7.6.1 All work areas must be kept neat and orderly.
7.6.2 Manufacturer’s safety instructions must be maintained in the department and made available to all
personnel.
7.6.3 Warn all staff of any potential hazard in the use or handling of equipment.
7.6.4 All staff must be aware of emergency procedures to take in case of an accident.
7.6.5 Staff must be informed of the proper incident reporting procedures. All accidents must be reported in
writing, by the employee’s head or supervisor. The head or supervisor is responsible for taking corrective
action, where possible, to prevent a recurrence.
7.6.6 Employees must immediately report the following to the head or supervisor:
7.6.6.1 Defective equipment
7.6.6.2 All injuries and accidents, regardless of how slight.
7.6.6.3 All cuts, sores, rashes, coughs and respiratory or gastrointestinal infections.
7.6.6.4 All unsafe conditions they are aware of.
7.6.7 SAFE HANDLING OF KNIVES
7.6.7.1 Always cut away from your body.
7.6.7.2 Store all knives in their proper location when not in use. Never leave a knife lying around.
7.6.7.3 Do not put knives in a sink.
7.6.7.4 Keep knives sharp – dull knives are dangerous.
7.6.7.5 Do not use knives as can openers, screwdrivers or anything other than for cutting food.
7.6.8 PREVENTION OF BURNS
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7.6.8.1 Always use mitts, potholders or tongs when working with hot items or steam.
7.6.8.2 Steam should warn others when they are carrying hot liquids and be sure that the path is clear before
starting in that direction.
7.6.8.3 Keep ovens clean.
7.6.8.4 Turn pot and pan handles so that they are not protruding over the edge of the stove.
7.6.8.5 Do not hand ladle over steam buffet table.
7.6.9 Keep doors closed at all times.
7.6.10 Wipe up spills and grease from floors IMMEDIATELY.
7.6.11 Walk – don’t run.
7.6.12 Wear safe shoes with rubber soles and rubber heels. Open toed shoes and high heels are not to be worn
in the kitchen or cafeteria.
7.6.13 Follow the proper procedure for lifting and moving materials.
7.6.14 FOOD CART SAFETY
7.6.14.1 Push only by the handle.
7.6.14.2 Keep to the center of corridors, passing oncoming traffic on the right side.
7.6.14.3 Move carts slowly. Get help if you need it and provide help if asked.
7.6.14.4 Use extra caution at corners.
7.6.14.5 Do not leave carts in the center of corridors, blocking doorways, or where they can cause an
obstruction.
7.6.14.6 Do not push doors open with food carts.
7.6.15 Use approved stepladders or stepstools to reach items. Where possible, place heavy objects at waist
height, to cut down the likelihood of muscle strains or back injury.
7.6.16 Use a brush and pan to pick up broken glass or china. Dispose of the pieces in the proper sharps
container. Do not handle broken glass or china with your hands.
7.6.17 Use only hospital supplied can openers.
7.6.18 Keep cleaning supplies, insecticides, chemicals etc. away from food and food preparation areas.
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7.6.19 Walk-in freezers and refrigerators must be easily opened from the inside, without tools. Test the
emergency release occasionally to make sure it works.
7.6.20 All staff must know how to report a fire, and what to do when the fire alarm is sounded.
7.7 Respiratory Therapy
7.7.1 OXYGEN CYLINDERS
7.7.1.1 Compressed gas cylinders shall be secured at all times.
7.7.1.2 Valves on compressed gas cylinders should be kept in the OFF position at all times except when in
use.
7.7.1.3 Back off valves about ¼ turn from the full open position so that a tightly opened valve will not be
mistaken for a closed valve.
7.7.1.4 Always crack cylinders, pointing the nozzle away from any persons, before attaching a regulator.
7.7.1.5 Never handle oxygen cylinders or oxygen administration apparatus with greasy hands. Oxygen and
petroleum products can produce an explosive mixture under pressure.
7.7.1.6 Never store oxygen, nitrous oxide or other oxidizing gases in the same room with flammable gases or
liquids.
7.7.2 NO SMOKING RULES
7.7.2.1 All areas where oxygen is present, including all rooms where a flow meter is plugged into the wall
outlet, must be posted as NOT SMOKING AREAS.
7.7.2.2 Therapists must verbally warn patients and visitors about the dangers of smoking – the placement of
signs is not enough. Be sure to physically remove all smoking materials from BOTH patients in rooms
where oxygen is present – not just from the patient to whom oxygen is being administered.
7.7.3 OTHER OXYGEN-ADMINISTRATION APPARATUS
7.7.3.1 Electrical call buttons, TV controls, etc. may be used by the patients / relatives, but should not be
placed near the patient’s head.
7.7.3.2 All electrical devices must be at least 3 feet from any bed where oxygen is being used. In the case of
oxygen mask or nasal units, these motors are safe is they are placed at the foot of the bed. With
oxygen tents, these motors must not be attached to the bed itself.
7.8 Rehabilitation Services
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7.8.1 Keep aisles and passageways clear and unobstructed.
7.8.2 Keep floors clean and dry at all times.
7.8.3 Store wheeled equipment in designated areas.
7.8.4 Use a stepladder or stool when taking objects from (or placing them onto) high shelving.
7.8.5 Use good body mechanics at all times.
7.8.6 Avoid overloading linen bags.
7.8.7 Lock wheelchairs before transferring patients to and from them. Wheelchairs with defective brakes should
be immediately taken out of service and a job order submitted for repairs.
7.8.8 Isolation procedures shall be followed at all times when working with isolation patients.
7.8.9 Keep cupboard doors and drawers closed when not in use.
7.8.10 Report all unsafe conditions to the supervisor.
7.8.11 Report all injuries to the supervisor promptly.
7.8.12 Patients in hydrotherapy areas must be attended at all times or provide with a means to call for
assistance.
7.8.13 Patients receiving treatment should be checked frequently and provided with a method to call for
assistance.
IV. INFECTION CONTROL: STANDARD PRECAUTIONS
Standard (Universal) Precautions should be consistently used for ALL patients. Since medical history and examination
cannot reliably identify all patients infected with HIV or other blood borne pathogens, Occupational Safety and Health
Administration (OSHA) blood borne pathogen rules are followed.
IV.1 Employees are trained in the use of Standard (Universal) Precautions as it applies to their work practices upon
orientation and annually thereafter.
IV.2 Personal Protective Equipment (PPE) is provided to all employees in compliance with the OSHA Blood-borne
Pathogen Regulations.
IV.3 Hands should be washed with soap and water when visibly soiled.
IV.4 Hand hygiene decontamination by hand washing with soap or water or by use of an alcohol based hand hygiene
product should be used before and after patient contact, following contamination with blood or other body fluids,
after contact with equipment or articles contaminated or potentially contaminated by them, and after removing
gloves.
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IV.5 Gloves do not replace the need for hand hygiene.
IV.6 Gloves should be worn for procedures where there is potential or actual exposure to blood or body fluids, when
health care workers have cuts and abraded skin, chapped hands or the like, during an instrumental exam of the
oropharynx, GI or GU tract, when performing an invasive procedure, phlebotomy, when cleaning blood and body
fluid spills and during decontamination process.
IV.7 Gloves should be made appropriate material and should be of appropriate size for each health care worker. If
gloves show evidence of peeling, cracking or tearing, discoloration or has other evidence of deterioration, it should
not be used. If the health care worker shows evidence of allergy to the glove material (e.g. latex allergy), an
alternate type of glove will be provided to the worker.
IV.8 Gloves should not be washed or disinfected for reuse.
IV.9 Gowns should be worn for performing tasks that may cause blood or other body fluid splashes to skin or clothing.
Gowns should be made of impervious material and should protect all areas of exposed skin.
IV.10 Masks and protective eyewear should be worn when performing tasks that may cause blood or other body
fluid splashes to mucosal membranes.
IV.11 Bag-mask devices are used for resuscitation equipment and minimize the need for emergency mouth-to-
mouth resuscitation. They are strategically located through the facility.
IV.12 Protective attire should be available for use when performing invasive procedures, in laboratories for
processing body fluid specimens and when performing or assisting with postmortem procedures.
IV.13 Housekeeping operations that minimize risks or direct exposure to blood and body fluids include provision
of protective attire for cleaning blood and body fluid spills and use of an approved environmental disinfectant.
IV.14 Only safety sharps and needles products are used. Sharps / needles should not be recapped or
purposely bent or broken by hand. Sharps / needles should not be removed from disposable syringes, or otherwise
manipulated by hand.
IV.15 Sharps / needles should be placed in puncture-resistant containers after use. Such containers should be
easily accessible to all personnel and shall not spill their contents if knocked over. Sharps / needles receptacles
should not leak, should be maintained in a sanitary condition and equipped with tight-fitting cover if necessary to
maintain sanitary and safe conditions.
IV.16 Lab specimens should be transported in a manner to prevent leaking. BIOHAZARD bags should be used
for preventing accidental injury or illness to employees when transporting specimens.
IV.17 Employees at substantial or reasonable risk of contacting blood or body fluids are offered hepatitis B
vaccinations. If the employee refuses to accept the immunization, they must sign a declination form or write a letter;
this is placed in the employee health file record.
IV.18 Soiled linen should be bagged at a point of origin and should not be sorted or rinsed in patient care areas.
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IV.19 Reusable patient equipment should be disinfected or sterilized before reuse.
V. HAZARD SURVEILLANCE
V.1 It is the policy of Davao Doctors Hospital to periodically audit (survey) the environment of care to determine unsafe
conditions and recommend corrective action. The Health and Safety Committee shall be responsible for
implementation of this program.
V.2 Hazard surveillance surveys include but are not limited to the following monitoring system:
 Safety audits
 Infection Control rounds
 Environmental Rounds
V.3 Safety surveys shall be performed semi-annually. The results of the surveys shall be reviewed by the Health and
Safety Committee and follow up actions taken as recommended. Where the situation is specific to a department,
the department head shall be requested to take appropriate action(s) and respond. This shall include the
submission of work orders to Facility Planning and Management or Engineering Department, education and training
of departmental staff, consideration of equipment purchase where necessary and similar actions.
V.4 Where department heads do not follow up requests for corrective actions, the Health and Safety Committee will
undertake the following course of action:
V.4.1 The Chairperson of the committee will communicate with this person and attempt to resolve the situation.
V.4.2 If the situation cannot be formally resolved to the satisfaction of the Chairperson, the department head should
be requested to meet with the Committee to discuss the matter in more detail and attempt resolution.
V.4.3 If the matter remains unresolved, it should be referred to the Management Committee or to the Board of
Directors for consideration.
V.5 Where the situation involves more than one department or more, or if otherwise felt appropriate by the Health and
Safety Committee, the committee shall be responsible for insuring that the situation is resolved.
V.6 Health and Safety Committee members should continually be on the lookout for unsafe acts and/or conditions, and
should bring these situations these to the attention of the supervisor, department heads and/or the Committee, as
appropriate to the situation.
VI. RISK ASSESSMENTS
VI.1The Health and Safety Committee is responsible for managing the different Safety Management Programs Risk
Assessment Process.
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VI.2 The goal of performing risk assessments is to reduce the likelihood of future incidents or other negative
experiences which have the potential to result in injury, an accident, or other loss to patients, staff or hospital
assets.
VI.3 Use of risk assessment process triggers organization linkages with other aspects of the Safety Management
Program. For example, a proposed change may indicate a need to create new or revise existing safety policies and
procedures, hazard surveillance in the area affected; safety orientation and education programs; or safety
performance improvement standards.
VI.4The Health and Safety Committee is responsible for coordinating the impact of proposed changes with other
aspects of the Safety Management Program
VI.5 The Health and Safety Committee in conjunction with department managers is responsible for performing follow-up
activities on any issues, findings, observations or recommendations that result from applying the risk assessment
process to a given project.
XI. ORIENTATION AND EDUCATION
10.1 All employees shall receive orientation and education about the environment of care areas consisting of Safety,
Security, Life Safety, Emergency Management, Hazardous Materials, Medical Equipments Management and Utility
Management.
10.2 Such orientation and training should include, but not limited to:
11.2.1 Reporting procedures for Safety and Security incidences
11.2.2 Use and functioning of fire alarm systems
11.2.3 Fire response needs and fire evacuation routes
11.2.4 Emergency procedures for utility failures
11.2.5 Right-to-Know and Hazardous Materials
11.2.6 What to do during emergency and fire drills
11.2.7 Emergency procedures for medical equipment failure
11.2.8 Infection Control procedures
10.3 Employees will receive job-specific training by their department heads. Annual training will also be conducted on a
departmental basis.
XII. ACCIDENT INVESTIGATION
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12.1Each supervisor will make documented investigation and analysis of every incident. Reports are to be completed as
soon as possible to avoid changes in physical conditions and witness reports.
12.2 Supervisors must be trained in accident investigation techniques and the following points regarding accident
investigation:
12.2.1 Accident investigation is a management function that must be carried out at the supervisory level.
12.2.2 All accidents / incidents must be investigated regardless of the extent of the injury or damage.
12.2.3 Employees are not permitted to fill out their own accident investigation reports, regardless of their position.
12.2.4 Focus must be on fact-finding, not fault-finding.
12.2.5 Supervisors must identify the unsafe act of condition or, in some instances, a combination of the two.
12.2.6 Supervisors should provide recommendations for corrective action; bring it to management’s attention and
assure that is acted upon.
12.2.7 The following “Key Point Summary” will assist with the investigation process:
Key Point Summary
Accident Investigation Techniques
A. The Investigation Process

