CLINICAL Laser Safety Policy

Policy Manager Ms Siobhan McVey

Policy Group Radiation Safety Committee

CLINICAL

Laser Safety Policy

Policy Established

May 2000

Policy Review Period/Expiry

1 year/April 2022

Last Updated

April 2021

This policy does / does not apply to Medical/Dental Staff (delete as appropriate)

UNCONTROLLED WHEN PRINTED

Document Control Document: Laser Safety Policy Version: 1.9 Version Date: Apr 2021 Policy Manager: Siobhan McVey Page 1 of 2 3 Review Date: Apr 2022

Laser Safety Version Control

Version Number

Purpose/Change Author Date

1.0

Version Control was introduced in July 2011 and the previous versions of this policy, prior to this date, are available

in the Electronic Document Store.

Alison Dave

July 2011

1.1

Review Complete

Harry Moseley

April 2012

1.2

Review Complete

Harry Moseley

April 2013

1.3

Review Complete

Harry Moseley

April 2014

1.4

Review Complete

Harry Moseley

April 2015

1.5

Review Complete

Harry Moseley

Sept 2016

1.6

Review Complete

Harry Moseley

Feb 2018

1.7

Review Complete

Lead director of manager changed Key contact details changed

Harry Moseley

Feb 2019

1.8

Review Complete

Siobhan McVey

April 2020

1.9

Review Complete

Siobhan McVey

April 2021


CONTENTS

Page Number

1. Introduction 3

2. Aims and Objectives 3

3. Responsibilities and Organisational Arrangements 3

4. Laser Safety Training 5

5. Laser Equipment 5

6. Medical Supervision 6

7. Incidents 6

8. Personal Protective Equipment 6 9. Communications 6

10. Key Contacts 6

APPENDIX 3a: Duties of the Laser Protection Supervi sor 7

APPENDIX 3b: Duties of the Clinical Laser Expert 9 APPENDIX 4a: Laser Training Requirements 11 APPENDIX 5a: Equipment Handover Procedure 13 APPENDIX 7a: Laser Incident Card Template 16 APPENDIX 7b: Laser Incident Procedure 17 APPENDIX 8: Policy Approval Checklist 21

APPENDIX 9: Equality Impact Assessment 22


1) Introduction

The purpose of this document is to:- 1.1 State the Tayside Health Board principle objectives in respect of establishing

a robust laser safety framework 1.2 To set out management responsibilities and supporting organisational and

monitoring arrangements for ensuring we meet these objectives

2) Aims and Objectives

It is the responsibility of Tayside Health Board to ensure, as far as is reasonably practicable, the health and safety of its employees, patients and the public who may be exposed to the hazards arising from the use of lasers. The Board is committed a policy of limiting the risk of accidental harm from exposure to laser radiation to as low as reasonably practicable.

3) Responsibilities and Organisational Arrangements i) Chief Executive

The overall and final responsibility for health and safety within the Board rests with the Chief Executive. They are responsible for providing the Board with the necessary organisation and resources to produce, implement and manage effective arrangements for laser safety. Responsibilities and organisational arrangements are as defined in the General Radiation Safety Policy.

i) ii) Organisational Structure a) Radiation Safety Committee

In accordance with section 3.12 of the NHS Tayside Management of Health and Safety Policy, the Chief Executive has made the Associate Medical Director of the Access and Assurance Directorate responsible to them for convening a Radiation Safety Committee, which will consider matters of laser safety.

b) Laser Protection Advisor The Associate Medical Director of the Access and Assurance Directorate will, on behalf of the Chief Executive, appoint Laser Protection Advisor(s) (LPAs) who will advise the Chief Executive, Medical Directorate, Board Members, Clinical Group Directors, Clinical Leaders, staff and the public on laser safety matters. The LPA shall be given adequate information and facilities to perform the work effectively. The LPA shall be knowledgeable in the evaluation of laser hazards and have responsibility for advising on their control. The duties of the LPA shall include carrying out hazard analysis and risk assessment for each laser installation and ensuring that suitable local


rules are drawn up and implement for each Class 3R, 3B and 4 installations.

