Beechdale Health Centre
Clinical Waste Protocol
Document Control
A.
Confidentiality Notice
This document and the information contained therein is the property of Beechdale Health
Centre.
This document contains information that is privileged, confidential or otherwise protected from
disclosure. It must not be used by, or its contents reproduced or otherwise copied or disclosed
without the prior consent in writing from Beechdale Health Centre.
B.
Document Details
Classification:
Author and Role:
Organisation:
Document Reference:
Current Version Number:
Current Document Approved By:
Date Approved:
C.
Jane Smith P.N
Beechdale Health Centre
CW
1
Jane Smith
07.03.2013
Document Revision and Approval History
Version
Date
Version Created By:
Version Approved By:
1
07.03.2013
Jane Smith
Arun Venogupal
1.1
01.04.2014
Arun Venugopal
Arun Venugopal
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Comments
Reviewed from Initial
Document
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Introduction
The Practice has a general duty to ensure, so far as is reasonably practicable, the health and
safety of employees and other persons who may be affected by the storage, handling or disposal
of waste products.
It is essential that waste is disposed of in a proper manner and that the method of disposal, and
the standard of record keeping, complies with both legislation and best practice. This Protocol is
specific to clinical waste.
Objective
To handle clinical waste in a safe manner, and observe correct procedures for safe disposal and
storage.
Clinical waste is classed as hazardous material and must therefore be handled and disposed of in
a safe manner to ensure that personnel are not injured or exposed to contamination.
The policy will be reviewed annually to ensure that it remains effective and complies with both
best practice guidelines and current legislation.
The aim of this protocol is to increase awareness among staff who may be involved in the
handling of clinical waste to ensure that safe procedures are maintained.
Waste handling risk assessments will be carried out for all employees handling clinical waste.
Disposal of clinical waste
Clinical waste is disposed of using colour coded bags, clearly marked clinical waste:
Key Colour-Codes of Bags:
Yellow
 Requires disposal via incineration.
 Includes anatomical waste.
 Classified as Hazardous Waste.
Orange
 May be treated to render it safe prior to disposal in a licensed facility.
 May contain pathogens.
 Classified as Hazardous Waste.
Purple
 Requires disposal via incineration.
 Contaminated or consisting of cytotoxic or cytostatic products.
 Practices should ensure proper colour-coded receptacles are available for this waste stream,
including bags, sharps bins, and rigid containers.
 Classified as Hazardous Waste.
Yellow / Black
 Offensive / hygiene waste. May be land-filled in a licensed facility.
 Not considered to be infectious.
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Full bags are collected from the hazard waste bin which is situated at the back of building on a
fortnightly basis and new clinical bags are delivered fortnightly
Each Consulting Room has a pedal bin which is clearly marked clinical waste, which is only used
for the purpose of clinical waste. These pedal bins must by lined with pedal bin liners of the
appropriate size.
Clinical Waste bins must be emptied daily, by removing the pedal bin liner and disposing of it in
to the yellow clinical waste bin bags.
Disposable gloves must be worn at all times during this procedure and then disposed of after use.
Pedal bin liners are not to be recycled - they need to be disposed of and replaced.
All Clinical bags must be securely fastened and labelled in accordance with instructions from the
Sandwell Clinical Waste to prevent spillage of the contents and placed within the designated
hazard waste bin, in staff car park in bin, to await collection.
All bags, whether partly or completely full, must be kept in the designated hazard waste bin,
which must be kept locked at all times.
No other storage facility must be used either temporarily or permanently, unless the designated
hazard waste bin is unavailable, in which case other suitable arrangements will be made by the
Practice Manager.
The hazard waste bin needs to be cleaned and mopped out on a weekly basis – the designated
day is Thursday, as this is the day the hazard waste bin is emptied.
All waste is to be handled and disposed of by an authorised contractor who will provide certified
waste transfer notices and who will be responsible for disposal of the waste using registered
disposal sites.
Casual disposal of waste, or the use of casual contractors is NOT permitted.
All transfer of waste from the Practice to an authorised contractor must be supported by a Waste
Transfer Note (WTN). This may be a note issued for the purpose of one transfer of waste only, or
it may be in the form of a certificate (perhaps annual) which states the nature of the waste and
its collection arrangements.
The Practice will retain the Waste Transfer Notes for at least 2 years; for Hazardous Waste, for a
3 year period.
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Notifying the CQC of Serious Injury to a person who uses the Service
The Practice Manager at the Practice is responsible for notifying the CQC without delay about
events that lead to:
 Serious injury to any person who uses the service.
 An injury requiring treatment by a healthcare professional to avoid death or serious injury.
These serious injuries include:

Injuries that lead to or are likely to lead to permanent damage – or damage that lasts or is
likely to last more than 28 days – to:
 A person’s sight, hearing, touch, smell or taste
 Any major organ of the body (including the brain and skin)
 Bones
 Muscles, tendons, joints or vessels
 Intellectual functions, such as
 Intelligence
 Speech
 Thinking
 Remembering
 Making judgments
 Solving problems.

