About the AuthorSheila Dunn, DA, MT (ASCP), holds a doctoral degree in clinical laboratory science from the Catholic

University of America in Washington, DC. She has helped thousands of outpatient medical facilities comply

with federal regulations such as CLIA and OSHA through her presentations at a nationwide seminar series.

She has written more than 150 articles about regulatory issues and healthcare delivery systems and serves

as an advisor to numerous companies.

14C

©2005–2014 HCPro, a division of BLR. All rights reserved, including right of reproduction. The author(s) and their agent(s) have made every reasonable effort in the preparation of this publication to ensure the accuracy of the information. However, the information in this book is sold without warranty, either expressed or implied. The authors, the editors, their agents, and the publishers will not be liable for any damages caused or alleged to be caused directly, indirectly, incidentally, or consequentially by the information in this publication. This publication cannot and does not provide specific information for a user’s exact situation. Users of this publication should exercise their own judgment and, where appropriate, seek the assistance of legal counsel regarding their particular situation.

HCPro, a division of BLR75 Sylvan Street, Suite A-101

Danvers, MA 01923Tel: 800/650-6787Fax: 800/639-8511

www.hcmarketplace.com

OSHAPROGRAMMANUALfor Medical Facilities

OSHA Program Manual for Medical Facilities is published by HCPro, a division of BLR.

Copyright © 2014 HCPro, a division of BLR.

All rights reserved. Printed in the United States of America. 5 4 3 2 1

ISBN: 978-1-60146-743-0

No part of this publication may be reproduced, in any form or by any means, without prior written consent of

HCPro, a division of BLR, or the Copyright Clearance Center (978-750-8400). Please notify us immediately

if you have received an unauthorized copy.

HCPro, a division of BLR, provides information resources for the healthcare industry.

HCPro, a division of BLR, is not affiliated in any way with The Joint Commission, which owns the JCAHO

and Joint Commission trademarks.

Sheila Dunn, DA, MT (ASCP), Author

Jay Kumar, Senior Managing Editor

Marge McFarlane, PhD, CHSP, CHFM, HEM, MEP, CHEP, Reviewer

Mike Mirabello, Senior Graphic Artist

Matt Sharpe, Senior Manager of Production

Elizabeth Petersen, Vice President

Advice given is general. Readers should consult professional counsel for specific legal, ethical, or

clinical questions.

Arrangements can be made for quantity discounts. For more information, contact:

HCPro, a division of BLR

75 Sylvan Street, Suite A-101

Danvers, MA 01923

Telephone: 800-650-6787 or 781-639-1872

Fax: 800-639-8511

E-mail: customerservice@hcpro.com

Visit HCPro online at: www.hcpro.com and www.hcmarketplace.com

3/1422065

i

Important Information About the Use of This Program

This product is intended for use in one facility and is copyrighted for this purpose. Please do not copy the con­tents or print additional copies for use in other facilities or for teaching anyone other than your em ployees. This manual may not be transferred to another workplace without the written consent of HCPro, Inc.

As an OSHA Program Manual owner, you may call or e­mail us anytime you have OSHA­related ques tions specific to your practice. HCPro also publishes a monthly newsletter, Medical Environment Update, to help you keep your OSHA Program Manual current from year to year. Should OSHA pass a revised or new regula tion, we will inform you of that change through Medical Environment Update. We will also provide forms, in structions, posters, and advice through this newsletter to help you keep your practice up to date and in compliance.

Follow these steps to determine if your manual is up to date:1. Check for the three­character code in the lower right­hand corner of the box on the title page of

this manual.

2. Then log into your HCPro account on your Medical Environment Update subscription page at www.hcpro.com/login-3265. If you have not established a username/password or have forgotten it, you may retrieve it by clicking the link on this page.

3. Once logged in to the Medical Environment Update subscription page, find the most recent issue.

4. There you will find an update file. If the file has the same code as on the title page, your manual is up to date.

5. If the update code is different, open the file and choose from the appropriate pdf to download for your manual (medical or dental).You also have the choice of printing your update pages one­sided or two­sided, depending on your printing capabilities.

6. Print the updated pages and replace the old pages.

Should you have difficulty logging in or accessing the updated pages, contact HCPro customer service: Telephone: 800/650­6787

E­mail: customerservice@hcpro.com Thank you for your business. Let us know how we can help.

HCPro, a division of BLR75 Sylvan Street, Suite A­101

Danvers, MA 01923Telephone: 800/650­6787

Fax: 800/639­8511www.hcmarketplace.com

How to Customize this Program

To come into complete OSHA compliance, the information in this program must be customized to reflect the actual circumstances in your workplace. For easy tracking, initial and date when you complete an item.

Item Initials Date

Post the “It’s The Law” poster in a place that is visible to all employees. This poster, OSHA #3165, is located in the front pocket of this manual.

↓

Hang the eyewash station sign located in the front pocket of this manual. Make sure it is clearly visible above or next to the eyewash.

↓

Designate the evacuation route, and post in several locations. Be sure to post the route in the reception area and break room. See Tab 3, page 3­18, 3­18A for details.

↓

Read each tabbed section and verify that the policies and procedures described apply to your practice.

↓

ii

Remove or strike through any procedure

you don’t perform!

iii

Item Initials Date

Either cross through the unused procedures, and initial and date your deletion.

OR

Remove the pages from the manual.

↓

Throughout, fill in all blanks with information specific to your facility. A master listing of “blanks” is on pages iv – v. Spaces to initial and date are provided on the master listing.

_______

↓

Use the Monthly and Annual Checklists to organize your OSHA activities.

↓

Document all activities performed. See Tab 11 for master copies of all forms.

