Dear HCPro Customer:

Enclosed is your latest supplement to the OSHA Program Manual for Medical Facilities. This supplement is designed to keep your product up to date. Your next supplement will be in December 2017. If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 or e-mail customerservice@hcpro.com. At HCPro, customer comments and suggestions are very important to us—let us know how we can serve you better.

Please insert these new and revised pages as indicated, and keep these filing instructions at the front of your book.

FILING INSTRUCTIONS

Rev. 9/17 OPMFMF Supplement to OSHA Program Manual for Medical Facilities

VISIT www.hcmarketplace.com for the latest compliance and training information.

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xxiii/xxv xxiii/xxv OSHA Program Manual Contents—updated

Tab 7 Contents Tab 7 Contents updated

7-1 through 7-21 7-1 through 7-20 Tab 7: The Hazard Communication Standard—updated

September 2017 Revisions

Dear HCPro Customer:

Enclosed is your latest supplement to the OSHA Program Manual for Medical Facilities. This supplement is designed to keep your product up to date. Your next supplement will be in September 2016.

If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 or e-mail customerservice@hcpro.com. At HCPro, customer comments and suggestions are very important to us—let us know how we can serve you better.

Please insert these new and revised pages as indicated, and keep these fi ling instructions at the front of your book.

FILING INSTRUCTIONS

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May 2016 Revisions

Dear HCPro Customer:

Enclosed is your latest supplement to the OSHA Program Manual for Medical Facilities. This supplement isdesigned to keep your product up to date.

If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 or e-mail customerservice@hcpro.com. At HCPro, customer comments and suggestions are veryimportant to us—let us know how we can serve you better.

February 2014 Revisions

Rev. 2/14 OPMFMF (22056)

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Supplement to OSHA Program Manual for Medical Facilities

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UPDATE to

a division of BLR

About the AuthorMarge McFarlane, PhD, MT (ASCP), CHSP, CHFM, CJCP, HEM, MEP, is an independent safety consultant with more than 40 years of healthcare experience. She has provided education, emergency management and safety plan review, life safety, and infection prevention facility surveys for healthcare and businesses in Wisconsin and across the nation since 2005. She is the author of The Compliance Guide to the OSHA GHS Standard for Hazardous Chemical Labeling, 2014 and the OSHA Training Handbook for Healthcare Facilities, Second Edition, 2014. 17I

©2005–2017 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 BLR35 Village Road, Suite 200

Middleton, MA 01949Tel: 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 © 2017 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.

Marge McFarlane, PhD, MT (ASCP), CHSP, CHFM, CJCP, HEM, MEP, Author

Sheila Dunn, DA, MT (ASCP), Contributing Editor

Jay Kumar, Associate Product ManagerMike Mirabello, Fulfillment Specialist

Susan Robinson, Content Management Specialist

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

35 Village Road, Suite 200

Middleton, MA 01949

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

9/17

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: 800­650­6787 E­mail: customerservice@hcpro.com

Thank you for your business. Let us know how we can help.

HCPro, a division of BLR35 Village Road, Suite 200

Middleton, MA 01949Telephone: 800/650­6787

Fax: 800/639­8511www.hcmarketplace.com

iii

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, pages 19–21 for details.

↓

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

↓

iii

Remove or strike through any procedure

you don’t perform!

ivv

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 vi – viii. 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 downloads folder.

↓

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 Key Contacts for the

OSHA Safety ProgramSafety officer name, employer name, phone numbers, safety manual location

2­10 Workplace Hazards Record other hazards found in facility2­17 Annual Review Safety officers review of plan 3­2 Emergency Phone List Local contact phone numbers3­18 Systems Failure Contact names and numbers3­193­20

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

3­21 Evacuation Route Evacuation route3­23 Emergency

Preparedness SuppliesItems that will be kept on hand for emergencies

3­26 Civil Disturbance Assembly location3­283­29

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

3­35 – 3­39

Workplace Violence Details of your Violence Prevention Plan (Note: 5 blanks and 7 lists that require checkmarks)

3­43 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)

3­50 – 3­53

Holiday Decorations A review of the combustible decorations allowed at your facility (Note: this assessment is not required)

5­10 Exposure Prone Procedures

Procedures performed in facility that could expose employees

5­11 BBP Determination List Employees who have definite risk of exposure (class I)

5­13 BBP Determination List Employees who have possible risk of exposure (class II)

5­14 Restricted Access Areas

Restricted areas not listed in items 1–3

vii

!

Page Item Information Needed Initials Date 5­16 Handwashing Locations Locations handwashing takes place5­20 Sharps Recapping Instances when recapping is allowed5­21 Safety Sharps Instances when safety sharps are not used5­23 Laundry How biohazardous laundry is cleaned, or

if only disposables are used5­25 PPE Locations PPE provided in facility and its locations5­30 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 Medical Air Purifying Respirators (PAPRs)

Will the facility provide N­95 masks or not Will the facility provide PAPRs 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 Pre­pandemic Planning Individual to be response coordinator, local

key agencies, and contact information6­22 Pre­pandemic Planning

(con’t)Communication plan, name of PR, and educational coordinators

6­24 Influenza Staff Shortage

Number of staff needed and who will cover

6­25 Influenza Reporting Frequency of reporting, who will review reports

7­20 Chemical Exposure Facility name and phone for exposure medical follow­up

8­3 Housekeeping Schedule

Your cleaning methods and frequency

8­21 Eyewash Stations Location and types of eyewashes8­22 Biohazardous Waste Company name and phone number of

who picks up your biohazardous waste10­8, 10­9

New Employee Orientation

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

10­18 Annual Employee Training Record

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

viii

What Is Included in this Program

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

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, slip/trip/fall prevention, electrical safety, exits and building evacuation, workplace violence, first aid and emergency action plans which includes bomb threats and severe weather. .There is also an overview for a drug­free workplace program.

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

ix

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.

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 Plan. There is an expanded section on preventing the spread of multidrug resistant organisms with the Centers for Disease Control and Prevention guidelines for outpatient facilities.

TAB 7: Hazardous Chemical SafetyEverything you need to know to comply with the Globally Harmonized System (GHS) update to the OSHA 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. The GHS update effective March 2012 is to ensure that workers have the “right to understand” the chemical hazards in their workplace.

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 frequency 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 as downloads.

x

TAB 12: OSHA Regulations & Key ResourcesTab 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.

