NAME OF ORGANISATION DOCUMENT CODE DATE OF ISSUE

NABH/MANUAL/02 MAY, 2023

SAFETY MANUAL
2023

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TABLE OF CONTENT
S. No Content
1 INTRODUCTION
2 PURPOSE
3 SCOPE
4 EMERGENCY CODES
4.1 CODE BLUE
4.2 CODE YELLOW
4.2.1 Disaster management
4.2.2 Purpose of Protocol
4.2.3 Aims of Protocol
4.2.4 What is a disaster
4.2.5 Functions of the members
4.2.6 Situations and Assumptions
4.2.7 Instruction to Personnel on duty
4.2.8 Instruction to Personnel who are called back
4.2.9 The Process
4.2.10 Communications Protocol
4.2.11 Standard Sections of a triage tag
4.2.12 Specific Responsibilities
4.3 CODE PINK
4.4 CODE ORANGE
4.4.1 Spill management
4.5 CODE GREY
4.5.1 Civil disturbance
4.5.2 Earthquake / structural collapse
4.5.3 Stray Animals
4.6 CODE VIOLET
4.7 CODE BLACK
4.7.1 Bomb threat Procedure
4.7.2 Terrorist Attack
4.8 FIRE PROTECTION / CODE RED
4.8.1 Fire Prevention
4.8.2 Fire Safety Plan
4.8.3 Introduction
4.8.4 Purpose
4.8.5 Objectives

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4.8.6 Scope
4.8.7 Fire safety plan
4.8.8 Responsibilities
4.8.9 RACE: Rescue, Alarm, Confine and Extinguish
4.8.10 Emergency Evacuation Guide
4.8.11 How to operate the fire extinguishing equipment
4.8.12 PATIENT EVACUATION PLAN
4.8.13 Purpose
4.8.14 System for aiding Evacuation
4.8.15 Process overview
4.8.16 Designated area & procedure
4.8.17 Evacuation protocol & procedure
5 HOSPITAL SAFETY COMMITTEE
5.1 Mission and Objectives
5.2 Patient and Employee Safety
5.3 Radiation Safety
5.4 Lab Safety
5.5 Disaster and Emergency Preparedness
5.6 Environmental Safety
5.7 Membership
5.8 General
6 POLICY: HEALTH AND SAFETY
6.1 Purpose
6.2 objectives
6.3 Health benefits to employees
6.4 Procedure in case of riots
6.5 Procedure in case of workplace riots
7 PATIENT SAFETY
7.1 Outcome
7.2 policy
7.3 Specific Information
7.4 General Precautions
7.5 Identification Bands
7.6 Side rails
7.7 Oxygen use
7.8 Patient’s role in promoting safe health care
7.9 Hazard recognition
7.10 Electrical Safety
7.11 Biological Hazard
7.12 Biomedical Waste Management
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8 MOCK DRILL
9 SAFETY INSPECTION & RECORDS
10 POLICY ON INCIDENCE REPORTING & RISK MANAGEMENT

1 INTRODUCTION

Safety of the hospital is the most important aspect of hospital management. The hospital should have a
disaster management plan to combat any external or internal disaster.

2 PURPOSE

This Safety Management Plan serves to describe the policies and processes to minimize the damage or
potential damage to staff, patient, relatives and environment through a correction, corrective action,
preventive action and risk management process.

3 SCOPE

The Safety Management Plan defines the mechanisms for controlling hazards, promoting and implementing
safety measures for the patients, staff in particular and the hospital in general.

4 EMERGENCY CODES

FOR ALL CODES: DIAL 150

CODE NAME FREQUENCY

CODE BLUE CARDIAC ARREST QUARTERLY

CODE YELLOW EXTERNAL DISASTER BI-ANNUAL

CODE PINK PATIENT/CHILD MISSING/ADBUCTION QUARTERLY

CODE ORANGE MAJOR HAZARDOUS SPILL QUARTERLY

CODE GREY INTERNAL DISASTER QUARTERLY

CODE VIOLET VOILENCE QUARTERLY

CODE BLACK BOMB THREAT BI-ANNUAL

CODE RED FIRE QUARTERLY

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4.1 CODE BLUE

• In every Indicated “CODE BLUE” situation, cardiopulmonary resuscitation (CPR) will be initiated
by any trained personnel in the vicinity.
• The staff on site for an area shall call “150” to alert the “CODE BLUE” team Message will be e.g.:
“Code Blue 3rd floor Room no 301” will be announced thrice by the call centre on Public Address
system.

CODE BLUE- CARDIAC ARREST

DAY NIGHT
S NO NAME S NO NAME
1 CCU(Anaesthetist and nurse) 1 On duty ICU SR
2 ICU(Anaesthetist and nurse 2 Nurse in charge/shift in charge of area
3 Nurse in charge/shift in charge of area 3 Assigned nurse
4 Assigned nurse 4 Nursing supervisor
5 Nursing supervisor 5 RMO
6 RMO 6 Security supervisor
7 Security supervisor 7 Night Manager

4.2 CODE YELLOW

Disaster is an event or series of events, which gives rise to casualties and damage or loss of properties,
infrastructures, environment, essential services or means of livelihood on such a scale which is beyond the
normal capacity of the affected community to cope with. In mass casualty situations, triage is used to decide
who is most urgently in need of transportation to a hospital for care.

4.2.1 DISASTER DEFINITION

Disaster is an event or series of events, which gives rise to casualties and damage or loss of properties,
infrastructures, environment, essential services or means of livelihood on such a scale which is beyond the
normal capacity of the affected community to cope with.

Disaster is also described as a “catastrophic situation in which the normal pattern of life or eco-system has
been disrupted and extra-ordinary emergency interventions are required to save and preserve lives and or
the environment”.

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The Disaster Management Act, 2005 defines disaster as “a catastrophe, mishap, calamity or grave occurrence
in any area, arising from natural or manmade causes, or by accident or negligence which results in substantial
loss of life or human suffering or damage to, and destruction of, property, or damage to, or degradation of,
environment, and is of such a nature or magnitude as to be beyond the coping capacity of the community of
the affected area”.

The United Nations defines disaster as “the occurrence of sudden or major misfortune which disrupts the
basic fabric and normal functioning of the society or community”. (Ref. National Disaster Management, India
website)

Disaster is an event or series of events, which gives rise to casualties.

Example: Earthquake, Train collision etc.
In mass casualty situations, triage is used to decide who is most urgently in need of transportation to a
hospital for care.

4.2.2 PURPOSE OF PROTOCOL

a. To provide policy for response to external disaster situations that may affect hospital staff, patients,
visitors and the community.
b. Identify responsibilities of individuals and departments in the event of a disaster situation.
c. Identify Standard Operating Guidelines (SOP’s) for emergency activities and responses.

4.2.3 AIMS OF PROTOCOL

a. To effectively treat the greatest no. of people through efficient and systematic triage.
b. Efficient integration and use of available staff and equipment..:
c. To control the large number of patients and the resulting problems as efficiently as possible by
enhancing the capacities of admission and treatment,
d. To treat patients based on the rules of individual medicine despite a greater number of patients
e. To ensure ongoing proper treatment for all patients who are already there
f. To smoothly handle all additional tasks caused by such an event.

4.2.4 SITUATIONS AND ASSUMPTIONS

a. Disaster threats affecting the community (large fires, flooding, explosions, Air field incidents etc.).

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TEAM MEMBERS:

CODE YELLOW –EXTERNAL DISASTER

DAY NIGHT
S NO NAME S NO NAME
1 MS 1 Operations team
2 Emergency HOD 2 Emergency SR on duty
3 Emergency nurse Incharge 3 Nursing supervisor
4 Nursing supervisor 4 Shift Incharge
5 Security supervisor 5 Security supervisor
6 Front office team 6 Front office co-ordinator
7 Quality team 7 Pharmacy staff both (IP & OP)
8 Pharmacy both (IP & OP) 8 Housekeeping supervisor
9 Housekeeping and facility head 9 CSO
10 CSO
11 Operations team
12 NS/DNS

4.2.5 FUNCTIONS OF THE MEMBERS

a) To establish and coordinate the Disaster Plan for AHL

b) To review and update the Disaster Plan on an annual basis or more frequently.
c) Run semi-annually drills.
d) After every drill or disaster, a debriefing must be carried out regarding the reviews of the event.
e) All phone numbers lists must be regularly up-dated and distributed to all Departments.(Call Centre)

DISASTER MANAGEMENT: HANDLING PROCESS

4.2.7 INSTRUCTION TO PERSONNEL ON DUTY

a) All Staff to remain at their own departments unless re-assigned otherwise.

b) Do not leave the hospital without permission.
c) Keep all phone lines open.
d) Accept transfer of station or duties without question.
e) Stay on duty until relieved.
f) Keep phone lines free.
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g) Do not call hospital.

h) If you are not called, come at your regular working hour.

4.2.8 INSTRUCTION TO PERSONNEL WHO ARE CALLED BACK AND SPECIALISTS / MEDICAL OFFICERS

a) Wear your Identity cards.

b) All park at staff parking area outside the hospital compound.
c) Report in as soon as possible.
d) Enter through the front entrance. Keep the Emergency entrance area clear.
e) If no duties are assigned, wait in the respective departments; GDA, and security in the staff parking
area.
f) Specialists/ medical officers who are pre-assigned duties to report accordingly. Those without, to
report to command nucleus.

PROCESS:

• Patients will be received in the Triage Area (outside emergency).

• Triaging will be done and patients will be shifted accordingly.
• Red tag- Emergency and ICU
• Yellow tag- Wards
• Green tag- OPD
• Black tag- Mortuary
• All patients received will be MLC cases.

4.2.9 THE PROCESS

A. Emergency Consultant / EMO in Emergency will inform MS about the details of information received
about any event which leads to increased number of patients being brought to Alchemist Hospital.

OR

Whoever gets the information of any such event will inform MS about the event on priority basis.

