Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

Document Name :

TPH GENERAL SAFETY

GUIDELINES

Date Created :

25 September 2016

Approved By :
SHELLEY ANN M. MANGAHAS, MD,
MHA, FPAO
OIC Chief of Hospital

Reviewed By :
ENGR. ROWIENITO GUIAB
Chairman, Hospital Safety Committee
Issued By :

TPH Hospital Safety Committee

Responsibility of Updating :

TPH Hospital Safety Committee

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

TABLE OF CONTENTS
NO.

PARTICULARS

PURPOSE

SCOPE

POLICIES

3.1

Care Environment

3.2

Safety Management

3.3

Disaster

3.4

Bomb Threat

3.5

Diagnostic Services Safety

3.6

Communicable Disease

3.7

Regulation and Standard

3.8

Hospital Safety Committee

3.9

Hospital Safety Officer

3.10

Safety Inspection and Records

3.11

Hazard Communication and Reporting of Event

1.

PURPOSE
2

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

The TPH GENERAL SAFETY GUIDELINES serves to describe the policies and
processes in place to minimize safety risks to patients and staff through a comprehensive
hazard surveillance program and analysis of aggregate information.
2.

SCOPE
The TPH GENERAL SAFETY GUIDELINES defines the mechanisms for controlling
hazards, promoting and implementing safety measures for the patients, staff in particular
and the hospital in general.

3.

POLICIES
3.1

CARE ENVIRONMENT (CE)

It is made up of three components: building(s), equipment, and people. The
following are identified as elements and issues that can contribute to positively or
negatively influencing patient outcomes, satisfaction, patient and staff safety that
are appropriate and consistent with the clinical philosophy, security, orientation
and access to the outside environment, ease in traversing both the inside and
outside of facilities, efficient layouts that support staffing and overall function.
To effectively manage the CE the following should be done:
(1) Reduce and control environmental hazards and risks.
(2) Prevent accidents and injuries.
(3) Maintain safe conditions for patients, staff, students and visitors.
(4) Maintain CE that is sensitive to patient needs for comfort, social interaction,
and positive distraction.
(5) Maintain CE that minimizes unnecessary environmental stresses for patients,
staff and visitors.

3.2

SAFETY MANAGEMENT
3.2.1

HAZARD RECOGNITION
Hazard identification is the process used to identify all possible situations
in the hospital where people (patient, staff, visitors etc) may be exposed to
injury, infections or disease. The risk management authorities undertake
periodic evaluation of safety precautions to be followed by each
department.

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

For hazard recognition the following steps will be undertaken:

(1) Both Clinical and Non-clinical audits will be undertaken on a
periodical basis to identify the measures taken to prevent/reduce the
impact of the potential hazards.
(2) All the staff of the hospital will be encouraged to routinely assess all
activities to identify potential hazards.
(3) Departmental Heads and Managers will identify hazards within their
specific area of control. The same should be notified to the appropriate
hospital authorities for immediate corrective actions.
3.2.2

ELECTRICAL SAFETY:
The following measures are undertaken to ensure Electrical safety:
(1) Routine Inspection of the power outlets through out the hospital by the
electrician.
(2) Trip Switches are located in different parts of the hospital to prevent
short circuits.
(3) Periodic inspection of wires to ensures that they are in appropriate
conditions.
(4) Before any electrical appliance is brought into Tarlac Provincial
Hospital, a safety inspection is provided.
(5) Electrical equipment not required during night are switched off.
(6) Areas around electrical switchboards must be kept clear for a distance
of at least 1 meter.
(7) ABC type fire extinguisher will be located adjacent to electrical
switchboards.

3.2.3

POWER LOSS
The Hospital may experience temporary power losses due to:
(1) Storms
(2) Power company disruptions, or damage to the service lines entering
the hospital.
(3) Malfunctioning of the internal electrical wire system of the hospital.
3.2.3.1 IMMEDIATE ACTION:

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

In the event of power loss, every effort should be made to

immediately turn off all electrical equipment (if required) within an
employees work area before power is restored to protect the
equipment.
3.2.3.2 REPORTING POWER LOSSES
In general, the loss of power or the disruption in normal electrical
service should be reported immediately to the Electrician.
Maintenance staff will investigate the scope and condition of
power loss and proceed to correct the matter accordingly.
3.2.4

BIOLOGICAL HAZARD
Two primary sources for biological hazards has been identified which are:
(1) INFECTIOUS SHARP OBJECTS.
(2) BLOOD AND BODY FLUID SPILLS.
3.2.4.1 INFECTIOUS SHARP OBJECTS
(1)

Sharps are any medical or non-medical equipment that is

capable of cutting and/or puncturing the skin.