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.

xi

OSHA PROGRAM MANUAL

Contents

Front Pocket OSHA Poster 3165: IT’S THE LAW! Laminated Eyewash Station Sign 4 Sample Biohazard Self­Adhesive Labels Available as downloads: Master Record Forms (Tab 11) from this Manual

for Customization.

xiii

IntroductionImportant Information About the Use of This Program ............................ iHow to Customize This Program ................................................................ iiiMaster List of Program Items for Customization ....................................... viiWhat Is Included in This Program ............................................................... ix

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

States with OSHA-Approved Plans ..................................................................................... 1-1

OSHA Consultative Services Division ................................................................................. 1-2

OSHA’s Jurisdiction ............................................................................................................. 1-2

OSHA’s General Duty Clause .............................................................................................. 1-2

Employee or Employer.................................................................................. 1-4Employer Responsibilities Under OSHA ............................................................................. 1-5

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

OSHA Inspections ......................................................................................... 1-6Employee Complaints .......................................................................................................... 1-6

If an On-site OSHA Inspection Occurs ................................................................................ 1-7

During the Inspection .......................................................................................................... 1-8

What OSHA Inspectors May Ask Employees ...................................................................... 1-8

The Typical OSHA Inspection .............................................................................................. 1-9

The Closing Conference ...................................................................................................... 1-10

OSHA Sanctions ............................................................................................ 1-11

Whistleblower Protection ............................................................................. 1-13

Students and Volunteers ............................................................................... 1-15

Page

Contents

xiv

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

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

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

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

Recordkeeping Requirements ..................................................................... 2-6Equipment & Facility Records ............................................................................................. 2­6Bloodborne Pathogens Records ......................................................................................... 2­6Hazard Communication Records ........................................................................................ 2­6TB Records ......................................................................................................................... 2­6Training Records ................................................................................................................. 2­7Employee Medical Records ................................................................................................. 2­7Evaluating Exposure Incidents ............................................................................................ 2­8

OSHA Focus on Healthcare ......................................................................... 2-8Workplace Hazard Analysis ........................................................................ 2-9Practical Ideas for Involving Employees ................................................... 2-10Organizing OSHA Compliance Duties ........................................................ 2-11Weekly Facility Review Checklist ............................................................... 2-12Monthly Facility Review Checklist .............................................................. 2-13Annual Facility Review Checklist ............................................................... 2-14Annual OSHA Safety Program (Includes Exposure Control Plan, Hazard Communication Program, and Respiratory Protection Plan) Review ... 2-17

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 ................................................................................. 3­5

Contents

xv

How 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 ............................................................................................ 3-9Physical Characteristics of a Safe Medical Facility ................................... 3-10

Automated 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 ..................................................................................................................... 3­28

Contents

xvi

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

Violence ................................................................................................................................ 3­30OSHA’s Jurisdiction Over Workplace Violence ........................................................... 3­30Prevalence of Violence ............................................................................................... 3­30Identifying Situations with the Potential for Violence .................................................... 3­32Violence Prevention Plan Introduction ........................................................................ 3­32Overview of Violence Prevention Plan Components ................................................... 3­33 Part 1 .................................................................................................................... 3­33

Workplace Violence Program Checklists .................................................... 3­35Part 2 .................................................................................................................. 3­38.9

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

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

Contents

xvii

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

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

Contents

xviii

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

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 (Form 17) ............................................................. 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

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TAB 6: TB/Infection Prevention and 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 .............................................. 6­4TB Risk Assessment ........................................................................................................... 6­4

TB Risk Assessment Results Form (Form 20) ............................................................ 6­5Early Identification of Patients with Active TB ..................................................................... 6­6

Symptoms of TB ........................................................................................................... 6­6Handout: Cover Your Cough/Clean Your Hands ................................................................. 6­8Managing Patients with Suspected or Confirmed TB ........................................................... 6­9

TB Isolation Procedures for Cough Inducing and Aerosol­Generating Procedures .... 6­9Respiratory Protection for Healthcare Workers: N­95 Respirators or Medical Powered Air Purifying Respirators (PAPRs) ................ 6­10

Seal Checking N­95 Respirators ......................................................................... 6­10Medical PAPRs ................................................................................................... 6­10

Employee TB Skin Testing (TST) ........................................................................................ 6­11Baseline Employee TST: The Two­Step Skin Test ...................................................... 6­12

Two­Step TST Interpretation ................................................................................ 6­12Interpreting the TST ..................................................................................................... 6­13

False Positive/False Negative TB Tests .............................................................. 6­13Workers Who Have Had BCG Vaccination .......................................................... 6­14

Periodic Retesting of Employees ................................................................................ 6­14Recording TST Results ............................................................................................... 6­14TST Record (Form 21) ................................................................................................ 6­15TST Declination (Form 22) .......................................................................................... 6­16

Evaluation and 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 and Skin Test Conversions ........................................... 6­17TB Exposure Log (Form 23) ......................................................................................... 6­19Decontaminating Patient Care Area and Equipment.................................................... 6­20

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

Pandemic Influenza Plan and Other Infectious Diseases ........................ 6-21Pre­pandemic Planning ....................................................................................................... 6­21Once a Pandemic Is Announced .......................................................................................... 6­24OSHA Enforcement for a Pandemic .................................................................................... 6­26

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

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

Multidrug-Resistant Organisms (MDRO) .................................................... 6-29CDC Classification of MDRO Threats ................................................................................ 6­29MDRO Prevention and Control ............................................................................................ 6­31

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Colonization vs. Infection .................................................................................................... 6­31MDRO Transmission ........................................................................................................... 6­32Patient Precautions ............................................................................................................. 6­32

Hand Hygiene ............................................................................................................. 6­33Contact Precautions .................................................................................................... 6­33

Environmental Cleaning ...................................................................................................... 6­34Infected Employees ............................................................................................................. 6­35MDRO Resources ............................................................................................................... 6­36

Pertussis and Worker Vaccination ............................................................. 6-36Supplement: How Antibiotic Resistance Happens ................................... 6-38Supplement: 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 ................................................................... 7­2Routes of Exposure to Hazardous Chemicals ..................................................................... 7­3

Safety Data Sheets ....................................................................................... 7-4Examples of Chemicals Requiring an SDS .......................................................................... 7­4Chemicals Not Requiring an SDS ....................................................................................... 7­4Information Required on SDS ............................................................................................. 7­4How to Get SDS .................................................................................................................. 7­11Where to Keep SDS ............................................................................................................ 7­11

Classification of Hazardous Chemicals ..................................................... 7-11Flammable Liquids ..............................................................................................................7­12

Storage of Hazardous Chemicals ............................................................... 7-12Hazardous Chemicals With Permissible Exposure Limits (PELs) ........... 7-13Labeling Hazardous Chemicals .................................................................. 7-14

HazCom Pictograms and Hazard Statements ..................................................................... 7­14Pictograms .......................................................................................................................... 7­15NFPA Label System ............................................................................................................ 7­16

Safety Tips for Working with Hazardous Chemicals ................................. 7-16Hazardous Chemical Waste Packaging and Disposal ............................... 7-17Medications Security and Disposal ............................................................ 7-18

Security for Prescription Drugs ............................................................................................ 7­18Security for Controlled Substances ..................................................................................... 7­18Disposal of Prescription Drugs ............................................................................................. 7­19Disposal of Hazardous Drugs .............................................................................................. 7­19

Medical Consultation and Injury Evaluation .............................................. 7-19HazCom Recordkeeping .............................................................................. 7-20

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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 ................................................................................. 8-4BBP Spill Clean­up Procedures .......................................................................................... 8­4Spills That Contain Broken Glass or Sharp Objects ............................................................ 8­5Chemical Spill Clean­up Procedures ................................................................................... 8­5Chemical Exposure to Skin ................................................................................................. 8­6Mercury Spills ...................................................................................................................... 8­6Cytotoxic Drug Spill Clean­up ............................................................................................. 8­7

Decontamination of Medical Instruments & Equipment ........................... 8-7When to Sterilize ................................................................................................................. 8­7Precleaning Instruments Prior to High­level Disinfection or Sterilization ............................. 8­8Sterilization .......................................................................................................................... 8­10Quality Checks for Sterilization ........................................................................................... 8­10High­level Disinfecting ......................................................................................................... 8­11

Using Glutaraldehyde ................................................................................................... 8­12Glutaraldehyde Spills .................................................................................................. 8­14Sources for Chemical Air Monitoring ........................................................................... 8­15Testing the Potency of Glutaraldehyde ....................................................................... 8­15Disposing of Glutaraldehyde ....................................................................................... 8­15

