risk/health and safety control of mercury

Risk/Health and Safety

Control of Mercury

Policy Manager Jean Ngoie

Policy Group Risk Management

Policy Established

Last Updated August 2017

Policy Review Period/Expiry

2 years/August 2019

UNCONTROLLED WHEN PRINTED

This policy does / does not apply to Medical/Dental Staff (delete as appropriate)

Document Control Document: Control of Mercury Version: 1.3 Version Date: August 2017 Policy Manager: Jean Ngoie of 25 Review Date: August 2019

Control of Mercury Version Control

Version Number

Purpose/Change Author Date

1.0

**Please note earlier versions of this policy are available prior to version control being implemented in July 2011

George Corner

1.1 Review Complete – no further amendments

George Corner Aug 2012

1.2 Review: Update of contact details

George Corner Mar 2014

1.3 Review: - Appendix 1. Pharmacy no

longer produces the spill kit. This is now available on PECOS. Added PECOS order codes as well as links to technical specifications.

- Review of Key contacts

Jean Ngoie August 2017


Policy Document RM/6 - Control of mercury in NHS Tayside

CONTENTS:-

Contents:- ........................................ .............................................................................................. 3 1 Purpose ......................................... ......................................................................................... 4

1.1 Policy aim ........................................................................................................................ 4 2 Policy .......................................... ............................................................................................ 4

2.1 Introduction ...................................................................................................................... 4 2.2 Purchase of Items Containing Mercury ............................................................................ 4 2.3 Use of Mercury Thermometers......................................................................................... 4 2.4 Use of Mercury Sphygmomanometers ............................................................................. 4 2.5 Handling and Storage of Mercury ..................................................................................... 5 2.6 Faulty Equipment and Disposal of Mercury ...................................................................... 5 2.7 Spillage of Mercury – Cleaning Up, Reporting .................................................................. 5 2.8 Further information ........................................................................................................... 5

3 Roles and Responsibilities ...................... ............................................................................. 5 3.1 Strategic Management ..................................................................................................... 5 3.2 Roles and Responsibilities ............................................................................................... 6

4 Organisational Structure ........................ ............................................................................... 6 4.1 Facilitating structures ....................................................................................................... 6 4.2 Monitoring and implementing the policy ........................................................................... 6 4.3 Audit ................................................................................................................................ 6 4.4 Review and update .......................................................................................................... 6

5 Key Contacts .................................... ..................................................................................... 6 Appendix 1 – Mercury Spillage Appendix 2 - Policy Approval Checklist Appendix 3 - Equality Impact Assessment


1 PURPOSE

To control the acquisition, use and disposal of mercury in NHS Tayside.

1.1 Policy aim

The aim of this policy is to ensure that risks associated with mercury in NHS Tayside are reduced to a safe level acceptable to Health and Safety Executive, while minimising compromise of clinical and laboratory quality standards and costs.

2 POLICY

2.1 Introduction

Mercury is a dense silver metal, liquid at room temperatures. It evaporates slowly and the vapour is toxic when absorbed over long periods or in high concentrations. Occupational exposure to very small quantities of mercury is not known to have an adverse effect on health. Mercury is used in sphygmomanometers, thermometers and dental amalgam. Mercury or mercury compounds may also be encountered in hospital laboratory areas.

2.2 Purchase of Items Containing Mercury

Spillage of mercury poses a health threat. NHS Tayside recognises the resultant dangers associated with the use of medical devices containing mercury and recommends that such devices should no longer be purchased. Any purchase of medical devices containing mercury such as thermometers or sphygmomanometers must have undergone a detailed risk assessment, a written record of which indicates that only mercury-containing equipment will satisfy the requirements of use rather than any non-mercury alternatives that are currently on the market.

2.3 Use of Mercury Thermometers

Neonatal incubators fitted with mercury thermometers are especially hazardous and should never be used. Clinical thermometers containing mercury should be replaced with alternatives. Scientific use of mercury thermometers should be risk assessed taking into account the likelihood and effects of breakage.