Analysis for Cause
1. Plan of action to eliminate causes

2. Fix responsibility for the elimination of hazards that caused accident
3. See that the plan is carried out
B. Determining Unsafe Condition of Acts
1. Observation
2. Inquiry
3. Review of past records
4. Surveys
C. Five-Step Interviewing Method
1. Remind employee of the investigation’s purpose (fact-finding, not fault-finding)

2. Ask employee for their complete version
3. Ask questions to fill in the gaps
4. Check your understanding of the accident
5. Discuss how to prevent a reoccurrence
D. Key Points for Witness Interviewing
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1. Interview witnesses promptly and separately

2. Reassure witness of investigation’s purpose (fact-finding, not fault-finding)
3. Direct specific questions to clarify and fill in
4. Summarize your understanding of what the witness related.
E. Other Points for Witness Interviewing
1. Don’t say anything to blame or threaten the employee

2. Don’t badger the witness or give him/her a bad time
3. Don’t resort to sarcasm, skepticism or accusations
4. Handle all discrepancies with tact
5. Let the witness feel that he/she is a partner in the investigation
6. Don’t try to write down what a witness says when he/she is trying to explain
XIII. WORKPLACE VIOLENCE
13.1 Workplace violence is a particular concern in health care facilities. A small percentage of patients or visitors may
turn violent due to mental illness, drug or alcohol abuse or emotional problems.
13.2 Health care staff or their family or friends may also create violence resulting from stress, substance abuse,
emotional problems or troubled relationships.
13.3 The availability of weapons heightens the danger. To prevent violence, all personnel must be able to recognize an
deal with actions, attitudes, and situations with the potential of violence.
13.4 Prevent situations that could invite violence:
13.4.1 Report any poorly lit halls, stairs, or parking area
13.4.2 Plan not to go alone dark unpatrolled parking areas
13.4.3 Report any unidentified persons in restricted access areas
13.4.4 Don’t leave purses or other personal belongings in view
13.4.5 Don’t lend anyone your identification card, badge, or security code
13.4.6 Be careful about isolated or solo work – have a buddy or means of communication
13.4.7 Maintain secured areas
13.5 Be aware of these signs:
13.5.1 Be alert to overemotional individuals who make threats or show extreme anger, especially if they appear to be
using alcohol or drugs.
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13.5.2 Get help if you feel unsafe while dealing with anyone.
13.5.3 Be alert to potential for violence in a co-worker who is often threatening, angry, defensive, or blames others for
problems.
13.5.4 Learn to distinguish co-workers “normal” anger and reactions from extreme reactions. Be concerned about unusual
expressions or resentments, anger, threats, etc.
13.5.5 Substance abuse often aggravates threatening or angry behavior and fosters unrealistic thinking and approaches.
13.5.6 Report any concerns about danger from a co-worker to the supervisor for confidential investigation and, if
necessary, counseling or discipline.
13.5.7 Inform the supervisor and/or security personnel if you have fear harm at work from an individual who is not an
employee.
13.6 Get counseling and assistance for help with your own personal problems. The Human Resource Department
provides a confidential Employee Assistance Program for any employee who needs counseling, assistance or referral
services.
XIV. RIGHT-TO-KNOW
14.1 All employees have the right to know about any hazardous materials or toxic substances that they may be
exposed to or might be working with.
14.2 Material Safety Data Sheets (MSDS) should be kept on file by each individual department.
14.3 Each MSDS contains the following information:
14.3.1 Name of the product and manufacturer’s information
14.3.2 A phone number to call for information about the product in the event of an emergency
14.3.3 A list of all hazardous ingredients that are in the product
14.3.4 The hazardous properties of the product and what effect exposure may have
14.3.5 Any appropriate recommendations for the use of protective apparel such as gloves, eye
protection, etc.
14.3.6 First aid information.
14.3.7 Information about cleaning up spills and any information about special disposal practices.
14.4 Safety precautions should be reviewed prior to each use product.
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14.5 New employees should receive MSDS information during their departmental orientation.
14.6 Whenever the department uses a new product, be sure to obtain a MSDS for the product and go over the
necessary safety precautions with the staff.
XV. MEDICAL TREATMENT FOR EMPLOYEE INJURIES
15.1 Should any employee become ill or injured while working, the Occupational Safety Officer / Infection Control Nurse
should be contacted to evaluate the problem.
15.2 A nurse may not dispense medication to an employee unless under the direction of the Company Physician.
15.3 Employees in cardiac or respiratory arrest will be treated accordingly using the protocol adapted by the Philippine
Heart Association from the American Heart Association.
XVI. SMOKING REGULATIONS
16.1 In order to provide a safe, smoke-free, and healthful environment for patients, visitors, and employees, smoking is
NOT within the premises of Davao Doctors Hospital.
16.2 Signs advising of the hospital’s smoking policy shall be placed.
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PART II
MANAGEMENT PLAN
I. SAFETY MANAGEMENT PLAN
A. Purpose
The purpose of the Safety Management Plan is to provide a programmatic framework to reduce the risk of loss. The
plan includes processes that are designed to reduce or eliminate risks, which may adversely affect the life or health of
patients, staff, physicians, or visitors.
B. Fundamentals
a. Safety is information driven. Without appropriate information, accident and incident causing situations
cannot be predicted and prevented.
b. Department heads and managers need appropriate information to develop an understanding of safe
working conditions and safe work practices within their area of responsibility.
c. Safe working conditions and practices are established by using knowledge of safety principles to educate
staff, evaluate existing conditions, and design appropriate work environments and purchase appropriate
equipment and supplies.
d. The Safety Management Plan establishes processes for identifying, evaluating and alleviating practices or
situations that have a potential to: harm patients, staff, physicians or visitors; damage property or
negatively affect the reputation of Davao Doctors Hospital.
C. Goals and Objectives
a. Comply with accepted standards of safety
b. Provide a safe environment for patients, staff, physicians, students and visitors
c. Foster the development of a safety culture
d. Reduce incidents that result in a loss
e. Identify opportunities to improve performance
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D. Organization and Responsibility
a. The Governing Authority receives regular reports on the activities of the Safety Program from the Health
and Safety Committee. The Governing Authority reviews reports and, as appropriate, communicates
concerns about identified issues and regulatory compliance.
b. The Management Committee receives regular reports on the activities of the Safety Program. The
committee reviews reports and, as necessary, communicates concerns about key issues and regulatory
compliance to the Head of the Facility Planning and Management; the Safety Officer, or other appropriate
staff.
c. The Safety Officer shares responsibility for the joint management of the Safety Program with Facilities
Planning and Management and the Health and Safety Committee. Together they are responsible for
identification of safety deficiencies; development of plans for improvement; accident and injury prevention
and investigation; and incident reporting system; and emergency response. The Safety Officer advises the
Health and Safety Committee regarding issues which may necessitate changes to policies, orientation or
education or expenditure of funds.
d. The Health and Safety Committee coordinates processes within the Occupational and Health Standards.
Membership on the Health and Safety Committee is by appointment from the Office of the President and
includes representatives from administration, clinical services, patient and support services, and the union.
The Health and Safety Committee meets every month to receive reports and conduct a timely review of
safety issues. Additional meetings may be scheduled at the call of the Health and Safety Committee
Chairperson.
e. The Governing Authority has delegated authority to the Safety Officer or their designees to take immediate
and appropriate action in the event of an emergency situation where there is a clear and present danger
which poses a threat to life, a threat of personal injury, or a threat of damage to property.
f. Department Managers are responsible for orienting new staff members to the department and, as
appropriate, to job specific safety procedures. Department Managers are responsible for training their staff
in safety procedures. When necessary, the Safety Officer provides department Managers with necessary
assistance in developing department safety policies.
g. Individual staff members are responsible for learning and following job and task specific procedures for
safe operations. Individual staff members are also responsible for learning and using emergency reporting
procedures.
E. Processes of the Safety Plan
a. Grounds and Equipment
Facility Planning and Management is responsible for managing the hospital grounds and external equipment
maintenance process.
The Head of the Facility Planning and Management is responsible for scheduling and performing maintenance
to hospital grounds and external equipment. Engineering staff makes regular rounds of various areas to
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observe and correct the current condition and safety of hospital grounds and external equipment. Hospital
grounds include lawns, sidewalks, roadways, parking lots, lighting, signage, fences, etc. External equipment
includes: loading docks, oxygen storage facility, electrical switch gear, transfer switches, underground storage
tanks, etc. Corrective maintenance is delivered on an as needed basis. The frequency of corrective
maintenance is dependent upon weather conditions or the effects of weather.
Some external equipment such as the oxygen storage facility, etc. do have established protocols for inspection,
testing or preventive maintenance.
Facilities Planning and Management owns and operates a variety of maintenance equipment that is used to
maintain grounds and external equipment. Maintenance equipment includes lawn mowers, blowers, other
miscellaneous small gasoline engine powered tools, etc. Orientation and education is provided to all
maintenance equipment operations.
b. Risk Assessment
The Health and Safety Committee is responsible for managing the Safety Management Program risk
assessment process.
The goal of performing risk assessments is to reduce the likelihood of future incidents or other negative
experiences which have the potential to result in injury, an accident, or other loss to patients, staff or hospital
assets.
Use of risk assessment process triggers organization linkages with other aspects of the Safety Management
Program. For example, a proposed change may indicate a need to create new or revise existing safety policies
and procedures, hazard surveillance in the area affected; safety orientation and education programs; or safety
performance improvement standards. The Health and Safety Committee is responsible for coordinating the
impact of proposed changes with other aspects of the Safety Management Program.
The Health and Safety Committee in conjunction with department Managers is responsible for performing
follow-up activities on any issues, findings, observations, or recommendations that result from applying the risk
assessment process to a given project.
c. Information Collection and Evaluation System
The Safety Officer through the Health and Safety Committee is responsible for managing the process for
examining safety issues.
Effective use of the Information Collection and Evaluation System is dependent upon receipt of written and
verbal reports from a number of different functions within the different departments in the hospital and the
Facility Planning and Management. Information Collection and Evaluation System reports are used to identify
and communicate problems, time-sensitive issues and general information about periodic or structured
activities to the Health and Safety Committee. Information Collection and Evaluation System reports help the
Health and Safety Committee to set priorities, focuses their attention and prepares the committee for