Cleaning Transvaginal and Transrectal Ultrasound Probes ................................................ 8­16Disinfect Transvaginal and Transrectal Probes After Each Use .................................. 8­16Cleaning Ultrasound Transducers ............................................................................... 8­16

Decontaminating Vaginal Specula ....................................................................................... 8­17Step 1: Contain & Transport ....................................................................................... 8­17Step 2: Clean ............................................................................................................. 8­17Step 3: Disinfect or Sterilize ....................................................................................... 8­17

Keeping Employees Safe During Instrument Disinfection ................................................... 8­18Decontaminating Semi­critical Patient Care Equipment ...................................................... 8­18Decontaminating Non­critical Patient Care Equipment ....................................................... 8­18Decontaminating Personal Protective Equipment (PPE) .................................................... 8­19

Eyewash Stations ......................................................................................... 8-19Number & Placement of Eyewash Stations ......................................................................... 8­20Eyewash Maintenance ........................................................................................................ 8­21

Waste Disposal ............................................................................................. 8-21Biomedical Waste Disposal ................................................................................................. 8­21Hazardous Waste Disposal ................................................................................................. 8­22Waste Handling & Storage .................................................................................................. 8­24

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TAB 9: Specialty ServicesAbout this Section ........................................................................................ 9-1Working Safely with Antineoplastic and Hazardous Drugs ...................... 9-1

NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2014 ... 9­2NIOSH Hazardous Drug List for Healthcare ........................................................................ 9­3Effects of Hazardous Drug (HD) Exposure on Health .......................................................... 9­3Safe Work Practices ............................................................................................................. 9­3Clothing ............................................................................................................................... 9­3Sample List of Drugs that Should be Handled as Hazardous ............................................. 9­4Drug Preparation and Administration .................................................................................. 9­5Cleaning the Drug Preparation Area ................................................................................... 9­6Caring for Patients Receiving HDs ...................................................................................... 9­6Waste Disposal .................................................................................................................... 9­6Spill Clean­up ....................................................................................................................... 9­7

Suggested Spill Kit Components .................................................................................. 9­7Receiving Antineoplastic and Hazardous Drugs ................................................................. 9­8Storage of Antineoplastic and Hazardous Drugs ................................................................. 9­8Transport of Antineoplastic and Hazardous Drugs ............................................................... 9­8Employee Training ............................................................................................................... 9­8Employee Medical Surveillance .......................................................................................... 9­9Employee Exposure ............................................................................................................ 9­9

Gas Cylinder Safety ...................................................................................... 9-10Electrosurgical Safety ................................................................................. 9-11

Safe Work Practices ............................................................................................................ 9­13

Surgical Safety .............................................................................................. 9-13General PPE Indications for Surgery .................................................................................. 9­13

Surgical Gowns ........................................................................................................... 9­14Surgical Gloves ........................................................................................................... 9­14Face and Eye Protection ............................................................................................. 9­15Headwear .................................................................................................................... 9­15Shoe Covers ................................................................................................................ 9­15Surgical Drapes ............................................................................................................ 9­15

Safe Sharp Strategies for the Surgical Setting .................................................................... 9­15Scalpels ....................................................................................................................... 9­15Suture Needles ........................................................................................................... 9­16

Transferring Sharps Safely .................................................................................................. 9­16How to Use the Neutral Zone (NZ) .............................................................................. 9­17Tips for Minimally Invasive Surgeries .......................................................................... 9­17Safety Techniques for Operating on Patients Infected with Known Bloodborne Pathogens ................................................................................................. 9­17

Preventing Surgical Fires .................................................................................................... 9­18

Laboratory Safety .......................................................................................... 9-19Laboratory Specimen Transport ........................................................................................... 9­20

Radiation Safety ............................................................................................ 9-20Regulation of the Medical Use of Nuclear By­products ....................................................... 9­20The “ALARA” Principle ........................................................................................................ 9­21

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Radiation Safety Guidelines for Personnel .......................................................................... 9­21Radiation Safety Policies for the Facility ............................................................................. 9­22Ionizing Radiation Exposure Limits ..................................................................................... 9­22Special Precautions for Pregnant Workers ......................................................................... 9­23Low­level Radioactive Waste Disposal ............................................................................... 9­23NRC Notification, Reports, and Record ............................................................................... 9­23NRC Resources and Publications ....................................................................................... 9­24

Working Safely with Cryogenic Liquids ..................................................... 9-25Precautions for Handling Liquid Nitrogen ............................................................................ 9­25Storing Liquid Nitrogen ........................................................................................................ 9­26Personal Protective Equipment ........................................................................................... 9­26Liquid Nitrogen Disposal ..................................................................................................... 9­26Steps to Take if There Is Accidental Exposure ..................................................................... 9­27

First Aid (cryogenic burns) .......................................................................................... 9­27First Aid (anoxia) ......................................................................................................... 9­27

Safe Vaccine Handling and Storage ............................................................ 9-28Waste Anesthetic Gases .............................................................................. 9-30

Where Exposures Occur ..................................................................................................... 9­31Preventing Exposures ......................................................................................................... 9­31

Controls ....................................................................................................................... 9­32Medical Surveillance ........................................................................................................... 9­32Recordkeeping .................................................................................................................... 9­33More Information ................................................................................................................. 9­33

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

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

General Safety ............................................................................................................. 10­3Fire Safety ................................................................................................................... 10­3Bloodborne Pathogens Safety ..................................................................................... 10­3Chemical Safety ........................................................................................................... 10­3TB Safety ..................................................................................................................... 10­4Infection Prevention ..................................................................................................... 10­4

Annual Employee Training ........................................................................... 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 Training: Sample Essay Test Questions (Form 28) ....................................... 10­11OSHA Annual Training: Sample Essay Test—Answer Key ................................................. 10­12

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OSHA Annual Training: Sample Multiple Choice Test Questions (Form 29) ....................... 10­13OSHA Annual Training: Sample Multiple Choice Test—Answer Key .................................. 10­15OSHA Annual Training: Sample True/False Test Questions (Form 30) ................................ 10­16OSHA Annual Training: 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 12­ASharps 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 .................................................................................... 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 Training (Sample Essay Test) ....................................................................... Form 28 OSHA Annual Training (Sample Multiple Choice Test) ........................................................ Form 29OSHA Annual Training (Sample True/False Test) ............................................................... Form 30Respiratory Protection Training Record ............................................................................... Form 31Qualitative Respirator Fit Test Report for N­95 Masks ........................................................ Form 31­AChecklist for Decreasing Surgical Fire Risks ....................................................................... Form 32

TAB 12: OSHA Regulations & Key ResourcesOSHA 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

Acronyms used in the OSHA Program Manual ......................................... 12-48

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TAB 7: THE HAZARD COMMUNICATION STANDARD

Contents

A Quick Look at HazCom ................................................................................. 7-1Determining Which Chemicals Are Hazardous .......................................................................7-2Routes of Exposure to Hazardous Substances ......................................................................7-3

Safety Data Sheets ........................................................................................... 7-4Examples of Chemicals Requiring SDS .................................................................................7-4Chemicals Not Requiring SDS ................................................................................................7-4Information Required on SDS .................................................................................................7-4How to Get SDS .....................................................................................................................7-11Where to Keep SDS ...............................................................................................................7-11

