GAIMS Safety Manual 12.05.22

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 151 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 10. Medical Administrator and the Security officer will try to communicate with the patient providing him emotional support with the help of his attendant/friends if available. 11. Remove any item or tool from that area so that patient cannot harm himself or other. 12. Medical Administrator/ MOD and Nursing Staff will try to take the patient to a separate room if required. 13. If the person becomes physically offensive/ aggressive then minimum force would be used so that any damage to the individual can be prevented. 14. Inform his /her relatives, If he/she alone. 15. After the patient has called down, advice relatives to seek consultation from doctor for further treatment. 16. Once situation is under control inform Front Office desk to announce Code Violet over. RESPONSIBILITY  Security In charge /Security  Head Operations  Consultants and MO  NS  Medical Administrator  Chief Medical Superintendent  Medical Director 12. MOCK DRILLS POLICY: Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 152 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Mock drills will be conducted at least twice in a year to test all the components of the emergency plan. Conclusion, variation is identified and recorded and analyzed. Debriefing of the drill conducted after every mock drill. PURPOSE  Each individual must know actions expected from him / her in a fire or other emergency situation. Mock drills demonstrate the readiness of the organization to take care of emergency situations and can point out deficiencies in the process if there are any.  The purpose of a Mock drill is to ensure that all staff is familiar with the procedure. Fire drills can be used to provide additional training for staff and building’s fire safety systems. SCOPE  Entire Hospital PROCEDURE  Drills are conducted according the annually scheduler. Staff should practice using the emergency voice communication system and other equipment where applicable during these drills to gain experience and confidence. It is very important that all personnel with specific responsibilities attend a debriefing meeting following every practice drill. This meeting is held to review the procedures and reactions of all participants.  During the debriefing, problem areas can be identified and, if necessary, solutions to overcome any deficiencies in the facility’s Fire Safety Plan can be discussed and corrected. The date and time of all fire drills, as well as the names of participating staff, should be recorded. Mock Drill plan & Frequency: Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 153 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Mock drills will be conducted for all identified Fire & non fire emergencies once in a six month. 13. SAFETY EDUCTION PROGRAM POLICY  Staffs are trained in the organization patient safety programme and quality improvement programme  Staff training includes disaster management plan, fire and non-fire emergencies, CPR, infection prevention control.  Staffs are also trained in detection, handling and minimizing or eliminating risk in the organizational environment.  Staffs are trained for occupational safety. PURPOSE  To prevent, reduce risks and provide a safe working environment for the employees. SCOPE  The organization staffs, doctors, consultants (including visiting) and the outsourced staff are to be covered for safety related trainings PROCEDURE  All staffs receive training on patient safety programme at the time of induction. Also retraining is done every six monthly. Training on workplace safety include guidelines to identify hazards, report them, and deal with incidents. (HRM 6.a)  Staff are trained for identifying, minimizing & eliminating the potential risks within the organization (HRM 6b) Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 154 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Appropriate training is done to staff on steps /procedures to be followed in the event of NSI, spillage, emergency evacuation (HRM 6.c).  Safety plan gives detail scheduling of mock drills. They are conducted at the interval of 3 monthly where staff actions are evaluated. In case of disaster management training staffs are trained for their specific roll.  It helps the employee to act in case of incident happens. Occupational hazards  Occupational Hazard: The hazard to which an individual is exposed during the course of performance of his job. These include physical, chemical, biological, mechanical and psychological hazards.  Organization identifies the areas with occupational hazards for which staff are trained on safety aspects like o Biological Hazards (NSI, cuts, wounds, airborne disease), o Chemical hazards (exposure to acids, chemicals, pesticides) o Physical Hazards (noise, slipping on floor, confined spaces) o Psychological Hazards (work load, harassment, discrimination, violence, stress) o Safety Hazards (electric hazard, equipment breakdown) Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 155 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL Sr. Type of Which When can it Where can it How have we addressed No. Hazard Hazard occur occur this hazard Injury, While handling CSSD, OT, Use of hand gloves, Cut on sharp Wards Established protocols for body transfer of sharps. (OT parts instruments procedures, Safety Manual) Use of TLD badges, Testing Exposur TLD badges every 3 e to While working Imaging CT, x- months for amount of ionized in ionized ray exposure and course of radiatio radiation action as given in BARC n rules. (Radiation safety, Safety Manual) Use of PPE like gloves, 1 Physical Injury While handling Laboratory glasses, masks when glassware appropriate. (Laboratory safety, Safety Manual) While handling Injury heavy objects Anywhere in Training to persons like shifting of premises involved in shifting on safe portable x-ray handling procedures. (Safety Manual) machine, shifting of equipment Safe handling procedures Injury Handling and Medical gas for gas cylinders, provision storage of gas storage, OT, of chain / securing ICU, wards mechanism to avoid fall of cylinders cylinders. (Medical gases safety, Safety Manual) Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 156 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL Injury, contact Exposure to Laboratory, Use of appropriate PPE like with chemicals / Stores, gloves, goggle, mask (Safety Manual) eye, skin kits Housekeeping contact, stores, burns 2 Chemical Injury, Storage and Storage area, Storage and handling burn handling of at the point precautions. (Safety due to Medical Spirit Manual) fire of use in wards Irritation Storage and Housekeeping Storage and handling or injury handling of storage, precautions, use of gloves due to (safety Manual) Contact cleaning chemicals like with eyes, Hypo, skin detergents etc Infectio Infection to All wards, OT, Procedures for pre- n healthcare CSSD, exposure and post Laundry exposure prophylaxis, workers Vaccination to healthcare working in workers, SOPs defined for safety while working in close such areas. (HIC Manual) proximity with infected patients 3 Biological Infectio Spills of blood Procedures for handling n and body spills and use of PPE (HIC fluids All wards Manual, Safety Manual) Procedures for segregation Infectio While handling All wards, and handling of bio- n, Injury bio medical BMW disposal medical waste and waste. disposal. Segregation at area the point of generation. (HIC Manual) Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 157 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 4 Mechanical Injury While Maintenance Providing appropriate Injury operating CSSD guards like belt guard, mechanical canopy for noise control, equipment like any/all areas SOPs, Preventive Generator, maintenance Fan, Lift. SOPs defined for safe During operation, Preventive operation of maintenance procedures. autoclaves Psycho- Workload, 5 logical violence at Hazard workplace  The training is provided to staff to understand what to do and how to respond to emergency situations. (HRM 6.e) RESPONSIBILITY  Safety Officer  Departmental Head RECORDS  HR Manual  Safety Manual  Training records 14. EMPLOYEE HEALTH SAFETY POLICY Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 158 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  GAIMS hospital implements occupational health and safety practices to reduce the risk of transmitting microorganism among health care providers PURPOSE  To reduce the HAI risk in health care workers.  