OSHA COMPLIANCE

OSHA stands for Occupational Safety and Health Administration. It is part of the U.S. Department of Labor and
is concerned only with employee safety and health in the work place. The regulations which OSHA enforces
only affect one group….the employees.
The regulations include Hazard Communications and Bloodborne Pathogens, however, they can (and do)
enforce workplace safety under the Occupational Safety and Health Act.
This safety clause states that all employees are entitled to a safe workplace and assigns employers the
responsibility for providing appropriate safety and health measures, as well as, the proper training. Baptist
Medical Group will comply with all government guideline and regulations to ensure the health and safety
of all their employees. They will provide initial training to all new employees and annually, thereafter.

The regional OSHA office phone numbers for Tennessee, Mississippi and Arkansas are listed below:

Tennessee: 615-741-2793
Mississippi: 601-965-4606
Arkansas: 501-224-1841

Mailing address for OSHA is:

U.S. Department of Labor

Occupational Safety and Health Administration
3rd and Constitution Ave., N.W.
Washington, DC 20210

OSHA’s web address:www.osha.gov

The numbers below may also be helpful if you have any questions.

EPA Hotline for Hazardous Materials- 800-424-9346

The Centers of Disease Control (CDC)- 404-639-3311
National Clinicians’ Post exposure (HIV) Hotline- 888-448-4911

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 INSTRUCTIONS FOR USING THIS MANUAL
OSHA requires every workplace to have a written safety program.
This OSHA Manual is designed to serve as the written safety program for BMG practices. OSHA has three basic
requirements:

 CUSTOMIZE THIS OSHA MANUAL

First, it must be customized to the practice. The name and address of the practice must be in the site
specific information and on policies and forms throughout the manual. Policies in the manual have
blanks that must be completed with site-specific information. Failure to customize your manual may
result in OSHA fines.

 INDICATE SUPPORT OF MANAGEMENT FOR YOUR WRITTEN SAFETY PROGRAM

Second, there is an Employer Policy Statement that must be read, customized, and signed by both the
Practice Representative and the Safety Coordinator. Each year afterward, the Safety Coordinator must
review the manual and sign and date these reviews.

 ALLOW EMPLOYEES ACCESS TO THE OSHA MANUAL

Third, OSHA requires that employees have access to their workplace’s written safety program. During
the annual OSHA-required employee training, make sure that the employees are told where the OSHA
Manual is kept. Make it available to them.

This manual contains the practice’s safety policies and other important information. OSHA requires
employers and employees to follow the OSHA standards and guidelines.

IMPORTANT: This OSHA Manual includes master forms.

This manual includes master forms that are useful for OSHA-required tasks such as maintenance, record
keeping, follow-up care for injuries, annual sharps review, and other OSHA-required duties. They are meant to
serve as masters only.

ALWAYS MAKE COPIES OF THESE FORMS BEFORE USING

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 OSHA TRAINING REQUIREMENTS
Who must receive OSHA training?
Training is required for all employees who could be at risk for any of the hazards being discussed. This includes
part-time employees, contract employees and temporary employees.

Training must take place:

Before the employee begins their work assignment in their prospective office. It must be offered during
regular working hours and at no expense to the employee. The training must be conducted annually. It must
include site-specific information and someone must be available to answer any questions and employee may
have.

Topics to be covered:
Training must cover any and all hazards or bloodborne pathogens that the employee may be exposed to. It
must include information about the potential hazards, the employer written protection plan, all protective
measures employees must take and how to recognize hazards in the office.

Training Records:
Training records must be kept for at least three years. The records must include the date of training, the
contents of training, the names, signature and job titles of those attending and the name of the trainer.

Trainer Qualifications:
The trainer must have knowledge of OSHA guidelines and must be able to answer or know where to get the
answer to any questions an employee may have. No certification is required.

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 OSHA Program Site-Specific Information
Practice Name:______________________________________________________

Practice Address:____________________________________________________

Safety Committee:

Management Representatives__________________________________________

Employee Representatives_____________________________________________

Safety Coordinator___________________________________________________

Infection Control_________________________________________________

Hazardous Communications________________________________________

Radiation Safety_________________________________________________

Laser Safety_____________________________________________________

OSHA Manual Location________________________________________________

Safety Data Sheet book Location___________________________________________________

Spill Kit Location_____________________________________________________

Eyewash Station Location______________________________________________

First Aid Kit/Supplies__________________________________________________

Resuscitation Equipment Type__________________________________________

Location_________________________________

Fire Extinguisher(s) Location___________________________________________

Emergency Phone
Numbers_____________________________________________________________________

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Warning Equipment: Emergency Response:

Smoke detectors Fire extinguishers

Gas detection equipment Sprinkler systems

Alarms Emergency gas shut-off

Verbal

Evacuation Meeting Area:______________________________________________

Laundry Service:_____________________________________________________

Biohazardous Waste Pick-up:___________________________________________

Disposable Sharps Containers Location:___________________________________

Personal Protective Equipment Locations:_________________________________

Gloves:__________________________________________________________

Eyewear:________________________________________________________

Masks:__________________________________________________________

Gowns:__________________________________________________________

Disinfectant Used:____________________________________________________

Sterilant Used:_______________________________________________________

Post-exposure evaluation and follow up will be done by:_____________________

___________________________________________________________________

Employee Medical Records Location:__Baptist Employee Health

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 OSHA REQUIRED TASKS

Initially: Hazard Analysis (facility inspection; recommended every 2 yrs.)

Weekly: Flush eyewash station for 3 minutes (15 minutes is preferable)

Monthly: Check fire extinguishers: properly charged, safety pin and set in place

Yearly/Annually: Bloodborne Pathogen Risk Identification for all employees

Review and sign BBP Exposure Control Plan

Review of Chemical List

Coordinate OSHA training for all employees

February 1- April 30: post OSHA posters

New Employees: OSHA training

Bloodborne Pathogen Risk Identification

Offer HBV vaccination (Employee Health)

Hepatitis B Vaccination documentation (Employee Health)

TB skin test (Employee Health)

As Needed: Sharps Injury Log (if applicable)

New Safety Data Sheets (SDS)

Additional training

Always: OSHA poster

BE SAFE

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 OSHA COMPLIANCE CHECKLIST

Please use the following checklist to help you when you are reviewing and evaluating your office each year, as
required by OSHA. This list will be a huge help to you when you first implement OSHA compliance in your
clinic(s). Each one of the bullet points are required by OSHA and will be explained during this training session.
You will have the opportunity to ask questions at the end of the presentation.

Comprehensive OSHA Compliance Checklist

o Commitment of management documented
o Safety Coordinator designated
o Safety Coordinator responsibilities established
o Safety Committee formed
o Worksite Hazard assessment completed
___Initially
___Annually
o Written Compliance program developed addressing hazards found during hazard assessment
___Bloodborne pathogens
___Hazardous chemicals
___Fire and electrical hazards
___Radiation
___Laser safety
___General safety
___Emergency action plan
___Workplace violence
___Ergonomics
___Other
___Training
o OSHA poster displayed
o Written program approved by management
o OSHA Manual reviewed and signed by Safety Coordinator and Management
o Training program developed to meet all needs, based on hazard assessment
o Training provided and documented
___Initially
___Annually
o Fire extinguishers professionally serviced annually
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o Fire extinguishers checked visually each month
o Exit route diagrams posted
o Evacuation meeting place assigned
o Bloodborne Pathogens Risk Identification performed
___Initially
___Annually
o Safer Medical Devices
___Evaluated
___Chosen
___Implemented
___Re-evaluated annually
o HBV vaccine offered to all employees at risk (EMPLOYEE HEALTH)
o Record keeping(EMPLOYEE HEALTH)
o Designated healthcare professional to do exposure follow-up (EMPLOYEE HEALTH)
o Handwashing facilities, sharps containers, and biohazardous waste containers where needed
o Chemical list completed
o SDS’s obtained and organized
o Tuberculosis Risk Assessment(EMPLOYEE HEALTH)
o Personal Protective Equipment Assessment
___Initially
___Annually
o PPE provided and replaced or maintained
o Eyewash Station
___Installed
___Checked and flushed weekly
o Commercial laundry service obtained and informed that some of the linen may be contaminated
o Reliable waste removal company contract verified
o Spill kit obtained
o First Aid kit readily available
o CPR mask or ambu bag available
o Training logs
o Sharps injury log (if applicable)

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 INJURY AND ILLNESS PREVENTION PROGRAM EMPLOYER POLICY STATEMENT
The purpose of this notice is to inform you that the office
of:________________________________________________________________________________________________
__________________________________________________________

Has appointed a Safety Coordinator, charged with overall responsibility for the Occupational Safety and Health Program,
in compliance with OSHA Standards, Title 29, Federal Regulations Code 1910.1200. The Safety Coordinator has the full
support and authority of Baptist Medical Group to ensure compliance as outlined in this manual, including the Hazard
communication Standard, The Bloodborne Pathogen Standard, Emergency Preparedness and General Safety. These
duties include but are not limited to:

1) Performing periodic hazard analysis and recommending hazard control measures

2) Ensuring that engineering controls, including fire extinguishers, are available and functional
3) Involving employees in the hazard analysis and control process
4) Determining and obtaining appropriate personal protective equipment
5) Establishing safe workplace practices
6) Providing necessary training for all employees
7) Implementing the emergency preparedness plan
8) Keeping all required documentation, including posters and training logs. (Immunization records and exposure
follow-up forms will be maintained in Employee Health).

