Form Cms-2786u - Fire Safety Survey Report - Asc & Esrd 2012 Life Safety Code Page 37
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39Name of Facility
2012 LIFE SAFETY CODE
ID
NOT
MET
N/A
REMARKS
PREFIX
MET
Features of Fire Protection – Fire Loss Prevention in Operating Rooms
K933
Periodic evaluations are made of hazards that could be encountered during
surgical procedures, and fire prevention procedures are established. When
flammable germicides or antiseptics are employed during surgeries utilizing
electrosurgery, cautery or lasers:
•
packaging is non-flammable.
•
applicators are in unit doses.
•
Preoperative "time-out" is conducted prior the initiation of any surgical
procedure to verify:
application site is dry prior to draping and use of surgical
o
equipment.
pooling of solution has not occurred or has been corrected.
o
solution-soaked materials have been removed from the OR prior to
o
draping and use of surgical devices.
policies and procedures are established outlining safety precautions
o
related to the use of flammable germicide or antiseptic use.
Procedures are established for operating room emergencies including alarm
activation, evacuation, equipment shutdown, and control operations.
Emergency procedures include the control of chemical spills, and
extinguishment of drapery, clothing and equipment fires. Training is
provided to new OR personnel (including surgeons), continuing education is
provided, incidents are reviewed monthly, and procedures are reviewed
annually.
15.13 (NFPA 99)
Form CMS-2786U (10/2016)
Page 37
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