Clinical Haematology Health and Safety Policy

Health and Safety Policy
Clinical Haematology
Local Policy
Version 005
Approval Date 04/01/2018
Version Approved By S Rowley
Publication Date 04/01/2018
Bim Laguda/Simon Hack, Haematology Quality
Author(s)
Managers, Clinical Haematology
Owner/Sponsor Transplant Governance
Review By Date Review date logged in Q-Pulse
Responsible Lead/
Stephen Rowley
Director
Monitoring Committee Clinical Haematology Governance
Target Audience Clinical Haematology Clinical Staff
Related Trust Policies Refer to Section 7
Number of Pages and
52 pages including appendices
Appendices
Equalities Impact
Low
Assessment
Policy Category Clinical Haematology
Document Number HAEM-POL.0001
UCL HOSPITALS NHS FOUNDATION TRUST Health and Safety Policy
Version
Approval Date Summary of significant changes
No:
1 11/06/2008 New - N/A
2 02/09/2009 New - N/A
New trust template. Updated references and changes in

3 23/06/2015
policies associated with this document.
Related Trust Policies updated

‘Use of mains extension leads’ removed.
Section 9.23, Slips Trips and Falls amended
Section 11.0, Trust incident reporting section amended to
4 21/10/2016 reference different document.
Update to broken links and minor changes to text
throughout.
Appendix A: Action Plan for a Sharps/Needlestick Injury
contact details updated
New Trust logo

Related Trust Policy links amended
5 04/01/2018
Health and Safety at UCLH Handbook now references
other policies
Document Title/Identifier: Health and Safety Policy Page: 1 of 52

Published Date: 04/01/2018 Approved By: S Rowley
Policies, procedures and guidelines only current on date printed. Refer to Insight for definitive version
Contents
Section Page number
1.0 Summary ................................................................................................................ 3
2.0 Introduction............................................................................................................. 3
3.0 Objectives............................................................................................................... 3
4.0 Scope ..................................................................................................................... 3
5.0 Definitions............................................................................................................... 3
6.0 Duties and Responsibilities .................................................................................... 5
7.0 Related Trust Policies............................................................................................. 5
8.0 Basic Safety Precautions........................................................................................ 5
9.0 Slips, Trips and Falls .............................................................................................. 7
10.0 First Aid and Medical Facilities ............................................................................... 9
11.0 Trust Incident Reporting ....................................................................................... 10
12.0 Sharps and other Occupational Exposures to Blood & Bodily Fluids ................... 19
13.0 Biological Product Spillage ................................................................................... 21
14.0 Control of Substances Hazardous to Health (COSHH) ........................................ 22
15.0 Identification of Hazardous Substances ............................................................... 25
16.0 Cytotoxic Drug Safety ........................................................................................... 27
17.0 Radiation Safety ................................................................................................... 32
18.0 Liquid Nitrogen Safety .......................................................................................... 32
19.0 Manual Handling .................................................................................................. 35
20.0 Display Screen Equipment ................................................................................... 38
21.0 House Keeping/Infection control........................................................................... 39
22.0 Hand Hygiene....................................................................................................... 39
23.0 Fire Safety ............................................................................................................ 41
24.0 Waste Disposal .................................................................................................... 45
25.0 Health & Safety Training....................................................................................... 45
26.0 References ........................................................................................................... 46
Appendices
Appendix A: Health and Safety Representatives .......................................................... 47
Appendix B: Action Plan for a Sharps/Needlestick Injury.............................................. 48
Appendix C: Cytotoxic Spillage ..................................................................................... 49
Appendix D: Cytotoxic Spillage Action Plan .................................................................. 50
Appendix E: Biological Product Spillage ....................................................................... 51
Appendix F: Key Contacts ............................................................................................ 52

1.0 Summary
1.1 The following policy enables all staff working within Clinical Haematology at
University College London Hospital Foundation Trust with the tools to comply with
Health and Safety standards within the workplace. This policy is not fully
comprehensive but guides those working under Clinical Haematology to follow the
Trust wide policies already in place and make sure that they are meeting all
required criteria.
2.0 Introduction
2.1 The Clinical Haematology Health & Safety Policy discusses the potential hazards
that staff may encounter in the workplace and identifies which precautions to take
and when. This policy allows clinical haematology staff to be confident in knowing
their responsibilities in the maintenance of a safe work environment
2.2 The Haematology Ward Managers together with the Lead Nurse for Cancer have
overall responsibility for approval and implementation of the Health and Safety
Policy
3.0 Objectives
3.1 The purpose of the Clinical Haematology Health and Safety Policy is to identify
hazards at work, precautions needed and to show who is responsible for carrying
out those precautions. This policy attempts to ensure a safe system of work,
however it cannot be completely comprehensive. If further information is required
please contact your line manager, UCLH Health and Safety Advisors or
occupational health.
4.0 Scope
4.1 This document is aimed at all Clinical Haematology staff and additionally, this policy
applies to bank, agency and locum staff and where pertinent visitors, domestic and
maintenance staff.
5.0 Definitions
Causal Factors The underlying reasons behind the occurrence of an
event.
Concern A perception that a set of circumstances or a potential
error or hazard presents a risk which could lead to harm,
loss or damage if not addressed.
Grade A measurement of the risk useful for assessing the priority
for control measures for the treatment of different risks.
Harm Injury (physical or psychological), disease, disability or
death; applies to patients when not related to the natural
course of the patient’s illness or underlying condition or
treatment.
Hazard Any situation or physical factor which has the potential to
cause an Incident, or a hazard is something which has the
potential to cause injury, illness, harm, loss or damage.
HSCT Haemopoietic Stem Cell Transplantation Programme
Incident Any unintended or unexpected event that could have or
did lead to harm, loss or damage
Investigation A formal process of analysing an event and recording the
outcomes.
Likelihood How often an event might happen (per procedure/episode
or within a specified timeframe).
Mandatory This is training that has been determined by the Trust as
Training essential to specified groups of staff. Mandatory training is
concerned with minimising risk, providing assurance
against policies, and ensuring the Trust meets external
standards (e.g. CNST, IWL and Healthcare Standards).
MDA Medical Device Alert
Near Miss An event that had the potential to cause harm loss or
damage but was prevented, resulting in no harm, loss or
damage.
Research Incident Incident to a patient who is a subject in a research study
or trial or incident in a research study or trial.
Risk The probability that a specific adverse event will occur in
a specific time period or as a result of a specific situation
or risk is the likelihood that a hazard will have an adverse
outcome with a consideration of how bad the outcome is
likely to be.
Risk Rating A measurement of the risk useful for assessing the priority
for control measures for the treatment of different risks.
Risk Reduction The process by which the outcome or likelihood of
occurrence of an event is managed to an acceptable
level.
Root Cause A structured approach to retrospectively review an
Analysis incident and identify the true cause(s) of a problem, via its
contributory factors.
Serious Untoward An event deemed at Director level to be sufficiently
Incident or SUI serious to warrant a formal investigation reportable to the
Quality & Safety Committee (or the Research and
Development Governance Committee) and Board of
Directors. Usually it would involve the risk of death or
serious injury, major damage to property, create a major
health risk or involve multiple clinical problems such as a
serial drug error, or be a threat to the strategic objectives
of the Trust.
Statutory Training This is training that the Trust is legally required to provide
as defined by law (e.g. Management of Health & Safety at
Work regulations; Data Protection Act; Race Relations

Act) or where a statutory body has instructed
organisations to provide training on the basis of
legislation.
6.0 Duties and Responsibilities
6.1 Details of duties and responsibilities are outlined in each individual chapter.
6.2 Please see Health and Safety Representatives for the named Health and Safety
officers for your area.
7.0 Related Trust Policies

• Infection Prevention & Control Policy
• New and Expectant Mother's at Work Policy
• DATIX Incident Report Form
• Bedrails-Safe Use for Adult Patients Policy
• Mandatory Training Policy
• Being Open Policy
• Waste Management Policy
• Risk Management Policy & Procedure
• Radiation Safety Policy
• Safer Handling Policy- A Policy for Safe Moving and Handling.
8.0 Basic Safety Precautions

8.1 Key elements of standard infection and control precautions:-
8.1.1 Hand hygiene is most effective at the point of care. Hands must be
decontaminated before and after direct contact with the patient and or the
patient’s environment. Any existing cuts, lesions or skin breakdown to
hands and forearms should be covered with a waterproof dressing.
8.1.2 The main use of Personal Protective Equipment (PPE) is to protect staff
from the risk of exposure to blood and other body fluids. PPE include
aprons, gloves and goggles and should be used to reduce the opportunities
for transmission of micro-organisms from staff to patient and vice versa.

8.1.3 Handling of sharps must be kept to a minimum. Sharps must not be

passed directly from hand to hand. Where possible needles must not be re-
sheathed except in cases of preparation for intravenous administration of
medicines where aseptic technique must be maintained. Otherwise
needles must not be re-sheathed, bent, broken or disassembled prior to
disposal. All preparation of medication requiring needles must be prepared
in the clean utility room.
8.1.4 The exposure of blood and other body fluids poses a risk of infection,
therefore swift and effective management of spillages is essential for the
management, prevention and control of infection. All staff who have the
potential to be exposed to spillages of blood or other body fluids should
receive training on the safe and management of blood and other body fluid
spillages.
8.1.5 Healthcare linen must be handled correctly to reduce the risk of cross
infection to health care staff as well as linen handlers. Ensure that any linen
contaminated with blood or body fluids is placed into a red alginate bag and
then a clear bag.
8.1.6 Reusable patient equipment used for infectious/isolated patients or those in

side rooms must be thoroughly cleaned and decontaminated between each
patient use. When visibly soiled use chlorine based cleaning agent as per
manufacturers guidance.
8.1.7 The hospital environment must be visibly clean, free from dust and spillage
and acceptable to patients, their relatives as well as staff. Every health
care worker must report to the domestic services manager any concerns on
the cleanliness of the patient environment.
8.2 Please see the Infection Prevention & Control Policy for more detailed information.
8.3 Expectant & New Mothers
8.3.1 The phrase “Expectant or New Mother” means a member of staff who is
pregnant, who has given birth within the previous six months or who is
breastfeeding. Given birth is defined as “delivered a live child or, after 24
weeks of pregnancy, a stillborn child.
8.3.2 While pregnancy should not be considered as ill health, the condition of
expectant and new mothers warrants careful consideration in respect of the
workplace, as some hazards in the work place may adversely affect the
health and safety of the expectant mothers and their new-born child, as
well as the women of child bearing age. The line manager of the Expectant
or New Mother is responsible for carrying out a risk assessment as detailed
in the UCLH Expectant and New Mother Policy and is responsible for
informing staff of all identified hazards and remedial actions or risk
avoidance measures.
8.3.3 Please contact the Health and Safety Adviser if you require any assistance
in completing your risk assessment.
8.4 Occupational Health and Safety Department

8.4.1 This department is responsible for:
• Immunisation of clinical staff and other related protective measures;

• Health monitoring or surveillance including:
• Pre-employment health assessment and new entrants;
• Periodic health surveillance for certain groups of staff where there
may be an ongoing risk to them;
• Health assessment on return to work after illness or accident;
• Liaising with the Health and Safety Advisor on all the above issues
8.4.2 For contact details, services and more information please visit the
Occupational Health & Safety page on Insight.
8.5 Protective Clothing
8.5.1 Protective clothing such as overalls, white coats and aprons are provided in
certain work areas in order to protect staff and service users. Where
protective clothing is provided and/or detailed in procedures it should
always be worn otherwise unnecessary health and safety risks will arise
and could lead to serious accidents.
8.6 Please see Health and Safety Representatives for the named Health and Safety
officers for your area.
9.0 Slips, Trips and Falls