The following are required by departments using Class 3R, 3B and 4 lasers: - Each department will ensure that master keys for their lasers are kept

in safe custody and only issued to authorised personnel. - Risk assessment and local rules must be in place for all lasers. Local

rules must contain any control measures identified in the relevant risk assessment.

- Each laser must have a Laser Protection Supervisor who has day to day responsibility for overseeing laser safety. Formal delegation of these functions to that person is made by appointment from the Associate Medical Director.

- Each laser must have a Clinical Laser Expert who has responsibility for assessing and confirming the competence of clinical therapeutic laser users within their area of responsibility prior to their approval as authorised laser users for a particular clinical application. Formal delegation of these functions to that person is made by appointment from the Associate Medical Director.

- Each laser will have a list of training requirements against which laser users are assessed prior to approval as an authorised user.

- Each laser should have a card that can be used in the case of known or suspected ocular injury

The role of the LPA shall include equipment purchase advice, installation planning, acceptance and regular safety audit.

c) Laser Protection Supervisors Laser Protection Supervisors (LPSs) are responsible for ensuring the safe use of all Class 3R, 3B, and 4 lasers within their area. Duties of the LPS are given in Appendix 3a.

d) Clinical Laser Experts Clinical Laser Experts (CLEs) are responsible for assessing and confirming competence of all therapeutic laser users within their area of responsibility prior to their approval as authorised laser users, and assisting in the supervision and training of clinical users. Duties of the CLE are given in Appendix 3b.

e) Authorised Laser Users Authorised Laser Users must ensure that they are competent to undertake the procedures they perform and maintain a training record of their clinical competence and laser safety training. Evidence of clinical competence must be made available to the LPA or LPS upon request.


f) Laser Assisting Staff Laser Assisting staff must ensure that they are competent to undertake their designated tasks including laser set up, designation of controlled areas and key control. Records of training must be maintained by the LPS and made available to the LPA upon request.

g) All Staff All staff members present during laser use are responsible for making themselves aware of any hazard associated with lasers, and following associated local rules and safety procedures established by the employer. Staff also have the responsibility of alerting their line manager if any potentially hazardous laser equipment is brought into the department, and reporting all laser incidents.

4) Laser Safety Training Laser Protection Supervisors, Clinical Laser Experts, and Authorised Laser Users should be familiar with the ‘Core of Knowledge’ for laser safety and be able to provide evidence of suitable training. It is recommended that this training is repeated at least every 5 years (MHRA Guidance notes). Authorised Laser Users must have sufficient supervised clinical training before undertaking any procedures involving a laser. It is recommended that Laser Assisting staff are also familiar with the ‘Core of Knowledge’ and must receive appropriate departmental training prior to acting as a Laser Assistant. Training may include (but is not limited to): laser set up, designation of controlled area, and key control. Staff present in the room during laser use and not considered in the above categories should complete the Laser Safety Awareness (Foundation) training in order to familiarise themselves with the hazards associated with lasers. All staff must follow the local rules and any associated safety procedures provided by the employer. The local rules must be read and signed annually. All training must be documented and available for audit purposes. Training resources for staff groups are given in Appendix 4a.

5) Laser Equipment

All equipment must comply with the NHS Tayside Medical Equipment Management Policy The LPA must be consulted before any laser is purchased, prior to any loan or demonstration unit being put into use and before any laser is brought onto NHS Tayside premises or used by NHS employees. Responsibility for ensuring that all laser equipment is purchased, installed and maintained to satisfy laser safety requirements lies with the relevant Clinical Lead. It is advised that all lasers are maintained according to the manufacturers recommendations and have appropriate service contracts in place. All documentation


relating to service history must be kept within the department and held by the LPS. An equipment handover form will be used during maintenance or repair visits by service personnel.

6) Medical Supervision Pre, interim and post employment eye examinations are not routinely recommended as part of a safety programme.

7) Incidents Any incident which leads to the inadvertent exposure of patients, staff or members of the public must be reported as soon as possible to the relevant line manager, LPS and the LPA. Incidents must be reported through the DATIX incident recording system and to the appropriate line manager and the LPA. In the case of a known or suspected ocular exposure, an eye examination should be carried out within 24 hours. If the injured person is exhibiting symptoms of shock or other injury requiring immediate attention, they should be taken immediately to the nearest A&E department with the associated laser card Appendix 7a. The LPA should carry out an investigation of the circumstances under which the incident occurred. Reports of the accidents and serious defects in equipment should be reported to appropriate authorities. Incident reports will be considered through the Radiation Safety Committee. Incident reporting procedure is given in Appendix 7b.

