COMPLIANCE INFO_1983-2005 - Laserfiche WebLink

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during hazard surveillance is to determine if current conditions and practices support safe handling and storage of hazardous materials and wastes. Department managers are responsible for initiating action on findings related to the appropriate use of handling and storage spaces in their areas of responsibility. The Safety Office/ Facilities Manager provides the Safety Committee with reports of findings and follow-up action related to appropriate use of space as determined through the hazard surveillance program. E. INCIDENT REPORTING The Safety Officer/ Facilities Manager is responsible for the incident reporting process. The Hazardous Materials and Waste program utilizes the Confidential Report of Occurrence to document different types of incidents. The Safety Officer/ Facilities Manager completes the Confidential Report of Occurrence form and is responsible for notifying governmental agencies of incidents as required by the nature of the incident. The Safety Officer/ Facilities Manager 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 and the Safety Officer/Facilities Manager will maintain documentation on incidents. The Safety Officer/ Facilities Manager is responsible for developing recommendations based on the conclusions of the investigation and taking appropriate action to implement any recommendation developed. The Safety Officer/ Facilities Manager 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 program could control or prevent future occurrences. The results of the analysis are reported to Safety Committee. The incident reporting and investigation program is not used to measure the Hazardous Materials and Waste Management program performance because of the unpredictable nature of incident data. GAS MONITORING The Safety Officer/ Facilities Manager is responsible for managing the program for monitoring gases and vapors. Gases used in the hospital include helium, carbon dioxide, nitrogen, nitrous oxide and oxygen. Products used by San Joaquin General Hospital that may release vapors during normal use include xylene, formalin and glutaraldehyde. Current results of monitoring indicate that exposure levels are below the regulatory action level. Direct reading equipment has been installed on anesthesia machines. Annual review by a Certified Industrial Hygienist is performed to evaluate practices using these products on an annual basis and additional sampling may be required. G. ANNUAL EVALUATION The Safety Officer/ Facilities Manger has overall responsibility for coordinating the annual evaluation process for performing the annual evaluation of the Hazardous Materials and Waste Management program. The annual evaluation uses a variety of information sources that may include internal policy and procedure reviews, incident report summaries, Safety Committee meeting minutes and reports and other summaries of activity. In addition, findings by outside agencies such as accrediting or licensing bodies, or qualified consultants are used. The annual review examines the objectives, scope, performance and effectiveness of the Hazardous Materials and Waste Management