This office provides written materials and seminar-style training sessions to teach these compliance responsibilities. .
OSHA requires each employee to be familiar with the employer’s hazard control plan and the OSHA Standards.

This practice supports all health and safety recommendations made by OSHA. It is our goal to provide a safe and
healthful workplace for all personnel. This practice endorses the policies and principles outlined in this manual and will
enforce all OSHA regulations. Employees are encouraged to report any concerns they have about workplace health and
safety. This practice will never discriminate or retaliate against any employee who reports hazards to us or to OSHA.

_______________________________________________ ____________________

Practice Representative Date

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I hereby acknowledge my appointment as Safety Coordinator and understand my responsibilities. I have reviewed this
manual and found it to be applicable in our practice initially and each year as documented below.

_________________________________________ _________________

Safety Coordinator Date

_________________________________________ _________________

Safety Coordinator Date

_________________________________________ _________________

Safety Coordinator Date

_________________________________________ _________________

Safety Coordinator Date

_________________________________________ _________________

Safety Coordinator Date

_________________________________________ _________________

Safety Coordinator Date

_________________________________________ _________________

Safety Coordinator Date

_________________________________________ _________________

Safety Coordinator Date

_________________________________________ ________________

Safety Coordinator Date

_________________________________________ ________________

Safety Coordinator Date

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 DISCIPLINARY ACTION POLICY
This practice is committed to providing a safe and health work environment for our staff. We strive to adhere
to all OSHA regulations, as described in our OSHA manual. Any staff member who after training fails to comply
with the OSHA standards and our policies is subject to disciplinary actions.

The Practice Manager has the authority to make determinations of disciplinary actions.

Individuals who witness violations must report them to the manager.

Based on the seriousness of an offense, management may enter immediately into any level of disciplinary
action, from verbal correction up to and including termination. Consequently, in case of what is deemed by
the manager to be a severe rule or policy violation by an employee, dismissal, suspension, or final warnings
may be made without prior warning. Training will follow each step of the progressive disciplinary steps listed
below.

The following procedure has been established as a guideline for disciplinary action.

1. Verbal written and counseling. Employee may be asked to sign a verbal warning form to
acknowledge receipt of the counseling. The form will become part of the employee’s personnel file.
2. Written warning. A verbal or written warning may be issued when the conduct of the employee
does not warrant suspension or discharge. Such warnings are considered serious matters, and each
warning becomes a part of the employee’s personnel file. Employees may be asked to sign a written
warning to acknowledge receipt of the counseling.
3. Final written warning. More serious misconduct or repetition of an offense for which a warning
may have been previously issued may result in disciplinary suspension without pay.
4. Discharge. Repetition of any offense or offenses similar in nature for which prior discipline may
have been imposed may result in discharge from the employment of this practice. An employee may
be discharged without prior warning for offenses deemed by the manager to be serious violations of
the practice’s rules, policies and regulations. In case of termination, the practice affirms its status as
an “ At-Will” employer.

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 WORKPLACE VIOLENCE
WORKPLACE VIOLENCE PREVENTION PLAN

INTRODUCTION
Workplace violence is defined by the National Institute of Occupational Safety and Health (NIOSH) as “violent
acts (including physical assaults) directed toward persons at work or on duty”.

CPL 01-02-052 “Enforcement Procedures for investigating or Inspecting Workplace Violence.”

OSHA has had “Guidelines for the Prevention of Workplace Violence” for specific industries for
several years. This new compliance directive, released September 8, 2011 uses the Guidelines for
the Prevention of Workplace Violence for Health Care and Social Service Workers, OSHA Publication
3148, 2004, as its foundation. OSHA encourages employers to establish violence prevention
programs and to track their progress in reducing work-related assaults. Although not every
incident can be prevented, many can, and the severity of injuries sustained by employees can
be reduced. Adopting practical measures such as those outlined here can significantly reduce
this serious threat to worker safety.

As with other hazards, the first step in prevention and response is hazard assessment. Employers are
expected to use the information gathered in that assessment to develop a plan, implement controls, and
provide employee training. The updated statistics compiled by OSHA make protection against workplace
violence even more compelling.

 For the time period of 2000-2009, the average annual total for reported assaults was 590.
 Ten percent of those were in healthcare.
 Assault is one of the top four causes of fatalities in the workplace.
 Assault is the most common cause for workplace deaths among women.

Based on these statistics, healthcare and social work is considered a high risk industry for workplace
violence. These include: The prevalence of handguns and other weapons among patients, their
families or friends■ The increasing use of hospitals by police c hronic mentally ill patients being
released from hospitals without follow-up care these patients have the right to refuse
medicine and can no longer be hospitalized involuntarily unless they pose an immediate
threat to themselves or others■ The increasing presence of gang members, drug or alcohol
abusers, trauma patients or distraught family members■ Low staffing levels during times of
increased activity such as mealtimes, visiting times and when staff are transporting patients.
Isolated work with clients during examinations or treatment■ Solo work, often in remote
locations with no backup or way to get assistance, such as communication devices or alarm
systems (this is particularly true in high-crime settings);■ Lack of staff training in recognizing
and managing escalating hostile and assaultive behavior; and poorly lit parking areas.

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OSHA perceives that workplace violence can be prevented or at least minimized. OSHA can and will use the
General Duty Clause to cite employers for failure to protect employees from workplace violence. Inspections
for workplace violence will generally be in response to a complaint, a referral, or a fatality or catastrophic
(three or more employees admitted for hospitalization), or programmed inspections where workplace
violence is recognized as a problem.

Instances of worker or personal threats of violence should be classified as intimidation or bullying and should
be referred to the appropriate government agency, such as the local police department, the National Labor
Relations board or OSHA’s Office of Whistleblower protection. This type of incident will not generally trigger
an inspection.

OSHA has identified for categories of workplace violence:

 Type 1- Criminal intent, often robbery

 Type 2- Customer/Clients/Patients; healthcare is in the classification
 Type3- Co-worker, current or former employee, supervisor, or manager
 Type4- Personal; someone who does not work there but knows or has a relationship with an employee

OSHA’s compliance model parallels guidelines for other hazard assessment for the entire OSHA program,
should be completed and kept in this manual. Include information provided here for employee training,
initially and each year.

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 Workplace Violence Report
Practice:___________________________________Department_________________________

Assailant:__________________________________Date/Time___________________________

Reported by:________________________________Date/Time__________________________

Person(s) Affected: ___Patient(s) ___Staff Member(s) ___Other

Name(s) of Person(s)
Affected:__________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________

Type of Incident:

___Threat ___Bomb ___Terrorism ___Personal ___Weapon

___Verbal Assault ___Inappropriate Behavior

(Describe)__________________________________________________________________________________
__________________________________________________________________

Injuries:
(Describe)__________________________________________________________________________________
__________________________________________________________________

Detailed
description:________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________

Describe Assailant:

___Armed/Weapon(what kind)________________________ ___Unarmed

___Intoxicated ___Depressed ___Distraught ___Dissatisfied with Care

___Dissatisfied with Waiting

Response:

___Called Police ___Contacted Legal ___Incident Diffused ___Assailant Left

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Patient Dismissed from Care: ___Yes/Date Notified___________________ _____NO

Comments:________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________

Documented by:_______________________________________________ Date:____________

HAZARD PREVENTION AND CONTROLS

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Engineering Controls selected for us in this practice:

____Silent alarm (panic button) that alerts authorities

____Closed circuit video recording’

____Guards

____Locked or monitored doors

Administrative and work practice controls implemented in this workplace:

____Maintain comfortable, clean waiting area

____Communicating zero tolerance plan to patients and employees

____Incident file

____Dismissing repeatedly unruly patients or workers

____Require all non-staff members to be escorted by staff members

____Staff nametags

____Escort or buddy system to parking areas

____Call security or the police

Methods for Dealing with Potential Problems:

 Educate patients about their responsibilities for co-pays, arrival times, insurance coverage and
compliance with prescription policies.
 Keep patients informed of wait times. Let them know you are aware that they are still there.
 If the wait is expected to be extended, give them an opportunity to reschedule.
 Stay calm. Take a time-out if needed, excusing yourself to “go check on this for you”.
 Help the other person regain control by keeping outwardly calm and keeping your voice soft.
 Keep your voice, your words, and your body language neutral.
 Acknowledge that the other patients is having a problem, but don’t take ownership of the problem.
 Don’t give others the power over you to make you angry. Only you should control your emotions.

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Training:
Training will be provided for all employees upon hire and every 12 months. It will include problem awareness,
employee rights and responsibilities, potential triggers, appropriate responses, de-escalation techniques, and
incident reporting.