2.4 Use of Mercury Sphygmomanometers

The problems of dealing with a large mercury spillage should be born in mind when using mercury sphygmomanometers. Dropping the equipment is an obvious danger for portable sphygmomanometers, and even stands can be knocked over. Use should be risk-assessed, and modified where appropriate. Electronic or aneroid sphygmomanometers have largely replaced mercury types.


2.5 Handling and Storage of Mercury

Plastic or rubber gloves, tight-weave clothing, overshoes and eye protection are advised when handling mercury. Mercury should be stored in sealed plastic jars or bottles which will not shatter when dropped.

2.6 Faulty Equipment and Disposal of Mercury

Faulty equipment which is leaking or may leak mercury should be safely packaged and delivered to the Area Pharmaceutical Stores at Ninewells using porters or hospital transport. Do no use the internal or external mail system.

The equipment should be double-bagged in clear plastic to stop the release of mercury and mercury vapour. Additional packaging such as a plastic or cardboard box should be used to protect the equipment from further damage. Label the package clearly as a mercury hazard.

Mercury for disposal is treated as special waste. Arrangements are made by Area Pharmaceutical Store to deal with such waste, and staff there should be contacted for further information.

2.7 Spillage of Mercury – Cleaning Up, Reporting

See appendix to this policy

2.8 Further information

Health & Safety Executive Guidance Note EH 17 (Revised) – Mercury and its inorganic divalent compounds.

Health & Safety Executive Guidance Note MS 12 (Revised) – Mercury: medical guidance notes.

Health & Safety Executive Guidance Note EH 40 (2002) – Occupational exposure limits 2002.

Guidance for Local Authorities IN2-9/98

Medical Devices Agency MDA DB2000(03) July 2000 – Blood pressure measurement devices – mercury and non-mercury.

3 ROLES AND RESPONSIBILITIES

3.1 Strategic Management

The Chief Executive is responsible to NHS Tayside Board for the overall implementation of this policy

The Medical Director, the Director of Nursing and Patient Services, Director of Human Resources, Clinical Group Directors and Clinical Group Managers, Heads of Clinical and Non-clinical Support Service Departments are accountable to the Chief Executive for ensuring that this policy is implemented within their respective Directorates and Departments.


3.2 Roles and Responsibilities

All staff members are responsible for the health and safety of themselves and others. Any staff using items containing mercury should be aware of this policy, and report any deviations from it to their Health & Safety representative. Remedial action should be taken, in consultation with the Health and Safety Manager and the Medical Physics representative as necessary.

Locality managers and Team Leaders are responsible for ensuring that Mercury Spillage Kits are available at all sites where mercury could be spilled (see appendix).

4 ORGANISATIONAL STRUCTURE

4.1 Facilitating structures

Each Department and Directorate has a Health & Safety group with representatives for all staff.

4.2 Monitoring and implementing the policy

Senior managers are responsible on behalf of Directorate General Managers for overseeing the implementation and compliance with this policy within their respective Directorates.

4.3 Audit

Compliance with the policy will not be subject to audit.

4.4 Review and update

The policy should have a scheduled review date.

5 KEY CONTACTS

Val Fyall (Health & Safety Officer) Ext 30270

Jean Ngoie (Medical Physics) Ext 32797

Mark Anderson (Head of Estates) Ext 32329


APPENDIX 1 – MERCURY SPILLAGE

How to deal with a mercury spillage • Instruct others to keep away from the immediate vicinity of the spillage area.

It is not usually necessary to evacuate the room. (Warning tape may be useful if a large area is contaminated). Consider opening windows and doors to provide additional ventilation.

• Spillage Kits are available to order through general procurement ordering system PECOS. Codes are: DSP Mercury Spillage Kit FAH505 and Mercury Spillage Kit FAH570 . The kit contains: Calcium Hydroxide, Microfined Sulphur, Face Masks, Disposable Gloves, 20ml Syringe, Measuring Scoop, Brush & Empty Bottle for Mercury Waste. Please see website links below for COSHH and further review; https://www.dental-directory.co.uk/IndexSearch/0/1/24/?search=FAH505 https://www.dental-directory.co.uk/coshh/ https://www.dental-directory.co.uk/coshh/FAH505.pdf

• A mercury spillage kit will be included in all Night Emergency Drug Cupboards (NEDCs) for access out of hours. These are available at Ninewells, Perth Royal Infirmary and Stracathro Hospital. If there is no NEDC at a particular site (e.g. at Dundee Dental Hospital) a local storage arrangement should be made by the locality manager or Team Leader.

