Safety being the primary concern in a hospital set up, the definition of Hospital Safety has evolved to cover various aspects such as Medicinal, Clinical, Infrastructural, Equipment, Physical, Social and Weather related Safety. It covers not only the patients but also the staff members and the visitors. This manual provides an orientation to the Hospital Safety and facilitates the determination of the hospital’s capacity to provide services after a natural adverse event, and guides necessary intervention actions to increase the hospital’s safety in case of disasters.

This manual details the safety measures to be taken to prevent and manage adverse events where safety is compromised. The manual is designed considering the physical facilities available in the Hospital. This manual is reviewed at least once in a year by the Safety & Risk Management Committee. Copy of this manual is made available in all the departments as soft copy and in critical departments as a hard copy.

Safety policy

The safety policy of a hospital is to provide a safe and healthy environment in which risks and hazards are eliminated for patients, visitors and employees. And also to minimize work-related injuries /illnesses through a programme of hazards reduction, elimination engineering controls, personal protective equipment training and regular environmental surveillance.

Each staff member is instructed to devote daily attention to making her or his activities and /or operations as safe and accidents free as possible by complying with safety policy and the safety programme.

Safety objectives

Safety policy shall be achieved through the following objectives:

• To establish a Safety Programme with responsibilities assigned to Safety Officer, Safety Committee and to each and every staff member.
• To identify and assess the hazards and risks throughout the hospital premises.
• To eliminate or minimize the risks and hazards thus identified.
• To train the staff on risk assessment and on taking preventive/ corrective actions.
• To establish and maintain an Incident Reporting System and to carry out Root Cause Analysis.

Employee’s responsibilities

Departmental head’s responsibilities

Department’s Heads, in charges and supervisors, are responsible for the day to day implementation of safety rules and regulations.

• Induct new employees on job safety rules, requirements and procedures.
• Enforce safety rules, regulations and procedures within their area of responsibility
• Investigates incidents, complete incident reports and submit reports to QI team.
• Conduct safety inspections of their work areas.
• Report and correct any safety deficiencies as soon as possible to the safety officer /committee members.
• Be a good role model for employees under his /her supervision.

Hospital employee’s responsibilities

Each employee is responsible for abiding by the safety program.

• Work in accordance with accepted safety rules regulations and standards operating procedures. Employees shall seek assistance or further information when needed from their HOD / in charge /Supervisor.
• Report to their supervisor any unsafe conditions and practices and make suggestions for improved safety.
• Attend safety meetings and safety training programs as required.
• Act as per the role defined in your respective teams (Mention later in this manual)

Safety Officer

The Safety Officer has been delegated the authority to act whenever conditions exist that pose an immediate threat to life, health, or property. The Safety Officer directs the planning and development of the safety program and the issuance of directives and recommendations concerning accident prevention.

Develop and implement a comprehensive safety program which provides for the following;

• Regular and periodic facility and equipment inspections.
• Investigation of employee job-related accidents.
• Educational and training programs for supervisors and employees.
• Programs to promote increased safety awareness and accident prevention throughout the campus
• Reports to the Quality Department on a weekly basis the status of the safety program.
• Accumulate, maintain, and analyze accident records.
• Communicating and coordinating with the other interfacing teams such as Infection Control Committee, Radiation Safety Committee and Laboratory Safety team.

Outline of the Safety Programme

An attempt is made to cover all kinds of toward incidents that may happen to disturb the normal functioning of the hospital. The plans detailed in this manual provide the information on the responsibilities of each and every individual. The teams that are mentioned in the plans will remain the same throughout. However additional responsibilities may be added on to them as demanded by the situation and instructed by the Command Center.

Safety Manual is divided into the following Chapters:

Chapter I: Risk Assessment, Reporting of risks & incidents

Chapter II: Patient Safety

Chapter III: Electrical Safety

Chapter IV: Engineering & Facility Safety

Chapter I: Risk Assessment, Reporting of risks & incidents

Risk assessment programme

• The purpose of this programme is to ensure the level of safety compliance at the hospital and to identify any situation that detracts from our goal of providing a safe and secure environment for our patients, employees and visitors.
• The Risk Assessment Program is based on a review of incident reports, employee accident reports, facility tours, grand rounds, Infection Control and Security Reports. In addition, reports from outside agencies, such as Fire Department, corporation etc., will be used in the Risk Assessment Program.
• The Safety Committee will review the hospital’s performance based on problem indicators selected by the Safety Committee developed from the data collected from the Risk Assessment Program. E.g. for Indicators – identifying open electrical wires, reducing the patient falls, etc.

