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Module 2
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Elements of Safety and Health Management SystemManagement System
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PDCA Model
Continual improvement
PDCA Model
OH&S Policy
Management ReviewPlanning
Management Review
• Hazard identification, risk assessment and determining controls
Implementation & OperatioChecking
• Legal Requirements
• Objectives & Programme(s)
Reso rces roles responsibilitg • Resources, roles, responsibility,accountability and authority
• Competence, training and awareness• Communication, participation and Consultation
D t ti & C t l f D t
• Performance measurement and monitoring
• Evaluation of compliance• Incident investigation
N f it CA & PA • Documentation & Control of Documents• Operational control & Emergency Preparedness & response
• Nonconformity, CA & PA
• Internal audit
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S S f & l h
NUS Occupational Health and Safety Management System
NUS Safety & Health Management Framework
– SMS@NUS
Faculty / Research Institute / Centre SMS
Departmental SMS
Laboratory SMS NUS Occupational Health and Safety (OH&S)NUS Occupational Health and Safety (OH&S)
Management System Standard for Laboratories
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NUS Occupational Health & Safety NUS Occupational Health & Safety Management System Standard for
Laboratories
• NUS Occupational health and safety (OH&S) management system standard for laboratories - Part A: Requirements
• NUS Occupational health and f (O &S)safety (OH&S) management
system standard for laboratories - Part B: Guidance Notes
http://www.nus.edu.sg/osh/programmes/ohscert.htm
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3.1 OH&S Management System
• Principal Investigator (PI) shall implement, maintain and continually improve his or her lab-based OH&S management System in a based OH&S management System in a documented manner
• PI shall manage the occupational safety and health risks associated with his or her laboratory
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3 2 C it t t OH&S 3.2 Commitment to OH&S Management System
a) Implementing the University policies
b) Defining roles and responsibilities
c) Ensure availability of resources
d) Establish a lab based OH&S management systemd) Establish a lab based OH&S management system
e) Continually improving the OH&S management and performance
f) Compliance to regulatory and university requirements
g) Set and review OH&S objectives
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NUS Safety & Health PoliciesNUS Safety & Health Policies
Policies– Overall OSH policy– Fire Safety Policy– Chemical Safety Policy– Radiation Safety Policy
Website screen shot
y y– Biological Safety Policy– Tenant Policy on Safety &
Health
http://www.nus.edu.sg/osh/policies/htm
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University Directives A T & S i i f UG i L b f • Access To & Supervision of UG in Lab for project & research work (Dir 0701)
• Authorized Access to Laboratories (Dir 0702)
• Staff & Student working in BSL3 Facility (Dir 0703)
• NUS Students Working In Non NUS Organizations (Dir 0704) g ( )
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3.3 Planning
3.3.1 Hazard identification, risk assessment & determining
t l (HIRADC)control (HIRADC)
3.3.2 Legal & other requirements
3.3.3 Objectives and programme(s)
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3.3.1H d Id tifi ti Ri k Hazard Identification, Risk
Assessment And Determining C l ( C)Controls (HIRADC)
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3.3.1 HIRADC• Identifying potential hazards during routine or Identifying potential hazards during routine or
non-routine lab activities , evaluating their risks and determining risk controls to eliminate or minimize the potential for harmp
• Considering hierarchy of controls
• Complying to legal requirements
– Documented and endorsed by PI
– Reviewed regularly (at least once every 3 year) and as and when there are major changes that and as and when there are major changes that may affect safety or any occurrence of incident/accident
– Record to be kept at least 3 years
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Risk Assessment FormExperiment-Based Risk Assessment Form
Name of Department Location of Lab
Name of Laboratory Name of PI
Name of Name of Researcher/LO Activity/Experiment
1. Hazard Identification 3. Risk Control
No Description/Details of Steps in Activity
Hazards Possible Accident / Ill Health & Persons-at-Risk
Existing Risk Control (Mitigation) Severity Likelihood (Probability)
Risk Level Additional Risk Control Person Responsible By (Date)
1 0
2 0
3 03 0
4 0
5 0
6 0
7 0
8 0
9 0
10 0
Conducted By Approved By
Name
Signature
Approval date Next Revision date
(Maximum 3 years)
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Risk Assessment MethodologyLikelihood Risk = Likelihood x SeverityLikelihood Risk = Likelihood x Severity
Likely Possibly Unlikely RISK DECISION PROCESS
ever
ity
Low 3 2 1< 3 RISK ACCEPTABLE
Med 6 4 23 4 CONSIDER ADDITIONAL RISK CONTROL
Se
3, 4 CONSIDER ADDITIONAL RISK CONTROL
High 9 6 3> 4 ADDITIONAL RISK CONTROL REQUIRED
Likelihood
1UnlikelyNot likely to occur
2Possible Possible or known to occur
3Very LikelyCommon or repeating occurrence
Severity1Low (e.g. No injury, injury or ill-health requiring first aid treatment only - includes minor cuts and bruises, irritation, ill-health with temporary discomfort)
2Medium (e.g. Injury requiring medical treatment or ill-health leading to disability – includes lacerations, burns, sprains, minor fractures, dermatitis, deafness, work-related upper limb disorders)
3High (e.g. Fatal, serious injury or life-treatening, occupational disease – includes amputations, major fractures, multiple injuries, occupational cancer, acute poisoning and fatal diseases)
Severity - Consider the magnitude/severity of the consequences of the Risk Factor occurring and then list this as 3 (High), 2 (Moderate) or 1 (Low). Severity normally will not change unless there is a physical change to the equipment or process.