• Wear a laboratory coat (or similar), plastic or rubber gloves and overshoes if available. Try to retrieve as much mercury as possible and place in a suitable container. Small amounts of mercury can be collected using a thin piece of plastic or card. A syringe may be useful.

• Stop the mercury from spreading or dispersing. Consider using plasticine or Blue Tac to build a containing wall round the spill. Mercury should not be allowed to enter cracks in the floor or work surface.

• Sprinkle zinc powder from the kit over the area of the spillage to form a paste with the mercury. The residue is then swept or mopped into the disposal container using disposable cleaning materials. The container must be clearly identified as containing mercury, and taken to APS for disposal.

• A major spillage (eg the whole contents of a sphygmomanometer) should be reported as an incident on an IR1 form.

• If the spilled mercury could not be totally removed from the area, it may be advisable to arrange for the room to be monitored for mercury vapour. Consult Occupational Health & Safety Advisory Services. DO NOT use a vacuum cleaner The cleaner will finely disperse the mercury

and become a health hazard itself

DO NOT use a stiff brush on the mercury The brush may disperse fine particles.

DO NOT discard any mercury into sinks, toilets or drains

It must be treated as special waste

DO NOT attempt to decontaminate and retain soft furnishings or carpets.

These must be removed and destroyed to prevent further use.

AVOID contaminating shoes or clothes

AVOID skin contact

https://www.dental-directory.co.uk/IndexSearch/0/1/24/?search=FAH505

https://www.dental-directory.co.uk/coshh/

https://www.dental-directory.co.uk/coshh/FAH505.pdf

Document Control Document: Control of Mercury Version:1.3 Version Date: August 2017 Policy Manager: Jean Ngoie of 25 Review Date: August 2019

NHS TAYSIDE - POLICY/STRATEGY APPROVAL CHECKLIST This checklist must be completed and forwarded with policy to the appropriate forum/committee for approval. POLICY/STRATEGY AREA: Risk Management POLICY/STRATEGY TITLE: CONTROL OF MERCURY LEAD OFFICER : Jean Ngoie Why has this policy/strategy been developed?

Revision

Has the policy/strategy been developed in accordance with or related to legislation? – Please give details of applicable legislation.

Yes, as in text

Has a risk control plan been developed? Who is the owner of the risk?

N/A

Who has been involved/consulted in the development of the policy/strategy?

N/A

Has the policy/strategy been assessed for Equality and Diversity in relation to:-

Has the policy/strategy been assessed For Equality and Diversity not to disadvantage the following groups:-

Race/Ethnicity Gender Age Religion/Faith Disability Sexual Orientation

Please indicate Yes/No for the following: Yes

Minority Ethnic Communities (includes Gypsy/Travellers, Refugees & Asylum Seekers) Women and Men Religious & Faith Groups Disabled People Children and Young People Lesbian, Gay, Bisexual & Transgender Community

Please indicate Yes/No for the following: Yes

Does the policy/strategy contain evidence of the Equality & Diversity Impact Assessment Process?

N/A

Is there an implementation plan?

N/A

Which officers are responsible for implementation?

All managers

When will the policy/strategy take effect?

Immediate

Who must comply with the policy/strategy?

All staff

How will they be informed of their responsibilities?

Policy on Intranet

Is any training required?

No

If yes, attach a template

N/A

Are there any cost implications?

No

If yes, please detail costs and note source of funding N/A

Who is responsible for auditing the implementation of the policy/strategy?

N/A

What is the audit interval?

N/A

Who will receive the audit reports?