(2)

Sharps' injuries represent the major occupational cause of

accidents involving potential exposure to blood borne illnesses.

3.2.4.1.1

POLICY
Any equipment designated as a sharp must be
handled and disposed of safely
(2) Sharps are to be handled carefully at all times.
(3) Sharps are designated as clinical waste.
(1)

3.2.4.1.2

PROCEDURE
(1) Sharps must be disposed of at point of use.
(2) Used needles:
a) must not be recapped after use unless using an
appropriate device.
b) must not be removed from syringes by hand.
c) must not be bent, broken or otherwise
manipulated by hand.
d) must be destroyed immediately after its use.

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

(3) Used disposable sharps are disposed of in a

designated, clearly marked, puncture resistant
container.
(4) Reusable sharps are disposed of in a clearly
labeled, puncture resistant container for transport
to the reprocessing area (CSSD).
(5) Sharp sections on intravenous giving sets are cut
off and disposed of in the sharp's container. The
remainder is disposed of in the general waste.
This only applies to giving sets that have no
visible blood in the line. This does not apply to IV
sets that have been used for cytotoxic drugs.
(6) Sharps containers must be sealed and replaced.
3.2.4.2 BLOOD AND BODY FLUID SPILLS
3.2.4.2.1

POLICY
Blood and body fluid spills must be cleaned up
immediately or as soon as possible.
(2) Standard precautions must be used when cleaning
up spills of blood or body fluids.
(3) Gloves and other personal protective equipment
appropriate for the task must be worn.
(4) Hands must be washed properly after the spill
has been cleaned up.
(1)

3.2.4.2.2

PROCEDURES
(1) The following points should be taken into account
while cleaning up body fluids:
a) Type of body fluid
b) Size of spill
c) Surface type area involved

3.2.4.2.2.1

Impervious Surfaces
(1) Wipe the spill up using absorbent paper towel.
(2) Wash the area with water and detergent.
(3) If there is a likelihood of bare skin contact with
the surface, the area is disinfected with sodium
hypochlorite solution.

3.2.4.2.2.2

Operating Room
(1) Spills should be attended to as soon as it is safe to
do so.

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

(2) Area to be disinfected with sodium hypochlorite.

3.2.4.2.2.3

Bathrooms and toilets

(1) Spill are hosed off into sewerage system and are
flushed with water and detergent.
(2) The area is disinfected with sodium hypochlorite.

3.2.4.2.3

A detailed inference to the preventive measures

undertaken to control biological hazards can be drawn
from the following policies:
1.) Hospital Infection Control Policy
2.) Waste Management Policy.

The Infection Control Policy can be referred for instruction

guidelines regarding management of hazardous waste.
3.2.5

FIRE PROTECTION
(1) Incidents of fire has been termed as CODE RED.
(2) In an incident of fire, the staff has been instructed not to shout the
word FIRE instead of that the word CODE RED to be used for
informing the other staff about the incidence of fire.
The two-fold objectives of the Fire Safety Plan are:
(1) FIRE PREVENTION
(2) EMERGENCY EVACUATION
3.2.5.1 FIRE PREVENTION
To prevent the incidence of fire by implementing appropriate
measure to control fire hazards in the building and by the
maintenance of the building facilities provided for the safety of
the occupants. (patients, staff, visitors etc.)
(1)
(2)

The hospital has been declared No Smoking zone.

Smoke Detection Devices are placed in different parts of the
hospital, incase of the fire, on detecting smoke the devices are
activated and a hooter is alarmed in the security office.

(3)

Fire Extinguisher: Fire extinguishers, in appropriate sizes and

types (ABC), are provided throughout the hospital in every
floor of the hospital. Extinguishers are inspected as required by

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

a qualified contractor. The theft of or tampering with an

extinguisher should be reported immediately to the
Maintenance in charge.
3.2.5.2 EMERGENCY EVACUATION
To establish a systematic method of safe and orderly evacuation
of an area or building, by and of its occupants, in case of fire or
other emergency.
3.2.5.3 The following procedures are observed to minimize the effects
of Fire Accidents in the hospital, The R.A.C.E. Procedure is
followed:
(1) RESCUE
Remove patients or others in immediate danger, and the door
behind is closed. If the person is busy in rescue effort, he
should shout CODE RED so that other employees can pull
the alarm.
(2) ALARM
Break open Alarm system are placed in different parts of the
hospital which can be activated at the time of fire by breaking
the glass panel.
Smoke detectors are also located in different parts of the
hospital which in the event of detecting smoke will activate the
alarm system in the in house telephone exchange.
(3) CONTAIN
Contain the fire by closing doors and windows so that it does
not spread to other parts of the hospital.
(4) EXTINGUISH / EVACUATE
a)
b)
c)
d)

Extinguish fire if possible.