Likelihood - Team should rely upon their experience and consider realistic scenarios. Listed below are examples of factors that may be considered in determining the likelihood.- Past experience / incidents- Complexity of the activity- Number of personnel involved in the activity (e.g. all personnel, a limited number of trained personnel, etc)- Frequency of use or execution
Degree of control (involvement of contractors)- Degree of control (involvement of contractors)- Strength/completeness of administrative controls- Sufficiency/formality of training- Other....
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Risk Assessment RegisterNo Name of Experiment Conducted
byDate Approval
DateNext
Revision D t
Remarks
Date123456789101112131415N t Pl tt h ll i k t i th t l t i th t k h tNote: Please attach all risk assessments using the template in the next worksheet
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3.3.23.3.2
Legal And Other RequirementsLegal And Other Requirements
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3.3.2 Legal and Other Requirements
• Take into account applicable legal and NUS requirements when establishing OH&S Management Systemg y
• Information to be communicated to all lab personnel
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OSH Legal Register OSH Legal Register
http://www.nus.edu.sg/osh/legalreg.htm
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Applicable Legal RegisterLegislations applicable to the labLegislations applicable to the lab
No Legislations/ guidelines Applicable to lab
1 Workplace Safety and Health Act
2 Petroleum And Flammable Materials (PFM) Regulations
3 Chemical Weapons Convention (NACWC)3 Chemical Weapons Convention (NACWC)
4 Poisons Act
5 Environmental Protection & Management Act
6 Environmental Public Health Act
7 Sewerage and Drainage Act
8 Misuse of Drug Act
9 Arms and Explosives (Amendment) Act
10 Radiation Protection Act
11 Fire Safety Act
12 Biological Agents and Toxin Act
13 WHO guidelines for biosafety
14Singapore Biosafety Guidelines for Research on Genetically Modified Organisms (GMOs)14 Organisms (GMOs)
15Singapore Guidelines on the Release of Agriculture-Related Genetically Modified Organisms (GMOs)
16 Any other Acts or Guidelines (if yes, please provide details)
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3 3 33.3.3Objectives and Programmes
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3.3.3 Objectives and Programmes
• Participation in university, faculty or department-level programmes
d l ddi i l bj i h• To develop additional objectives where applicable
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Objectives and Programmes
E t bli h d i t i t hi OH&SEstablish and maintain programmes to achieve OH&S
OObjectives and programmes include :– Responsibility and authority for
– Achievement at relevant
– functions and levels;
– Means; and
– Time scale
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Objectives and ProgrammesObj i d i i l fi h • Objectives expressed in numerical figure where possible
• Objectives should be:S – SpecificpM – MeasurableA – AchievableR – Realistic/RelevantT – Timeliness
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Examples of Objectives & Targets
PolicyReduce injuries
ObjectiveTo reduce the number of chemical related incidents by50% by Sep 0850% by Sep 08
Programmes– Proper storage of chemicals by June 2008– Implement 5 S good housekeeping programme by Dec
2008
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Establishing Management ProgrammeEstablishing Management Programme
S ACTIVITIES J F M A M J J A S O N D WHO
1 Id if l i f h i l d L b T h
To eliminate chemical hazards from chemical storage and handling by end 2008
1 Identify locations of chemical storage and usage within lab
Lab Tech
2 Identify potential chemical hazards arising Lab Tech
3 Identify suitable material handling equipment Lab Tech
4 P h d k il bl i t PPE L b4 Purchase and make available appropriate PPE at areas of chemical use and storage
Lab Manager
5 Establish safe work procedures on chemical handling
Lab Manager
6 Conduct safety inspections Lab Manager
7 Identify deviations and implement corrective actions
Lab Manager
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B f Ch i l t d iBefore: Chemicals stored in a haphazard manner
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After : Proper segregation ofAfter : Proper segregation of chemicals
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Aft P l b lliAfter : Proper labelling
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3.4 Implementation & Operation
3.4.1 Resources, roles, responsibility, accountability
