3.2.12 Handling hazardous substances

1 Aim and purpose

Hazardous substances are handled in the hospital. The necessary protective measures are described taking into account the Hazardous Substances Ordinance and the Technical Rules for Hazardous Substances (TRGS).

2 Application

In all areas of the hospital where hazardous substances are handled.
Radiation substances and biological agents are also classified as hazardous substances, but are not covered by these procedural instructions. The handling of ionising substances is described in the procedural instruction on radiation protection (VA 3.2.06), the handling of biological substances in the procedural instruction VA 3.3.09 "Hygiene measures in general".

3 Description

3.1 Basic concerns of the Hazardous Substances Ordinance

The provisions of the Hazardous Substances Ordinance serve to protect employees and other persons, e.g. patients and visitors, against actual or potential risks to their health and safety from the effects of hazardous substances or mixtures of substances.

3.2 Risk assessment

The Managing Director of Hospital GmbH is responsible for the risk assessment. He has delegated this task to the Deputy Administrative Director.
The Deputy Administrative Director has commissioned a risk and exposure analysis for St Catherine's Hospital together with the occupational safety specialist. The report records all hazardous substances, their properties and the risks to the health and safety of hospital employees when handling them and assesses the hazards in terms of substances and activities.
The safety data sheets form the basis for assessing the hazards. They can be used to determine the protection level to be assigned to the respective activity. For the handling of biological substances, e.g. bacteria, viruses, fungi, the risk assessment has been supplemented by the risk assessment in accordance with the Biological Substances Ordinance (see VA 3.2.13 "Risk assessment"). The division/department heads are responsible in their respective areas in particular for ensuring that

- the risk assessments are carried out and documented

- Measures are taken to ensure the safety and

to ensure health protection and to eliminate or minimise hazards.

These responsibilities are documented in the respective job/task descriptions.

3.3 Operating instructions

Based on the risk assessment, operating instructions must be drawn up for employees containing information on the hazardous substances handled at the workplaces in the area (e.g. designation, classification, labelling), health and safety hazards, appropriate protective measures (e.g. hygiene regulations, measures to reduce exposure, e.g. decanting antibiotics in a closed system, protective equipment, protective clothing). It must also be ensured that employees have access to safety data sheets at all times and are instructed in methods and procedures to protect themselves from hazards caused by hazardous substances in the workplace.
The area/department manager is responsible for creating the operating instructions. The operating instructions are filed in the hazardous substances folder of the respective area.

3.4 Instruction, occupational health and toxicological advice

Before taking up employment and then at least once a year, employees must be instructed verbally (by whom?) on the basis of the operating instructions about any hazards that arise and the corresponding protective measures (VA 3.2.02). The content and time of the instruction must be recorded in writing and signed by the instructed person.
The area/department manager or, in the care sector, the ward manager is responsible for carrying out the instructions. The area/department managers must also ensure that all employees who carry out activities involving hazardous substances receive general occupational health and toxicological advice, in which they are made aware of the particular health risks involved in handling certain hazardous substances, e.g. cytostatics, and of the possibility of occupational medical examinations. This counselling should take place as part of the instructions.

4 Documentation

List of hazardous substances
Risk assessment
Effectiveness tests
Operating instructions
Instructions

5 Resources

Time requirements of the managers addressed
Time requirements of the authorised representatives involved
Office equipment pro rata
Space required for documentation

6 Responsibility, qualification

Employees with expertise in occupational health and safety, employees with expertise in the hospital's work processes

7 Notes and comments

8 Applicable documents

8.1 Literature

Hazardous Substances Ordinance
Technical rules for hazardous substances TRGS 400, 440, 500, 525, 555

8.2 Terms

Creation date: January 2008 Author: Voss/ S. Böhm Modification (reduction) August 2008 Dr U. Paschen

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