Classification of Hazardous Chemicals ......................................................... 7-11Flammable Liquids ..................................................................................................................7-12

Storage of Hazardous Chemicals ................................................................... 7-12Hazardous Chemicals With Permissible Exposure Limits (PEL) ................. 7-13Labeling Hazardous Chemicals ...................................................................... 7-14

HazCom Pictograms and Hazard Statements ........................................................................7-14Pictograms ..............................................................................................................................7-15NFPA Label System ................................................................................................................7-16

Safety Tips for Working with Hazardous Chemicals..................................... 7-16Hazardous Chemical Waste Packaging & Disposal ...................................... 7-17Medications Security & Disposal .................................................................... 7-18

Security for Prescription Drugs ...............................................................................................7-18Security for Controlled Substances ........................................................................................7-18Disposal of Prescription Drugs ...............................................................................................7-19Disposal of Hazardous Drugs .................................................................................................7-19

Medical Consultation & Injury Evaluation ...................................................... 7-19HazCom Recordkeeping .................................................................................. 7-20

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THE HAZARD COMMUNICATION STANDARD

A Quick Look at HazComOSHA’s Hazard Communication Standard (HazCom) has been in effect since May 1988, and is also called the “Right to Know” Standard. Its intent is to protect healthcare workers from hazardous substances in the workplace. The HazCom Standard May 2012 updates align the OSHA standard with the United Nations’ Globally Harmonized System (GHS) for chemical classification and labeling. While the basic requirements of HazCom are still in place, the intent was to provide employees the right to “understand” the hazards of the chemicals in their workplace. The purpose of the GHS is to ensure quality and consistency of labeling by using pictograms, signal words, and hazard and precautionary statements in an international economy. GHS is meant to unify all the different and sometimes conflicting systems of labeling and identifying hazardous chemicals throughout the world, thereby reducing trade barriers. The advantages of the GHS as stated by OSHA include:Reduced confusion about hazard classificationsIncreased understanding about safety precautions to take, approved use, proper

storage and disposal of chemicals and mixturesIncreased downstream risk management by increasing understanding of the risks

of hazardous chemicalsFacilitated training with uniform safety data sheets (SDSs) and well-defined hazard

classesEnhanced worker understanding, especially for low-literacy workers and those

workers where English is a second languageImproved worker safetyEnhanced international trade

The GHS update adds appendices to the Hazard Communications Standard that better define health and physical hazards, require that mixtures of chemicals be assessed for hazards, and require that a pictogram for each hazard class be placed on the label of each chemical container received or each secondary container used in the workplace.

There are key elements of the original Hazard Communication Standard that are still in effect. This includes the need for a written Hazard Communication Plan that is reviewed annually. Other items that remain include:An accurate, frequently updated list of chemicals in the facilityA safety data sheet (SDS) (formerly a material safety data sheet (MSDS)) for

each hazardous chemical that is readily accessible at all times

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Training for all workers before they are potentially exposed to hazardous chemicals and when new chemical hazards are introduced

Identification and training on required Personal Protective Equipment (PPE) Knowledge of signs and symptoms of exposure to hazardous chemicals in their areaProper segregation and storage of all chemicalsSpill kits/emergency equipment for each class of hazardous chemicalEmergency response and first aid proceduresMedical evaluation protocols in cases of overexposureArchiving MSDS and SDS no longer in use for 30 years

To ensure that information about the dangers of hazardous chemicals used in this facility are known by all affected employees, this Hazard Communication program has been established and requires the transition to the use of uniformly formatted SDS and new labeling requirements for all for all hazardous chemicals. These standardized SDS should have been fully implemented by June 2016. If you still have an MSDS in your files, contact the manufacturer or the distributor for an SDS replacement. Often, the SDS for the product is available on line, usually in the technical section. Revised SDS are required to be sent by the distributor with the first shipment of product after the revision. Check each shipment for new or revised SDS information. Review all new SDS for any changes and ensure that all staff using the products are trained on the appropriate hazards, procedures and any required PPE.

Although the initial training was completed in December 2013, all employers must continue to maintain the updated SDSs, review the current hazard communication program annually and update it as new health/risk Information becomes available. Ongoing training is required to ensure that all employees understand the meaning of the new labels and pictograms.

Determining Which Chemicals Are HazardousChemical exposure may cause or contribute to many serious health problems such as heart ailments; central nervous system, kidney and lung damage; sterility; cancer; burns; and rashes. Some chemicals may also be physical safety hazards and have the potential to cause fires, explosions, and other serious accidents.

To determine whether any chemical in a medical practice needs an SDS, use the following criteria:

1. Is the chemical hazardous?2. Are employees exposed to it?

Check all locations for chemicals, liquid or aerosol drugs and medications (tablet and capsule forms are exempt), disinfectants, and x-ray developers. (Note that the use of digital films eliminates the need for hazardous developer and fixer chemicals.)

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Examine the label of each to see if a hazard statement is present, such as “flammable,” “danger,” or “warning.” The pictograms on the new labels will indicate if the chemical is a health hazard, an irritant/sensitizer, corrosive, oxidizer or toxic. If a hazard statement and/or pictogram is present, the chemical is considered hazardous by OSHA and is regulated under the HazCom Standard. All labels from chemical manufacturers are required to have a product identifier, pictograms, a signal word, hazard and precautionary statements, and supplier identification. If you have any old stock of chemicals, the label may not have all the required GHS elements. You will need to ensure that employees are aware of and can identity any additional precautions identified under GHS when working with these chemicals. Sometimes the easiest way to get the information to staff is to add the information to the label.

Determine whether employees are involved with the products in such a way that they could be exposed. For instance, do employees administer medications to patients or do they simply give the bottles to patients to take home? If the latter is the case, then you do NOT need an SDS for that medication, since there is no chance of employee exposure.

If employees administer or handle a product (i.e., crushing or cutting the medications), check the product label or package insert that accompanies it. If there is a health, flammability or “warning,” or “danger” listing, then an SDS is required. Imagine an employee accidentally getting the solution in their eye or on their skin. What would need to be done in this instance? The answer is on the SDS in Section 4 (first aid measures). Any employee handling that product would need to know what to do.

Routes of Exposure to Hazardous Chemicals

The safest way to prevent chemical injury is to know the routes of entry that each chemical may take into the body and take precautions to ensure that contact is not made. In general, routes of exposure of a substance fall into one of the following categories:

1. Inhalation. Many occupational exposures result from breathing chemical vapors. These substances may affect the respiratory track or pass from the lungs to other organs by way of the blood stream or lymphatic system. The type and severity of the effect depends on the nature of the chemical, the amount of chemical absorbed, the rate of absorption, individual susceptibility, and other factors.

2. Ingestion. This route of exposure may occur if the worker is not using preventive measures such as gloves and proper handwashing techniques, or is eating food or consuming drink in the work area. This mode of exposure is far less common in medical surroundings than inhalation.

3. Skin Contact. This is a frequent mode of chemical exposure, often resulting in localized irritation. A wide variety of substances can penetrate the skin and produce skin hypersensitivity, including latex, formaldehyde and phenols. Skin is abundantly supplied with blood vessels, which facilitate the absorption of chemicals into the body.

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4. Eye Contact. Eyes are very sensitive to contact with most chemicals, resulting in irritation. Eyes are vascular organs and rapidly absorb many chemicals. Alkaline materials, phenols, and strong acids are particularly corrosive and can cause permanent loss of vision.

