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MEMORIAL HERMANN (YOUR) HOSPITAL
POLICY AND PROCEDURE MANUALPOLICY TITLE: Medical Gas System
CATEGORY: Engineering Services
INDEX NUMBER: UM 705
LAST REVIEW DATE:
1.1 Medical gas/vacuum systems will be designed, installed, operated, and maintained to provide a safe and adequate supply and distribution of medical gases/vacuums for proper patient care. All system operators and users will be familiar with emergency procedures and alternatives in case of system failures or shutdowns.
2.1 The medical gas/vacuum system may include:
2.1.1 Piped oxygen
2.1.2 Piped medical air
2.1.3 Piped nitrous oxide
2.1.4 Piped nitrogen
2.1.5 Piped vacuum
2.2 Each department that uses, operates, or maintains the medical gas/vacuum systems will do the following:
2.2.1 Establish a written plan and procedures for emergency response to partial or complete system failures. This plan will define responsibilities for emergency response on each shift and list instructions about how to conduct and evaluate periodic exercises in simulating system failures.
2.2.2 Train all personnel who use, operate, or maintain systems in the essentials of the operation of medical gas systems and emergency responses to system failures.
2.3 The Engineering department will do the following:
2.3.1 Maintain systems in full compliance with applicable national standards and local, state, and federal codes and regulations.
2.3.2 Document all inspections, repairs, corrective actions, and testing of medical gas/vacuum systems (especially after construction and/or modification). All systems must receive certification from a licensed contractor or trained, certified, engineering personnel.
2.3.3 Maintain complete and updated documents on medical gas/vacuum systems, modification, or shutdown, to ensure safety and adequacy of system and that the system was not cross-connected before placing it back in service.
3.1 JCAHO Utility Management
4.1. Testing and Maintenance Matrix