To reduce accidental HAI risk SCOPE  Entire Hospital PROCEDURE Following are the provisions which are implemented in hospital to reduce healthcare associated infection in staff  Active HIC Department  Availability of adequate resources for HIC activities in hospital  Adherence to Standard precaution  Health checkup programme for all hospital staff  Provision of pre-employment screening for staff health and immunization  Vaccination programme for health care providers and all staff who expose to patient and infection related activities.  Strict following of NSI Protocol  Adherence to Kitchen and Beverages sanitation programme  Yearly medical checkup, screening and vaccination programme for canteen staff  Strict adherence to Engineering control programme  Implementation of pre and post exposure programme  Continuous trainings on HIC related topics  Implementation of Environmental cleaning programme Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 159 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Implementation of food and water testing programme  Training for Barrier nursing to take care of communicable disease treatment  Monitoring of Antibiotic surveillance and prophylaxis RESPONSIBILITY  HIC department  HR department  Management and  HIC team members RECORD  Records for staff fitness and vaccination  Food and water testing report  Environmental surveillance report  ICRA 15. RADIATION SAFETY Radiation Radiation may be defined as energy traveling through space. Non-ionizing radiation is essential to life, but excessive exposures will cause tissue damage. All forms of ionizing radiation have sufficient energy to ionize atoms that may destabilize molecules within cells and lead to tissue damage. Radiation sources are found in a wide range of occupational settings. If radiation is not properly controlled, it can be potentially hazardous to the health of workers. Gamma rays, X-rays and the higher energy range of ultraviolet light constitute the ionizing part of the electromagnetic spectrum. The lower-energy, longer-wavelength part of the spectrum including visible light, infrared light, microwaves, and radio Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 160 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL waves is non-ionizing; Radiation is useful in medicine because of its ability to penetrate tissue, allowing imaging and non-surgical treatment of internal structures. However, radiation may produce harmful biological effects. Observations of exposed human populations and animal experimentation indicate that exposure to low levels of radiation over a period of years may lead to a slight increase in the incidence of cancer and leukemia. Radiation Safety  Radiation safety in the hospital refers to safety issues related to radiation hazards arising from the exposure to x-ray from x-ray machines. SCOPE OF RADIATION SAFETY Scope of Radiation safety is applicable to Radiology, OT, ICU department where radiation exposure occurs:  The Hospital Radiation Safety program applies to all locations where radiation- producing machines are used.  It applies to all persons working at or frequenting these locations, regardless of their relationship with the Hospital.  It applies to all radiation-producing machines at these locations, regardless of ownership of the machines. OBJECTIVES  Ensure radiation safety polices and procedure is fully implemented.  Ensure radiation safety protocol is followed for patient and employee and visitor’s safety.  Ensure education and training to support radiation safety. Job Description OF RSO Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 161 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 1. The Radiological Safety Officer shall be responsible for advising and assisting the employer and licensee on safety aspects aimed at ensuring that the provisions of these rules are complied with. 2. The Radiological Safety Officer shall carry out routine measurements and analysis on radiation and radioactivity levels in the controlled area, supervised area of the radiation installation and maintain records of the results thereof; a) Investigate any situation that could lead to potential exposures; b) Advise the employer regarding I. The necessary steps aimed at ensuring that the regulatory constraints and the terms and conditions of the safe storage and movement of radioactive material within the radiation installation; II. Initiation of suitable remedial measures in respect of any situation that could lead to potential exposures III. Routine measurements and analysis on radiation and radioactivity levels in the off-site environment of the radiation installation and maintenance of the results. IV. Reports on all hazardous situations along with details of any immediate remedial actions taken are made available to the employer and licensee for reporting to the competent authority and a copy endorsed to the competent authority; V. Quality assurance tests of structures, systems, components and sources, as applicable are conducted; 3. Monitoring instruments are calibrated periodically. a) assist the employer in instructing the workers on hazards of radiation and on suitable safety measures and work practices b) Aimed at optimizing exposures to radiation sources and developing suitable emergency response plans to deal with accidents and maintaining emergency preparedness; c) advise the licensee on - Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 162 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL d) the modifications in working condition of a pregnant worker; and the safety and security of radioactive sources; e) Furnish to the licensee and the competent authority the periodic reports on safety status of the radiation installation and inform the competent authority when he leaves the employment. DEFINITIONS & ABBREVIATIONS 1. Definitions a) ALARA  For As Low As Reasonably Achievable. b) Calibration  The check or correction of the accuracy of a measuring instrument to assure proper operational characteristics c) Critical Organ  The organ or tissue, the irradiation of which will result in the greatest hazard to the health of the individual d) Declared Pregnant Worker  A woman who has voluntarily informed her employer, in writing, of her pregnancy and the estimated date of conception e) Occupational Radiation Dose  The dose received by an individual in the course of employment. f) Radio sensitivity  The relative susceptibility of cells, tissues, organs, organisms, or other substances to the injurious action of radiation g) Thermo Luminescent Dosimeter (TLD)  A portable instrument for measuring and registering the total accumulated exposure to ionizing radiation. 2. Abbreviations: Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 163 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL a) AERB: Atomic Energy Regulatory Board b) BARC: Bhaba Atomic Research Center c) ALARA: As Low As Reasonably Achievable d) RSO: Radiological Safety Officer e) Pb: Lead f) TLD: Thermo luminescent Dosimeter g) NOC: No Objection Certificate h) SSD: Source-Skin Distance i) THF: Tuned High Frequency POLICY  The hospital imaging services comply with all legal and statutory requirements. PURPOSE  To aware the legal and other requirements of imaging services and the same are documented for information and compliance by all concerned in the organization. SCOPE  Is applicable to Radiology, OT, ICU department where radiation exposure occurs. PROCEDURE  Whenever a new machine installed in organization, need to inform to AERB through ELORA.  Before machine installation we need to get sanction layout plan from AERB.  After installation we have to do Quality assurance by AERB authorized agency to check whether machine is working good or not. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 164 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Then we required to upload the layout plan, QA and installation report through EORA for license for operation.  For PCPNDT registration of CT, MRI and USG machine is mandatory. RESPONSIBILITY  RSO (Radiological Safety Officer)  Radiology manager RECORDS  License displayed at appropriate locations. References  AERB guidelines, PCPNDT regulations. Statutory Requirements with regard to radiation safety are as follows:  Commissioning and Decommissioning of X-ray Equipment has to be registered with AERB.  X-rays equipment meeting design certification and type approval requirement by AERB only shall be used.  Direct assistance to the patient while being X-rayed has to be avoided. If assistance is required, appropriate precautions have to be taken by the person who will assist by making use of appropriate protective material and devices which are available.  