5. Injection. This route of exposure can occur inadvertently through mechanical injury from glass or metal contaminated with chemicals, or when toxic chemicals are handled in syringes with needles.

Safety Data SheetsA key requirement for compliance with HazCom is the availability of SDS for hazardous chemicals. An SDS contains emergency, precautionary and general information about hazardous chemicals and chemical mixtures.

Compile a master list of all hazardous substances using the Hazardous Substances List behind Tab 11: Master Record Forms (Form 19) in this OSHA Program Manual.

Examples of Chemicals Requiring an SDS

Drugs and pharmaceuticals except those in solid, “final form” (tablets, pills, capsules) for direct administration to the patient. Tablets or pills designed to be dissolved or crushed by employees prior to administration are not in “final form” and require an SDS. Package inserts and the Physicians’ Desk Reference cannot substitute for manufacturers’ SDS.

A product containing a hazard warning that is available commercially to the general public. Chemicals such as bleach, chemotherapy drugs, some injectable drugs, alcohol hand sanitizer, disinfectants and peracetic acid or hydrogen peroxide DO require an SDS.

Chemicals Not Requiring a SDS

Any product that does not bear a hazard warning. ALL other products require a SDS.

Information Required on a SDS

Safety data sheets will have a specified 16-section standard format and include the following information.

Section 1: IdentificationThis section:Lists the chemical name as well as any other common names by which the

product is knownIdentifies the recommended uses for the product

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Identifies any restrictions on use as recommended by the supplier/manufacturerGives the chemical manufacturer or supplier address and contact information

Example: isopropyl alcohol, 70%,Frequently used in healthcare as a topical antiseptic Other listed names for this chemical include 2-propanol, isopropanol, rubbing

alcohol, or IPAIdentified uses include cleaning of skin prior to procedures, as in venipuncture

or injection. Identified restrictions include not using isopropyl alcohol on internal wounds or for

drinking (ingestion).

Section 2: Hazard(s) identificationThis section identifies all the different hazards of a chemical and the appropriate warning information associated with each of those hazards. This section changed from a performance-based process to specific criteria for the classification of health and physical hazards. The information also provides specific criteria for the classification of mixtures. GHS requires that mixtures are classified by the percentage of each component included, and a revised hazard rating be provided. These specific criteria will help to ensure the evaluations of hazardous effects are consistent across manufacturers, and that labels and SDSs are more accurate as a result. The information required on the container label includes:The hazard classification of the chemical (i.e. flammable, irritant/sensitizer or

corrosive)Signal word (Danger or Warning): a single word to indicate the relative severity

of the hazard“Danger” is used for more severe hazards, while “warning” is used for less

severe hazardsHazard statement(s) describes the nature of the hazards and the degree of

hazard, i.e., may cause liver or kidney damagePictograms for each hazard class: a symbol intended to convey specific

information regarding the hazard(s) of a chemical, i.e., flammable, irritant, toxicPrecautionary statement(s) related to minimizing or preventing adverse effects

resulting from exposure and improper storage or handling of a chemicalDescription of any hazards not otherwise classified or of unknown toxicity. This is

a change from previous HazCom information, as the statement of acute toxicity would be relative to the percentage of the ingredients in the mixture, and is not just a statement about that ingredient alone

Examples of chemicals that fall into this category include simple asphyxiates and/or combustible dust

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Example: isopropyl alcohol, 70%:- Hazard classification: flammable liquid, eye irritation- Signal word: Danger- Hazard statements: Highly flammable liquid and vapor- Causes serious eye irritation- Causes mild skin irritation- May cause drowsiness or dizziness- Pictogram: flame and irritant (exclamation mark)- Precautionary statements:

o Keep away from heat/sparks/open flame. No smoking. o Do not breathe vapors

- In case of fire, use dry chemical (BC) or carbon dioxide fire extinguisher

Section 3: Composition/information on ingredients This section lists the chemical identity and common names; percentage of each ingredient if it is a mixture; chemical listing (unique identifiers); and impurities or stabilizers, which are also classified and contribute to the hazard classification of the product. A statement that a chemical is claimed as a trade secret or proprietary is made in this section.

Section 4: First-aid measuresThis section lists the signs and symptoms, acute and delayed effects of exposure to the chemical. This is key information and required for employee training. This section lists first aid measures for skin and eye exposure, as well as inhalation and ingestion. Required treatment listed in this section might include the use of an eyewash station for a corrosive or caustic chemical, or the need to move to fresh air and get medical attention.

Example: isopropyl alcohol, 70%, Symptoms of isopropyl alcohol poisoning or overexposure include flushing, headache, dizziness, central nervous system depression, nausea, vomiting, and loss of consciousness. Poisoning/overexposure can occur from ingestion, inhalation, absorption, or consumption of isopropyl alcohol.

First aid:Eyes: Rinse with plenty of water for 15 minutes and seek medical attention.Inhalation: Move person to fresh air and keep at rest. If breathing is difficult, give

oxygen. If not breathing, give artificial respiration. Get medical attention.Skin: Flush with plenty of water for at least 15 minutes while removing contaminated

clothing and wash using soap. Get medical attention.Ingestion: Do not induce vomiting! Never give anything by mouth to an unconscious

person. If conscious, wash out mouth with water. Get medical attention.

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Section 5: Firefighting measures This section lists suitable (and unsuitable) extinguishing media (agents like water, dry chemical, or foam), precautions, and special PPE for firefighters, as well as specific hazards arising from products of combustion (fire). Toxic byproducts from the fire and the chemical are listed here.

Example: isopropyl alcohol, 70%,Is flammable in the presence of spark or flame. Use water spray, alcohol-resistant

foam, dry chemical, or carbon dioxide.Firefighters are to wear self-contained breathing apparatus and full protective

clothing, including eye protection and boots.Gives off toxic fumes (carbon oxides) under fire conditions. (This section also

references the Stability and Reactivity information in Section 10.)

Section 6: Accidental release measures This section references emergency response precautions and personal protective equipment needed. Appropriate procedures for cleanup of spills, leaks, or releases are listed here. It differentiates between protocols for large and small spills, where the spill volume has an impact on the level of the hazard. It gives recommendations for evacuation, methods of containment, and cleanup procedures.

Example: isopropyl alcohol, 70%,Personal Protective Equipment: For large spills, wear chemical safety glasses or

goggles, nitrile gloves, and a lab coat or apron. (Section 8 is where one would find the PPE recommendations.)

An eyewash station or quick drench shower is recommended, since isopropyl alcohol is a severe eye hazard

Environmental Precautions: Prevent spillage from entering drainsMethods and materials for containment and cleanup: Neutralize spill. Absorb spill

with noncombustible absorbent material, then place in a suitable container for disposal. Clean surfaces thoroughly with water to remove residual contamination. Dispose of waste in accordance with local, state, and federal regulations

Section 7: Handling and storage This section lists precautions for safe handling, storage, and use. It includes incompatibilities—that is, how these chemicals need to be stored away from certain other chemicals.

Quick note: If one mixes ammonia with bleach, the result is chlorine gas. Inhaled chlorine gas turns into acid in the lungs. Not a recommended process, yet some facilities and laboratories like to store all their chemicals alphabetically because it looked more orderly.

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Example: isopropyl alcohol, 70%,Precautions for safe handling: See Section 8 for recommendations on the use of PPE. Use with adequate ventilation. Wash thoroughly after using. Keep container closed when not in use.