developing or approving recommendations. It is the responsibility of the Safety Officer to review the content of
reports submitted.
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The processing of information submitted through the Information Collection and Evaluation System by the
Health and Safety Committee is generally an informal discussion of findings and in committee minute
recommendations outlined in the agenda for the meeting. Health and Safety Committee minutes serve to
document the information received and discussed by the Health and Safety Committee. The minutes also
serve to document recommendations the Health and Safety Committee has developed or otherwise approved.
d. Reporting and Investigating
The Safety Management Program uses a variety of reporting methods to document different types of activities.
Reports of staff incidents are reported using the Hospital Incident report form and directed to the Office of the
Marketing.
Reports of staff, outpatient, student, visitor who are injured on facility property are reported using the
appropriate Accident Injury Report.
Reports of property damage are directed to the Office of the Facility Planning and Management and/or
Engineering Department.
One of the goals of the reporting processes is for the responsible manager to be able to receive reports of
incident within twenty-four hours or ASAP of the occurrence. This goal is intended to set for a timely
investigation and to perform appropriate follow-up activities.
The respective managers are responsible for performing an analysis on those incidents which are required to
be reported to them and for reporting the findings of such analysis to the Health and Safety Committee. This is
intended to provide an opportunity to identify trends or patterns that can be used to identify if changes to the
Safety Management Program could control or prevent future occurrences. Summary information related to
incidents and analysis of such incidents is reported to the Management Committee and the Health and Safety
Committee.
Feedback from the analysis of incidents is used to further develop and improve the Safety Management
Program.
The incident reporting and investigation process is not used to measure Safety Management Program
performance because of the unpredictable nature of incident data and the general inability to control variables
such as human behavior. The most important long-term measure of effectiveness of the incident reporting and
investigation process is linked to the organizational goal of reducing those incidents which result in a loss.
e. Hazard Surveillance
The Health and Safety Committee is responsible for managing the hazard surveillance process. Hazard
surveillance surveys are conducted to evaluate staff knowledge and skill, life safety compliance, observe
current practice and evaluate environmental conditions. Results from hazard surveillance activities serve as a
tool for improving safety policies and procedures, life safety, orientation and education programs and staff
performance.
Hazard surveillance surveys at the facility are conducted according to an annual schedule that is prepared by
the Health and Safety Committee. The annual schedule is designed with a frequency to meet the needs and
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requirements of the various areas that are surveyed. Hazard surveillance cycles are scheduled as follows: (1)
All patient care areas are scheduled for two annual hazard surveillance cycles and (2) Non-patient care areas
are scheduled for only one hazard surveillance cycle each year.
Additional hazard surveillance surveys are performed when indicated through use and application of Interim
Life Safety Measures. The scope of such additional hazard surveillance is limited to those projects which have
an indicated need to implement Interim Life Safety Measures. Hazard surveillance surveys associated with
Interim Life Safety Measures can be usually performed daily, however; the frequency can vary based upon the
unique needs of each individual project.
The Health and Safety Committee is responsible for: conducting the surveys, analyzing information collected,
preparing a summary of findings report and submitting the summary of findings report to appropriate staff
responsible for correction. The report includes the issue, the person responsible for correction, a severity rating
and appropriate follow-up activity options.
Individual department managers are responsible for initiating appropriate action on specific findings applicable
to their scope of authority or responsibility. The Health and Safety Committee is responsible for coordinating
follow-up activities with individual department managers to ensure each specific finding is brought to closure.
f. Safety Officer Appointment
The Management Committee (MANCOM) and Human Resource Department are responsible for managing the
Safety Officer Appointment process.
The MANCOM, in conjunction with the Chair of the Health and Safety Committee, is responsible for selecting a
qualified individual that is capable of overseeing the development, implementation, and monitoring of the
Safety Management Program. The candidate selected is formally appointed through a document which is
signed by the President and CEO of the hospital. By appointment, the Safety Officer is assigned overall
operational responsibility for the Safety Management Program. The appointee is introduced to managers,
directors, and other executives through a memorandum. All other staff members are advised of the
appointment via e-mail and other publications.
The Safety Officer reviews changes in law, regulation and standards; assessed the need to make changes to
general safety, procedures, training and performs other activities essential to implement the Safety
Management Program. The Safety Officer participates in organizational responsibility for risk management,
security, emergency preparedness and fire safety programs with other managers and directors.
g. Immediate Threat to Life Policy
The Office of the President is responsible for managing the process for identifying individual(s) who may
intervene whenever conditions pose an immediate threat to life or health or threaten damage to equipment or
buildings.
To support this process, the facility shall develop an Immediate Threat Policy. This policy is intended to define
authority and responsibility in situations which pose an immediate threat: to the life or health of patients, staff,
physicians, or visitors; or the risk of major damage to buildings or property. The goal of the Immediate Threat
Policy is to identify and mitigate an immediate threat situation before such situation results in a loss and to
return the institution to a normal condition as quickly as possible.
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Through the Immediate Threat Policy, the President and the Head of the Facility Planning and Management
have the authority to appoint individual designees and empower them to immediately intervene and take
appropriate action(s) to mitigate the effects of such situations. Such delegation of authority enables the
institution to take swift and decisive action to implement the policy when needed on twenty-four hours a day /
seven days a week basis.
The Safety Officer has primary responsibility for implementing the policy during immediate threat situations.
The Safety Officer is also responsible for notification whenever the policy has been implemented. Facts
relevant to the situation are documented and the Safety Officer provides the Health and Safety Committee with
a report at the next regularly scheduled meeting.
The Immediate Threat Policy shall be revised when necessary and reviewed at least every three years.
h. Orientation and Education
Department Managers with support from Human Resource Department and Facility Planning and Management
have responsibility for coordinating the orientation and education program for the functions associated with
management of the Occupational Health and Safety Standards. The individual department managers are
responsible for managing the Safety and Management Program orientation and education program.
Every new staff member of the hospital receives general orientation related to the Safety Management
program, including how to report an accident and general safety awareness.
New staff members also receive a department-specific orientation to the department where they are assigned
to work. Each department manager is responsible for providing their new staff members with a department-
specific orientation to the Safety Management program. The goal of the department orientation program is to
provide new staff members with current fire and life safety information regarding area or job specific safety
issues, measures to avoid fire and hazards specific to the department.
All staff members of the hospital must participate, at least once each year, in a mandatory continuing education
program. Information specific to the Safety Management program is included within the scope of the continuing
education program. Meeting the annual continuing education requirement may be satisfied through completion
of a regularly scheduled continuing education program. The individual Department records attendance for each
staff member who completes a regularly scheduled continuing education program.
i. Performance Improvement Standard
The Health and Safety Committee has overall responsibility for coordinating the performance improvement
measurement program. The Safety Officer is also responsible for the Safety Management Program
performance improvement measurements.
The Safety Officer is responsible for establishing performance measurements which objectively measure the
Safety Management program. Human, equipment, and programmable characteristics are evaluated with the
goal of improving the organizational performance of the Life Safety Program. As part of the program to
appropriate data sources, documentation methods and frequencies of data collection and analysis must be
part of the report of the Health and Safety Committee.
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The Safety Officer reports on performance improvement measurements data to the Health and Safety
Committee. The Safety Officer is also responsible for reviewing established performance improvement
measurements on an as-needed basis. During such reviews, the Safety Officer evaluates whether existing
performance improvement measurements should be retired, revised or continued to be monitored and when
new performance improvement measurements are indicated.
The intent of establishing performance improvement measurements is to identify opportunities to improve the
Safety Management Program through an objective measure of demonstrated performance. Performance
improvement measurements should have been established to measure the important aspect of the Safety
Management Program. The degree of compliance with this performance improvement measurement serves as
one indicator to the continued effectiveness of the Safety Management Program and assists the Head of the
Facility Planning and Management; the Safety Officer, the Health and Safety Committee, hospital
administration; and the governing body in identifying or targeting areas for future improvement.
j. Policies and Procedures
The Health and Safety Committee has overall responsibility for coordinating the safety policy and procedure
process with the Facility Planning and Management and the individual department managers. A current
inventory of organization wide safety policies and procedures is maintained in Hospital Health and Safety
Manual.
Individual department managers are responsible for managing the department specific safety policy and
procedure process. Department specific safety policies and procedures address: safe operations use of
hazardous equipment or processes and use of personal protective equipment. The Safety Officer assists
department managers in the development of new and reviewing of existing department safety policies and
procedures.
Department managers are responsible fro distribution of department level policies and procedures to their staff.
The department managers are responsible for ensuring that safety policies and procedures are enforced. Each
staff member is responsible for following safety policies and procedures.
Both organization-wide and departmental safety policies and procedures are reviewed at least every three
years. Additional interim reviews may be performed on an as needed basis. The Safety Officer reviews
organization wide safety policies and procedures.
II. SECURITY MANAGEMENT PLAN
A. Purpose
The purpose of the plan is to assure the personal safety of patients, staff, and visitors coming into Davao Doctors Hospital
as well as the security of the facility, equipment, supplies, and patient information.
B. Objectives
 Address security issues affecting patients, staff, visitors, and facilities