 EMO after briefing the MS, CODE YELLOW is announced through call centre only after approval
from MS.
 Until members of command centre arrive, the Emergency Consultant / RMO in Emergency will
assume the responsibilities of the command centre. Triage will be carried out by Emergency
Consultant / RMO’s on duty; Nursing Supervisor will assume the role of Deputy Nursing
Superintendent and carry out her responsibilities.

B. Call Centre will announce the “Code” and inform the following

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 Head of the Departments: NS/DNS, EMO, CSO, Facility Head, Biomedical, Engineering and Materials
 Doctors: Full and part-time consultants, intensivists, resident doctors
 Nursing & Paramedical - Nursing supervisors and Sr. Technicians of laboratories, radiology, blood
bank, operation theatre and CSSD.
 HR & Admin, Medical Record Officer, IT, Marketing, Finance and Quality department.

 If head of the department is not available then next in line is to be informed. Head of the
departments to notify the departmental personnel.

C. Disaster patients to be received in Triage of the hospital. The first qualified, medically trained person
available will immediately begin initial triage.

 TRIAGE TEAMS - Soon after the announcement the disaster teams will arrive in the assigned areas:

Two triage teams shall report to triage area. Each team shall consist of

 1RMO (from wards)

 1 Resident from CCU
 2 nursing staff (from wards)
 1 Front office Coordinator

 Helpers/ attendants and security personnel for transportation of patients from ambulance or
vehicles to triage and from triage to red, yellow and green areas.
 Main emergency entrance outside area to be cleared for triage by security personnel and
housekeeping staff.
 Floor area of front office to be cleared of surrounding benches for easy movement of patients and
hospital personnel.
 Coordinator will do the patient registration and put the colour wrist band with the registration
number: Triage bands and patient identification number shall be given/ done alongside.

Coordinators to report to red, yellow, green and black area for getting further patient details and care
of valuables if any. After compiling the data, to report to Medical Record Officer who then reports to
MS. Head Front office after approval of MS will further share and display the information for public
and media.

 Four trolleys and six wheel chairs will be kept on standby by housekeeping.

TRIAGING:

I. Red area –Priority 1 patients will be transported to the Emergency. Emergency Consultants
/ Intensivists and anaesthetists particularly to be guided towards designated red area

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II. Yellow Area - Priority 2 to the IP areas viz. Wards / critical areas
III. Green Area - Priority 3 patients would be shifted to the OPD consultation rooms. OPD
rooms to be evacuated and used
IV. Black Area - Brought dead patients would be shifted to the mortuary.

4.2.10 COMMUNICATIONS PROTOCOL

 During a disaster all communications between members of the disaster team will be through the use
of personal cell phones.
 No personal calls will be made.
 Calls regarding information about next of kin will be diverted to call centre.
 Information centre will be set up at the Triage Counter.

4.2.11 STANDARD SECTIONS OF A TRIAGE TAG

The basic sections of a triage tag include:

 The four colours of triage and they come in the form of:
o Black (Deceased) which entails no care needed
o Red (Immediate) which entails life threatening injuries
o Yellow (Delayed) which entails non-life threatening injuries
o Green: (Minor) which entails minor injuries
 A section on the patient’s demographics i.e., gender and name and disaster number

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D. Security: Security services will be operational at very early stages:

 Traffic control: Security staff will bear the role of directing excess traffic away from the hospital
until traffic police assume this responsibility. The aim is to reduce congestion as far as possible
to facilitate victims’ access to the entrance of the hospital. To secure the driveways for
ambulances. Only vehicles carrying patients and vehicles of doctors to be allowed inside the
hospital. To ensure areas near entry and exit gates free of vehicles and public for free movement
of patients and doctors.
 Crowd control: Patients’ relatives/ attendants to be directed towards park near the hospital
Security personnel to be stationed. Drinking water arrangements to be provided by
housekeeping. .
 Transportation of patients: Along with other departments, the first response of security will be
to clear the traffic near Triage
 Mortuary: Security personnel to be stationed. Patients who are brought in dead will be held in
and near to mortuary under the supervision of security incharge. Police will be intimated &
bodies will be handed over.
 To protect personnel and patients.

E. Operations: To ensure coordination for patient care. Broadly divided to two areas: one includes
triage, emergency and OPD and second wards, critical areas and operation theatres.
F. Biomedical engineering: to provide support for smooth functioning of all equipment’s especially
critical equipment’s.
G. Store and pharmacy: to arrange for materials and drugs as required
H. Engineering and IT: to provide support as per functions of the department
I. Quality department: - to fill up the code yellow running sheet and for further improvements in
disaster management.
J. Marketing and finance to provide support as required.

REFERRAL HOSPITALS:

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Contact Persons – EMO/MS/MS of the respective institutes / hospitals.

I. Government Medical College & Hospital, Sector 32 Chandigarh. Phone nos.0172- 2665545 - 49,
2665253 – 60, 2662201-04, 2669180, 2669182, 2669569, 2663301
II. OJas Hospital, Phone no. 0172-5234700 / 8909844444
III. PGIMER, Sector 12 Chandigarh. Phone nos.0172-2746018, 2756565, 2747585
IV. General Hospital Sector 6, Panchkula. Phone nos. 0172 - 2587162, 9417894162
V. General Hospital Sector 16 Chandigarh. Phone nos. 0172 - 2549523 – 29

4.2.12 SPECIFIC RESPONSIBILITIES

1. MS
 Check with local authorities to verify the disaster and obtain additional information.
 Ask for help from referral hospitals, local police and volunteer organizations as deemed necessary.
 Is responsible for notifying all doctors.
 Be responsible to see that families of victims are notified as soon as possible.

2. NS/DNS
 To coordinate for adequate numbers of nursing personnel and nursing services.
 Assign nursing staffs to designated areas to prepare for incoming patients.
 Nursing staffs available for immediate use and in 30 minutes.

3. Operating Room Staff

 Shift in charge will supervise Operating Room and call all needed personnel after reporting to
Command Center, till the arrival of OR in-charge.
 Check area for supplies and equipment.
 Ask for additional help to carry out surgery and treatments in Operating Rooms and Recovery Room.
 Keep minimum list of supplies on hand and be prepared to process additional sterile supplies
quickly.
 Notify anesthetists who will maintain adequate anesthesia and drug supplies.

4. Nursing Personnel Assigned to Disaster Victims

 Any pertinent information to be made available to Medical Records
 DO NOT leave your patient unattended. Patient may be signed off to person in charge when admitted
to a unit.
 Make out the appropriate lab slips and x-ray requisitions with disaster number. It is essential that
they have these slips made out.

5. Front Office / Call Centre

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 Quick registration of all victims

 Set Up Patient Information Center
 Assign one front office executive to aid with discharge of hospital patients, if required
 Will announce Code Yellow Clear on authorization from MS.
6. Maintenance
 To be on standby at their room in the event there is a trip due to sudden increase in the load. To
reset immediately.
 Maintain full operation of all facilities.
 Be responsible for setting up extra beds in hospital if needed, as well as transporting storeroom
supplies and bringing in extra supplies from other areas.

7. Responsibilities of Bio-Medical Department

 To support the departments with equipments if necessary
 To be able to mobilize equipment from one department to critical department referring to the
equipment master list

8. Materials Management
 Be prepared to supply all departments with needed supplies.
 Manager Materials will designate staff to supply runners or volunteers to deliver supplies.
 Have an up-to-date list of suppliers who can quickly supply extra materials / drugs
 To ensure smooth distribution of materials / pharmaceuticals.
 Maintain proper recording of materials/ drugs used during the disaster.

10. Laboratory / Blood Bank

 Have arrangements made to obtain additional blood, equipment and supplies from area agencies.
 Evaluate number of extra staff required and arrange
 Co-ordinate actions between red, yellow, green areas.
 Assign staff to designated job/ task to prepare for incoming patients.
 Whatever laboratory tests results obtained will be hand written.
 All laboratory results will still be recorded in the various record books.

11. Radiology Services

 To monitor the radiology department is prepared to accept the patients.
 To liaise with the command centre from time to time.
 To report the films as soon as possible.
 To be ready to perform procedures as required.
 Co-ordinate actions between red, yellow, green areas.

12. Responsibilities of Housekeeping and Linen Department

 The housekeeping supervisor to arrange staff for transportation of patients
 To assist facilities in bringing down equipment, etc.

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 To arrange for linen supply to the departments due to increase in demand, if required.
 To send housekeepers to ward to clear rooms as soon as possible, if necessary.
 To assist security in clearing pathways.

CODE YELLOW RUNNING SHEET

 Each departmental head/ incharge to fill Code Yellow Running Sheet and submit to quality
coordinator.

DEBRIEFING

 Will take place after Code Yellow Clear is announced.

 After all, victims of minor injury are discharged.
 After all victims of serious injury are admitted or shifted to an alternative hospital.
 Will consist of a comparative log of all activities carried out by department heads
 Will consist of a complete log of all patients registered and/ or shifted.
 Assessment of current supplies, and impending requirements.
 All patients will be treated as Medico-Legal Cases.

4.3 CODE PINK

INFANT/CHILD ABDUCTION AND PATIENT MISSING

To reduce the risk of patient missing and abduction / harm to the new born baby in the hospital
premise.-

• Identification band to be used for every patient.

• Educate mothers to handover the baby only to the staff who had photo id card
• Never handover babies to helpers.
• Restricted entry for unauthorized person
• Strictly follow visiting policy
• All staff should wear ID cards
• There should always be 3 checks by security whenever patient is going out of premises. (ID band &
patient dress, cannula removed and discharge clearance slip.)