For Fetal protection pregnant worker & pregnant patients are not allowed.  Personnel monitoring facility is provided to all radiation workers.  Presence of uninvolved staff, patients and persons in any X- ray room must be avoided.  Regular maintenance and calibration of the unit must be carried out. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 165 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Servicing and calibration of X-rays equipment should be undertaken by qualified, trained and authorized service engineer.  Radiographer should avoid repeated X-rays examinations.  X-ray examination of pregnant women and children should be avoided as far as possible.  RSO of the Organization is responsible for maintaining safety standards, developing safety rules and supervising and training personnel in departmental standards.  RSO of the Organization is responsible for notifying the management in case of any safety hazard.  All radiology employees shall report defective equipment, unsafe conditions, acts or safety hazards to Radiological Safety Officer.  Keep electrical cords clear of passage ways. Do not use electrical extension cords without prior informing the facility department. All equipment’s and supplies must be properly stored.  All electrical machines, with heat producing elements, must be turned off or unplugged when it is in not use.  Notify the facility department immediately of illumination and Air conditioning effect Problems.  Only authorized personnel shall be allowed in X-ray room.  Individuals who are present in a radiographer room during any exposure shall wear protective aprons of at least 0.25 mm lead equivalent during every exposure.  When a patient must be provided with auxiliary support during a radiation exposure and mechanical holding devices are insufficient; the following procedures shall be followed:  The person holding the patient shall be protected with a lead apron of at least 0.25 mm lead equivalent. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 166 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Radiographers not to hold the patient during a radiation exposure, except in a life-threatening situation.  No person shall be employed, routinely assigned, or required to hold a patient during radiographic and fluoroscopic procedures.  The operator shall collimate x-ray beam limitation to ensure that the x-ray field does not extend beyond the Region of interest.  The Radiographic field shall be restricted to the areas of clinical interest as far as practical.  A method to observe the patient during the x-ray exposure (Lead glass/partition) shall be provided for all units.  During radiographic exposure, the operator shall stand behind the protective barrier.  The Department in charge /RSO shall provide safety rules to each individual operating x-ray equipment including any restrictions as to the operating technique required for the safe operations of the particular x-ray apparatus, and require that the operator sign a form acknowledging that the safety manual was read.  No person shall permit or arrange for the intentional irradiation of a human being except for the purpose of medical diagnosis or treatment.  No person shall deliberately expose an individual to the useful beam for the sole purpose of training or demonstration.  No person shall operate a machine unless that person understands and uses the principles of radiation safety to keep radiation exposure as low as reasonably achievable (ALARA).  To minimize the biological effects of radiation, special rules and regulations are set for the individuals occupationally exposed to radiation. The amount of radiation received by persons exposed occupationally should not exceed the dosages specified in the AERB for Protection against Radiation.  In general, minimal external radiation hazard to hospital personnel from procedures involving radiation. Depending on your specific job duties, you may Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 167 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL or may not be classified as a “radiation worker” and may or may not be required to wear personnel monitoring devices. All X-ray equipment operators are considered “radiation workers” and most require personnel monitoring. Adherence to guidelines contained in this manual will help all X-ray equipment operators and radiology staff members keep their exposures as low as reasonably achievable (ALARA), and for most staff members should reduce radiation exposures to levels allowable for individual members of public or in some cases, to levels indistinguishable from natural background.  Radiation protection support services are provided for GAIMS AERB governing Body, Govt. of India. These services include the oversight and administration of the personnel monitoring program, area surveys and in-service training of hospital workers. X-ray equipment inspections are performed by Bio Medical department and by the vendors. Questions regarding the radiation protection program should be directed to the Radiological Safety Officer (RSO).  The radiation protection program is guided by the concept of keeping radiation exposure as Low as Reasonably Achievable (ALARA). The ALARA concept is based on the assumption that any radiation dose, no matter how small, can have some adverse effect. GAIMS undertakes, radiation exposure of all individuals routinely working with sources of radiation is monitored with a TLD (Thermo Luminescent Dosimeter). The dosimeters are changed out and analyzed on a quarterly frequency. Radiation exposure can be minimized by utilizing three basic principles detected with radiation survey meters.  Time: Shorter exposure time means a lower dose.  Distance: Doubling the distance from a radiation source means one-fourth the dose rate. Tripling the distance gives one-ninth the dose rate.  Shielding: The use of appropriate shielding reduces the dose rate. PERSONAL PROTECTIVE ACCESORIES  Above 0.25 mm Lead Apron Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 168 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  0.25 to 1.5 mm Lead Protective Barriers (shielding) Moving.  Above 0.25 mm Lead Thyroid shields.  Lead head shield  Lead gonad shield  2.0 mm Lead Glass In CT Scan  Lead Lined doors of All Radiation source areas. DOSE LIMITS  The average annual dose of GAIMS radiation worker should not exceed 20msv. And the cumulative effective dose constraint for consecutive five year (current year+ last four years) should not exceed 100msv.  If exposure limit exceeds individual TLD exposure dose report. Staff will be isolated from radiation field and will be assigned for non-radiation work.  Reports are received by AERB 3 monthly, with analysis, where RSO checks the reports & maintains the record.  It is the responsibility of the Radiation workers to have thorough knowledge and apply on the job instructions for all personnel regarding safe practices.  Department in charge /RSO is responsible for the degree to which his/her personnel have gained the knowledge and skills necessary to perform safely and effectively in their particular position. Individual departments will establish and publish safe work rules which reduce accident probability.  Development of these rules should involve: o A review of all work methods and practices. o A review of all past accident experiences. o Recommendations by supervisory personnel. o Recommendations by personnel. o Investigate personnel injuries within the department. o Cooperate with the Department in charge/RSO in the promotion of these activities. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 169 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL o Assist in monitoring Safety Recommendations. o This programme is aligned with organizations safety programme. o All safety guidelines shall be observed. o Report every injury, no matter how slight, to in charge/RSO. o No intoxicating liquor shall be consumed while on duty. Anyone who is found under the influence of alcohol or drugs will be suspended as per rule. o Remember your ethics like cutting nails, before and after wash your hands while handling patients. o Keep fit for your job, eat properly and get sufficient rest to meet the demands of your job. o Take a special interest in the new or inexperienced persons and help them with the small details of the job. o Be sure to notify all persons of any dangerous situations that might affect your work area. o Remember the patient; never leave him/her unattended. o Know all the hospital emergency codes and be sure of your responsibilities. o When dealing with the extremely large patient, be sure to seek help and lift the patient correctly. o Know your fire extinguishers, their locations and the use. o Use good housekeeping techniques at all times. o Remember the department security. o A qualified radiographer must only do all radiographic techniques and procedures. All radiographers must take necessary steps in reducing radiation dose to the patient. o Check the correct patient for correct examination. o Plan your technique to reduce the radiation dose o Close the X-ray room door properly and tightly. o Provide the necessary radiation protection. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 170 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL o Collimate the radiation beam to necessary area only. o Give proper and correct instructions. o Select the appropriate exposure factor. o Place the correct ID/CR for correct patient. o Avoid unnecessary repeats. o For female patients check whether they are pregnant. o Limit number of people in the X-ray room while X-ray is being done. o Mobile X-ray request only if it is necessary. o All staffs must wear radiation-monitoring badge while in the radiology department. o Clear all staffs from room during Mobile X-ray /Provide Lead apron to the next Bed patient if he he/she is not able to move. o Everybody should be 6 feet away from x-ray tube during Mobile x-ray. RESPONSIBILITY  RSO (Radiological Safety Officer)  Radiation Worker RECORD  Radiation Safety Manual Reference  AERB guidelines and regulations. POLICY  GAIMS Hospital screens the patients for safety and risk before any Imaging test. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 171 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL PURPOSE  To avoid any harmful injury for patient. SCOPE  Is applicable to all Radiology services. PROCEDURE  Avoid radiation risk in child bearing age group and pediatric patients.  For MRI patients screening for any metallic substances and screening form maintained.  Informed consent for contrast injection, moderate sedation/anesthesia maintained. RESPONSIBILITY  Radiology technician  Radiology Nurse  Ward Nurse RECORDS  MRI screening forms file  Contrast consent forms file. References  NABH guidelines, AERB guidelines and regulations POLICY Prepared by Reviewed by Approved by Signatory Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 172 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  The hospital using Radiation safety accessories and monitoring devices for Radiation workers. PURPOSE  To avoid Radiation and monitor radiation dose for individual radiation worker. SCOPE  Is applicable to Radiology, and C-Arm guided operation theatre procedures. PROCEDURE  Shielding of body parts with lead protective accessories, while attending the patient.  Radiation workers have TLD (Thermo Luminescent Dosimeter) for radiation monitoring. RESPONSIBILITY  RSO (Radiological Safety Officer)  Radiation Worker RECORDS  Forms maintained in particular files References  NABH guidelines, AERB guidelines and regulations. POLICY Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 173 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  The hospital radiation safety accessories and monitoring devices periodically tested and results are maintained. PURPOSE  To check integrity of lead protective accessories and monitored radiation dose for radiation worker. SCOPE  Is applicable to Radiology and C-Arm guided operation theatre procedures. PROCEDURE  All lead protective accessories have given department wise unique number.  Lead protective accessories checked under CT scan scout view for cracks and damages.  It is checked 6 monthly. Images of same stored as electronic format and results are documented in QA file of PPE.  Thermo luminescent dosimeter (TLD) is provided to all radiation workers. It was replaced on quarterly basis as per AERB guidelines, reports of radiation dose of all workers are documented in TLD record file by RSO. RESPONSIBILITY  RSO (Radiological Safety Officer) RECORDS  QA PPE file, TLD record file. References Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 174 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  NABH guidelines, AERB guidelines and regulations. POLICY  The hospital imaging staffs are trained in imaging safety practices and radiation safety measures. PURPOSE  To prevent patient fall, safety in MRI and radiation safety measures to protect unwanted radiation. SCOPE  Radiology department. PROCEDURE  Follow the policy from Radiology manual (AAC.9.e) -Patients are transported in a safe and timely manner to and from the imaging services.  Periodic training taken by Housekeeping department to avoid patient fall.  All the radiology and ancillary staff undergoing training of radiation safety and MRI safety by RSO. RESPONSIBILITY  RSO (Radiological Safety Officer)  Housekeeping supervisor. RECORDS  Radiation safety training register, Housekeeping training register. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 175 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL References  NABH guidelines, AERB guidelines and regulations. POLICY  The hospital has adopted a policy to protect the fetus/embryo of pregnant employees exposed to ionizing radiation in their work. PURPOSE  To protect the fetus/embryo of pregnant employees exposed to ionizing radiation. SCOPE  Radiology and OT department. PROCEDURE  Employees should inform the Head of the department/Medical Administration & Radiological Safety Officer to discuss possible precautions to limit radiation exposure.  The Radiological Safety Officer will review work assignments and radiation exposure history, and may recommend limitations in work assignment if necessary. Dosimeters will be assigned with radiation exposures to be reviewed 3 monthly.  Pregnant patients are strictly not allowed to do the radiographic examination; all female Patients are asked to inform the radiographer before the examination. Only in emergency condition physician can advise for an x-ray of a pregnant patients, Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 176 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL RESPONSIBILITY  RSO (Radiation Safety Officer)  HR department  Medical administration RECORDS References  NABH guidelines, AERB guidelines and regulations. Radiation Workers Contribution to the Safety Program:  It is the responsibility of the Radiation workers to have thorough knowledge and apply on the job instructions for all personnel regarding safe practices.  Department in charge /RSO is responsible for the degree to which his/her personnel have gained the knowledge and skills necessary to perform safely and effectively in their particular position. Individual departments will establish and publish safe work rules which reduce accident probability.  Development of these rules should involve: o A review of all work methods and practices. o A review of all past accident experiences. o Recommendations by supervisory personnel. o Recommendations by personnel. o Investigate personnel injuries within the department. o Cooperate with the Department in charge/RSO in the promotion of these activities. o Assist in monitoring Safety Recommendations. Guidelines for Radiation Worker Personnel Working In Radiology Department/Operation theatre Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 177 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  A personnel monitoring dosimeter (TLD badge) should always be worn when working with radiographic/fluoroscopic equipment or in radiographic / fluoroscopic procedures. The dosimeters worn should be those issued for the current time period and should be worn at the chest level, under the lead apron. Remain in room during radiographic/fluoroscopic procedures only if necessary. Less time spent around a radiation source means a lower radiation exposure to the individual.  Remember: The main source of exposure is radiation scattered from the patient.  If you must remain in the room during these procedures, you must wear a lead apron of at least 0.25 mm lead equivalence.  Note: A lead apron of 0.25 mm lead equivalence will reduce scattered X-rays by 95%.  If it is necessary to restrain a patient during an X-ray exam, mechanical restraining devices should be used whenever possible. If a patient must be held in place by an individual for an X-ray exam, that individual shall be protected by whole body apron of at least 0.25 mm lead equivalence. Any part of the individual’s body in the X-ray beam during the exposure must be protected by at least 0.25 mm lead equivalence  Since radiation decreases rapidly with distance, the further one is from the patient during the actual X-ray examination, the smaller your exposure. Maintain the maximum distance possible from the patient during radiography and fluoroscopy.  