Use correct extinguisher for the type of fire.
Evacuate all persons to a safe area, if necessary.
Follow directions of Safety Officer, Fire Department or
Nursing Supervisor.

3.2.5.4 Fire plan is placed in every floor which indicates the exact
location of the fire exits and fire extinguishers hence in case of
any fire accidents; the nearest fire exit in the floors can be easily
traced.
3.2.5.5 Fire Extinguishers

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

The procedure for use of any fire extinguisher are:

a)
b)
c)
d)

Pull Pin (from handles)

Aim at base of fire
Squeeze handles
Sweep nozzle or hose from side to side:

3.2.5.6 Fire Training and Drills:

Fire Training and Fire drills are held at periodic intervals. All
employees are provided adequate fire training; they are informed
about the fire evacuation procedures including fire exits located in
their work places.
3.2.5.7 The following special precautions are also undertaken:
3.2.5.7.1

EXITS
(1) No obstructions may be placed in front of or upon
any exit door.
(2) No aisle, exit access, or stairway may be obstructed
with furniture or other obstructions so as to reduce
the required width of the exit unless it is required
for some maintenance purpose or during night hours
when the main entrance is closed.

3.2.5.7.2

RAILINGS, STEPS AND WALKS

The area immediately outside of building exits will be
maintained free of material at all times. Vehicles are not
permitted on sidewalks immediately adjacent to an exit.

3.3

DISASTER
The Tarlac Provincial Hospital shall coordinate with the Provincial Disaster and
Risk Reduction Management Council (PDRMMC) in order to identify the various
kind of internal and external disaster and specifies the measures to be undertaken
for ensuring appropriate prevention and management of disasters.

3.4

BOMB THREAT

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

Bomb threats are delivered in a variety of ways with the majority of threats being
called in to the target. In the event of a bomb threat, all personnel will follow the
following procedures:

3.5

(1)

The staff member receiving the call should make reasonable efforts to gain
as much information as possible. Keep the caller on the line as long as
possible. Ask who is calling, and have the caller repeat the message. Write
down every word spoken by the person making the call.

(2)

If the caller does not indicate the location of the bomb or the time of the
possible detonation, the person receiving the call should ask the caller to
provide this information.

(3)

Inform the caller that the building is occupied and the detonation of a
bomb could result in death or serious injury to many innocent people.

(4)

Pay close attention to any strange or peculiar background noises such as

motors running, background music, or other noises that might give some
clue concerning the origin of the call.

(5)

Listen closely to the callers voice, voice quality, accents, and speech
impediments. Immediately after the caller hangs up, the person receiving
the local Police Station.

(6)

Evacuation notification procedures will be activated to evacuate the

buildings.

(7)

The staff should direct and assist patients to exit the buildings consistent
with fire evacuation procedures.

(8)

All staff should exit the buildings the buildings.

(9)

The police and assigned staff (Security Personnel) will conduct an

extensive search of the buildings.

(10)

The Head of security or authorized representative will approve re-entry

into the building after a search is completed and after consultation with the
police.

DIAGNOSTIC SERVICES SAFETY

Policies and procedures pertaining to Laboratory Safety and Radiation Safety can
be referred from the TPH Manual.

