Joint Commission Revisions for Hospitals Related to Life Safety Code Update

PUBLISHED: Oct 24, 2017
Relevant to: Hospitals

As a part of updates related to the adoption of the 2012 editions of the National Fire Protection Association’s NFPA 101: Life Safety Code and NFPA 99: Health Care Facilities Code, the Joint Commission has made revisions to EC.02.04.03 for the Hospital program, effective January 1, 2018.

Revisions include:

  • A new Element of Performance (EP 8) which requires all equipment that is used or intended to be used in oxygen-enriched atmospheres to be clearly labeled. The label must be permanent and able to tolerate cleaning/disinfecting. Labeling should be placed on:
  • Oxygen-metering equipment (label shall read: "OXYGEN–USE NO OIL")
  • Pressure-reducing regulators (label shall read: "OXYGEN–USE NO OIL")
  • Humidifiers
  • Nebulizers shall be labeled with name of manufacturer or supplier.
  • Labels on flowmeters, pressure-reducing regulators, and oxygen-dispensing apparatuses shall designate the gases for which they are intended.
  • Cylinders and containers are labeled in accordance with Compressed Gas Association (CGA) C-7. Note: Color coding shall not be used as the primary method of determining cylinder or container contents. (For full text, refer to NFPA 99-2012:
  • A new Element of Performance (EP 8) which requires all hospitals that have hyperbaric facilities must comply with construction, equipment, administration, and maintenance requirements of NFPA 99-2012: Chapter 14.
  • A new Element of Performance (EP 26) which requires hospitals to conduct equipment maintenance on anesthesia apparatus.
  • The apparatus shall be tested at the final path to patient after any adjustment, modification or repair.
  • Each apparatus connection shall be checked to verify proper gas flow and an oxygen analyzer will be used to verify oxygen concentration prior to returned to service.
  • Areas designated for servicing of oxygen equipment shall be clean and free of oil, grease, or other flammables.

Included with today’s notice are example polices related to this topic.

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