Conditions for safe storage, including any incompatibilities: Store in cool, dry, well-ventilated area. Store away from oxidizing agents (bleach) and aluminum. (What this says is that one should never store isopropyl alcohol in an aluminum container.) See also Section 10 for incompatible materials.

Section 8: Exposure controls/personal protectionThis section lists any regulatory exposure limits, use of personal protective equipment (PPE), work practice controls, and ventilation requirements used to minimize exposures. There are several agencies that have developed occupational exposure limits for an 8-hour workday. OSHA has Permissible Exposure Limits (PEL) which have the force of law but are somewhat outdated. National Institute for Occupational Safety and Health (NIOSH) has Recommended Exposure Limits (REL), and the American Conference of Governmental Industrial Hygienists (ACGIH) has published Threshold Limit Values (TLV). The NIOSH and ACGIH limits are guidelines but have the advantage of being updated as additional hazards of chemicals become known.

Example: isopropyl alcohol, 70%,OSHA PEL = 400 ppm.NIOSH REL = 400 ppmACGIH TLV = 200 ppm

These are average exposures over an eight-hour workday where the average worker would not suffer health effects. Many of these exposures were developed for industrial settings and not healthcare.

Personal Protective Equipment:Eyes: wear chemical safety glasses or goggles. (Remember that isopropyl alcohol

is a severe eye irritant.)Inhalation: provide local exhaust.Skin: wear nitrile or rubber gloves, apron or lab coat.Other: provide eyewash stations, showers, and washing facilities.

Section 9: Physical and chemical propertiesThis section lists the properties of the chemical such as vapor pressure, specific gravity, color, odor, pH, appearance, and physical hazards of the chemical (i.e., flammability and explosive limits). This is the beginning of more technical information, but it is helpful to know what the chemical looks like (solid, liquid, green, yellow, or clear) as well as whether it has a characteristic smell.

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Quick note: While smell is not an approved way to detect the extent of chemical exposure, some hazardous chemicals have good warning properties. Formalin, glutaraldehyde, bleach, and hand sanitizer all have a distinct smell. Other chemicals like ethylene oxide (a known carcinogen used for gas sterilization) have no odor at all.

Example: isopropyl alcohol, 70%,Some of the recognizable characteristics include:Appearance: Clear, colorless liquidOdor: Alcohol-likeOdor threshold: 22 ppm (that means one can readily smell isopropyl alcohol)Solubility: readily soluble in water (that means it mixes readily with water)

Section 10: Stability and reactivity This section discusses the risks of explosion of the product in the presence of sparks, shocks, and fire. It also lists incompatible materials and conditions to avoid (like high temperature).

Example: isopropyl alcohol, 70%,Isopropyl alcohol is chemically stable. Conditions to avoid include heat, flames,

and sparks. Extremes of temperature and direct sunlight. Sunlight can warm the liquid, giving off vapors that readily ignite in the presence of a spark or flame.

Incompatible materials include aluminum, acids, and oxidizing agents such as bleach.

Section 11: Toxicological information This section discusses routes of exposure, symptoms, delayed and immediate effects, listing as to whether the chemical is toxic, a carcinogen or reproductive hazard including the OSHA permissible exposure level, any limits recommended by the manufacturer, NIOSH, ACGIH, International Agency for Research on Cancer (IARC), National Toxicology Program (NTP), and Agency for Toxic Substances and Disease Registry (ATSDR). These last three agencies report on chemicals that are stated to be toxic, carcinogens, mutagens, or reproductive hazards.

Example: isopropyl alcohol, 70%,All of the references listed indicate that isopropyl is not classifiable as a human carcinogen.

Signs and symptoms of exposure:Skin: irritation, redness, and itchinessEyes: irritation, redness, watering eyes, and itchinessRespiratory: irritation, coughing, wheezing, dizziness, drowsiness

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Ingestion: irritation, nausea, vomiting, diarrhea, dizziness, drowsinessChronic toxicity: may cause damage to kidneys, liver, skin, central nervous systemReproductive toxicity: Classified as a reproductive system/toxin/female and a

developmental toxin

Section 12: Ecological information This section lists any environmental impacts if known. This section is not enforceable by OSHA, but included in SDS and indicates if the product is hazardous to the aquatic environment through acute (immediate) or chronic (long-term) aquatic toxicity, or if it is hazardous to the ozone layer.

Section 13: Disposal considerations This section indicates that users should review how to handle, manage, and dispose of the chemical waste according to applicable federal, state, and local regulations. This section is also not enforced by OSHA but is enforced by the Environmental Protection Agency (EPA) and state regulations.

Example: isopropyl alcohol, 70%,Isopropyl alcohol may still be flammable even as a waste product. Local and state regulations would need to be consulted to determine the appropriate method of disposal.

Quick note: Some states allow flammable liquids to be recycled and used for fuel blending. Check with local and state vendors to see if that option is available in your area.

Section 14: Transport information This section lists shipping and labeling requirements for the Department of Transportation (DOT), Transportation of Dangerous Goods (Canada), the International Maritime Dangerous Goods Code, and the International Air Transport Association. All the agencies have agreed to use the UN Code for identification of the chemical.

Section 15: Regulatory information This section lists the safety, health, and environmental reporting regulations specific for the product not otherwise listed on the SDS. This information may include any national or regional regulatory information from the Department of Transportation, the Environmental Protection Agency, or Consumer Product Safety Commission regulations.

Section 16: Other information This section includes the date of preparation or last revision. The revisions or changes are often listed here.

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How to Get SDS

SDS are available free of charge from the manufacturer or distributor of the chemicals and may be sent with the shipment. SDS are also available over the Internet at the manufacturer’s or distributor’s website.

Where to Keep SDS

File SDS in a binder. Copies of SDS may also be kept at each location where the hazardous chemical is used, if it is distant from the central location. Be sure employees know where SDS are kept and that they have easy access to them. Many facilities have found that alphabetizing the SDS by common chemical name aids in prompt retrieval during an emergency or spill.

It is permissible to have your SDS files online or on a computer if employees can readily access the files in the workplace. Be sure to train employees on how to access the SDS file and that there are no barriers to online access such as password-locked computers or locked doors to access the computer. Identify backup measures in the written Hazard Communication Plan in case the online system goes down.

Classification of Hazardous ChemicalsChemicals often used in medical facilities are classified as:1. Health Hazards:

a. Acutely Toxic. A term that can be applied to almost any substance in quantity. A substance is considered toxic if serious biologic effects may follow inhalation, ingestion, or skin contact with relatively small amounts.

b. Sensitizer/irritant. These substances cause little or no reaction upon initial contact, but may cause a marked reaction after subsequent exposures. This category may include some adhesives, latex, detergents and high-level disinfectants (glutaraldehyde or OPA).

c. Carcinogen, mutagen, teratogen, reproductive toxins. Mercury and lead are examples of “teratogenic substances” which can cause malformation of a fetus. Women who are pregnant or trying to become pregnant should be aware of teratogens in their workplace. Other reproductive toxins can cause reproductive issues in both men and women.

d. Corrosive. Corrosive substances destroy tissue and cause permanent changes in the tissue, such as scarring. Common corrosive agents may include ammonia, acids, potassium hydroxide (KOH for wet preps) and descaling products. The use of corrosive chemicals requires ready access to an eyewash station.