PROCESS:

• Code pink announcement will be done

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• The exit door will be closed by security immediately

• Ask identification points of baby
• Circulate among all by what’s app etc.
• CCTV cameras will be checked by security
• Frisking will be initiated from the area the child was last seen.
• The security team checks all areas.
• Police will be intimated if baby not found or if after finding the baby security officer/ patient family
wants to lodge a formal complaint

TEAM MEMBERS

CODE PINK
INFANT/CHILD ABDUCTION/PATIENT MISSING
DAY NIGHT
S NO NAME S NO NAME
1 MS 1 Operations team
2 CSO 2 Security team
3 Security team 3 On duty Nursing supervisor
4 On duty Nursing supervisor 4 On duty Security supervisor
5 Quality Manager
6 NS/DNS

4.4 CODE ORANGE

Spill Management

Refer Infection control Manual for details

Procedures for handling a Spill:

S. No. Activity Responsibility

1. The individual reporting the incident on 150 will provide the following All Hospital
information.
Employees
 His / Her name.
 Department name and location.
2. If safe to do so, the person reporting the incident shall remain at the site of All Hospital
incident and cordon it off with the absorbent material like tissue till the
Employees
arrival of the Hazmat Team.
3. Ensure that all data regarding the substance spilled is available. HAZMAT team

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4. Ensure that the PPE available for handling the spill is adequate. Housekeeping
Supervisor
5. Ensure that proper precautions are taken for handling the incident. Housekeeping
Supervisor
6. External help shall be called for if necessary. HAZMAT team
7. It shall be ensured that the clean-up is done in an efficient manner using HAZMAT team
information available in MSDS.
8. An incident report and investigation process shall be initiated and report to ICN
be submitted to the safety committee for further action.

Patient Exposure to Blood/body Fluids

 Accidental exposure to blood/body fluid has to be treated the same way as a needle sticks injury is
treated.

HAZMAT

It stands for Hazard Management. The team would be activated in case of any kind of major spill. The team
would comprise of:

CODE ORANGE SPILL MANAGEMENT

DAY NIGHT
S NO NAME S NO NAME
1 ICN 1 Housekeeping Supervisor
2 Housekeeping Supervisor 2 Security team
3 Security team 3 Housekeeping team
4 Housekeeping team 4 Operations team

Protocol for HAZMAT team to be activated is as follows:

 The Nursing in charge / shift in charge / area in charge would call 150 for CODE ORANGE.
 The Nursing in charge / shift in charge / area in charge would call the ICN
 The Nursing in charge / shift in charge / area in charge would call the Nursing Supervisor on duty
 The HK Supervisor would call the HK staff available in the area

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 HK staff would come with the spill kit (Depending upon the type of spill)
 Spill management would be done under the supervision of the HK Supervisor & ICN.

4.5 CODE GREY – INTERNAL DISASTER

CODE GREY INTERNAL DISASTER

DAY NIGHT
S NO NAME S NO NAME
1 MS 1 Operations team
2 Maintenance head 2 Maintenance team
3 BME head 3 BME engineer
4 Housekeeping head/facility head 4 Housekeeping supervisor
5 security team 5 Security team
6 Quality team 6 CSO/ security supervisor
7 CSO
8 NS/DNS

S.No Activity Responsibility

1. Call to 150 for Code Grey announcement First Observer

2. Code announcement on PAS Call centre staff
3. Response team will reach the site and assessment of the situation will be Response Team
done.
4. Area is cordoned off to prevent any other staff / patient to enter the site Security Head
5. The situation will be handled accordingly:- MS / Maintenance Head/
 Main water supply of the area is cut off in case of water pipe bursting, Facility Head
if the line is not identified entire water supply is turned off.
 Intimation to critical area regarding power failure, gas or vacuum
supply is given and estimated time for correction is also informed.
 ETO Gas leakage- ETO room is sealed, all the doors and windows of
the rooms are closed and CSSD is also closed

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6. Reason for breakdown is identified and work is started for repair Maintenance Head/
maintenance personnel
7. If the estimated breakdown time is more than 15 mins alternate sources of Maintenance Head/
Electricity, medical gas (additional cylinders) are arranged maintenance personnel &
BMED
8. Only the supply of affected area is cut, rest of the supply is continued. Maintenance Head/
Immediate repair is done maintenance personnel
9. Help of the biomedical to supply UPS backups for critical area is taken Biomedical Engg.
10. Code Grey Over announcement is made in PAS Console staff
11. Root cause of the incident is done and report is generated within 7 days Maintenance Head/
maintenance personnel

4.5.1Civil Disturbance

Purpose
To minimize panic and loss to life & property

Notify authorities and key personnel

MS
Procedure

On receiving the information from security officer about the civil disturbance in the vicinity of hospital from
the security officer the MS will designate somebody who would act as a decision maker and command centre.
He would advice on:-

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 Advise for closing of OPD waiting lounge and lobby; and divert the customers and patrons to other
more secured outlets.
 Coordinate with local Police and Fire Authorities. Maintain contact and take steps to ensure they
are available in the event of an emergency, bearing in mind that there will be many demands on
their limited capacity.
 Coordinate and maintain daily contact with the intelligence community.
 Maintain communication lines with counterparts in other hospitals and share information.
 Add additional security staff as needed (entrances, perimeters, car park and other sensitive areas)
as agreed with the MS.
 Reduce number of entrances where possible for both staff and customers.
 Double up duties at all entry points lock all secondary entrances. However, if main lobby is
threatened divert customer traffic to other entrance
 Instruct Security Staff to closely screen people entering the main entrance or other designated
entrances to ensure that only legitimate customers/patrons are allowed ingress.
 Position member of permanent security force on the roof of the hospital to provide early warning
by radio or phone of incidents in vicinity of hospital.

4.5.2Earthquakes / Structural Collapse

Purpose
To minimize the damage to Life and property by avoiding panic
Introduction
An earthquake is a natural disaster, which can strike without warning and is capable of creating major
destructive or disruptive damage to a hospital property.
The actual movement of the ground in an earthquake is seldom the direct cause of injury or death. Most
casualties result from falling objects and debris because the shocks can shake, damage, or demolish building
and other structures.
Training and increased preparedness are essential to survival both during and following the earthquake.
In every case the ultimate concern should be for the safety of our customers and employees, for that crisis
management and emergency response team can handle the situation effectively.

During the Earthquake

The Call Centre will announce the following message on public Announcement system
:

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“ATTENTION PLEASE, WE ARE EXPERIENCING AN EARTHQUAKE. GET UNDER A HEAVY OBJECT OR

TABLE IF POSSIBLE, OR DROP TO THE FLOOR AND COVER YOUR HEAD. DO NOT RUN. REMAIN CALM.
PLEASE AVOID WINDOWS AND HEAVY OBJECTS SUSPENDED FROM THE CEILING SUCH AS LIGHTS OR
OTHER THINGS FALLING FROM THE CEILING.

Following the cessation of the initial shock waves, make the safety of guest and employees our
first concern. Be aware that there may be possible after shocks.
Injuries
Injuries as the result of an earthquake are commonly caused by:
 Partial building collapse, such as toppling of chimneys, falling bricks, falling roof parapets, falling
walls, falling light fixtures and falling paintings etc.
 Flying glass from broken windows.
 Overturned iron shelves, fixtures and other furniture and appliances.
 Fire from broken gas lines.
 Fallen power lines etc.
After the Earthquake
 On receipt of message from MS the Call Centre would announce “code yellow” and the disaster
response would be set.(Refer above for code yellow)
General Points
 Do not touch downed power lines or objects touched by the wires.
 Immediately clean up the spilt chemicals and other potentially harmful materials
 Do not eat or drink anything from open containers.
 Do not use matches, lights or open flame appliance utensils. You are sure that no gas leak exists.
 Do not operate electrical switch or appliance if gas leaks are suspected as they create spark that can
ignite gas from broken gas lines.
 Security staff should keep road adjacent to the hospital clear for passage of emergency vehicles.
 Be prepared for additional earthquake shocks. May most of these are smaller than the main shocks;
some may be large enough to cause additional damage.

Some Additional Consideration

 During/ after an earthquake all hospital employees and customers/patients should be urged to
remain calm.
 As we are in a high-rise building do not dash for exit, since staircase may be broken, may be
obstructed by broken material.
 If in a crowded place, do not rush for a doorway since hundreds may have the same idea. If you
should leave the area, choose your exits as carefully as possible.
 If possible move to an open area away from all hazards.

4.5.3 Stray Animals

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Purpose
To provide safety to patients, visitors and employees maintain the hygiene.

Preventive measures
1. Seal the Boundary/ Parameter wall.
2. All the gates should be manned around the clock.
3. Use pest control for rats & other animals.
4. Conduct training for the staff for being vigilant while patrolling in different areas
5. Report any observation on Stray animals’ movement inside the premises.

Active measures

1. Close and man building entry/exit points to prevent stray animal’s inward movement.
2. Try to push stray animals outside the hospital, whenever any such movement is observed inside the
premises.
3. Take help of MCD as per requirements.
4. Use pest control for rats & other animals.

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4.6 CODE VIOLET

VIOLENCE / SECURITY ALERT.

Emergency code announced for Violence/Security threat:

 An incident where increased hospital security personnel are needed.
 To protect employees, patients, visitors, and hospital premises from any situation or person posing a
threat to the safety of any individual(s) within the hospital premises.

Purpose:

To protect employees, patients, visitors, and hospital premises from any situation or person posing a threat to
the safety of any individual(s) within the hospital premises.

PROCESS:

•The area staff identifies situations where extra security may be needed
Recognize

•Nearest employee witnessing such situation should immediately inform to Security

Inform
personnel of that area and Nursing Supervisor.

•The security personnel will intervene.

•The staff will announce the CODE if needed, at 150
Act •The team arrives the spot and try to calm the situation.

