The requirement was NOT MET as evidenced by the following:
Finding #1
Hospital should evaluate and clarify the procedure on transporting and streaming diesel in to a generator diesel fuel tank. Pump for diesel streaming is not suitable for dangerous liquids and no grounding is put in place while streaming is performed.
Finding #2
While PPE for working with chemicals is listed there is opportunity for improvement to list the exact required PPE rather just saying “gloves”. Specific PPE should be listed for individual dangerous substance.
Finding #3
In technical gasses storage room they have two tanks of 50l of CO2 each. The policy in case of CO2 leakage should be revised. As established through staff interview they would use half face filter mask in case of leakage.
Finding #4
There is no spill kit in place in generator room, there are two diesel tanks installed of over 1000l each. Appropriate spill containment material and adequate quantity should be evaluated.
Finding #5
MSDS polity is in place and it is being updated – evidence was presented. MSDS included in Folder are mostly in English language which is not understood by the hospital staff. Since normally the MSDS in Thai language would not be provided by the supplier they will try to find a different way or translate them by them self – which might be a problem with translator of understanding the HAZMAT system.
Finding #6
Hospital has no policy regarding spill trays under dangerous chemicals, like it was observed in Waste H2O treatment facility and on wards where chemicals are stored.