Facility Tour

• The facility tour is carried out at least twice a year
• This tour will be done by the safety committee members

What is an incident?

Chapter II: Patient Safety

What is patient safety?

• Patient safety is simply defined as “the prevention of harm to patients”.
• Patient safety is an integral part of the delivery of quality of care and a fundamental right of all patients.
• Although simple in definition, the road to ensuring patient safety in health care facilities is complex and replete with obstacles.
• Our Organization has made patient safety a declared and serious aim by establishing comprehensive patient safety programs with defined executive responsibility, operated by trained personnel and in a culture of safety.

Objectives of patient safety

• To provide, clear and visible attention to safety
• To implement a system for analyzing and reporting any errors within their Organizations
• To incorporate well-understood safety principles.
• To establish multidisciplinary team training programs for providers.
• To identify and analyze system failures
• To involve the participation of patients and their families wherever required and be responsive to their Inquires
• To communicate findings to the concerned department.
• To provide education related to patient safety to all the health care workers.

Patient safety policy

Improve the accuracy of patient identification

• Use at least two patient identifiers when providing care, treatment or services. The intent for this goal is to:
  • To reliably identify the individual as the person for whom the service or treatment is intended.
  • To match the service or treatment with the person.
• Patient identifiers used:
  • ID Band
  • Patient NAME/AGE/SEX/ ID.No
• “The patient’s room number or physical location should not be used as an identifier”.

Improve the effectiveness of communication among caregivers

• Ineffective communication is the most frequently cited category of root causes of sentinel events.
• Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces error and results in improved patient safety.
• All the orders in the ward preferably are taken in written format.

Improve the safety of using medications

• When medications are part of the patient treatment plan, appropriate management is critical to ensuring patient safety.
• Every drug is been countersigned and checked by one another health care workers

(Refer: Medicine administration policy)

Reduce the risk of healthcare-associated infections

• Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
• Compliance with the CDC hand hygiene guidelines will reduce the transmission of Infectious agents by staff to patients, thereby decreasing the incidence of healthcare-associated infections. (Refer: Infection control manual)

Accurately and completely reconcile medications across the continuum of care

• The development, reconciliation and communication of an accurate medication list throughout the continuum of care are essential in the reduction of transition-related adverse drug events.
• We provide extended teaching about the drug and treatment in continuum of care at the time of discharge.

Reduce the risk of patient harm resulting from falls

• The organization should evaluate its patients’ risk for falls and take action to reduce the risk of falling and to reduce the risk of injury.
• The ratio of patient and healthcare workers is followed in all the patient care area as approved.
• Medical and chemical restrain are used as and when required with the written order from the physician.

Encourage patients’ active involvement in their own care as a patient safety strategy

Communication with patients and families about all aspects of their care, treatment or service is an important characteristic of a culture of safety.

(Refer: patient rights and responsibilities)

Patient age-related hazards

To ensure a safe environment for patients of all ages, the following guidelines have been developed.

Pediatric Patients

• Side rails should be utilized all the time, except when side rails were found to interfere with the ease of nursing or clinical care and at these times a child should not be left unattended.
• Light plastic wrappings are never permitted on sheets or pillows.
• Small candies, toys, etc., should not be accessible to a small child as he/she may choke or insert them into a body orifice.
• Toys should be suitable for the age and condition of the child
• All cleaning supplies will be kept in locked areas and never left were accessible to children.
• Medications will be kept locked at all times.

Elderly Patients

• Side rails should be utilized as and when found necessary. The decision shall be made by the nurse.
• Patient rooms and corridors should be especially clear of furniture or equipment that may lead to falls.
• Floors are to be kept clean and dry.
• Patients will be instructed on fall prevention measures.
• Be watchful for patient hypersensitivity to medications.
• Application of hot or cold compresses should be monitored closely.
• Nurse call button should be kept within reach.