8) Personal Protective Equipment There shall be adequate personal protective equipment (PPE) for all persons (including the patient) who are at risk in the laser controlled area. Advice should be sought from the LPA on the selection of suitable PPE. Staff have a responsibility to use any such equipment provided and management must ensure that they do so.

9) Communications It is vital to the success of this policy that good communications and co-operation exists between the Laser Protection Advisor, Board Management, Clinical Group Directors, Heads of Departments and other support managers

10) Key Contacts

Dr James Cotton Associate Medical Director, Access and Assurance

Ms S McVey (Laser Protection Advisor) ext 36551 Dr Ewan Eadie (Assist LPA) ext 33894


Appendix 3a

Duties of a Laser Protection Supervisor (LPS) The prime function of this appointment is: To supervise work with a laser or lasers within their area or department and ensure the local rules are implemented in practice. The LPS will have responsibility for supervising the overall safety or the laser environment but the clinician carrying out the procedure remains responsible for the safety of the patient. In addition the LPS will be expected to take responsibility, working with the Departmental Manager and to the LPA for the following:

1. To assist the LPA with development of the Risk Assessment and Local Rules. This must detail the principles and working practice to ensure safe use of the laser, and must be kept under continuous review.

2. To ensure that procedures are performed in a safe manner. Any problems or potential issues with regard to safety that cannot be readily addressed should be reported to the LPA.

3. To notify the LPA of any change in work or facility where they may have an impact on laser safety. Changes would include purchase of new equipment, modifications to equipment, or a new location or alterations to the current location.

4. To report any known or suspected incidents to the LPA and to assist the LPA in their investigation.

5. To ensure collaboration with the LPA, Clinical Laser Expert, Authorised Laser Users, and the employer to ensure staff receive information on laser safety, instruction, and training as appropriate.

6. To ensure all members of staff involved in work with lasers have read the Local Rules and signed to say that they have done so.

7. To maintain the registers of Authorised Laser Users, and of Laser Assisting staff. 8. To maintain the training records for Authorised Laser Users. 9. To ensure, with advice from the LPA, that protective eyewear is appropriate to the

type of laser used, that all Personal Protective Equipment (PPE) is stored and labelled correctly and that staff are trained in its use.

10. To examine all Personal Protective Equipment (PPE), warning signs and lights, and other safety features as appropriate at regular intervals for damage and correct function and to keep a record of such checks.


LETTER OF APPOINTMENT OF LASER PROTECTION SUPERVIS ORS

Dear [INSERT NAME} NHS Tayside Radiation Safety Committee has endorsed the recommendation that you be appointed Laser Protection Supervisor for: Hospital: Department: Laser (s): Enclosed is a document outlining the duties of a Laser Protection Supervisor working for NHS Tayside. Please familiarise yourself with this document. Yours sincerely, Associate Medical Director Access and Assurance Directorate Chair of the Radiation Safety Committee

NHS Tayside Ninewells Hospital

Dundee DD1 9SY

Tel. 01382 660 111

www.nhstayside.scot.nhs.uk

Date: XX Month YYYY


Appendix 3b Duties of the Clinical Laser Expert The prime function of this appointment is:

1. To exercise supervision of the clinical work with lasers for which you are appointed Clinical Laser Expert

2. To advise other users on clinical aspects of laser procedures and practice 3. To assist in the supervision and training of clinical laser users 4. To advise on suitable training for clinical laser users within your area and maintain

records of clinical training. 5. To confirm the competence of all clinical laser users within your area of responsibility

prior to their approval as authorised laser users by the Laser Protection Supervisor 6. To ensure that authorised laser users within your area maintain their competence. 7. To ensure that procedures are performed in a safe manner. Any problems or potential

issues with regard to safety that cannot be readily addressed should be reported to the LPA.

8. To notify the LPA of any change in work or facility where they may have an impact on laser safety. Changes would include purchase of new equipment, modifications to equipment, or a new location or alterations to the current location.

