Hospital Safety Committee

Netaji Subhas Medical College and Hospital, Amhara, Bihta, Bihar

(Established by Sitwanto Devi Mahila Kalyan Sansthan)

1: Name and Status

1.1. This Committee shall be called the "Hospital Safety Committee" (hereinafter referred to as "the Committee") of Netaji Subhas Medical College and Hospital, Amhara, Bihta, Bihar.

1.2. The Committee is established in accordance with the National Medical Commission regulations, National Accreditation Board for Hospitals & Healthcare Providers (NABH) standards, and applicable safety regulations to ensure a safe environment for patients, visitors, employees, and all stakeholders.

1.3. The Committee shall function as a multidisciplinary body responsible for establishing, implementing, and maintaining a comprehensive patient safety and facility safety program throughout the hospital premises.

2: Objectives and Functions

2.1. Objectives:

To establish and maintain a progressive patient safety program to provide safe environment to patients, visitors, and employees.

To create and promote a culture of safety throughout the hospital through continuous monitoring, education, and training.

To identify, assess, and mitigate safety risks to patients, staff, and visitors in a proactive manner.

To ensure compliance with national patient safety goals, international patient safety standards, and NABH accreditation requirements.

To monitor and improve environmental safety, facility safety, equipment safety, fire safety, and emergency preparedness.

To implement systematic processes for identifying, reporting, analyzing, and responding to safety incidents and near misses.

To ensure safe use and management of hazardous materials, medical gases, radiation sources, and biomedical waste.

2.2. Functions and Powers:

The Committee shall have the following functions and powers:

To propose, develop, and implement safety policies, procedures, and guidelines for the hospital and recommend them to the Principal and Managing Committee for approval.

To receive, review, and investigate reports of safety incidents, adverse events, near misses, sentinel events, and patient safety concerns from all sources.

To conduct proactive risk assessment using tools such as Hazard Identification and Risk Assessment (HIRA), Failure Mode and Effects Analysis (FMEA), and facility safety rounds.

To conduct comprehensive facility safety inspections of the entire campus - twice a year in patient care areas and once a year in non-patient care areas - to identify and map potential safety hazards.

To monitor and analyze safety-related key performance indicators, incident trends, and sentinel events to identify patterns and implement corrective actions.

To conduct root cause analysis (RCA) for major safety-related incidents and ensure implementation of appropriate corrective and preventive actions (CAPA).

To review and update the list of sentinel events periodically based on emerging evidence, international studies, and guidance from organizations like NABH, Joint Commission, and WHO.

To ensure implementation of National Patient Safety Goals and International Patient Safety Goals including proper patient identification, effective communication, medication safety, infection prevention, fall prevention, and surgical safety.

To oversee environment and facility safety aspects including building safety, electrical safety, fire safety, medical gas safety, water quality, ventilation, lighting, signage, accessibility for differently-abled persons, and general infrastructure safety.

To monitor emergency management preparedness including fire drills (Code Red), cardiac arrest response (Code Blue), infant abduction prevention (Code Pink), bomb threat response, disaster management, and mass casualty management.

To ensure safe storage, handling, labeling, and disposal of hazardous materials including chemicals, flammable substances, radioactive materials, cytotoxic drugs, medical gases, and biomedical waste.

To oversee equipment safety including preventive maintenance, calibration, user training, safe operation protocols, and timely repair/replacement of medical devices and equipment.

To monitor radiation safety practices across imaging services (X-ray, CT scan, MRI, Nuclear Medicine) ensuring ALARA principle (As Low As Reasonably Achievable), proper shielding, pregnancy screening, and adherence to AERB guidelines.

To ensure clinical safety measures including medication management, high-risk medication protocols, look-alike-sound-alike drug management, prevention of wrong-site/wrong-patient surgery, blood transfusion safety, and clinical handover protocols (SBAR).

To promote patient fall prevention program including fall risk assessment, use of bed rails, grab bars, non-slip flooring, adequate lighting, and staff education.

To ensure safe practices in operation theaters, intensive care units, blood banks, laboratories, and other high-risk clinical areas.