Reporting:
All employees are encouraged to report any potential triggers for workplace violence and any incidents that
were observed or experienced. There will be not reprisals against these workers.

Recordkeeping:
The Worksite Hazard Analysis is kept in the OSHA Manual. Training records are maintained in personnel files
or in the Training section of the manual. The Safety Coordinator will assist with the documenting incidents
and will maintain the reports in an Incident File. The Incident File will be available to all employees as a means
of informing them of potentially abusive patients. The Violence Incident Report Form follows.

The following management signature documents the commitment of this practice to this Workplace Violence
Prevention Plan.

_________________________________________ ____________________

Practice Manager Date

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 EMERGENCY PREPAREDNESS FOR POTENTIAL TERRORISM
The Occupational Health and Safety Administration (OSHA) have not issued any comprehensive rules or
regulations at this time dealing with terrorism in the workplace; however, they have addressed the issue of
worker health and safety for anthrax exposure. The newly created Department of Homeland Security (DHS),
along with the American Red Cross, has attempted to address these issues and educate the American people
about potential threats so that we are better prepared to react. On DHS’s website www.ready.gov, you will
find an information packet to help in preparing for such attacks. As DHS Secretary Tom Ridge has said,”
Terrorism forms us to make a choice. We can be afraid, or we can be ready”.

It is the intent of this facility to protect employees from all recognized hazards. Terrorism, which is an act of
war, does not strictly meet the guidelines for workplace hazards. Terrorism, although recognized in certain
industries, is not yet a recognized hazard in healthcare. We will do our best to protect our employees should
there be a threat of terrorism in our facility.

We will provide information to our employees on how to recognize potential acts of terrorism and how to
respond.

If we receive any communication of potential terrorism, whether from our staff, our patients, or from the
general community, our office will immediately contact the appropriate emergency agency.

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 POTENTIAL MAIL HAZARDS
Handle all mail as little as possible, using a letter opener or method that minimizes movement. Do not blow
into the envelopes or packages, or shake or pour out the contents. Keep hands away from the nose and
mouth, and wash hands after handling the mail.

 Be on the alert for suspicious letters and packages

 If you receive a suspicious piece of mail
1. Handle it as little as possible- do not open it!
2. Immediately place it on the nearest surface; cover it with anything, even a piece of clothing.
3. Evacuate that room and close the door.
4. Wash your hands with soap and water.
5. Notify the practice manager.
6. Do not re-enter the room until directed to do so.
7. The practice manager will contact the appropriate authority.

 If you open a piece of mail with suspicious contents (powder)\

1. Do not try to clean up the powder.
2. Immediately cover the powder with anything (trash can, e.g.).
3. Leave the area and close the door.
4. Wash your hands with soap and water.
5. Notify the practice manager, who will contact the proper authority.
6. Remove and contain clothing and take a shower as soon as possible.
7. Anyone else who was in the room should do the same.

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 EMERGENCY ACTION PLAN

1910.38(a)
This practice may experience situations that would require an immediate and safe evacuation from this
facility. These potential hazards include but are not limited to (cross out any that do not apply):

Fire Major chemical contamination Chemical or biological terrorism

Earthquake Civil defense emergencies Bomb threat

Flood Hurricane Radiological accident

Gas leak Chemical spill Tornado

Explosion Workplace violence resulting in bodily harm

If the emergency involves a civil defense or terrorism incident, the practices will proceed as directed by civil
defense authorities. In case of a tornado, proceed to the lowest part of the building to a room with no
windows or doors to the outside.

Evacuation Procedure:
When an emergency requiring evacuation occurs, the first person to discover the emergency will report the
emergency to _____________________________, who will then alert others by the most appropriate
methods. In this practice, that means:

_____ Quietly and calmly announcing, “We need to leave the building”.

_____ Use the intercom system to announce the need to evacuate.

_____ Pull the emergency alarm.

_____ The person in charge of phones will call 911 or______________________and tell the answering party
the nature of the emergency.

_____ The first person reaching the fire alarm will pull it if it is not already ringing.

_____ If a fire is involved, the following person(s) will use the portable fire extinguisher to put out the
fire:____________________________________________________________________

The fire extinguisher(s) is/are located_______________________________________________

_____ All personnel will evacuate. The portable extinguisher(s) will be used only if a human being, clothing
or hair is burning.

_____ Emergency gas shut off is located_________________________________________

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 And is the responsibility of __________________________________________to turn off.

_____ The smoke detector will sound an alarm.

_____ The sprinkler system will automatically activate.

_____ We will knock on the doors of any adjoining businesses to advise them to evacuate.

Everyone in the office will quickly and safely leave the building. Personnel in the business areas will assist
their coworkers and anyone in the reception areas. Those in the clinical areas will assist their coworkers as
needed and anyone else in the clinical areas. Everyone will exit through the nearest unobstructed exit,
avoiding the area affected by the emergency. Stairwells will be used rather than elevators. Additional
assistance will be provided to disabled persons as needed.

Everyone will meet at the designated meeting place (__________________________________) and check in
with the Safety Coordinator, and remain there until instructed otherwise. The Safety Coordinator will account
for all personnel and will inform the emergency responders if anyone is missing.

Injured persons will be: ____offered appropriate first aid and/or ____transported to the nearest
emergency room (________________________________) if needed.

_____Employers trained in CPR may administer CPR if needed.

First aid equipment location: _____________________________________________________

CPR/AED device located: _________________________________________________________

Staff members responsible for administering CPR:

__________________________________________________________________________________________
______________________________________________________________________________________

SHELTER-IN-PLACE PLAN
Depending on the type of emergency, it may be safer to “shelter-in-place” than to evacuate. If toxic chemicals
are released into the atmosphere local authorities and/or Homeland Security will issue a “Shelter-in Place”
warning. Your written plans should identify a safe location within your facility. It should be a room or rooms
with no windows and vents that can be closed or blocked off. Be sure your employees know your plan and the
location of your safe room. If the Shelter-in-place warning is issued, all employees, visitors and patients should
go there directly. Our Shelter-in Place location is:

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 MEANS OF EGRESS
EMERGENCY EVACUATION FROM THE AREA
This practice will ensure necessary emergency escape routes according to OSHA guidelines. Emergency
escape routes are to be developed to ensure that employees evacuate the workplace or seek a designated
refuge area in the event of an emergency.

 Exits will be properly marked with exit signs illuminated by a reliable light source. The line of sight to
an exit sign will be uninterrupted.
 Signs will be posted along the exit route indication the direction of travel to the nearest exit.
 Exit routes will be at least 28 inches wide and will be free of obstructions and debris, including snow
and ice.
 Signs like “Not an Exit,” “To Storeroom” will be used if a door to any of these could be confused with
an exit, possibly trapping the individual.
 Fire alarms will be used to warn occupants of a fire if possible.
 Automatic sprinkler systems, fire detection systems, and alarm systems or fire doors shall be
maintained in continuous proper operating condition.

NATURAL DISASTER PLAN

 Plans will vary depending on your geographical location as well as the physical layout of your office.
Your written plans should have information included on what to do in case of a tornado, earthquake,
flood, winter storm or whatever “natural disaster” you may anticipate. Plan ahead of time in case you
experience any of these emergencies. Use the space below to write out your plan and make sure ALL
employees are aware of these plans.

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

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SUGGESTED CONTENTS FOR FIRST AID KITS
(16) ¾ x 3” Adhesive plastic bandages

(1) 2”X4” Elbow & knee plastic bandage

(1) 1-3/4 X2” Small fingertip fabric bandage

(4) 2”X2” Gauze dressing pads (2pks)

(4) 3”X3” Gauze dressing pads (2pks)

(2) 4”X4” Gauze dressing pads (2pkgs)

(1) 2” X 4.1 yds Conforming gauze roll bandage

(1) 3”X4.1 Conforming gauze roll bandage

(1) Triangular sling/bandage

(1) 6”X9” Instant cold compress

(2) 5”X9” Absorbent compress dressings

(2) Roller bandages (one 3”wide, one 4” wide)

(12) Cotton balls and cotton tipped swabs

(10) Tongue blades

(1) Sterile eyewash (saline solution)

(1) Bottle antacid

(1) Bottle calamine lotion

(1) Bottle Benadryl or EpiPen

(1) Tube petroleum jelly

(2) Pairs nan-latex gloves, goggles, mask gown

(2) Exam quality gloves, 1 pair

(1) Sterile eye pad

(3) Triple antibiotic ointment packs

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(1) Burn relief pack, 3.5gram

(6) Alcohol cleansing pads

(1) 1”X 5yds. First aid tape roll

(6) Antiseptic cleansing wipes

(6) Aspirin tablets

(1) 4-1/2” Scissors, nickel plated , safety pins

(1) Tweezers

(1)First aid guide

(1) 10 yds. X 1” Adhesive cloth tape

(1) Breathing barrier (with one-way valve)

(1) Aluminum finger splint

(1) Bottle anti-diarrhea medication

(1) Bottle syrup of ipecac

(2) Vials ammonia inhalant

(2) Hydrocortisone ointment

(1) Blanket

(1) Bottle of soap or instant hand sanitizer

For your facility’s first aid kit, you may gather basic supplies and keep them in a
simple plastic bin that is labeled or a centralized location in your facility. Please
ensure that ALL team members are aware of the location of your kit. Also, your
kit must be inspected every 6 to 12 months for expired supplies.