N/A

When will the policy/strategy be reviewed and by whom? (please give designation)

August 2019. Head of Instrumentation & Clinical Engineering.

Name: Jean Ngoie ________________________ Date: 29 August 2017

Appendix 2


EQUALITY IMPACT ASSESSMENT Name of Policy, Service Improvement, Redesign or St rategy: Control of Mercury Lead Director of Manager: Dr Gavin Main What are the main aims of the Policy, Service Impro vement, Redesign or Strategy? Reduce the risk of patient and staff exposure to mercury within NHS Tayside. Description of the Policy, Service Improvement, Red esign or Strategy – What is it? What does it do? Who does it? And wh o is it for? The policy allow NHS staff to avoid the use of devices containing mercury. Also how to handle a spillage of mercury in case it is in use for specific application within NHS Tayside. What are the intended outcomes from the proposed Po licy, Service Improvement, Redesign or strategy? – What will happen as a resul t of it?- Who benefits from it and how? Reduce the risk of contamination to patient and staff that may come into contact with mercury within NHS Tayside. Hope to meet the WHO Minamata convention for environmental and public health on Mercury free in public health. Name of the group responsible for assessing or cons idering the equality impact assessment? This should be the Policy Working Grou p or the Project team for Service Improvement, Redesign or Strategy. Clinical Engineering, Health & Safety and Dentistry.

Appendix 3


SECTION 1 Part B – Equality and Diversity Impacts Which equality group or Protected Characteristics d o you think will be affected?

Item Considerations of impact Explain the answer and if applicable detail the Impact

Document any Evidence/Research/Data to support the consideration of impact

Further Actions required

1.1 Will it impact on the whole population? Yes or No. If yes will it have a differential impact on any of the groups identified in 1.2. If no go to 1.2 to identify which groups

.


Item Considerations of impact Explain the answer and if

applicable detail the Impact Document any Evidence/Research/Data to support the consideration of impact


1.2 Which of the protected characteristic(s) or groups will be affected?

• Minority ethnic population (including refugees, asylum seekers & gypsies/travellers)

• Women and men • People in religious/faith

groups • Disabled people • Older people, children

and young people • Lesbian, gay, bisexual

and transgender people • People with mental

health problems • Homeless people • People involved in

criminal justice system • Staff • Socio- economically

deprived groups

None

None none





1.3 Will the development of the policy, strategy or service improvement/redesign lead to

• Discrimination • Unequal opportunities • Poor relations between

equality groups and other groups

• Other

No No No


SECTION 2 – Human Rights and Health Impact. Which Human Rights could be affected in relation to article 2, 3, 5, 6, 9 and 11. (ECHR: European Conv ention on Human Rights)



Further Action s required

2.1

On Life (Article 2, ECHR) • Basic necessities such as

adequate nutrition, and safe drinking water

• Suicide • Risk to life of / from others • Duties to protect life from

risks by self / others • End of life questions

No No No

2.2

On Freedom from ill -treatment (Article 3, ECHR) • Fear, humiliation • Intense physical or mental

suffering or anguish • Prevention of ill-treatment, • Investigation of reasonably

substantiated allegations of serious ill-treatment

• Dignified living conditions

No No No





2.3 On Liberty (Article 5, ECHR) • Detention under mental

health law • Review of continued

justification of detention • Informing reasons for

detention

No No No

2.4 On a Fair Hearing (Article 6, ECHR) • Staff disciplinary

proceedings • Malpractice • Right to be heard • Procedural fairness • Effective participation in

proceedings that determine rights such as employment, damages / compensation

No No No





2.5 On Private and family life (Article 6, ECHR) • Private and Family life • Physical and moral integrity

(e.g. freedom from non-consensual treatment, harassment or abuse

• Personal data, privacy and confidentiality

• Sexual identity • Autonomy and self-

determination • Relations with family,

community • Participation in decisions

that affect rights • Legal capacity in decision

making supported participation and decision making, accessible information and communication to support decision making

• Clean and healthy environment

No No No





2.6 On Freedom of thought, conscience and religion (Article 9, ECHR) • To express opinions and

receive and impart information and ideas without interference

No No No

2.7 On Freedom of assembly and association (Article 11, ECHR) • Choosing whether to belong

to a trade union

No No No

2.8 On Marriage and founding a family • Capacity • Age

No No No

2.9 Protocol 1 (Article 1, 2, 3 ECHR) • Peaceful enjoyment of

possessions

No No No


SECTION 3 – Health Inequalities Impact Which health and lifestyle changes will be affected ?