9.1 Slips and trips resulting in falls are the most common cause of injuries in all
workplaces in the country and the second biggest cause of “over 3 day” injuries.
9.1.1 The four main causes of slip and trip accidents involving staff and visitors in
a hospital are:
• Slippery/wet surfaces – caused by water and other fluids

• Slippery surfaces caused by dry or dusty floor contamination such as
plastic, lint or talcum powder
• Obstructions, both permanent and temporary
• Uneven surfaces and changes of level, such as unmarked ramps.
9.2 Roles and Responsibilities
9.2.1 Roles and responsibilities are defined in more detail in the associated
policy.
9.2.2 Ward Staff must:
• Ensure that patients (as far as possible) are orientated to the ward or
department,
• Assess the patient’s risk of a fall using the Trust’s Slips, Trips and
Falls Risk Assessment Tool. The risk score and subsequent actions
taken must be recorded in the clinical notes and care plan. If the
patient’s admission is thought to be as a result of a fall caused by
medication, this should be brought to the attention of the ward
pharmacist.
• Ensure that beds are left at the lowest level unless a member of staff
is with the patient and adhere to the Trust’s Safe Use of Bedrails
Guidelines
• Ensure that bed areas are kept free of clutter and items that may be
hazardous or increase the risk of falling
• Encourage patients to wear suitable footwear and ensure that they are
adequately supervised if unsteady when walking.
• Ensure that patients with walking aids have them close by.
9.2.3 All Staff must:
• Be vigilant and report to their manager any slip, trip and fall hazard
that they are aware of.
• Follow the Slips, Trips and Falls Staff Checklist (available in the
associated policy).
• Report spillages promptly and ensure that action is taken.
• Appropriately clear up spillages and use appropriate signage to warn
people of hazards
• Assess seating and beds to ensure these are of the correct height and
in good working condition for patients who are at high risk of falling,
adhering to the Trust’s Safe Use of Bedrails Guidelines.
• Position equipment to avoid cables crossing pedestrian routes.
• Ensure that they do not carry drinks around if they are likely to create
a hazard.
• Ensure that the incident is reported to DATIX, the Trust incident
reporting system, for all adverse events, near misses or hazards
associated with slips, trips and falls.
• Ensure that they wear suitable footwear for the activities they are
carrying out.
9.3 Risk Assessments
9.3.1 Risk assessments should be undertaken when there is a potential for slips,
trips and falls. The UCLH Slips Trips and Falls Policy - Management and
Prevention directs staff to:
• Slips, Trips And Falls Audit Checklist For Ward Sisters/Departmental

Managers
• Patient Slips, Trips and Falls Risk Assessment Tool and Patient Plans
9.3.2 All risk assessments should be recorded and reviewed at regular intervals,
at least annually and more frequently if circumstances change. When
undertaking slip, trip and fall risk assessments, the following factors should
be considered:
9.3.3 The Individual - The age, fitness and dexterity of the individual must be
considered.
9.3.4 The Task or Activity Being Performed - Consideration will be given to

whether employees need to carry objects which are awkward in shape,
there are obstacles to be avoided etc.
9.3.5 The Immediate Environment - Consideration will be given to slip, trip and
fall hazards created by the physical layout of the area.
9.3.6 Footwear - Footwear plays an important part in preventing slips, trips and
falls. Staff, especially those working in higher risk environments, are
responsible for ensuring that they wear suitable enclosed footwear for the
environment in which they work with non-slip soles.
9.4 Incident Reporting and Investigation
All adverse events and near misses involving slips, trips and falls, whether there has been
an injury or not, must be reported in line with the Trust’s Incident Reporting Policy by
completion of a DATIX, on line reporting of incidents. This will then be investigated by the
line manager to ensure that any necessary preventive action is taken to prevent
recurrence
10.0 First Aid and Medical Facilities

10.1 First Aid is defined as treatment to preserve life and minimise the consequence of
any injury until help from a medical practitioner or nurse arrives. It also includes the
treatment of minor injuries, which may otherwise receive no treatment or would not
require treatment from a medical practitioner. The Trust as a health care provider
does not need to provide a first aid room as access to medical help and accident
and emergency facilities is not difficult. Adequate numbers of first aid personnel
however, must be provided to cover the needs of the Trust.
10.2 Who are First Aiders: First Aiders are employees who have volunteered for the role
and who have been suitably trained and passed an examination in accordance with
the Health & Safety Executive’s requirements. A notice should be provided in each
department stating who the First Aiders are, where they can be found or contacted
and also where the First Aid box is kept.
10.3 In clinical areas with a high proportion of doctors & nurses as in wards or outpatient
departments, it may be more appropriate to nominate the nurse in charge of each
shift as the ‘First Aider’. This would allocate the responsibility of assessing first aid
situations and either treating a minor illness/injury or calling for more help if deemed
a major injury. The nurse in charge should direct other members of staff to the First
Aid box if necessary.
10.4 First Aid Boxes
10.4.1 First Aid boxes may be ordered via the procurement system

10.4.2 First Aid boxes should contain at least minimum supplies, which are
required by law. Only specified first aid supplies should be kept. No
creams or drugs, however seemingly mild, should be kept in the boxes.
10.4.3 The location of the first aid boxes and the name of the persons responsible
for their upkeep must be clearly indicated on the notice boards within each
department. The contents of the first aid box must be examined frequently
and restocked after use and any expired contents must be disposed of
safely.
10.5 First Aid Boxes Should Display The Following Information:
• The name of the person responsible for their upkeep;
• The contents of the first aid box and replenishing arrangements;
• The location of accident/incident report forms.
10.6 Occupational Health Services
10.6.1 If you have a needlestick/sharps or splash injury, the Occupational Health

department should be contacted during office hours (08.30 - 16.30)
Monday to Friday on 0203 447 5474. Out of office times, report to A&E at
UCH,(16.30 - 08.30, weekends, public holidays). It is important to mention
that, while our clinical staff are qualified doctors and nurses, we do not offer
a treatment service for general cuts and bruises etc. However, we can, if
asked by you, support your efforts to obtain treatment through your doctor
or hospital.
Detailed information about facilities, risk assessment and procedures relating to first aid
can be found in the Health and Safety at UCLH Handbook.
11.0 Trust Incident Reporting

11.1 This section describes how staff should report Trust reportable clinical and non-
clinical incidents, including hazards, near misses and potential incidents. It covers
all incidents, whether they involve patients, relatives, visitors, members of staff,
contractors, the general public or are associated with research.
11.1.1 Incident reporting is an important tool in the drive to reduce risk and
improve safety. University College London Hospitals NHS Foundation Trust
recognises that incidents usually occur because of a combination of human
errors and systems problems (i.e. issues with training, procedures,
maintenance, communication etc.) and are rarely one person’s fault.
11.1.2 For further information refer to Risk Management - Incident Reporting

Policy and Procedure
Roles and Responsibilities
11.1.3 Roles and responsibilities are defined in more detail in the appropriate
policy
11.1.4 Every member of staff

Everyone in the organisation has a responsibility to:
• Maintain general risk awareness and accept personal responsibility for

maintaining a safe environment, notifying line managers of any
identified risks.
• Report incidents, accidents, mistakes and ‘near misses’ and action
taken using the incident reporting process.
• Comply with Trust rules, regulations and guidance to protect the
health, safety and welfare of anyone using, staying within, or visiting
Trust premises.
• Maintain confidentiality of patient and Trust information.
• Be aware of emergency procedures, e.g. resuscitation, first aid,
evacuation and fire precautions, as relevant to the employee’s
particular work area.
• Co-operate in the investigation and review of incidents to improve
future services and reduce future risks.
11.1.5 Ward sisters/charge nurses, department heads and/or those with line
management responsibility
Every ward sister/charge nurse and department manager has a

responsibility to:
• Review incidents, accidents, mistakes and ‘near misses’ reported to
their department.
• Undertake initial categorisation of the type of event and seriousness
on the incident form;
• Foster an environment in which staff are encouraged to report
incidents and discuss the implications constructively and openly.
• Maintain departmental policies and procedures and ensure staff are
aware of them and are trained to follow them.
• Contribute to clinical division and corporate discussions and reviews
(both on own initiative and when asked to do so).
11.2 Reporting Incidents & Near Misses
11.2.1 A reportable incident is any unintended or unexpected event that could

have or did lead to harm, loss or damage that contains one or more of the
following components:
• It is an accident or other incident which results in injury or ill health.

• It is contrary to the specified or expected standard of patient care or
service.
• It places patient(s) or staff member(s), or visitor(s), contractor(s) or
members of the public at unnecessary risk.
• It puts the Trust in an adverse position with potential loss of
reputation.
• It puts Trust property or assets in an adverse position or at risk of loss

or damage.
11.2.2 All incidents, including near misses must be reported on the Trust Incident
Reporting System, called DATIX. The portal is available via the Trust
Intranet
11.3 Reporting a ‘near miss’ event is as important as reporting incidents that actually
occurred and caused harm. Although a ‘near miss’ did not cause harm the potential
for recurrence probably still exists and this needs to be managed effectively.
11.4 Steps to Take Following an Incident or a Near Miss:
11.4.1 Immediate Action
11.4.2 Before the reporting system is commenced some incidents will require
prompt and specific action to deal with the problem. This may involve:
• Emergency medical care.

• Summoning assistance.
• Ensuring that all at risk patients, staff, visitors and others are moved to
a safe environment.
• Treating/caring for others affected.
• If the incident could recur, taking immediate action to prevent this.
• If equipment/machinery is involved, removing it from service (marking
it clearly out of order). Isolate any faulty equipment in a safe place for
later inspection without altering its settings. You should record any
settings that may be lost when the machine is turned off.
• Notifying senior members of staff on duty.
• Where appropriate, notifying a patient’s family.
• Considering the need to make an apology to the patient and family; an
apology invariably improves relationships and communications and,
note, is not an admission of liability.
• Recording the action taken in the patient’s medical record, and
consideration should be given to copying or retaining the patient
record at this stage to aid further analysis.
11.4.3 Where death or serious injury has occurred or you regard the incident as
very serious, reporting must be immediate, i.e. by telephone to senior
managers, or to Site Managers or on call managers outside normal working
hours. The Risk Management Department should also be informed at the
earliest possible time and the Trust Datix reporting form completed.
11.4.4 If any piece of equipment is involved in an incident:
• Remove it from service (marking it clearly out of order).