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 FIRE EXTINGUISHERS
This practice will provide and maintain fire extinguishers as needed. Location are listed in the site-specific
information section of this manual. A label on the fire extinguisher explains the extinguisher type and is
based on the National Fire Protection Association classification system. This practice has a Class A-B-C
extinguishers that meet the needs of this facility.

Class A- for extinguishing fires involving wood, paper, and trash, where the area needs to be wet down and
cooled.

Class B- for flammable liquid and gas fires, either by cutting off oxygen or reducing flame.

Class C- for electrical fires. Do not use water on electrical fires.

Extinguishers must be maintained (fully charged) and operational at all times. OSHA Standard 29 CFR
1926.150 calls for the periodic inspection of portable fire extinguishers. These extinguishers will be
visually inspected by our Safety Coordinator each month and the inspection will be documented on the tag
attached to the extinguisher itself or on a separate log. The extinguishers will be serviced professionally
annually.

OSHA’s General Industry Standard 29 CFR 1910.38 requires employers to have fire prevention and
emergency action plans. General Industry Standard 29CFR 1910.157 sets forth requirements for portable
fire extinguishers. The plans must be based on the hazards present in the workplace and the response
methods chosen by the employer.

_______ All employees will evacuate according to our Emergency Action Plan described elsewhere in
this manual. Our plan complies with OSHA Standard 1910.38. Portable fire extinguishers are present as
required by other agencies and are to be used only if a human being is on fire. Fire extinguishers will be
maintained per General Industry Standard CFR 1910.157

_______ All employees are required and trained to fight incipient stage fires. Portable fire extinguishers
are available for this purpose. An employee Emergency Action Plan is not needed. Our Fire Prevention
Plan complies with OSHA Standard 1910.157.

_______ Some employees will fight the fire and others will evacuate. Therefore, we have both a Fire
Prevention Plan and an Emergency Action Plan in compliance with both OSHA Standards 1910.38 and
1910.157.

25
 EXTINGUISHING A FIRE
When a fire is spotted, pull on the alarm before trying to put out the fire. When the alarm sounds, evacuation
procedures should be followed quickly but calmly by those who are told to evacuate.

Employees responsible for extinguishing the fire must remove the extinguisher from its brackets, break the
seal and remove the safety pin, and then aim the nozzle at the base of the fire. Begin 8-10 feet away from the
fire and approach the fire using a sweeping motion.

Using a fire extinguisher is easy if you remember the acronym “PASS”.

PULL the pin

AIM at the base of the fire

SQUEEZE the top handle

SWEEP from side to side

In case of a fire, stay calm and follow the fire response plan:

R. Rescue any person(s) in immediate danger.

A- Activate the fire alarm system by pulling the nearest fire alarm pull station

C.- Contain the smoke or fire by closing all doors to rooms and corridors.

E.- Evacuate or Extinguish the fire (when safe to do so)

Employees trained and responsible for extinguishing fires

include____________________________________________________________________________
__________________________________________________________________________________
_______________________________

26
 FIRE SAFETY CHECKLIST
YE
S NO N/A CORRECTIVE ACTIONS
Are any flammable items or chemicals present?
Do you minimize clutter to prevent fire hazards?
Do you burn candles?
Are other sources of fire or sparks present?
Do you limit reflective surfaces in your laser room?
Do you have a portable fire extinguisher near the kitchen?
Do you have a portable fire extinguisher at each exit?
Are all fire extinguishers mounted as required?
Have the extinguishers been serviced professionally?
Does someone on your staff visually check extinguishers monthly?
Do you have smoke detectors?
If so, do you routinely check and change the batteries?
Do you have sprinklers?
Do they function properly?
Are your exits marked with illuminated signs?
Do you have exit route diagrams posted?
Are your exits blocked?
Are your employees expected to fight a potential fire?

If so, have they been trained?

Has your staff been assigned responsibilities in case of a fire?
Do you have a designated meeting place in case of evacuation?
Does everyone know the number to call for help?

27
 MONTHLY FIRE EXTINGUISHER CHECKS
This verifies that the fire extinguisher(s) in this facility have been checked visually and that:

 They are properly charged

 The safety pin and seal are intact
 The nozzle is accessible and unobstructed

MONTH LOCATION LOCATION LOCATION LOCATION LOCATION LOCATION

January
February
March
April
May
June
July
August
Septembe
r
October
November
December

Annual Fire Extinguisher Service

This verifies that fire extinguishers have been professionally serviced for the current year.

Fire Extinguisher Fire Extinguisher Fire Extinguisher Fire Extinguisher Fire Extinguisher Fire Extinguisher
Location Location Location Location Location Location
Annual Service Annual Service Annual Service Annual Service Annual Service Annual Service
Date Date Date Date Date Date

Comments/Corrective Action_______________________________________________

Facility ______________________________________________ Date ______________

28
 RADIATION SAFETY
The Nuclear Regulatory Commission (NRC) and each individual state impose strict regulations concerning
human exposure to ionizing radiation, including x-rays. OSHA has its own guidelines that are generally
superseded by the stricter NRC or state regulations. See OSHA standards 1910.97 (Non-ionizing Radiation).
1910.1096 (Ionizing Radiation)., 1910.120 App C (Compliance Guidelines) and 1910.133 and 1515.153 (Eye and
Face Protection). The strictest guidelines always prevail.

Regardless of the regulatory agencies involved, radiation safety is one of the utmost importance in healthcare
facilities, and therefore deserves recognition in this safety manual. Compliance with OSHA regulations is
mandatory, but may be superseded by stricter state or NRC guidelines. This facility will comply with all
applicable guidelines.

Employee Exposure and Monitoring:

OSHA guidelines require employers to provide exposure monitoring to all employees who enter restricted
areas and may be exposed to radiation that may exceed 25% of the maximum dose, to anyone under the age
of 18 who may be exposed to an excess of 5% of the limit, and to all persons in high radiation areas. Wearing
dosimeter film badges, pocket dosimeters, or film rings usually does this monitoring. Results from this
monitoring are normally reported in Rems, which means a measure of dose of any ionizing radiation to body
tissue in terms of its estimated biological effect relative to a dose of 1 roentgen of x-ray.

Most states require personnel monitoring in medical facilities only.

_____YES _____NO This facility uses film badges to monitor employee exposure. Records will be
maintained for the duration of the employee’s employment here plus thirty years.

Maximum Rems (exposure) limits per calendar quarter are:

Whole body……………………………………1.25

Hands, forearms, feet, ankle………….18.75

Skin of whole body…………………………7.50

Under age 18………………………………….10% of the above

The whole body limit may be exceeded provided that:

 The whole body exposure does not exceed 3 Rems in any one calendar quarter,
 The accumulated occupational dose does not exceed 5 (N-18) where N equals the individual’s age in
years at his last birthday
 And that the employer maintains records that document that these limits are not exceeded.

Patient Exposure

29
 OSHA does not address patient exposure. Safety standards set by the NRC and states are designed to
reduce patient exposure through lead linings for radiology room walls, warning signs, etc. This facility
will adhere to those guidelines.

Warning Signs
The approved symbol is the purple three-bladed design on a yellow background. It will be displayed in
areas where radiation is present, including on the doors to the x-ray room, on the x-ray machine itself,
and on the control panel.

Radiology Chemicals
The supplier will recover silver for reuse prior to the disposal of radiology developing chemicals. This
waste will then be disposed of according to state, federal and local regulations. Radiology fixer and
developer will be labeled in accordance with the Hazard Communication Standard and the practice’s
labeling procedures. If/when this labeling becomes worn, employees will notify the Safety Coordinator
and/or the supplier to replace the labels.

Personal Protective Equipment

Personal Protective Equipment (apron, gloves) will be available at all times and will be stored so as not
to destroy the protective lining (hanging, not folded).

Equipment Operation
The employee responsible for taking x-ray will remain behind the protective shield while activating the
equipment.

Pregnant Workers
The dose limit to an embryo/fetus from occupational exposure during a woman’s entire pregnancy
must not exceed 0.5 Rem. The woman may choose to declare the pregnancy and have the exposure
prior to that declaration estimated. She may at any time withdraw the declaration. Declaration and/or
withdrawal are voluntary. Excessive exposure can result in birth defects.

SAFETY IN NUCLEAR MEDICINE

As with all occupational hazards, the safety goal in nuclear medicine is to prevent exposure as much as
possible using engineering controls, to provide appropriate personal protective equipment, and to
provide medical monitoring.

In the nuclear medicine department, nuclear medicine personnel and other individuals may be
exposed to ionizing radiation from the pharmaceuticals, from the environment, and from the patients
themselves. The level of exposure is based on many factors, especially the type of radioactive
materials used. The Federal occupational exposure limit is 5,000 millirem/year. Safety in nuclear

30
medicine is so effective that personnel rarely reach that limit. The goal is ALARA- as low as reasonably
achievable.

