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Safety management Policy and Procedure Manual Table of Contents

SECTION I - SAFETY MANAGEMENT Program Organization Preamble, Documentation, Records Keeping Safety Management Plan Responsibilities EHSMS Policy Library Policy Reporting Policy Drills Policy Environment of Care Criteria Emergency Service Access Safety Committee Meetings Safety Committee Reporting Action Summaries Report Risk Assessment Risk Assessment Program

Ref. #

HSE-I-000 HSE-I-001 HSE-I-002 HSE-I-003 HSE-I-004 HSE-I-005 HSE-I-006 HSE-I-007 HSE-I-008 HSE-I-009 HSE-I-010 HSE-I-011

HSE-I-012

Safety management Policy and Procedure Manual Table of Contents Incident Report Protocol Entity Incident Reporting Entity Monthly Reporting HSE-I-013 HSE-I-014 HSE-I-015

Sector Submission of EHSMS Documents

HSE-I-016 HSE-I-017 HSE-I-018 HSE-I-019

Incident Reports Illness or Injury Work Related Back Injury Accident Investigation and Analysis Hazard Surveillance Safety Hazard Surveillance Exposure Control Plan - Engineered Sharps Injury Protection General Safety General Hospital Safety and Patient Management Visitor Safety Patient Orientation Patient Identification Fall Prevention Medication Error - Medication Precautions

HSE-I-020 HSE-I-021

HSE-I-022 HSE-I-023 HSE-I-024 HSE-I-025 HSE-I-026 HSE-I-027

Safety management Policy and Procedure Manual Table of Contents Beds and Side Rails Patient Age-Related Hazards Education and Training Employee Safety, Training and Communication Information Safety Orientation Registry Personnel Safety Orientation Special Training Body Mechanics Safety Continuing Education Staff Safety Questionnaire Medical Supplies and Devices Safe Medical Devices Manufacturer Recalls and Hazardous Device Notices Medical Device Recall Disposing of Recalls Electrical Safety Electrical Safety HSE-I-041 HSE-I-037 HSE-I-038 HSE-I-039 HSE-I-040 HSE-I-030 HSE-I-031 HSE-I-032 HSE-I-033 HSE-I-034 HSE-I-035 HSE-I-036 HSE-I-028 HSE-I-029

Safety management Policy and Procedure Manual Table of Contents Electrical Equipment Condition Lockout/Tag out Policy) Lockout/Tag out Training Personal Electrical Equipment Electrical Extension Cords Use of Electrical Equipment in Oxygen Enriched Environment Electrical Safety - Preventing Overload Electrical Safety - Electrical Beds Electrical Safety - Distribution Systems Equipment Condition Equipment Condition Biomedical Equipment Reporting Malfunction Operators Responsibility Preventative Maintenance HSE-I-051 HSE-I-052 HSE-I-053 HSE-I-054 HSE-I-055 HSE-I-042 HSE-I-043 HSE-I-044 HSE-I-045 HSE-I-046 HSE-I-047 HSE-I-048 HSE-I-049 HSE-I-050

Safety management Policy and Procedure Manual Table of Contents Recommendations For Laser Safety HSE Audits / Non Conformity / Inspection HSE Implementation and Monitoring HSE-I-056 HSE-I-057

HSE-I-058

HSE Target and Objective

HSE-I-059

Legislative

HSE-I-060

Motivation

HSE-I-061

Management Review

HSE-I-062

Contractor SECTION II - DEPARTMENTAL SAFETY Administrative and Business Office Safety Cardiopulmonary Safety Central Service Safety Dietary Department Safety Dialysis Safety Engineering Department/Service Safety Environmental Services Safety

HSE-I-063

HSE-II-001 HSE-II-002 HSE-II-003 HSE-II-004 HSE-II-005 HSE-II-006 HSE-II-007

Safety management Policy and Procedure Manual Table of Contents Clinical Laboratory Safety Laboratory Safety Quiz Materials Management Safety Nursing Services Safety Patient Safety Pharmaceutical Department Safety Physical Therapy Services Safety Diagnostic Radiology Safety Special Care Units Safety Surgical Department Safety SECTION III - SECURITY MANAGEMENT Security Management Plan Sample Security Mission Statement Hospital Security Security Authority Infant Security HSE-III-001 HSE-III-002 HSE-III-003 HSE-III-004 HSE-III-005 HSE-II-008 HSE-II-009 HSE-II-010 HSE-II-011 HSE-II-012 HSE-II-013 HSE-II-014 HSE-II-015 HSE-II-016 HSE-II-017