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TEAM MEMBERS:

CODE VIOLET SECURITY ALERT/VIOLENCE

DAY NIGHT
S NO NAME S NO NAME
1 MS 1 Member from operation department
2 CSO 2 security supervisor
3 Security team 3 Security team
4 Nursing supervisor 4 Nursing supervisor
5 One team member from HR
6 One team member from
Operation department
7 Quality team
8 HOD of concerned department

4.7 CODE BLACK – BOMB THREAT

Sr. No Activity Responsibility

1 Upon receiving a call/information about Bomb Threat note down all Staff Receiving Call
the information and inform the higher authorities including MS or
HOD

2 In case it’s a telephonic call try to elongate the conversation and Front Office Staff/ Staff
note down accent, background sounds and other details, inform all
receiving the call
this to Administrator/MS. Try to Pacify the Caller for not attempting
any such actions in a hospital.

3 MS will take a call on announcing Code Black MS

4 Code Black is announced on PAS after approval Front Office Staff

5 Head Operations to inform the Police Station Head Operations/ MS

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6 All staff to remain at their positions, Security, Maintenance and Housekeeping

Housekeeping Staff to search for the Bomb at all possible locations /Maintenance/Security

7 If Bomb located do not touch it, inform MS and evacuate the Housekeeping /Maintenance/
patients and staff form surrounding Areas swiftly to Assembling Security/Nursing /Clinicians
Area (in front of Emergency)

8 If bomb is not located, wait for Police to arrive and help in Head Operations/
searching. Administrator to brief police about the incident on
Administrator/MS
arrival.
9 Evacuation to be ordered if guided by police MS

10 When the Police either finds and destroys the bomb or declares the MS
building safe otherwise CODE BLACK OVER to be communicated to
Front Office

11 Announce CODE BLACK OVER Front Office Staff

4.7.1 BOMB THREAT PROCEDURE

RECEIPT OF WARNING

When a phone call is received:

a. Prolong the conversation as long as possible;

b. Be alert for distinguishing background noises, such as music, voices, aircraft, and church
bells;
c. Note distinguishing voice characteristics;
d. Note if the caller indicates knowledge of the hospital by his/her description of the location.

NOTIFY AUTHORITIES AND KEY PERSONNEL

MS
Search Procedure

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1. After the basic details are provided by the person receiving the call, the MS or his designee should
make all the necessary decisions, issue orders, and prepare for the arrival of assistance. The handling
of bombs and bombing investigations is solely an official police function. At no time should the
healthcare facility security staff try to touch a bomb or suspected bomb. The role of the facility
security staff is to help the police find the bomb, and to evacuate patients, visitors and facility
personnel, Police should be put in complete authority upon arrival. Cooperation with the police and
others involved is most important. Hospital personnel with master keys should be available.
2. The Management must depend upon his key personnel and the equipment immediately available.
Local authorities may not be as familiar with the floor plan as hospital personnel, nor will they have
sufficient manpower to conduct an adequate search within a reasonable period of time.
3. Watch for and isolate suspicious objects such as packages and boxes.
4. Elevators should be kept available for local authorities.
5. If what appears to be a bomb is found, DO NOT TOUCH IT. Clear the area and obtain professional
assistance. Also, try to isolate the object as much as possible by closing doors.
6. Generally, personnel should remain calm and alert. Personnel should be properly trained so that
patients will not become alarmed.
o Notify the MS of significant developments, and do not divulge to the patients that a bomb
threat has been received.
o In the event the patients do learn what is taking place, they should be reassured that all is
well.

EVACUATION

If a bomb is found, the police will notify the proper authorities to come and disarm it. WE WILL NOT
EVACUATE UNLESS A BOMB IS FOUND. If evacuation becomes necessary, this will be a decision of the Head
Admin/MS of the Hospital and the police. The evacuation of the premises is the sole responsibility of floor
security

4.7.2 TERRORIST ATTACK

Purpose
To minimize the panic and loss of property

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Process
1. Upon receiving the Intimation/ observation about the Terrorist Strike the Security Personnel
will immediately note down the details as under-
 Name & Department of the staff/ Name of the Person Informing
 Exact Location of the Terrorist Attack
 No. of Terrorists.
 The time of Intimation

2. The confirmation about the same will be done through security personnel deployed in/around
the area.
3. The Front Desk will be informed immediately by security Personnel manning Security Room to
inform Management & HOD’s & patient floor coordinators about the same.

4. Police Control Room will be informed by Security Officer after confirmation Security Supervisor
giving the details:
 Area affected
 Approximate No. of Terrorists
 Weapon details if possible
 No. of Casualties if any
 No. of Hostages if any
 The safe route for the Police Personnel

5. Call centre will be advised to make Public announcement through the PA system about the
emergency situation and advice to avoid the area affected.

6. Instruction will be given to all security personnel to isolate the area of incident by locking all doors
leading to the affected area.

7. The Patient floor staff will be evacuated, if possible form the area in guidance of the security staff.

8. The nursing & medical staff on all floors will be instructed to communicate to the patient to lock
them inside the room in case they can’t be evacuated and are vulnerable to the attack.

9. Important strategic areas like Security Room, Engineering Room will be locked from inside.

10. On arrival of the Police the Security personnel if possible will guide them through the safest route to
the area of incident.

11. Once the situation has been under control the following needs to be done by
 Assess the number of casualties and injured – Medical Administration
 Shifting the injured to the Emergency for Treatment- Nursing Staff
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 Assess the damage to the property- Engineering/Security

 Coordinate with the Govt. Authorities- MS

4.8 CODE RED

FIRE PROTECTION/ CODE RED PROTOCOL

The Code Red has been divided into two categories: - Code Red (Analysis and Minor fire management) and
Code Red –Major (Evacuation).

4.8.1 Fire Prevention

The Code Red Protocol is implemented to protect staff, patients, visitors, property and assets of Hospital. The
Code Red Protocol serves as a guide for establishing and maintaining fire safety conditions at the hospital.

It is the responsibility of every employee to observe report and check any condition or act that may be a
potential cause of fire. The main points to be observed in fire prevention are as under:

 Old and frayed electric cables damaged switch boards, loose fixtures and sparking appliances, will be
reported to the Maintenance Department by the concerned department, managers and supervisors
for immediate repair/replacement. Follow up action will be taken until work is complete.

 Cleaning of hands/feet with petrol/thinner/diesel will not be permitted. The concerned department
may ensure this.

 Chemicals and oil stored in material store will be divided into small stocks with adequate spacing in
between.

 The Supervisor of the Food & Beverages Department will be personally responsible for operation and
safety of Liquid Petroleum Gas installation in the canteen kitchen. He will ensure that all valves on
the main feed pipeline and regulators on the gas stoves are shut, when not in use.

 Excessive paper, plastic, cardboards and wooden scrap will not be allowed to accumulate in office.
Supervisor Housekeeping will ensure that prompt action is taken on complaint by concerned
department.

 Used bandage/cotton etc. will not be allowed to accumulate.

 Fireworks are not permitted inside the hospital on Diwali and other festival days.

 Private electric appliances like heaters, immersion rods are not allowed inside the hospital.

 Fire fighting equipment will not be removed or misused for industrial/administrative purposes.
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Department concerned will prohibit people for any such misuse.

 Tapping of hydrant lines for industrial/administrative use is a serious violation of the safety policies.
Maintenance Department will ensure that existing underground and surface tapings are
disconnected immediately.

4.8.2 Fire Safety Plan

Introduction
This Fire Safety Plan has been framed to ensure that in case of a fire in Hospital premises, safe evacuation of
its occupants may present serious problems unless a plan for orderly and systematic evacuation is prepared
in advance and all occupants are well drilled in the operation of such plan. These guidelines are intended to
assist them in this task. The term "Emergency Evacuation" has different meanings according to the
vulnerability of the building in question. When a building such as the Hospital affords protection because of
its construction and fire suppression systems, "evacuation" will mean removal of patients, personnel, and
visitors to areas deemed fire-safe for as long as it may be necessary to decide further action. The plan of
action for the Hospital is for vertical evacuation to a fire-safe area until fire department officials and safety
officers deem the area safe.

Purpose
1. To establish method of systematic, safe and orderly evacuation of the hospital premises by and of its
occupants in case of fire or other emergency, in the least possible time, to a safe area by the nearest safe
means of egress; (way out) also the use of such available fire appliances as may have been provided for
controlling or extinguishing fire and safeguarding of human life.
R-RESCUE : Patients or person if in immediate danger
A-ALARM : Raise alarm or alarm switches
C-CONFINE : Close doors and windows to keep the fire contained
E-EXTINGUISH
/EVACUATION : Use fire-fighting equipment if trained in its use.

2. To define and fix up the responsibilities of various key personnel for generating desired actions during an
emergency situation such as evacuation plan and firefighting arrangements.
3. Give clear instructions regarding what is to be done during an emergency by the occupants and other staff.

Objective
To provide proper education as a part of continuing employee training in principle and through continuing
written programmes for all occupants to ensure prompt reporting of fire, the response of fire alarms as
designated, and the immediate initiation of fire safety procedures to safeguard life and contain fire until the
arrival of the Fire Brigade.

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Scope
The following Fire Protection System has been provided to detect and control an early outbreak of fire.
a) Public address system
b) Portable fire extinguisher
c) Fire hose boxes and hose reels
d) Water storage available for fire fighting
e) Fire Hydrant Pumps
f) Water Sprinkler

Fire Safety Plan

a) The overall responsibility regarding fire prevention and fire fighting will be of CSO & FSO while the Security
Department staff will assist them. CSO/FSO will be responsible for proper working of fire fighting
equipment’s, fixed fire fighting installations, fire fighting evacuation and mock drills etc.

b) Each floor of building shall have a Floor Security In charge, who will be in charge of evacuation of respective
floors. He is responsible for evacuation of his designated floor. In our hospital the assembly area for all the
floors is the parking area inside the hospital. The CSO along with HR post evacuation will head count the
people.