↓

Make photocopies of forms and logs that are used repeatedly. To customize any form, see the enclosed CD.

↓

Keep this manual up to date! Download updates and insert them into this manual immediately upon receipt of the current issue of Medical Environment Update Newsletter, which explains how to access the update Web page.

Master List of Program Items for Customization

Throughout this OSHA Program Manual, blanks are included for you to fill in information specific to your facility.

The following pages contain “blanks” for you to customize. Enter your initials and the date you made the entry in the far right columns. This way when you do your annual review you can quickly tell if you need to update old information.

Page Item Information Needed Initials Date 2­2 Facility Details Facility Name, Safety Officer Name,

Phone Numbers, Safety Manual Location 2­7 Workplace Hazards Record other hazards found in facility2­14 Annual Review Safety officers review of plan 3­2 Emergency Phone List Local contact phone numbers3­17 Systems Failure Contact names and numbers3­183­19

Evacuation Procedures How alarms and announcements will be made, employee duties in emergency, assembly location

3­20 Evacuation Route Evacuation route3­22 Emergency

Preparedness SuppliesItems that will be kept on hand for emergencies

3­25 Civil Disturbance Assembly location3­263­27

Severe Weather Safest location in building (Note: 3 blanks)

3­30 – 3­37

Workplace Violence Details of your Violence Prevention Plan (Note: 6 blanks and 2 lists that require checkmarks)

3­413­42

Crash Kit/Cart Components

Items included in facility’s crash kit/cart

3­43 – 3­47

Drug­Free Workplace Program

Details of your Drug­Free Workplace Pro gram (Note: if no options selected on 3-43, other customizations not necessary)

5­11 Exposure Prone Procedures

Procedures performed in facility that could expose employees

5­12 BBP Determination List Employees who have definite risk of exposure (class I)

5­14 BBP Determination List Employees who have possible risk of exposure (class II)

5­15 Restricted Access Areas

Restricted areas not listed in items 1­3

5­17 Handwashing Locations Locations handwashing takes place

iv

Page Item Information Needed Initials Date 5­21 Sharps Recapping Instances when recapping is allowed5­22 Safety Sharps Instances when safety sharps are not used5­24 Laundry How biohazardous laundry is cleaned, or

if only disposables are used5­26 PPE Locations PPE provided in facility and its locations5­31 When to Wear PPE If tasks not already listed are performed in

facility, add to table5­33 Hepatitis Vaccinations The provider and location for HBV vaccine5­43 BBP Post ­exposure

Testing Who does medical evaluation and lab testing in case of an employee exposure

6­5 TB Risk Assessment Previous year data on TB from health department and facility

6­7 Early TB Identification Procedures to ID active TB patients and where they are referred for treatment

6­9 Managing TB Patients Where suspected TB patients will wait and where they will be transferred to

6­10 N­95 Masks Will the facility provide N­95 masks or not 6­15 TST Record Each employee’s TST details6­18 Employee TB Infections Where employees with positive TST or

symptoms of TB will be referred6­19 TB Exposure Log Only fill in if employee is exposed to TB6­21 Pre-pandemic Influenza

PlanningIndividual to be response coordinator, local key agencies, and contact information

6­22 Pre-pandemic Influenza Planning (con’t)

Communication plan, name of PR, and educational coordinators

6­23 Influenza Staff Shortage

Number of staff needed and who will cover

6­24 Influenza Reporting Frequency of reporting, who will review reports

7­11 Chemical Exposure Facility name and phone for exposure medical follow­up

8­2 Bleach Contact Time If you use bleach for decontamination, check and document state specific contact time

8­3 Housekeeping Schedule

Your cleaning methods and frequency

8­18 Eyewash Stations Location and types of eyewashes8­19 Biohazardous Waste Company name and phone number of

who picks up your biohazardous waste10­8 10­9

New Employee Orientation

Copy master from Tab 11, or CD­ROM, and use for new hires

10­18 Annual Employee Training Record

Copy master from Tab 11, or CD­ROM, and use to document annual retraining

v

What Is Included in this Program

Contents at a GlanceOccupational Safety and Health Administration (OSHA) regulations protect employees from unsafe working conditions. This includes on­the­job exposure to infectious diseases, such as HIV, hepatitis and tuberculosis, and hazardous substances such as glutaraldehyde.

This OSHA Program Manual is intended to help outpatient medical facilities develop their particular policies and procedures in order to achieve compliance with the major federal OSHA regulations that impact medical practices.

Here’s what you’ll find inside:

TAB 1: What Is OSHA?This first section provides a quick look at OSHA, including what types of people and workplaces are protected under the agency’s jurisdiction, and what to expect from an OSHA inspection.

TAB 2: OSHA Program AdministrationTab 2 introduces medical facilities to administration of an OSHA Program Manual, including appointing an OSHA Safety Officer, establishing the duties and authority of the OSHA Safety Officer, and organizing compliance duties.

TAB 3: General Facility SafetyThis section provides an overview of the general workplace requirements applicable to ambulatory medical facilities, including fire safety, electrical safety, exits and building evacuation, workplace violence, and an emergency action plan.

TAB 4: Ergonomics in the Medical WorkplaceFind out how to protect employees from repetitive motion disorders in the workplace in this section. Though OSHA’s Ergonomics Standard was rescinded, Tab 4 provides commonsense measures to prevent the musculoskeletal disorders most frequently found in healthcare employees.