The following table summarizes ALARA trigger levels, as well as annual occupational dose limits. The
ALARA levels are a fraction of the annual dose limits.

Exposure Type Quarterly ALARA trigger Annual Dose Limit

Whole body 250 5,000
Lens of eye 250 15,000
Extremity 1,875 50,000

Exposure to radioactive materials may come from the pharmaceuticals, from the environment, and
possible from the patients themselves. If the patient could emit radiation, he/she may be placed in a
lead-lined room. Again, this is very dependent on the type of radioactive materials used. Most
radiation will not penetrate the body and reach the internal organs, but may affect the eyes and skin.

The entrance to the nuclear medicine department should be labeled with a sign that reads “CAUTION:
RADIOACTIVE MATERIALS.” The Nuclear Regulatory Commission’s form 3, “Notice to Employees” must
be posted in the department. All radioactive materials, including radiopharmaceuticals, vials and
syringes must be labeled “Caution: Radioactive Materials”.

Engineering controls used to protect workers include vial and syringe shields. Some of your work, such
as drawing up medications, may be done under a hood to reduce contamination of the area as well as
the lined aprons are very effective against x-rays but are not very protective against alpha, beta and
gamma emitters, such as Iodine-131, Phosphorous-32, Strotium-89 and Yttrium-90. These particles
may, however, be harmful if inhaled or ingested.

Work practice controls involve organizing your activities and materials before you begin, staying as far
away as possible from the source of radiation, and staying there for as little time as possible. Personal
protective equipment includes gown, gloves, eye protection, and shoe covers. Eating, drinking, storing
food or beverages, applying cosmetics, and smoking must be forbidden in areas where radioactive
materials are used or stored.

Nuclear medicine personnel should wear dosimeters, or badges that measure exposure. One should
be worn between the collar and the waist (best nearer to the collar) and one on the index finger.
These are tested periodically and documentation is kept for the duration of employment plus 30 years.

Some nuclear medicine personnel require bioassays as well. This is especially true after handling more
than 1 mCi of unsealed iodine-131 or more than 30 mCi of iodine in a capsule. These reports should
also be kept for the duration of employment plus 30 years.

31
Special considerations must be made for pregnant employees. If a nuclear medicine worker becomes
pregnant, the acceptable exposure level drops to 10% of the original limit, or 500 mCi during the entire
pregnancy.

SPILL PROCEDURE:
 Notify all affected individuals.
 Limit access to those needed to handle the spill.
 Don gown, gloves, booties, and eye protection.
 Cover the spill with an absorbent pad (Chux) or paper
 Have someone outside the area retrieve the meter and monitor from the door inward toward
the spill to evaluate the extent of contamination.
 Clean with paper towels and commercially available cleaner until the meter reading is
indistinguishable from the background reading.
 Discard all contaminated items according to department protocol.
 Remove personal protective equipment and discard accordingly.
 Wash your hands with soap and water.
 Document the incident.

LASER SAFETY
32
As laser technology grows and more laser procedures are being performed in physician offices as well
as other settings, so has the potential for the spread of infections that have resulted from exposure to
improperly evacuated smoke.

The Occupational Safety and Health Administration (OSHA) currently have no standards addressing the
safe use of laser technology. OSHA relies on ANSI (American National Standards Institute) and NIOSHA
for guidelines concerning this and other workplace hazards. OSHA expects employers performing laser
technology in their clinics to have written protocols that include personnel training, equipment
operation monitoring, and periodic safety audits and the use of PPE (Personal Protective Equipment).
As with all potential hazards, documentation is a must.

This practice will comply with all safety guidelines as described below:

Training:
Personnel using laser technology and performing laser procedures will have proper documentation of
training by the manufacturer of the equipment.

Controls:
This practice has appointed _______________________________ as the Laser Safety Officer. He/She
will be responsible for hazard evaluations, staff education and training, patient education,
implementation of laser policies and all documentation of said above.

Beam Hazards:
Beam hazards are those directly related to impact. They include fire, burns, and ocular damage, and
are present anytime the laser is on. Therefore, the laser operator will be at the controls and will put
the laser in standby mode when the beam is not focused on the target.

Fires may occur when lasers are used in the presence of oxygen, alcohol or dry flammable materials.
Make sure there are a fire extinguisher and an open basin of water readily available.

To limit the potential for fires, only wet or non-flammable materials will be used in the area where the
laser is being used. Any solution containing alcohol and Betadine will be kept away from the laser site.
If hair spray has been used by the patient and the procedure takes place at the hair line, the patient
should be asked to wash the hairspray of their hair before the procedure can take place.

Laser beams can be reflected and can cause an unexpected fire. All reflective instruments should be
covered before the laser is used.

33
Lasers can also cause damage to the eyes. Goggles MUST be worn by all personnel present using the
laser or in the room where the laser is being used. Eye gear must be specific to the laser procedure.
Eyewear will be inspected regularly and should be labeled according to ANSI standards with
wavelength and optical densities.
Prescription glasses are not adequate protection. Patients should be given the same eye protection if
they are awake during the procedure. A damp cloth can be placed over the eyes of the patient if
general anesthesia is used.

Because lasers can cause thermal damage to the skin as well, additional PPE, such as gloves and gowns
will be provided and used on an as needed basis, determined by the Safety Coordinator.

Non-beam hazards:
Plume or non-evacuated smoke can cause both chemical and biological hazards to employees.
Facemasks or shields, eye protection, gloves, gowns, capes, and shoe covers are required. Smoke
evacuators are recommended. They are up to 98.6% effective if properly positioned, but that
effectiveness is reduced to 50% if the collection tube is moved to 2cm from the point of impact. Laser
masks are recommended but must be worn properly.

General Safety Precautions:

 A sign on the door to prevent unauthorized entry.
 Windows are to be used with certain wavelengths to prevent the beam from being transmitted
through the window.
 The laser is to be checked with each use to ensure proper working order.
 The beam is not be aimed at any reflective surface.
 Only non-flammable anesthetics will be used if possible.
 Employees will never look directly at the laser reflection surfaces.

34
 ERGONOMICS

Ergonomics is the science of fitting workplace conditions and job demands to the capabilities of the working
population. Effective and successful "fits" assure high productivity, avoidance of illness and injury risks, and
increased satisfaction among the workforce. Although the scope of ergonomics is much broader, the term
here refers to assessing those work-related factors that may pose a risk of musculoskeletal disorders and
recommendations to alleviate them. Common examples of ergonomic risk factors are found in jobs requiring
repetitive, forceful, or prolonged exertions of the hands; frequent or heavy lifting, pushing, pulling, or carrying
of heavy objects; and prolonged awkward postures. Vibration and cold may add risk to these work conditions.
Jobs or working conditions presenting multiple risk factors will have a higher probability of causing a
musculoskeletal problem. The level of risk depends on the intensity, frequency, and duration of the exposure
to these conditions. Environmental work conditions that affect risk include intensity, frequency and duration
of activities.

Ergonomics is the science of fitting the job to the worker. When there is a mismatch
between the physical requirements of the job and the physical capacity of the worker,
work-related musculoskeletal disorders (MSDs) can result. Ergonomics is the practice of
designing equipment and work tasks to conform to the capability of the worker, it
provides a means for adjusting the work environment and work practices to prevent
injuries before they occur. Health care facilities especially nursing homes have been
identified as an environment where ergonomic stressors exist.

Potential Hazard

Employee exposure to work related MSDs from ergonomic stressors that have not been
effectively identified and addressed in a facilities safety and health program.

 Many patients/residents (especially nursing home residents) are totally

dependent on staff members to provide activities of daily living, such as dressing,
bathing, feeding, and toileting. Each of these activities involves multiple
interactions with handling or transferring of patients/residents and could result in
employee injuries. Employee injuries lead to increased injury costs, higher
turnover rates, increased sick/injured days, and staffing shortages.

Possible Solutions

 OSHA's OSH Act of 1970 strives to "assure safe and healthful working conditions
for working men and women..." and mandates that "each employer shall furnish
to each of his/her employers employment and a place of employment which are
free from recognized hazards that are causing or are likely to cause death or
serious physical harm to his/her employees."

 OSHA recommends minimizing manual lifting of patients/residents in all cases

and eliminating lifting when possible.

 OSHA recommends that employers identify and address ergonomic stressors in

their facility's safety and health plan. General safety and health plan information
can be found in the Administration - Safety and Health Program.

Areas that should be addressed a facility's safety and health program include:

Management Leadership/Employee Participation

Workplace Analysis
Accident and Record Analysis

35
 Hazard Prevention and Control

Management Leadership/Employee Participation:

 Management Leadership should demonstrate a commitment to reduce or

eliminate patient/residents handling hazards through establishing a written
program that addresses issues, such as:

Continued training of employees in injury prevention.

Methods of transfer and lifting to be used by all staff.

 Compliance with transfer and lift procedures.

Procedures for reporting early signs and symptoms of back pain and other
musculoskeletal injuries.

