Audit

EC.02.02.01 The hospital manages risks related to hazardous materials and waste.

EP1 - The hospital maintains a written, current inventory of hazardous materials and waste that it uses, stores, or generates. The only materials that need to be included on the inventory are those whose handling, use, and storage are addressed by law and regulation. (See also IC.02.01.01, EP 6; MM.01.01.03, EP 3)

EP3 - The hospital has written procedures, including the use of precautions and personal protective equipment, to follow in response to hazardous material and waste spills or exposures.

EP4 - The hospital implements its procedures in response to hazardous material and waste spills or exposures. (See also IC.02.01.01, EP 2)

EP5 - The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals.

EP6 - The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of radioactive materials.

EP7 - The hospital minimizes risks associated with selecting and using hazardous energy sources. Note: Hazardous energy is produced by both ionizing equipment (for example, radiation and x-ray equipment) and nonionizing equipment (for example, lasers and MRIs).

EP8 - The hospital minimizes risks associated with disposing of hazardous medications. (See also MM.01.01.03, EPs 1–3)

EP9 - The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous gases and vapors. Note: Hazardous gases and vapors include, but are not limited to, ethylene oxide and nitrous oxide gases; vapors generated by glutaraldehyde; cauterizing equipment, such as lasers; waste anesthetic gas disposal (WAGD); and laboratory rooftop exhaust. (For full text, refer to NFPA 99-2012: 9.3.8; 9.3.9)

EP10 - The hospital monitors levels of hazardous gases and vapors to determine that they are in safe range. Note: Law and regulation determine the frequency of monitoring hazardous gases and vapors as well as acceptable ranges.

EP11 - For managing hazardous materials and waste, the hospital has the permits, licenses, manifests, and safety data sheets required by law and regulation.

EP12 - The hospital labels hazardous materials and waste. Labels identify the contents and hazard warnings. * (See also IC.02.01.01, EP 6)  Footnote *: The Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens and Hazard Communications Standards and the National Fire Protection Association (NFPA) provide details on labeling requirements.

EP 17 - For hospitals that provide computed tomography (CT), positron emission tomography (PET), or nuclear medicine (NM) services: The results of staff dosimetry monitoring are reviewed at least quarterly by the radiation safety officer, diagnostic medical physicist, or health physicist to assess whether staff radiation exposure levels are “as low as reasonably achievable” (ALARA) and below regulatory limits. Note 1: For the definition of ALARA, please refer to US Nuclear Regulatory Commission federal regulation 10 CFR 20.1003. Note 2: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.

EP18 - For hospitals that use Joint Commission accreditation for deemed status purposes: Radiation workers are checked periodically, by the use of exposure meters or badge tests, for the amount of radiation exposure.

EP19 - For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has procedures for the proper routine storage and prompt disposal of trash.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.