and authority
3 4 2 Competence training and awareness3.4.2 Competence, training and awareness
3.4.3 Communication, participation and consultation
3.4.4 Documentation & document control
3.4.5 Operational control
3.4.6 Emergency preparedness & response
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3.4.1R l ibilit Resources, roles, responsibility,
accountability and authority
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Resources
• PI to ensure availability of resources to establish, implement, maintain and improve OH&S Management SystemOH&S Management System
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Roles, Responsibility, Accountability and Authority (R2A2)
• Define roles
• Allocate responsibilities and accountabilities
• Delegate authorities
• Facilitate effective OH&S management
R2A2 to be defined, documented & communicated
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E l 1 Th ibilit d th it t d f l b b
Area of Principal Research Lab Student OSO/
Example 1: The responsibility and authority expected of lab members should be defined, documented and communicated. Eg. via a matrix system
Area of Responsibility
Principal Investigator
Research Fellow
Lab. Officer
Student OSO/ Contractors/
Visitors
Conduct Risk A t
Assessment
Approve Risk Assessment
Coordinate on Coordinate on waste disposal
Coordinate maintenance of equipment
equipment
Developing lab. Specific protocols
Report any p yaccidents/incidents
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Example 2Example 2
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Example (cont’d)Example (cont d)
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Roles & Responsibility RegisterNo Description of Duties Frequency Responsible Person Remarks
Primary Secondary1239
101112131415161718192021222324
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3.4.23.4.2Competence, Training and
AwarenessAwareness
Ref: Pg 23
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Training, Awareness & Competence
• PI to ensure person(s) performing tasks are competence
– Education
– Training
– Experience
• Records to be kept
• Identify training needs
OSHE’s mandatory training courses– OSHE s mandatory training courses
– Induction training by faculty, Department
– Lab-specific needsp
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Example 1: Training Needs AnalysisType of training
Research Fellow
Lab. Officer Student OSO /Contractorstraining Fellow /Contractors/Visitors
Risk Assessment
Agent Specific training - SSTS
Lab. Specific equipment
Lab Specific Lab. Specific protocols
General lab. S f t
Safety orientation
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Training Needs Analysis (TNA) Training MatrixMinimum Training Requirements
Role in the Lab Faculty Safety
Orientation
Department Safety
Orientation
Lab Specific Training
Biosafety Training (OSHE)
Chemical safety
Training (OSHE)
Radiation safety
Training (OSHE)
Non-ionizing radiation
f
Fire safety
Training (OSHE)
First Aid
Training
Others-pls specify
(OSHE) (OSHE) safety Training(OSHE)
(OSHE)
1 Research Fellow
2 Research Assistant2 Research Assistant
3 Post Graduate Students
4 Honors Students
5 Urops Students5 Urops Students
6Short Term attachment Students
7 Visitors
8 Others8 Others
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Example 2 - Training
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ExampleExample
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Example 3 – New Staff Orientation
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Example 3 – New Staff Orientation (cont’d)
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Training recordsb i i h kliLaboratory Training Checklist
Name of lab member Designation Faculty Safety
Orientation
Department Safety
Orientation
Lab Specific Training
Biosafety Training (OSHE)
Chemical safety
Training (OSHE)
Radiation safety
Training (OSHE)
Fire safety
Training (OSHE)
First Aid Training
External Training
Others-pls
specify
1
2
3
4
5
6
7
8
9
(indicate training completed and date of completion of the respective training courses by each lab member)
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3.4.33.4.3Communication, participation
and consultation and consultation
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3.4.3. Communication, participationand consultationand consultation
PI shall establish, implement and maintain procedures for:
• External communications with external parties (communication with regulators via OSHE)
• Internal communications
– within lab (hazards, risks, controls & OS&H management system)g y )
– with department & safety committee and safety officer and OSHE.
