Safety Fact Sheet 2018-01-03T22:21:55+00:00

Safety Fact Sheet

Safety Compliance Requirements

  • Facility safety can be confirmed through a certificate of occupancy and/or facility license that indicates Fire Marshal inspection.
  • OSHA and state regulations should minimally include access to safety data sheets for hazardous materials, availability of personal protective equipment (e.g. googles, gloves) and eyewash stations when required. (Reference Standard K-2)
  • The facility must have a policy that addresses hazardous materials used in the facility. This policy is to include proper disposal for all hazardous materials according to the manufacturer and applicable lab regulations. (e.g. sharps containers, waste bins.)

Safety Analysis Requirements

  • Annually a safety analysis must be performed. This risk analysis includes a walkthrough of the facility documenting facility safety risks that may be hazardous to the patient. (Reference Standard K-4 for examples.) Additionally, the policy needs to reflect efforts to mitigate any risks identified during the safety risk analysis facility walkthrough. This is to be reviewed by the Facility Director.
  • The facilities “Significant Adverse Events” policy needs to indicate how to perform investigation of all significant events. Reference Standard K-5 for, minimally, all significant events that must be included in the “Significant Adverse Events” policy.
  • The facility must have a policy & procedure that addresses the investigation, discovery and mitigation for adverse events. This needs to include a root cause analysis which is to be reviewed by the Facility Director.
    • It is acceptable to submit a policy addressing the events or the tool used to track and record the investigation process.
  • The facility needs to have a policy that minimizes the risk for assault or allegations of inappropriate behavior during the testing timeframe. The policy should consider continuous video monitoring throughout the patient encounter when working alone or the use of a chaperone when two technologists are working at the same time.

Applicable Accreditation Standards

The physical facility used by the facility complies with all required standards, regulations and codes for construction, fire safety and building codes applicable in the jurisdiction where the facility is located and appropriate to the facility type.

The facility must demonstrate compliance with all applicable OSHA requirements as well as appropriate state authorities. This includes but is not limited to: Access to safety data sheets for hazardous materials; Availability of personal protective equipment; and Eyewash stations when required.

The Facility disposes of all hazardous materials in compliance with the manufacturer’s recommendation and applicable laws and regulations
The facility must complete and document an analysis of safety risks to patients related to the procedures performed by the facility. This analysis must be updated periodically and no less frequently than every five years. The risk analysis must be reviewed, and the review documented, on an annual basis. Examples of risks may include: patient falls after receiving hypnotics, slippery shower surfaces, and uneven ground to/from the facility. The facility must implement policies to mitigate risks identified.
Within the facility, the facility director must document the occurrence of significant adverse events for its patient population. At a minimum, the following events must be considered significant adverse events, (1) Patient or staff death; (2) Permanent loss of function or of a body part by a patient or staff; (3) An event that leads to the hospitalization of a patient or staff; (4) An event that requires activation of an emergency medical response; (5) An event that requires activation of an emergency medical response; (6) Sexual or physical assault of a patient or staff or allegations thereof; (7) Release of a minor or a patient lacking capacity or competency to an unauthorized individual; (8) Elopement of a patient; (9) Complications arising from the effects of hypnotics used for the purpose of sleep testing; (10) Any event required by the applicable jurisdiction to be reported to a government agency.
The facility must create a policy and procedure for performing a root cause analysis of any significant adverse events. Consistent with the policy, the facility must conduct an investigation of all significant adverse events that occur.
Recognizing the unique vulnerability of patients and staff in a sleep testing environment, facilities must have explicit policies and procedures to minimize the risk for assault or allegations of inappropriate behavior during the testing timeframe. This may include the use of continuous video monitoring throughout the patient encounter in the lab and/or specific training for the use of chaperones during interactions between patients and staff.

Key Things to Keep In Mind

  • Comprehensive hospital wide safety, risk management and OSHA policies must include the specifics as they relate to the sleep facility.
  • Hospital wide risk analysis policies must include an indication that the inspection is sleep facility specific.
  • A hospital wide Risk Management Policy must include the events specific to a sleep facility.
    • There is no need for the hospital to revise their comprehensive policy; an addendum from the facility will show compliance.
  • The facility must identify high-risk areas that would require methods to minimize potential risks. Include in the policy if the facility has identified high risk areas that would require methods to minimize potential risks. For example: Video monitoring in the hallways and waiting room. For facilities with multiple beds, there could be 2 technologist present during patient interactions.
  • Falls risk assessment on each patient does not meet compliance to Standard K-4. A facility walk through of hazardous risk analysis is required.
  • Policies are to reflect maintenance and access of safety data sheets for the sleep facility staff.