• Retain the device/equipment involved in the incident, including
packaging and instructions where appropriate.
• Isolate any faulty equipment in a safe place for later inspection without
altering its settings.
• If it is a machine try to leave all switches and controls as they were at
the time of the incident unless it is not safe to do so, in which case
make a note of all settings.
• Send the device to the Medical Physics department.
• Medical Physics will be responsible for reporting any relevant
incidents to the Medicines and Healthcare Products Regulatory
Agency.
11.5 Reporting an incident, near miss or concern
11.5.1 Your Duties as a Trust Employee
• As a member of staff, you are required to inform your line manager of

incidents, near misses, hazards and concerns. Your duty to report
applies even if you are not directly or potentially affected.
• When an incident or a near miss occurs, the Trust Incident Reporting
System, DATIX must be used – this is available via the Trust Intranet
portal. All incidents must be reported as promptly as possible.
• You should complete the on line form, available here, in the
mandatory field areas – these are displayed by a ‘red asterix’. The
severity of the incident or potential incident will also need to be
included. Once submitted, a notification is sent to your line manager
and the investigating managers from the area involved. Note: Do not
delay reporting because some information is unavailable; this
can be added later.
11.5.2 The Line Manager’s Role
On receipt of an incident form, the line manager’s role is to:
• Identify if any harm has come to the patient (near miss, no harm, short
term, long term or death).
• Ascertain immediate causes (i.e. local analysis of what happened, and
why (root causes).
• Take action and record what actions were taken, or will be taken,
including an indication of whether further analysis/investigation is
required.
• Inform the member(s) of staff who completed the incident form on
what action you intend to initiate or to take.
• Inform other staff who are able to take action by copying the form to
them or ensuring that the appropriate section is ticked on the DATIX
form, e.g. medication errors to the Pharmacy or needlestick injuries to
Occupational Health.
• Where the incident affects a patient, ensure that relevant information
is added to the patient record.
• Ensure that staff preserve all relevant documents, equipment,

devices, drugs or any other item that may be used to assist any
subsequent investigation. Medical records should be copied so that
the originals can be made available for ongoing treatment, and kept
securely, in preparation for a legal claim for example.
• Grade the actual incident likelihood and severity using the Trust risk
grading matrix.
• Let the Quality and Safety team know if they are unable to view the
incident form or need to be reallocated.
• Line managers and staff should work together to ensure that the
specific concerns raised are acted upon and information about the
incident and the outcomes shared as widely as possible, seeking
corporate advice if needed from relevant departments, e.g.: -
• the Risk Management Team in the Governance Department,
• the Research and Development Directorate if the incident is research
related,
• the Infection Control Team,
• Occupational Health and safety services.
• Partner organizations i.e. Interserve, CGI etc.
11.5.3 This information would normally be discussed locally within the Divisional
Governance Groups.
11.5.4 Notifying the Risk Management Team in the Governance Department,

while necessary, is not a sufficient response to an incident.
11.6 Follow-up Action and Lessons Learned
11.6.1 For all incidents and near misses, After Action Review (AAR) may be
conducted in order for lessons to be learned and behavioural patterns to be
altered post the event. AAR is not a substitute for formal investigation, but
may be used in conjunction with the incident reporting and investigation
process. Where AAR has taken place, the summary report may be
included with any completed report and the AAR box ticked.
11.6.2 For no harm and low harm, incidents actions and learning shall be
managed at a local level.
11.6.3 Moderate harm incidents shall be managed at a divisional level
11.6.4 Severe incidents and those that led to the death of a patient, should be
managed to a serious incident procedure.
11.6.5 The line manager if necessary should communicate with colleagues,

formally via the local Governance Committee or informally and agree
measures needed to resolve the issue and consider possible preventative
measures to reduce the likelihood of recurrence.

11.7 Action Plans
11.7.1 Where formal actions are required to prevent a recurrence of an adverse

event, near miss or concern, an action plan should be prepared detailing
• Root cause/s
• Actions to be taken,
• Member of staff leading on the action,
• Timescale for action to be implemented, and
• Deadlines for completion.
11.7.2 Action plans should be reported and monitored at local governance

meetings in accordance with the timescales stated for each action. Once
the action plan has been implemented it should be retained by the relevant
department. SI action plans will be monitored by the Quality & Safety
Committee.
11.8 Communicating With the Patients and Families
11.8.1 When an incident has occurred, the UCLH Being Open Policy is to
communicate the facts as openly and rapidly as possible with patients and
their families or individuals close to the family. This should be done
whenever possible by a member of staff known to the person affected. It is
particularly important in circumstances where external agencies may
become involved to inform those affected, including staff, before this
happens.
11.9 What is a “Serious Incident”?
11.9.1 A Serious Incident, or SI, is an event determined by the Director of Quality

& Safety or Corporate Medical Director to be sufficiently serious to warrant
a formal investigation reportable to the Quality & Safety Committee and
Board of Directors, which meets the definitions of the NHS England
Serious Incident Framework. A RCA investigation is required into all
incidents classified as an SI. If a serious incident is reported initially as a
complaint or claim, this process must also be followed.
11.9.2 An investigation is required into all incidents classified as an SI as detailed

in the Risk Management - Incident Reporting Policy and Procedure
11.10 Risk Assessment
11.10.1 Risk assessment is a technique for proactively identifying and addressing

risks in all settings. It is a key tool for effective risk management both in the
context of health and safety management and for management of risks in
all other settings across the Trust (including clinical risks, financial risks,
environmental risk etc). The Trust has a legal duty to undertake risk
assessments to protect staff under the Health and Safety at Work Act
1974, in addition it is a key building block of the Trust’s approach to
governance and risk management.
11.10.2 Effective risk assessment is based on a series of steps, involving

identifying risks, assessing the extent of the risk, determining whether
action needs to be taken to reduce the risk, and then taking action and
evaluating the results of the action. The UCLH Risk Assessment policy
describes these steps for generic risk assessment in more detail, but is not
designed to be prescriptive, as different types of risks and different settings
may require local adaptation of the principles.
11.10.3 Should you require assistance with risk assessment issues please contact
the Health & Safety Advisors or your Health & Safety Officer.
policy.
11.11.2 All Members of Staff:
All staff have individual responsibility for engaging in risk management

activities at the Trust. Key responsibilities of staff in respect of risk
assessment are to:
• Bring immediate /hazard issues to the attention of their line manager.

• Act safely at all times.
• Co-operate with risk assessments and action plans in operation to
reduce risk.
• Comply with the Trust’s policies, procedures and guidelines that are in
place to protect the health, safety and welfare of anyone affected by
the Trust’s activities.
11.11.3 Risk Leads: Risk Leads are responsible for ensuring relevant risk
assessments are carried out, divisional/departmental risk registers are
updated and reviewed and incidents are reported in a timely manner by
staff.
11.11.4 All Line Managers: Managers working throughout the Trust are response
for ensuring that local risk management activities including risk
assessments are carried out to support Trust-wide learning from risk
issues.

11.12 The Risk Assessment Process
The risk assessment process involves five steps:-
Figure 1: Five steps to risk assessment (source National Patient Safety Agency)
11.12.1 Identify the Hazards (What Can Go Wrong?)
11.12.2 To prevent harm it is important to understand not only what is likely to go

wrong but also how and why it may go wrong. Consider the activity within
the context of the physical environment, the culture of the organisation and
the staff who perform the activity. Take into account things that have gone
wrong in the past and near-miss incidents.
11.12.3 Learn from the past:
• Walk around the workplace and talk to staff.

• Map or describe the activity to be assessed.
• The risk assessment may require a multi-disciplinary team.
11.12.4 Decide who or how people might be harmed or what the impact will be on
the organisation (assets, environment and reputation)
11.12.5 People will make mistakes. It is necessary to anticipate some degree of

human error and try to prevent this error resulting in harm:
• Consider the number of staff members or patients that might be

affected over a stated period of time. When quoting the number of
patients affected you should always state the length of the
assessment period.
• Think about the complexity of the task.

11.12.6 Evaluate the risks (how bad? how often?) and decide on the precautions (is
there a need for further action?)
11.12.7 Consider both the severity (how bad?) and likelihood (how often?). Is there
a need for additional action? The law requires everyone providing a service
to do everything reasonably practical to protect patients and staff from
harm.
• Identify the current controls/precautions that are in place to prevent

the risk from causing harm or loss
• Use the risk matrix and guidance in the HSCT Risk Assessment
tool to grade the risk.
• Decide on the precautions (controls) that will most effectively
reduce consequence and / or likelihood.
• Re-evaluate the risks assuming the precautions (controls) have
been taken.
11.12.8 Record your findings, proposed action and identify who will lead on what
action. Record the date of implementation.
11.13 It is a key part of this procedure that risk assessments must be recorded, either on
the UCLH risk assessment template or on a local proforma such as HSCT Risk
Assessment Form (HSCT-FORM.00023.
11.14 Risk assessments and action planning should be reviewed and changed when
necessary. This is easy only if the assessment is well recorded and the logic
behind the decisions transparent. By clearly documenting the findings on the risk
assessment form you will be able to show that:
• A thorough check was made to identify all the hazards and treat all the
significant risks;
• The precautions that are in place are appropriate to the risk and remain
effective;
• The solutions proposed or being actioned to reduce the risk are realistic,
sustainable and effective.
11.15 Storing Completed Assessments
11.15.1 Completed risk assessments should be stored in the local Health and
Safety File. A copy of risk assessments with a risk score > 6 should be
forwarded to the Divisional Lead for Risk. Clinical risk assessments relating
to an individual patient should be stored in the patient’s medical records.
11.16 Review your assessment and update if necessary
11.16.1 Risk assessments should be reviewed in the following circumstances:
• When a change is planned that could have an impact on the risk.

• If the proposed action generates a new hazard;

• When there has been a significant change.

• Following the completion of an action plan designed to reduce the risk
(to confirm that risk reduction has been achieved)
• Routinely at least on an annual basis; (more frequently for high risks)
11.17 Organisational Management of Risk
11.17.1 Line Managers are responsible for ensuring risk assessments are
undertaken in their areas. The Health and Safety Advisors will support the
line managers and provide training as appropriate.
11.17.2 The management of risks identified through the risk assessment process
will be determined by the risk rating:
• High (15-25): The risk should be escalated to and managed at a

Divisional Level and recorded on the Divisional/departmental risk
register. The risk and associated action plan to reduce it should be
reviewed every quarter.
• The Divisional /department risk register will be reviewed by the Risk

Register review Group to determine which risks should be escalated
to the Corporate Risk register.
• Medium (5-12): The risk should be managed at a departmental level.

The risk should be recorded on the divisional/departmental risk
register, as above this register will be reviewed by the Risk Register
review Group to determine which risks should be escalated to the
Corporate Risk register.
• The risk should be reviewed at least annually, and in a shorter time
frame if the associated action plan is less than a year.
• Low (1-4): The risk can be managed at a local level. The risk should
be reviewed at least annually.
11.18 The level of management action is for guidance only. Where management action is
insufficient to reduce the risk rating this should be escalated via the Line
Management structure.
12.0 Sharps and other Occupational Exposures to Blood & Bodily

Fluids
12.1 Sharps and splash injuries pose a risk of transmission of blood-borne viruses.
Health care workers are recognised as at particular risk. Most injuries are avoidable
and every effort must be made to avoid sharps injuries. Sharps must not be passed
directly from hand to hand and handling must be kept to a minimum. Needles must
not be bent or broken before use or disposal. Needles and syringes must not be
separated by hand before disposal. Needles should not be recapped.
12.1.1 A sharps incident is defined as:-

• inoculation with an instrument such as a needle or scalpel blade which

has been contaminated with blood or other body fluid, or
• blood or body fluid splashed into the eye or onto a mucous membrane
or onto a skin surface which has an open cut or abrasion.
12.1.2 The recipient is defined as the person who has suffered the injury. The
donor is defined as the person whose blood/body fluid has contaminated
the injury. Usually, a member of staff is the recipient and a patient is the
donor. However, sometimes a patient may be a recipient, for example in
surgery. A member of public may also occasionally be a recipient of a
sharps injury.
12.2 Prevention
12.2.1 Safe devices have been introduced into the Trust to replace conventional
devices. Initiatives promoting safe sharps practice are run in the Trust and
are reported to the ICT and ICCs. The risk can be reduced by safe
practices when handling sharp instruments and proper disposal of used
sharps.
12.2.2 Sharps injuries can be avoided by:
• Use common sense to prevent injuries.

