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* EC: Clarifications and Expectations: HazMat-ter of Fact (PDF/QV) [REF: EC, SFT] EC News, December 2015, Vol 18, #12, Pg 6 JCe1512_B7
The article identifies 7 categories of hazardous material (i.e., radioactive materials, energy sources, gases/vapors; laboratory samples, chemicals, medications and infectious/medical waste). The last three of these may be most relevant to psychiatric hospitals. The standard that addresses the management of risks related to these hazards is EC.02.02.01. And, it was the 10th most frequently cited standard for TJC hospitals in the first half of this year. This article is the first of two parts that will address this standard. This installment addresses the following EP:
Re: EP 1_This EP requires an inventory. Pay particular attention to items addressed by OSHA, EPA, DEA, NRC and DOT. The article includes a wealth of additional detail about what specifics (e.g., material/manufacturer’s name, SDS sheet on file, PPE required, CAS catalog number, etc) should be documented in the inventory and [Pearl] a sample form is included at the top of page 7.
Re: EP 3-4_ These EP address having, documenting and implementing appropriate procedures. The author suggests much of the detail required for this can be found in related safety data sheets (SDS).
Re: EP 5-8_ These EP are about minimizing risks. EPs 5 and 7 are cited by surveyors as most problematic in this challenging standard. The author recommends conducting a risk assessment to help ensure compliance. The three steps required by the OSHA Certification of Hazard Assessment are referenced here.
Tip: Use the sample form for your HazMat inventory or ensure that all of its elements are included and addressed on the form you use.
See also: OSHA PPE Hazard Assessment Certification Form
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6 responses to “RTN1512_B7_C&E: Hazardous Material Management (EC.02.02.01) – Part 1/2”
Dr. Fields
What type of hazardous materials could a psych hospital have? We haven’t been able to come up with anything that is governed by law that needs to go on a written inventory as suggested in the EC News article (title is below). Thanks for your input….
Gayle
EC News: Dec 2015 Taking a closer look at EC.02.02.01 and the management of
hazardous materials and waste
Gayle Edgerly, M.A., CPHQ
Quality Management Director
Logansport State Hospital
gayle.edgerly@fssa.in.gov
Gayle – Great question, that I am going to pass along to an Associate more expert in EOC issues than I am. RAF
Hi Gayle!
As a provider of psychiatric hospital services, there are very few hazardous materials (regulated by law) compared with a general hospital that has Nuclear medicine and gases used for operating rooms etc.,
However, it is important to look at the intent of this chapter ie reducing the risk to patients, staff, visitors and others from contact with hazardous materials and waste that are used, generated and/or stored in the environment. The idea is to reduce risk by reducing the number and types of these hazards. This can be measured easily as part of the hospitals annual EOC evaluation.
Do not be tempted into taking what looks like an easy shortcut eg. We have no materials regulated by law.
A written assessment of what hazardous materials and waste the hospital has must still be conducted to demonstrate the above statement, otherwise, how do you know for sure?
In state hospitals, especially ones with older grounds and power plants, be careful not to overlook the following items that are regulated by law;
Underground fuel storage tanks (EPA), Electrical Transformers that contain PCB’s (EPA), Asbestos (EPA), for starters.
Psychiatric hospitals also care for the “medical needs” of patients and that generates Bio-hazardous wastes (EPA), and most Pharmacy’s utilize medications that are labeled “Hazardous” ( Hint- Birth control medications sometimes fall into this category and require special handling by Pharmacy and Nursing staff) and must be disposed of according to law and regulation (EPA and State Law, State Pharmacy Board).
These are the biggies, but let’s broaden the discussion to risk reduction;
OSHA requires that all chemicals be labeled for their harmful effects. This has become known over time as the MSDS sheets that every hospital needs to have available. Most hospitals have moved away from the MSDS books in every housekeepers closet and gone to an 800 number that, given the chemical product, can identify the hazards of any chemical found in the work place and describe what to do in an emergency.
But do you know what hazards each chemical possesses? What are the risks to patients, staff, students, visitors?
Some chemicals have labels that say “may cause irreversible eye damage”.
Why have such a chemical when alternatives may exist? Find that alternative and you have a measurable reduction of risk.
If the psychiatric hospital has Activity Therapy programs that include painting, have the safety officer check what spray cans are stored there for use and read the labels for hazards, call the MSDS 800 number if uncertain. (Note- These are risks that general hospitals do not usually encounter, because patients don’t come in contact with these chemicals.)
Psychiatric hospital, power plants, especially the old coal fired plants use powerful chemicals used for cleaning and treating boilers.
Have the safety officer find out if these chemicals pose a risk and whether alternative chemicals can reduce the risk to staff. If an alternative exists, risk is measurably reduced.
On the clinical side, make sure that Nursing staff, housekeeping staff, or Activity therapy staff or admin staff don’t bring in there own chemicals from home to use in the work site, because “They work better”. This is part of the management of hazardous materials.
Once the psychiatric hospital has reached a point where the list of hazardous or harmful chemicals is as low as it can possibly be (risk wise), then the inventory can remain small or list nothing other than the Bio-hazardous waste that is disposed of according to law and regulation.
Hope this is helpful.
Joseph J. Gigliotti, MSW
Thank you for the information. This was helpful.
I agree with the response. However, I would add some information about Global Harmonized System. (Big change in that they are no longer referred to as MSDS but SDS. See* below)
In my opinion, the facility should just start some where if they do not have anything. Start with the basics, most facilities have Hazardous Chemicals in Housekeeping (floor stripper , cleaning supplies etc), Facilities Engineering often will have cleaners for equipment which should be added. What a facility should not do is include items such as white out, non toxic fire stop materials, dish washing liquid.
* ” In 2003, the United Nations (UN) adopted the Globally Harmonized System of Classification and Labeling of Chemicals (GHS). The GHS includes criteria for the classification of health, physical and environmental hazards, as well as specifying what information should be included on labels of hazardous chemicals as well as safety data sheets. The United States was an active participant in the development of the GHS, and is a member of the UN bodies established to maintain and coordinate implementation of the system. The official text of the GHS can be found on the UN web page.” This link may help or may just confuse the issue more to some: https://www.osha.gov/dsg/hazcom/appendix_a.pdf
Barbara Pankoski – CHFM, CHSP-FSM|
Compliance Consultant
Healthcare Compliance Team LLC
4813 Ridge Road Suite 111-39
Douglasville, GA 30134
Clarification (by TJC in EC News, February 2016, Vol 18#2, page 10)
The article, “HazMat-ter of Fact: Taking a closer look at EC.02.02.01 and the management of hazardous materials and waste,” in the December 2015 issue of this newsletter stated on page 8 that the US Occupational Safety and Health Administration (OSHA) classifies a material as corrosive if it has a pH level of less than 2.5 or greater than 11.0. This information is outdated. OSHA considers a substance corrosive if it has a pH level that is less than 2 or greater than 11.5.