TAB 5: Bloodborne Pathogens Exposure Control PlanBehind Tab 5 is a “fill-in-the-blanks” Exposure Control Plan for compliance with OSHA’s Bloodborne Pathogens Standard (29 CFR 1910.1030). Once customized, this becomes your facility’s policies to protect healthcare employees from occupationally acquired exposure to certain infectious organisms such as the human immunodeficiency virus (HIV) and hepatitis viruses (especially hepatitis B and C). The Bloodborne Pathogens Standard has been in effect since 1992, and was amended January 18, 2001 to include the requirement for sharps with built­in safety features.

vi

TAB 6: TB/Infection ControlTab 6 contains a “fill-in-the-blanks” TB Exposure Control Plan to protect employees from occupational exposure to Mycobacterium tuberculosis. It also contains measures to protect employees from respiratory infections, such as influenza, and a Pandemic Flu Plan.

TAB 7: Hazardous Chemical SafetyEverything you need to know to comply with OSHA’s Hazard Communication Standard (29 CFR 1910.1200) is in this section. This Standard (also called the “Right To Know”) has been in effect since 1987 for all medical facilities, and is designed to protect employees from on­the­job exposure to hazardous chemicals.

TAB 8: DecontaminationTab 8 covers all aspects of decontamination in a medical practice, including chemical and biological spills and waste, and routine disinfection and sterilization of medical instruments.

TAB 9: Specialty ServicesThis section includes safety considerations for specialty services such as x­rays, laser and other ambulatory surgery, compressed gas handling, laboratory testing, and administration of chemotherapy. This section may or may not be applicable to your practice. Please disregard information on any services that are not performed in your facility.

TAB 10: Employee TrainingTab 10 describes the types and amount of employee training necessary for medical employees.

TAB 11: Master Record Forms This section contains master copies of Record Forms that will be needed repeatedly, from Equipment and Facility Records, to Bloodborne Pathogens, TB and HazCom Records, to Employee Training Records. Be sure to photocopy the original form before removing it from this section. These forms are also included on the CD­ROM in the front pocket of this OSHA Program Manual.

TAB 12: OSHA Regulations & Key ContactsTab 12 contains copies of actual OSHA regulations pertinent to ambulatory medical facilities and key contacts for selected Federal agencies.

OSHA Regulations that Are Not Included in this Safety ProgramThe following OSHA Standards are not addressed in this manual, since they do not apply to the activities in typical ambulatory medical facilities:Chemical Hygiene Standard (*29 CFR 1910.1450). Laboratories within medical

facilities that use hazardous chemicals in bulk amounts must comply with this regulation.

vii

Formaldehyde Standard (*29 CFR 1910.1048). Medical facilities that work with bulk quantities of formaldehyde (pouring it into specimen containers and/or processing specimens contained in formalin) may be required to comply with this regulation.

Hazardous Waste Operations and Emergency Response (HAZWOPER) (29 CFR 1910.120), applies to workplaces that store, treat and dispose of large volumes of hazardous waste, or respond to emergencies caused by the uncontrolled release of infectious material.

viii

OSHA PROGRAM MANUAL

Contents

Front Pocket OSHA Poster 3165: IT’S THE LAW! Laminated Eyewash Station Sign 4 Sample Biohazard Self­Adhesive Labels CD­ROM (MS Word for Windows 2000) with Master Record Forms (Tab 11) from this Manual

for Customization.

ix

IntroductionImportant Information About the Use of This Program ............................ i

How to Customize This Program ................................................................ ii

What Is Included in This Program ............................................................... vi

TAB 1: What Is OSHA?A Quick Look at OSHA ................................................................................. 1-1

States with OSHA­Approved Plans ..................................................................................... 1­1OSHA Consultative Services Division ................................................................................. 1­2OSHA’s Jurisdiction .............................................................................................................. 1­2OSHA’s General Duty Clause .............................................................................................. 1­2

Employee or Employer? ............................................................................... 1-3Employers’ Responsibility Under OSHA .............................................................................. 1­4

Overview of OSHA Standards ...................................................................... 1-5

OSHA Inspections ......................................................................................... 1-5Employee Complaints .......................................................................................................... 1­6If an On­site OSHA Inspection Occurs ................................................................................ 1­6During the Inspection ........................................................................................................... 1­7What OSHA Inspectors May Ask Employees ...................................................................... 1­8The Typical OSHA Inspection .............................................................................................. 1­8The Closing Conference ...................................................................................................... 1­9

OSHA Sanctions ........................................................................................... 1-10

Whistleblower Protection ............................................................................ 1-12

Students and Volunteers ............................................................................. 1-14

Page

Contents

x

TAB 2: OSHA Program AdministrationInjury and Illness Prevention Plan Flowchart ............................................ Reverse Side of TOC

Injury and Illness Prevention Plan .............................................................. 2-1Management Leadership and Employee Involvement ........................................................ 2­1Key Contacts for the OSHA Program Manual ..................................................................... 2­1Location of the OSHA Manual Program ............................................................................... 2­2

Duties of the OSHA Safety Officer ............................................................... 2-2Accident/Incident Investigation & Reporting Procedure .......................... 2-4

Definition of an Accident and/or Incident ............................................................................. 2­4When to Investigate an Accident and/or Incident ................................................................. 2­4How to Document an Accident and/or Incident .................................................................... 2­4Recording Accidents or Injuries for OSHA ........................................................................... 2­4Correcting Unsafe or At­Risk Conditions ............................................................................. 2­5

Recordkeeping Requirements ..................................................................... 2-5Workplace Hazard Analysis ......................................................................... 2-7Practical Ideas for Involving Employees .................................................... 2-8Organizing OSHA Compliance Duties ........................................................ 2-9

Weekly Facility Review Checklist ........................................................................................ 2­10Monthly Facility Review Checklist ....................................................................................... 2­11Annual Facility Review Checklist ......................................................................................... 2­12Annual OSHA Safety Program Review ................................................................................ 2­15