• Learn to avoid any action which directs a used sharp towards the
hand.
• Do not pass sharps from hand to hand.
• Obtain help when taking blood from or putting up a drip on
uncooperative patients.
• Do not leave used sharps for others to clear up.
• Do not use receivers to carry used sharps after phlebotomy but carry
a sharps bin to the bedside.
• Dispose of used sharps straight away in a sharps bin
(UN3291/BS7320) See waste management policy.
• Discard sharps bins when 3/4 full.
• Keep sharps bins away from children.
• Do not put needles in plastic bags.
• Never resheath or bend used needles.
• Follow the guidelines for the safe handling of sharp instruments in
operating theatres.
• Wearing eye protection if there is any risk of aerosol or spray from the
procedure.
• Examine ways to make surgery safer for the operators
• Training and competence in procedure
• Use safety equipment where available
• Do it in good light
• Don’t do it when tired
• Use PPE including gloves.
12.2.3 Action Following a Sharps Incident
12.2.4 Report to their immediate superior or a senior member of staff present

wherever possible if this can be done without undue delay. For staff
working on their own in the community, and experiencing any delay in
contacting someone more senior, they should proceed with the steps on
the sharps procedure and report to their manager as soon as possible after
this.
12.2.5 See Action Plan for a Sharps/Needlestick Injury: for the Sharps and or
blood/bodily fluid action plan.
12.3 Manager/Senior Member of Staff
• Reassure the recipient.

• Instruct the recipient to telephone the Occupational Health and Safety
Service or, out-of-office hours, A&E.
• Check from the notes or computer whether the donor (patient) has
recently had a test for hepatitis B, hepatitis C, HIV, or is known to be
positive. If the donor is HIV positive, the recipient must get antivirals
immediately.
• Arrange for the donor's notes or to be checked to establish if there are
any results of tests for blood-borne viruses – HBV, HCV and HIV.
• Arrange for donor blood to be taken and tested.
• Arrange for the recipient's blood to be taken for SERUM SAVE.
• Complete an incident form with the recipient.
12.3.1 For further information refer to the Health and Safety at UCLH Handbook.
13.0 Biological Product Spillage

13.1 A spillage may be defined as a leak or spill of blood or other body fluid from a
patient, equipment, specimen, container or cadaver. All spillages present a potential
infection hazard so they must be dealt with promptly. For further information refer to
the infection control Insight page.
13.2 Equipment Required:
13.2.1 Minimum information required on specimen label:
• A face visor is recommended

• Disposable cloths and towels or incontinence pads

• Yellow plastic sack.
13.3 Appropriate chemical disinfectant:
• For all BLOOD spills, (and any spillage from a patient suspected of being
infected by HIV, HCV or HBV), use Sodium Dichloroisocyanurate granules
directly or tablets in solution*, (e.g. ten 1.7g Acticlor Tablets™ per 1 litre of a
tap water = 10,000 ppm free chlorine). Read the instructions.
• For other body fluids (not indicated above) use a phenolic (Hycolin 2%)
solution (if available) or 10,000 ppm free chlorine* as above.
• *Chlorine fumes will be released when Chlorine-releasing (eg Haztab, or

Presept) granules are used, so ensure the area is well ventilated. If possible,
stay away from the spillage while the disinfectant is acting. Danger: do not
put granules on urine spills until they have been mopped up.
13.4 Action Required:
• Move patients and other workers away from the spillage
• Don protective clothing before handling the spillage and chemical

disinfectant; use domestic gloves
• Cover the spillage with the appropriate disinfectant; leave to act for a
minimum of 5 minutes
• Mop up the spillage using disposable cloths or wipes until the area is visibly
clean
• Dispose of wipes and protective clothing in yellow plastic sack; seal sack and
send for incineration; label with biohazard tape if appropriate
• Wash and dry hands thoroughly
• Contact Domestic Staff to "spot" clean area with general purpose detergent
• Note that chlorine solutions tend to leave floors slightly sticky or slippery
13.5 Please see Appendix E: Biological Product Spillage for more information.
14.0 Control of Substances Hazardous to Health (COSHH)

14.1 To comply with COSHH Regulations employers must demonstrate that hazardous
substances have been identified and the significant risk formally assessed, and the
effective control measures have been put in place, and that the risk assessment
and the means of controlling risk are recorded. For more information refer to the
UCLH COSHH policy.
14.2 Substances hazardous to health are defined as:

• A substance that has been assigned a Workplace Exposure Limit (WEL) in

the HSE Guidance Note EH40- Workplace exposure Limits.
• It has black/orange label on the container which classifies it as very toxic,

toxic, harmful, corrosive or irritant.
• Biological agents such as bacteria and viruses.
• Dust present in substantial quantities.
• Any substances having properties similar to the above.
policy.
14.3.2 Line Managers will ensure that;
• All staff are made aware of the COSHH policy

• All hazardous substances used, produced or that the department is
exposed to have been identified and documented using the Trust
COSSH assessment form.
• A risk assessment has been carried out for each hazardous
substance identified and documented using the Trust COSHH risk
assessment form.
• Material Safety Data Sheets are obtained for all hazardous
substances available to all exposed staff.
• Their staff are trained on use, handling and storing all hazardous
substances, (including clinical waste) and that all staff are familiar with
spillage policies, first aid, and the use of protective equipment, and
accident/incident reporting.
• The control measures identified by the assessments are prioritised
and implemented.
• Health and Safety advisors are contacted if any environmental
monitoring is needed or any assistance required for proper
implementation of this policy.
• Their staff are aware of the result of COSHH risk assessments
including preventing and control measures that affect their work.
• They identify those of their staff for whom health surveillance is
appropriate and arrange through Occupational Health Department for
the surveillance to be conducted.
• Staff have received screening and vaccinations appropriate to their
role and tasks.
• Unplanned exposures are reported via the Trust’s incident, Untoward
Serious Incidents and Near Misses procedure.

• Drawing up plans (emergency procedure) to deal with accidents

involving hazardous substances accompanied with appropriate risk
assessment identifying control measures and responsible person for
co coordinating emergency procedures.
• No work is carried out that is liable to expose employees and others to
substances hazardous to health unless a suitable and sufficient risk
assessment has been completed and that the 8 steps recommended
by the HSE have been taken to ensure compliance with the
regulations.
14.3.3 Laboratory managers will ensure that:
• They undertake risk assessment of staff exposure to biological

agents.
• They introduce adequate preventive measures including:
o Keeping numbers of exposed staff to the minimum.
o Designing processes etc. to prevent or minimise the release of
biological agents.
o Displaying the biohazard sign and other relevant warning signs at
the entrance of the laboratory. The entrance to the laboratories
handling biological agents of containment level.
o Drawing up plans to deal with accidents involving biological
agent, specifying appropriate decontamination and disinfecting
procedures.
o Drawing up procedures of safe means for collection, storage and
the disposal of the contaminated waste.
o Arranging for the safe handling and transport of biological
agents, or materials that may contain such agents.
o Specifying procedures for taking, handling and processing
samples that may contain biological agents.
• Effective vaccines are available (where appropriate).
• Hygiene methods are introduced to reduce accidental transmission or
release of agents including adequate washing and toilet facilities, and
prohibiting of eating, drinking, smoking and application of cosmetics in
work area.
• A list of staff exposed to a Group 3 or Group 4 biological agent,
indicating the type of work done and where known the biological agent
to which they have been known and keeping records for any exposure
to biological agents for 40 years following the last known exposure.
• Exposure accidents and incident are reported following the Trust
procedures.
14.3.4 Employees will ensure that they:
• Identify, use, handle, and store all hazardous substances used in their
section in the prescribed manner.
• Properly use all the safety/protective equipment provided.
• Report spillage of any hazardous substances following the Trust

Accident/Incident reporting procedures as soon as possible.
• Report any ill health condition that incurred by them due to exposure
to any hazardous substances even in suspicion.
• Co-operate with the Trust management so far as this is necessary to
enable the Trust to meet it legal obligation under the regulations.
• Attend, where appropriate, medical examination and provide
appointed doctor information about their health that may be
reasonably required.
15.0 Identification of Hazardous Substances

15.1 The COSHH regulations 2002 applies to a very wide range of substances and
preparations (a mixture of two or more substances) with the potential to cause harm
if they are inhaled, ingested or come to contact with or are absorbed through skin.
Hazardous substances can occur in many form including solid, liquids, vapours,
gases, dusts, fibres, fumes, mist and smoke.
15.2 Under the COSHH Regulations a Substances hazardous to health is that:
• One that has already been classified as being very toxic (T+), toxic (T),
harmful (X), corrosive (C) or irritant (Xi) under the Chemicals (Hazard
Information and Packaging) Regulations or CHIP (The Approved Supply
List).
• or a substance which has been assigned Exposure Limits
• or a substance that is Carcinogenic, mutagenic or toxic to reproduction
• or a biological agent,
• or dust in substantial concentrations in air and
• Any substance not mentioned above but which creates a hazard to health
comparable to those mentioned above.
15.3 Substances not covered by COSHH are substances which are only hazardous
because they are:
• Radioactive
• Have explosive or flammable properties
• At high pressure
• At extreme temperatures
• Asbestos and lead, which have their own regulations
• Biological agents over which you have no control, e.g. someone catching a
cold from another person in the laboratory.
15.4 Risk Assessment under COSHH Regulations
15.4.1 COSHH Regulations require that employers assess the risks created by
work involving substances hazardous to health, and to take steps to
eliminate the risk or effectively control it. The risk assessments shall be
recorded on the COSHH Risk Assessment Form, stored locally and a copy
sent electronically to the Health and Safety advisor. A HSCT specific
COSHH assessment form is available for use on the intranet.
15.4.2 Step 1 Assess the risks
• Assess the risks to health from hazardous substances used in or

created by your workplace activities.
• What Risk:
o The risk from a substance is the likelihood that it will harm people
in the actual circumstances of use. This will depend on many
factors, including:
o the hazard presented by the substance;
o how it is used (or misused);
o how exposure to it is controlled;
o how much of the substance you are exposed to and for how long;
15.4.3 Step 2: Decide what precautions are needed
• You must not carry out work which could expose your employees to
hazardous substances without first considering the risks and the
necessary precautions, and what else you need to do to comply with
COSHH.
15.4.4 Step 3: Prevent or adequately control exposure
• You must prevent your employees being exposed to hazardous

substances. Where preventing exposure is not reasonably practicable,
then you must adequately control it.
15.4.5 Step 4: Ensure that control measures are used and maintained
• Ensure that control measures are used and maintained properly and
that safety procedures are followed.
15.4.6 Step 5: Monitor the exposure
• Monitor the exposure of employees to hazardous substances, if

necessary.
15.4.7 Step 6: Carry out appropriate health surveillance

• Carry out appropriate health surveillance where your assessment has

shown this is necessary or where COSHH sets specific requirements.
15.4.8 Step 7: Prepare plans and procedures to deal with accidents, incidents and
emergencies
• Prepare plans and procedures to deal with accidents, incidents and

emergencies involving hazardous substances, where necessary.
15.4.9 Step 8: Ensure employees are properly informed, trained and supervised
• You should provide your employees with suitable and sufficient

information, instruction and training.
15.5 Accidental Release and Spillage
15.5.1 The chemicals used across the Trust are varied and as such there are no
generic spillage instructions. Please refer to the appropriate material safety
datasheet (MSDS) or procedure.
16.0 Cytotoxic Drug Safety

16.1 The term ‘cytotoxic drug’ is generally used to refer to any agent that may be
genotoxic, oncogenic, mutagenic or teratogenic. The health risk of any procedure
involving cytotoxic drugs stems from the inherent toxicity of the drug and the extent
to which workers and patients are exposed.
16.2 For further information please refer to the Guidelines for the Safe Prescribing,
Handling and Administration of Cytotoxic Drugs, North London Cancer Network.
policy.
16.2.2 Employees and Medical Staff
• Ensure that all safety requirements according to COSHH (Control of

Substances Hazardous to Health) guidelines and the joint NLCN &
NELCN Cytotoxic Policy are followed.
• To only carry out potentially hazardous activities when competent or
trained to do so.
• To follow departmental standard operating procedures where
available.
• Report all unsafe acts and conditions.
• Actively participate in the recommended health surveillance programs.
• Actively participate in the training programs provided.