Safety management Policy and Procedure Manual Table of Contents Emergency Department Security Security Education - Emergency Department High-Risk Visitors Security Door Lockout Security Measures Involving VIP(s) Release of Patient Information to News Media HSE-III-006 HSE-III-007 HSE-III-008 HSE-III-009 HSE-III-010 HSE-III-011

SECTION IV - HAZARDOUS MATERIALS AND WASTE MANAGEMENT Hazardous Materials and Waste Management Plan Hazardous Materials and Waste - Notebook Hazardous Materials and Waste - Storage Hazardous Materials and Waste - Ordering and Receiving Hazardous Materials and Waste - Receiving MSDS How To Read MSDS Compressed Gas and Oxygen Use Hazardous Materials and Waste - Spills Hazardous Materials and Waste - Responsibilities HSE-IV-001 HSE-IV-002 HSE-IV-003 HSE-IV-004 HSE-IV-005 HSE-IV-006 HSE-IV-007 HSE-IV-008 HSE-IV-009

Safety management Policy and Procedure Manual Table of Contents Hazardous Materials and Waste - Departmental Management Hazardous Materials and Waste - Waste Disposal Disposal of Radioactive Materials Hazardous Materials and Waste - Training Hazardous Materials and Waste - Employee Injury Hazardous Chemical Communication Program Hazardous Materials and Waste - Engineering Department Hazardous Materials and Waste - Nursing Department/Service Hazardous Materials and Waste - Pharmaceutical Department Hazardous Materials and Waste - Materials Management Formaldehyde Precautions Mercury Handling Waste Anesthetic Gases Disposal of Sharps Asbestos Handling HSE-IV-010 HSE-IV-011 HSE-IV-012 HSE-IV-013 HSE-IV-014 HSE-IV-015 HSE-IV-016 HSE-IV-017 HSE-IV-018 HSE-IV-019 HSE-IV-020 HSE-IV-021 HSE-IV-022 HSE-IV-023 HSE-IV-024

Safety management Policy and Procedure Manual Table of Contents

SECTION V - EMERGENCY PREPAREDNESS Emergency Management Plan Hazard Vulnerability Analysis Emergency Preparedness - Preparations Emergency Preparedness - Committee Meeting Emergency Preparedness - Communications Emergency Preparedness - Security Emergency Water Supply Emergency Preparedness - Supplies, Utilities and Equipment Hospital Emergency Incident Command System Responsibilities

Ref. # HSE-V-001 HSE-V-002 HSE-V-003 HSE-V-004 HSE-V-005 HSE-V-006 HSE-V-007 HSE-V-008 HSE-V-009

Safety management Policy and Procedure Manual Table of Contents Emergency Management Control/Operations Center Emergency Preparedness - Personnel Pool Emergency Preparedness - Admission Policy and Registration Patient Chart and Victim Registration Log Disaster Welfare Inquiry Emergency Preparedness - Medical Staff Assignments Emergency Preparedness - Evacuation Disaster Nearby Community Staff Support Programs Emergency Preparedness - Staff Training Emergency Preparedness Plan - Drills Emergency Preparedness Evaluation Bomb Threat Bomb Threat Bomb Threat Room Search Bomb Threat Report Form HSE-V-022 HSE-V-023 HSE-V-024 HSE-V-010 HSE-V-011 HSE-V-012 HSE-V-013 HSE-V-014 HSE-V-015 HSE-V-016 HSE-V-017 HSE-V-018 HSE-V-019 HSE-V-020 HSE-V-021

Safety management Policy and Procedure Manual Table of Contents Riot or Civil disturbance Riot or Civil Disturbance Response Plan Earthquake Earthquake Response Procedure Radioactive Disaster Radioactive Disaster Functions Radioactive Disaster Disruption of Services Disruption of Services Procedure Disruption of Hospital Services Notification Disruption of Services Electric Disruption of Services Medical Gas Disruption of Services Natural Gas Disruption of Services Sewage Disruption of Services Water Failure of Air Conditioning System Failure of Operating Room Air Conditioning HSE-V-029 HSE-V-030 HSE-V-031 HSE-V-032 HSE-V-033 HSE-V-034 HSE-V-035 HSE-V-036 HSE-V-037 HSE-V-027 HSE-V-028 HSE-V-026 HSE-V-025