TAB 3: General Facility SafetyKeeping Employees Safe ............................................................................. 3-1

Important Phone Numbers & Contacts ................................................................................3­1Emergency Phone List ........................................................................................................ 3­2

Fire Safety ...................................................................................................... 3-3Automatic Sprinkler Systems ............................................................................................... 3­3Fire Alarms ........................................................................................................................... 3­3Fire Procedures: Immediate Actions .................................................................................... 3­3Building Evacuation ............................................................................................................. 3­4Fire Extinguishers ................................................................................................................ 3­4

Purchase the Right Extinguisher ................................................................................. 3­5How Many Fire Extinguishers to Have & Where to Put Them ..................................... 3­6To Use a Fire Extinguisher: Think “PASS” .................................................................. 3­7When to Extinguish Fires with a Portable Fire Extinguisher ........................................ 3­7When NOT to Extinguish Fires and to Evacuate ......................................................... 3­7Fire Extinguisher Inspections ...................................................................................... 3­7Fire Extinguisher Maintenance .................................................................................... 3­8

Fire Risks During Surgery ................................................................................................... 3­8

Fire Extinguisher Supplement ..................................................................... Supplement

Fire Drills ............................................................................................................................. 3­9

Electrical Safety ............................................................................................ 3-9

Contents

xi

Physical Characteristics of a Safe Medical Facility ................................... 3-10Automated External Defibrillators ........................................................................................ 3­10Air Quality ............................................................................................................................. 3­10

Mold ............................................................................................................................. 3­11Mold Remediation ............................................................................................... 3­12

Aisles ................................................................................................................................... 3­13Emergency Lighting ............................................................................................................. 3­14Employee Dress Code ......................................................................................................... 3­14Exits, Means of Egress ........................................................................................................ 3­14Exit Doors ............................................................................................................................ 3­15Exit Signs ............................................................................................................................. 3­15Floors ................................................................................................................................... 3­16Lighting ................................................................................................................................ 3­16Noise .................................................................................................................................... 3­16Portable Space Heaters ....................................................................................................... 3­17Restricted Access Areas ...................................................................................................... 3­17Sinks .................................................................................................................................... 3­17Storage ................................................................................................................................ 3­17

Systems Failure ............................................................................................. 3-18Evacuation Plan ............................................................................................ 3-18

Evacuation Procedures ........................................................................................................ 3­19Methods for Carrying Patients During an Evacuation .................................................. 3­20

Evacuation Floor Plan .......................................................................................................... 3­21Example Evacuation Floor Plan .......................................................................................... 3­22

Emergency Preparedness Supplies ........................................................... 3-23Emergency Action Procedures ................................................................... 3-23

Bioterrorism: Suspicious Letters or Packages ..................................................................... 3­24What Is a “Suspicious Package”? ................................................................................ 3­24

Bomb Threat ........................................................................................................................ 3­25If You Discover a Bomb or a Suspicious Item .............................................................. 3­26Explosion ..................................................................................................................... 3­26

Civil Disturbance .................................................................................................................. 3­26Earthquake ........................................................................................................................... 3­27

If a Tremor Occurs when You Are Inside ..................................................................... 3­27After the Tremor Is Over .............................................................................................. 3­27

Severe Weather ................................................................................................................... 3­28Flood ............................................................................................................................ 3­28Hurricane ..................................................................................................................... 3­28Severe Thunderstorm or Tornado Warning ................................................................. 3­28Tornado Safety Tips ..................................................................................................... 3­29Severe Thunderstorm or Tornado Watch ..................................................................... 3­29Toxic External Atmosphere .......................................................................................... 3­29

Violence ............................................................................................................................... 3­30Violence Prevention Plan Introduction ................................................................................. 3­30Overview of Violence Prevention Plan Components ........................................................... 3­31

Violence Prevention Plan; Part 1 ................................................................................. 3­31Violence Prevention Plan; Part 2 ................................................................................. 3­38

More Sources for Prevention of Workplace Violence ........................................................... 3­39

Contents

xii

First Aid .......................................................................................................... 3-40Crash Kit/Cart Components ......................................................................... 3-43Drug-Free Workplace Program .................................................................... 3-43Service Animals ............................................................................................. 3-48Holiday Decorations ..................................................................................... 3-50

Sample Checklist: Spot Check Your Facility’s Holiday Decorations .....................................3­50

Safe Decorations and Displays Policy ........................................................ 3-52Slip, Trip, and Fall Prevention ...................................................................... 3-54

Contaminants on the Floor ...................................................................................................3­54Poor Drainage: Pipes and Drains .........................................................................................3­54Indoor Walking Surface Irregularities ...................................................................................3­54Outdoor Walking Surface Irregularities ................................................................................3­55Weather Conditions: Ice and Snow ......................................................................................3­55Inadequate Lighting ..............................................................................................................3­55Stairs and Handrails .............................................................................................................3­55Stepstools and Ladders........................................................................................................3­56Tripping Hazards: Clutter, Including Loose Cords, Hoses, Wires, Medical Tubing ..............3­56Improper Use of Floor Mats and Runners ............................................................................3­56Healthcare Facility Slip, Trip, and Fall Hazard Checklist ......................................................3­57

TAB 4: Ergonomics in the Medical WorkplaceA Quick Look at Ergonomics ....................................................................... 4-1Common Musculoskeletal Disorders .......................................................... 4-2

Back Injuries .........................................................................................................................4­3Techniques to Reduce Injury ........................................................................................4­4

Fatigue .................................................................................................................................4­5Repetitive Stress Injuries/Wrist Injuries ................................................................................4­6