To monitor infection control practices in coordination with Hospital Infection Control Committee including hand hygiene, sterilization, disinfection, isolation precautions, and outbreak management.

To organize and conduct safety training programs, mock drills, orientation sessions, and continuing education programs for all categories of staff.

To display patient education materials and signage throughout the hospital to educate patients and families about their role in ensuring safety.

To maintain comprehensive records of all safety inspections, incident reports, investigation reports, root cause analyses, CAPA implementation, training programs, and committee meetings.

To coordinate with other hospital committees including Infection Control Committee, Disciplinary Committee, Quality Improvement Committee, Emergency Management Committee, and Medical Equipment Committee.

To submit quarterly progress reports to the Principal and annual comprehensive safety reports to the Managing Committee.

To ensure compliance with all applicable safety laws, regulations, and accreditation standards including Fire Safety Act, Atomic Energy Regulatory Board (AERB) guidelines, Biomedical Waste Management Rules, and NABH standards.

3: Composition and Membership

3.1. Constitution of the Committee:

The Hospital Safety Committee shall consist of the following members representing diverse departments and expertise:

Table 1: Composition of Hospital Safety Committee

3.2. Ex-Officio Members:

The Principal cum Dean and Medical Superintendent shall be ex-officio Chairperson and Vice-Chairperson respectively by virtue of their positions.

3.3. Patient Safety Officer:

The Principal shall nominate a senior faculty member (preferably Associate Professor or above from clinical department) as Patient Safety Officer who shall serve as Convener of the Committee and shall report directly to the Principal on safety matters.

3.4. Multidisciplinary Representation:

The Committee ensures representation from clinical services (medicine, surgery, anesthesiology), diagnostic services (laboratory, radiology), nursing services, facility management, support services, and quality assurance to provide comprehensive safety oversight.

3.5. Special Invitees:

The Chairperson may invite external experts, consultants, representatives from fire department, police, civil administration, or other relevant authorities as special invitees without voting rights.

4: Term of Office

4.1. The term of office for all nominated members shall be three years from the date of their appointment/nomination, except for ex-officio members who shall continue as members by virtue of holding their respective positions.

4.2. Members may be re-nominated for subsequent terms.

4.3. A member ceasing to hold the position by virtue of which they were appointed shall automatically cease to be a member of the Committee.

4.4. The Principal may nominate substitute members in case of death, retirement, resignation, or prolonged absence of any member.

5: Chairperson, Vice-Chairperson, and Convener

5.1. Chairperson:

The Principal/Dean shall be the Chairperson of the Committee.

The Chairperson shall have overall supervision and control of the Committee's functioning and safety program implementation.

The Chairperson shall approve major safety policies, investigation reports, and budgetary provisions for safety initiatives.

In the absence of the Chairperson, the Vice-Chairperson shall preside over meetings.

5.2. Vice-Chairperson:

The Medical Superintendent shall be the Vice-Chairperson of the Committee.

The Vice-Chairperson shall assist the Chairperson in discharge of duties and preside over meetings in the absence of the Chairperson.

The Vice-Chairperson shall oversee day-to-day implementation of safety measures in the hospital.

5.3. Convener (Patient Safety Officer):

The Patient Safety Officer nominated by the Principal shall serve as Convener.

The Convener shall report directly to the Principal on all patient safety and facility safety matters.

The Convener shall be responsible for:

Coordinating all activities of the Hospital Safety Committee.

Convening meetings in consultation with the Chairperson.

Receiving and documenting all safety incident reports and near-miss reports.

Constituting sub-committees or investigation teams for specific safety incidents.

Conducting facility safety inspections and safety rounds.

Organizing root cause analysis and FMEA studies.

Preparing and circulating agenda, investigation reports, and minutes.

Maintaining comprehensive records of all safety-related activities.

Coordinating implementation of corrective and preventive actions.

Organizing safety training programs, mock drills, and awareness campaigns.

Preparing quarterly and annual safety reports.

Acting as liaison with external safety authorities and accreditation bodies.