 Employee Participation should include:

Complaint/suggestion program which includes employee reports of unsafe

working conditions.

Prompt reporting of signs and symptoms as well as injuries.

Workplace Analysis to identify existing and potential workplace hazards and find ways
to correct these hazards. Assessment of work tasks involves an examination of duration,
frequency, and magnitude of exposure to ergonomic stressors such as force, repetition,
awkward postures, vibration and contact stress to determine if employees are at risk of
pain or injury. Observation, workplace walkthroughs, talking with employees and periodic
screening surveys are used to help identify hazards such as stressful tasks.

Accident and Record Analysis: Records of injuries and illnesses should be analyzed to
identify patterns of injury that occur over time, enabling the hazards to be addressed and
prevented. This includes reviewing OSHA 300 logs, OSHA 301 forms and Workers'
Compensation reports.

Hazard Prevention and Control including implementing administrative and

engineering controls.

 Administrative controls: Provide for adequate staffing, assessment of

patient/resident’s needs, and restricted admittance policies.

 Engineering controls: Help to isolate or remove the hazards from the workplace,
for example providing proper selection, training, and use of assist devices or
equipment (see Patient Handling Controls Section).

Medical Management: A medical management program, supervised by a person

trained in the prevention of musculoskeletal disorders, should be in place to manage the
care of those injured. The program should:

 Accurate injury and illness recording.

36
  Early identification and treatment of injured employees.

 "Light duty" or "no lifting" work restrictions during recovery periods.

 Systematic monitoring of injured employees to identify when they are ready to

return to regular duty.

Training: A training program, designed and implemented by qualified persons, should

be in place to provide continual education and training about ergonomic hazards and
controls to managers, supervisors and all healthcare providers, including "new
employee" orientation. Training should be updated and presented to employees as
changes occur at the workplace, and be at a level of understanding appropriate for those
individuals being trained, and should also include:

 The opportunity to ask questions of the trainer.

 An overview of the potential risks, causes, and symptoms of back injury and other
injuries. Be able to identify existing ergonomic stressors and methods of control,
such as the use of engineering, administrative, and work practice controls
particularly safe resident handling techniques.

 Recognizing the signs and symptoms of MSDs and the procedures for reporting
potential problems.

 Encouragement of staff physical fitness.

 Lifting guidelines for health care workers (nurse assistants, licensed practical
nurses, registered nurses) which should include:

 Never transfer patients/residents when off balance.

 Lift loads close to the body.

 Never lift alone, particularly fallen patients/residents, use team lifts or use
mechanical assistance.

 Limit the number of allowed lifts per worker per day.

 Avoid heavy lifting especially with spine rotated.

 Training in when and how to use mechanical assistance.

Additional Information:

 Ergonomics. OSHA Safety and Health Topics Page.

 Ergonomics - Additional Information

37
 Slips/Trips/Falls
Potential Hazard

Slips/trips and falls from spills or environmental hazards.

 Environmental hazards such as:

 Slippery or wet floors.

 Uneven floor surfaces.

 Lifting in confined spaces.

 Cluttered or obstructed work areas/passageways.

 Poorly maintained walkway or broken equipment.

 Inadequate staffing levels to deal with the workload, leading to single person lifts and greater
chances of falls.

 Inadequate lighting, especially during evening shifts.

Possible Solutions

Good work practice includes implementing engineering and work practices controls to help prevent
slips/falls such as:

 Eliminate uneven floor surfaces.

 Create non slip surfaces in toilet/shower areas.

 Immediate clean-up of fluids spilled on floor.

 Safely working in cramped working spaces-avoiding awkward positions, using equipment that makes lifts
less awkward.

 Eliminate cluttered or obstructed work areas.

 Provide adequate staffing levels to deal with the workload.

For additional information, see HealthCare Wide Hazards -

38
 OSHA's comprehensive plan features targeted
guidelines and tough enforcement.
OSHA's recently unveiled ergonomics plan offers a comprehensive,
practical approach to reducing ergonomic injuries that, according to
OSHA Administrator John L. Henshaw, "we can put to work now-and
that will reduce injuries now." The plan combines industry-specific
guidelines, tough enforcement measures, outreach, research, and
dedicated efforts to protect Hispanic and other immigrant workers.
"Musculoskeletal disorders (MSDs) are serious injuries, and we are
committed to reducing the pain and suffering that occur from workplace
injuries," says Henshaw. "This comprehensive plan is the best approach
to achieve immediate results."

"Our goal is to help workers by reducing ergonomic injuries in the shortest possible time frame," agrees Labor
Secretary Elaine L. Chao. "This plan is a major improvement over the rejected old rule because it will prevent
ergonomics injuries before they occur and reach a much larger number of at-risk workers."

The new plan reflects input from a wide range of stakeholders, including organized labor, workers, medical
experts, and businesses. Over the last year, the Department of Labor conducted three major public forums
around the country and met with scores of stakeholders, collecting hundreds of sets of written comments and
taking testimony from 100 speakers. OSHA analyzed and evaluated the comments and recommendations,
studied the options, and researched the alternatives.

Guidelines
Henshaw says OSHA will work with various stakeholders and develop industry-
and task-specific guidelines that ensure prevention, flexibility, and feasibility.
"We can move forward rapidly on this and we will have guidelines this year," he
says.

OSHA will target industries and tasks where Henshaw says "we can have the
quickest and most effective results." The agency will begin its efforts by
focusing on industries and tasks associated with ergonomic injuries and for which successful strategies are
known. "Real-life solutions come from real-life experience," notes Henshaw.

This approach, he believes, will offer employers and workers the flexibility they need to tailor
recommendations and best practices to their workplaces.

"We know that one size does not fit all, and this provides the flexibility needed to reduce injuries," Henshaw
says.

Enforcement
39
The Department of Labor will develop an ergonomics enforcement plan coordinating inspections with a legal
strategy designed for successful prosecution. The department will place special emphasis on industries with
serious ergonomic injuries. OSHA and DOL attorneys will build on experience where they have had success
under the Occupational Safety and Health Act's General Duty Clause.

For the first time, OSHA will have a successful enforcement strategy designed from the start to target
ergonomics violations. In addition, Henshaw says the agency will have special ergonomics teams that work
closely with DOL attorneys and handpicked experts "to crack down on bad actors."

Outreach and Assistance

OSHA plans to offer assistance to workers and businesses, particularly small businesses, to help them address
ergonomics in the workplace. The agency will offer advice and training on industry- and task-specific
guidelines it develops and help on how to develop an effective ergonomics program.

In addition, OSHA will provide a wealth of materials on its website, support development of ergonomic
training materials and training sessions, and make ergonomics training available through the 12 Education
Centers around the country. The new plan includes a specialized focus to help Hispanic and other immigrant
workers, many of whom work in industries with high ergonomic injury rates.

OSHA also plans to develop new recognition programs to highlight the achievements of worksites with
exemplary or novel approaches to ergonomics.

Finally, the agency will provide its compliance officers with training on ergonomic hazards and abatement
methods. It will designate 10 regional ergonomics coordinators who will be involved in enforcement,
outreach, and assistance.

Research
The new plan includes an important research component because, Henshaw says, "We want to use the best
available science in all that we do." He says information from the National Academy of Sciences and from
OSHA's ergonomics forums made it clear that many gaps remain. OSHA will establish a national advisory
committee, representing a broad range of experts, to advise the agency on gaps in ergonomics and effective

40
 prevention techniques. In concert with the National Institute for Occupational Safety and Health, the
committee will help OSHA serve as a catalyst to expand current research on the subject.

Henshaw says the new plan is designed to accelerate an encouraging workplace trend as quickly as possible.
"Bureau of Labor Statistics' data show that musculoskeletal disorders are already on the decline," he says.
Decline in Ergonomic-related Injuries
Involving Days Away from Work, 1992-1999

"Thousands of employers are already working to reduce ergonomic risks without government mandates. We
want to work with them to continuously improve workplace safety and health. We will go after the bad actors
who refuse to take care of their workers."

The new plan was announced barely a year after Congress rejected the previous administration's ergonomics
rule. That rule was denounced broadly as being excessively burdensome and complicated. For more
information visit OSHA's website at www.osha.gov.

OSHA's Plan

 Industry- and task-specific guidelines

 Enforcement
 Outreach and assistance
 Research

41
 BLOODBORNE PATHOGEN EXPOSURE CONTROL PLAN
INTRODUCTION AND COMMITMENT OF MANAGEMENT
This practice is committed to protecting employee safety and health. We have developed this Exposure
Control Plan (ECP) to protect workers against potential exposure to bloodborne pathogens in accordance with
OSHA standard 29CFR 1910.1030. “Occupational Exposure to Bloodborne Pathogens.”

This plan will determine employee who could potentially be exposure to bloodborne pathogens,
implementation of universal precautions, use of engineering procedures, offering Hepatitis B vaccination and
post-exposure evaluation, training, and appropriate recordkeeping.