Wrist and Hand Exercises ............................................................................................4­6Eye Strain .............................................................................................................................4­8

Why Prevent CVS? ......................................................................................................4­8Symptoms of CVS ........................................................................................................4­8Other Suggestions for Relieving Eye Strain .................................................................4­9

Selecting Equipment ..................................................................................... 4-10

TAB 5: Bloodborne Pathogens Exposure Control PlanExposure Control Plan Introduction ........................................................... 5-1Overview of Bloodborne Pathogens Standard Components .................... 5-2A Quick Look at Occupational Exposure .................................................... 5-3Industries Subject to the Bloodborne Pathogens Standard ..................... 5-3Universal/Standard Precautions .................................................................. 5-4

Other Potentially Infectious Materials (OPIM) ..................................................................... 5­4Implementing Universal/Standard Precautions ................................................................... 5­5

Contents

xiii

Bloodborne Pathogens ................................................................................ 5-6Epidemiology of Bloodborne Pathogens of Concern to Healthcare Workers ...................... 5­6Update on AIDS in the Workplace ....................................................................................... 5­9Transmission of Bloodborne Pathogens .............................................................................. 5­9

Exposure Determination .............................................................................. 5-9Personnel Who Are Occupationally Exposed ...................................................................... 5­9

Exposure Prone Procedures ....................................................................................... 5­10Bloodborne Pathogens Exposure Determination List #1 (Form 8) ...................................... 5­12Other Personnel Who Could Potentially Be Occupationally Exposed ................................. 5­12Bloodborne Pathogens Exposure Determination List #2 (Form 9) ...................................... 5­13Employees Who Are Not Occupationally Exposed .............................................................. 5­14

Restricted Access Areas .............................................................................. 5-14Engineering/Work Practice Controls ........................................................... 5-14

Biohazard Labels ................................................................................................................. 5­15Handwashing ....................................................................................................................... 5­15

When to Wash Hands .................................................................................................. 5­17How to Wash Hands .................................................................................................... 5­17Artificial Nails ............................................................................................................... 5­17

Sharps Safety ...................................................................................................................... 5­18What to Look for in Safety Devices ............................................................................. 5­18Sharps Evaluation Procedure ...................................................................................... 5­19Use of Non­Safe Sharps .............................................................................................. 5­20Phlebotomy Needles ................................................................................................... 5­21

Sharps Containers ............................................................................................................... 5­21Sharps Container Maintenance ................................................................................... 5­22Sharps Container Disposal Procedure ........................................................................ 5­22

Biohazardous Waste (See Tab 8) ........................................................................................ 5­23Laundry ................................................................................................................................ 5­23

Personal Protective Clothing & Equipment ............................................... 5-24PPE Strategy ....................................................................................................................... 5­24Locations of PPE ................................................................................................................. 5­25

Gloves ......................................................................................................................... 5­26When to Wear Gloves ......................................................................................... 5­26How to Wear Gloves ........................................................................................... 5­26Latex Allergy ....................................................................................................... 5­27Preventing Allergic Reactions ............................................................................. 5­28

Face Protection ........................................................................................................... 5­29Body Protection ........................................................................................................... 5­29Emergency Resuscitation Equipment ......................................................................... 5­30

When to Wear PPE .............................................................................................................. 5­30

Hepatitis B Vaccine ....................................................................................... 5-31Safety of the Hepatitis B Vaccine ......................................................................................... 5­32Documenting Employee Hepatitis Vaccines ........................................................................ 5­32Titering Employees after the Hepatitis B Vaccination .......................................................... 5­33

How to Determine Employee Immunity ....................................................................... 5­33Testing Employees Vaccinated before the Titer Requirement ..................................... 5­34

Contents

xiv

Types of Hepatitis B Tests ........................................................................... 5-34Interpreting Hepatitis B Test Results .................................................................................... 5­35

New Employee Hepatitis B Virus Vaccination Flow Chart ........................ Supplement

Post-exposure Evaluation & Follow-up ...................................................... 5-37What Is an Exposure? .......................................................................................................... 5­37What to Do after an Occupational Exposure ....................................................................... 5­37For HCV Exposures ............................................................................................................ 5­39For HBV Exposures ............................................................................................................. 5­39For HIV Exposures .............................................................................................................. 5­40When to Get Expert Consultation for HIV Post­exposure Prophylaxis ................................ 5­41Confidentiality of Post-exposure Procedures ...................................................................... 5­41Employee Counseling/Precautions ..................................................................................... 5­42

Occupational Exposure Management Resources ..................................... 5-42Incident Report/Sharps Injury (Form 14) .................................................... 5-43Post-exposure Checklist ............................................................................. 5-45Post-exposure Medical Evaluation Declination Form (Form 18) .............. 5-46Injection Safety ............................................................................................. 5-47

Information for Providers ..................................................................................................... 5­47

Frequently Asked Questions: Injection Safety FAQs for Providers ........ 5-48Overview ............................................................................................................................. 5­48Injection Procedures ............................................................................................................ 5­50

Infection Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens ..................... Supplement

Infection Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens (fingerstick, blood glucose sampling) ........................................................ Supplement

Bloodborne Pathogens Resources ............................................................. 5-53

TAB 6: TB/Infection Control PlanA Quick Look at TB ....................................................................................... 6-1

TB Transmission .................................................................................................................. 6­1Risk Factors for Developing Active TB ................................................................................ 6­2

TB Exposure Control Plan Policy ................................................................ 6-3Overview: How to Protect Staff from Contracting TB at Work ............................................. 6­3TB Risk Assessment ........................................................................................................... 6­4

TB Risk Assessment Results Form (Form 21) ............................................................ 6­5Early Identification of Patients with Active TB ...................................................................... 6­6

