Biomedical Engineering Reference
In-Depth Information
laser safety audit plan
Audit is essential for any Quality Assurance Program and doc-
uments compliance, as well as areas of defi ciencies needing
improvement. Audit is a means of looking at all aspects of your
laser safety program, in a formal and comprehensive manner
as follows:
I. Laser Safety Offi cer
Materials needed: Job Descriptions for LSO
Written Statement of Authority from Management Points to
be evaluated:
3. Incident/accident report forms and procedures for
reporting
4. Problems identifi ed (any QA reports or accidents
that have occurred)
5. Knowledge/presence of ANSI standards
6. Equipment inventory (biomed) with service con-
tract information
7. State license or registration (where required)
V. Program Development
No specifi c materials needed to evaluate the following points:
1. New procedures/instrumentation to be acquired or
initiated
2. Clinical research projects—industry partnerships
3. Alternative/ additional practice sites or redesign/
expansion
4. Teaching program involvement (medical and/or
nursing)
VI. Use of Third Party Equipment
Laser equipment being rented or borrowed must meet the
same standards as owned equipment. Facility is still responsi-
ble for all administrative and procedural control measures.
Materials needed:
1. LSO appointed: statement of authority from admin-
istration
2. Training and qualifi cations documented
3. Time available for related duties
4. Continuing education plan
5. LSO deals appropriately with problems and is
available when needed
6. Safety audits and reporting completed
II. Equipment
Materials needed: Lasers and all accessory equipment.
Points evaluated:
1. Status and condition of equipment (history and
documentation)
2. Physical plant (handling and moving, fi re extin-
guishers, storage, etc.)
3. Proper handling, setup, storage by staff
III. Continuing Education
Materials needed: records of all inservice and training pro-
grams for nursing and technical staff
Credentialing criteria, forms, policies for medical staff:
Points evaluated:
Terms of agreement between a facility and rental
company
Copies of rental company patient case logs
Rental company policies and procedures
Credentials of technicians running rental lasers
Intake Checklist
Points evaluated:
a. Who is responsible for the intake procedures?
b. Are proper documentation forms being completed?
c. Are facility staff trained in basic operations and
equipment handling?
d. Whether surgeons have been credentialed
e. Education and training of rental company staff
f. Do rental company staff comply with ANSI stan-
dards and basic OSHA requirements?
g. Appropriate supervision of rental company staff
1. Medical staff credentials (policies and forms) in
order and current
2. Nursing staff training documented
3. New or additional staff orientation
4. Annual refresher and skills validation
5. Conferences/ workshops attended or planned
6. Learning needs assessment (current and future)
IV. Documentation
Materials needed and points evaluated:
Audit will be documented in a written report that contains
:
Identifi cation of areas of noncompliance with standards,
needs assessment, recommendations for remedy of defi cien-
cies, and a follow-up plan.
See further Tables 17.1-17.12.
1. Policies/procedures
2. Log sheets (review of current logs and a copy of
blank form)
