Section: Departmental Safety

Date: November 25, 1996

Replaces: November 1, 1993

This section is provided for your department, school, or unit's safety policies and procedures. No one safety manual can cover all the needs for a diverse university/hospital environment. Some departments within the university and hospital, like Pathology, have developed their own departmental safety manual. For those departments, just a note in this section referring the staff to the safety policies and procedures will meet this section's requirements.

If you have not developed your own departmental safety policies and procedures, a committee should be appointed to address the individual safety needs of your area.

The Office of Environmental Health and Safety is available as a resource by calling 828-7899.

Safety Surveys

The Academic Medical Campus Safety Committee (SC) is required to perform a number of functions in order to comply with safety requirements under JCAHO. Some of these functions require departmental cooperation and response.

Operational and Facility Survey

The SC is required to assure, by monitoring and review, that each department within MCVH and MCVAP regularly survey their operations for compliance with all VCU/MCVH/MCVAP Safety Policies and Procedures. The results or summaries of such surveys need to be submitted to the SC annually in a written report. A copy of the completed survey should remain in the department's copy of this manual.

The surveys require physical inspection and observation of both facilities and operations, documentation of staff training, and query and evaluation of staff knowledge of safety policies and procedures.

Each report should include departmental corrective actions (and the positions responsible for any such action) for each areas identified by the survey as being sub-standard.

Policy and Procedure Review

In addition, each department will need to review departmental maintenance of and access to all applicable safety policies and procedures, within the department. This annual review requires each department to submit to the SC a statement, signed by the department head, that all relevant safety policies and procedures are in place and available to staff. A copy of the signed statement should remain in the department's copy of this manual.

Survey and Review Procedures and Documentation

Survey and review procedures may require different approaches by different departments. Departments of varying size, and operations may require more or less sophisticated survey instruments than those provided in this manual. Some departments may need to perform surveys much more frequently than annually to assure compliance. The following documents are meant to be instructive, but may be altered to meet the needs of individual departments.

Section: Departmental Safety

Date: November 25, 1996

Replaces: November 1, 1993

Department Survey: Survey must be submitted at least annually to the Hospital Safety Committee. A copy of the completed survey should remain in the department's copy of this manual.

Department Name:___________________________________Dept. Code___________      

Location: _______________________________________________________________

Department Head: Name_____________________________Signature:_____________

Date of Survey: ______________________________________

Surveyor(s): Name(s)___________________________Signature(s):___________________

Staff Training

Number of staff: ________________

Number with current Safety Awareness Documentation.

(Health Care Providers require annual updates. Non-Health Care Providers need 1 time documentation)

Health Care Providers: Current :_________ Out of Date:________

Non-Health Care Providers: Current :_________ Out of Date:________

Annual Performance Evaluations:

Are staff evaluated for safety training compliance during annual performance reviews? Yes _____ No _____

Do all staff know the location of and have access to the VCU/MCVH and

departmental Safety Manuals and Employee Safety Awareness Handbooks?

Yes ______No _____

Corrective Action Required:

Section: Departmental Safety

Date: November 25, 1996

Replaces: November 1, 1993

Workers Right To Know Statements

All employees must have a completed Workers Right To Know Statement on File. (Right To Know Statements should be up-dated to coincide with any change in an employees position or duties that result in new hazardous conditions or exposures.)

Staff with Statements on File: #______________

Staff without Statements: #__________________

Corrective Action Required:

Hazardous Communication

All employees have been instructed as to the location and use of Material Safety Data Sheets (MSDS)

Number of staff with documentation of such instruction: _________________ Without:_________________

Departmental MSDS are located where? _______________________________

Departmental chemical inventory is up to date. Yes _______ No ________

                                                                              (Copy attached)

Departmental chemical inventory is available to staff. Yes _______ No ________

All chemicals in work area are properly labeled. Yes _______ No (#) ________

(If no, record the number of containers not labeled)

Staff can identify hazardous materials in their work areas

Yes (#) _______ No (#) ________

(Record the number of staff surveyed as yes or no)

Staff can identify emergency procedures. Yes (#) _______ No (#) ________

(Record the number of staff surveyed as yes or no)

Corrective Action Required:

Section: Departmental Safety

Date: November 25, 1996

Replaces: November 1, 1993

Emergency Procedures

Employees have been issued R.A.C.E.R. procedure Cards. Yes (#) _______ No (#) ________

(Record the number of staff surveyed as yes or no)

Employees can identify:

Nearest Exits (at least 2 different exits) Yes (#) _______ No (#) ________

(Record the number of staff surveyed as yes or no)

Fire alarm pull station locations in their work areas. Yes (#) _______ No (#) ________

(Record the number of staff surveyed as yes or no)

Patient unit staff can identify patient relocation on demand. Yes (#) _______ No (#) ________

(Record the number of staff surveyed as yes or no)

Patient unit staff can identify Oxygen cutoff procedure. Yes (#) _______ No (#) ________

(Record the number of staff surveyed as yes or no)

All Dr. Red drills on unit have been rated satisfactory Yes _______ No ________

(If no attach dates and details of substandard drills)

Patient staff can identify procedures to be followed

in an external disaster. Yes (#) _______ No (#) ________

(Record the number of staff surveyed as yes or no)

Patient staff can identify procedures to be followed

in an internal disaster. Yes (#) _______ No (#) ________

(Record the number of staff surveyed as yes or no)

Corrective Action Required:

Section: Departmental Safety

Date: November 25, 1996

Replaces: November 1, 1993

Departmental Safety Audits

Are regular inspections of the work areas conducted?

Yes_______ No______ Frequency______________

If yes, who conducts these inspections _________________________________

To whom are deficiencies reported _______________________________________

Who is responsible for follow-up to assure corrective action is taken _________________________________

Are staff injury reports reviewed to assure accident prevention

steps have been implemented to prevent similar injuries.

Yes (# past 12 months)________ No ______

Are patient occurrence reports reviewed to assure accident prevention

steps have been implemented to prevent similar occurrences.

Yes (# past 12 months)________ No ______

Are the following VCU/MCVH/MCVAP Safety Manual, Safety Audit Guideline Forms Used: (Attach completed copies of all forms used.)

Safety Profile - General Safety Yes_____Yes (modified version)_____No ____ N/A ___

Safety Profile - Fire & Disaster Yes_____Yes (modified version)_____No ____ N/A ___

Safety Profile - Hallways, Stairs

& Exit Paths Yes_____Yes (modified version)_____No ____ N/A ___

Safety Profile - Electrical Safety Yes_____Yes (modified version)_____No ____ N/A ___

Safety Profile - Laboratory Yes_____Yes (modified version)_____No ____ N/A ___

Safety Profile - Vehicles Yes_____Yes (modified version)_____No ____ N/A ___

Are any custom departmental audit forms used? Yes_____ No _____ N/A _____

Audit reports kept on file for at least 2 years? Yes ______ Location of Files __________________________  No _______

Corrective Action Required:

Section: Departmental Safety

Date: November 25, 1996

Replaces: November 1, 1993

Radiation Safety

This unit has how many radiation workers?   (#) ________________

Can radiation workers identify radiation safety procedures?

(Record the number of staff surveyed as yes or no) Yes (#) ____________ N/A_________

Corrective Action Required:

Departmental Policies and Procedures

Are there departmental safety policies and procedures

in place, in addition to the VCU/MCVH/MCVAP Safety Manual?

Yes (#) _______ No _______

If yes, are they attached to or referenced in the

the "Departmental Safety Section" of your department's

copy of the VCU/MCVH/AP Safety Manual. Yes (#) _______ No _______

Please list any such policies:

Section: Departmental Safety

Date: November 25, 1996

Replaces: November 1, 1993

Policy and Procedure Review: Must be submitted annually to the Academic Medical Campus Safety Committee and a copy maintained in the departmental copy of the VCU, MCVH & MCVAP Safety Manual.

Department Name: ___________________________________________________

Location: ___________________________________________________________

This department has reviewed the VCU, MCVH & MCVAP Safety Manual, all applicable MCVH and MCVAP Departmental Safety Policies and Procedures. These policies and procedures are located within the department, and have been made known and available to staff. In addition supervisory staff have been made aware of their responsibilities to apply and enforce such policies.

Department Head: ___________________________________________________

Signature : _________________________________________ Date: ___________

OEHS