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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Electrical Safety
Effective Date: August 23, 2017
Chapter: Safety/ Emergency Management
To protect patients, visitors and staff from electrical safety hazards throughout UW Health facilities; to
establish guidelines for insuring the safety of electrical equipment and devices.
Patient care vicinity: is defined as “a space, within a location intended for the examination and treatment
of patients, extending 6 ft (1.8 m) beyond the normal location of the bed, chair, table, treadmill, or other
device that supports the patient during examination and treatment and extending vertically to 7 ft. 6 in.
(2.3 m) above the floor”. Ref: NFPA 99 2012, 3.3.139
Patient-Care-Related Electrical Equipment: is defined as “Electrical equipment appliance that is intended
to be used for diagnostic, therapeutic, or monitoring purposes in patient care vicinity.
Ref: NFPA 99 2012, 3.3.137
III. POLICY ELEMENTS
All electrical equipment brought into UW Health facilities either for hospital or clinic use or for the use of
patients or staff must meet electrical safety criteria. This policy applies to all electrical equipment used
within UW Health facilities as appropriate.
Any equipment judged to be unsafe will not be allowed for use.
Electrical extension cords are a frequent cause of electrical faults, improper grounding, and accidents
involving falls and fire. The use of extension cords can cause electrical hazards and increases the
probability of sparks and/or electric shock. In addition, use of extension cords may cause excessive
voltage drop resulting in low efficiency, equipment malfunctions or damage, and subsequent patient
All cord connected electrical equipment used in UW Health facilities must be:
1. UL listed (which may have two prongs and be stamped or tagged as UL listed), or have a
three-wire power cord and a three-prong grounding-type plug.
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2. And be compliant with NFPA 99 Health Care Facilities Code 2012 Edition
All UW Health owned medical equipment is inspected according to the Medical Equipment Management
All UW Health owned non-medical equipment is inspected by Facilities and Engineering Services or
Department Managers, according to departmental policies, procedures, and this policy.
A. Facilities and Engineering Services Service Request (found on U-Connect).
B. Clinical Engineering Service Request Form (found on U-Connect)
A. Electrical Equipment
1. Nonpatient care–related electrical equipment, including facility- or patient-owned
appliances that are used in the patient care vicinity and will, in normal use, contact patients,
shall be visually inspected by the patient’s care staff or other personnel.
2. All patient care–related electrical equipment used in patient care rooms shall be tested in
accordance with NFPA 99 Health Care Facilities Code2012 Edition before being put into
service for the first time and after any repair or modification that might have compromised
Patient owned, physician prescribed medical equipment is to be reviewed and checked by Clinical
Engineering, Facilities and Engineering Services or Respiratory Therapy (or appropriate
designee), as appropriate prior to use.
3. Rental Patient Care Equipment provided to UW Health:
a. All rented patient care equipment shall be inspected by the applicable department
(e.g., Clinical Engineering or Facilities and Engineering Services). The equipment
must be grounded or double insulated per NFPA 70.
b. If the equipment passes the safety check, documentation will be made and the
equipment will be sent to the ordering department.
c. If the equipment does not pass the safety check, it will be returned to the vendor.
4. Hospital and/or Staff Owned Equipment:
a. For new incoming medical equipment refer to the Medical Equipment Management
Plan for safety inspection information.
b. Toaster ovens, convection ovens, electric grills, coffee pots with open heating
elements, etc. are prohibited. Contact Safety for questions. Toasters, microwaves and
coffee pots with closed heating elements are allowed.
5. Special Hazards During Oxygen Administration:
a. Electrical devices (e.g., hair dryers, curling irons, electric razors, heat lamps, etc.)
should not be operated within five (5) feet of oxygen administration devices.
B. Electrical Extension Cords/Power Strips
1. The following does not apply to approved multi-outlet power strips/surge suppressers
commonly used with computers and peripherals for computer support.