9. To report any known or suspected incidents to the Laser Protection Supervisor or Laser Protection Advisor, and assist in their investigation as required.

10. To ensure collaboration with the LPA, Clinical Laser Expert, Authorised Laser Users, and the employer to ensure staff receive information on laser safety, instruction, and training as appropriate.


LETTER OF APPOINTMENT OF CLINICAL LASER EXPERTS

Dear [INSERT NAME} NHS Tayside Radiation Safety Committee has endorsed the recommendation that you be appointed Clinical Laser Expert for: Hospital: Department: Laser (s): Enclosed is a document outlining the duties of a Clinical Laser Expert working for NHS Tayside. Please familiarise yourself with this document. Yours sincerely, Associate Medical Director Access and Assurance Directorate Chair of the Radiation Safety Committee

NHS Tayside Ninewells Hospital

Dundee DD1 9SY

Tel. 01382 660 111

www.nhstayside.scot.nhs.uk

Date: XX Month YYYY


Appendix 4a Laser Training Requirements Authorised Laser Users

Safety Training: Authorised Laser users should be familiar with the ‘Core of Knowledge’ for laser safety and be able to provide evidence of suitable training. It is recommended that this training is repeated at least every 5 years (MHRA Guidance notes). Authorised Laser Users must have sufficient supervised clinical training before undertaking any procedures involving a laser. The BMLA ‘Core of Knowledge’ is available online and a multiple choice questionnaire must be completed (and passed) in order demonstrate the required level of safety training to become an Authorised Laser User. The LPA will issue a certificate of completion. In order to access the online course and questionnaire please contact the Laser Protection Advisor: Siobhan McVey, Medical Physics Department, Ninewells Hospital and Medical School [email protected] Direct Dial: 01382 496551 or ext 36551 Equipment Training: The manufacturer or their supplier usually provides the equipment-based training to the authorised user(s) at the time of installation. After this, training may be provided to additional staff internally either by the Clinical Laser Expert or an Authorised Laser User. If the equipment is upgraded or replaced, additional training may be required. This should be determined by the Clinical Laser Expert. Clinical Training: The Clinical Laser Expert is responsible for determining the clinical training required. Appropriate records must be kept to demonstrate that the user has the appropriate clinical training prior to becoming an authorised laser user.

Laser Assisting Staff

Safety Training: It is recommended that Laser Assisting staff should be familiar with the ‘Core of Knowledge’ for laser safety and be able to provide evidence of suitable training. It is recommended that this training is repeated at least every 5 years (MHRA Guidance notes). The BMLA ‘Core of Knowledge’ is available online and a multiple choice questionnaire must be completed (and passed) in order demonstrate the required level of safety training to become an Authorised Laser User. The LPA will issue a certificate of completion. In order to access the online course and questionnaire please contact the Laser Protection Advisor: Siobhan McVey, Medical Physics Department, Ninewells Hospital and Medical School [email protected] Direct Dial: 01382 496551 or ext 36551


Equipment Training: The manufacturer or their supplier usually provides the equipment-based training to the authorised user(s) at the time of installation. After this, training may be provided to additional staff internally either by the Laser Protection Supervisor or Laser Assisting staff. If the equipment is upgraded or replaced, additional training may be required. This should be determined by the Laser Protection Supervisor.

Other Staff It advised that staff who do not operate lasers but who are present during laser procedures should be aware of the hazards from laser radiation. A LearnPro module – NHS Tayside: Laser Safety (Foundation) – is available to all staff in NHS Tayside (http://nhs.learnprouk.com/). This LearnPro module provides basic laser safety information but is not a replacement for the Laser Safety Core of Knowledge. Refresher training should be performed at least every 3 years for Foundation Level training. The Laser Protection Advisor may also deliver face-to-face session on Laser Safety as required. Please contact the LPA to arrange.