3.6

COMMUNICABLE DISEASE

10

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

The Tarlac Provincial Hospital (TPH) is committed to assure, to the extent

possible, that each employee enjoys safe and healthful work conditions. The
Hospital, in its effort to control communicable diseases on the hospital, has
adopted this provision.
(1) Persons infected or reasonably believed to be infected with communicable
diseases will not be restricted in their access to Hospital services or facilities
unless medically-based judgments in individual cases establish restriction is
necessary to the welfare of the individual, patients and other members of the
institution, or others associated with the institution through clinical,
cooperative, intern, or other such experience, involving the general public.
(2) Persons known to have, or have a reasonable basis for believing, that they
have been infected or have a communicable disease which may pose a threat
to others are expected to seek expert advice about their health circumstances
and are obligated, ethically and legally, to conduct themselves so as to protect
themselves and others.
(3) Employees or Applicants Currently Infected
Any applicant or currently enrolled employee who is known to have a
communicable disease (including human immunodeficiency virus (HIV),
hepatitis B, and other blood borne disease) will be individually evaluated and
all enrollment decisions concerning the individual will be based upon a
consideration of the following factors:
a) The potential harm that the individual poses to other people,
b) The ability of the individual to accomplish the objectives of the
assignment, and
c) Whether or not a reasonable accommodation can be made that will
enable the individual to safely and efficiently accomplish the objectives
and specific tasks for the assignment without significantly exposing the
individual or other persons to the safety of infection. All employees who
have a known communicable disease will be assessed as needed by
appropriate medical staff. The evaluation of an applicant or currently
enrolled employee with a known communicable disease will include a
physician's statement of the individual's health status as it relates to the
individual's ability to adequately and safely accomplish the essential
objectives of the applicant's or employee's assignment. The physician's
statement must also indicate the nature and extent of the individual's
susceptibility to infectious diseases often encountered when
accomplishing the objectives of the individual's assignment.
Each new employee is required to undergo pre employment medical examination
prior to their reporting to duty and all the existing employees of the organization
have to undergo annual medical check on a regular basis. The Food Handlers are
required to under medical check up once every six months.

11

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

3.7

REGULATIONS AND STANDARDS

The Tarlac Provincial Hospital (TPH) ensures strict adherence to the required
standards and performs its operations within the purview of the law of the land so
as ensure utmost safety for its patients, staff, visitors etc. The required licenses
and other regulatory requirements are duly satisfied. The Chief of Hospital is the
custodian of all the statutory documents/licenses.

3.8

HOSPITAL SAFETY COMMITTEE

The Hospital Safety Committee is a multidisciplinary committee consisting of
five members. It meets at least ONCE in every quarter to evaluate the various
safety aspects of the hospital. The Committee undertakes detail analysis of the
ongoing monitoring activities and gives its feedback on the same. The Committee
submits its report to the Chief of Hospital.
3.8.1

The Hospital Safety Committee evaluates the ongoing monitoring

activities on various aspects of the following problems:
(1)
(2)
(3)
(4)

Injuries to patients / visitors

Property damage.
Occupational illnesses and injuries to staff
Hazardous materials and waste spills, exposures, and other related
incidents
(5) Security incidents involving patients, staff, students and visitors at
Tarlac Provincial Hospital.
(6) Fire-safety management problems, deficiencies, and failures.
(7) Medical equipment-management problems, failures, and user errors
(8) Utility systems management problems, failures, or user errors.
(9) Staff Unavailability (such as Weather Emergencies, natural disasters)
(10) Mass Casualty Patient Influx (such as Infectious Disease Outbreaks).
3.8.2

Role of the Hospital Safety Committee

(1)
(2)
(3)
(4)
(5)
(6)

3.8.3

Provide guidance and direction in all phases of the Safety

Management Program.
Pro-active safety risk assessments of the clinical and clinical support
areas of hospital.
Facilitates the Environmental Monitoring Rounds.
Advising management of unsafe conditions or of non-compliance
with regulations and standards.
Conducts on-going safety education classes.
Responsible for proposing/revising safety policies.

Records and Reports:

(1)

Both the quarterly and annual reports are to evaluate the objectives,
scope,

12

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

(2)
(3)
(4)
(5)
(6)
3.9

performance and effectiveness of each of the CE management plans.

Both quarterly and annual reports are compiled, trended and
presented to the Hospital
Safety Committee.
The Hospital Safety Committee submits the reports to the Chief of
Hospital.
The annual evaluation includes recommendations for Performance
Improvement during the following year.

HOSPITAL SAFETY OFFICER

3.9.1

AUTHORITY
Appointed by the Chief of Hospital.
Reports to the Chief of Hospital / designated authorities on all matters
pertaining to safety matters
(3) Has the authority to shut down any process that is considered to be in
violation of policy until the issue is resolved by Head of Department or
Officer.
(4) Has the authority to enter all areas of the Hospital, assess safety
practices.
(1)
(2)

3.9.2

RESPONSIBILITIES
(1)
(2)
(3)
(4)

(5)

(6)
(7)
(8)

3.10

Administer safety policies of the hospital and department.