Remember
• All fires begin small but grow fast
• Use only stairs (fire exit)
• Do not take refuge in toilets or in closed doors - Go out
• Smoke is dangerous. Get out of smoke filled area quickly and keep close to the ground. In case of
thick smoke, cover your face with a wet cloth and crawl
• Move to a safe place but do not leave the Hospital premises till instructed
• Fire fighting is everyone's responsibility
• Do not use elevators. Whenever possible use staircase
• When in a safe area, check that all patients and personnel are present

Note
a) Till the CSO/Fire Safety Officer arrives, use the available extinguishing media to extinguish the fire.
b) The CSO/Fire Safety Officer arrives will note the actual location and type of fire and accordingly
collect the equipment to rush to the scene of fire. He will instruct the concerned people to cut off
power and air supply to the affected area.
c) Arrange to start the pump to build up adequate pressure in fire hydrants, if required.

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d) Be in touch with local fire brigade in case of requirement.

e) The CSO will assess the situation, intensity of fire, manpower with him, and fire fighting equipment’s
with him. He will make arrangements for additional water using tankers in case it is required.
f) The Call Centre will act as Control Centre for informing all concerned for information/additional
help/any emergency.
g) The Front Office will maintain contact with other civil/military fire brigades, police station and other
requirements as and when required, according to the intensity of fire.
h) After the fire is extinguished the stop message will be passed to the Fire Safety Officer, and they will
record the time, date, location and cause of fire from which he will make an Adverse Event Report
which is to be submitted to the CEO/MD and the Insurance Company.
i) The used fire appliances are to be replaced with serviceable ones and sand/water buckets to be
refilled.
j) Follow up action as per protocol.

Responsibilities

CSO/FIRE SAFETY OFFICER

Responsibilities:
a) Shall be familiar with the written Fire Safety Plan, providing for fire drill and evacuation procedure.
b) Shall select qualified employees for fire party and organize, train them and supervise their duty.
c) Shall be responsible for availability and state of readiness of fire party.
d) Shall conduct fire and evacuation drills.
e) Shall be responsible for fire training of the Security In charge for each floor.

Each floor of a building shall be under the direction of a designated Security In charge for the evacuation of
occupants in the event of fire.

Each Security In charge shall be familiar with the Fire Safety Plan, the location of exits and the location and
operation of any available fire alarm system

RESPONSIBILITY OF SECURITY SUPERVISOR ON DUTY (FIRE WARDEN)

In the event of fire, or fire alarm the CSO/FSO shall ascertain the location of the fire, and direct evacuation of
the floor in accordance with directions received and the following guidelines:

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a. The most critical areas for immediate evacuation are the fire floor and floors immediately
above. Evacuation from the other floors shall be instituted when conditions indicate such
actions. Evacuation shall be via fire exit. The Fire Warden shall try to avoid stairs/ramps
being used by the fire department. If this is not possible, he shall try to attract the attention
of the Fire Department personnel before such personnel open the door to the fire floor.
b. Evacuation to two or more levels below the fire floor is generally adequate.

c. CSO/FSO shall see that all occupants are notified of fire, and that they proceed immediately
to execute the Fire Safety Plan.

d. Have an available updated listing of all personnel with physical disabilities who cannot use
stairs unaided. Make arrangements to have these occupants assisted in moving down the
stairs to two or more levels below the fire floor.

RACE: Rescue, Alarm, Confine and Extinguish

This easy to remember acronym is our Hospital procedure in the case of a fire. Particularly in the hospital,
every staff member is trained to recognize and respond appropriately in the case of a fire using this term.

PRINCIPLE OF R.A.C.E.
When faced by a Fire Situation, always remember the principle of R.A.C.E. while taking any action in the matter:

S. No. Action

1 R-escue – Remove everyone from the area. If a fire has occurred in a patient room the staff shall
immediately remove the patient from the area.

2 A-larm – Activate the Fire Alarm by breaking glass of the nearest Manual Call Point. Manual Call
Points (MCP) are located throughout the building, several on each floor. By activating the Fire Alarm
a fire action plan is set into motion where Security receives the signal and initiates the emergency
response. The Engineering department is also alerted to act immediately to cut off AHUs and
Electrical Power wherever necessary to retard the spread of fire.

3 C-onfine – Once the room or area has been cleared of patients the door shall be closed thus
confining the fire, which enables the fire response team the time needed to arrive.

4 E-xtinguish or Evacuate – When practical and only when an employee has been properly trained

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in the safe and proper use of a fire extinguisher, extinguishing shall be attempted using one fire
extinguisher. Evacuate if you are not comfortable using a fire extinguisher or if more than one
extinguisher is needed.

Emergency Evacuation Guide

In the event of a fire or other emergency, seconds count. The safe, orderly and prompt evacuation of building
occupants depends on having the physical safety features of a building in operating condition as well as
having an emergency evacuation plan. The cooperation and participation of every building occupant is
essential. Every person that lives and works in a building on campus has an individual responsibility to know
how to evacuate in an emergency and to accomplish the evacuation when the fire alarm device sounds or
when directed by an authority. This guide will help you to prepare for emergency situations that might arise
in the facility.

Pre plan Your Escape

 Know the location of fire alarm pull box locations.
 Make sure your floor has at least two unobstructed ways out.
 Check the fire exits to make sure they are usable.
 Do not use the elevators. They could become disabled, trapping you on the fire floor.
 Know the location of stairwells that will provide a protected path all the way to the outside.
 Recognize the sound of the fire alarm.
 If there is a fire or fire alarm EVERYONE EVACUATES!
 If you discover a fire or smoke condition, call the CSO/FSO/ASO (daytime), On Duty Security Supervisor
(night).
 Whenever you hear the alarm sound, LEAVE IMMEDIATELY! Don't assume the alarm is false or a test
and wait to see what others do. In a fire seconds count.
 Try to help others, if you can do so safely.
 Unless unusual conditions dictate otherwise, the best evacuation route is the nearest stairway and out
the nearest exit.
 When leaving, close (do not lock) the door behind you.
 Once outside, meet at your assembly point and take a head count to make sure everyone is out and
accounted for. Never attempt to re-enter the building to search for someone missing - let fire or police
officials know.

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Before opening a door, you shall make sure there is no fire on the other side by using the back of your hand to
touch the door, door knob, or door frame. If any of these feel hot, do not open it, there is probably fire on the
other side. If cool, open the door slowly, leave the area and close the door behind you.

Stay low when there is smoke

If you encounter smoke while escaping, crawl or get as low as you can. Always put a wet handkerchief or
cloth on your nose for easy breathing. The cleanest air will be within 1 to 2 feet of the floor. If the main exit is
blocked by fire or smoke, you shall use your alternate route. If feasible, go back in your room to wait for
rescue.

If you cannot escape

Close all doors between you and the fire. Seal cracks around doors with damp cloth to keep the smoke out.
Call Security to notify them of your location. While waiting for rescuers, signal from a window by hanging
clothes out the window, waving an object, or shouting.

THE EVACUATION PLAN

Following exits have been planned to evacuate in case of an emergency and shall be used as follows:-

Employees and patients who are ground shall be evacuated through the fire exit stairs on each floor
depending on involvement in the catastrophe. At the time of disaster evacuation should be vertical and never
use a lift in case of fire

 The Fire safety officer (Security Supervisor at night) would assess the fire and if the fire is intense
(i.e. when the fire has the possibility to cause damage to patients, men or materials) the safety officer
or the security supervisor would inform the call centre & the front desk at night by dialling 100 / 150
and simultaneously fight the fire.

 After code red would be announced on the PA system by the call centre, and immediately all the
teams would be activated.

Following are the teams for Code Red (The teams have been formed for all the 3 shifts & during night
time the role of the safety officer would be taken over by the Security Supervisor till the Safety Officer
arrives)

1. Evacuation Team: Comprises of the hospital staff from each of

the floors & security guards of the respective floors

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2. Fire Fighting Team: Comprises of maintenance staff & security who would
extinguish the fire by reaching the fire floor with the extinguishers & by
starting the jockey pump
3. First Aid Team: ICU / CCU Consultant, EMO, NS/DNS on duty
4. Attendance Team: Comprises of the CSO & HR who would take a head
count post evacuation in the assembly area
 The evacuation team would start evacuating their respective floors.

 The fire fighting team would:

o Asses the fire fighting requirements, mobilize equipment’s & lead the fire fighting team (i.e.
Facilities and security personnel)
o Isolate the area from electricity
o Fresh air and exhaust systems to be shut down
o Ensure that sprinkler systems and hydrant are operational
o Elevators to brought to ground level and power to be shut down
o Isolate the area from Gas supply
o Safety officer to keep the call centre updated about the intensity of fire

 The first aid team would be waiting at the assembly areas for giving medical assistance to the
casualties. Ambulances would be ready for transporting patients to the nearby hospitals. The CSO
would finally conduct a head count post evacuation. (The security supervisor has an updated list
of the total number of staff on duty that they get from the time office on a daily basis)

 The critical, bed ridden patients would be given second priority, walking patients would be given
first priority.
 Only the MS has the right to call off code red after analysing the whole situation

How to Operate the Fire Extinguishing Equipment

Instructions on how to operate most fire extinguishers

Remember the word - PASS
PULL the pin. Some units require the release of a lock latch, pressing a puncture lever, inversion, or other
motion.
AIM low. Aim the extinguisher nozzle (horn or hose) at the base of the fire.
SQUEEZE the handle. This releases the extinguishing agent.
SWEEP from side to side.

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Watch for re flash. Move in close. Pull apart the burned area to get at hot spots. Discharge
the contents of the extinguisher.

NOTE: Foam, CO2, water or other types of extinguishers may require slightly different actions.

READ THE INSTRUCTIONS given on the fire extinguisher

Summary

 Know how to operate the extinguishers. A small fire can easily become a big fire if an extinguisher is
used incorrectly.
 Fight only small fires and preferably not alone!
 Make sure you have access to a safe exit.
 If you have the slightest doubt about whether to fight or not to fight the fire. DO NOT!

Get out and call the Fire Department.