Symptoms of TB .......................................................................................................... 6­6Managing Patients with Suspected or Confirmed TB ........................................................... 6­9

TB Isolation Procedures for Cough­Inducing & Aerosol­Generating Procedures ........ 6­9Respiratory Protection for Healthcare Workers: N­95 Respirators .............................. 6­10

Seal Checking N­95 Respirators ......................................................................... 6­10

Contents

xv

Employee TB Skin Testing (TST) ......................................................................................... 6­10Baseline Employee TST: The Two­Step Skin Test ...................................................... 6­11

Two­Step TST Interpretation ............................................................................... 6­12Interpreting the TST ..................................................................................................... 6­12

False Positive/False Negative TB Tests .............................................................. 6­12Workers Who Have Had BCG Vaccination ......................................................... 6­13

Periodic Retesting of Employees ................................................................................ 6­13Recording TST Results ............................................................................................... 6­14TST Record (Form 22) ................................................................................................ 6­15TST Declination (Form 23) .......................................................................................... 6­16

Evaluation & Management of Healthcare Employees Exposed to TB ................................. 6­17Employees with Symptoms of TB ................................................................................ 6­17Employees Who Have Been Exposed to a Known TB Patient ................................... 6­17Positive Employee Skin Tests & Skin Test Conversions .............................................. 6­17TB Exposure Log (Form 24) ........................................................................................ 6­19Decontaminating Patient Care Area and Equipment ................................................... 6­20

Employee Training ............................................................................................................... 6­20

Pandemic Influenza Plan .............................................................................. 6-21Pre-pandemic Influenza Planning ....................................................................................... 6­21Once a Pandemic Is Announced ......................................................................................... 6­24OSHA Enforcement for H1N1 Influenza .............................................................................. 6­26

Identifying Very High and High Exposure Risks .......................................................... 6­26Dealing with N95 Respirator Shortages ...................................................................... 6­27Prioritize Your Facility’s Use of N95 Respirators ......................................................... 6­27Documentation ............................................................................................................ 6­28

Pandemic Influenza Resources ........................................................................................... 6­29

MRSA Prevention and Control .................................................................... 6-29MRSA Transmission ............................................................................................................. 6­30Patient Precautions .............................................................................................................. 6­30Hand Hygiene ...................................................................................................................... 6­31Contact Precautions ............................................................................................................ 6­31Environmental Cleaning ....................................................................................................... 6­32Infected Employees ............................................................................................................. 6­33MRSA Resources ................................................................................................................ 6­33

Pertussis and Worker Vaccination .............................................................. 6-34Supplement: Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care ......................................................... S1-S10

TAB 7: The Hazard Communication StandardA Quick Look at HazCom ............................................................................. 7-1

Determining Which Chemicals Are Hazardous .................................................................... 7­1Routes of Exposure to Hazardous Substances ................................................................... 7­2

Material Safety Data Sheets/Safety Data Sheets ........................................ 7-3Examples of Substances Requiring MSDS (SDS) ............................................................... 7­3Substances Not Requiring MSDS (SDS) ............................................................................. 7­3MSDS (SDS) Flowchart Determination ................................................................................ 7­4

Contents

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Information Required on MSDS (SDS) ................................................................................ 7­4How to Get MSDS (SDS) ..................................................................................................... 7­5Where to Keep MSDS (SDS) .............................................................................................. 7­5

Classification of Hazardous Substances ................................................... 7-6Flammable & Combustible Liquids ...................................................................................... 7­6

Storage of Hazardous Substances .............................................................. 7-7Hazardous Chemicals with Permissible Exposure Limits (PEL) ............. 7-8Labeling Hazardous Substances ................................................................ 7-8

HazCom Pictograms and Hazard Statements ..................................................................... 7­8Pictograms ........................................................................................................................... 7­9NFPA Label System ............................................................................................................. 7­10

Safety Tips for Working with Hazardous Substances ............................... 7-10Hazardous Chemical Waste Packaging & Disposal .................................. 7-11Medications Security & Disposal ................................................................ 7-12

Security for Prescription Drugs ............................................................................................ 7­12Security for Controlled Substances ...................................................................................... 7­12Disposal of Prescription Drugs ............................................................................................ 7­13Disposal of Hazardous Drugs .............................................................................................. 7­13

Medical Consultation & Injury Evaluation .................................................. 7-13HazCom Recordkeeping .............................................................................. 7-14

TAB 8: DecontaminationA Quick Look at Decontamination .............................................................. 8-1Routine Housekeeping Procedures ............................................................ 8-1

Decontaminating Work Surfaces ......................................................................................... 8­1Sample Housekeeping Schedule (Form 7) .......................................................................... 8­3

Spill Containment Plan ................................................................................. 8-4Spill Clean­up Procedures ................................................................................................... 8­4Spills That Contain Broken Glass or Sharp Objects ............................................................ 8­5Chemical Spill Clean­up Procedures ................................................................................... 8­5Chemical Exposure to Skin ................................................................................................. 8­5Mercury Spills ...................................................................................................................... 8­6Cytotoxic Drug Spill Clean­up .............................................................................................. 8­6

Decontamination of Medical Instruments & Equipment ........................... 8-7When to Sterilize .................................................................................................................. 8­7Precleaning Instruments Prior to High­Level Disinfection or Sterilization ............................ 8­8Sterilization .......................................................................................................................... 8­9Quality Checks for Sterilization ............................................................................................ 8­9High­Level Disinfecting ........................................................................................................ 8­10

Using Glutaraldehyde .................................................................................................. 8­11Sterilant Safety ............................................................................................................ SupplementGlutaraldehyde Spills ................................................................................................... 8­13Sources for Chemical Air Monitoring ........................................................................... 8­14