The Safety Coordinator is responsible for implementation of the ECP (Exposure Control Plan) and will review
our written program and evaluate safety devices at least once per year. The ECP will be updated as needed to
incorporate new procedures such as safer medical devices. This practice will ensure that the Safety
Coordinator has sufficient authority and resources to implement, maintain, and enforce the ECP. All
employees are responsible for complying with our ECP. Failure to adhere to this policy may result in
disciplinary actions.

Employees are encouraged to discuss any concerns with their supervisor or the Safety Coordinator. This
includes notifying the Safety Coordinator of any uncontrolled hazards observed and suggesting additional or
better controls.

The ECP is available to all employees at all times.

EMPLOYEE TRAINING
ALL employees who have risk of occupational exposure to blood or other potentially infectious materials must
participate in a training program that will be provided at no cost to the employee and during regular working
hours.

Training shall be provided as follows:

1. At the time of initial assignment to tasks with risk for occupational exposure
2. At least annually thereafter
3. When changes, such as modification of tasks or procedures or institution of new tasks or procedures,
affect the employee’s occupational exposure. Additional training may be limited to the new exposures.
4. The training program shall include:
 An accessible copy of this standard and an explanation of its contents
 Explanation of the epidemiology and symptoms of bloodborne diseases
 The modes of transmission of bloodborne pathogens
 The employer’s Exposure Control Plan and how to obtain a copy
 Appropriate methods of recognizing tasks that my involve exposure

42
  The use and limitations of methods that will prevent or reduce exposure, including the use of
engineering controls
 Means of disposal of personal protective equipment
 Hepatitis B vaccine: safety, administration and benefits of vaccination
 Appropriate actions in bloodborne pathogen emergency
 Protocol for exposure incidents – reporting, follow-up
 Employer’s responsibility after exposure incidents
 Biohazardous signs and labels
 Interactive questions and answers session

Records shall be maintained on the training sessions and shall include the following information:

 The dates of the training sessions

 The contents or a summary of the training sessions
 The names and qualification of persons conducting the training
 The names and job titles of all persons attending the training sessions

Training records shall be maintained for three years from the date on which the training occurred. These are
not confidential.

Certain pathogenic microorganisms found in the blood of infected individuals can be transmitted to other
individuals by blood or other body fluids. Healthcare workers whose occupational duties expose them to
blood and to other potentially infectious materials are at risk of contracting anyone these bloodborne
pathogens. Hepatitis B and C and HIV are three of the most significant of these diseases.

Bloodborne pathogens are microscopic organisms that thrive only in blood or certain other bodily fluids. They
do not survive well outside a support system, such as the human blood stream or a specifically engineered
environment. They may be fungi (yeast and molds), bacteria, prions and parasites, in addition to the well
published viruses. There are more than 25 bloodborne pathogens known today, and that number is ever
increasing.

Other pertinent viruses include CMV, (cytomegalovirus), Ebola (causes bleed-out), and Epstein-Barr (infectious
mononucleosis). Fungal infections include Rhizopus, Candida albicans, Coccidioded immitis, Blastomyces,
and Histoplasma. Bacteria that invade the bloodstream include Syphilis, Brucellosis, Pseudomonas, S.
epidermidis and S. aureus; Strep. Anginosus, sanguis, mutans and bovis; Haemophilus influenza and
parainfluenza; Listeria monocytogenes and Bacillus fragilis; Clostridium perfringens, and Campylobacter
species. Parasites include Plasmodium (malaria), Babesia, Tryanosoma (Chagas’ Disease, for example),
Leishmania, Loa loa, and Toxoplasma.

Bloodborne pathogens are spread through several routes:

 Contact with mucous membranes, such as eye, nose, or mouth, or non-intact skin
 Puncture wounds
 Organ transplants and blood transfusions

43
  Sexual contact
 Mother to unborn child through the placenta
 Mother to child through the breast milk

HEPATITIS B AND C
Hepatitis B and Hepatitis C are the major infectious occupational health hazards in the healthcare industry.
The Centers for Disease (CDC) believes that as many as 18,000 healthcare workers may be infected by HBV
each year. Nearly 10% of these become long-term carriers of the virus and may have to give up their
profession. Several hundred healthcare workers will become actively ill or jaundiced from Hepatitis B.
Approximately 300 workers may die annually as a result (directly or indirectly) of Hepatitis B.

Healthcare workers are at a much higher risk for HBV or HCV infection than the general public, due to their
frequent occupational exposure to blood and other body fluids. Studies have shown that approximately 30%
of healthcare workers show evidence of past or present HBV infection. Strong concentrations of HBV in body
fluids make it highly contagious and easily spread. One drop of blood from HBV patient can contain up to
100,000 viral particles. The virus may remain infective for months outside of a support system. Co-infection
with the delta particle (Hepatitis D) is a more severe infection.

Hepatitis C has similar etiology and symptoms, with a higher chance of developing chronic disease. It is more
prevalent in the United States than Hepatitis B. There is no immunization or cure. The only currently available
treatment is Interferon, with an effectiveness rate of 15-50%. Low effectiveness may be related to low patient
compliance due to unpleasant side effects of the medication. Patients may remain asymptomatic for up to
twenty years.

Hepatitis A and Hepatitis E are transmitted through the fecal-oral route usually due to poor hand washing
techniques. Because they are not bloodborne, these forms of Hepatitis are not addressed by the Bloodborne
Pathogen Standard.

Hepatitis is an inflammation of the liver. It does not automatically mean an infection, and it can also be
caused by hazardous chemicals.

Symptoms of HBV may include jaundice, anorexia, nausea, arthritis, rash and fever. Chronic carriers of HBV,
who may be asymptomatic but still infectious to others, are at risk of chronic liver disease and liver cancer
later in life. Patients may have no systems, have flu-like symptoms, or experience a more severe course with
classic symptoms.

HIV
Infection with HIV in the workplace represents a small but real hazard to healthcare workers. With just over
1.1 million AIDS cases reported in the general population, there is ever-creasing potential for exposure to
healthcare workers. About 18,000 people die in the U.S. every year from AIDS/HIV. Although there is
currently no vaccine that is effective against HIV, the barrier techniques that help prevent HBV will also be
effective against HIV.

44
HIV primarily attacks the CD4 (T4) lymphocytes of an individual’s immune system. T4 cells are vital to the
body’s ability to recognize and defend itself from infection and disease. Although HIV is a fragile virus that has
difficulty surviving outside the human body, it causes progressive damage to the human immune system over
a variable period of time, making the individual vulnerable to a host of infections or malignancies. The
condition known as AIDS represents the end stage of HIV infection.

Due to the long incubation period of HIV (potentially up to 10 years), many of HIV-infected individuals have no
symptoms and may not know that they are infected. These individuals can transmit the virus to others via
direct contact with blood or other body fluids and through sexual intercourse, regardless of whether or not
they have developed the symptoms of AIDS. Only blood and blood products, semen, and vaginal secretions
have been directly linked to transmission of HIV.

Approximately 50% of HIV-infected individuals will exhibit one or more of the following symptoms within 2-4
weeks of initial infection: febrile illness resembling mononucleosis or influenza, which resolves spontaneously;
malaise; body aches; rash (similar to measles); swollen lymph glands and headache. Presently it is not
understood why some people develop symptoms faster than others. It is thought that certain co-factors, such
as stress, poor nutrition, alcohol or drug abuse, and certain sexually transmitted diseases (syphilis), may
trigger the virus to begin replication.

Because of job-related risks and their profound negative impact on healthcare personnel, considerable
interest has focused on the possible prevention of HIV infection after an exposure incident. Currently, there is
no cure for HIV. Several chemicals are available as treatments. Current treatment guidelines change
frequently. Clearly, any person would like to avoid the risk of HIV infection, with its attendant social,
economic, and emotional costs, and its virtual certainty of death. The importance of participating in an
organized program with immediate counseling available cannot be overemphasized. The decisions involved
are extremely complex, and healthcare workers who have suffered an exposure often need emotional support
as well as medical advice.

STATISTICS
Chance of contracting diseases through occupational exposure:

HIV: Almost 1.2 million people in the U.S. have been infected with HIV. If the source patient is a member of
the general population, the chance that the exposed employee will contract HIV is 1 in 10 million. If the
source patient has HIV, the chance of transmission of the disease to the exposed employee is - <0.5% (0.3%).

HEPATITIS B: There are currently about 1.4 million people in the U.S. with HBV. If the exposed employee has
not been immunized and the source patient has HBV, the chance that the employee will become infected
following an exposure is a high as 30%. The chance of developing chronic disease once an individual is
infected with HBV is about 5%.

HEPATITIS C: The U.S. currently has about 3.2 million Hepatitis C patients. If an employee sustains an
exposure involving a patient with HCV, the chance that the employee will become infected with HCV is 2 –
10%. The chance that anyone with HCV will develop chronic disease is as high as 85%.
45
 OCCUPATIONAL EXPOSURE
OSHA defines occupational exposure as any reasonably anticipated skin, eye, mucous membrane or parenteral
contact with blood or other potentially infectious materials that may result from the performance of an
employee’s duties. Other potentially infectious materials include: semen, vaginal secretions, cerebrospinal
fluid, synovial fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any bodily
fluid that is visibly contaminated with blood, all body fluids in situations where it is difficult or impossible to
differentiate between body fluids, any unfixed tissue or organ (other than intact skin) from a human (living or
dead), HIV-containing cell or tissue cultures, organ cultures, HIV or HVB-containing culture medium or other
solutions, and blood, organs or other tissues from experimental animals infected with HIV and HBV.