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RI/RC Safety WikiRI/RC – Safety Wiki
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3.4.43.4.4Documentation & Document ControlDocument Control
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Documentation & Document Control
• NOT A PAPER CHASE!
• DOCUMENT AS MUCH AS IS NECESSARY FOR EFFECTIVE MANAGEMENT OF OH&S RISKS AND LEGAL COMPLIANCE!
P d f t lli d t d d t • Procedures for controlling documents and data • Ensure that :
– They can be located– They be periodically reviewed revised & approved– They be periodically reviewed, revised & approved– Only current versions available– Obsoletes promptly removed & identified
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Some examplesRoles & responsibilities • Roles & responsibilities
• Legal register • Licences from authorities
Ri k t• Risk assessment• SOPs• Training Needs Analysis and training records
f h ( )• Safety Data Sheets (SDS)• Chemical and Agent Inventory List • Maintenance records (BSC, Fume Hood)• Notes of safety meeting• PPE maintenance (respirator)
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Documentation and Document Control
NUS standard format for procedure writing:• Objective• Scope• Responsibilities• Definition
Procedure• Procedure• Records• Appendixes
Include: Author, Reviewer, Approving Officer, Page number, Date, Reference Number, Revision Number
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ExampleExample
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Standard Operating Procedure RegisterNo Name of Procedure Prepared
byDate Approval
DateNext
Revision Date
Remarks
1123456789
10111213141415
Note: Please attache all approved Procedures
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3 4 53.4.5Operational Control
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Operational Control
• To implement controls identified in risk assessment
• Stipulate operating criteria and conditions
• To consider :
– purchasing of equipment, materials and services
– risk associated with contractors and visitors
• Operation controls to be communicated to all relevant partiesparties
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U i it L l M l University Level Manuals, Procedures and Programmes
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SMS@NUS documentation structure
• Laboratory Biorisk Management Manual
• Chemical Safety Manual
• Radiation Safety Manual
• General Lab Safety Manual
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University-Level SOPs
L b i ti d l b lli• Lab sign posting and labelling
• Project / task risk assessment
• Accident/Incident reporting
• Control of Contractors Working in Laboratories and H ll f R id Halls of Residences
• Laboratory Decommissioning Procedures
• Etc.
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Hazards in the Lab Personal Protection Required
Special Procedures or Precautions for Entry:
9694176068745961Peck TGIn Emergency
9694176068745961Peck TGFor Entry or Advice
Contact after Office HourOffice TelCall or SeeNotice
67795555NUHx2880Unversity Health
995Ambulance / Fire999Police
Mr/Ms Jesslyn Soh - 68745966
Faculty Safety Officerx1616Campus
Security
67795555NUHx2880and Wellness Centre
Date Posted: 1/31/2005 Department: OSHE
Room No: 68745961 Name of Lab: OSHE
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Compulsory Occupational Health screening required prior to commencement of work
Health hazard Condition/s Mandatory Occupational HealthHealth hazard Condition/s Mandatory Occupational Health Controls
Animal (vertebrate)work
If staff or students are working with animals (vertebrate)
• Staff and students - tetanusvaccine prior to working with these animals(vertebrate) animals
• Booster shot every 3 years.
Human Material If staff or student will be in • Staff and students to be tested if contact with human blood, tissues, etc (non commercial sources)
Hepatitis antibodies are present. If negative, staff and student to be administered with a Hepatitis B vaccine. After six months screening of antibody levelsscreening of antibody levels should be done. Re-screening should be done 10 years later.
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Compulsory OH screening required prior to commencement of work
Health hazard Condition/s Mandatory Occupational Health Controls
Any materialcontaining
If staff or student is conducting deliberate
• To determine appropriate medical surveillance,containing
infectious agents of risk group 2.
conducting deliberate research on materials containing risk group 2 and above agents
medical surveillance, immunization needed by referring to the MSDS of the infectious agent.
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Compulsory OH screening required prior to commencement of work
Health hazard Condition/s Relevant Legislation To Comply With
Noise If staff or student is exposed to noise sources
• WSHA and its subsidiary legislation
resulting in noise exposure levels of 85 dBA over a period of 8 hours.
• WSHA (Noise) Regulations• WSHA (Medical Examinations)
Regulations
Chemical If staff or student is • Workplace Safety and Health expected or suspected to be exposed to permissible exposure limits (PELs) of scheduled chemicals
Act (General Provisions) Regulations
Radiation If staff or student is towork with ionizing or non ionizing radiation sources or equipment.