Item Considerations of impact Expla in the answer and if applicable detail the Impact



3.1 What impact will the function, policy/strategy or service change have on lifestyles?

For example will the changes affect:

• Diet & nutrition • Exercise & physical activity • Substance use: tobacco,

alcohol or drugs • Risk taking behaviours • Education & learning or

skills • Other

None None None

3.2. Does your function, policy or service change consider the impact on the communities?

Things that might be affected include:

• Social status • Employment (paid/unpaid) • Social/family support • Stress • Income

No No No





3.3 Will the function, policy or service change have an impact on the physical environment? For example will there be impacts on:

• Living conditions • Working conditions • Pollution or climate change • Accidental injuries/public

safety • Transmission of infectious

diseases • Other

No No No

3.4 Will the function, policy or service change affect access to and experience of services? For example

• Healthcare • Social services • Education • Transport • Housing

No No No





3.5 In relation to the protected characteristics and groups identified:

• What are the potential impacts on health?

• Will the function, policy or

service change impact on access to health care? If yes - in what way?

• Will the function or policy

or service change impact on the experience of health care? If yes – in what way?

None None None


SECTION 4 – Financial Decisions Impact How will it affect the financial decision or propos al? Item

Considerations of impact Explain the answer and if applicable detail the Impact



4.1

• Is the purpose of the financial decision for service improvement/redesign clearly set out

• Has the impact of your financial proposals on equality groups been thoroughly considered before any decisions are arrived at

Yes, There is no extra cost associated with the proposed changes

N/A none

4.2 • Is there sufficient information to show that “due regard” has been paid to the equality duties in the financial decision making

• Have you identified methods for mitigating or avoiding any adverse impacts on equality groups

• Have those likely to be affected by the financial proposal been consulted and involved

N/A N/A N/A





5. Involvement, Consultation and Engagement (IEC) 1) What existing IEC data do we have?

• Existing IEC sources • Original IEC • Key learning

2) What further IEC, if any, do you need to undertake?

N/A N/A N/A





6. Have any potential negative impacts been identified?

• If so, what action has been proposed to counteract the negative impacts? (if yes state how)

For example: • Is there any unlawful

discrimination? • Could any community get

an adverse outcome? • Could any group be

excluded from the benefits of the function/policy?

(consider groups outlined in 1.2) • Does it reinforce

negative stereotypes? (For example, are any of the groups identified in 1.2 being disadvantaged due to perception rather than factual information?)

None None None





7. Data & Research • Is there need to gather

further evidence/data? • Are there any apparent

gaps in knowledge/skills?

No No No

8. Monitoring of outcomes • How will the outcomes

be monitored? • Who will monitor? • What criteria will you use

to measure progress towards the outcomes?

Specific users Spillage will be considered an incident and reported through Datix

None

9.. Recommendations State the conclusion of the Impact Assessment

N/A N/A N/A





10. Completed function/policy • Who will sign this off? • When?

Risk Management N/A N/A

11. Publication

As per NHS Tayside procedures N/A N/A


Conclusion Sheet for E quality Impact Assessment

Positive Impacts (Note the groups affected)

Staff will be able to identify the spillage, order the correct spillage kit and use it

when necessary.

Negative Impacts (Note the groups affected)

None

What if any additional information and evidence is required

N/A

From the outcome of the Equality Impact Assessment what are your recommendations? (refer to questions 5 - 10) No further action to be taken. This conclusion sheet should be attached to the relevant committee report. MUST BE COMPLETED IN ALL CASES Manager’s Signature Date: 12 Sep. 17 Jean Ngoie

risk/health and safety control of mercury

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