Report any unusual or unsafe condition involving sources of radiation to the Radiological Safety officer.  The Hospital X-ray registrations, regulations, QA reports and exposure reports are available for review with the RSO.  All radiation protection safety signages are displayed outside the Radiology, OT as per AERB guidelines.  Red bulb lights are fitted outside the radiation producing rooms where the investigations & procedures are carried out in Radiology & Cath lab department. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 178 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Aprons must be stored properly in hangers. Do not fold or pile up.  All X-ray switches shall be in allocation where they cannot be accidentally energized.  TLD shall be worn by all Staffs during working hours in department. Badges will be processed and recorded Quarterly.  A routine check shall be made X-ray equipment before using. Recalibrate when tubes are changed or machines modified.  If a patient must be held during x-ray, the assistant holding the patient will wear lead apron during the entire procedure.  Nurse or Radiographer who calls for patient will check the correct identify of the patient.  The radiographer shall always stand behind the lead partition when making an exposure.  The X-ray tube shall never be pointed directly towards the lead partition, in unavoidable circumstances to collimate accurately and wear lead apron and follow ALARA technique.  The doors to the X-ray room must always be kept closed.  Return equipment’s 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.  Patients such as a children and pregnant women shall be shielded.  The radiographer will ensure that all the Infant/children being radio graphed have proper shielding and proper collimation of the X-ray beam to expose only the required anatomy.  All expectant females if necessary to be X-rayed will be properly shielded and the X-ray Beam Collimated to the area of interest only.  Pregnant females will not be permitted in the X-ray room during exposure.  Appropriate personal protective equipment (Radiation Protective devices) is to be worn where there is a risk of radiation exposure. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 179 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Personnel monitoring devices should always be worn when working with radiographic equipment. The devices worn should be those issued for the current time period and should be worn under the lead apron. Those workers wearing TLD badges should ensure that the Card has been properly inserted into the Cassette holder.  Only persons whose presence is necessary should be in the radiographic room during exposure. All such persons who are subject to direct scatter radiation shall be protected by aprons or whole body protective barriers of not less than 0.25 mm lead equivalent.  Note: A lead apron (Pb) of 0.25 mm lead equivalence will reduce scattered x- rays by 95%.  Mechanical supporting or restraining devices shall be used when a patient or film must be held in position for radiography. If a patient must be held by an individual, that individual shall be protected with appropriate shielding devices of at least 0.25 mm lead equivalence for whole body protection and at least 0.5 mm lead equivalence for any part of the holder’s body that is exposed to the primary x-ray beam.  The x-ray beam should always be collimated to the smallest area consistent with clinical requirements and should always be aligned accurately with the patient and film.  Mobile equipment should be used only for examinations where it is impractical to transfer patients to permanent radiographic installations. Cordon off area, call loudly “shootout”  The operator should stand behind the barrier provided for his/her protection during radiographic exposures at permanent radiographic installations and should stand as far as possible (at least 6 feet) from the patient when operating the mobile equipment.  Each mobile radiographic equipment operator, prior to making an exposure, should ask anyone within 6 feet of the x-ray tube and/or patient being radio graphed to move further away until the exposure is complete. Those persons Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 180 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL who must remain within 6 feet of the patient and/or x-ray tube must be protected by whole body aprons or barriers of at least 0.25 mm lead equivalence. The operator shall give an audible warning before the exposure is made.  When making X-ray exposures, it is advisable to place the image intensifier closest to the region of interest. This results in better image quality and reduces risk from potential hazards.  Special precautions, consistent with clinical needs, should be taken to minimize exposure of the embryo or fetus in patients known to be or suspected of being pregnant.  No abdominal area radiographic imaging shall be performed on a pregnant or potentially pregnant patient without the approval of a qualified physician. If the x-ray procedure does include the abdominal region of the pregnant or potentially pregnant patient, the examination shall not be performed without approval from a diagnostic radiologist. Although it is the responsibility of the referring physician to determine pregnancy status, those operating diagnostic x-ray equipment will ask all patients of childbearing age whether or not they are pregnant and the date of their last menstrual period. This information is to be recorded on the study requisition prior to examination.  If the x-ray procedure does not include the abdomen or pelvis of the pregnant or potentially pregnant patient, the abdominal region should be shielded with at least 0.25mm lead equivalence & the examination performed without regards to pregnancy. 16. LAB SAFETY PROGRAM POLICY  GAIMS has an established Laboratory – Safety programme Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 181 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL Definition 1. Hazardous Material – A Hazardous material is any item or agent (biological, chemical, radiological and/or physical), which has the potential to cause harm to humans, animals or the environment, either by itself or through interaction with other factors. 2. Bio hazardous material /Bio hazardous Waste– Bio hazardous material is any material containing infectious material or potentially infectious substances such as blood. Of special concern are sharp objects such as needles, blades, glass pipettes that can cause injury 3. Occupational Exposure/Exposure Incident – Exposure incident means a specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious material that results from the performance of an employee’s duties 4. Parenteral contact – means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts and abrasions RISK FACTORS IN CLINICAL LABORATORY 1. Hospital Acquired Infection 2. Body fluid Spillage 3. Chemical Spillage 4. Fire due to explosive chemicals, LPG cylinders, chemical vapors, electrical short circuits, Accidental fire etc. PURPOSE Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 182 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  To ensure safety of Laboratory employees  To provide guideline about handling of Safety related issues in laboratory.  To minimize needle, stick injuries  To minimize major blood and body fluid spillage  To train all laboratory staff for handling of hazardous material (Chemical and Biological)  Train all laboratory person in handling, transportation and disposal of specimen  Train all laboratory staff in “Emergency Codes” SCOPE  Biological material exposure  Needle Stick  Body fluid exposure  Chemical spillage  Fire  Cross infection RESPONSIBILITY  Safety officer  Laboratory in Charge  Laboratory Staff PROCEDURE 1. General Personal Safety  Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in areas where specimens are handled. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 183 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Food and drink are not stored in refrigerators, freezers, cabinets, or on shelves, countertops, or bench tops where blood or other potentially infectious materials are stored or in other areas of possible contamination.  Long hair, ties, scarves and earrings should be secured.  Keep pens and pencils OUT OF YOUR MOUTH.  