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Testing the Potency of Glutaraldehyde ....................................................................... 8­14Disposing of Glutaraldehyde ....................................................................................... 8­14

Cleaning Transvaginal and Transrectal Ultrasound Probes ................................................ 8­14Disinfect Transvaginal and Transrectal Probes After Each Use .................................. 8­15Cleaning Ultrasound Transducers ............................................................................... 8­15

Decontaminating Vaginal Specula ....................................................................................... 8­15Keeping Employees Safe During Instrument Disinfection ................................................... 8­16Decontaminating Semi­critical Patient Care Equipment ...................................................... 8­16Decontaminating Non­critical Patient Care Equipment ....................................................... 8­17Decontaminating Personal Protective Equipment (PPE) ..................................................... 8­18

Eyewashes ..................................................................................................... 8-18Number & Placement of Eyewash Stations ......................................................................... 8­18Eyewash Maintenance ........................................................................................................ 8­19

Waste Disposal ............................................................................................. 8-20Biomedical Waste Disposal ................................................................................................. 8­20Hazardous Waste Disposal ................................................................................................. 8­21Waste Handling & Storage ................................................................................................... 8­23

TAB 9: Specialty ServicesAbout this Section ........................................................................................ 9-1Working Safely with Cytotoxic Drugs ......................................................... 9-1

NIOSH Hazardous Drug List for Healthcare ........................................................................ 9­1Effects of CD Exposure on Health ....................................................................................... 9­1Safe Work Practices ............................................................................................................ 9­2Clothing ................................................................................................................................ 9­2Drug Preparation & Administration ...................................................................................... 9­2Sample List of Drugs that Should be Handled as Hazardous ............................................. Supplement

Selecting Biological Safety Cabinets (BSC) ................................................................ 9­3Cleaning the Drug Preparation Area ............................................................................ 9­4

Caring for Patients Receiving CDs ...................................................................................... 9­4Waste Disposal .................................................................................................................... 9­4Spill Clean­up ....................................................................................................................... 9­5

Suggested Spill Kit Components ................................................................................. 9­5CD Receiving ....................................................................................................................... 9­6CD Storage .......................................................................................................................... 9­6CD Transport ....................................................................................................................... 9­6Employee Training ............................................................................................................... 9­6Employee Medical Surveillance ........................................................................................... 9­7Employee Exposure ............................................................................................................. 9­7

Gas Cylinder Safety ...................................................................................... 9-7Electrosurgical Safety (Laser, LEEPs) ........................................................ 9-9

Safe Work Practices ............................................................................................................ 9­10

Surgical Safety .............................................................................................. 9-11General PPE Indications for Surgery ................................................................................... 9­11

Surgical Gowns ........................................................................................................... 9­11

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Surgical Gloves ........................................................................................................... 9­12Face and Eye Protection ............................................................................................. 9­12Headwear .................................................................................................................... 9­13Shoe Covers ................................................................................................................ 9­13Surgical Drapes ........................................................................................................... 9­13

Safe Sharp Strategies for the Surgical Setting .................................................................... 9­13Scalpels ....................................................................................................................... 9­13Suture Needles ........................................................................................................... 9­13

Transferring Sharps Safely .................................................................................................. 9­14How to Use the Neutral Zone (NZ) .............................................................................. 9­14Tips for Minimally Invasive Surgeries .......................................................................... 9­15Safety Techniques for Operating on Patients Infected with Known Bloodborne Pathogens .................................................................................... 9­15

Preventing Surgical Fires .................................................................................................... 9­15

Laboratory Safety ......................................................................................... 9-16Laboratory Specimen Transport .......................................................................................... 9­17

Radiation Safety ............................................................................................ 9-18Regulation of the Medical Use of Nuclear By­products ........................................................ 9­18The “ALARA” Principle ......................................................................................................... 9­18Radiation Safety Guidelines for Personnel........................................................................... 9­19Radiation Safety Policies for the Facility .............................................................................. 9­19Ionizing Radiation Exposure Limits ...................................................................................... 9­20Special Precautions for Pregnant Workers .......................................................................... 9­20Low­level Radioactive Waste Disposal ................................................................................ 9­21NRC Notification, Reports, and Record ................................................................................ 9­21NRC Resources and Publications ........................................................................................ 9­22

Working Safely with Cryogenic Liquids ..................................................... 9-23Precautions for Handling Liquid Nitrogen ............................................................................ 9­23Storing Liquid Nitrogen ........................................................................................................ 9­24Personal Protective Equipment ........................................................................................... 9­24Liquid Nitrogen Disposal ...................................................................................................... 9­24Steps to Take if There Is Accidental Exposure .................................................................... 9­25

First Aid (cryogenic burns) ........................................................................................... 9­25First Aid (anoxia) .......................................................................................................... 9­25

Safe Vaccine Handling and Storage ........................................................... 9-26Waste Anesthetic Gases .............................................................................. 9-28

Where Exposures Occur ...................................................................................................... 9­29Preventing Exposures .......................................................................................................... 9­29

Controls ....................................................................................................................... 9­30Medical Surveillance ............................................................................................................ 9­30Recordkeeping .................................................................................................................... 9­31More Information .................................................................................................................. 9­31

TAB 10: Employee TrainingA Quick Look at the Employee Training Program ..................................... 10-1Training Format ............................................................................................ 10-1

Checklist for an Effective Safety Training Session ............................................................... 10­2

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Interactive Safety Training Exercises .................................................................................. 10­2General Safety ............................................................................................................. 10­3Fire Safety ................................................................................................................... 10­3Bloodborne Pathogens Safety ..................................................................................... 10­3Chemical Safety ........................................................................................................... 10­3TB Safety ..................................................................................................................... 10­4