2. Each department Director/Manager has primary responsibility for restricting the use of
extension cords and for ensuring that all safety problems encountered are investigated.
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Indications of problems include, but are not limited to, hot plugs or cords, burning odor,
sparks, bent plug blades, intermittent connections, and loose or missing parts.
3. Extension cords or Temporary Power Tap (TPT) or Relocatable Power Tap (RPT), plug
strips, are prohibited from use in Patient Care areas unless for temporary use and approved
by the Facilities and Engineering Services Electrical shop.
4. Where multi-location usage or other considerations make the occasional use of extension
cords unavoidable, special attention will be given to ensure that the cord meets all
requirements for safety.
5. Extension cords will not be placed loosely across floors, through door openings, over door
frames or hanging from ceiling grids or pipes, etc.
6. Contact the Safety Department or Facilities and Engineering Services for review of
C. Portable Space Heaters and Fans
1. All efforts will be made by the Facilities and Engineering Services Steamfitter and HVAC
shops to correct problems or deficiencies that would require a portable space heater or fan
to be used.
2. Only approved space heaters and fans can be used within UW Health facilities.
3. Department managers are responsible for insuring that approved space heaters and/or fans
are obtained through Facilities and Engineering Services by entering a service request via
4. Space heaters cannot be used anywhere in an inpatient module where patients sleep, known
as healthcare occupancies.
5. Employees using space heaters or fans are responsible for the following:
a. Check the cord before plugging in the equipment. If the cord has exposed wires, is
kinked or damaged, cut the cord off with a scissors (while unplugged) and submit a
work order to Facilities and Engineering Services
b. Never use an extension cord with space heaters or fans.
c. Keep space heaters away from enclosed spaces where excessive heat buildup from
operation would occur.
d. Keep space heaters and fans at least three feet away from curtains, papers, clothing or
anything that might burn or get caught in the blades.
e. Never leave the space heater or fan which is turned on unattended and never leave the
site without turning the unit off.
f. Do not hang items to dry above a space heater.
g. When relocating a space heater or fan, check the cord for damage and ensure that the
unit is in the "OFF" position before inserting or removing from an outlet.
h. When disconnecting, always pull the plug and not the cord.
i. Keep space heaters and fans away from areas open to children.
D. Holiday Decorations
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Each year the holiday decorations guidelines are posted on U-Connect. This policy enforces those
E. Blanket and Solution Warming Cabinets
1. Cabinets used to warm blankets are to be limited to 130° F.
2. To reduce the serious burn risk presented by excessively heated solutions, cabinets used to
warm solutions are limited to 110° F, unless the particular solution has a recommended
temperature setting lower than this.
3. If both blankets and solutions are warmed in the same cabinet, the 110° F temperature limit
applies, unless it is a combination cabinet with dedicated compartments with separate
heating elements and controllers.
4. Do not overload the cabinet and leave clearance around the load for air circulation.
5. Some units warn against using the bottom rack, as doing so will block heat distribution.
6. Departments should review the operating instructions for the blanket warmer(s) in their
area to ensure correct and safe operation.
7. Staff members in each clinical area where the warming cabinets are used will be
responsible for periodically monitoring the temperature of the warming cabinets per
8. Warming cabinets will be inspected annually by Facilities and Engineering Services to
verify proper temperature settings and performance.
A. NFPA 101, 2012 Edition, Life Safety Code,
B. NFPA 70, 2008 Edition National Electric Code
C. NFPA 99, 2012 Edition Health Care Facilities Code
D. ECRI Institute. “Hazard Report Update: ECRI Institute Revises Its Recommendation for
Temperature Limits on Blanket Warmers.” Health Devices, July 2009
Sr. Management Sponsor: VP, Facilities & Support Services
Author(s): Director(s), Safety, Clinical Engineering, and Facilities and Engineering Services
Reviewer(s): UW Health Environment of Care Safety Committee
Approval Committee: UW Health Administrative Policy & Procedure Committee
UW Health Chief Administrative Officer