• Inform managers/supervisors if they are pregnant, breastfeeding or

trying to conceive.
16.3 New, Expectant and Breastfeeding Mothers
16.3.1 Employees should notify their managers as soon as possible if they are
pregnant, trying to conceive or are breastfeeding. This is particularly
important as the greatest risk is during the first three months of pregnancy,
when rapid cell division and differentiation occurs.
16.3.2 At the point where an employee discloses pregnancy, a risk assessment

specific to the individual should be carried out and any appropriate action
taken. New, expectant and breastfeeding mothers should be specifically
advised against any direct involvement in the management of a cytotoxic
drug spillage.
16.4 Personal Protective Equipment (PPE) to be Used When Handling Cytotoxic Drugs.
16.4.1 The correct use of personal protective equipment can shield staff from
exposure to cytotoxic drugs and minimise the health risks. The following
recommendations are considered to be the absolute minimum protective
clothing/equipment that should be worn, in clinical areas, for the defined
work tasks. Local policy, or specific and individual staff needs, may dictate
the use of further supplementary protection.
16.4.2 PPE recommended for Administration of Cytotoxic Drugs
• Gloves
• Protective plastic armlets
• Plastic apron
• Eye protection: to be used when splashes or sprays of cytotoxic drugs
might be generated, for example during intracavitary or intrathecal
administration.
16.4.3 PPE for Handling Waste from Patients Receiving Chemotherapy
• Gloves
• Plastic apron
16.4.4 PPE to be used in the event of a cytotoxic spillage:
• Gloves
• Protective disposable gown
• Protective plastic armlets.
• A recommended brand of goggles.
• Plastic overshoes.
• Mask e.g. surgical masks.

16.4.5 Personal Accidents
• If a patient, member of staff or visitor is involved in a spillage of

cytotoxic drugs or potentially contaminated patient waste the following
procedures must be followed. All such events/accidents should be
reported to a senior member of staff and fully documented on the local
Trust adverse incident forms.
16.4.6 Skin
• Remove any contaminated clothing immediately.

• The contaminant must be removed as rapidly as possible by flushing
the affected area with a large volume of cold water. If running water is
not immediately available, bottles or bags of sterile water or normal
saline should be kept as an alternative.
• After initial copious flushing with water, the contaminated skin should
be thoroughly washed with liquid soap or antiseptic scrub and water.
After rinsing, the process should be repeated.
• Shower facilities should be available for use if large areas of skin are
contaminated.
• Do not use hand creams and emollients as these may aid absorption
of the drug.
• Medical attention must be sought from the nearest Accident &
Emergency Department.
• An adverse incident report form must be completed, and the Head of
Department & Occupational Health informed.
16.4.7 Eyes
• An eye wash kit should be available in all areas where chemotherapy

is administered.
• The contaminant must be removed as rapidly as possible by flushing
the eyes and surrounding areas with a large volume of sterile normal
saline. Alternatively, cold tap water can be used if necessary.
• Medical attention must be sought immediately from the nearest Eye
Clinic or Accident & Emergency Department.
• An adverse incident report form must be completed and the Head of
Department & Occupational Health informed.
16.4.8 Needlestick Injuries
• Encourage the wound to bleed.

• Wash the puncture site/wound thoroughly with copious amounts of
cold water.
• If the needle contained any cytotoxic drug contaminant, check the
vesicant status of the drug by referring to the Guidelines for the Safe
Prescribing, Handling and Administration of Cytotoxic Drugs, available

on the intranet, or by seeking advice from a senior oncology or

haematology pharmacist.
• Report the incident immediately to a senior member of staff.
• Follow the Trust’s Needle stick injury procedure, and consider seeking
advice from the Accident & Emergency Department or Occupational
Health, especially if the needle had been in contact with a patient.
16.4.9 Clothing
• Any contaminated clothing must be removed immediately. Put on

gloves and an apron.
• Rinse the clothing under running tap water. Squeeze dry and place in
a plastic bag.
• Uniforms or hospital linen should be double bagged in the appropriate
laundry bags and sent to the hospital laundry according to the
procedures described in the individual Trusts Control of Infection
Policy Manual.
• Personal clothing should be taken home for laundering. Such items
should be laundered twice where possible. The first wash should be
separate from other clothing.
• They may be laundered with other items for the second wash.
• Dispose of gloves and apron into a double yellow clinical waste bag.
• If there is a likelihood that the drug has soaked through the outer
clothing, underwear must be removed and treated as above, and the
area of skin treated as above.
16.5 Cytotoxic Spillages
• A cytotoxic spillage kit must be available, at all times, in all clinical

areas where cytotoxic drugs are administered, and in all pharmacy
areas where cytotoxic drugs are handled or stored. All staff must know
how to use it and where it is stored. If a kit is used it must be replaced
immediately. At no times must access to a kit be impeded by blocking
the surrounding area. Cytotoxic spillage kits are available from
pharmacy
16.5.1 Information aimed at patients and carers regarding cytotoxic spillages in
the home or community environment is outlined in Trust policy.
16.5.2 Immediate Action
• Restrict access to the spillage area.

• Alert other members of staff in the vicinity and inform a senior member
of staff.
• If you have been injured or contaminated, another member of staff
must deal with the spillage while you receive attention for the injury or
contamination.
• New and expectant mothers should not have direct involvement in the
management of a cytotoxic spillage.
• Turn off all fans and reduce any draughts.

• Open a Cytotoxic Spillage Kit.
• If protective clothing has been contaminated during the spillage,
remove the contaminated items and put on fresh protective clothing
from the spillage kit. Place all contaminated items in the 'sharps' bin.
• Before dealing with the spillage ensure you have:
o Don a disposable protective gown.
o Put on a pair of protective plastic armlets. Not needed if wearing
a gown.
o Put on a pair of gloves (tuck the armlet sleeves inside the glove
cuffs).
o Put on a mask e.g. surgical mask.
o Put on protective eye wear.
o Put on a pair of plastic overshoes (only if spillage is on the floor).
o Follow the cytotoxic spillage action plan (below).
16.6 Contents of In-House Cytotoxic Spillage Kits for Hospital Use
16.6.1 The sealed cytotoxic spillage kit comes in two parts:
1. The Personnel Pack Containing
• 2 white plastic aprons or a ¾ length disposable gown with absorbent

surface, impermeable backing
• 2 pairs of protective armlets
• 2 pairs of medium sized marigold gloves
• 2 masks
• 2 pairs of eye goggles
• 2 pairs of plastic overshoes
2. The Spillage Pack Containing
• 1 large 'sharps' bin (20 litre)

• 10 self-seal plastic bags
• 1 roll of blue paper towel
• 1 bottle (1 litre) of water
• 2 pairs of plastic tweezers
• A “Warning! -Cytotoxic spill” sign
16.7 Please see Appendix C: for Cytotoxic Flow Chart.

17.0 Radiation Safety

17.1 Radiation safety guidelines are provided in “Radiotherapy Local Rules for Wards”
which is available on the intranet and in this H&S file, if applicable.
18.0 Liquid Nitrogen Safety

18.1 Nitrogen is colourless, odourless and tasteless. It is classified as non toxic and does
not support life or combustion. At standard atmospheric pressure it has a liquid
temperature of -196ºC.
18.2 Very small amounts of liquid nitrogen can vaporise into large volumes of cold gas
which may damage delicate tissue such as the eyes even in the briefest exposure.
Human flesh is frozen very rapidly by contact with the liquid or its vapour.
Therefore, liquid N2 must be handled with extreme care. All employees must take
reasonable steps to protect themselves and others from the risks imposed by liquid
Nitrogen.
18.3 Hazards of Nitrogen
18.3.1 Asphyxiation: Nitrogen can produce local oxygen-deficient atmospheres,

which will cause asphyxia if breathed. This is especially true in confined
spaces and areas of little or no air movement. Asphyxia due to oxygen
deficiency is often rapid with no prior warning to the victim. Attempts to
rescue persons from oxygen deficient atmospheres should only be made
by trained persons using breathing apparatus.
18.3.2 Effect of Cold on Lungs: Whilst transient and short exposure produces
discomfort in breathing, prolonged inhalation of vapour or cold gas can
produce serious effects on the lungs.
18.4 Cold (Cryogenic) Burns
18.4.1 Severe damage to skin may be caused by prolonged contact with liquid or
cold gaseous nitrogen. Prolonged exposure to cold can result in frostbite.
There may well be insufficient warning through localised pain while the
freezing action is taking place. All cold burns should be checked by a first-
aider or, in extreme circumstances, by a medical expert to confirm the
extent of damage. Cryogenic liquids and vapour can damage the eyes.
18.4.2 The low viscosity of cryogenic liquids means that they will penetrate woven
or other porous clothing materials much faster than, for example, water. For
this reason protective clothing should always be worn.
18.5 Protective Clothing
18.5.1 Protective clothing for handling low-temperature, liquefied gases serves

mainly to protect against cold burns and should be worn when handling,
filling or using dewars: -
• Eye protection: Goggles should be worn at all times when handling

liquid nitrogen. Ideally a face visor or glasses with cheek and brow
guards should be used.
• Hand protection: Non-absorbent, insulated gloves, made from a

suitable material such as leather. The gloves should be loose fit for
easy removal. Sleeves should cover the ends of the gloves.
• Protective shoes: Closed shoes should be worn. Trousers should be
worn outside boots.
• Body protection: A laboratory coat should be worn. Where dewars are
being carried over uneven ground or on stairs at chest height, the user
should consider additional splash protection. A splash resistant apron
may be appropriate.
18.6 First Aid Procedures
18.6.1 First Aid (Asphyxiation)
The victim may well not be aware of the asphyxia. If any of the following
symptoms appear in situations where asphyxia is possible, immediately
remove the affected person to the open air, following up with artificial
respiration if necessary:-
• rapid and gasping breathing