Patient safety orientation

• Patients with valuables should be informed of hospital policy on patient valuables. They shall be requested to the location and use of call button, TV control, other switches, and side rails should be explained to patients.
• Patients should be informed of the smoking policy.
• Patients should be informed of the policy concerning personal appliances.
• Hospital fire drills should be explained to prevent any panic or discomfort experienced by the patient.
• Patient Directory will be provided to the patient.

Patient transport

Stretchers

• During the transfer, bedclothes should be loosened to make for easier movement. Arrange bed clothing so the patient will not be exposed or hampered.
• Communicate with the patient, work in unison with the patient, and do not permit the patient to overexert himself.
• During the transfer of the patient from his bed to a stretcher, brakes should be applied to the bed and stretcher to prevent separation between bed and stretcher.
• Patients on a stretcher should be covered with a sheet or blanket and should be cautioned to keep hands, feet and arms under the cover while on the stretcher.
• Patients being transferred on a stretcher should be transported feet forward.
• When using an elevator, always check to see that the corridor floor and the elevator floor are at the same level before entering or exiting.
• Any defective stretcher should be removed from service, tagged and sent for repair.
• Side rails should be in an upright position.

Wheelchairs

• Brakes will be locked when assisting patients in and out of a wheelchair.
• Patients should always be supported when getting in/out of a wheelchair.
• Footrest should be raised when the patient is getting in/out of a wheelchair.
• When using an elevator, always check to see that the corridor floor and the elevator floor are level before entering or exiting.
• Any defective wheelchair should be removed from service and sent for repair.

Patient safety and hospital beds

• Side rails may be used as and when found necessary
• Upon admission to the unit, the patient shall be told the purpose and importance of bed rails being in the up position. The fact should be stressed that this is for their own safety and welfare. If a patient is not capable of understanding, a family member should be informed of the need for side rails to be in the up position.
• Items such as water, telephones, call buttons, etc., should be in easy reach of patient so he/she does not have to overreach and possibly fall from the bed.
• Beds should always be lowered before patients attempt to stand.
• When side rails are placed in the up position, Nursing Services should give it a tug to ensure the latch is engaged.
• Brakes should always be locked when in position and especially during patient transfer. Patients often use the bed for support when getting in and out of bed and could be injured if the bed moves. When setting the brakes, push and pull bed to ensure stability.
• Any defective bed should be removed from service and repairs requested.

Chapter III: Electrical Safety

General electrical safety measures

The following procedures shall be followed at all times when electrical devices are used:

• Electrical devices shall be protected from wet floors.
• Always switch to “OFF” position before plugging or unplugging an electrical device.
• Do not disconnect the device from the wall by grasping the cord. Only disconnect from the wall by grasping the plug.
• Electrical devices that malfunction should be removed from Service immediately and sent for repair/replacement.
• Electrical cords that show evidence of fraying, extreme wear cut in insulation or evidence of burning shall be removed from service and sent for repair/replacement.
• If the ground pin is missing from the plug, remove the device from service and send for repair/ replacement.
• Any device that has been dropped, abused, had a liquid spill on it or has evidence of overheating shall be removed from service and be checked for electrical integrity.
• Extension cords for patient care equipment must be approved by the Biomedical Engineering Department.
• Maximum care should be taken to ensure that no medical equipment with a load greater than 20 amp will be operated with an extension cord.
• If you find an open/ broken electrical socket or any open-wire or any other electrical device which may seem to be precarious when safety is concerned, inform the Safety Officer or the Maintenance Department immediately.
• In case of any sparks or burning smell, put off the main switch (if possible) and inform the maintenance department immediately.
• Turn Off all the switches that are not in use.
• NAKED WIRES (WITHOUT PLUG) SHALL NOT BE INSERTED IN THE SOCKET

Backup resource for electricity

• Monitor the power supply from MSEDCL with the help of Voltmeters and indication lamps provided on two panels before and after the transformer.
• Ensure that all UPS systems throughout the hospital are in working condition to supply the uninterrupted power to all the life saving and critical equipment and areas.
• If power from the main source fails, check whether one of the Diesel Generators has started automatically within 01minutes.
• When the power from the main source comes back to restore the supply within 30 seconds.

