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UNIVERSITY OF WASHINGTON MEDICAL CTR
VENTILATION, LIGHT, TEMPERATURE CONTROLS
Tag No.: A0726
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Based on interview and document review, the hospital failed to ensure that rooms where ortho-Phthalaldehyde (OPA) was used had the required air exchanges per hour.
Failure to perform the required number of air exchanges per hour places staff at risk of exposure to potentially toxic vapors from OPA.
Findings:
1. The Material Safety Data Sheet for Cidex OPA (a disinfectant) states in part, "Handling: Technical measures/precautions: Use in well-ventilated area and use with appropriate exhaust ventilation, for example a minimum of 10 air exchanges per hour ..."
2. On 12/1/2016 at 9:35 AM, Surveyor #2 asked the Facilities Manager (Staff Member #5) for the Eastside Specialty Center for documentation that the endoscope reprocessing room was achieving at least 10 air changes per hour (ACH). A document titled "DOH Design Parameters" was provided specifying that the reprocessing room was designed to achieve 21 ACH, but no documentation was provided that showed that the ACH had been verified. A ventilation station was present in the room, but staff were not placing the CIDEX beneath it during reprocessing.
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