Injuries or events leading to psychological harm, including:
 Post-traumatic stress disorder
 Other stress that requires clinical treatment or support
 Psychosis
 Clinical depression
 Clinical anxiety
 The development after admission of a pressure sore of grade 3 or above that develops
after the person has started to use the service (European Pressure Ulcer Advisory Panel
Grading)
 Any injury or other event that causes a person pain lasting or likely to last for more than
28 days
 Any injury that requires treatment by a healthcare professional in order to prevent:
 Death
 Permanent injury
 Any of the outcomes, harms or pain described above.
Where the Registered Person is unavailable, for any reason, Jane Smith will be responsible for
reporting the serious injury to the CQC.
There is a dedicated Notification form for this type of incident. The form is contained in the
Outcome 20 document “Notification of Other Incidents – Outcome 20 Composite Statements
and Forms”
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Guidance on completing the Hazardous Waste Regulations 2005
Collection Consignment note:
Please complete the following form on a Thursday,
ready for collection on Thursday.
Sharp Boxes
The Practice Nurse within the practice.
Courier for Sandwell Hospital who is collecting
The designated person will:
 Check all boxes are labelled correctly.
 Ensure correct and adequate information is provided for the carrier, if there are any specific
handling requirements.
 Count up the number of sharp boxes there are to be collected.
 Enter the number of 4 litre boxes in the ‘qty ‘column.
 Enter the number of 13 litre boxes in the ‘qty’ column.
 Sign the declaration to state all boxes are labelled correctly and the carrier has been
informed of any specific handling requirements.
 Leave the folder with the Practice Manager.
Clinical Bags
Julie Stevens
Gail Kesterton
When collecting from the surgery and placing clinical waste into the clinical waste bins, the
designated person must:
 Make sure all bags, including those already in the hazard waste bin, are labelled correctly.
Courier from Sandwell Hospital
When collecting Clinical waste from the hazard waste bin, the designated person must undertake
the following activity:
 Count up the number of clinical waste yellow bags there are to be collected.
 Enter the number of bags onto the consignment form in the ‘qty’ column.
 Sign the consignor’s declaration section to confirm that all bags are labelled correctly.
 Every Thursday, leave folder containing the completed hazardous waste forms in the labelled
box with the Practice Manager. (This is shared between Dr Sharmas surgery and Dr
Leadbeatter and Bhimjie surgery).
Guidelines on weighing clinical waste
All clinical waste must be weighed prior to collection and the weight entered on to the
consignment note.
As the clinical waste can be put into the designated hazard waste bin by several different people
(for example district nurses, cleaners etc.) prior to collection, each time waste is added to the
waste bin, it is essential that each individual waste bag and box is weighed and the weight
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written on the bag / box in indelible black marker pen, together with the Practice’s Environment
Agency Reg number (BUT/773932).
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The person completing the consignment note must insert a TOTAL weight for all bags or boxes
under the heading ‘Qty’ or ‘Qty in Kgs’, together with the count of each in the column to the right
of the note under the headings ‘container type, number, and size’.
A signature, time and date must also be clearly entered onto the consignment note.
Patients’ diabetic boxes do not need to be weighed and are not to be entered on the
consignment notes, but should be marked “Non-Hazardous” in indelible black marker pen.
Used Medicines
Waste, including unused medicines and sharps are not accepted from patients or members of
the public as the Practice is not a licensed waste contractor. However, unused medicines and
sharps bins (diabetic patients) will be accepted from patients who have their medication
dispensed by the Practice.
Non-dispensing patients are to be directed to community pharmacies.
Sharps
Sharps are any items which may cause a puncture and include needles, syringes with attached
needles, broken glass, ampoules, scalpel blades etc.
Syringes containing residual products should not be intentionally discharged fully in order to
dispose of them in a “fully discharged” sharps bin (i.e. the orange – lidded bin).
If the syringe is only partially discharged and contaminated, it must be disposed of in the yellowlidded sharps bin.
Syringes that have contained cytotoxic or cytostatic drugs (see list on next page) should be
disposed of in a purple lidded sharps bin.
Sharps waste excludes syringe bodies where there is no needle attached.
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List of non-chemotherapy hazardous (cytotoxic/cytostatic) drugs (ex HTM 07-01,
2nd edition consultation)
Anastrozole (ARMIDEX)
Azathioprine
Bacillus Calmette-Guerin (BCG) Vaccine
Bicalutamide (CASODEX)
Chloramphenicol
Ciclosporin
Cidofovir
Coal-Tar containing products
Colchicine
Danazol
Diethylstilbestrol
Dinoprostone
Dithranol containing products
Dutasteride (AVODART)
Estradiol
Exemestane (AROMASIN)
Finasteride (PROSCAR)
Flutamide (DROGENIL)
Ganciclovir
Gonadotropin Chlorinic
Goserelin (ZOLADEX)
Interferon containing products
Leflunomide
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Letrozole
Leuprorelin acetate
Medroxyprogesterone
Megestrol
Menotropins
Mifepristone
Mycophenolate mofetil (CELLCEPT)
Nafarelin
Ostrogen containing products
Oxytocin + Sytocinon & syntometrine
Podophyllyn
Progesterone containing products
Raloxifene (EVISTA)
Ribavirin
Sirolimus
Streptozocin
Tacrolimus (PROGRAF)
Tamoxifen
Testosterone
Thalidomide
Toremifene citrate
Trifluridine
Valganciclovir
Zidovudine
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