• rapid fatigue
• nausea
• vomiting
• collapse or incapacity to move
• unusual behaviour.
18.6.2 If medical attention is not immediately available, arrange for the casualty to
be transported to a hospital without delay.
18.7 First Aid (Cryogenic Burns)
Flush the affected areas of skin with copious quantities of tepid water, but do not
apply any form of direct heat, e.g. hot water, room heaters, etc. Move the casualty
to a warm place (about 22°C/295K.) If medical attention is not immediately
available, arrange for the casualty to be transported to hospital without delay. While
waiting for transport:
• loosen any restrictive clothing
• place the affected part in tepid water, or run tepid water over, until the
skin changes from pale yellow through blue to pink or red
• protect frozen parts with bulky, dry, sterile dressings. Do not apply too
tightly so as to cause restriction of blood circulation
• keep the patient warm and at rest
• ensure that the ambulance crew or the hospital is advised of details of
the accident and first aid treatment already administered.
• Smoking and alcoholic beverages reduce the blood supply to the
affected part and should be avoided.
18.8 Emergency Procedures
18.8.1 Spillage
• Evacuate all personnel from the area likely to be affected by the liquid
and the evolved nitrogen gas.
• Pay particular attention to pits, basements, cellars and stairwells
because the cold gas will collect in those areas. Try to prevent the gas
flowing along the ground into such areas by closing doors.
• Take appropriate action to ensure that the ventilation system does not
spread the nitrogen to other areas.
• Open exterior doors and windows to encourage evaporation of the
liquid and safe dispersal of the nitrogen gas.
• Allow the liquid to evaporate naturally.
• The evolved gas will be very cold and will create a cloud of condensed
water vapour restricting visibility. Do not allow anyone to enter this
cloud.
• Do not allow anyone to enter the area until you are sure that the
nitrogen gas has all dispersed and that the air is safe to breathe. If in
doubt, use an oxygen monitor to check oxygen levels.
18.8.2 Ice Plug Formation
• An ice plug is a sheet of ice that can form in the neck of the dewar due
to condensation of atmospheric moisture. Ice plugs can be avoided by
ensuring that a protective cap is always used which is in good
condition and that dewars are fully emptied before being taken out of
use or put into storage.
• If an ice plug forms there is a danger that:
o It will detach at high velocity when the dewar pressure rises.
o It will cause sufficient pressure build up in the dewar to cause it
to rupture.
• Extreme caution shall be exercised if an ice plug is found. All
personnel, except the minimum number required to deal with the
incident, should be evacuated from the area. The recommended
method of dealing with the plug is to insert a copper tube into the neck
and blow warm nitrogen gas onto the blockage. Compressed air is not
recommended as it contains moisture.
• Ensure that the dewar is completely sandbagged before approaching
it. Extreme caution should be taken when inserting the copper tube.
Insert the tube into the neck without making contact with the ice
blockage. The gas supply should be set up so that the defrosting
process can be initiated in a remote or protected position. Once the
defrost has been initiated the operator can retire to a safe place whilst
the blockage is being cleared.

• The pressure build up may have damaged the inner wall of the dewar.
Ensure that the dewar is examined by a competent person before
returning it to service. For advice in dealing with an ice blockage,
contact your gas supplier or dewar manufacturer.
19.0 Manual Handling

19.1 Injuries occur due to the incorrect handling of loads, including patients. These
injuries can result in pain, time off work and sometimes permanent disability leading
to loss of skilled staff. The majority of such injuries are preventable.
19.2 The Trust is committed to assessing the risks to all staff involved in manual
handling and to providing such equipment, training and conditions necessary to
avoid the risk of injury whenever practicable. The Risk assessment is available in
the Health and Safety at UCLH Handbook.
19.3 Responsible Staff
policy.
19.3.2 Ward Sisters/Charge Nurses and Departmental Managers
Ward sisters/charge nurses and departmental managers are

responsible for ensuring that:
• risk assessments of manual handling tasks are undertaken and

recorded. Written records of these assessments must be maintained
and should be accessible to all at a local level.
• staff are released from duty to attend relevant manual handling
training courses. This includes part time and night duty staff.
• staff are supplied with appropriate manual handling equipment to
enable them to carry out their role.
• Ensure that any manual handling incidents are reported, followed up
and appropriate action taken, e.g. re-training, risk assessments etc
19.3.3 Employee Responsibilities
All employees are responsible for:
• Using equipment when it is provided for a task in order to eliminate or

reduce the risk of injury. The equipment should be used in the
manner in which the employee has been trained and / or instructed
and for its intended purpose.
• Undertaking manual handling operations in the way in which he/she
has been trained.
• Informing their manager of any physical condition which may
reasonably be considered to affect his/her ability to undertake manual
handling operations safely.
• Identifying and alerting their manager to any new activity or equipment

which requires a risk assessment.
• Informing their manager of any equipment that is faulty, out of date
with statutory annual maintenance or statutory six monthly inspection.
The equipment must be withdrawn from use and relevant repairs,
maintenance or inspection arranged.
• Attending training in accordance with the UCLH Training Needs
Analysis
19.4 Risk Assessments & Heavier Patient Safety Checklist
19.4.1 A nominated and trained competent person must carry out risk
assessments on all manual handling tasks in their area/ward. Advice may
be sought from the Back Care/Manual Handling Adviser. This will include
individual risk assessments for patients who require assistance plus task
related risk assessments for other activities.
19.4.2 The Trust has provided an assessment tool which can be found in the
Health and Safety at UCLH Handbook.
• Manual Handling Risk Assessment

• Patient Manual Handling Risk Assessment
19.4.3 Risk assessments should be reviewed annually and / or when any change
occurs. All written assessments must be kept at a local level and retained
as long as the task/risk exists. However individual patient handling (risk)
assessments should remain in the patient’s file.
19.4.4 The process for the development and review of an organisational action
plan for manual handling risks following risk assessment is as follows:
• Information on risks identified using the Manual Handling Risk

Assessment tool is added to local risk registers and reviewed at local
clinical governance committees.
• The Health and Safety Adviser reports to the Health and Safety
Committee on all manual handling risks that have been identified
across the Trust. The Health and Safety Committee reviews the plans
for reducing manual handling risks that have been developed by the
Health and Safety Adviser and Back Care/Manual Handling Adviser.
This committee ensures that actions to reduce manual handling risks
are implemented throughout the Trust and oversees the
implementation of action plans.
19.5 Control of Risk
19.5.1 If a manual handling operation has been assessed as a risk, steps should
be taken to redesign the task to eliminate or reduce the risks to as low as is
reasonably practicable, through the use of changes in process or use of
mechanical aids and/or specialist lifting equipment.
General Guidelines on Moving a Load
Don’t move a load:-
• unless you have to if you feel it would be unsafe for you to do so
• if you cannot clearly see where you are going
• if you cannot get a secure hold
• if it is too large or heavy – get help and / or use equipment
• if there is insufficient space for you to do so safely
19.6 Guidelines on the Handling of Patients
19.6.1 All employees handling patients will promote privacy and dignity and offer
the required amount of assistance to ensure safety and patient
independence. All patients must be encouraged to move themselves where
it is safe for them to do so.
19.6.2 Patient handling is inherently unsafe, therefore all patients who require help
to move must have a manual handling assessment completed using the
appropriate form.
19.6.3 The form should be retained in the patient’s care record and should record:
• patient’s weight, medical history, mobility and mental state

• the number of staff required to move the patient safely
• methods of movement and equipment required
19.6.4 Where there are particular issues with a patient, e.g. impaired mobility,
obesity, a manual handling risk assessment must be completed. Advice
should be sought from the Back Care/Manual Handling Adviser and the
Heavier Patient Guidelines, in the Manual Handling Policy should be
followed.
19.7 Condemned/Unsafe Techniques
19.7.1 The following manual handling techniques are considered unsafe and
should not be used:
• ‘orthodox’ or ‘armchair’ lift (2 carers stand either side of the patient,

clasp each other’s wrist under the patient’s thighs and at the patient’s
back)
• ‘drag’ or ‘underarm’ lift (any lift which involves moving a patient with
carer’s arms under the patient’s axilla, including walking a patient)
• lifting with patient’s arms around the carer’s neck
• ‘shoulder’ or ‘Australian’ lift with the carer’s shoulders under the
patient’s axilla
• ‘bear hug’ (when a patient places arms on the carer’s waist and is
rocked into a standing position)
19.8 The Falling/Fallen Patient
19.8.1 A patient who is about to fall presents a risk of injury to the handler. If the
patient is falling away from the handler, is any significant distance away,
the patient is heavier than the handler or there are environmental hazards,
the handler may not be able to control the patient’s descent. If there is risk
of injury to the handler the handler should not try to catch the patient.
19.8.2 If a patient has fallen the person may get up either with verbal assistance
or with the use of a hoist. Only in exceptional life threatening circumstances
should the patient be lifted manually from the floor.
20.0 Display Screen Equipment

20.1 The Trust acknowledges that whilst it is generally recognised that the use of
DSE/VDU does not present any significant health hazards the incorrect use of the
system together with poor design of workstations, equipment, furniture, incorrect
posture, unsatisfactory job design may do so. DSE users have reported mental
tiredness, soreness or visual fatigue and RSI (Repetitive Strain Injury) or WRULD
(Work Related Upper limb Disorders). RSI conditions are characterised by
discomfort and pains in the upper part of the body e.g. neck, back, shoulders,
hands, arms and wrists that affect musculoskeletal system.
20.2 Who is a VDU user?: A VDU user for the purpose of the regulations and
assessment by employers is a person who is an employee who normally use VDU
for a continuous spell of one hour or more at a time and
• Uses it more or less daily in this way.
• Has to transfer information quickly to or from screen.
• Needs to apply high levels of attention or concentration; or is highly

dependent on VDU or have little choice about using it;
• Needs special training or skills to use the equipment.
20.3 Effect on Pregnant Women
20.3.1 There has been considerable concern about high levels of miscarriage and
birth defects reported among some groups of VDU users. However,
reliable studies have been unable to demonstrate any link between
miscarriages or birth defects and VDUs. The National Radiological
Protection Board considers that VDU radiation emissions do not put unborn
children at risk. Pregnant women need not stop work with VDUs. However
to avoid problems caused by anxiety, women who are pregnant or planning
children and worried about working with VDUs should be advised to talk to
their doctors or the Occupational Health Department.

20.4 Safe Use of DSE Equipment
20.4.1 Display screen equipment can be used in complete safety by making sure
that furniture or equipment used does not result in discomfort by:
• Adjusting the furniture and equipment to suit your need - and not
adjusting your own posture.
• Avoiding static posture, and taking the opportunity to vary your
activities.
• Reporting any signs and symptoms of discomfort to your manager. A
risk assessment must be undertaken by a Health and Safety Advisor.
• Reporting your training needs to your manager.
• Not tampering with your equipment, reporting any problems with your
equipment or furniture to your manager.
• You are entitled to eye and eyesight check-ups, ask for details.
20.5 Further details are provided in the Health and Safety at UCLH Handbook
21.0 House Keeping/Infection control

21.1 Healthcare Associated Infection (HCAI) has become a major concern for healthcare
staff and the public. The work of the Infection Control Department/Team supports
the Trust in minimising the risk of healthcare acquired infection to patients.
21.3 Roles and responsibilities are defined in detail in the appropriate policy.
21.3.1 Nursing Team: Responsible for ensuring that everyone has information and
the facilities required to follow the procedures.
21.3.2 Unit/Ward Manager: Responsible for ensuring the required facilities and
equipment are available and that all clinical staff within their area of
responsibility have received training. They should be monitoring
compliance with infection prevention and control policy.
22.0 Hand Hygiene

22.1 Hand hygiene is the single most important way of reducing cross-infection. During
clinical work, wear sleeves above the elbows and DO NOT WEAR a wristwatch or
costume jewellery. Hand washing should be carried out using either liquid soap
(social hand washing) or using an approved skin disinfectant before a clinical
procedure. Alcohol gel is now widely available as an alternative to hand washing to
reduce bacterial load on clean hands. It would also seem sensible to put alcohol gel
on non-sterile gloved hands before doing a patient procedure.
• Use alcohol on hands immediately before you touch a patient and before
putting on non-sterile gloves.

