HAZARDOUS MATERIALS RESPONSE PLAN

“Code Black – Spill – Location”

DEFINITION:
Unexpected spill of potentially harmful chemical agent(s) that may have an adverse affect on patients, visitors, staff, or others coming into the hospital’s facilities.
MITIGATION / PREPARATION
  • Staff Education
  • Material Safety Data Sheets
  • Emergency Hotline (6SAFE)
  • Established Relationship with External Agencies
  • Risk Assessment
  • Staff education during orientation
  • Department-specific staff education during orientation and ongoing
  • Environmental rounds as per regulatory requirements
  • Placement of staff reminders throughout the facility (6-Safe phone stickers) and on the HUB (MSDS information)
/
  • Written Hazardous Materials plan and policies
  • Annual review of the plan and policies to ensure best practices (i.e. hazardous material handling, spill prevention and response)
  • Maintained chemical /hazardous materials inventory list
  • Maintained Material Safety Data Sheets
  • Periodic testing of staff knowledge
  • Adequate supply and maintenance of response equipment
  • Training and testing of spill response staff

RESPONSE / RECOVERY
  • HICS Activation
  • Staff Activation
  • External Agency Activation
  • HERT Team Activation
  • Emergency Event Announcement
  • Communication Systems
/
  • After Action Report / Review
  • Maintain HICS
  • Replenish Equipment and Supplies

HAZARDOUS MATERIALS SPILL RESPONSE

Unless familiar with the product and how to clean a spill involving the product, do not attempt to clean the spill yourself!

  • Specific spill clean up requirements and procedures are listed on all Material Safety Data Sheets (MSDSs) for all chemical products used in a specific department.
  • Any employee can contact Safety Link at any time for a MSDS at 6-Safe (67233)
  • An inventory of all SRHS MSDSs is maintained by the MSDS Administrator.

Minor Spills

A minor spill is one that:

  • The staff is capable of handling safely without assistance.
  • Staff has knowledge of the material (if not or the product is unknown, follow theprotocol for major spills)
  • A small quantity has been spilled
  • Staff knows how to properly clean up the material
  • No immediate toxicity to exposed staff

Spill response supplies and appropriate personal protective equipment (PPE) should be available to clean up minor spills.

If staff is cleaning the spill:

  • Cordon off the area to prevent persons from walking through a spill area or the spill itself.
  • Seek assistance for anyone injured as a result of the spill
  • Notify the department coordinator or manager
  • Obtain the appropriate PPE and materials to clean the spill
  • Use the established procedures (manufacturer or MSDS) for cleaning up the spill.
  • Dispose of the waste according to regulatory requirements
  • Complete the Hazardous Materials Spill/Exposure Occurrence form and submit to Safety for review by the EOC. Submission of this form is mandatory for all spills.

Major Spills

A major spill is one that:

  • Staff cannot safely handle without assistance
  • Staff does not have adequate knowledge of the material or the material’s identity is not known
  • Requires the use of respirators or other specialized spill response equipment
  • Poses a significant risk of toxicity to those exposed

Protocol for Unknown Product, Assistance Required or Major Spills

  • Evacuate all persons from the immediate spill area and cordon off the spill
  • If a fire occurs as the result of the spill, activate the fire alarm and, if appropriate, extinguish the flames using the appropriate fire extinguisher.
  • Obtain medical assistance (Code PI) for those exposed
  • Post staff at a safe distance to prevent others from entering the spill area
  • Contact Safety Link (6-Safe) to report the spill and initiate response. If you know the identity of the material involved, give this information to the 6-Safe representative.

Response is initiated in 4 tiers:

  • Tier 1 – Security will respond to provide security and to bring the Spill Cart to the scene
  • Tier 2 – A Hazardous Materials Specialist will be contacted to assess the scene and determine additional response requirements.
  • Tier 3 – If a number of individuals require decontamination, the HERT team will be activated
  • If the spill and subsequent waste generated are beyond the scope of training of the response staff, an outside emergency response contractor will be notified

Response staff will clean the spill, in accordance with established procedures or information from the MSDS for the material, unless the spill exceeds their scope of training.

Additional Response Resources

Chemotherapy Materials – Pharmacy

Chemicals – Laboratory

Radioactive Materials – Nuclear Medicine

Reporting Requirements

Response staff, along with the department involved, will complete the Hazardous Materials Spill/Exposure Occurrence form. The form will then be submitted to Safety for review by the EOC.

The EOC Manager will be responsible for notifying the Spartanburg County Emergency Management Departmentunder the spill reporting requirement under SARA Title II and the Community Right To Know Act of 1986.

Injury/Illness

Any employee or other person(s) who may be injured or become ill as a result of a spill/exposure incident are to be immediately transported to the EmergencyCenter for medical treatment. A copy of the MSDS should accompany the individual to the EmergencyCenter. For employee injury or illness, a SREO is to be completed as soon as possible after the incident.

Control of Hazards

A spill that occurs at any SRHS site is controlled by one of the following methods:

Containment Segregation Ventilation

Neutralization Substitution Isolation

Dilution General Housekeeping Wetting

The following materials are available to contain, absorb and neutralize chemical spills:

Pigs – absorptive material to contain spills

Kitty Litter- general duty absorptive

Sand – general duty absorptive

Neutralex – used for formaldehyde, formalin or 2% glutaraldehyde

TEAM- liquid acid neutralizer

BuCAIM – liquid caustic neutralizer

Note: TEAM and BuCAIM contain indicators to indicate when the spill has been neutralized.

ORIGINATION DATE:
11/20/06 / KEYWORDS:
HAZMAT SPILL (INTERNAL)
REVISION DATES: / REVIEW DATES:
11/30/07
12/01/2008