Emergency protocol for electricity outage

1. If you experience an electrical outage in your area for more than a minute immediately notify the Maintenance Department. After hours and on public holidays notify the Operator to connect the line to the Maintenance personnel on duty.
2. The Maintenance Team looks into the problem and analyses the approximate time it takes to repair and bring back the normal functioning. Depending on this the Safety Officer decides whether the outage will be a long-term or a short-term one.

Short-Term Outage

It can be a part of the hospital affected or breakdown of UPS or planned and announced power cut from the MSEDCL. The hospital with in-house resources i.e. Generator, UPS, backup UPS etc will be able to adequately meet patient care needs with few if any terminations of services.

Long-Term Outage

Complete hospital building involved and the outage is expected to be more than 24 hours. It can be announced by the MSEDCL in advance or due to any other disaster. Hospital cannot adequately meet all patient care needs with available in-house resources. The relocation of some or all patients may be necessary. The loss or termination of some or all services may be necessary.

• Certain actions to be considered by GM Operations or Operations Team in consultation with the doctors during a long-term outage:
  • No new admissions to the wards except for emergencies.
  • Interventional Procedures – cancel elective procedures – only emergency cases will be performed.
  • Visiting patients restricted or stopped.
  • OPD will be stopped
  • Radiology – will be down – only available X-ray will be portable units – film processors will be down.
  • Clinical Laboratory – workload restricted to essential testing
• The Command Center instructs the following common to all the departments:
  • To keep the minimum lights on in the corridors, administrative offices, bathrooms not in use, patient rooms.
  • To keep the air conditioners on only if the circulation of air is required.
  • To put off all the computers, TV, printers, etc. Keep them on only for emergency work.
  • If the refrigerators have only a few items in it, the same can be labelled appropriately and stored in one refrigerator in the ward. And the others can be put off.
  • To put off all the equipment which are not required?
  • To pull off the plugs of all Microwave Ovens.
• If the situation requires a complete shutdown of the hospital relocation may be required. Evacuation will be planned as per the Evacuation Procedure explained in this manual.

Chapter IV: Engineering & Facility Safety 

Prevention plan

• Inspect all the floors in the hospital and check the facilities provided. Enter the observations in a logbook.
• Any breakdowns/repairs to be performed must be entered in the logbook and attended at the earliest. Attend to the major complaints after completing the inspection.
• In case the problem is major and needs to be attended immediately, inform the seniors in the maintenance department. Make sure that these attended immediately by the concerned personnel.
• Attend to all the complaints given by the concerned department representative by prioritizing the same.
• Carry out Preventive Maintenance of all critical areas, like, PET CT, Operating Rooms, ICU on non-working days like Sundays and Holidays
• When it comes to another critical area like ICU, concerned ICU Nursing in-charge will identify the day and inform maintenance whenever the ICU wing or cubicle becomes free. Carry out preventive maintenance during that time. The details of preventive maintenance activities are as follows:
• Checking and rectifying the loose connection of all electrical Power Outlets.
• Replacement of defective switch and sockets
• Checking for any leakage in the Oxygen Line and arresting the same by replacing the spares or the entire outlet.
• Checking for any leakage in Vacuum Line and arresting the same by replacing the spares or the entire outlet.
• Checking and cleaning the Supply and Return Air diffusers in the department
• Checking and arresting fresh and drain water leakage at all points.
• Painting of areas, which need painting.
• Maintenance of Equipment
  • Carry out the Preventive Maintenance periodically for those equipments that are not under AMC. Record the activities carried out in the Maintenance Checklists.
  • And for those under AMC, make sure that PM visits are given on the assured dates. If in case you find it is not been done, inform the same to the electrical or chief engineer immediately.
• Ensure the elimination of Electromagnetic interference and prevent any damage or leakage to ensure radio frequency interference proof environment.
• Make sure that the gas connections are not interchanged.
• Ensure smooth and proper working of the circuit breaker mechanism.