 Report security issues to the appropriate committee(s)
 Identify potential security risks and address them before they become a problem
 Train staff to identify and report security risks
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C. Leadership of the Plan
The Head of the Facility Planning and Management / Personnel in-charge of the Security of the hospital shall implement and
monitor the plan. The plan shall be coordinated with the Hospital Health and Safety Committee.
D. Risk Assessment
1. Staff Identification
All staff are required to wear the Company Identification Card when entering the hospital, within the hospital
premises, involved in patient care, interacting with patients, visitors, or representing the hospital outside, as
applicable.
2. Facility Security
a. A key distribution and monitoring system is maintained by the Head of the Security Personnel or his designate (i.e.
R2). The keys shall be kept in the Pharmacy Cashier and once taken by the concerned department staff; it shall be
recorded in the logbook / notebook that outline who has the key, department, date taken, and signature.
b. During normal operating hours, security guards and their immediate head shall be designated in different entrance
and exit points. When an office (i.e. Stockroom) needs to be accessed after business hours because of operational
needs, the opening shall be coordinated with the Hospital Supervisor with the assistance of R2.
c. Access to the building is through the main driveway (across the Medical Tower), laboratory entrance, and the back
door (going to the Engineering Department Office). All other exterior doors are locked and used for emergency
purposes only.
d. Every building door and window is equipped with a lock, and it is the department practice to lock all doors and
windows when leaving the building for the day.
e. Ramped accesses are available at the main entrance and going to the Medical Tower. Prominent signs are in place
to indicate handicapped access.
3. Personal Security
a. For patient and employee safety, reports of threats, theft, or any violence of different natures shall be coordinated
with the immediate head of the Security personnel (i.e. R2 or Virgo 3) and the Hospital Supervisor on-duty shall
likewise make an investigation and incident reporting.
b. Uniformed security personnel conduct security rounds of the building every day including offices at the Medical
Tower.
4. Security of Property
a. Department’s equipment (e.g. computer) are kept on the premises of the department. Bringing out of hospital
equipment shall require a Gate Pass.
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b. Personal items (e.g. wallet / cellular phones) are to be kept at the risk of the owner and neither the department nor
the hospital is responsible for their safety, security or loss. If theft occurs, it shall be reported immediately to the
Security personnel and Hospital Supervisor on-duty.
5. Pharmacy Security
a. Security in clinical use of all medications is addressed by the Pharmacy Department thru its Pharmacy
Manager. This includes staffing, management of controlled substances, prescriptions, sample
medications, and over-the-counter products.
6. Medical Record Security
a. All Medical Records are secured in locked areas to protect patient confidentiality. The Medical Records
Section addresses Medical Records security.
b. In the nursing units, all departmental records shall be kept in an area where unauthorized personnel have
no access on it. Charts of discharged patients shall be kept in a closed cabinet or locked drawer.
7. Computer Security
a. The Information Technology Manager addresses security of electronic information and equipment in
collaboration with the Human Resources Department particularly in matters related to hiring, separations,
and compensation benefits; Medical Records Section for patient’s data; and other concerned departments.
F. Report Security Issues
1. Any breaches in security must be reported to the immediate head or Senior Managers and Head of the Facility
Planning and Management. If the situation includes a potential for violence, it shall be reported immediately.
2. Alerting event reports or Incident and Investigation Report Form (DDH-SF-007) are used to document property
damage, theft, or suspected criminal activity. These incidents are brought to the attention of the Head of the Facility
Planning and Management and Senior Managers who report incidents to the Management Committee and the
nearest police office as appropriate.
G. Hazard Surveillance
1. A Hazard and Vulnerability Assessment Tool has to be created to identify potential security risks. Procedures and
controls may then be implemented to achieve the lowest potential for adverse impact on security.
2. Quality monitors for security issues must be reviewed monthly by the Facility Planning and Management and must
be documented in the minutes. Opportunities for improvement must be referred to the Management Committee and
monthly hazardous surveillance surveys address security issues.
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H. Staff Training
New staff orientation to the Security Management Plan shall include how to minimize security risks for staff, visitors,
and patients, procedures to follow in breaches of security, and when and how to complete an Incident and
Investigation Report Form.
III. MANAGEMENT PLAN ON THE DISPOSAL AND CONTROL OF HAZARDOUS