Appropriate Personal Protective Equipment (PPE) will be used where indicated: o Lab coats or disposable aprons should be worn in the lab to protect you and your clothing from contamination. Lab coats should not be worn outside the laboratory. o Lab footwear should consist of normal closed shoes to protect all areas of the foot from possible puncture from sharp objects and/or broken glass and from contamination from corrosive reagents and/or infectious materials. o Gloves should be worn for handling blood and body fluid specimens, touching the mucous membranes or non-intact skin of patients, touching items or surfaces soiled with blood or body fluid, and for performing venipuncture’s and other vascular access procedures. Cuts and abrasions should be kept bandaged in addition to wearing gloves when handling bio hazardous materials. o Protective eyewear and/or masks may need to be worn when contact with hazardous aerosols; caustic chemicals and/or reagents are anticipated.  NEVER MOUTH PIPETTE!! Mechanical pipetting devices must be used for pipetting all liquids.  Frequent hand washing is an important safety precaution, which should be practiced after contact with patients and laboratory specimens.  Hands are washed: o After completion of work and before leaving the laboratory. o After removing gloves. o Before eating, drinking, smoking, applying cosmetics, changing contact lenses or using lavatory facilities. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 184 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL o Before all other activities which entail hand contact with mucous membranes or breaks in the skin. o Immediately after accidental skin contact with blood or other potentially infectious materials. o Between patient contact and before invasive procedures.  Laboratory work surfaces must be disinfected daily and after a spill of blood or body fluid follow the Blood and Body Fluid Spillage Protocol.  Laboratory doors should be closed when work is in progress. Persons who are at increased risk of acquiring infection (children, pregnant women, immune deficient or immunosuppressed persons) should not be allowed inside the laboratory.  At the time of handling specimen consider each specimen as potentially bio hazardous material. Universal Precautions should be followed at all times.  After completing work switch off all necessary electricity connection and remove the LPG regulator and put the cap. Unattained open Flame is not allowed in Microbiology Laboratory.  All Laboratory workers must know the location and proper use of all laboratory safety equipment, including eyewash, fire extinguisher, and emergency telephone number. 2. EYE SAFETY  Know where the nearest eye wash station is located and how to operate it.  Eye goggles should be worn: o When working with certain caustic reagents and/or solvents, or concentrated acids and bases. o When performing procedures that are likely to generate droplets/aerosols of blood or other body fluid. o When working with reagents under pressure. o When working in close proximity to ultra-violet radiation (light). Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 185 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Wearing contact lenses in the laboratory is discouraged and requires extra precaution if worn. Gases and vapors can be concentrated under the lenses and cause permanent eye damage. Furthermore, in the event of a chemical splash into an eye, it is often nearly impossible to remove the contact lens to irrigate the eye because of involuntary spasm of the eyelid. Persons who must wear contact lenses should inform their supervisor to determine which procedures would require wearing no-vent goggles. 3. Safe Handling of Biologically Hazardous Material  You should handle all patient samples as potentially bio hazardous material.  This means UNIVERSAL PRECAUTIONS should be followed at all times  When working in the laboratory: o Wear protective clothing (lab coat, gloves. If you have a cut/abrasion, also wear a Band-Aid o Avoid spillage and aerosol formation. o Hands should be washed immediately and thoroughly if contaminated with blood or other body fluids. o Gloves should be removed before handling a telephone, computer keyboard, etc., and must NOT be worn outside the immediate work area. Hands should always be washed immediately after gloves are removed. o You should wash your hands after completing laboratory activities and before leaving the area. All protective clothing should be removed prior to leaving the lab.  All biohazard us material should be discarded in a biohazard bag to be autoclaved.  All counter and table tops should be disinfected with a proper disinfecting solution: o At the beginning of the day. o If you should spill a patient sample. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 186 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL o At the end of the day. 4. When performing venipuncture:  Wear clean gloves for each patient you draw.  Wash your hands whenever you change gloves.  Dispose of contaminated needle, syringe and test tubes in a proper bio hazardous receptacle.  When drawing blood from a patient in an isolation room. o All material taken into this room must remain in the room. o Label all tubes drawn from this patient with isolation stickers/ marking. 5. Proper handling of SHARPS:  Contaminated needles and other sharps are never broken, bent, recapped or re- sheathed by hand.  Used needles are not removed from disposable syringes.  Needles and sharps are disposed of in Sharp containers located near the point of use. 6. Chemical and gas safety  To provide a safe working environment, all personnel should be aware of potentially hazardous materials and the proper way of handling this material. Avoid unnecessary exposure to chemicals. Occupational Safety and Health Administration (OSHA) requires any necessary information in the form of MATERIAL SAFETY DATA SHEETS (MSDS) concerning the handling of hazardous materials to be available to all laboratory personnel, so that they may achieve & maintain safe working condition. Flammable (Red); Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 187 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL Instability (Yellow); Health (Blue) Special Notice (White) NFPA Chemical Hazard Sign 7. TOXIC AND CORROSIVE MATERIALS (ACIDS AND ALKALI):  To avoid dangerous splatter, ALWAYS ADD ACID TO WATER!  Toxic materials should be labeled with special tape when used in compounded reagents and stored in separate containers. These materials should be handled carefully and kept in the hood during preparation.  Acids and alkali should be carried by means of special protective carriers when transported.  Acid and alkali spills should be covered and neutralized by using the material from the ‘spill bucket’. All material, spill and compound, should be swept up and placed in a plastic bucket for proper disposal.  In case of spillage, wash all exposed human tissue (including eyes) generously with water and notify your supervisor for proper reporting of the incident. 8. CARCINOGENS  All laboratory chemicals identified as carcinogens must be labeled CARCINOGEN.  When working with these substances, protective clothing and gloves should be worn. 9. FLAMMABLE COMPOUNDS  All flammable reagents should be kept in the flammable storage facilities (closet or refrigerator) at all times when not in use.  Any solutions compounded from these reagents should be labeled as flammable. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 188 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Flammable substances should be handled in areas free of ignition sources.  Flammable substances should never be heated using an open flame.  Ventilation is one of the most effective ways to prevent accumulation of explosive levels of flammable vapors. An exhaust hood should be used whenever appreciable quantities of flammables are handled.  Flammable compounds should be placed in proper receptacle for disposal. 10. Ether Precautions (flammable compound)  These compounds tend to react with oxygen to form explosive peroxides. When ether containers are opened they are to be dated and all material remaining after six (6) months must be disposed of immediately.  Disposal of ether compounds is through the Hazardous Materials Office.  Ether compounds will be stored in an explosion-proof refrigerator. (boiling point of ether is approximately room temperature) 11. Compressed Gases  The storage of all compressed gases shall be in containers designed, constructed, tested and maintained in accordance with the U.S. Department of Transportation Specifications and Regulations.  