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Administrative (Non-Clinical) Policy
UWHC only (Hospital Administrative-entity wide) UWMF only (entity wide)
UWHC Departmental (indicate name) UWMF Departmental (indicate name)
UWHC and UWMF (shared)
Policy Title: Hazardous Materials and Gases/Radioactive Materials
Policy Number: 12.25
Effective Date: August 1, 2015
Chapter: Environmental Safety
To safeguard the health of employees, patients and visitors of the University of Wisconsin Hospital and
To ensure that all potentially hazardous materials (including radioactive) and gases are purchased, utilized
and disposed of in a safe manner. This policy is an outline of the UW and Laboratory Safety Guide and
University Radiation Safety Regulations.
A. Chemicals used in the UWHC must be handled in the following manner:
1. All chemicals are ordered, received and stored using the standard UWHC purchasing and
2. All chemicals are received at the UWHC receiving dock where the shipping cartons are
inspected for carton integrity. If the shipment has been damaged, the shipper will be
informed and the ordering department will be contacted prior to signature. If the damage
results in a spill, the UWHC Director, Life Safety must be notified via the paging and
message center (262-2122) in order to implement the UWHC Spill Response Plan.
3. Chemicals are transported to the department via cart or hand truck where they are then
stored in accordance with their hazardous chemical classification.
4. Employees using chemicals have access to all pertinent Safety Data Sheets (SDS) online
through MSDSOnline on U-Connect.
5. Unused chemicals and chemical wastes are disposed of within University guidelines and
local municipal regulations. These guidelines and regulations are explained in the UW
Laboratory Safety Guide supplied by the UW Safety Department. Contact UW Safety
Department at http://www2.fpm.wisc.edu/chemsafety/ for disposal pickup requests.
6. Chemical spills are cleaned up in accordance with UWHC Code Orange, Hazardous
Materials emergency operations plan.).
7. All employees exposed to toxic chemicals in excess of limits as established by OSHA or
as defined in the MSDS for that chemical should report the exposure to their supervisor
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and in an emergency to Employee Health Department during normal work hours and the
Emergency Department at other times.
B. Radioactive materials used in the UWHC must be handled in the following manner:
1. Applications for initial use of radionuclide must be submitted to the University Radiation
Safety Committee (URSC). Medical use of radioactive material must be conducted under
URSC approved authorized physician and the sponsorship of an approved clinic (e.g.
Nuclear Medicine, Radiation Therapy, PET Center etc).
2. All radionuclide must be transported and received in accordance with State of Wisconsin
- Radiation protection procedures as outlined in the UW Madison Radiation Safety
Regulations available from University Radiation Safety.
3. The University Radiation Safety Committee grants permission for various radionuclide to
applicants following a thorough review of the applicant's intended use and safety
4. All radionuclide must be stored in accordance with the University Radiation Safety
Regulations that requires shielding and security.
5. Radionuclide must be used in the manner outlined in the original University Radiation
Safety Regulations use applications. All users must read these University Radiation
Safety Regulations, attend the Radiation Safety for Radiation Workers class and pass a
written exam on the content. Staff using quantities greater than one (1) millicurie of high-
energy beta or gamma emitters are required to wear radiation dosimeters.
6. Radionuclide must be disposed of in accordance with University Radiation Safety
Regulations. University Radiation Safety must be informed of disposal so adjustments
can be made in the researchers or clinic's Central Ordering, Receiving and Distribution
(CORD) inventory program. The Central Ordering, Receiving and Distribution Program
(CORD) is a computer assisted system to order, receive, deliver and track radioactive
materials at the University.
7. Radionuclide accidents must be handled in accordance with the University Radiation
Safety Regulations. Contact the Radiation Safety Officer through paging; ask for
“radiation safety”. Radiation Safety will provide technical assistance in clean up.
C. Hazardous drugs must be prepared, administered and disposed of according to the procedures
outlined in Hospital Administrative policy 8.89-Preventing Non-therapeutic Exposure to
D. Ethylene Oxide must be used according to the procedures outlined in the Central Service
Department's Policy of Ethylene Oxide Use. In an emergency, contact Plant Engineering at 263-
5205 or the Safety Officer via the paging and message center at 262-2122.
E. Infectious Waste must be handled according to the procedures outlined in the Hospital
Administrative policy 5.27-Infectious Waste Management and Nursing Procedure Manual 12.10-
F. Nitrous Oxide (N20) must be used in the following manner:
1. The main N20 supply is delivered through a permanent line/wall outlet system. Each
anesthesia machine is equipped with a backup N20 tank. The outlets are pressure tested
annually or when gas monitoring detects a problem. N20 tanks are received and stored in
accordance with manufacturers recommendations.
2. N20 is administered in a manner that minimizes environmental pollution in the operating
rooms. Surgical cases are routinely monitored. The findings are reported to the UWHC
Environment of Care Safety Committee.
3. N20 is exhausted through a non re-circulating exhaust system. A scavenging system is
connected to each anesthesia machine to facilitate the disposal of N20.
G. Monitoring of Hazardous vapors and gases will be conducted by the UWHC Director, Life Safety
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Sr. Management Sponsor: VP, Facilities & Support Services
Author: Director, Life Safety
Review/Approval Committee(s): Environment of Care Safety Committee; Administrative Policy &
President, University of Wisconsin Hospitals and Chief of Clinical Operations
Previous revision: 082012
Next revision: 082018