Safety management Policy and Procedure Manual Table of Contents Failure of High Pressure Boilers Failure of Elevators Failure of Fire Alarm System Failure of Nurse Call System Failure of Telephone System Failure of Piped Vacuum System and Compressed Air SECTION VI - DEPARTMENTAL EMERGENCY PREPAREDNESS Admitting/Switchboard Accounting, Business Office, Data Processing Cardiopulmonary Department Central Service Dialysis Dietary Department Emergency Department Emergency Triage Engineering & Security Department HSE-VI-001 HSE-VI-002 HSE-VI-003 HSE-VI-004 HSE-VI-005 HSE-VI-006 HSE-VI-007 HSE-VI-008 HSE-VI-009 HSE-V-038 HSE-V-039 HSE-V-040 HSE-V-041 HSE-V-042 HSE-V-043

Safety management Policy and Procedure Manual Table of Contents Environmental Service Clinical Laboratory Services Material Management HSE-VI-010 HSE-VI-011 HSE-VI-012

Emergency Triage Material Management

HSE-VI-008 HSE-VI-012

Emergency Triage Material Management

HSE-VI-008 HSE-VI-012

Medical Records Department

HSE-VI-013

Medical Staff Coordinator

HSE-VI-014

Medical/ Surgical/ Special Care Units Obstetric Department

HSE-VI-015 HSE-VI-016

Human Resources Department Pharmaceutical Department

HSE-VI-017 HSE-VI-018

Physical Therapy Services

HSE-VI-019

Safety management Policy and Procedure Manual Table of Contents Obstetric Department HSE-VI-016

Human Resources Department Pharmaceutical Department

HSE-VI-017 HSE-VI-018

Physical Therapy Services Diagnostic Radiology Department

HSE-VI-019 HSE-VI-020

Surgical Services Volunteer Services

HSE-VI-021 HSE-VI-022

Life Safety Management Plan Fire Safety Chain Of Command Key Fire Safety Duties Of Department Directors & Supervisors Fire Safety Duties Of Personal Fire Safety Hazards Fire Safety Evacuation Of Patient Fire Safety / Smoking Policy Fire Safety Hazards

HSE-VII-001 HSE-VII-002 HSE-VII-003 HSE-VII-004 HSE-VII-005 HSE-VII-006 HSE-VII-007 HSE-VII-005

Safety management Policy and Procedure Manual Table of Contents Fire Safety / Smoking Policy Fire Safety Hazards Fire Safety / Smoking Policy Material Of Equipment Purchases HSE-VII-007 HSE-VII-005 HSE-VII-007 HSE-VII-008

Life Safety Code Compliance

HSE-VII-009

Fire Safety / Construction Suitability Fire Safety / New Construction Statement Of Condition Fire Safety / Interim Construction Fire Drill Policy Fire Alarm System Testing & Inspection Fire Door Inspection

HSE-VII-010 HSE-VII-011 HSE-VII-012 HSE-VII-013 HSE-VII-014 HSE-VII-015 HSE-VII-016

Fire Control Valves Sprinkler Heads Fire Sprinkler System Repair

HSE-VII-017 HSE-VII-018 HSE-VII-019

Safety management Policy and Procedure Manual Table of Contents Fire Hydrant Inspection Fire Extinguisher Check Types Of Fire Extinguishers Fire Dampers Inspection Fire Safety General Instruction Business Office HSE-VII-020 HSE-VII-021 HSE-VII-022 HSE-VII-023 HSE-IIX-001 HSE-IIX-002

Cardiopulmonary Department Cardiac Rehab & Cardiology

HSE-IIX-003

Central Service

HSE-IIX-004

Dietary Department

HSE-IIX-005

Emergency Department

HSE-IIX-006

Engineering Department

HSE-IIX-007

Environmental Department Laboratory Services Material Department

HSE-IIX-008 HSE-IIX-009 HSE-IIX-010

Medical Records Department

HSE-IIX-011

Safety management Policy and Procedure Manual Table of Contents Nursing Department HSE-IIX-012

Obstetrics, Delivery Rooms & Nursery

HSE-IIX-013

Pharmaceutical Department Physical Therapy Services Diagnostic Radiology

HSE-IIX-014 HSE-IIX-015 HSE-IIX-016

Special Care Units

HSE-IIX-017

Anesthetizing Locations/ Surgical Services

HSE-IIX-018

Surgical Services

HSE-IIX-019

Switchboard Volunteers, Student/ None Staff Personnel

HSE-IIX-020 HSE-IIX-021