• Radiation Protection Act • Radiation Protection Act
(Ionizing Radiation)• Radiation Protection Act
(Non-ionizing Radiation)(Non-ionizing Radiation)
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NUS Occupational Health ProgrammeProgramme
htt // d / h/ /http://www.nus.edu.sg/osh/programmes/occup_health/programme.htm
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NUS R i t P t ti NUS Respirator Protection Programme
http://www.nus.edu.sg/osh/programmes/ 30040 h/rpp300407.htm
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3.4.63.4.6Emergency Preparedness &
ResponseResponse
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Emergency Preparedness & Responsep
• PI to identify possible emergency situations in the lab.
• Develops lab-specific emergency procedures (to be consistent with CEM Framework)
f f l• Ensure proper maintenance of emergency facilities (Fire extinguisher, Emergency shower , Eye wash) and consumables (first aid boxes)
• PI to ensure staff and students participate in NUS emergency response training (eg. fire safety, first aider) and drills
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3.5 Checking
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Checking
3 5 1 Performance measurement and monitoring3.5.1 Performance measurement and monitoring
3.5.2 Incident investigation, corrective action and preventive action
3.5.3 Internal audit
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3.5.13.5.1Performance Measurement and
MonitoringMonitoring
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3.5.1 Performance Measurement & Monitoringg
• Monitor extent to which OH&S objectives are met
• Monitor effectiveness of controls (thru’ regular • Monitor effectiveness of controls (thru regular inspections)
• Evaluate compliance with legal and other regulations
• Maintain and calibrate measuring equipment (e.g. GM counter, noise meter)
• Maintain records • Maintain records
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Measurement & Monitoring Medical Surveillanc and Hygiene Requirements
No Activity Medical Checkup/Vaccination Required
Hep A Hep B
Annual Medical Checkup
EYE Checkup Others
Hygiene Monitoring
1
2
3
4
5
6
7
8
9
10
11
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3.5.2I id t I ti ti Incident Investigation,
Corrective and Preventive iAction
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3.5.2 Incident investigation, corrective & preventive action
All shall
• Report to OSHE via On-line Online Accident and Incident Reporting (AIRS) within 24 hrsIncident Reporting (AIRS) within 24 hrs
PI shall investigate the incident
• Analyse and determine root cause(s)• Analyse and determine root cause(s)
• Propose corrective and preventive actions
• Implement and evaluate its effectiveness p
Accident reporting and investigation is for purpose of l i it i t it h h t!learning; it is not a witch hunt!
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Accident & Incident ReportingI id t R i tIncident Register
No Name of Incident Breif Description of IncidentReport Date Reported by
Incident Reprot Filed Remarks
Note: Please attach all past incidents reports
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3 5 33.5.3Internal Audit
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Department
3.5.3 Internal Audit (IA)
• Internal auditors are appointed by HOD
• Internal auditors are adequately te a aud to s a e adequate ytrained
• Internal audits are to be conductedte a aud ts a e to be co ducted
• PIs are to participate and support IAs.
IA is not a witch hunt! Auditors help auditees to identify areas for improvement.
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Management Review
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Management Review
• PI to review OHSMS
– at pre-determined interval; and p
– ensure it is suitable, adequate & effective
• Necessary information to be collected
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PI Licensing/Certification
Issued to PIs who have Issued to PIs who have demonstrated an effective SMS
being implemented in their l b t ilaboratories
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S
Certified Labs Are S.A.V.E.D.Self – regulating : ownership of laboratory safety by the PI
All encompassing : covers all lab activities, and looks at the holistic interaction of 4M - Man, Materials, Machines and Methods
V l Addi PValue Adding Process : Sharing of Best Practices by PeersNot fault finding but stress on continual improvement
Educating : Lab group is educated on risk assessments, safety management systems
D hb d f fDashboard : Provides a gauge on safety compliance status of labs
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Benefits from the scheme Waiver of submission of PRA No delay in activation of new grants Approval is immediate
Sharing of best practices among peers (including common SOPs)
Enhanced safety awareness among l b tlaboratory group
Improved safety performance
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Certification Maintenance Certification is valid for 3 years Surveillance audit on annual basis Review and revise Risk Assessment
whenever Any changes in materials, protocols,
equipment etc. or A f i id t id t Any occurrence of incident or accident or
Once every 3 years
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Lab OHS Certification Scheme Lab OHS Certification Scheme
http://www.nus.edu.sg/osh/programmes/ohscert.htm
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Th k Y !Thank You!