Handling correspondence on behalf of the Committee.

6: Scope of Safety Oversight

6.1. Patient Safety:

Implementation of National and International Patient Safety Goals

Patient identification using two identifiers

Prevention of medication errors and adverse drug events

High-risk medication management (anticoagulants, insulin, narcotics, chemotherapy)

Look-alike-sound-alike (LASA) drug safety

Prevention of wrong-site, wrong-patient, and wrong-procedure surgery

Surgical safety checklist compliance

Prevention of patient falls

Prevention of pressure ulcers

Prevention of hospital-acquired infections

Blood transfusion safety

Clinical handover safety (SBAR communication)

Prevention of retained surgical instruments and gauze

6.2. Environmental and Facility Safety:

Building structural safety and maintenance

Electrical safety including wiring, grounding, backup power supply

Fire safety including fire detection systems, fire extinguishers, fire exits, emergency lighting

Medical gas pipeline safety (oxygen, nitrous oxide, medical air, vacuum)

Water quality and potable water testing

Adequate lighting in all patient care and non-patient care areas

Proper ventilation and air conditioning

Floor safety including prevention of slippery floors, uneven surfaces, holes, and obstacles

Furniture placement to prevent falls

Accessibility for differently-abled persons including ramps, grab bars, special toilets, wheelchairs

Signage (internal and external wayfinding)

Elevator safety including regular inspection and maintenance

Roof and terrace safety including boundary grills

Prevention of seepage and water leakage

Noise and vibration control during construction/maintenance activities

6.3. Equipment Safety:

Preventive maintenance of all medical equipment

Calibration and performance verification

Connection of critical equipment to uninterrupted power supply (UPS)

Safe operation protocols and user training

Equipment risk assessment (e.g., laser, cautery, surgical instruments)

Timely repair and replacement of faulty equipment

Proper labeling and inventory management

6.4. Radiation Safety:

ALARA principle implementation (As Low As Reasonably Achievable)

Appropriate screening before imaging (pregnancy screening, metallic implant screening for MRI)

Use of shielding for patients and attendants

Optimization of CT scan protocols for lowest appropriate dose

Compliance with Atomic Energy Regulatory Board (AERB) guidelines

Personal dosimetry monitoring for radiation workers

Prevention of radiation source leakage

6.5. Hazardous Material Safety:

Safe storage, handling, and labeling of chemicals and hazardous materials

Maintenance of Material Safety Data Sheets (MSDS)

Management of flammable and explosive materials

Cytotoxic drug handling protocols

Radioactive material management

Medical gas cylinder storage and handling

Biomedical waste segregation, storage, and disposal

Chemical spillage management protocols

6.6. Laboratory Safety:

Biosafety practices and personal protective equipment (PPE)

Chemical safety in laboratories

Safe handling of blood and body fluids

Prevention of needle-stick injuries (one needle, one syringe, one time policy)

Laboratory equipment safety

Disinfection and sterilization practices

6.7. Emergency Preparedness:

Fire emergency response (Code Red)

Cardiac arrest response (Code Blue)

Obstetric and neonatal emergency (Code Pink)

Security threat and violent patient management

Bomb threat response

Natural disaster and mass casualty management

Hospital evacuation plans

Regular conduct of mock drills

6.8. Security and Access Control:

Restricted entry into Operation Theaters, ICUs, and other sensitive areas

CCTV surveillance coverage

Visitor management

Prevention of infant abduction

Protection of patients, staff, and property

6.9. Staff Safety:

Occupational health and safety

Prevention of exposure to infectious diseases

Immunization of healthcare workers

Prevention of needle-stick and sharp injuries

Ergonomic workplace design

Prevention of violence against healthcare workers

7: Meetings

7.1. Frequency of Meetings:

The Committee shall meet once every two months (minimum six meetings per year). Additional emergency meetings may be convened as required.

7.2. Notice of Meetings:

The Convener shall convene meetings with at least 2 days' prior notice to all members.

The notice shall include the date, time, venue, and agenda for the meeting.