• Wash your hands with soap and water:
• When starting a shift

• When visibly soiled
• Before drug rounds
• When serving food
22.2 Uniform: It is the responsibility of each staff member to ensure that his/her uniform
is worn according to hospital policy and is neat. Wear a clean uniform every day.
22.2.1 You should keep the following points in mind when deciding what to wear:-
• Keep sleeves short and above the elbow during clinical work
• Wear a name badge at all times
• Do not wear a wrist watch or jewellery
• Keep hair neat and tidy; long hair must be tied back
• Keep fingernails short and no false nails or varnish are permitted
22.2.2 When providing care to a patient, (e.g. bed bathing, changing dressings,
when dealing with body fluids, etc.) it is important even when wearing a
uniform that healthcare workers wear some sort of protective clothing.
22.3 Protective Clothing Guidance
22.3.1 Plastic Aprons:-
• The general use of plastic aprons for protection of clothing is

increasing due to the lack of an integral apron in the nurses' uniform,
and the introduction of a non-uniform policy in certain areas.
• Aprons must be removed and discarded appropriately. Hands should
then be washed and dried or decontaminated with alcohol gel. Aprons
that have been contaminated with blood or body fluids should be
discarded immediately into a yellow clinical waste bag. Aprons used
for other purposes should be discarded into a black bag for domestic
waste.
22.3.2 Face Protection/Masks: Goggles and visors must be worn to prevent

splashing of body fluids into the eye when performing risky procedures.
Surgical masks do not protect against aerosol inhalation but may protect
against splashes in surgery.
22.3.3 Other: Other PPE may be in use as directed by senior staff or as detailed in
procedures or policies.

22.4 Disinfection Guidelines
22.4.1 Disinfectants and antiseptics are expensive and often ineffective so they
tend to be used excessively and ineffectually. The most effective means of
disinfection, that is the reduction of microbial contamination, is thorough
cleaning. Chemical disinfectants are ineffective in the presence of dirt.
They may be inactivated by dirt, biological fluids or by rubber. They may
destroy certain substances, particularly rubber and metal. Antiseptics may
reduce bacterial counts on the surface of the skin or a wound but rarely
enhance and more likely will interfere with healing.
22.4.2 Disinfection Guidelines are available on the Infection Control webpage on

the Intranet.
23.0 Fire Safety

23.1 Fire can be prevented through constant vigilance by trust staff and by ensuring the
necessary precautions are taken to avoid dangerous situations. All staff have a
duty to ensure that they understand what constitutes a dangerous situation and how
this should be avoided. Fire prevention must be understood as comprehensively as
knowledge of action to be taken in the event of fire. It is the best way to ensure
individual safety.
23.2 Roles and responsibilities
policy.
23.2.2 All Staff have a duty to:-
• be familiar with the Trust’s requirements for fire prevention, fire

precautions, fire-fighting and evacuation procedures
• attend a Trust fire safety training session as required, and participate
in fire evacuation drills as required
• accept individual responsibility for ensuring the fire safety within their
areas, particularly if they are the last to leave a department at the end
of a working day
• know the location of, and how and when to operate, medical gas shut-
off valves if in use in a clinical area
• pay attention to “good housekeeping” practices to reduce the
likelihood of fire
23.2.3 Clerical or Day Treatment area staff have a duty to:-
• ensure when leaving their place of work, that they have taken all the
necessary precautions to prevent potential hazards, ensuring that
corridors are clear of rubbish and provide a clear way through to exits;
securing electrical appliances, closing windows and doors
• ensure the last person leaving an area (that is, anyone who thinks
they may be the last to use the area for the day) checks the area and
takes the necessary measures to ensure fire safety
23.2.4 General Managers, Heads of Department, Ward Sisters or Charge Nurses

and all levels of management staff are responsible for ensuring:-
• that the fire safety instructions (both general and specific to the
working location) are brought to the attention of, and observed by,
their own staff. It is especially important for agency staff to receive
local information
• that every member of staff participates in fire training and a record of
attendance is maintained
• that new staff are inducted into local fire procedures on their first day
of duty within the department and participate in the first available Trust
fire safety training session after they arrive
• that the fire exits, means of escape, location of fire alarm call points
and fire-fighting equipment are identified within the department
• that each area has a Fire Lead who is trained appropriately and can
act as the Nominated Fire Officer if needed
• that at UCH at night there are at least three nursing staff in areas with
30 patients or more
• A report of any fire (however small and including false alarms) is to be
sent to the Trust Fire Advisor within 24 hours of the incident occurring.
The report format can be found on the UCLH insight Intranet in the
Fire Safety pages. All details of the fire should be entered onto the
form and sent to the fire advisor ASAP. In addition an e mail informing
him of the fire should be sent so investigations into the cause of the
fire can begin as soon as is practicable.
23.2.5 Responsibilities of the Nominated Fire Officer/ Deputy Nominated Fire

Officer
• take overall charge of the building or designated area in response to a

fire alarm
• co-ordinate the deployment of staff, receive and act on any messages
from the site of the fire
• ensure that appropriate information/advice/instruction is given to areas
affected by the fire and immediately adjacent areas
• answer queries as necessary from staff in patient areas about the
location and progress of the fire
• arrange for entrances to the building to be blocked to stop visitors and
staff, not concerned with the fire incident or other emergency, entering
the building whilst the alarms are sounding
23.3 Fire Equipment / Notices
23.3.1 Fire Alarm System: Fire alarm call points are placed at strategic locations
throughout the Trust buildings. In some of the Trust buildings, on activation
of the fire alarm system, the alarm will emit a continuous signal in the area
of the fire and an intermittent signal will be heard elsewhere within the
same building. In other Trust buildings, on activation of the fire alarm, the
alarm will emit a continuous signal throughout the building. On hearing the
alarm staff must follow the evacuation procedure for their building (detailed
on Intranet and in H&S File).
Fire Safety Notices are placed at strategic locations throughout the Trust
premises, indicating emergency exits and direct routes leading out of the
building to the authorised assembly point.
23.3.2 Manual Fire Fighting Equipment is generally located close to fire alarm call
points. There is a ‘Fire Action’ notice explaining how to use the equipment
placed on the wall above. Additional equipment will be located in risk
areas such as kitchens and plant rooms. Staff must only use fire-fighting
equipment if they feel competent to do so and must not put themselves in
danger.
23.3.3 Any concerns you have on the location or condition of the equipment
should be addressed to the Trust Fire Advisor.
23.4 Summary of Action in the Event of Fire
23.4.1 On finding a fire (if you see a fire or smell smoke):-
• Sound the alarm by operating the nearest fire alarm call point
• Ensure that staff and/or patients are not in immediate danger
• Attack the fire if possible, with the fire-fighting equipment provided, but
without taking risks
• Close all windows and doors in affected areas on leaving only if it is
safe to do so
• In the UCH buildings, door and windows are not to be closed manually
due to the smoke extraction air windows and doors requiring to remain
in the open position
23.4.2 On hearing the fire alarm in buildings with patient services:
• Staff not working in a patient area should evacuate the building via the
nearest available fire exit
• Staff working in a patient area should report to the Nurse in Charge of
the ward or the Head of Department for instructions even if you are
visiting the area from another ward or department
• Visitors on the wards and in-patient areas must be asked to act on
instructions of the Nurse in charge.
• Fire safety notices should be displayed in all areas to inform all

visitors of required action.
23.4.3 The Nurse in Charge of the ward or the Head of Department will: -
• Ensure all doors and windows are closed if it is safe to do so. In UCH
building doors and windows are not to be closed manually due to the
smoke extraction air. Windows and doors will remain in the open
position.
• Ensure all persons are accounted for.
• Ensure preparations are made for evacuation if it is anticipated that it
may be required.
23.4.4 On hearing the fire alarm in buildings without patient services, all staff
should:-
• Ensure all doors and windows are closed only if it is safe to do so. In
UCH building doors and windows are not to be closed manually due to
the smoke extraction air. Windows and doors will remain in the open
position
• Ensure all persons in the area are accounted for.
• Evacuate the building using the nearest available fire exit.
• Go to the designated assembly point as detailed in the building
specific evacuation plans
23.4.5 In all areas:
• Do not stop to collect personal belongings

• Do not use the lifts unless directed to do so by a member of the Fire
Response Team or Fire Service
• Do not use the telephone, except to inform the Fire Service and
hospital of the incident or where necessary in order to save life
• Do not re-enter the building unless advised by the Nominated Fire
Officer, their deputy or by a member of the Fire Service.
23.5 Fire Safety Training
23.5.1 All staff receive fire training in their induction week and this must be
repeated on an annual basis. It is the responsibility of each individual,
General Manager or Departmental Manager to ensure that staff receive
annual fire training. Each Directorate and department should maintain a fire
training record for all staff in their area. Nursing staff and other staff with
direct responsibilities for patients, and members of the Fire Response
Team, will require additional training on an annual basis.
23.5.2 The training needed for fire safety is summarised below:
• Group 1 Staff without specific fire safety responsibilities

• Group 2 Nursing staff, staff with direct responsibilities for

patients.
• Group 3 All staff who respond to the fire bleep and are members
of a Fire Response Team and fire leads in clinical
areas.
Group Initial Training Additional Annual Refresher Training

Training
Group 1 Induction Module None 1 hour training
Group 2 Induction Module 1 hour 1.5 hours + 30 minutes local training
Group 3 Induction Module 2 hours 2 hours + 1 hour local training
Additional Training Group 2 Group 3

Duties & Responsibilities  
Fire Fighting, Fire Evacuation Procedures (Practical)  
Fire Response Team Procedures 
Operation of Fire Alarm Control 
Patient & Staff Evacuation Procedures/ Techniques (Practical)  
Identification - Places of Safety (Refuges)  
It is everyone’s responsibility to ensure that they are aware of which training group they
belong to and to actively seek to attend training sessions.
24.0 Waste Disposal

24.1 All staff have a responsibility to identify any materials that are to be disposed of,
and to ensure that all waste is segregated into its appropriate category as defined in
the UCLH Waste Management Policy.
25.0 Health & Safety Training

25.1 The bulk of Health and Safety Training, which is generally either statutory or
mandatory training, is delivered via two main training programmes:
25.2 Trust induction, for all permanent members of staff who join the Trust. New starters
are expected to complete their Trust Induction programme within 4 weeks of joining
the Trust (see Trust Induction Guidance for further information and full Induction
programme)
25.3 Health & Safety update day, incorporating a number of refresher training sessions,
including Adult Basic Life Support. The current programme is available on the Trust
intranet.
25.4 Other training outside of the Trust Induction and Health & Safety update days may
be delivered locally by specialist advisers via regular briefing sessions,
departmental or site training sessions, or via e-learning. Managers are responsible

for maintaining a training log of staff attendance at statutory and mandatory
courses. A list of the statutory and mandatory subject areas is available in the
UCLH Statutory and Mandatory Training Policy.
26.0 References
None

Appendix A: Health and Safety Representatives
Area/Section Manager:
Area/Section H&S Officer:
Deputy H&S Officer:
Manual Handling Advisor:
First Aid Officer(s)*:
Radiation Protection Supervisor:

* This may not be relevant for ward areas when any state registered nurse can act as a First Aid Officer.
FIRST AID BOX LOCATIONS

1) 2)
3) 4)
The relevant officers listed above must:-
• Ensure that relevant safety regulations are implemented and strictly

observed and that staff are competent to handle infectious materials.
• Be consulted about any new procedures to be introduced.
• Provide first aid treatment in the event of an accident or in the case of
sudden illness, using facilities, materials and first aid available. Ensure
that first aid boxes are available and that the contents are up to date.
• Carry out regular safety audits of working procedures in designated
areas and of the equipment used.
• Verify that correct disposal and decontaminating procedures are
carried out. Including the appropriate decontamination of equipment
requiring repairs.
• Ensure that the following information is recorded: -
• Name, address and telephone number of all staff, including that of
their General Practitioner and details of person to be contacted in the
event of an emergency.
• Attendance/sick leave.
• Details of any accidents, incidents of near misses.
• Details of monitoring and decontamination of items of equipment.
• Ensure that all staff are aware of the Clinical Haematology Health and
Safety policy.

