This research aims to determine the handling of externalities and their implications for the implementation of environmental accounting at RSUD XYZ (XYZ Hospital) from the perspective of the amanah metaphor. The method used is qualitative research with a case study approach at XYZ Hospital. Data was collected through observation, interviews, and documentation. Data validity was also tested using two types of triangulation. The results show XYZ's Hospital commitment to maintaining environmental balance and reducing the negative impacts of its operations by taking health, safety, and environmental control measures in accordance with Minister of Health Regulation No. 7 of 2019 concerning hospital environmental health. In terms of the application of environmental accounting, XYZ Hospital still does not specifically separate environmental burdens from supply and service burdens. From the perspective of amanah metaphors XYZ Hospital has fulfilled its responsibilities, including those of the trust giver, the trust recipient, and the trust itself.