MATERIALS & BIOLOGICAL WASTES
A. Purpose
1. To control all hazardous materials and corresponding waste and to

ensure regulatory compliance to disposal requirement
B. Fundamentals
1. The scope of the Hazardous Materials and Waste Management Plan is

determined by the materials in use and the wastes generated.
2. Hazards associated with materials and wastes are defined by law or

regulation are identified in materials sheets or similar documents
provided by suppliers and manufacturers.
3. The hazards are managed by involving Department Managers and other

appropriate staff in the plan.
4. Protection from hazards require all staff, who use or are exposed to
hazardous materials and wastes, to become educated to the nature of
the hazards and to use equipment provided for safe use and handling
when working with or around hazardous materials and wastes.
5. Proper chemical storage is required if a spill, release or exposure to a

hazardous material and waste occurs.
C. Goals and Objectives
1. Develop criteria to identify and classify those types of hazardous wastes

present at the facility.
2. Identify those chemicals, chemotherapeutic agents, sharps or biological

materials that may pose a risk to staff, patients and visitors.
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3. Obtain material safety data sheets or similar information for hazardous

materials and related references for staff and emergency medical care
providers.
4. Identify, through labeling or signage, areas where hazardous materials

are used or stored and the areas where waste is stored and disposed of.
5. Provide training for staff that handles or uses hazardous materials or

wastes.
6. Identify sources where hazardous wastes are generated.
7. Prepare plan for accidental exposures, spills or release of hazardous

materials or wastes
8. Maintain records, manifests and other documentation pertaining to the

plan.
9. Identification of problems which require attention and action and

reporting of such problems to the appropriate party.
10. Identification of performance improvement standards and reporting of

findings to the appropriate committees.
11. Identification of opportunities to improve program performance,

emergency response or staff training.
12. Conducting an annual evaluation of the objectives, scope, performance

and effectiveness and reporting findings to the appropriate Department
Managers.
D. Organization and Responsibility
1. The Housekeeping Head and Pollution Control Officer (or Waste Management
Officers) have overall responsibility for coordinating the Hazardous Waste and
Materials Management Program. They shall establish the operating and capital
budgets for the program. It interfaces with the Infection Control Committee to
coordinate biochemical waste operations for the facility.
2. Training of personnel is the responsibility of each Department Administrator.

Department Managers are responsible for orienting new personnel to the
department and, as appropriate, to job and task specific uses of hazardous
material or wastes. When necessary, other appropriate Departments at the
facility will provide assistance such as the Human Resource Department and the
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Clinical Training Officer for the Nurses. Individual personnel are responsible for
learning and following job and task specific procedures for safe handling and
use of hazardous materials and wastes.
E. Risk Assessment / Processes of the Hazardous Materials & Waste

Management Plan
1. Selection
1.1 Each manager who uses hazardous materials is responsible for the
product from the time it enters the department until the product is disposed
as a waste.
1.2 Each manager is responsible for evaluating the Material Safety Data
Sheet for hazards before purchase. Each Department Manager is responsible
for performing an evaluation of products in close coordination with the
Purchasing Department thru the Suppliers Accreditation Committee to
identify hazards as part of the selection process. Selection should be based
upon associated hazards as part of the selection process. Selection should be
based upon its intended use, cost benefits, infection control, associated
hazards, waste disposal, storage, engineering and safety controls, and the
need for the substance.
1.3 Depending on the substance, the office of the Facility Planning and
Management, the Purchasing Department, and the Suppliers Accreditation
Committee are responsible for working together to develop criteria for the
selection, handling, storing using and disposal activities associated with
hazardous chemicals. These activities are monitored through period physical
inspections.
1.4 An MSDS (Material Safety Data Sheet) Program is the responsibility of

each Department Manager / Head, ensuring availability of MSDS to all users
of chemicals and chemical compounds. Active chemical fume hoods are
inspected and certified on an annual basis and re-evaluated when moved or
structural modifications are done. Personal Protective Equipment (PPE) is
obtained as required. Proper use of PPE is monitored by the immediate head.
1.5 The purchase of disinfectant products is reviewed by the Housekeeping

Head with the Infection Control Nurse prior to purchase.
1.6 Pharmacy Department manages drugs and drug waste, some of which
may contain hazardous chemical constituents and carcinogenic substances.
2. Inventory
35
2.1 Department Managers / Heads are responsible for managing any

Hazardous Waste inventories required for their operation.
3. Waste Handling
3.1 Department Managers / Heads, working with the Office of the Facility
Planning and Management and Housekeeping Head, are responsible for
developing policies and procedures for handling hazardous waste.
Departmental Managers, Supervisors are responsible for ensuring that these
policies and procedures are followed. Hazardous waste handled includes:
chemical, chemotherapeutic, medical/infectious and special waste.
3.2 Each Departmental Manger who generates waste is responsible for

identifying wastes which require regulated disposal. Departmental Managers
review Material Safety Data Sheets to determine proper disposal methods for
all hazardous materials and regulated waste. Disposal methods must be in
compliance to all national and local regulations.
3.3 The Office of the Facility Planning and Management, in conjunction with
the Housekeeping Department, manages the collection and storage of all
regulated chemical waste.
3.4 Pharmacy Department manages drug waste, which may include

chemotherapeutic drug waste. Legend and non-hazardous drug waste follow
the biochemical waste disposal. Drugs classified as hazardous waste are
collected for disposal. Narcotic drugs are disposed of following the regulation
of the Bureau of Food and Drug Administration.
3.5 Housekeeping Department oversees the collection, handling and disposal

of all regulated medical waste with complete PPE. Waste is segregated at the
point of origin in appropriately marked containers. The Housekeeping
Department is responsible for the collection of regulated medical waste from
the point of generation to the staging area for pick up and disposal. The
facility maintains a storage area where biological waste (e.g. blood, placenta)
is held until transported to Ma-a cemetery where a designated area for DDH
intended for disposal is in place. Biological waste particularly blood
products / units shall be submerged in a container with allowable
concentration of Sodium Hypochlorite for disinfection purposes. Blood from
the blood bag shall be released from the bag by the Housekeeping personnel
so that the blood components will be treated accordingly.
3.6 Facility Planning and Management thru the Engineering Department

oversees the collection, handling and disposal of all special category waste.
Special category waste includes universal waste such as spent mercury
36
lamps, medical devices with elemental mercury, batteries, tires, heavy metal
waste products, paints and any other regulated waste not specifically
identified in any of the other waste categories. In relation to DOH A.O. 2008-
0021 regarding the Gradual Phase out of Mercury in all Philippine Healthcare
Facilities and Institutions, please refer to PP-PRE-023 or the Mercury
Minimization Policy of the hospital.
4. Space Management
4.1 Facility Planning and Management is responsible for managing the