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4.8.12 PATIENT EVACUATION PLAN

4.8.13 PURPOSE

The Hospital Evacuation Planning Guide is meant to provide planning assistance and assist a hospital in
refining and augmenting its efforts to prepare for the possible evacuation of part or all of the facility.

4.8.14 SYSTEMS FOR AIDING EVACUATION :

The following systems have been provided to enable early warnings and adequate communication network to
facilitate safe egress from the building, when necessary:-

 Automatic Fire Alarm and Smoke / Fire Detection System.

 Manual Call Points (MCP).
 Public address system.
 Defined exit routes and points of egress put up as large displays in each independent ward / area for
all to see.

4.8.15 PROCESS OVERVIEW

The Code Red has been divided into two categories: - Code Red (Analysis and Minor fire management) and
Code Red –Major (Evacuation).

4.8 CODE RED

 In case of any incident of fire reported in the hospital, the staff/ employee from the concerned area will
call at Emergency dialing no. 150 and raise alarm for CODE RED.
 The person at the Console will announce CODE RED along with the area.

Calls will be made to all the members of the Basic Code Red Team:-

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CODE RED- FIRE

DAY NIGHT
S NO NAME S NO NAME
1 MS 1 Operations team Member
2 Security supervisor\team 2 Security supervisor/team
3 Maintenance supervisor 3 Maintenance supervisor
4 Bio-medical Engineer 4 Bio-medical Engineer ( On call)
5 Nursing supervisor 5 Nursing supervisor
6 Quality team 6 Fire safety officer/CSO
7 HR
8 MRD
9 Fire safety officer/CSO/ASO
10 NS

The Basic team for CODE RED will reach the concerned area and analyse the situation.
The security personnel (total 5 personnel) will be responsible for fire fighting to the affected area:-

1 person: - ABC Fire extinguisher 2 Persons: - for bringing Hose Pipe

1 person: - CO2 type Fire Extinguisher 1 Person: - Cordon off
The GDA staff will be responsible for getting wheel chairs and stretchers (scoop stretchers) to the affected
area.
After analysing the situation, it will be decided that whether it is required to announce CODE RED –Major
(Evacuation).
In case it is not required and the fire can be extinguished along with practicing ‘RACE’ for the affected area,
the CODE RED shall be cleared.
The employee/ staff of the affected area will call 150 and announce ‘CODE RED clear.’

CODE RED –Major: - If fire is big, apparently dangerous, may be spreading, uncontrollable, damaging life and
property.
After the announcement of CODE RED, the Basic team will reach the location and analyse the situation.
After analysing the situation and approval of all the members, Code Red –Major will be announced at
Emergency dialling no. 150.

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The orders will be generated by the team leaders of the Maintenance team and biomedical team for
disconnecting electrical supplies, lifts, medical gas supplies and arrangement of the alternate source of
supply.
The evacuation can be planned in two ways:-
Horizontal Evacuation: - It is mainly done for the Critical patients/ patients with restricted movements/
post op patients/ on lines & supports
Vertical Evacuation: - It is mainly done for relatively stable patients/ Patient attendants using stairs
In case of serious patients, alternate complex lift can be cured.
The Nursing team leader along with the assigned Medical officer will be responsible for analysing the medical
condition of the patient. All lines shall be closed and detached (if possible) and kept on the patient body
before transferring the patient.
The GDA staff will be responsible for getting wheel chairs and stretchers (scoop stretchers) to the affected
area.
The security and GDA staff will be responsible for evacuation (basic evacuation techniques) along with the
nursing staff.
The Common Assembly area in case of Vertical evacuation is in front of Emergency (outside near Exit gate).
The HR team will be responsible for Head count of employees.
The Nursing Supervisor and MRD are responsible for patient count according to Census

4.8.16 DESIGNATED AREAS AND PROCEDURES:

The following areas have been designated for making the Alchemist Hospital Emergency Evacuation Plan
effective:
Each floor in Alchemist Hospital has a long corridor which covers the entire length of the building. There are
access points for each floor along the entire length of the building.

S. No. Activity Responsibility

1. Fire spreading from one end to the other end of the building is a remote
possibility.
2. In case of a fire in any of the Fire Zones where patients are admitted, the first CSO
stage evacuation shall be Horizontal Evacuation to the other Fire Zone on the
same floor and the same part of the building.

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3. The ambulatory patients can be evacuated vertically to the ground floor. CSO
4. The critical patients and the patients who cannot walk shall be moved on their CSO
beds only.
5. The evacuation shall be effected by the first rescue team reaching the site and CSO
the Nursing Staff and GDAs present in the area.
6. In case of requirement for Vertical Evacuation of the patients, the patients shall CSO
be shifted to the Ground Floor. The IPD and OPD waiting areas shall be utilized
for keeping the patients.
7. The lifts in the part not affected by fire shall remain operational, if possible. HOD Maintenance
8. Lifts in the effected part of the building shall not be used and shall be Security Guard
immediately brought to the Ground Floor.
9. Any critical patient that needs to be evacuated vertically can be evacuated by CSO
lifts in the area not affected by fire.
10. The Nursing Staff shall escort patients who can walk. Nursing Staff
11. Patients, who cannot walk and are not critical, shall be carried as per
procedures in Annexure I.
12. All people who can walk shall be guided to follow the escape routes to outside Security Guard
the building in case of fire in any part of the building.
13. In case of need for Full Evacuation, a list of Hospitals near Alchemist Hospital MS
along with their contact numbers shall be available with the MS and the Head Front office team
Security.
14. The MS shall contact and make arrangements for accommodation of the MS
patients in these hospitals and pass on the information to the Head Security
and Front office team for further co-ordination.
15. The Head Security and Front office team in consult with the MS shall make Head Security
arrangements for Transport by requisitioning vehicles through the designated Head Front office
agencies. Operations team
16. The MS shall ensure that the Medical Coordinators keep a complete record of MS
the patients being evacuated outside the Hospital.

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ASSEMBLY POINT:
Parking area outside Triage

4.8.17 EVACUATION PROTOCOLS AND PROCEDURES :

S.No Activity
1. The Nursing Head is responsible for ensuring patient care during evacuation / relocation events.
2. All patient evacuation / transfers to be appropriately documented per required transfer sheet
process.
3. 24-hour supply of medications necessary for continuity of care for each resident will be placed in a
plastic bag.
4. The transfer information sheet will be stapled to his/her medication bag and transported along with
him / her to the evacuation site.
5. Medications sent will be documented.
6. The Nursing Head or designee will notify the attending physician of the patient transfers.
7. The following detailed evacuation process to be used in time of emergency is as follows:
a. 1. Staff will immediately remove any person(s) that might be in a room wherein there is a
hazard. The door or doors and windows to this area will then be closed. The adjoining
rooms will then be evacuated.
2. Evacuees will be moved away from the danger area in the direction of the nearest safe
exit, on the same floor. Evacuees must be beyond the nearest smoke barrier.
3. Persons that may be in the hall or corridors will also be moved in the direction of the
nearest safe exit away from the danger area.
4. If conditions warrant, evacuees are to be taken out of the building to a pre-designated
safety zone where the Medical Person in charge will take a census.
5. Total evacuation to another facility is in keeping with Government of India, Zonal
Disaster Management protocols, to other facilities that are detailed as Nodal Hospitals,
with adequate capacities & capabilities.
8. In case of ‘Partial Evacuation’, another facility can also be identified depending upon the spectrum of
facilities that can adequately support such partial evacuation or even a short term total evacuation.
Due to the expected shorter term of use, these facilities need not offer the full range of services

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required for total and / or longer duration evacuations, but safety and quality of care will not be
compromised.

BASIC EVACUATION TECHNIQUES

1. THE BACK PACK LIFT BY ONE RESCUER.

The rescuer kneels in front of the

handicapped person and places the person’s
arms up and over his shoulders and across
his chest. The rescuers then lean forward
and slowly rise to a full standing position.
NOTE: This method shall to be used only
if one rescuer is available. It is preferred to
use one of the two person methods as
follows.

2. SEAT CARRY TWO RESCUERS

Two rescuers position themselves on either side of the handicapped person, in order to grasp each other's
upper arms or shoulders (Fig. 2). The person being assisted places his arms firmly around both rescuers'
necks (Fig 3).

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The two rescuers then lean forward placing their free arms under the individual's legs, firmly grasping each
other's wrists (Fig 4 and 5). Lifting at the same time, with backs erect, using the strength of their legs, the
rescuers slowly rise to a standing position and then proceed carefully forward.
3. EXTRA CARRY BY TWO RESCUERS
Two rescuers place the person being assisted on the stairwell
landing. One rescuer at the legs, places their arms under the
person's shoulders with fingers locked across the chest. Lifting at
the same time, with backs erect using the strength of their legs, the
rescuers slowly rise to a standing position and then proceed
carefully forward (Fig. 6)

S.NO TEAM MEMBER RESPONSIBILITIES

1 FIRST RESPONDER- AREA  Call 150 and inform Code Red with Location & area.
INCHARGE  Follow ‘RACE’ & ‘PASS’
2 SECOND RESPONDER- SECURITY 1 Bring Fire extinguishers and Hose pipes to the affected area
2 Cordoning off the area
3 Follow ‘RACE’ & ‘PASS’
3 TEAM LEADER- FIRE SAFETY  Assess the situation
OFFICER/ CHIEF SECURITY  Leading operations of Fire Fighting, Rescue & Evacuation
OFFICER/ MANAGER ON DUTY Teams.
 Communicate with code team members.
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4 THIRD RESPONDER-  Ensuring cutting off of power to the affected areas if