In the laboratory, gas containers are to be limited to the number of containers in use at any time. Low pressure (LP) gases shall also be limited to the smallest size container.  Containers shall be securely strapped, chained or secured in a cylinder stand so they cannot fall.  Oxidizing gases should be separated from flammable gasses. 12. FIRE SAFETY  Know where all fire exits, fire extinguishers and fire alarms are located  Know how to properly operate appropriate fire alarms and fire safety equipment Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 189 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Portable fire extinguishers are classified by their ability to handle specific classes of fires:  FOR BURNING COMBUSTIBLE MATERIALS (wood, paper, clothing, trash). 13. ELECTRICAL SAFETY  The use of extension cords is prohibited.  All equipment must be properly grounded.  Never operate electrical equipment with fluid spillage in the immediate area or with wet hands.  Never use plugs with exposed or frayed wires.  If there are sparks or smoke or any unusual events occur, shut down the instrument and notify the manager or safety officer. Electrical equipment that is not working properly should not be used.  If a person is shocked by electricity, shut off the current or break contact with the live wire immediately. Do not touch the victim while he is in contact with the source of current unless you are completely insulated against shock. If the victim is unconscious, call 444 to report the incident and request assistance. General Procedures and Equipment  Cracked or chipped glassware should not be used.  Centrifuges should not be used without the covers completely closed.  When removing tops from evacuated test tubes, care must be taken to prevent aerosol formation. 1. ACCIDENT MANAGEMENT All types of Spills are classified on volume and manageable level  Minor Spill – A minor spill is a spill less than 30ml with/without fumes and/or vapors. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 190 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Major Spill – A major spill is a spill approximately more than 30ml with/without vapors and /or fumes  Manageable Spill – A manageable spill is a situation in which an individual, who is competent and has been trained, can safely contain, clean up and dispose of the spill without risk to him and others.  Unmanageable Spill - An unmanageable spill is a situation in which an individual is not competent, is untrained or is simply unable to safely contain clean up or dispose of the spill without risk to him and others. 2. Needle Stick Injury (NSI) Management/ Sharp injury Management/ splash of body fluid  Wash the area with running tap water and soap. Do not squeeze the finger or the body part.  Report immediately to the Medical officer, department seniors and Infection Control Nurse (ICN).  ICN inform all details to HIC Consultant and continue according to his/her instruction.  In case of splash on body part, clean the area with plenty of water and then informed to ICN.  Infected cloths, coat, shoes are changed immediately and send for disinfecting procedure.  The concerned staff shall be made aware of the program and SOP during the awareness training sessions of Infection Control Team. 3. SPILLS INSIDE A CENTRIFUGE  Shut centrifuge off and do not open the lid for 20 minutes to allow aerosols to settle.  Put on PPE. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 191 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Use a squeeze bottle to apply disinfectant to all contaminated surfaces within the chamber, taking care to minimize splashing.  Allow 20-minute contact period and then complete clean-up of the chamber. 4. DISPOSAL OF SPECIMEN  All specimens are discarded as per the biomedical waste management policy of the hospital.  Urine & stool samples are discarded every day.  All blood samples are discarded after three days.  All isolates & used media are decontaminated by autoclaving & then discarded into yellow bin.  All microbiology specimens are discarded after report dispatch Disposal Method 1. Specimen Bulb - Autoclave at 15 lbs for 30minutes and discarded. 2. Glass slide and Glass tubes - After examining slides (wet mount slides and stained slides) immerse in 1 % sodium hypochlorite solution and then wash as per Washing SOPs. Glass tubes are also immersed in 1% hypochlorite solution and washed as per Washing SOPs 3. Syringes and needles - After blood collection, the needle is discarded in the puncture proof sharp can and then the blood is emptied inside the vacutainer. Discard the remaining syringe in red bag. 4. Urine and other liquid specimen - After Autoclaving at 15lbs for 30minutes, containers are discarded in yellow bag 5. Processed culture Plate and Solid media Tubes - Autoclaved at 15lbs for 30 minutes and then media is discarded in yellow bag and plates and glass tubes are washed with soap and water solution. 6. Specimen Container in Microbiology laboratory - Autoclaved at 15lbs for 30 minutes and then discarded in yellow bag. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 192 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 7. Hand gloves are also discarded in Red Bag. 8. Micropipette tips are also immersed in 1 % sodium hypochlorite solution immediately. And after 30 minutes washed with soap solution. Dry in hot air oven if the tips are to be reused or discard in red bag. 9. Masks are discarded directly in yellow bag. 10.Expired reagents, Reagent Kits, Staining kits, antibiotic discs, serological sera’s are discarded as per product discard protocol written on same. If disposal protocol is s not available, then discard this in yellow bag. PREPROPHYLAXIS/VACCINATION TO STAFF  All staff is vaccinated for Hepatitis B Vaccination. TRAINING  Safety induction Training is mandatory for all laboratory staff before start work.  Monthly at least one Safety Training is carried out by the organization. RECORD  Training Sheets. 17. HAZARDOUS MATERIAL SAFETY POLICY  GAIMS is committed to protect patients, staff, visitors and property from hazardous material. Hazardous material will be identifying all over the hospital and follow standard procedure for sorting, storage, handling, transportation and disposal and managing spill of such material to provide fast and safe means of containment and cleanup of hazardous spills. Staff are educated for handing such material. Requisite regulatory requirements are taken care for radioactive Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 193 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL material. MSDS are displayed in various area where applicable. All the spills are managed by using HAZMAT kit as part of PPE. PURPOSE  To protect staff, visitor and property from hazardous material.  To educate the staff for handling, storage and distribution & transportation of hazardous material and managing spill. PROCEDURE  All department will identify the hazardous material in the department.  A list is prepared for all hazardous material. MSDS sheet is made available for all type of hazardous material. All hazardous material is stored, handled, labeled and transport according to MSDS.  Hazard identification and risk analysis are done for all type of hazardous material in the hospital in every six months.  Display of MSDS sheet at designated area.  Staff is trained in handing of such hazardous material.  Regular training program for management of hazardous material is conducted on regular basis.  Spillage management program is prepared for all type of hazardous material thought the organization.  Mock drill of spillage management is done as per the mock drill schedule. MANAGEMENT OF SPILLAGE OF HAZARDOUS MATERIAL Definition  Hazardous Materials are materials that contain ingredients that are harmful to health. These include materials that are lethal and non-lethal, corrosive, toxic, irritant, sensitizing, mutagenic, teratogenic or carcinogenic. The concentration Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 194 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL level of each ingredient in a mixture is taken into account in determining whether the mixture as a whole is determined to be hazardous. Objective:  In the event of spill, competent, prompt action is necessary for immediate clean up to reduce and eliminate the hazards present. RESPONSIBILITY  All staff and management of the Hospital.  