MEHTA MULTISPECIALITY HOSPITAL

Issue Date: 10 -06-2024

Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

HAZMAT MANUAL

MMH

Prepared by: Mr. Sumit 1

Approved by: Dr. RAKESH SHARMA

 MEHTA MULTISPECIALITY HOSPITAL
Issue Date: 10 -06-2024
Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

INDEX

SR. NO. PARTICULARS PAGE NO.

1. COVER PAGE 1
2. INDEX 2
3. AMENDMENT SHEET 3
4. CONTROL OF MANUAL 4
5. INTRODUCTION 5
6. SCOPE 5-6
7. DEFINITION 5-6
8. LABELING OF HAZARDOUS MATERIALS 6-8
9. MINOR SPILLS 8-9
10. CLEAN UP OF SMALL CHEMICAL SPILLS 9-10
11. MAJOR SPILLS 10
HAZARDOUS MATERIAL SPILL (OTHER THAN 10-11
MERCURY, FORMALIN, & ETO)
12.
EMPLOYEE CONTAMINATION DURING CHEMICAL 11
SPILLS
13.
14. PROCEDURE 11
15. HAZMATS LIST 11
16. MSDS SHEET 11-14

AMENDMENT SHEET

Prepared by: Mr. Sumit 2

Approved by: Dr. RAKESH SHARMA

 MEHTA MULTISPECIALITY HOSPITAL
Issue Date: 10 -06-2024
Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

Sr. No. Section No. Details of the Reasons Signatureof Preparatory Signature of the
& Page No. Amendment Authority Approval
Authority

Control of the Manual:

Prepared by: Mr. Sumit 3

Approved by: Dr. RAKESH SHARMA

 MEHTA MULTISPECIALITY HOSPITAL
Issue Date: 10 -06-2024
Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

 The holder of the copy of this manual is responsible for maintaining it in good and safe condition and
in a readily identifiable and retrievable.
 The holder of the copy of this Manual shall maintain it in current status by inserting latest amendments
as and when the amended versions are received.
 Quality Manager is responsible for issuing the amended copies to the copyholders, the copyholder
should acknowledge the same and he /she should return the obsolete copies to the Quality Manager.
 The amendment sheet, to be updated (as and when amendments received) and referred for details of
amendments issued.
 The manual is reviewed once a year and is updated as relevant to the hospital policies and procedures.
Review and amendment can happen also as corrective actions to the non-conformities raised during the self-
assessment or assessment audits by NABH.

Preparation Approval

Safety Officer M.D.,MMH

The authority over control of this manual is as follows:

The procedure manual with original signatures of the above on the title page is considered as ‘Master Copy’,
and the photocopies of the master copy for the distribution are considered as ‘Controlled Copy’.
Distribution List of the Manual:

[Link]. Designation
1. M.D.
2. Quality Manager
3. Safety Officer

Purpose :

To protect the health and well being of all employees, patients, patients attendants and visitors and to

Prepared by: Mr. Sumit 4

Approved by: Dr. RAKESH SHARMA

 MEHTA MULTISPECIALITY HOSPITAL
Issue Date: 10 -06-2024
Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

avoid exposure to a hazardous environment.

Scope :

Hospital Wide

Definition:

Hazardous materials are materials which, because of their chemical, physical orbiological properties,
poses a potential risk to life, health, the environment, or Property when not properlycontained.
It includes materials that are explosive, flammable, combustible, corrosive, reactive, poisonous,
biological or radioactive. They can be solid, liquid or Gaseous

Policy:

Current environmental regulations requirean in-house hazardous materials team to be a part of hospital
operations. However, the need for prompt response to hazardous materials releases and proper
mitigation of these incidents often makes having an own team a necessity.

Having a team and managing the operations of the team are critical tasks. This team requires us to
organize resources, plan for handling emergencies, evaluate and purchase equipment, and train
response personnel. These tasks must also be part of a continuing management program to keep the
team ready for any emergencies.

1 CLASSIFICATION OF HAZARDOUS MATERIALS

Class 1: Explosives-Materials in this category include projectiles as well as sensitive and insensitive
explosives. All must be handled with extreme caution. They should never be shaken or dropped and
should be kept away from open flames.
Class 2: Hazardous Gases-This class includes flammable and non-flammable compressed gases as
well as poisonous gases.