MAINTENANCE HEAD required and provision of uninterrupted emergency supply.
 Ensuring that Fire Pump House is manned.
 Ensuring that water supply source remains intact.
 Maintaining water and power supply to the areas that are
not affected
 Ensuring that lifts are not used in case of fire.
5 BIO- MEDICAL ENGINEER  Cutting off medical gas supplies to the areas that are
affected.
 Maintaining interruptions free Medical Gas Supplies to the
areas that are not affected
6 MS  Overall direction and leadership in the matter
 Coordinate for ‘No Panic Situation’
 Interface with medical staff, nursing and ancillary
disciplines to ensure the appropriate level of medical
response
 Ensure arrangement of drugs, medical oxygen cylinders,
linen etc. in co-ordination with support departments
7 NURSING HEAD  Identify nursing needs.
 Ensure Nursing staff on the patient bedside
 Identify vulnerable age group
 Allocate extra nursing staff in essential areas
 Re-deploy existing staff and Recall of off duty staff
 Periodically review nursing arrangements.
 Coordinate in evacuation process
8 SUPPORT STAFF  Clearing area
(Facility, Maintenance, BME)  Attention for any other command
 Providing support for Firefighting, if required, on request
from CSO/FSO.
 Providing technical support for rescue and evacuation

9 HR  Ensure Head count of all employees with biometric punch

details.
10 MRD  Ensure Patient count according to the census in
coordination with nursing supervisors.
 Ensure tracking of Medical records in case the patients are
required to be shifted to other hospitals in coordination
with nursing supervisors

5 Hospital Safety Committee

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5.1 Mission and objective

There are various aspects to the safety committee. The gamut of safety related monitoring in the hospital will
include the following:
i) Patient safety
ii) Employee safety
iii) Radiation safety
iv) Laboratory safety
v) Facility safety.
vi) Environment Safety
The Committee will see to all the above mentioned aspects as:

5.2 Patient and Employee Safety

 Devise a framework for adverse event, sentinel events and near miss monitoring, management
and prevention.
 Devise a systematic course of action for analysis of all reported incidents within a specified time
frame and formulate recommendations for implementation.
 Ensure education and training to support safety and quality improvement.
 Conduct safety audits, assessments and present reports so that recommendations for corrective
action. .
 Monitor effective implementation of corrective actions.
 To encourage the non-punitive environment for the reporting of the above mentioned events.

5.3 Radiation Safety

 To set up safety standards for radiations throughout the hospital.

 To align with the statutory and regulatory bodies like BARC.
 To monitor that the radiation safety program is implemented in the concerned area
 Monitoring of the training of the radiology staff by a trained Radiation Safety Officer.

5.4 Laboratory Safety

 To formulate a laboratory safety manual.

 To start and regularly update the Vaccination against hepatitis B of all the staff.
 Monitor proper storage of all the hazardous materials.
 Training of all the staff against all the hazards.

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5.5 Disaster and emergency preparedness

 To prepare, train, monitor and perform mock drills for the emergency and disaster management
plan.
 To prepare, train, monitor and perform mock drills for the community emergencies,
 To prepare train monitor and perform mock drills for Fire and Non-fire Emergency
preparedness plan.
 To monitor the corrective and preventive actions on the results of mock drills.

5.6 Environmental safety

 To set up BMW disposal program.

 Ensure that the same are covered under ICC
 The emission norms and various measures are taken to prevent air pollution
 The water drained out is done in a proper way.

5.7 Safety Committee Members-

S. No Designation

1 MS Chairperson

2 Quality Manager Secretary

2 CSO Member

3 Consultant – Microbiology Member

4 Emergency- Consultant Member

5 Infection Control Nurse Member

6 NS/DNS Member

7 Nursing Supervisors Member

8 Biomedical Engineer Member

9 Sr. Manager – Engg. & Maint. Member

10 Quality executive Member

11 Nursing coordinator Quality Member

12 Representative from Facility Department Member

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13 Fire safety officer Member

14 Paramedic Staff Member

15 Radiation safety officer Member

16 Lab Safety officer Member

17 Safety officers Member

18 Safety Champions Member

5.8 General

The committee shall meet every month or earlier in case the need may be felt by chairperson or any issue
brought by any member.

6 POLICY: HEALTH & SAFETY

6.1 Purpose
The policy is intended to protect staff from job-related injuries and illnesses; preventing accidents and fires;
planning for emergencies; identifying and controlling physical, chemical, and biological hazards in the
workplace; communicating potential hazards to employees; and maintaining sanitary environment.

6.2 Objective
a. Provide safe and healthy conditions and reduce injuries and illnesses to the lowest possible level.
b. Assure compliance with local regulations providing for environmental and occupational safety and health.
c. Provide information, training, and safety measures to staff regarding health and safety hazards.
d. Install and maintain facilities and equipment in accordance with recognized and accepted standards
essential to reduce or prevent exposure to hazards.
e. Provide appropriate personal protective equipment to concerned employees.

Assigning responsibilities
a.MS: has the ultimate responsibility for establishing and maintaining health and safety programs and
initiatives.
b. Head of Departments: are responsible for:
i) Formulating, reviewing health and safety policies applicable to the department/hospital.

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ii) Providing necessary facilities and equipment required for a safe work environment in the department
and hospital.
iii) Providing training materials, assistance, and programs in safe and healthy work practices.
iv) Ensuring areas under their management are in compliance with the health and safety policies, practices
and programs.
v) Establishing procedures for implementation of safety policies.
vi) Establishing a system for assessing safety performance.
c. Staff: All staff is responsible for:
i) Participating in mandatory training programs provided by the Hospital.
ii) Safety instructions and rules are to be obeyed. Safety devices installed and safety equipment
provided are to be used. Defective tools and other equipment without proper guarding are not to be
used.
iii) Unsafe conditions or practices are to be reported to the immediate supervisor.
iv) All injuries occurring on the job and any illness associated with the job are to be reported
promptly and in writing to the supervisor. Questions concerning medical treatment of these injuries/illnesses
should also be addressed to the supervisor.
v) All employees entering a designated hazardous, caution, or restricted area are required to use
personal protective equipment and adhere to environment, health and safety procedures immediately upon
access to the area.
vi) All fires, accidental damage to property, hazardous material spills and other emergency
occurrences no matter how slight must be reported as per the protocols.
vii) All hazardous materials are to be disposed of according to prescribed procedures, incompliance
with the regulations.
viii) Working under the influence of alcohol or illegal drugs is specifically forbidden.
ix) Failure to comply with or enforce environment, health and safety rules and regulations may result
in disciplinary action up to and including dismissal.

6.3 Health benefits to staff

Policy:
 All new employees have to go through pre-employment check-ups which includes medical history,
occupational history, and immunization history, Radiological exam, pathological tests and cardiac
tests if required
 The employee’s occupational medical records will be kept confidential and shall not be disclosed
without the written consent from the employee.
 The employee’s medical record will be kept in the personal file with the HR

Specific instruction

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Pre-Employment Check up
 All the employees have to undergo a medical check-up before joining the organization. The
examination includes:

1. Hb/TLC/DLC/ESR
2. Urine R/E
3. RBS
4. ECG
5. Chest X-ray
6. Blood Group
7. ENT
8. Consultation with the Gynaecologist for females and with the Surgeon for males
 The cost of all the investigations and the consultation will be borne by the organization. The
basic registration fees is paid by the employee
 The reports of all the investigation and the examination will be kept in the personal file
 The initial and annual check up report of all the outsourced staff members is obtained from the
HR.

Yearly Employee check up

 Yearly routine examination of all the employees coming in contact with the patients will be done by
the organization.
 The records of all the checkups will be kept in the personnel files.
 The cost of all these examinations will be borne by the organization.
 In case of outsourced staff the checkups are done in the hospital and the cost is jointly borne by the
hospital and the outsourced agency
Surveillance
The people who are under exposure to some specific agent need to undergo an annual check-up and a specific
examination. The areas where detailed examination should be done are:
 Radiology Technicians
 Pathology technicians
 Cath Lab
 CSSD workers
Immunizations
 The immunizations of the people coming in direct contact with the patients need to undergo a
complete course of the hepatitis B vaccines.
 The vaccination is provided by the AHL free of cost.
 Those who are already vaccinated need not go for the vaccination.
 The records of all the vaccination is kept with the HR department, ICN & the employees are given a
vaccination card.

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 New needs for other vaccinations will be identified by the ICN.

6.4 Procedure in case of riots etc.

Hospital will function during riots or communal disturbances. It is the responsibility of the management to
ensure the safety of staff. During such communal disturbances the following procedures will be followed:
1. The hospital will function with the emergency department staff.
2. It is department heads responsibility to ensure minimum staffing in the department.
3. The department head will refer to the location list of its team members.
4. All staff staying in and around the facility will be assigned duty.
5. The department head will use his/her discretion if additional staffs that are at distant places are required
for manning the department.
6. The staff that is unable to attend duty will either applies for casual leave or compensate by working an
additional day.
7. The ambulance may be used for transporting staff, should a need arise
8. In almost all situations the outpatient and Inpatient department will function with the emergency staff.
9. The Head Admin has the authority to declare Out Patient department closed during riot situations, should a
need arise.

6.5 Procedure In Case Of Workplace Accidents

In case of workplace accidents the employee has to fill the adverse event form.
Refer to the Policy on Adverse Events

7 PATIENT SAFETY

7.1 Outcome

Provision of a safe patient care environment and prevention of injury to patient

7.2Policy:

All Patient Care Services staff shall use every reasonable precaution to provide a safe environment. With the
exception of restraints, safety precautions and devices do not require a physician's order for implementation.

7.3 Specific Information

The precautions listed here in should not be considered to be all inclusive, as safe practice requires sound
judgment in individual situations and constant awareness of the environment.