program for providing appropriate space for handling and storage of
hazardous materials and waste for the various users.
4.2 The appropriateness of space shall be evaluated by each departmental

manager on an as needed basis. Findings of an evaluation are communicated
to the Head of the Facility Planning and Management for his action as
necessary.
4.3 Departmental managers are responsible for initiating appropriate action

on findings related to the appropriateness of space that is applicable to their
scope of responsibility.
5. Hazard Surveillance and Incident Reporting
5.1 The Hazardous Materials and Waste Management Program utilizes the
facilities Incident and Investigation Report Form (DDH-SF-007) for reporting
and documentation of different types of incidents, accidents or injury.
5.2 In the event of a hazardous materials and/or waste spill, an Incident and
Investigation Report Form (DDH-SF-007) and the Mercury Spill Form (for
mercury spillage) must be completed and forwarded to the Head of the
Facility Planning and Management or his designate for his action.
5.3 In the event of an exposure and/or injury, the employee’s immediate

must be notified immediately. The employee’s immediate head must fill out
an Incident and Investigation Report Form (DDH-SF-007) and report the same
to the Hospital Supervisor on-duty. Copies of these reports are sent to the
Human Resources Department.
5.4 If immediate treatment is required, consultation from the Company

Physician or ER Consultant / Resident on-duty shall be sought. The employee
may seek non-emergency treatment through the Company Physician. The
Company Physician shall note any treatment rendered on the employee
health record and submit report to the Human Resources Department for
investigation and proper charging of the amounts incurred for the treatment
37
and/or laboratory / diagnostic examinations with consultation with the

Quality Assurance Committee.
6. Orientation and Education
6.1 As appropriate for their operation, Department managers are responsible

for providing basic training in Right To Know, chemical safety, blood borne
pathogens and infection control, basic biological safety, biomedical waste
handling and disposal policies and procedures and any other materials or
wastes that can be classified as hazardous.
6.2 The Infection Control Committee is responsible for training in infection

control and blood borne pathogens. Policies and procedures are also provided
in the institution’s Infection Control Manual.
7. Performance Improvement Standard
7.1 The intent of developing and establishing performances improvement

standards is to identify opportunities to improve the Hazardous Materials and
Waste Management Plan.
7.2 The Hospital Health and Safety Committee has provided a more direct
line of communication for sharing information relative to the Hazardous
Waste and Materials Plan with other Department members on the
committee.
IV. UTILITY SYSTEMS MANAGEMENT PLAN
A. Purpose
1. To provide an environment of care that is safe, controlled, and comfortable;

reduce the potential for nosocomial illness; minimize the risks associated with
utility failures; and to ensure the operational reliability of utility systems.
B. Objectives
1. This plan is designed to protect people, equipment, property, and the

environment by ensuring the safe and reliable operation of the utility systems
that impact life support, infection control, environmental support, equipment
support, and communications. The primary objectives of this plan are:
1.1 Ensuring compliance with applicable regulatory requirements, standards

and guidelines, and manufacturers’ recommendations.
1.2 Carrying out an effective preventive maintenance program.
38
1.3 Providing operator and user training.
1.4 Maintaining reference documents for each system.
1.5 Establishing effective contingency plans in the event of a utility system

failure.
1.6 Monitoring equipment performance and identifying improvement

opportunities.
1.7 Maintaining required permits and licenses.
C. Responsibilities
a. The Head of the Facility Planning and Management is responsible for

developing, implementing, and monitoring this plan and ensures that required
inspections, tests, maintenance of the utility systems.
b. All staff must be trained and competent in safe operation and use of utility
systems and emergency response and reporting procedures.
D. Utility Systems Management Processes
a. Design and Installation of Utility Systems

a.1 The Head of the Facility Planning and Management uses guidelines of the
Building Code of the Philippines or RA 6541 as reference to make sure
that the utility systems meet the patient care and operational needs of
the services of the hospital.
b. Risk Assessment, Inventory, and Strategies
b.1 All utility systems having an impact on the environment, life support,
infection control, support of the environment, equipment, and
communications are classified as critical systems. The Facility Planning
and Management shall maintain an accurate, current inventory of the
utility systems and their critical operating components. Newly acquired
equipment is added to the inventory within three months of
acquisition/installation.
c. Inspecting, Testing, and Maintenance Strategies
c.1 Refer to the following policies and operating procedures:
39
PA-ENG-003 Preventive Maintenance, Inspection, Testing, and

Calibration)
PA-ENG-004 Preventive Maintenance Program of Equipment and Facilities
PA-ENG-008 Calibration and Verification of Instruments and Equipment
PA- OFF-011 Preventive Maintenance of Equipment done by Suppliers or
Manufacturers
PA-OFF-049 Repair of Hospital Equipment
DDH-GP-030 Guidelines for Responsibility and Control of Hospital
Assets
d. Emergency Procedures
d.1 The emergency procedures shall address the following:
(1) Specific procedures in the event of utility systems malfunction

(2) Identification of an alternate source of essential utilities
(3) Shutoff of malfunctioning systems and notification of staff in affected
areas
(4) Procedures of obtaining repair services when utility systems fail
e. Emergency Electrical Power Systems
e.1 The Engineering Department conducts testing of the emergency power

at least every 30 days. When normal power is interrupted, the
emergency power source supplies electricity to the following:
(1) Alarm systems

(2) Emergency communication systems
(3) Illumination of exit signs
(4) Emergency/urgent care areas
(5) Medical Air Compressors
(6) Areas where electrically powered life-support equipment is used
(7) Operating rooms
(8) PACU
(9) Delivery rooms
(10) NICU
f. Pathogenic Biological Agents in the Water Systems
(1) The key steps for managing pathogenic biological agents in water
systems are to ensure that equipment that re-circulates water
continuously is properly designed, accurately installed, and
adequately maintained.
40
(2) If there is a case of suspected or known nosocomial infection, the

Facility Planning and Management Head works together with the
Infection Control Committee to review engineering policies and
procedures related to inspections, preventive maintenance, and the
culturing guidelines to be used.
g. Incident Reporting and Investigation
(1) The Facility Planning and Management Head identifies, documents,

investigates, and evaluates utility system incidents, failures,
problems, or use errors to identify trends and problems that pose a
potential threat to life and safety and opportunities for improvement.
Investigations may include a review of equipment service reports,
incident reports, utility failures, and user errors. Corrective actions are
implemented in a timely manner and the results are evaluated for
effectiveness.
(2) Typical incidents that require reporting and investigation include

normal electric power system failures, emergency power system
failures, water system failures or contamination, steam system
failures, sewer system leaks and major blockages, medical system
failures, disruption of HVAC service to patient care units and service
areas, and any other incident deemed appropriate by the Facility
Planning and Management head.
h. Orientation and Education Program
(1) The orientation and education component pertaining to safety

addresses the following criteria:
1.1 The utility system’s capabilities, limitations, and special

applications
1.2 Emergency procedures in the event of system failure
1.3 Certification, license or information and skills necessary to perform
assigned maintenance responsibilities
1.4 Location and instructions for use of emergency shutoff controls
1.5 Processes for reporting utility system management problems,
failures and user errors
1.6 New employees are scheduled to attend orientation before their
hiring date
i. Monitoring of Performance
(1) Performance monitoring is used to
41
(a) Identify areas of concern and strengths in the safety

program
(b) Identify or determine actions necessary to address areas of
concern
(c)Assess actual compliance with relevant security standards
(d) Identifies at least one measurable performance
improvement standard to monitor performance regarding actual
or potential risk related to one or more of the following:
1. Staff knowledge and skills

2. Level of staff participation
3. Monitoring and inspection activities
4. Emergency and incident reporting
5. Inspection, preventive maintenance, and testing of equipment
V. EMERGENCY AND DISASTER PREPAREDNESS MANAGEMENT PLAN
5.1 Refer to the following for the policies and operating procedures
5.1.1 DDH-GP-020 Disaster Management Program
5.1.2 DDH-GP-021 Internal Disaster Evacuation Plan (Fire Safety)
VI. RADIATION SAFETY MANAGEMENT PLAN
6.1 Refer to the following for the policies and operating procedures
6.1.1 Radiation Safety and Management Program c/o Cancer Institute
6.1.2 PA-NUC-059 Personnel Radiation Exposure Monitoring
6.1.3 PA-NUC-051 Disposal of Radioactive and Non-Radioactive Sharps
6.1.4 PA-RAD-064 General Guidelines for Radiation Safety and Protective