http://nhs.learnprouk.com/


Appendix 5a Handover Procedure The Laser Protection Supervisor must ensure that lasers for which they are responsible are serviced and maintained in accordance with the manufacturer’s recommendations. During servicing/maintenance, the risks from a laser may be very different to those in normal use (for example, because covers may be removed or interlocks disabled). For this reason, control of the equipment and the associated work area should be handed over to the engineer, using the handover form. When the equipment and area is handed back to the control of NHS Tayside, the Laser Protection Supervisor should consider whether the advice of the LPA is required in relation to any equipment modification that has been carried out. Part 1 and Part 2 of the hand-over form must be completed by the Operator passing the laser equipment/ Controlled Area to the 3rd party. Exact details of any known fault or other reason for the visit should be given. The 3rd party must complete the ‘External Contractor’ declaration in Part 2, to declare that they have received adequate training, are competent to work on the specific equipment and that they are working to the relevant manufacturer’s protocols and procedures. The 3rd party signature also confirms that they acc ept responsibility for the Controlled Area on behalf of the service company. Part 3 - The 3rd party completes and signs Part 3 when returning the laser equipment/Controlled Area. The first ‘tick list’ on the form serves to draw the attention of the user to what ‘major’ work was undertaken and helps to determine the requisite level of testing needed to ensure that the equipment remains in a satisfactory condition to be used. Remember that repairs or modifications may have been undertaken even though a routine service visit was booked. Part 4 - The person completing Part 4 must only tick the ‘YES’ box at the end of the form when the equipment has been declared to be in a satisfactory condition for clinical use. The person signing Part 4 on behalf of the employer must be satisfied that the work of the 3rd party has not resulted in alterations to safety devices such as interlocks or warning signals and has not adversely affected the safety of staff/patients. If the person signing Part 4 is in any doubt about tests required, then they should contact their Laser Protection Supervisor or Laser Protection Adviser. If the person accepting the equipment is NOT satisfied with the radiation safety of the equipment, they must sign the first section in Part 4 and ask the engineer to take remedial action. If the person accepting the equipment is satisfied with the radiation safety of the equipment, they must sign the second section in Part 4 and tick the ‘fit for clinical use’ box. The person signing Part 4 also confirms that they accept responsibility for the Controlled Area on behalf of the NHS Employer.


If the 3rd party’s work is completed after staff have left the department, the 3rd party must be asked to attach a ‘Do Not Use’ notice to the equipment declaring that it must not be used until further notice. The warning notices must be stuck on so that they cannot slip off. The equipment must not be used on patients before the handover form has been completed and the ‘fit for clinical use’ box has been ticked, except in extreme emergency.


Appendix 7a

Laser name and location details:

If you KNOW you have received an eye injury from a laser Contact the LPS

Telephone Extension

TAKE THIS SHEET AND ANY EYE PROTECTION THE CASUALTY WAS WEARING TO THE HOSPITAL WITH THE CASUALTY AND GIVE THEM TO MEDICAL STAFF

If you think you MAY have received an eye injury from a laser Contact the LPS

Telephone Extension

Go to Ninewells Hospital as soon as possible and within 24 hours of the exposure. Do not drive yourself. Get a taxi or a friend to take you.

Ask for a referral to the Ophthalmology department TAKE THIS SHEET TO THE HOSPITAL WITH YOU AND GIVE I T TO MEDICAL STAFF

STATING YOU HAVE RECENTLY WORKED WITH THIS LASER AN D THINK YOU MAY HAVE RECEIVED AN EYE INJURY

Report ALL accidents to LPA within 24 hours (Extension 36551)

An accident report must also be submitted using the NHS Tayside incident reporting procedure and via DATIX

INFORMATION FOR OPHTHALMOLOGY DEPARTMENT LASER DETAILS:

Type of laser: Class of laser:

Wavelength: nm

Power Output (CW):

or Pulse Energy, Duration, and Rate (pulsed):

=================COMPLETE ACCIDENT DETAILS BELOW ================

EXPOSURE DETAILS:

Name of casualty:

Circumstances of accident/injury:

Time/Date of Injury:

Eye affected: Left/Right/Both* delete as appropriate

Was protective eyewear being worn? Yes/No* delete as appropriate


Appendix 7b

ARRANGEMENTS IN THE EVENT OF A LASER INCIDENT A medical examination by an appropriate Ophthalmologist should be carried out within 24 hours of a suspected incident involving an ocular exposure.

