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Facilities Management and Environmental Services completes the Hazardous Chemical Spill Report form and is responsible for notifying governmental agencies of incidents as required by the nature of the incident. 2. The Safety Officer will investigate a hazardous material or waste incident. in all cases where a spill is involved, the Department Manager where the spill occurred will receive a copy of the findings from the investigation. The Facilities Management office maintains documentation on incidents. The Safety Officer and Director of Facilities Management and Environmental Services are responsible for developing recommendations based on the conclusions of the investigation and taking appropriate action to implement any recommendation developed. 3. The Safety Officer is responsible for performing a quarterly analysis of incidents. The incident analysis provides an opportunity to identify trends or patterns to be used to determine if changes to the Hazardous Materials and Waste Management Plan could control or prevent future occurrences. The results of the analysis are reported to the Environment of Care Committee. C. Hazardous Materials Contamination 1. in the event of facility contamination due to an internal spill, exposed and contaminated person(s) entering the building, or a bioterrorism incident that involves the hospital, additional measures and response could be required. 2. Exposed Patient Arrival at the ED For the patient arriving at the ED for medical assistance, decontamination may be required..The staff will use the Hazardous Material Exposure Harm/Risk Assessment Worksheet;.(see ATTACHMENT A)jo determine if iiecontamination is required. Should it become necessary to perform decontamination procedures for an ED patient; the area must be fully secured to avoid further contamination and possible closure of the entire area.: 3. employees wha wlil particrpate in the process have received training appropriate totheir expected level of partictpaEion. No individual may;participate beyond their skill or ability. a. Instructions for Set -Up of Hazardous Materials Decontamination System is provided for staff required to set-up the portable decontamination System All staff who may be required to participate in the set-up process has received training to do so. Facilities Management and Environmental Services staff has received training in the set-up of the Decontamination System. b. Refer to Policy EOC policy #C-8420-180, "Decontamination Shelter", L:1LMH1P&PtEOC1C- HA2ARDOUS WASTEIC-8420-180 doc — To access, hold CTRL key down and click on link. D. Bloterrorlsm Act Involving Hazardous Materials Should there be an incident involving a suspected bioterrorism act, the situation may be addressed as a CODE ORANGE type incident with additional security measures and reporting requirements. 1. Emergency Response Procedures A CODE ORANGE may be initiated when spills involving a disruption of services or one that may be life threatening. To implement such an emergency response, the employee will contact the hospital operator using the emergency dispatch number of "66" when calling from within a Lodi area facility. Out-of-town facilities will contact the local fire department by dialing 9-911. a. Small Spills are those where a non -harmful chemical or substance and the quantity is less than one quart by volume depending on the chemical properties. Department staff using the product or materials will respond to and control small spills within their department. Environmental Services may be contacted to assist providing there is no risk to humans or the Exposure, Spills And Releases, C-8420-140. Retricved 02/1712016. Official copy at http:/4odiheatth.policyst it.com/polieyn50818/. page 2 of 3 Copyright 0 2016 Lodi Health