Measures
PART III
SAFETY PROGRAMS
A. ELECTRICAL SAFETY PROGRAM
42
I. PURPOSE
1.1 The purpose of this program is to prevent injuries and accidents and protect
DDH employees from low voltage electrical hazards. “Low Voltage” is defined by
Occupational Safety and Health Administration (OSHA) as work performed directly
on or in proximity of systems of 600 volts, nominal, or less.
1.2 Work unit specific safety procedures for preventing electric shock or other
injuries resulting from direct/indirect electrical contact to employees working on or
near energized or de-energized parts will be developed and implemented as
required.
1.3 Moreover, this program aims to ensure that all employees understand the
hazards associated with electric energy and are capable of performing the
necessary steps to protect themselves and their coworkers.
II. SCOPE
2.1 This program applies to all work operations at DDH involving electrical systems
of 600 volts or less where employees may be exposed to live parts and/or those
parts that have been deenergized.
2.2 Any work on energized equipment may be done only after it has been
determined that this type of work must be performed with the equipment
energized.
III. DEFINITIONS
3.1 Current - (measured in amps/amperage) Term used to

describe electric flow. It is current that can cause
electric shock.
3.2 Deenergized – Electrical devices that are disconnected from all

energy sources including direct electric connections,
stored electric energy such as capacitors, and stored
non-electrical energy in devices that could reenergize
electric circuit parts
3.3 Energized Electrical Work – Work conducted by an employee on or near

an exposed energized circuit greater than 50 volts
and less than or equal to 600.
3.4 Grounding - Provides a safe path between electricity and the

earth, preventing leakage of current. The creation of a
43
conductive path for electricity between a circuit and

the equipment to ground.
3.5 High Voltage – Electrical systems or equipment operating at or

intended to operate at a sustained voltage of more
than 600 volts.
3.6 Low voltage - Electrical systems or equipment operating at or

intended to operate at a sustained voltage of 600
volts or less.
3.7 Polarized Plug - Helps reduce the potential for shock with easily
identifiable plugs. One prong is wider than the other
and can only be inserted into outlets one way.
3.8 Resistance - The ease with which electricity flows through the
material (conductor). Materials (conductors) with
higher resistance properties can become hot.
(Measured in ohms)
3.9 Voltage - Electric potential or potential difference assigned to

a circuit or system expressed in volts.
IV. RESPONSIBILITIES
4.1 Primary responsibilities include:
4.1.1 Hazard identification
4.1.2 Training
4.1.3 Reporting/correcting safety hazards
4.2 DDH Employees
4.2.1 Are aware of electrical safety issues
4.2.2 Comply with safe operating procedures when working with electrical
equipment
4.2.3 Attend appropriate safety training.
4.2.4 Report safety concerns
44
4.3 Senior Managers
4.3.1 Ensure staff are trained, qualified, and authorized to work on electrical
equipment
4.3.2 Conduct periodic hazard analysis of work areas
4.3.3 Correct identified safety hazards
4.4 Health & Safety Committee
4.4.1 Provide assistance in identifying electrical safety issues
4.4.2 Provide electrical safety training for hospital staff
4.4.3 Review electrical equipment safe operating procedures as necessary
4.5 Facility Planning and Management
4.5.1 Ensure that all authorized or qualified persons have received appropriate
levels of training
4.5.2 Ensure appropriate Personal Protective Equipment is provided to

authorized or qualified staff who work with electrical equipment
V. GENERAL PRECAUTIONS
5.1 All Staf
5.1.1 Never work on “hot” or energized equipment unless it is necessary to

conduct equipment troubleshooting.
5.1.2 Use extension cords only as temporary power sources.
5.1.3 Do not connect too many pieces of equipment to the same circuit or
outlet as the circuit or outlet could become overloaded.
5.1.4 Plug strips, such as those used on computers, should be plugged directly
into outlets and not into extension cords or other plug strips.
45
5.1.5 Inspect all equipment periodically for defects or damage.
5.1.6 All cords that are worn, frayed, abraded, corroded or otherwise damaged
must be replaced.
5.1.7 Grasp the plug to remove it from a socket - never pull the cord.
5.1.8 Keep all cords away from heat, oil and sharp edges.
5.1.9 Always follow the manufacturer's instructions for use and maintenance
of all electrical tools and appliances.
5.1.10 Keep equipment operating instructions on file.
5.1.11 Never touch an electrical appliance and plumbing at the same
time.
5.1.12 Always unplug electrical appliances before attempting any repair
or maintenance.
5.1.13 All electrical devices must be properly grounded with approved
three wire plugs unless they are "double insulated". Grounding provides
a safe path for electricity to the ground, preventing leakage of current in
circuits or equipment.
5.1.14 Keep cords out of the way of foot traffic so they don't become
tripping hazards or become damaged by traffic.
5.1.15 Never use electrical equipment in wet areas or run cords across
wet floors.
5.1.16 Ensure energized parts of electrical equipment operating at 50
volts or more are guarded against accidental contact.
46
5.1.17 Only properly trained employees should work on electrical
equipment.
5.1.18 Know how to respond to emergencies such as electric shock
incidents or fires.
5.2 Localized Electrical Outage
5.2.1 All Staff should immediately report electric outages to Facility Planning
and Management Office.
5.2.2 If possible, identify the defective equipment or the cause of the failure
and remove it from service.
5.2.3 Report this information to Facility Planning and Management personnel
upon their arrival.
5.3 Engineering and Facility Management
5.3.1 Be able to recognize electrical safety hazards in the work area.
5.3.2 Ensure that all authorized or qualified persons have received appropriate
training in order to operate or repair equipment.
5.3.3 Keep equipment in good working order to help prevent electrical accidents.
5.3.4 Maintain a three-foot clearance around electrical panels.
5.3.5 Electrically operated equipment must be deenergized before work may
commence.
47
5.3.6 Always follow lockout/tag-out procedures when working on electrical
equipment and wear appropriate Personal Protective Equipment (PPE) such
as safety glasses, rated rubber gloves, rated rubber sleeves, insulated
boots, or face shield.
5.3.7 Never override safety devices such as electrical interlocks.
5.3.8 Remove all rings, key chains or other metal objects when working around
electricity.
5.3.9 Wear appropriate personal protective equipment, such as eye protection or
insulated gloves, as needed.
5.3.10 Never use metal ladders when working near energized wiring.
5.3.11 Damp or wet environments may be dangerous when working with
electricity.
5.3.12 Never plug in cords that are wet or touch electrical equipment with wet
hands.
5.3.13 Employees working with lasers, performing hardware or software testing,
or other activities that do not require direct contact with electrical
components, should be aware of electrical safety issues and be alert to the
possibility of other employees.
5.3.14 NEVER work with electricity greater than 600 volts without specific
permission, training and written procedures. Notify the Department Head
immediately if there are any questions.
VI. REPORTING
48
6.1 Damaged or Defective Electrical Equipment
6.1.1 Report malfunctioning equipment or devices to the Hospital Supervisor
or Facility Planning and Management / Engineering Department. Typical
issues include:
6.1.1.1 Damaged cords, plugs or outlets;
6.1.1.2 Receiving a shock when touching the equipment; and
6.1.1.3 Arcing, sparking, smoking, or otherwise malfunctioning
equipment.
6.1.2 Any electrical equipment not operating properly should be:
6.1.2.1 Taken out of service immediately.
6.1.2.2 Tagged or labeled as “Do Not Use”.
6.1.2.3 Reported to the appropriate department or individual for

repair.
7. Training Requirements and Competency Assessment
Training Requirement, Target Audience Frequency

Class Title
Basic Electrical Safety All DDH Employees At time of employment and
Awareness periodically thereafter as
part of the DDH Safety
Training Program
Advanced Electrical Safety DDH employees who work Annually
directly with electrical
systems from 50 to 600
volts, Qualified or Authorized
Persons
Lock Out/Tag Out DDH employees who work Annually
directly with electrical
systems from 50 to 600
49
volts, Qualified or Authorized