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7.4 General Precautions

1. All patients shall be oriented to the clinical area(s). Orientation may include the
following :
a. room number and unit layout;
b. call bell and how to request assistance;
c. bed operation;
d. room/bathroom layout;
e. Visiting hours, as applicable.
2. All staff shall wear photo I.D. badges when on duty.
3. The patient care area and corridor are clean, well-lighted, and free from clutter.
4. The floor shall be clean and dry. Appropriate signage is in place when floor is wet.
5. Furniture is in good condition.
6. Patient room night lights are functional.
7. Patient beds shall be kept at the lowest possible height
8. Staff shall accompany all patients while ambulation especially during initial
ambulation posts surgery, after prolong bed rest, after procedures requiring
sedation.
9. Transportation:

 Wheels of stretchers, wheelchairs, and beds are locked when a patient is

lifted from or assisted onto them; Side rails are raised on stretchers, when
present.
 Where no side rails exist, safety belts are fastened.
 Approach intersections carefully, Be sure traffic on other side is clear when
opening swinging doors,
 Do not push doors open with equipment. Use door knob.
 Do not leave equipment standing in traffic lanes. Return equipment to its
proper location when not in use.
 Do not obstruct fire equipment. Know location of fire fighting equipment
and how to use it.
 Know evacuation routes and what to do in case of fire.

10. Supplies, machines, and equipment are stored in designated areas. Promptly return
equipment not in use.
11. Patient care equipment is inspected and labelled by the Biomedical Engineering
Department prior to initial use and according to Preventive Maintenance Schedules.
12. Do not use equipment if biomedical calibration sticker is out-of-date.
13. Broken or malfunctioning equipment
a. Remove from clinical area
b. Report immediately to the Biomedical Engineering Department

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14. All spills are cleaned immediately according to applicable guidelines for the type of
spill.(Spillage policy)
15. Each staff member continuously assess for unsafe conditions and takes appropriate
corrective action.
16. "Near misses", accidents, and occurrences (patients, visitors, and staff) are
immediately reported to Safety Officer and are documented.
a. Patient and visitor's occurrences are documented on the Adverse Event
Report Form
b. Staff occurrences are to be documented.

7.5 Identification Bands

1. The identification band is applied following initial identification of the patient.

2. The identification band is placed on the wrist of inpatients admitted
3. If the patient's medical condition prohibits the application of the identification band
to the patient's wrist, the identification band must be attached to a visible part of the
patient's body using tape appropriate to the patient's condition/allergies.
4. If the Identification Band must be removed by a staff member, then a new band shall
be made, identification re-confirmed, and the band placed on the patient.
5. Before a patient is transferred, the transferring nurse verifies the identification
band is in place.

7.6 Side Rails

1. Patients shall be placed in a bed that has functional side rails.

2. The following patients have side rails raised when unattended by staff:
a. those given pre-op or pre-procedural medication;
b. patients on stretchers (unless equipped with safety belts)
c. All paediatric patients in cribs

7.7 Oxygen Use

Compressed Gas Storage: Rooms in which compressed gas or oxygen cylinders are stored shall be identified
with a "Compressed Gas Storage" or "Oxygen Storage" sign.

All compressed gas cylinders located or stored in units/practice areas are:

i. Stored in an upright position

ii. Affixed to the wall with a chain or placed in a stand to prevent tipping
iii. Should have label of full and empty to avoid confusions
iv. Oxygen signs are required on emergency (crash) carts.

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7.8 Patient's Role in Promoting Safe Health Care

Patients are encouraged to become an active, involved, and informed member of their health care team.
Listed below are ways that the patients may be encouraged to promote their own safety.

 Patients are instructed to ask if they have questions about their health or safety.
 If the patient is having an operation, the patient is asked to verify prior to the
procedure, the site/side of the body that will be operated on.
 The patient is taught to know what medications they take and why they take them.
 The patient is reminded to look for an identification badge to be worn by all health
care providers.
 Patients are instructed to adhere to AHL’s No Smoking policy.

7.9 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 Safety Officer undertakes
periodic evaluation of safety precautions to be followed by each department.
For hazard recognition the following steps will be undertaken:
 Both Clinical and Non-clinical audits are carried out on a periodical basis to identify the measures
taken to prevent/reduce the impact of the potential hazards.
 All the staff of the hospital will be encouraged to routinely assess all activities to identify potential
hazards.
 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.

7.10 Electrical Safety

Scope: Hospital Wide

Policy:
1. Electrical devices shall be protected from wet floors.
2. The frame of all electrically operated machinery shall be grounded.
3. If a "shock is felt" from any electrical equipment, immediately remove from service, and report it to
the Maintenance Department for repair.
4. Care is to be maintained when connecting and disconnecting electrical equipment. Switch to "off"
position before connecting or disconnecting.
5. Do not disconnect the plug from the wall by grasping the power cord. Grasp the plug itself and
disconnect.
6. Report and remove from service any device that has been dropped, abused, had liquid spilled on it
or has evidence of overheating.

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7. Discontinue use of equipment that has any wire or power cord that shows fraying, extreme wear,
cut in insulation or evidence of burning. Report the same to Maintenance Department.
8. Preventing overload
a. When adding a receptacle:
i. Ascertain what is to be used on the circuit and check to see how many amps the item will be using.
ii. Find out what is already on the circuit and if you may tap into the circuit.
iii. Add the new circuit only if the amperage is available.
b. When using extension cords:
i. Using only one duplex receptacle to one extension cord. This restriction prevents the plugging of
too many types of equipment into the same circuit.
ii. Report any suspected overloaded systems to the facility executive immediately.

The following measures are undertaken to ensure Electrical safety:

 Routine Inspection of the power outlets throughout the hospital by the electrician.
 MCBs are located in different parts of the hospital to prevent short circuits.
 Periodic inspection of wires to ensures that they are in appropriate conditions.

Before any electrical appliance is brought into Hospital, it is checked from safety point of view by the safety
officer.

 Electrical equipment’s not required during night are switched off.

 Areas around electrical switchboards must be kept clear for a distance of at least 1 meter.

 ABC type fire extinguisher will be present in every area.

Power Loss:
The Hospital may experience temporary power losses due to

 Storms

 Power company disruptions, or damage to the service lines entering the hospital.

 Malfunctioning of the internal electrical wire system of the hospital.

Immediate Action:

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 In the event of power loss, every effort should be made to immediately turn off all electrical
equipment (if required) within an employee’s work area before power is restored to protect the
equipment.

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.

7.11 Biological Hazard

The Infection Control Manual can be referred for instruction guidelines regarding management of hazardous
waste.

7.12 Biomedical Waste Management

Refer to Biomedical waste management protocol

9. MOCK DRILLS

Code Red mock drills are held twice yearly. The drills are conducted to verify:
a. If staff follow correct protocols to announce Code Red.
b. If staff are using the correct exit routes.
c. Correct assembly of staff and patients at designated areas.
d. Evacuation times.

10. SAFETY INSPECTION AND RECORDS

The hospital undertakes periodic inspection of the safety precautions undertaken. The reports of the safety
inspections are reviewed by the hospital’s safety committee and the same is submitted to management. The
safety Inspection records are maintained by the secretary of safety committee.

The Safety Management Committee may require periodic assessment of the following inventory:

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

b. Hazardous materials (flammable and caustic).

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c. Equipment (biomedical equipments etc.).

d. Power equipment (boilers, motors, etc.).
e. Electrical equipment (switches, breakers, fuses, outlets, connections).
f. Personal protective equipment (safety glasses, ventilators, radiation safety aprons etc).
g. Personal service/first aid supplies (Medical Check Up).
h. Fire protection equipment (alarms and extinguishers).
i. Walkways/roadways (sidewalks, roadways).
j. Transportation equipment (Ambulances, lifts).
k. Containers (hazardous waste bags).
l. Structural openings (windows, doors, stairways).
m. Buildings/structures (floors, roofs, planter walls, fences).
n. 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.

10.POLICY ON INCIDENT REPORTING AND RISK MANAGEMENT

Policy Statement
The Hospital recognizes and attaches greatest importance to, and concern for, the safety of all its patients,
Hospital staff and the users of the premises under its control. Consequently the Hospital strives to ensure that
accidents, incidents and near misses are identified, reported and action taken to help ensure the safety and
security.
The Hospital is committed to the elimination and or control of all risks. Risk management is seen as integral
part of:
 Delivering the highest standard of patient care
 Continuous quality improvement
 Protecting the Hospitals resources ensuring that these remain available for patient services
 Maintaining the statutory obligation to maintain safe systems of work

Scope of Risk Management

Risk management covers the following aspects:
 Environmental Risk
 Clinical Risk
 Complaints & Grievance Handling (For Patients & Staff)
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 Mandatory Training related to Risk Management

Process of Risk Management
 Identification of Potential Risks & Hazards
 Evaluate the likelihood and degree of risk
 Documentation & Reporting of Risks and Incidents & near misses
 Implementation of Corrective actions & Control Measures to reduce, prevent incidents
 Review and monitor risk management process for continuous quality improvement

Hospital Safety Committee

Philosophy
 The Hospital is committed to provide the highest possible quality of care in an environment that is of
minimal risk to its patients, visitors, employees, and medical staff. Essential to the achievement of the
objective is risk management, its systematic process of identifying, evaluating, and addressing
potential and actual risk.

 The emergence of risk management as an operational component of Quality Assurance Program is

the result of a variety of factors, such as the increased use of Hospital services, rising Hospital cost,
government, and self-policing, greater patient expectations, adverse claims experience, higher court
settlements, escalating insurance premiums, and the need for self-insurance and risk assumption
programs. The factors that mandate risk management programs in Hospital will have an even greater
impact in the future.
Functions and Responsibilities
The many varied facets of the Risk Management Program functions and responsibilities include, but are not
limited to:
 Risk detection procedures, including analysis of quality assurance data, incident reports, patient and
staff complaints, malpractice claims, inspections of the physical plant, preventive maintenance, staff
development, and audits of policies and procedures.
 Delineation and assignment of staff level functions in gathering risk management data.
 Encouragement of physicians to report incidents and instances of inappropriate care.
 Administrative responsibility for risk management through delegated authority of Quality Assurance
Committee functions.
 Centralization for the coordination and integration of risk management activities with quality
assurance.

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