Annual Employee Retraining ....................................................................... 10-5Bloodborne Pathogens Annual Training Contents ............................................................... 10­6Respiratory Protection Annual Training Contents ................................................................ 10­6Hazard Communication Annual Training Contents .............................................................. 10­7

New Employee Orientation .......................................................................... 10-7New Employee OSHA Orientation Checklist (Form 26) ...................................................... 10­8

Sample Tests with Answer Keys ................................................................. 10-10OSHA Annual Retraining: Sample Essay Test Questions (Form 28) ................................... 10­11OSHA Annual Retraining: Sample Essay Test—Answer Key .............................................. 10­12OSHA Annual Retraining: Sample Multiple Choice Test Questions (Form 29) .................... 10­13OSHA Annual Retraining: Sample Multiple Choice Test—Answer Key ............................... 10­15OSHA Annual Retraining: Sample True/False Test Questions (Form 30) ............................ 10­16OSHA Annual Retraining: Sample True/False Test—Answer Key ....................................... 10­17

Documenting Employee Training ................................................................ 10-17Annual Safety Training Record (Form 27) ................................................... 10-18

TAB 11: Master Record FormsGeneral Equipment and Facility Records

Safety Report ....................................................................................................................... Form 1Autoclave Log ...................................................................................................................... Form 2Eyewash Station Weekly Check Log ................................................................................... Form 2­AAnnual OSHA Program (Exposure Control Plan) Review ................................................... Form 3Weekly Facility Review Checklist ........................................................................................ Form 4­AMonthly Facility Review Checklist ....................................................................................... Form 4­BAnnual Facility Review Checklist ......................................................................................... Form 5Fire Drill Evaluation Form .................................................................................................... Form 5­AEmployee Fire Drill Participation Sign­up Sheet ................................................................. Form 5­BRisk Assessment for Workplace Violence ............................................................................ Form 6Housekeeping Schedule ...................................................................................................... Form 7Emergency Telephone List .................................................................................................. Form 7­AHealthcare Facility Slip, Trip, and Fall Hazard Checklist ..................................................... Form 7­B

Bloodborne Pathogens RecordsBloodborne Pathogens Exposure Determination List #1 ..................................................... Form 8Bloodborne Pathogens Exposure Determination List #2 ..................................................... Form 9Bloodborne Pathogens PPE Compliance Checklist ............................................................ Form 9­AFailure to Use PPE .............................................................................................................. Form 9­A­1Bloodborne Pathogens Compliance Checklist: ECP, Training, and Records ...................... Form 9­BSafety Needle/Syringe Evaluation ....................................................................................... Form 10Phlebotomy Device Evaluation ............................................................................................ Form 11Generic Safety Device Evaluation ....................................................................................... Form 12Sharps Disposal Container Locations .................................................................................. Form 12­A

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Sharps Evaluation Results ................................................................................................... Form 13Exposure Prevention Checklist ............................................................................................ Form 13­A

Bloodborne Pathogens Employee Medical RecordsIncident Report/Sharps Injury .............................................................................................. Form 14Sharps Injury Log ................................................................................................................. Form 14­AHBV Vaccination Declination Form ...................................................................................... Form 15HBV Employee Vaccination Form ........................................................................................ Form 16Post­exposure Checklist ...................................................................................................... Form 17Post­exposure Medical Evaluation Declination Form .......................................................... Form 18Source Patient Testing Consent Form ................................................................................. Form 18­A

Hazard Communication Records Hazardous Substances List ................................................................................................. Form 19

TB/Infection Control Records TB Risk Assessment Results Form ..................................................................................... Form 20TST Record ......................................................................................................................... Form 21TST Declination Form .......................................................................................................... Form 22TB Exposure Log ................................................................................................................. Form 23Influenza Vaccine Log .......................................................................................................... Form 24Influenza Vaccine Declination Form (Seasonal and H1N1) ................................................ Form 25­AChecklist for Infection Prevention for Outpatient Settings ................................................... Form 25­B List of Infection Prevention Contact Persons and Roles/Responsibilities ................................ Form 25­C

Training RecordsNew Employee OSHA Orientation Checklist ....................................................................... Form 26Annual Employee Training Record ...................................................................................... Form 27OSHA Annual Retraining (Sample Essay Test) ................................................................... Form 28 OSHA Annual Retraining (Sample Multiple Choice Test) .................................................... Form 29OSHA Annual Retraining (Sample True/False Test) ............................................................ Form 30Respiratory Protection Training Record ............................................................................... Form 31Qualitative Respirator Fit Test Report .................................................................................. Form 31­AChecklist for Decreasing Surgical Fire Risks ....................................................................... Form 32

TAB 12: OSHA Regulations & Key ContactsOSHA Regulations

Bloodborne Pathogens Standard ........................................................................................ 12­1Amended Bloodborne Pathogens Standard (Sharps Safety) .............................................. 12­13Hazard Communication Standard ........................................................................................ 12­14Exit Routes, Emergency Action Plans, and Fire Prevention Plans ...................................... 12­29Ionizing Radiation ................................................................................................................ 12­33Table of Other OSHA Standards for Outpatient Medical Facilities ...................................... 12­41

Additional OSHA ResourcesHealthcare Worker Vaccination Recommendations (Revised 2011) ................................... 12­42Suggested Work Restrictions for Employees ...................................................................... 12­44

Key ContactsState OSHA Consultative Services Directory ....................................................................... 12­48Directory of States with Approved OSHA Plans ................................................................... 12­51

Acronyms used in the OSHA Program Manual ......................................... 12-53