In case of emergency, meetings may be convened by oral or telephone communication with justification for the emergency meeting.

7.3. Quorum:

The quorum for meetings shall be 50% of the total members or 15 members, whichever is higher.

The Chairperson or Vice-Chairperson must be present for the meeting to proceed.

If quorum is not present within 30 minutes of the scheduled time, the meeting shall stand adjourned.

7.4. Conduct of Meetings:

Meetings shall be conducted in accordance with established rules of procedure.

All members shall have the right to participate in discussions.

Special invitees may participate in discussions but shall not have voting rights.

7.5. Decisions and Resolutions:

Decisions shall ordinarily be taken by consensus after thorough discussion.

Where consensus cannot be reached, matters shall be decided by simple majority vote of members present.

In case of a tie, the Chairperson shall have a casting vote.

Trial studies may be conducted if needed before making final decisions on safety interventions.

7.6. Minutes:

The Convener shall prepare minutes of each meeting within 3 days of the meeting.

Minutes shall be submitted to the Chairperson for approval within 3 days.

After approval, minutes shall be circulated to all members within 2 days for implementation.

A copy of agenda and minutes shall be submitted to the Quality Manager and Principal.

Confirmed minutes shall be maintained in a permanent record book.

8: Safety Incident Reporting and Investigation

8.1. Incident Reporting System:

The Committee shall establish and maintain a systematic incident reporting system for all safety-related events.

All staff members shall be encouraged to report safety incidents, near misses, adverse events, and potential hazards without fear of punitive action.

Reporting shall be made to the Convener (Patient Safety Officer) through designated reporting forms or electronic system.

The Committee shall promote a culture of "Do No Harm" and encourage reporting of near misses to prevent actual harm.

8.2. Categories of Reportable Incidents:

No harm incidents (near misses)

Adverse events causing temporary harm

Adverse events causing permanent harm

Sentinel events (unexpected events resulting in death or serious injury)

Equipment failures and malfunctions

Facility and infrastructure hazards

Medication errors

Patient falls

Wrong-site/wrong-patient incidents

Surgical complications

Hospital-acquired infections

Fire incidents and safety breaches

Any other safety concerns

8.3. Investigation Process:

Upon receipt of incident report, the Convener shall conduct preliminary assessment to determine severity and required level of investigation.

Minor incidents may be addressed through departmental intervention and corrective action.

Major incidents and sentinel events shall undergo detailed root cause analysis (RCA) conducted by an investigation team constituted by the Committee.

Investigation team shall collect evidence, interview witnesses, review documentation, and analyze contributing factors.

Root cause analysis shall identify system failures, human factors, and environmental factors contributing to the incident.

Investigation report shall include findings, root causes, and recommendations for corrective and preventive actions (CAPA).

8.4. Corrective and Preventive Actions:

The Committee shall review investigation reports and approve recommended CAPA.

CAPA shall be implemented with defined timelines and responsible persons.

The Convener shall monitor implementation of CAPA and verify effectiveness.

Follow-up review shall be conducted to assess whether implemented actions have prevented recurrence.

8.5. Confidentiality:

All incident reports, investigation proceedings, and related documents shall be maintained in strict confidentiality.

Identity of reporting persons shall be protected to encourage open reporting culture.

Information shall be used solely for quality improvement and safety enhancement purposes.

9: Safety Inspections and Audits

9.1. Facility Safety Inspections:

The Committee shall conduct comprehensive facility safety inspections as per the following schedule:

Patient care areas (wards, ICUs, OTs, emergency, OPD): Twice per year

Non-patient care areas (administrative offices, stores, workshops): Once per year

Safety inspection teams shall consist of members from relevant disciplines based on the area being inspected.

Inspections shall use standardized checklists covering all aspects of environmental safety, facility safety, equipment safety, and fire safety.

Documented findings with photographs shall be submitted to the Convener within 7 days of inspection.

The Convener shall prepare comprehensive inspection reports with recommendations and submit to the Committee and Principal.

9.2. Safety Rounds:

The Convener and designated members shall conduct regular safety rounds in various departments on a rotational basis.