1. The laser procedure should be suspended. The operator should then decide whether it is appropriate to continue.

2. The Laser Protection Supervisor and the Laser Protection Advisor should be informed of the incident and should investigate the cause and take any remedial action required to prevent a recurrence.

3. If eye exposure suspected: a. An eye examination should be carried out within 24 hours by an

ophthalmologist and the Laser Protection Advisor informed as soon as possible.

b. If the injured person is exhibiting signs of shock, they should be taken immediately to the nearest A&E department.

4. The incident must be logged through the DATIX system to provide a record of the incident and the LPA must be informed.

5. If equipment failure is suspected, the laser should be removed from use pending inspection and the key secured. Equipment faults will be reported to HFS-IRIC.


PROCEDURE FOR DEALING WITH LASER INCIDENT

Incident or near-miss occurs

NHS Tayside incident form completed by person involved in the incident

Inform LPS

Incident reported on RIDDOR /

HFS-IRIC as per current procedure.

LPS completes relevant section of the NHS

Tayside incident form

NHS Tayside incident form sent to LPA

Incident investigation carried out by LPA;

internal report written

Incident reported at next Radiation Safety

Committee meeting

Any recommendations for improvements to working practice must be fed back to department where incident occurred and all other laser users across Tayside, as appropriate.

LPSs must discuss contents of feedback with staff and implement any recommendations.

Organisation

response

Local

response


FORM FOR RECORDING LASER INCIDENT

Date of incident:

Name of person(s) involved:

DOB / CHI:

Operator of equipment:

Department:

Room:

Referring clinician & Ward (if applicable):

Nature of incident: Reasons for incident occurring: Details of source (N.B. further details of the source may be requested by the LPS/LPA): Make / Model: Duration of exposure: Has the Laser Protection Supervisor been informed?

Yes No Signed: Date: ___________ Designation: Contact number:


To be completed by the LPS: Have any procedures been broken?

Yes No

If yes, which? Have any procedures been found to be inadequate?

Yes No

If yes, which?

Remedial action required to reduce likelihood of further event: Signed: Date: Printed name: Contact number: * Send form to LPA: Siobhan McVey, Medical Physics Dept, Ninewells Hospital Tel: ext 36551 Direct Dial: 01382 496551 Email: [email protected] To be completed by the LPA: Has an investigation been carried out?

Yes No Details of investigation & recommendations (use separate sheet if required) Has incident been reported to the Radiation Safety Committee or other authorities?

Yes No Other:

Have details of the incident and recommendations for improvements to working practice been disseminated to all laser users in NHS Tayside?

Yes No Signed: Date: Laser Protection Adviser


NHS TAYSIDE - POLICY APPROVAL CHECKLIST POLICY AREA: Clinical Policy POLICY TITLE: Laser Safety Policy POLICY MANAGER: Ms S McVey

Why has this policy been developed?

To establish a robust system for implementing Laser Safety Management

Has the policy been developed in accordance with or related to legislation? – Please give details of applicable legislation.

Control of Artificial Optical Radiation at Work Regulations (AORWR)

Has a risk control plan been developed and who is the owner of the risk? If not, why not?

The Associate Medical Director of the Access and Assurance Directorate will be advised by the Laser Protection Advisor

Who has been involved/consulted in the development of the policy?

Radiation Safety Committee

Has the policy been Equality Impact Assessed in relation to:- Has the policy been Equality Impact Assessed not to disadvantage the following groups:-

Age Disability Gender Reassignment Pregnancy/Maternity Race/Ethnicity Religion/Belief Sex (men and women) Sexual Orientation

Please indicate Yes/No for the following: Yes Yes Yes Yes Yes Yes Yes Yes

People with Mental Health Problems Homeless People People involved in the Criminal Justice System Staff Socio Economic Deprivation Groups Carers Literacy Rural Language/Social Origins

Please indicate Yes/No for the following: Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Does the policy contain evidence of the Equality Impact Assessment Process?

Yes

Is there an implementation plan? Yes, via the Radiation Safety Committtee

Which officers are responsible for implementation?

Board Executive

When will the policy take effect?

May 2000

Who must comply with the policy/strategy?

Board Management and Employees

How will they be informed of their responsibilities?