Safety officer , HSK supervisor, HSK in charge and ICN are the members who are taking responsibility of creating awareness on handling hazardous materials, training the concerned people and also oversees the management of hazardous spills in case of an occurrence. Consequences of a Hazardous Chemical Spill  A major spill of a hazardous chemical can lead to a catastrophic event. The actual results depend on the chemical involved and the size of the spill. Among the possible results are: o Fire o Explosion o Reaction with another chemical or with air or water o Hazardous substances released in the air o Hazardous substances entering the water supply o Harm to individuals who come in contact with the spilled substance  The MSDS for the chemical will identify the hazards posed by the chemical and describe the proper action to take following a spill. Management of Spill Definition Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 195 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 1. Small spill: A small spill is defined as a spill less than 30 ml with no fumes/vapors. 2. Manageable spill: A manageable spill is a situation in which an individual, who is competent and has been trained, can safely contain, clean up and dispose of the spill without risk to him and others. Management of minor spill (for other hazardous materials):  Wear PPE (available in the HAZMAT kits).  Cordon the area of spill. Put precaution signboard.  Put alkaline solution for neutralizing the acidic spill and acidic solution to neutralize the alkaline spill.  Wait for five minutes (Contact Time).  Put the absorbent pads on the spill and wait for five minutes.  After this drag the folded absorbent pads from the margin towards inside and with the help of prongs discard all the pads in yellow bag.  After this mop the area with 1% Sodium Hypochlorite solution.  Strict Hand Washing to be done after the spill management.  Use appropriate personal protective equipment (PPE) like coat, gloves, face shield or goggles etc.  Use forceps or heavy gloves to pick up any broken glass and dispose of into sharps container. Managing a large spill: Definition of a Large Spill: A large spill is defined as a spill more than 30 ml and/or toxic fumes/vapors. Procedures for handling a Large Spill:  The same process as described above will be followed for major spills also. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 196 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Adequate PPE is available for handling the spill. The members will also ensure that proper precautions are taken for handling the incident and once cleared the materials used are discarded in yellow bags. When a Spill Occurs  Employees should be trained to notify a supervisor immediately whenever they notice a spiller leak—no matter how small. They should report: o Substance that is leaking or spilled o Location of the leak or spill o Size of the leak or spill o Rate off low  The supervisor will give instructions to the employee. He or she may say one of the following:  It is safe to clean it up yourself (in the case of a very small spill) Spill Kits/Hazmat Kit  Spill kits should be provided and be readily accessible in relevant locations at the workplace. It is important that spill kits are tailored to meet the specific needs of each location where chemicals are stored. A good spill kit should include the following items: o Universal Spill Absorbent: Tissue paper, all-purpose absorbent is good for most chemical spills including solvents, bases and acids (with the exception of hydrofluoric acid) o Acid Spill Neutralizer: sodium bicarbonate, sodium carbonate or calcium carbonate o Alkali (Base) Neutralizer: sodium bisulphate, boric acid or oxalic acid o Solvents/Organic Liquid Absorbent: Inert absorbents such as vermiculite, clay, sand. PROCESS TO SPILL MANAGEMENT Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 197 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL Neutralizing Acid spills  Contain the liquid first. Acid spills can be neutralized with sodium bicarbonate, sodium  Sprinkle powder over the spill slowly, carbonate, or calcium carbonate. starting from the outside. Neutralizing Alkali spills  Acid is neutralized if effervescence Alkali spills can be neutralized with ceases in the presence of excess sodium bisulphite, boric acid or oxalic bicarbonate. acid. Many alkalis can result in serious burns to skin and eyes, so proceed  Avoid breathing in the fine powder with extreme caution. and the gas evolved (carbon dioxide).  Ensure that there is adequate ventilation  Eliminate all sources of ignition as neutralization of alkali can produce heat. This includes removing all combustible materials that are close to the spill.  Right any overturned containers where the spill originated or stop leak at source only if safe to do so.  Avoid handling fluid even with nitrile gloves.  Liberally apply the alkali neutralizer around the perimeter of the spill to limit the extent of spreading and continue sprinkling it towards the center. This should be done until the entire spills  covered and there is no free liquid or liquid migration. The neutralization reactions should occur 1-5 minutes after application.  Stand clear as splattering of reaction products might occur. The Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 198 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL Solid Spills heat and vigor of the reaction will depend on the type and Liquid Spills (other than flammable concentration of the alkali being liquids) neutralized.  The alkali will be neutralized when the reaction has stopped and there is no more fizzing from the liquid.  Caution: Neutralized alkalis may produce heat. Wait until mixtures have cooled before sweeping up spilled material.  Avoid handling spilled material until absorption is complete.  Use non-metal, non-sparking tools such as a broom, scoop or scraper to clean-up neutralized spill. Take care not to overly disturb the neutralized spill.  Sweep solid material into a plastic dust pan and place in a sealed container. Care should be taken so as to minimize dust or the contaminated powder becoming airborne. Use of a dust masks inadvisable.  Wipe the area down with a wet paper towel and dispose of the used paper towel in a strong polyethylene bag. Seal the bag and ensure all waste is collected for proper disposal.  Spread absorbent pads over the spill starting with the edges first. This will help to contain the spill to a Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 199 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL Flammable Liquid Spills smaller area. Enough pads should be Personal Protective Equipment (PPE) used to completely cover the liquid.  Pick up the contaminated pads with tongs or a scoop and place into a chemical resistant bin.  If the chemical is water soluble, wipe the area down with a paper towel, followed by wet mop and detergent.  Appropriately dispose of used paper towel.  Control all sources of ignition- turn off all electrical and heat generating equipment.  Spread the absorbent pads over the spill starting from the edge. Allow the pads to completely soak up the liquid.  Pick up the contaminated pads with tongs or scoop and minimize direct contact.  Place the waste into the chemical resistant bin.  Wipe the area down with a paper towel and copious amounts of water.  Dispose of paper towel into a chemical resistant bin and seal the bin so it is airtight.  Never use wet vacuum cleaner on flammable solvents. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 200 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Hand protection: chemical resistant safety gloves (i.e. disposable neoprene or nitrile gloves)  Eye protection: Safety goggles  Body protection: Laboratory coat /Corrosive apron  Foot protection: Enclosed footwear/ shoe covers  Respiratory protection: Dust mask/Respirator (All personnel must be properly fit tested before using a respirator) Clean Up Material  Dry mobs, plastic dustpan and square mouth shovel to sweep up the absorbent material  Paper towels for minor spills  Plastic tongs/ scoops/forceps to pick up contaminated absorbent material  A chemical resistant bin with a close fitting lid to hold the volume of spill and absorbent residues prior to disposal  Heavy duty plastic bags for wrapping contaminated PPE. Spill Response  Dangerous goods or hazardous substance spills should be cleaned up immediately, taking appropriate precautions for the hazards of the material. BLOOD AND BODY FLUID SPILL MANAGEMENT Procedure:  In case of spills of blood or body fluids, the staff shall report immediately to the Link nurse of the ward or area.  The record of the incident shall be maintained in a Register in each Ward.  The Housekeeping staff shall immediately manage the spill, according to the protocol. Signatory Prepared by Reviewed by Approved by Name Designation Signature