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+St.a case p is Medical Center <br />A..—.1 .o(CIM <br />At frequencies prescribed by governmental standards, hazardous waste is then transport to a <br />permitted, licensed treatment, storage and disposal facility (TSDF), by a licensed contracted <br />hazardous waste transporter (in accordance with applicable regulations). Safety, Materials <br />Management, EVS, Radiology, Engineering, and Pharmacy ensures that required documents <br />pertaining to this transaction are completed, signed and submitted, as appropriate (including <br />manifests, "milk run" shipping documents, land disposal restriction forms, etc.) <br />Regulated medical (biohazardous and sharps) waste is segregated from solid municipal wastes at <br />the point of generation. Further sharps waste is contained separately from biohazardous waste. <br />Biohazardous waste is contained within rigid, leak resistant, labeled containers; accumulated on- <br />site within secured areasi and treated to render it non-infectious. Sharps waste is accumulated <br />and offered for transport and recycling by a licensed transporter and permitted recycler. (See <br />Medical Waste Management Plan) <br />Emergency Procedures: <br />Emergency procedures and spill materials provide preventative, and precautionary to a spill or <br />release. The Safety Officer participates with department managers in the development and <br />implementation of emergency procedures and the uses of appropriate personal protective <br />equipment (PPE). <br />Releases will be managed from a standpoint of relative risk. Small relatively innocuous <br />hazardous material spills will be addressed by the individual causing or discovering the spill, <br />assuming it is safe to do so, appropriate containment materials are used and the responder has <br />received education and training on proper spill clean up. The management of large spills will <br />revert to emergency response agency personnel. In the event of a release or exposure involving <br />radioactive materials, the Radiation Safety Officer will immediately be notified and will coordinate <br />the response. The Safety Officer will ensure all releases and exposure incidents are duly <br />investigated and reported to the EOC/Safety Committee. <br />Equipment, materials, suppression systems, alarm systems and other features of the hazardous <br />materials and wastes management program are inspected and maintained primarily through <br />Engineering in concert with the Environmental Services, Materials Management, and Safety. <br />Examples include, but are not limited to: <br />• Hazardous waste accumulation areas and hazardous materials storage areas are inspected <br />routinely; and <br />• Engineering performs preventive maintenance on alarm systems and fire suppression <br />equipment systems. <br />PERFORMANCE MEASUREMENT <br />In an effort to continuously improve the safety efforts of the organization, the EC/Safety Committee, <br />through an Information Collection and Evaluation System, evaluates the Hazardous Materials and <br />Waste Management Program, including the appropriateness of design and the effectiveness of <br />implementation on an ongoing basis. Relevant reports of actions, as well as concurrent and <br />retrospective data are tracked, trended, and analyzed relative to the success of problem <br />identification and resolution, and ultimately program improvement. Reports provided to the <br />EC/Safety Committee will include the following: <br />simc 7 Revised 1110 <br />