Appendix B: Action Plan for a Sharps/Needlestick Injury

Appendix C: Cytotoxic Spillage

A cytotoxic spillage kit must be available, at all times, in all clinical areas where cytotoxic
drugs are administered, and in all pharmacy areas where cytotoxic drugs are handled or
stored. All staff must know how to use it and where it is stored. If a kit is used it must be
replaced immediately. At no times must access to a kit be impeded by blocking the
surrounding area. Information aimed at patients and carers regarding cytotoxic spillages in
the home or community environment is outlined in Trust policy.
Immediate Action
• Restrict access to the spillage area.
• Alert other members of staff in the vicinity and inform a senior member
of staff.
• If you have been injured or contaminated, another member of staff
must deal with the spillage while you receive attention for the injury or
contamination.
• New and expectant mothers should not have direct involvement in the
management of a cytotoxic spillage.
• Turn off all fans and reduce any draughts.
• Open a Cytotoxic Spillage Kit.
• If protective clothing has been contaminated during the spillage,
remove the contaminated items and put on fresh protective clothing
from the spillage kit. Place all contaminated items in the 'sharps' bin.
• Before dealing with the spillage ensure you have:
o Put on a disposable protective gown.
o Put on a pair of protective plastic armlets.
o Put on a pair of gloves (tuck the armlet sleeves inside the glove cuffs).
o Put on a mask (preferably a respirator).
o Put on protective eye wear.
o Put on a pair of plastic overshoes (only if spillage is on the floor).
o Follow the cytotoxic spillage action plan (below).
Contents of In-House Cytotoxic Spillage Kits for Hospital Use

The sealed cytotoxic spillage kit comes in two parts:-
1. The Personnel Pack Containing 2. The Spillage Pack Containing

• 2 white plastic aprons or a ¾ length • 1 large 'sharps' bin (20 litre)
disposable gown with absorbent • 10 self-seal plastic bags
surface, impermeable backing • 1 roll of blue paper towel
• 2 pairs of protective armlets • 1 bottle (1 litre) of water
• 2 pairs of medium sized marigold • 2 pairs of plastic tweezers
gloves • A “Warning! -Cytotoxic spill” sign
• 2 masks
• 2 pairs of eye goggles
• 2 pairs of plastic overshoes

Appendix D: Cytotoxic Spillage Action Plan

Liquid spillages Powder spillages
• Put paper towels in a ring around the spill • Put paper towels in a ring around the spill to contain the
to contain the fluid so that it cannot spread fluid so that it cannot spread to a larger area.
to a larger area. • Pick up any broken glass using the tweezers and place
• Pick up any broken glass using the it in the 'sharps' bin.
tweezers and place it in the 'sharps' bin. • Cover the liquid with paper towel until all the fluid has
• Cover the liquid with paper towel until all been absorbed.
the fluid has been absorbed. • Keep adding paper towels until the fluid has distributed
• Keep adding paper towels until the fluid has itself throughout the towel and the towel is just moist
distributed itself throughout the towel and i.e. when the towel is picked up the fluid will NOT drip
the towel is just moist i.e. when the towel is out of the towel.
picked up the fluid will NOT drip out of the • Pick up the moist towel and place it into he self-seal
towel. plastic bags. Seal the bags and place in the ‘sharps’
• Pick up the moist towel and place it into the bin. Be careful not to contaminate the outside of the
self-seal plastic bags. Seal the bags and sharps bin.
place in the ‘sharps’ bin. Be careful not to • Use the paper towels to create a ring around the spill.
contaminate the outside of the sharps bin. This will contain any fluid added to wet the powder and
prevent it spreading to a larger area.
• Pick up any broken glass using the tweezers and place
it in the 'sharps' bin.
• Carefully cover the spillage with a large layer of paper
towel moistened with water for irrigation, this will
prevent mobilisation of the powder particles, and so
contain the spillage.
• Add a little more water through the towel until all the
powder has been wetted.
• Add paper towels until the fluid has distributed itself
throughout the towel and the towel is just moist i.e.
when the towel is picked up the fluid will NOT drip out
of the towel.
• Carefully pick up the wetted powder with the moist
towel and place into the self-seal plastic bags. Seal the
bags and place in the 'sharps' bin. Be careful not to
contaminate the outside of the Sharps bin.
• Pick up the paper towel used to create a ring around the spill, seal in self-seal bag and place in the
'sharps' bin. Be careful not to contaminate the outside of the cytotoxic 'sharps' bin.
• Use the water for irrigation and paper towel to clean the contaminated area and place used paper towel in
a self-seal bag. Repeat this at least five times working from the outside of the contaminated area inwards
to prevent spreading the contamination.
• Place all the self-seal bags, tweezers and protective clothing in the cytotoxic 'sharps' bin.
• The protective eye wear and respirators must be returned to pharmacy.
• Put the lid on the cytotoxic 'sharps' bin and seal.
• Tape up the cytotoxic 'sharps' bin with cytotoxic hazard tape and add a location sticker.
• The floor and all other contaminated surfaces should be given a routine clean a minimum of three times
with an appropriate cleaner as soon as possible.
• A Trust Adverse Incident Form should be completed and the Head of Department and Occupational
Health informed.
• Arrange for immediate collection of the cytotoxic 'sharps' bin or return to pharmacy.
• Ensure a replacement cytotoxic spillage pack is obtained immediately and the pack is stored in its
designated storage area.
• Inform the Pharmacy Cytotoxic Preparation Unit of any spillage, as drugs may have to be remade.
For more information please see:
London Integrated Care Systems (ICSs) Guidelines for Safe Prescribing, Handling and
Administration of Systemic Anti- Cancer Therapy
Appendix E: Biological Product Spillage

A spillage may be defined as a leak or spill of blood or other body fluid from a patient,
equipment, specimen, container or cadaver. All spillages present a potential infection
hazard so they must be dealt with promptly. For further information refer to the Infection
Control Insight page.
8
Equipment Required:
Minimum information required on specimen label:
• A face visor is recommended
• Disposable cloths and towels or incontinence pads
• Yellow plastic sack.
Appropriate chemical disinfectant:

• For all BLOOD spills, (and any spillage from a patient suspected of being
infected by HIV, HCV or HBV), use Sodium Dichloroisocyanurate granules
directly or tablets in solution*, (e.g. ten 1.7g Acticlor Tablets™ per 1 litre of a
tap water = 10,000 ppm free chlorine). Read the instructions.
• For other body fluids (not indicated above) use a phenolic (Hycolin 2%)
solution (if available) or 10,000 ppm free chlorine* as above.
• *Chlorine fumes will be released when Chlorine-releasing (eg Haztab, or

Presept) granules are used, so ensure the area is well ventilated. If possible,
stay away from the spillage while the disinfectant is acting. Danger: do not
put granules on urine spills until they have been mopped up.
Action Required:
• Move patients and other workers away from the spillage
• Don protective clothing before handling the spillage and chemical

disinfectant; use domestic gloves
• Cover the spillage with the appropriate disinfectant; leave to act for a
minimum of 5 minutes
• Mop up the spillage using disposable cloths or wipes until the area is visibly
clean
• Dispose of wipes and protective clothing in yellow plastic sack; seal sack and
send for incineration; label with biohazard tape if appropriate
• Wash and dry hands thoroughly
• Contact Domestic Staff to "spot" clean area with general purpose detergent
• Note that chlorine solutions tend to leave floors slightly sticky or slippery

Appendix F: Key Contacts

Accident 2222
Cardiac Arrest Team 2222
Fire 2222
Health and Safety Adviser 77746
Infection Control Adviser 79082 & Mobile 07903 714 671
Interserve 79050
Local Police Station Switchboard - Dial 0 and ask for 'operator'
Needlestick Hotline 75474
Occupational Health Department 79056, OHandSS@uclh.nhs.uk
Patient Manual Handling Advisor 77473
Security 2222
Switchboard 0


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Health and Safety Policy

2 02/09/2009 New - N/A

New trust template. Updated references and changes in

Related Trust Policies updated

New Trust logo

Document Title/Identifier: Health and Safety Policy Page: 1 of 52

Document Title/Identifier: Health and Safety Policy Page: 2 of 52

Work regulations; Data Protection Act; Race Relations

6.0 Duties and Responsibilities

7.0 Related Trust Policies

• New and Expectant Mother's at Work Policy

• DATIX Incident Report Form

• Bedrails-Safe Use for Adult Patients Policy

• Mandatory Training Policy

• Being Open Policy

• Waste Management Policy

• Risk Management Policy & Procedure

• Radiation Safety Policy

• Safer Handling Policy- A Policy for Safe Moving and Handling.

8.0 Basic Safety Precautions

Document Title/Identifier: Health and Safety Policy Page: 5 of 52

8.1.3 Handling of sharps must be kept to a minimum. Sharps must not be

8.1.6 Reusable patient equipment used for infectious/isolated patients or those in

8.3 Expectant & New Mothers

8.4 Occupational Health and Safety Department

Document Title/Identifier: Health and Safety Policy Page: 6 of 52

8.4.1 This department is responsible for:

• Immunisation of clinical staff and other related protective measures;

8.5 Protective Clothing

9.0 Slips, Trips and Falls

• Slippery/wet surfaces – caused by water and other fluids

9.2 Roles and Responsibilities

9.2.2 Ward Staff must:

9.2.3 All Staff must:

• Slips, Trips And Falls Audit Checklist For Ward Sisters/Departmental

9.3.4 The Task or Activity Being Performed - Consideration will be given to

9.4 Incident Reporting and Investigation

10.0 First Aid and Medical Facilities

10.4 First Aid Boxes

Document Title/Identifier: Health and Safety Policy Page: 9 of 52

10.5 First Aid Boxes Should Display The Following Information:

• The name of the person responsible for their upkeep;

• The contents of the first aid box and replenishing arrangements;

• The location of accident/incident report forms.

10.6 Occupational Health Services

10.6.1 If you have a needlestick/sharps or splash injury, the Occupational Health

11.0 Trust Incident Reporting

11.1.2 For further information refer to Risk Management - Incident Reporting

Roles and Responsibilities

11.1.4 Every member of staff

Everyone in the organisation has a responsibility to:

• Maintain general risk awareness and accept personal responsibility for

Every ward sister/charge nurse and department manager has a

11.2 Reporting Incidents & Near Misses

11.2.1 A reportable incident is any unintended or unexpected event that could

• It is an accident or other incident which results in injury or ill health.

• It puts Trust property or assets in an adverse position or at risk of loss

11.4 Steps to Take Following an Incident or a Near Miss:

11.4.1 Immediate Action

• Emergency medical care.

11.4.4 If any piece of equipment is involved in an incident:

• Remove it from service (marking it clearly out of order).

11.5 Reporting an incident, near miss or concern

11.5.1 Your Duties as a Trust Employee