Class 3: Flammable Liquids-This class includes both flammable liquids with a

Flashpoint below 140 degrees F and combustible liquids with a flash point between 141 and 200
degrees F.
Class 4: Flammable Solids-This includes spontaneously combustible and "dangerous when wet"

Prepared by: Mr. Sumit 5

Approved by: Dr. RAKESH SHARMA

 MEHTA MULTISPECIALITY HOSPITAL
Issue Date: 10 -06-2024
Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

solids that become combustible when brought into contact with water.
Class 5: Oxidizers-This class includes organic peroxide. These substances can become catalysts for
fire hazards.
Class 6: Toxic Materials-This includes inhalation hazards, other poisons, and infectious substances.
Swallowing, bodily contact, or inhalation of gases released by toxic substances may cause irritation of
skin and mucous membranes, or in more severe cases, serious illness. Contact a physician immediately
if exposed.
Class 7: Radioactive Materials (Not Applicable)
Class 8: Corrosive Materials-Corrosive materials can harm living tissue and nonliving matter, such
as steel, on contact.
Class 9: Biohazard agents: includes biological waste, mercury.
Class 10: Hazardous Chemical hazardous chemicals as any chemical that is a Physical or health
hazard and which meets the definition of:
(a) Carcinogen,
(b) Corrosive,
(c) Highly-toxic, Irritant, and/orToxic

4.2 LABELING OF HAZARDOUSMATERIALS

Any hazardous materials received in the wards / units should have proper signages on it.
When hazardous materials are stored in bulk it will be labelled with a NFPA Diamond.

Storage of the HAZMAT material

All hazardous material are segregated and stored separately. and placed in HAZMAT rack and
Cupboard. Stored with a NFPA diamond shaped sticker.

Inventory of Hazmat: All the hazardous material has a defined inventoryand maximum storage
quantity unit wise and storelevel.

Hazardous MaterialsHandling
 There shall be identified list of hazardous materials in thehospital.

 The staff shall be educated about the handling and storage of thosematerials.

Prepared by: Mr. Sumit 6

Approved by: Dr. RAKESH SHARMA

 MEHTA MULTISPECIALITY HOSPITAL
Issue Date: 10 -06-2024
Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

 The hazardous materials shall be stored in the designated areas marked for thesame.

 The storage of hazardous material shall be done according to the consumption pattern in that

particulararea.

Spillkit

Spill kit is available in each unit for MINOR spills and MAJOR spills.

Responsibilities in case of HazmatSpillage:

Responsible person:

• Housekeeping Supervisor /Staff floorwise

• Incharge ofarea/floor

Responsibility:

Nursing:

Attend to/monitor emergency medicalsituation.

Housekeeping Supervisor:
• Available round the clock.
• Reach site of emergency as soon aspossible.
• Ensure that any required personal protective equipment (e.g. eyewear or gloves) is available.
• Ensure that spill control materials are located in a readily accessiblelocation

Housekeepingstaff:

Containing/managing thespill.

Record information regarding any spills using the Spill Report Form. Completed forms must be
submitted to (Housekeeping In charge).

Responsibilities of Staff:

 Be familiar with the properties and hazards of the materials at worksite.

Prepared by: Mr. Sumit 7

Approved by: Dr. RAKESH SHARMA

 MEHTA MULTISPECIALITY HOSPITAL
Issue Date: 10 -06-2024
Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

 Before beginning work with a chemical, be aware of its hazards and the use of appropriate personal
protectiveequipment.
 Ensure proper reporting procedures are followed in the event of aspill.

5. MANAGEMENT OF HAZARDOUS MATERIAL SPILLS

The notification, building evacuation, and spill reporting procedures outlined below apply to Minor
and Major spills.

5.1 MINORSPILLS

5.4.1Bloodspills:

1. If less than 30ml.

2. Wear PPE (Gloves, Mask,Gown)
3. Pickupanybrokenglasswithtongsorothermechanicaldevice. Do not use your hands.
4. Place absorbent materials (Bloating Paper) over the spill, making sure not to spread liquid.
5. Put 1%sodium hypochlorite and keep it for 20minutes.
6. Dispose off all contaminated material in a yellow plastic bag, label it and contact housekeeping
fordisposal.

Complete a Spills Report Form and submit to Housekeeping Incharge.

The person responsible for spill may fill up the form and counter signed by the in- charge of that area.
However, the overall responsibility will be ofin-charge.