Safety rounds shall focus on proactive identification of hazards, observation of safety practices, and interaction with staff regarding safety concerns.

Findings from safety rounds shall be documented and brought to the attention of concerned departments and the Committee.

9.3. Safety Audits:

Periodic safety audits shall be conducted for specific high-risk areas and processes:

Medication safety audit

Surgical safety checklist compliance audit

Hand hygiene compliance audit

Fire safety equipment audit

Medical gas pipeline audit

Biomedical equipment safety audit

Radiation safety audit

Infection control practices audit

Audit findings shall be analyzed for compliance levels and areas of improvement.

Non-compliance issues shall be addressed through CAPA with timelines.

10: Training and Education

10.1. Safety Orientation:

All new employees (faculty, residents, nurses, technicians, support staff) shall undergo mandatory safety orientation within one week of joining.

Orientation shall cover hospital safety policies, incident reporting, fire safety, infection control, patient safety goals, and emergency response procedures.

10.2. Continuing Education:

The Committee shall organize regular training programs, workshops, and awareness sessions on various safety topics.

Annual refresher training shall be conducted for all staff on fire safety, emergency response, and patient safety.

Specialized training shall be provided for high-risk areas such as OT staff, ICU staff, blood bank staff, and laboratory personnel.

10.3. Mock Drills:

The Committee shall organize and conduct mock drills for various emergency scenarios:

Fire drill (Code Red) - Quarterly

Cardiac arrest response drill (Code Blue) - Quarterly

Infant abduction drill (Code Pink) - Biannually

Disaster management drill - Annually

Bomb threat drill - Annually

Mock drills shall be conducted at different times and in different areas to ensure comprehensive preparedness.

Debriefing sessions shall be held after each mock drill to identify gaps and areas for improvement.

Records of all mock drills shall be maintained with attendance, observations, and action points.

10.4. Patient and Family Education:

Patient education materials on safety topics shall be displayed prominently throughout the hospital.

Educational materials shall cover topics such as fall prevention, hand hygiene, infection prevention, medication safety, and patient rights.

Audio-visual materials and posters shall be used for effective communication.

11: Sub-Committees

11.1. The Committee may constitute the following sub-committees for specific functions:

Fire Safety Sub-Committee

Radiation Safety Sub-Committee

Clinical Safety Sub-Committee

Facility and Equipment Safety Sub-Committee

Emergency Preparedness Sub-Committee

Hazardous Material Management Sub-Committee

11.2. Each sub-committee shall consist of members nominated by the Chairperson from among the Committee members and other relevant experts.

11.3. Sub-committees shall meet as required and report to the main Committee.

11.4. Recommendations of sub-committees shall be subject to approval by the main Committee.

12: Coordination with Other Committees

12.1. The Hospital Safety Committee shall coordinate with the following committees:

Hospital Infection Control Committee (for infection prevention and control)

Quality Improvement Committee (for quality and safety integration)

Pharmacy and Therapeutics Committee (for medication safety)

Blood Transfusion Committee (for transfusion safety)

Medical Equipment Committee (for equipment safety and maintenance)

Biomedical Waste Management Committee (for waste disposal safety)

Disaster Management Committee (for emergency preparedness)

Radiation Safety Committee (for radiation protection)

12.2. Regular joint meetings may be held with related committees to ensure integrated approach to safety.

13: Reporting and Accountability

13.1. Quarterly Reports:

The Committee shall submit quarterly progress reports to the Principal and Managing Committee covering:

Summary of safety incidents reported and investigated

Root cause analysis findings and CAPA implementation status

Safety inspection and audit findings

Safety training programs conducted

Mock drills performed

Key safety performance indicators and trends

Challenges faced and proposed solutions

13.2. Annual Report:

The Committee shall prepare and submit a comprehensive annual report detailing:

Overall safety performance metrics

Analysis of incident trends and sentinel events

Facility safety inspection outcomes

Safety improvement initiatives implemented

Compliance with safety standards and accreditation requirements

Training programs and mock drills conducted

Budget utilization for safety initiatives

Future plans and recommendations

13.3. Accountability:

The Committee shall be accountable to the Governing Body for all its decisions, actions, and safety outcomes.