Via Staff Bulletin, Radiation Safety Committee and the NHS Tayside Intranet

Is any training required?

No

If yes, attach a template

N/A

Are there any cost implications?

No

If yes, please detail costs and note source of funding

N/A

Who is responsible for auditing the implementation of the policy? Radiation Safety Committee What is the audit interval? 12 months Who will receive the audit reports? Radiation Safety Committee When will the policy be reviewed and provide details of policy review period (up to 5 years)

Annually by Ms S McVey

POLICY MANAGER: _Siobhan McVey_____________ DATE: ___14/04/2020_____________ APPROVAL COMMITTEE TO CONFIRM: ___Radiation Safety Committee_____________________ ADOPTION COMMITTEE TO CONFIRM: ___Radiation Safety Committee______________________

Appendix 8


Equality Impact Assessment Name of Policy, Service Improvement, Redesign or St rategy: NHS Tayside Laser Safety Policy Lead Director of Manager: Dr James Cotton / Ms S McVey What are the main aims of the Policy, Service Impro vement, Redesign or Strategy? Overview of NHS Tayside arrangements for Laser Safety Description of the Policy, Service Improvement, Red esign or Strategy – What is it? What does it do? Who does it? And wh o is it for? Policy gives oversight of NHS Tayside arrangements for Laser Safety. Identifies roles responsibilities and arrangements. Applies to every employee of NHS Tayside. What are the intended outcomes from the proposed Po licy, Service Improvement, Redesign or strategy? – What will happen as a resul t of it?- Who benefits from it and how? To give an overview of NHS Tayside arrangements for Laser Safety and identify roles and responsibilities Name of the group responsible for assessing or cons idering the equality impact assessment? This should be the Policy Working Grou p or the Project team for Service Improvement, Redesign or Strategy. NHS Tayside Radiation Safety Committee

Appendix 9


SECTION 1 Part B – Equality and Diversity Impacts Which equality group or Protected Characteristics d o you think will be affected?

Item Considerations of impact Explain the answer and if applicable detail the Impact

Document any Evidence/Research/Data to support the consideration of impact

Further Actions required

1.1 Will it impact on the whole population? Yes. If yes will it have a differential impact on any of the groups identified in 1.2. If no go to 1 – 2 to identify which groups

Yes: it is concerned with anybody exposed to medical uses of lasers. No

. MHRA Guidance on the safe use of lasers, intense light source systems and LEDs in medical, surgical, dental and aesthetic practices, April 2008

None





1.2 Which of the protected characteristic(s) or groups will be affected?

• Minority ethnic population (including refugees, asylum seekers & gypsies/travellers)

• Women and men • People in religious/faith

groups • Disabled people • Older people, children

and young people • Lesbian, gay, bisexual

and transgender people • People with mental

health problems • Homeless people • People involved in

criminal justice system • Staff • Socio- economically

deprived groups

None disproportionally so N/A





1.3 Will the development of the policy, strategy or service improvement/redesign lead to

• Discrimination • Unequal opportunities • Poor relations between

equality groups and other groups

• Other

No


SECTION 2 – Human Rights and Health Impact. NOT APPLICABLE Which Human Rights could be affected in relation to article 2, 3, 5, 6, 9 and 11. (ECHR: European Conv ention on Human Rights)




2.1

On Life (Article 2, ECHR) • Basic necessities such as

adequate nutrition, and safe drinking water

• Suicide • Risk to life of / from others • Duties to protect life from

risks by self / others • End of life questions

2.2

On Freedom from ill -treatment (Article 3, ECHR) • Fear, humiliation • Intense physical or mental

suffering or anguish • Prevention of ill-treatment, • Investigation of reasonably

substantiated allegations of serious ill-treatment

• Dignified living conditions


2.3 On Liberty (Article 5, ECHR) • Detention under mental

health law • Review of continued

justification of detention • Informing reasons for

detention

2.4 On a Fair Hearing (Article 6, ECHR) • Staff disciplinary

proceedings • Malpractice • Right to be heard • Procedural fairness • Effective participation in

proceedings that determine rights such as employment, damages / compensation

2.5 On Private and family life (Article 6, ECHR) • Private and Family life • Physical and moral integrity

(e.g. freedom from non-consensual treatment, harassment or abuse

• Personal data, privacy and confidentiality

• Sexual identity • Autonomy and self-

determination


• Relations with family, community

• Participation in decisions that affect rights

• Legal capacity in decision making supported participation and decision making, accessible information and communication to support decision making

