SOP1.

Hospital Security and Safety Management

1. Scope : Hospital wide.
This covers all infrastructure & services provided by hospitals which have direct
bearing on security and safety such as
 Infrastructure & hospital property
 Control & flow of visitors
 Safety of Patients, visitors and service providers.
2. Purpose
 To ensure safety and security of the Hospital building, equipments,
patients and staff.
 To provide safe and assuring environment in the hospital premises for
efficient delivery of healthcare services and review for improvement.
3. Responsibility:
A) Security- Hospital Manager and Security Personnel are responsible for
effective implementation of the process.
B) Safety- Medical Superintendent/Hospital Manger/ Departmental In charge
and all staff.
4. Procedure:
Sl. Activity/ Description Responsibility Ref.
No. Documents
/ Record
Security
Planning the requirements for Infrastructure Security
Requirements are identified for resources needed for
safety and security of Hospital infrastructure and
environment
Duty hours of the Security Guards are twelve hours
and guards are on duty for two shifts. They are:
 Morning Shift: AM to PM
 Night Shift: PM to AM
Allocation / Posting of Security Staff at various points As Per
Security staff is positioned at different entry gates or Aggrement
points in the hospital.
Special duties are also assigned for VIPs based on the
information received.
24X7 security guards are available in hospital.
Control of Incoming & Out going Items NRGP (Non
All purchased items (infrastructure items. general Returnable
stores items, engineering items , pharmacy & Gate Pass)
medicine related items , vegetables or food / kitchen RGP ()
items ) when received in hospital are checked by Inward
security at Security Gate. After security check, the Register
items are allowed to move in hospital stores. Same (Courier
process is followed before moving any item out. Etc)
Inter
A Gate Pass System is used for outgoing and incoming Hospital
items. For goods/Articles “going out” from hospital, a Equipment
gate pass is raised along with goods/articles in Shifting
Triplicate. The distribution is as under.1. Guard at Book
hospital Gate.2. User (Along with goods/articles). 3.
Hospital/ Office copy.(b) Any articles/goods “coming
in” to HOSPITAL are raised in triplicate. Distribution is
as under.1. One copy along with goods/Articles 2.One
copy with Guard at HOSPITAL 3. Office copy. All
Passes are countersigned by
Pharmacist/Accountant/Hospital Manager.
Keys Control Daniel 2 Key
A key records register with details of keys and Registers
department concerned is maintained with details of
Keys Issue, and Keys returned.
Restricted visiting Hours:
Visiting Hours for attendants and visitors are fixed and
displayed in the Hospital:
Morning: :00 am – :00 am.
Evening: :00 pm- :00 pm
Two Visitors passes-Yellow and Green are issued for all
the patients admitted in the Hospital. Yellow is for
attendants requiring staying along with the patient in
night, and Green pass for visitors visiting other than
visiting hours. Attendants are allowed Entry only after
producing the relevant Pass.
(Only For ICU & NICU PICU)
Fire Safety and Its controls Daniel
The Hospital obtains NOC of Fire Safety from the Fire (Anually)
Department and an annual request is sent to the
department for appraisal of the Building and fire
safety measures.
The hospital has been declared „No Smoking‟ zone. Daniel
Fire extinguishers and sand buckets are placed at
different marked points throughout the hospital. A
Hospital layout indicating fire extinguisher / sand
bucket is also kept/ displayed in the hospital premises
Hospital Layout with fire exit plan is also displayed.

Fire exit is marked in the hospital for exit during fire.

In collaboration with Fire Department, Fire Training

and Fire drills are held at periodic intervals. All
employees are provided adequate training, on Fire
Safety. They are informed about the fire evacuation
procedures including fire exits located in their work
places.

Checking and testing of Fire extinguishers and its

refilling is maintained. A list of all fire devices is
maintained with Hospital Manager for effective
control.

Weekly Testing for auto Start of Fire Pumps

Testing of Smoke detectors and Fire Safety alarms &

Apparatus
Training to Security Personnel
Training on security related issues such as queue
management, crowd control, etc. and use of fire
extinguisher, sand bucket are conducted as per the
need on approval of Facility In charge
Safety
Hospital Safety Committee:
The Hospital Safety Committee is a multidisciplinary
committee consisting of XXX members. It is
constituted by BOD. It meets at least two times in a
year or when required, 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 in the meeting of BOD conducted
for the hospital.
Evaluation of Hospital Activities with respect to Safety

The Hospital Safety Committee evaluates the ongoing

monitoring activities on various aspects of the
following problems:
1. Injuries to patients/ visitors
2. Property damage.
3. Occupational illnesses and injuries to staff
4. Hazardous materials and waste spills, exposures,
and other related incidents
5. Security incidents involving patients, staff, and
visitors in the hospital
6. Fire-safety management problems, deficiencies,
and failures.
7. Utility systems management problems, failures, or
user errors.
8. Staff mobilization during Weather Emergencies, and
natural disasters.
Hazard recognition:
Departmental Heads and Hospital Manager identifies
hazards within their specific area of control. The same
is notified to the appropriate hospital authorities for
immediate corrective actions.
Audits are undertaken on a periodical basis to identify
the measures taken to prevent/reduce the impact of
the potential hazards
SAFETY INSPECTION AND RECORDS
The hospital undertakes periodic inspection of the
safety precautions. These inspections are conducted
at least twice a year or when required. The reports of
the safety inspections are reviewed by the hospital‟s
safety committee and the same is submitted to BOD
as and when required. The safety Inspection records
are maintained with respective departmental
authorities

The Hospital Safety Committee may require periodic

assessment of the following safety aspects:
1. Infection control for e.g. hand hygiene, cleaning,
disinfection, sterilization.
2. Patient safety
3. Electrical/Fire safety for e.g. open wiring, fire
extinguishers, fire mock drill etc.
4. Biological and chemical hazards
5. Personal Protective Equipments status.
6. Building safety for e.g. seepage, broken windows
etc.
7. Hospital security

Each inspection report records 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.
Corrective and preventive measures are undertaken
and implemented.
ELECTRICAL SAFETY
 The hospital undertakes the following measures to
ensure Electrical Safety:
 Inspection of the power outlets throughout
the hospital at defined frequency & SOS.
 Trip Switches are located in different parts of
the hospital to prevent short circuits.
 Inspection of wires to ensures that they are in
appropriate conditions, at defined frequency.
 Electrical equipment not required during the
night is switched off.
 Areas around electrical switchboards are kept
clear for a distance of at least 1 meter.
 Suitable fire extinguishers are located adjacent
to electrical switchboards.
BIOLOGICAL HAZARDS

The Hospital identifies primary causes for biological

hazards which are:
 Infectious Sharp Objects
 Blood and Body fluid spill
 Biomedical Waste
 Hospital Acquired Infections
Biological Hazards are prevented and managed as per
standard Procedures for Hospital Infection Controls.
LABORATORY SAFETY

Standard precautions like personal protective

equipment (PPE), safety devices and proper
decontamination and disposal of biohazard wastes are
the Laboratory Safety Policy specifies in details the
safety measures undertaken by the hospitals
Staff Safety:

All staff including out sourced staff goes through

periodic health check up. All staff is vaccinated against
TT and Hepatitis-B.
Adequate PPE are provided to all categories of staff.
Radiographers are provided with lead aprons and TLD
batches which are evaluated periodically at BARC or
its designated laboratory.

5. Records
Sr. no Record Name Record No. Retention
Period
Duty Roster Of Security Personnel
Attendance Register
Safety Inspection Report & Their Action
Details of Fire Extinguisher &
maintenance
Accident Report file