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viii. Spills (ruptured bags, etc.) from biohazardous waste bags will <br /> be picked up promptly. Proper personal protective equipment <br /> shall be used at all times. Contents will be placed into a red <br /> biohazardous waste bag for disposal. Remaining blood or other <br /> body fluids will be wiped up immediately with an approved <br /> disinfectant, which will be allowed a contact time of no less than <br /> 10 minutes. Responding staff shall always wear appropriate PPE <br /> and wash hands after cleanup. Upon discovering a small leak or <br /> a tear in the bag,the damaged bag will immediately be placed <br /> into another approved bag to avoid further spillage. <br /> ix. For response to major spills (any medical waste spill beyond the <br /> training and equipment capacity of the responder),the <br /> department's supervisor shall be contacted immediately. Refer <br /> to Code Orange procedure in the Sutter Health Emergency <br /> Management Guide. <br /> x. Employees will report any puncture wounds or similar exposures <br /> to their immediate supervisor for possible blood borne pathogen <br /> exposures and appropriate follow up. <br /> c. Hazardous Drug Waste Spills: <br /> i. Every department handling hazardous (including chemotherapy) <br /> drugs will have a HD spill kit. <br /> ii. If a spill occurs,the department is responsible for clean-up <br /> following the directions on the spill kit. <br /> iii. After initial clean-up, perform final deactivation, <br /> decontamination, cleaning and disinfection (DDCD) of the <br /> contaminated area using approved wipes. <br /> iv. All waste and spill clean-up materials will be disposed of by <br /> placing them in a bulk RCRA waste container. <br /> v. Responding staff shall always wear appropriate PPE and wash <br /> hands after cleanup. PPE will be disposed of in trace yellow <br /> containers. <br /> d. Pathology Waste Spills: <br /> i. Staff is trained in the safe management of formalin-related <br /> spills. <br /> ii. Clinical staff maintains all materials required for the safe <br /> handling and cleanup of formalin spills. <br /> iii. For response to major spills (any medical waste spill beyond the <br /> training and equipment capacity of the responder),the <br /> department's supervisor shall be contacted immediately. Refer <br /> to Code Orange procedure in the Sutter Health Emergency <br /> Management Guide. <br /> iv. Employees will report any puncture wounds or similar exposures <br /> SVMF Waste Policy.Retrieved 9/23/2023.Official copy at littp://sh-somf.policystat.com/policy/13569979/.Copyright Page 8 of 14 <br /> 2023 Sutter Gould Medical Foundation <br />