• Clean and healthy environment

2.6 On Freedom of thought, conscience and religion (Article 9, ECHR) • To express opinions and

receive and impart information and ideas without interference

2.7 On Freedom of assembly and association (Article 11, ECHR) • Choosing whether to belong

to a trade union

2.8 On Marriage and founding a family • Capacity • Age


2.9 Protocol 1 (Article 1, 2, 3 ECHR) • Peaceful enjoyment of

possessions


SECTION 3 – NOT APPLICABLE Which health and lifestyle changes will be affected ?




3.1 What impact will the function, policy/strategy or service change have on lifestyles?

For example will the changes affect:

• Diet & nutrition • Exercise & physical activity • Substance use: tobacco,

alcohol or drugs • Risk taking behaviours • Education & learning or

skills • Other

3.2. Does your function, policy or service change consider the impact on the communities?

Things that might be affected include:

• Social status • Employment (paid/unpaid) • Social/family support • Stress • Income





3.3 Will the function, policy or service change have an impact on the physical environment? For example will there be impacts on:

• Living conditions • Working conditions • Pollution or climate change • Accidental injuries/public

safety • Transmission of infectious

diseases • Other

3.4 Will the function, policy or service change affect access to and experience of services? For example

• Healthcare • Social services • Education • Transport • Housing





3.5 In relation to the protected characteristics and groups identified:

• What are the potential impacts on health?

• Will the function, policy or

service change impact on access to health care? If yes - in what way?

• Will the function or policy

or service change impact on the experience of health care? If yes – in what way?


SECTION 4 – Financial Decisions Impact NOT APPLICABLE What will affect the financial decisions? Item

Considerations of impact Explain the answer and if applicable detail the Impact



4.1

• Is the purpose of the financial decision clearly set out

• Has the impact of your financial proposals on equality groups been thoroughly considered before any decisions are arrived at

4.2 • Is there sufficient information to show that “due regard” has been paid to the equality duties in its decision making

• Have you identified methods for mitigating or avoiding any adverse impacts Have those likely to be affected by the proposal been consulted and involved





5. Involvement, Consultation and Engagement (IEC) 1) What existing IEC data do we have?

• Existing IEC sources • Original IEC • Key learning

2) What further IEC, if any, do you need to undertake?

Clinical Governance Arrangements throughout Access, Medicine & Surgery. Radiation Safety Committee Interaction with regulators. None

Clinical Governance & Radiation Safety Committees Inspection Reports

None





6. Have any potential negative impacts been identified?

• If so, what action has been proposed to counteract the negative impacts? (if yes state how)

For example: • Is there any unlawful

discrimination? • Could any community get

an adverse outcome? • Could any group be

excluded from the benefits of the function/policy?

(consider groups outlined in 1.2) • Does it reinforce

negative stereotypes? (For example, are any of the groups identified in 1.2 being disadvantaged due to perception rather than factual information?)

NO

None





7. Data & Research • Is there need to gather

further evidence/data? • Are there any apparent

gaps in knowledge/skills?

No No

None

8. Monitoring of outcomes • How will the outcomes

be monitored? • Who will monitor? • What criteria will you use

to measure progress towards the outcomes?

Audit & Reports to NHS Tayside Board . Regulatory Inspections

None

9.. Recommendations State the conclusion of the Impact Assessment

No adverse impact or discrimination

None





10. Completed function/policy • Who will sign this off? • When?

Chief Executive. September 2016

Sign off

11. Publication

September 2016

None


Conclusion Sheet for Equality Impact Assessment

Positive Impacts (Note the groups affected)

Neutral

Negative Impacts (Note the groups affected)

None

What if any additional information and evidence is required

None

From the outcome of the Equality Impact Assessment what are your recommendations? (refer to questions 5 - 10) There is no adverse impact or discrimination.

CLINICAL Laser Safety Policy

Documents

Transcript of CLINICAL Laser Safety Policy