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2. Physical Hazards:a. Flammable. GHS revised the definition of flammable liquids to include any

liquid with a flash point below 140° F. OSHA no longer has a “combustible” category. Common flammable items are acetone, isopropyl alcohol and alcohol based hand sanitizer. Note that NFPA 30 still uses the former definitions for flammable and combustible. This could be the basis for miscommunication in the event of a fire or emergency.

b. Oxidizers. Chemicals that give off oxygen when heated are classified as oxidizers. These chemicals do not cause fires but contribute oxygen to the fire triangle. Bleach is an oxidizer that may be present in medical offices.

c. Gases under pressure. Cylinders of oxygen, carbon dioxide or nitrous oxide may be found in many medical offices. If tipped over or dropped, these cylinders can become missiles.

Flammable Liquids

The adoption of GHS includes a revision of the definition of flammable liquids to include any liquid with a flashpoint below 140° F. The flash points are divided into four categories and eliminates the combustible class previously used. It is important to note that the NFPA 30, Flammable and Combustible Liquids Code used by fire fighters has not changed the definitions and still uses Class I ABC for flammable liquids and Class II and III for combustible liquids. NFPA publishes consensus codes and standards while Haz Com with the GHS is a federal OSHA Labor law. It is easy to see where one needs to be clear about which standard is being referenced as a GHS Category 2 is flammable whereas NFPA Class II is combustible.

Flammables Have Flashpoints Below 140°F (GHS)Category Flash Point Boiling Point Examples

1 <73° F <95°F acetaldehyde, ethyl ether2 <73° F >95°F acetone, and alcohol hand sanitizers3 >73° F <140°F hydrazine, styrene, and turpentine4 >140°F <199.4°F acetic acid, naphtha, and Stoddard solvent

Storage of Hazardous ChemicalsRead all chemical labels carefully to determine other factors for the proper use and storage of hazardous liquids such as ignition temperature, explosive limits (LEL or UEL), vapor pressure, specific gravity, and vapor density. Purchase chemicals in a volume that will be consumed before the expiration date.

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OSHA does not require the use of flammable storage cabinets unless the total amount of flammable liquids reach a given amount. The amount of liquid that may be stored outside of a cabinet in any one fire area of a building cannot exceed: 25 gallons of Category 1 liquids in containers. 120 gallons of Category 2, 3, or 4 liquids in containers.

Not more than 60 gallons of Category 1 liquids may be stored in a storage cabinet. Also, not more than three such cabinets may be located in a single fire area.

Local authorities and insurance companies may require the use of flammable storage cabinets in quantities less than that of OSHA.

The exceptions to this rule are medicines, beverages, foodstuffs, cosmetics, and other common consumer products, when packaged according to commonly accepted practices.

Hazardous Chemicals with Permissible Exposure Limits (PEL)Some chemicals frequently used in medical facilities that have recommended or required employee exposure limits are shown below. Most medical offices will not be required to monitor these levels since exposures are well below these limits. For instance, medical facilities that store small vials of formaldehyde to transport tissue for pathology testing would certainly fall below the established limits. Glutaraldehyde, which is often used as a high-level disinfectant in medical practices should also remain well below the permissible exposure limits when diluted in a tightly covered container. Safety measures for glutaraldehyde are discussed in detail in Tab 8: Decontamination.

Chemical Exposure LimitFormaldehyde 0.75 part per million (ppm) over 8 hours or 2 ppm over a

15-minute periodGlutaraldehyde There is no OSHA PEL. 0.2 ppm NIOSH REL;

ACGIH 0.05 ppm ceiling concentrationEthylene Oxide (EtO) 1 ppm over 8 hours or 5 ppm over a 15-minute periodNitrous Oxide 25 ppm per 8-hour shiftMercury 0.1 mg/m3 over an 8-hour shift

If there is any question whether employee exposure exceeds permissible limits, contact a local industrial hygiene company to test the HVAC system. These companies will ensure that your workplace air supply system has an adequate number of air changes per hour to reduce or eliminate employee exposure to these chemicals.

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For circumstances where exposure limits in your workplace fluctuate or reach permissible limits, provide clip-on monitoring badges for employees. Companies that supply air monitoring badges are listed in Tab 8: Decontamination.

Ensure that anesthesia equipment is serviced and monitored for leakage per the manufacturer’s recommendations.

Labeling Hazardous ChemicalsHazCom Pictograms and Hazard Statements

Hazardous chemicals are labeled appropriately when bought from the manufacturer, so there is no need to re-label them upon receipt. The label must include:Identity or contentsChemical name and the common or trade name of the contentsPictogram (s)Signal word, “danger” or “warning”Hazard and precautionary statements about storage use, first aid, and

emergency proceduresThe name, address, and phone number of the chemical supplier

Be sure to label, tag, or mark containers of any chemical that has been transferred to a secondary, unlabeled container with the contents, the dilution, and any hazardous warning, including specific effects of the chemical and target organs affected. Advise the OSHA Safety Officer if there are unlabeled containers in the workplace or if a label has become illegible. The OSHA Safety Officer ensures that labels are replaced when deteriorated or illegible.

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Pictograms

These pictograms must include the red “diamond” (technically a square on point), with the black picture and text. OSHA feels that these pictograms will be more readily understood than other means of hazard labeling.

Health Hazard

• Carcinogen• Mutagenicity• Reproductive Toxicity• Respiratory Sensitizer• Target Organ Toxicity• Aspiration Toxicity

Flame

• Flammables• Pyrophorics• Self-Heating• Emits Flammable Gas• Self-Reactives• Organic Peroxides

Exclamation Mark

• Irritant (skin and eye)• Skin Sensitizer• Acute Toxicity• Narcotic Effects• Respiratory Tract Irritant• Hazardous to Ozone Layer (Non-Mandatory)

Gas Cylinder

• Gases Under Pressure

Corrosion

• Skin Corrosion/Burns• Eye Damage• Corrosive to Metals

Exploding Bomb

• Explosives• Self-Reactives• Organic Peroxides

Flame Over Circle

• Oxidizers

Environment(Non-Mandatory)

• Aquatic Toxicity

Skull and Crossbones

• Acute Toxicity (fatal or toxic)

The new pictograms can be downloaded from the OSHA website: www.osha.gov/dsg/hazcom/pictograms.

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NFPA Label System

NFPA or other custom labels can be used as long as all of the hazard information of the GHS is included. If the NFPA system is used, workers must understand both the GHS and NFPA labeling systems. While OSHA never specifically mandated the NFPA’s standard hazard identification system (see the diamond-shaped, color-coded symbol below), some medical facilities have adopted it to standardize hazard labels. The NFPA system offers hazard assessments for health (blue quadrant), flammability (red quadrant), reactivity/stability (yellow quadrant), and special hazards (white quadrant) at a glance.

0 = minimal 1 = slight 2 = moderate 3 = serious 4 = severe

♦ The top diamond is RED and contains the flammability hazard rating.

♦ The right diamond is YELLOW and indi cates the reactivity rating of the chemical.

♦ The left diamond is BLUE and indicates the health hazard rating.

♦ The bottom diamond is WHITE and focuses attention on any special hazards of the chemical, such as oxidizer, water reactive, corrosive or carcinogen.

Note: the GHS labeling system uses “1” as the most severe hazard and “4” as the least severe hazard.

Safety Tips for Working with Hazardous ChemicalsAll employees working with hazardous substances are provided with personal protective equipment (PPE) according to specific OSHA standards or, where indicated, by the SDS in section 8. These employees receive education regarding when PPE is necessary; how to properly don (put on), doff (take off), adjust, and wear it; the limitations of PPE; and the proper care, maintenance, useful life, and disposal of PPE.

quality-america.com 1-800-946-9956

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Labeling Hazardous Substances

Hazardous chemicals are labeled appropriately when bought from the manufacturer, so there is no need to relabel them upon receipt. The label must include:

Identity or contents.