Persons
Hazardous Electrical DDHemployees who work Annually
Voltage Safety with or in the proximity of
electrical equipment or
systems over 600 volts,
Qualified Electrical Worker
(QEW)
B. COMBUSTIBLE SAFETY PROGRAM
I. INTRODUCTION
1.1 Solids, liquids and gases capable of catching fire or exploding in the presence
of ignition source. Flammable liquids have a flashpoint below 37.8°C;
combustible liquids have a flashpoint of 37.8°C or more. Examples: white
phosphorus, acetone, propane.
II. BASIC SAFETY PRACTICES
2.1 Obtain and read the Material Safety Data Sheets (MSDS’s) for all of the
materials you work with.
2.2 Evaluate permeation rate and wear appropriate gloves.
2.3 Prevent hazard from long term storage (peroxides).
2.4 Be aware of all the hazards (fire, explosion, health, chemical, reactivity)
of all the materials you work with.
2.5 Know which of the materials that you work with flammable or
combustible liquids are.
2.6 Avoid or eliminate ignition sources (sparks, smoking, flames), and hot
surfaces when working with flammable or combustible liquids.
2.7 Store, handle, and use flammable and combustible liquids in well-
ventilated areas.
50
2.8 Use approved equipment, including labeled safety containers for
flammable and combustible liquids.
2.9 Keep all containers closed when not in use.
2.10 Bond and ground metal containers when transferring flammable and
combustible liquids.
2.11 Make sure fire extinguishers are available, access unobstructed, straps in
place.
2.12 Know how to handle emergencies (fires, spills, personal injuries)
involving the flammable and combustible liquids you work with.
III. STORAGE OF FLAMMABLE MATERIALS
3.1 Storage Conditions and Quantities
3.1.1 Store in dry, cool, ventilated area.
3.1.2 Not more than 25 liter of flammable liquids shall be permitted in the
open laboratory out side of approved storage cabinets, approved safety
cans and approved refrigerators.
3.1.3 The volume of liquids shall be determined by the capacity of the

containers.
3.1.4 Store flammables in approved flammable liquid storage cabinets.
o Do not exceed 500 L combustible+ flammable

o Do not exceed 250 L flammable
3.1.4 Cold storage only in explosion proof unit.
3.1.5 Do not store in or adjacent to exits, elevators, or routs that provide
access to exits.
51
C. CHEMICAL SAFETY PROGRAM
I. GENERAL SAFETY PROCEDURES
1.1 DDH personnel should:
1.1.1 Know the potential hazards of the materials used. Review the Material
Safety Data Sheet (MSDS) and container label prior to using a chemical.
1.1.2 Know the location of safety equipment such as emergency showers,

eyewashes, fire extinguishers, fire alarms, spill kits, first aid kits, and
telephones.
1.1.3 Review emergency procedures to ensure that necessary supply and

equipment for spill response and other accidents are available.
1.1.4 Practice good housekeeping to minimize unsafe work conditions such as

obstructed exits and safety equipment, cluttered benches and hoods,
and accumulated chemical waste.
1.1.5 Wear personal protective apparel when working with chemicals. This
includes eye protection, lab coat, gloves, and appropriate foot protection
(no sandals). Gloves should be made of a material known to be resistant
to permeation by the chemical in use.
1.1.6 Wash skin promptly if contacted by any chemical, regardless of

corrosivity or toxicity.
1.1.7 Label all new chemical containers with the “date received” and “date
opened.”
1.1.8 Label and store chemicals properly. All chemical containers should be
labeled to identify the container contents (no abbreviations or formulas)
and hazard information. Chemicals should be stored by hazard groups
and chemical compatibilities.
52
1.1.9 Use break-resistant bottle carriers when transporting chemicals in glass

containers that are greater than 500 milliliters.
1.1.10 Use fume hoods when processes or experiments may result in the
release of toxic or flammable vapors, fumes, or dusts.
1.2 DDH personnel should not:
1.2.1 Eat, drink, chew gum, or apply cosmetics in areas where chemicals are
used and stored.
1.2.2 Store food in laboratory refrigerators, ice chests, cold rooms, or ovens.
1.2.3 Drink water from laboratory water sources.
1.2.4 Use laboratory glassware to prepare or consume food.
1.2.5 Smell or taste chemicals.
1.2.6 Pipette by mouth.
1.2.7 Work alone in the laboratory.
1.2.8 Leave potentially hazardous experiments or operations unattended

without prior approval from the immediate head. In such instances, the
lights in the laboratory should be left on and the telephone should be
functional.
D. MECHANICAL SAFETY PROGRAM
A. Protection
1. Personnel shall be protected from hazardous moving parts, e.g., pulleys

and shafts, sharp edges and other potential hazards by using one of the
following:
53
a. Interlocked safety covers.
b. Safety covers requiring a tool for removal.
2. Personnel shall be protected from flying particles, dust and mists, by

inherent design, capture ventilation, or by shielding enclosures.
3. All hazards which could result in serious laceration or dismemberment

shall be eliminated by designing the equipment with inherent protection.
B. Wire Mesh Shields
1. Where a wire mesh or perforated cover is used for the protection of fans,
blowers, etc., the mesh shall meet the requirements.
C. Sliding Parts
1. Stops - Drawers, gates and other sliding units shall have stops to
prevent disengagement.
2. Pinch points - Wherever the sliding action between two hard surfaces
creates a pinch point, a guard or shield shall be installed.
D. Weights
1. Units exceeding 16 kg (35 lb.) designed to be removed for service shall

be labeled.
2. Lifting aids (e.g., mechanical device, handles) shall be provided for:
- Lifts in excess of 16 kg (35 lb.).
- Frequent lifts in excess of 4.5 kg (10 lb.).
- Awkward lifts in excess of 4.5 kg (10 lb.).
E. Covers
1. Top covers shall be provided to prevent objects from falling into the
machine.
54
2. Bottom covers shall be provided to contain burning material inside the

machine. Mesh may be used, if required.
3. Horizontally-hinged covers, which are likely to present a hazard, shall be

counterbalanced or provided with a fail-safe device to prevent personnel
injury.
4. Sliding covers that move in vertical plane shall be counterbalanced or

provided with a fail-safe device to prevent personnel injury.
5. Vertical lift doors shall be secured by mechanical means.
F. Edge and Corner Breaks
Edges or corners of guards, shields, and equipment shall have a break or

radius.
G. Stability
1. A machine, when in the stand alone condition, shall not overbalance

when tilted 15°.
2. A machine shall not tilt when a force in proportion to the machine weight
is applied in either a horizontal or vertical direction at the point of
maximum moment when hinged frames, drawers, etc., are extended for
service in their most unfavorable positions.
55

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FOREWORD

This policy is intended to enhance safety awareness in all employees,

Safety related disciplinary actions will be administered through the

Thus, this policy must be followed by all employees of the hospital.

In achieving our goals, we will endeavor to have:

II. INRODUCTION TO MANUAL

 Employees exposure to unsafe or unhealthy work conditions or

 Perform regular and unannounced site safety inspections

 Report all accidents immediately and perform a timely accident investigation

 Perform an analysis of the patterns of injuries and occupational illnesses

2. Hazard Prevention and Control

In an effort to prevent accidents and injuries, managers must:

 Perform preventive maintenance as required or recommended

 Establish a plan to prepare for emergencies

3. Safety and Health Training

All supervisors must:

10. Make safety suggestions

4. Never engage in horseplay. Avoid distracting others.

7. Do not handle chemicals unless trained in the safe handling procedures.

III. GENERAL SAFETY RULES FOR ALL AREAS

3. Open doors slowly – there may be somebody on the other side.

7. All fires and/or smoke must be immediately reported.

13. Wear uniforms as specified.

III.1 Administrative and Office Areas

III.2 Nursing Services

III.2.8 Employees are not permitted to smoke in the workplace.

III.3 Housekeeping Services

7.3.1.1 Defective equipment

7.3.3.1 Use a dry mop before using a wet mop.

7.3.3.3 Post wet floor signs near the wet areas.

7.3.3.6 Do not block doorways or elevator entrances with equipment.

III.3.7 CART SAFETY

7.3.7.4 Store materials in the carts in an orderly manner.

7.3.10 ALWAYS handle electrical equipment with dry hands.

7.3.15 Report slipping and tripping hazards to the supervisor immediately.

7.4.3 Keep floors and aisles clear of obstructions.

7.4.4 When working with hazardous substances:

7.4.1 Do not wear contact lenses.

7.4.2 Always wear safety glasses.

7.4.10.9 Picric acid

7.4.11 Some flammables in safety cans and safety cabinets.

7.5.2 Permit no unidentified substances to remain in the pharmacy.

7.5.11 Do not combine partial bottles of drugs under any circumstances.

7.5.12 Measure out drugs on clean papers to avoid contamination.

7.6 Dietary Services

7.6.1 All work areas must be kept neat and orderly.

7.6.6.1 Defective equipment

7.6.6.2 All injuries and accidents, regardless of how slight.

7.6.6.4 All unsafe conditions they are aware of.

7.6.7 SAFE HANDLING OF KNIVES

7.6.7.1 Always cut away from your body.

7.6.7.3 Do not put knives in a sink.

7.6.7.4 Keep knives sharp – dull knives are dangerous.

7.6.8 PREVENTION OF BURNS

7.6.8.3 Keep ovens clean.

7.6.8.5 Do not hand ladle over steam buffet table.

7.6.9 Keep doors closed at all times.

7.6.10 Wipe up spills and grease from floors IMMEDIATELY.

7.6.11 Walk – don’t run.

7.6.14 FOOD CART SAFETY

7.6.14.1 Push only by the handle.

7.6.14.4 Use extra caution at corners.

7.6.14.6 Do not push doors open with food carts.