5.4 Hazardous material spills (other than mercury, formalin)

1. Rescue anyone immediately affected by the emergency. Only perform rescue if it does not put you
to greatrisk.
2. If emergency involves a fire, use the manual pull box to activate the firealarm.
3. For spills that do not involve fire or explosion, contact hazardous material team and describe the
emergency. Request Hazmat team for chemical or radiologicalincidents.
Warn others in the area about emergency and stay clear of the spillarea.

Prepared by: Mr. Sumit 8

Approved by: Dr. RAKESH SHARMA

 MEHTA MULTISPECIALITY HOSPITAL
Issue Date: 10 -06-2024
Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

Clean up of Small ChemicalSpills

If less than 30 ml.

Review Material Safety Data Sheets (MSDS) or other references for recommended spill cleanup
methods and materials, and the need for personal protective equipment (e.g.,
respirator,gloves)

Pick up any broken glass with tongs or other mechanical device. Do not use your hands.

Place absorbent materials (Bloating paper) over the spill, making sure not to spread liquid.

Dispose off all contaminated material in a plastic bag, label it and contact housekeeping for disposal.

Wash the area with copious amounts of water.

Complete a Spills Report Form and submit to the House keeping in charge.
the person responsible for spill may fill up the form and counter signed by the in-charge of that area.
However, the overall responsibility will be of in-charge.

MAJOR SPILLS (If more than 30 ml).

5.6.1 Blood Spill:
Call housekeeping staff & restrict the area. Housekeeping staff:
Wear PPE (Gloves, Mask, Gown)
Pick up any broken glass with tongs or other mechanical device. Place absorbent materials(cotton)
over the spill,Put 10%sodium hypochlorite and kept it for30 [Link] off all contaminated
material in a yellow plastic bag, label it.

Complete a Spills Report Form and submit to the House keeping in charge.

Prepared by: Mr. Sumit 9

Approved by: Dr. RAKESH SHARMA

 MEHTA MULTISPECIALITY HOSPITAL
Issue Date: 10 -06-2024
Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

5.7 Hazardous material spill (other than mercury, formalin)

Clean up of large spills

a) Large chemical spills are greater than 30cc.

b) Immediately evacuate the area and close all doors. Notify others not to enter the area.
c) Call Housekeepingsupervisor.
d) Inform the location, name of material, and approximatequantity.

Employee contamination during Chemicalspills

1. If the skin becomes contaminated with hazardous material, wash the affected are thoroughly with
copious amounts of water. If available, use an emergency shower for at least 15minutes.
2. If hazardous material is splashed in the eyes, flush the eyes immediately with water, preferably
using an eye wash station, for at least 15minutes.
3. Remove grossly contaminated clothing immediately. Place the contaminated clothing in a
plasticbag.
4. Report the spill to the supervisor of the area and seekmedicalattention. If possible, bring the
label or information on the chemical withyou.

PROCEDURE

1. Housekeeping staff to be available round the clock for cleaning up large spills of
hazardousmaterials.
2. Appropriate Personal Protective Equipment and Absorbents and Containers are available to control
thesituation.
3. Contaminated waste to be placed in a Yellow bag with proper labellingi.e.
a. Name of theSubstance:
b. Date & Time ofIncident:
c. Unit /Area:
d. Quantity ofSpill:

Prepared by: Mr. Sumit 10

Approved by: Dr. RAKESH SHARMA

 MEHTA MULTISPECIALITY HOSPITAL
Issue Date: 10 -06-2024
Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

e. Signature:and to be sent to Waste Disposal area

4. Other Hazardous material will be handed over to an outside agency (Synergy Biomedical Waste
Management pvt ltd) fordisposal.
5. HAZMAT Spill report form to be filled up and sent to the Housekeeping incharge.

HAZMATS LIST

1. Sodium Hypochlorite 1%
2. D-125
3. D-256
4. Microkleen Spray
5. Microkleen IR
6. M3 Multizyme
7. OPODEX
8. LUBI-SPRAY
9. Activated Gluteraldehyde Solution

MSDS SHEET:

Prepared by: Mr. Sumit 11

Approved by: Dr. RAKESH SHARMA

 MEHTA MULTISPECIALITY HOSPITAL
Issue Date: 10 -06-2024
Rev No.: 01 on 02.02.2025
MMH/ NABH STANDARD FOR HCO
/HAZMAT MANUAL FMS Effective Date: Page No.
03.02.2025 1-12

Prepared by: Mr. Sumit 12

Approved by: Dr. RAKESH SHARMA