Chemical name and common or trade name of the contents.

Hazard warnings, including words, pictures, symbols, or combinations that convey the health

and/or physical hazards of the container’s contents; these warnings must be specific as to the

effect of the chemical and specific target organs involved.

The name, address, and phone number of the chemical manufacturer.

Be sure to label, tag, or mark containers of any chemical that has been transferred to a secondary,

unlabeled container with the contents, dilution, and any hazardous warning, including specific effects of

the chemical and target organs affected.

Advise the OSHA safety officer if there are unlabeled containers or if a label has become illegible. The

OSHA safety officer assures that labels are replaced when deteriorated or illegible.

NFPA Label System

Although OSHA does not specifically mandate the National Fire Protection Association’s (NFPA) standard hazard identification system (see the diamond-shaped, color-coded symbol below), some

dental facilities may wish to adopt it to standardize hazard labels. The NFPA system offers hazard

assessments for health (blue quadrant), flammability (red quadrant), reactivity/stability (yellow quadrant), and special hazards (white quadrant) at a glance.

In addition, each quadrant shows the magnitude of severity, graded from 0 to 4:

0 = minimal 1 = slight 2 = moderate 3 = serious 4 = severe

♦ The top diamond is RED and contains the flammability hazard rating.

♦ The right diamond is YELLOW and indicates the reactivity rating of the chemical.

♦ The left diamond is BLUE and indicates the health hazard rating.

♦ The bottom diamond is WHITE and focuses attention on any special hazards of the chemical, such as oxidizer, water reactive, or corrosive.

Safety Tips for Working with Hazardous Substances

All employees working with hazardous substances are provided with personal protective

equipment (PPE) according to specific OSHA standards or, where indicated, by material safety

data sheets. These employees receive education regarding when PPE is necessary; how to

properly don, doff, adjust, and wear it; the limitations of PPE; and the proper care, maintenance, useful life, and disposal of PPE.

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Other general safety rules for working with chemicals are:Avoid direct contact with hands, face, and clothing, including shoesNever taste or smell a chemicalDo not smoke, drink, or eat in chemical use and storage areasNever use any chemical from an unlabeled containerKeep appropriate safety devices available for employees who work with, or near,

hazardous chemicals. For example, if a substance could cause eye damage, an emergency eyewash must be available within 10 seconds clear travel or within about 55 feet of the workstation. Specifications for the types of eyewashes required and their locations are located behind Tab 8: Decontamination.

If flammable liquids or vapors are present, the proper fire extinguishers must be present and readily accessible (within 50 feet)

Hazardous Chemical Waste Packaging and DisposalRead the SDS carefully for guidance on disposal of hazardous chemicals. The Resource Conservation and Recovery Act (RCRA) statutes of the Environmental Protection Agency (EPA) affect the handling of chemical hazardous waste (not infectious waste). Most physician offices are affected by RCRA (or its state-administered counterpart) because they generate chemical hazardous waste, although those that generate less than 100 kg (about 27 gallons) per month are classified as very small-quantity generators that are conditionally exempt from RCRA.

Facilities that generate between 100 kg and 1,000 kg per month are considered small-quantity generators and must obtain a 12-digit EPA identification number. Hazardous wastes must be tracked from the time it is generated until its disposal with a manifest system (cradle to grave) and shipped in EPA-approved hazardous waste trucks.

Typical healthcare hazardous wastes are:Acetone Ethyl etherInsulinMethanolPotassium cyanideNitrous oxideEpinephrine base*MercuryFormaldehydeTolueneSilver (from wet x-ray developer)

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Regardless of your RCRA classification, do not discharge pollutants into the water/sewer system without first verifying with local publicly owned treatment works that it meets your state’s criteria for discharge. For more information about disposing of chemical hazardous waste, see the Hazardous Waste Disposal section in Tab 8, or contact your state or local Environmental Protection Agency office.

* In October 2007, the EPA determined the scope of the epinephrine hazardous waste listing is only epinephrine base, and does not include epinephrine salts. Most, if not all, of the epinephrine used in medical applications is one of several epinephrine salts. The EPA statement applies to the federal level only. As most states implement their own EPA programs, some may regulate epinephrine salts more stringently than the federal regulations. Therefore, we recommend you contact your state agency to determine the regulation in your state, especially if your facility is in California, Minnesota, Michigan, Oregon, Rhode Island, or Washington (where laws are typically stricter than the federal regulations.) Find your state contact information at www.epa.gov/osw/wyl/stateprograms.htm.

See Tab 9: Specialty Services for disposal of cytotoxic drugs and radioactive mater-ials. For instructions about cleaning up large volume spills, see Tab 8: Decontamination.

Medications Security and DisposalThis information is not specifically required by OSHA, but is included in this section because of the fact that some prescription drugs are considered hazardous substances and require SDSs.

Security for Prescription Drugs

Store all prescription drugs, including samples and prescription pads, in a secured area with controlled access to minimize the risk of theft or unauthorized use.

Security for Controlled Substances

Keep Drug Enforcement Administration (DEA) ordering forms and controlled substances in a secure and locked area. Limit access to these forms and drugs to specific staff selected by management.

Maintain a record of the date, name, strength, and amount of controlled drugs ordered.

Keep a dispensing record that includes date, patient name, drug name and strength of drug, amount dispensed, physician name, and name and signature of person who dispensed the drug.

Take inventory at regular intervals and resolve discrepancies between the inventory record and the dispensing record.

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Disposal of Prescription Drugs

Check prescription drugs periodically for expiration.Remove expired drugs from stock. Check package insert or SDS for any special disposal requirements. Document how expired drugs are disposed of after removal from stock (e.g.,

sharps containers or pharmaceutical collection containers, etc.).

Disposal of Hazardous Drugs

Special handling may be required for toxins, biological and cytotoxic drugs, see Tab 9: Specialty Services. As above, check the SDS and have proper disposal containers available.

Appoint one staff person to have overall responsibility for ensuring proper disposal of expired medications.

Medical Consultation and Injury EvaluationEmployees who need medical attention due to a chemical exposure will use the health services at the following facility:

_____________________________________ _________________________ Name of healthcare facility Telephone number

If an employee requests evaluation by a personal physician, that request will be honored. Medical evaluations and consultations are performed by or under the supervision of a licensed physician without cost to the employee, without loss of pay, and at a reasonable time and place.

Employees will be medically evaluated when:

Signs and symptoms are consistent with a chemical exposure.Environmental monitoring reveals an exposure level above the proper threshold, if

appropriate (formaldehyde, etc.).

Record chemical exposures on the Incident Report/Sharps Injury Log located behind Tab 11: Master Record Forms (Form 14).

The OSHA Safety Officer will provide the following information to the referring physician:

Identity of the hazardous chemical to which the employee was exposed.A description of the conditions under which exposure occurred.A description of the signs and symptoms of exposure.A copy of the SDS for the chemical involved.

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HazCom RecordkeepingOSHA’s Hazard Communication Standard requires that records of employee exposures to hazardous chemicals are kept for 30 years plus the length of employment. There’s no need to keep them in your SDS binder that is accessible to employees if they take up too much space. Archiving or filing SDS that are no longer in use meet the intent of the Hazard Communication Standard.