At the time of construction

• Smoking is strictly prohibited in all Hospital facilities. This includes smoking in or adjacent to all construction areas. An increased level of enforcement will be initiated for the prevention of smoking in all construction areas.
• Combustible debris must be removed from the work site at least daily. This is the responsibility of the contracting company doing the job in our hospital.
• Housekeeping inspections must be conducted at least daily in all construction areas. This is the responsibility of the Department of Operations.
• Proper storage practices must have adhered in order to ensure that flammable and combustible liquids and solids are appropriately stored and safeguarded. Flammable liquid containers, flammable liquid storage cabinets and rag cans will be used wherever required. Flammable/combustible liquids shall be properly stored in approved flammable storage cabinets anytime not in use- Department of Maintenance.
• Increased frequency and intensity of hazard surveillance inspections will be implemented for all buildings, grounds and equipment during construction, demolition, repair or renovation activities.
• Welding, cutting, brazing, soldering and other hot work inside the hospital requires a fire watch sign must be posted at all areas other than those sites expressly designed for this purpose.
• Electrical tools, extension cord lights, grinding wheels or any spark-producing devices are not to be used where flammable liquids are used or stored.
• Welding, cutting, burning, or other hot work equipment must be in good working condition. Excess cylinders may not be stored in the facility. All cylinders must be capped and secured, with fuel gases and oxidizers properly segregated and permission is sought from the fire officer for the same.
• Temporary structures shall not be constructed inside buildings under construction/ renovation.
• Extinguishers, if not present in construction area shall be provided in rating and spacing suitable to the construction activity.

Sudden failures of supply of gas and vacuum

Prevention plan

• Ensure the availability of medical gases like Oxygen, Nitrous Oxide, and suction outlets are in working condition.
• Monitor the level of Liquid Oxygen, in the manifold room. Instruct the respective supplier to replenish the same. The supplier will do so based on the requirement within 24 hours of intimation.
• Periodically check the pressure level at different outlets to make sure there is no leakage through the supply lines.
• Checking for leakage is done using soapy water, if it gives bubbles at certain points, it indicates the leakage of gas/ minor cracks on the pipeline.

Action Plan

• Wherever central supply of Oxygen is not available, the maintenance department will make sure that cylinders are in adequate number and there is a backup.
• If in case there is a problem in the supply of Oxygen, the maintenance department will make sure that the supply is continuous through the standby cylinders.

Emergency protocol for lift outage

This protocol is to see that the use of elevators on emergency power is appropriately managed to best meet the needs of our patients during lift outage and restore service as soon as possible.

• The Safety Instructions are displayed in the Lift along with the Emergency Contact numbers.
• At the time of a normal power loss event and lifts are on emergency generator power. There may be stopping of lift for a few seconds. Once the power comes back the lift will automatically start again.
• In cases where the lift breaks down in between the Emergency Button is pressed. The Maintenance staff should respond to the trapped passengers and assist with removing them.
• The maintenance staff opens up the lift door with manual control.
• In cases of any disaster, lifts are grounded and are shut down.
• Depending on the time and length of the outage, the Chief Administrative Officer or Administrator may limit or stop visitors from entering the hospital.
• In case of major breakdown estimated time for repair must be mentioned to the concerned staff.

Transferring patient in the lift

• If you are transferring a patient in a wheelchair or stretcher call the lift or ask security or any other staff present to call the lift before the patient could reach near the lift.
• In case you find the lift is not in working condition, do not move the patient to the corridor unless and until you are sure that the lift has resumed functioning. Or if the patient can be transferred in the wheelchair (when other lifts are functioning) or by walk facilitate the same. If not speak to the relatives regretting the inconvenience and inform the approximate time that would take to resume the normal functioning.
• When the lift outage is estimated to be more than 5 minutes and if the patient condition requires emergency intervention, inform the doctor and move him/her to the close by room with an emergency facility such as oxygen line, suction, crash cart and continue the treatment.
• While shifting the corpse of the expired patient, make sure the lift is in working condition before moving out of the ward. If not call up maintenance and ask how long it would take to recommence the functioning. If the time estimated is more than 10 minutes, MSW will convince the relatives to move down and assure them that the corpse will be brought to the ground floor by the staff safely.