The Patient Safety Officer (Convener) shall report directly to the Principal on safety matters requiring immediate attention.

14: Record Keeping

14.1. Records to be Maintained:

The Convener shall maintain the following records:

List and details of all Committee members

Terms of Reference of the Committee

Copy of all agendas and minutes of all meetings

Attendance sheets of meetings

All safety incident reports and investigation reports

Root cause analysis documentation

CAPA implementation records

Safety inspection reports with photographs

Audit reports

Training program records and attendance

Mock drill records and debriefing reports

Correspondence with Committee members and external authorities

Copy of any studies conducted for the Committee

Safety performance indicator data and trend analysis

14.2. Retention Period:

All records shall be maintained for a minimum period of 5 years or as required by applicable regulations.

14.3. Confidentiality:

All records shall be maintained in strict confidentiality and shall not be disclosed to unauthorized persons except as required by law or regulatory authorities.

15: Amendments

15.1. This Constitution may be amended by a resolution passed by two-thirds majority of the total members of the Committee.

15.2. Proposed amendments shall be circulated to all members at least 14 days prior to the meeting where they are to be considered.

15.3. All amendments shall be subject to approval by the Managing Committee of Sitwanto Devi Mahila Kalyan Sansthan and must be in conformity with NMC guidelines, NABH standards, and applicable safety laws.

16: Interpretation

16.1. In case of any doubt or dispute regarding the interpretation of any provision of this Constitution, the decision of the Chairperson shall be final, subject to the approval of the Managing Body.

16.2. Matters not covered by this Constitution shall be governed by applicable provisions of the NMC Act, NABH standards, Fire Safety Act, AERB regulations, Biomedical Waste Management Rules, and other relevant laws and regulations.

17: Commencement

17.1. This Constitution shall come into force with effect from the date of its adoption by the Managing Committee of Sitwanto Devi Mahila Kalyan Sansthan.

Annexure A: Safety Incident Reporting Form

Hospital Safety Committee - Incident Reporting Form

Incident No.: ______________________ Date of Report: __________________

Details of Reporter:

Name: ________________________________________________

Designation/Department: ________________________________________

Contact Number: ____________________ Email: _____________________

Type of Incident: (Check all that apply)

• [ ] Patient Fall [ ] Medication Error [ ] Equipment Failure [ ] Fire/Electrical Hazard
• [ ] Needle-stick Injury [ ] Patient Identification Error [ ] Surgical Safety Issue
• [ ] Infection Control Breach [ ] Facility Hazard [ ] Near Miss [ ] Other: ____________

Date, Time, and Location of Incident:

__________________________________________________________

Description of Incident:

__________________________________________________________

__________________________________________________________

__________________________________________________________

Persons Involved/Affected:

Patient Name (if applicable): ___________________________ MR No.: ______________

Staff Involved: ________________________________________________

Outcome/Consequence:

• [ ] No harm [ ] Temporary harm [ ] Permanent harm [ ] Death [ ] Near miss

Immediate Action Taken:

__________________________________________________________

Witnesses (if any):

_______________________________________________________

_______________________________________________________

Signature of Reporter: _________________________

Date: __________________

For Official Use Only:

Received by Convener: _____________________ Date: __________________

Severity Assessment: [ ] Minor [ ] Moderate [ ] Major [ ] Sentinel Event

Investigation Required: [ ] Yes [ ] No

Investigation Team: _____________________________________________

Adopted by:

FOR AND ON BEHALF OF THE INSTITUTION:

Dr. __________________ [Name & Signature] Principal/Director Netaji Subhas Medical College & Hospital Date: _______________ Seal:

Prof. _________________ [Name & Signature] Chairperson, Governing Body Date: _______________

APPROVED AND NOTIFIED BY:

Sitwanto Devi Mahila Kalyan Sansthan

Secretary: _________________ [Name & Signature] Date: _______________