Liaise with hospital authorities and other regulatory authorities.
Inspect laboratories and other areas to ensure safety practices are being
observed.
Advise Head of Department of the various department on new and
proposed legislation, together with safe work practices needed for
compliance.
Ensure suitable personnel are appointed to positions to oversee
biohazards, chemicals and radiation matters within the respective
department.
Prepare Departmental procedures dealing with health and safety issue
within the Department.
Identify training needs and arrange for Departmental staff and student
training in consultation with Hospital Officers.
Must ensure that all tasks associated with and required for the position
of Chairperson of the Hospital Safety Committee are undertaken.

SAFETY INSPECTION AND RECORDS:

The hospital undertakes periodic inspection of the safety precautions undertaken
either internally or with the help of an appropriate external agency. The reports of
the safety inspections are reviewed by the hospitals safety committee and the
same is submitted to appropriate Government Department/Agency as and when
required. The safety Inspection records are maintained with respective
departmental authorities.

13

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

The Safety Management Officer or Committee may require periodic assessment

of the following inventory:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)

Environmental (lighting, dusts, gases, sprays, noises).

Hazardous materials (flammable and caustic).
Equipment (biomedical equipments etc.).
Power equipment (boilers, motors, etc.).
Electrical equipment (switches, breakers, fuses, outlets, connections).
Hand tools.
Personal protective equipment (safety glasses, ventilators, radiation safety
aprons etc).
Personal service/first aid supplies (Medical Check Up).
Fire protection equipment (alarms and extinguishers).
Walkways/roadways (sidewalks, roadways).
Transportation equipment (Ambulances, lifts).
Containers (hazardous waste bags).
Structural openings (windows, doors, stairways).
Buildings/structures (floors, roofs, planter walls, fences).
Miscellaneous (any items not covered above).

Each inspection report will record pertinent safety management violations,

noncompliance items, and observe deficiencies. Employees directly involved in
the use or operation of the facilities or function being inspected is to participate in
the inspection process.
3.11

HAZARD COMMUNICATION:
3.11.1 GENERAL
Any incident in the hospital which effects the safety policies of the
hospital will be investigated by the Hospital Safety Committee and the
report would be forwarded to the appropriate higher authority for further
action. The following incidents should be immediately informed to the
Safety Officer of the hospital:
(1)
(2)
(3)
(4)
(5)

Serious injury to patients.

Serious injury to employees.
Serious injury, caused by Hospital operations, to another party.
Major loss of Hospital equipment or property.
Major loss of equipment or property belonging to another party
caused by hospital operations.

3.11.2 REPORTING ACCIDENTS

(1) Any accident should be immediately investigated by the employees
supervisor or appropriate staff member.

14

Provincial Government of Tarlac

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
Landline: (045) 491 8970, Fax: (045) 982 1306
Email: [email protected]

(2) A Supervisors Accident Report Form should be completed and filed

as soon as possible with the Safety Management Officer for reporting
purposes and for further investigation and resolution.
(3) Upon learning of a serious accident involving employees, employees,
or equipment, an
employee must notify the Hospital Safety Officer
immediately. Serious accidents will be investigated by the Hospital
Safety Officer. Reports for any such incident is to be forwarded to the
Safety Management committee of the hospital.
3.11.3 RELEASE OF INFORMATION
In the case of accidents, supervisors and employees must not release
information to the news media so as to avoid creation of unwanted panic
among the people. Information to the media is to be provided by the top
management authorities not less than the designation of Vice President. If
contacted by the media, please refer these individuals to the appropriate
persons.
3.11.4 SAFETY EDUCATION
The Hospital requires all new employees to attend new employee safety
orientation programme. This orientation is intended to provide new
employees with an awareness of safety importance and their responsibility
for maintaining a safe and healthy work environment, and to give an
overview of workplace safety basics. The results should be more safety
conscious employees who are receptive to learning and practicing the
specifics of a safe, healthy workplace.
3.11.5 SAFETY ORIENTATION FOR NEW EMPLOYEES
All new employees receive safety orientation. The orientation will consist
of the following information: The Safety Management Officer or external
instructors will present the general safety policies of the Hospital, and the
new employees supervisor will present:
(1)
(2)
(3)
(4)
(5)
(6)

Procedures and policies specific to the new employees position

Fire reporting procedures
Fire extinguisher location and use
Fire prevention
Safe lifting techniques
Any information the supervisor feels will provide the new
employee with a safe environment.

15