EMPLOYEE GROUP ONE

This classification includes employees whose routine duties involve potential for exposure to bloodborne
pathogens.

Personnel:

 Physicians Physician Assistant

 Dentists Nurse Practitioners
 Veterinarians Nurse Midwives
 Veterinarians Assistants Phlebotomist
 Ophthalmic Assistants Nurses
 Anesthetists Medical Assistants
 Dental Assistants Laboratory Testing Personnel
 Dental Hygienists Housekeeping
 Dental Laboratory Technicians Certified Nursing Assistant
 Surgical Technicians Radiology Technicians
 Other_______________________ Nuclear Medicine Techs

EMPLOYEE GROUP TWO

46
 Some of the employees in this job classification may perform the tasks that are considered exposure risk
but others may not.

Job Titles:

 Phone Nurse
 Practice Manager
 Medical Assistants
 LPN/RN/LVN
 Receptionist
 Housekeeping
 Other____________________________
 None

RISK DETERMINATION FACTORS

Tasks and procedures that have occupational exposure to blood or other potentially infectious materials:

 Surgical procedures
 All invasive procedures
 Handling instruments during patient sterilization
 Instrument clean-up and sterilization
 Treatment area cleanup and disinfection
 Collection, handling and preparation of lab specimens
 Phlebotomy
 Starting IV’s
 Administering injections to patients
 Handling biohazardous waste
 Handling and cleaning contaminated laundry
 Dental hygiene procedures
 Wound care
 Handling contaminated items
 Performing x-rays of the oral cavity or open wound
 Assisting doctor (medical or dental) or other provider with patient procedures
 Other___________________________________________

METHODS OF COMPLIANCE

47
UNIVERSAL PRECAUTIONS:

In this practice we will use the Universal Precautions approach to infection control.

All human blood and other potentially infectious body fluids will be treated as though they are known to be
infectious for HBV, HCV, HIV and other bloodborne pathogens.

Other potentially infectious body fluids include all body fluids containing visible blood, saliva in dental
procedures, semen, vaginal secretions, synovial fluid, cerebrospinal fluid, pleural fluid, peritoneal fluid and
amniotic fluid. It does not include feces, nasal secretions, sputum, sweat, tears, urine, saliva (in most settings),
breast milk and vomitus, unless visible blood is present. It does cover unfixed tissues and cultures.

ENGINEERING AND WORK PRACTICE CONTROLS:

This practice has instituted the following engineering controls and work practices to help minimize
employee exposure to bloodborne pathogens. It is imperative that all employees utilize these techniques
and observe these rules:

HAND WASHING:
At Baptist appropriate hand hygiene is expected at all times.

When hands are visibly dirty, after going to the bathroom, and before eating, wash hands with soap and water:

1. Wet hands with water and apply soap

2. Rub hands together for at least 15 seconds
3. Rinse and dry with disposable towel
4. Use towel to turn off faucet.

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USE OF HAND GEL:

If hands are not visibly dirty and in settings other than those listed under Handwashing, use an approved
alcohol-based hand rub:

 Apply product to palm of one hand and rub hands together

 Cover all surfaces of hands and fingers until hands are dry
 Alcohol is flammable; store hand rub away from fire or flames.

Keep natural nails short. Artificial fingernails, overlays or extenders (tips) are not to be worn by health-care
workers (including agency and/or temporary staff) who have direct (hands on) contact with patients.

Assemble and inspect all equipment after cleaning your hands and before touching the patient.

49
 Sharps Inventory
Practice _________________________ Date Prepared___________________

Address ______________________________ Prepared by_____________________

Sharp Device Use Safety If no safety feature included, Suggestion for safer
(Type, Brand Name, Size) (procedure) Feature explain why this device device is in use
Y/N is in use
Example: Injections
Needle, Turumo, ½”, 32 gauge

50
 Safer Sharps Evaluation
Device: ________________________________ Evaluator: _____________________

Safety Feature: _________________________ Comments: ____________________

Intended Use: __________________________ ______________________________

Date Evaluated: ________________________ Acceptable ( ) Yes ( ) No

Evaluation (circle one):

1. Allows/requires employees’ hand to stay behind the needle after use ( ) Yes ( ) No
2. Safety feature an integral part of the device, present before the device was contaminated ( )
Yes ( ) No
3. Safety feature stays in place throughout the waste stream ( ) Yes ( ) No
4. Easy to use with little instruction ( ) Yes ( ) No
5. Interferes with patient care ( ) Yes ( ) No
6. Safety feature activated with a one-handed technique ( ) Yes ( ) No

Device: ________________________________ Evaluator: _____________________

Safety Feature: _________________________ Comments: ____________________

Intended Use: __________________________ ______________________________

Date Evaluated: ________________________ Acceptable ( ) Yes ( ) No

Evaluation (circle one):

1. Allows/requires employees’ hand to stay behind the needle after use ( ) Yes ( ) No
2. Safety feature an integral part of the device, present before the device was contaminated ( )
Yes ( ) No
3. Safety feature stays in place throughout the waste stream ( ) Yes ( ) No
4. Easy to use with little instruction ( ) Yes ( ) No
5. Interferes with patient care ( ) Yes ( ) No
6. Safety feature activated with a one-handed technique ( ) Yes ( ) No

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 Sharps Injury Log
Practice Name: _______________________________________________________
Year _________________

Date Case/Report Type of Brand Work Area Brief Description of Action

No. Device Name of Where Injury How Incident Taken
(e.g. , Device Occurred Occurred (procedure
Needle, being done, action
syringe) being performed such
as disposal)

29 CFR 1910.1030, OSHA’s Bloodborne Pathogens Standard, in paragraph (h) (5), requires an employer
to establish and maintain a Sharps Injury Log for recording all percutaneous injuries in a facility
occurring from contaminated sharps. The purpose of this Log is to aid in the evaluation of devices
being used in healthcare and other facilities and to identify problem devices or procedures requiring
additional attention or review. This log must be kept in addition to the injury and illness log required by
29 CFR 1904. The Sharps Injury Log should include all sharps and injuries occurring in a calendar year.
The log must be kept in a manner that preserves the confidentiality of the affected employee.

Personal Protective Equipment

52
 Practice Name: _______________________________________

Practice Address: ______________________________________

Personal Protective Equipment Required

Procedure Gloves Gown Goggles Mask Location

 Medical
 Utility
 Puncture-
Resistant

 Administering Medical
Injections
 Starting IVs
 Wound Care
 Venipuncture
Cleaning Surfaces Utility
and Handling Waste
CPR (Ambu Bag Required)

Handling
Phenol, TCA
Lancing Cyst or Medical
Abscess
Laser Procedures

Mixing or Administering Utility

Chemotherapy
Scrubbing Instruments Puncture-
Resistant
Surgical Procedures Medical

TB Patient Care

Vaginal /Rectal Exams Medical

X-Ray Lead- Lined Lead-Lined

PERSONAL PROTECTIVE EQUIPMENT

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Personal protective equipment will be used to prevent blood or other potentially infectious material
from passing through or contracting the employees’ work clothes, street clothes, or undergarments,
or to the skin, eye, mouth, or other mucous membranes. This office maintains an inventory of
personal protective equipment, including protection for the eyes, hands, face, head, extremities, air
passages, and clothing. Although this equipment is meant to reduce the risks of exposure, it may not
eliminate it. All protective equipment must be removed prior to leaving the work area. It must be
replaced when damaged or contaminated. Contaminated personal protective equipment must not
leave the work area and must be discarded properly.

Gloves: Disposable latex, nitrile or vinyl gloves are available for use in this facility.

 These gloves are NOT puncture-resistant, nor are they 100% protective against infectious
agents.
 Gloves must be replaced as soon as practical when contaminated (at a minimum, after each
patient).
 Torn or punctured gloves must be replaced as soon as feasible.
 Gloves will be removed prior to leaving the treatment area.
 Gloves will be removed prior to writing in a patient’s chart or prior to answering the
telephone.
 Grossly contaminated gloves will be discarded into the biohazardous waste container located
in each treatment room. They may go into the regular trash if they are not grossly
contaminated.
 Heavy-duty utility gloves (nitrile or neoprene type) used for clean-up may be decontaminated
for reuse if glove integrity is not compromised.
 Employees must wash their hands with soap and running water immediately after removing
their gloves.
 Hand sanitizer may be used as an intermediate measure but not in place of hand washing.
 Petroleum based hand creams may not be used when latex gloves are worn. Petroleum
products (and glutaraldehyde) may compromise glove integrity.

Type of gloves and their use:

 Use sterile gloves for procedures involving contact with normally sterile areas of the body.

Use examination or procedure gloves for procedures involving contact with mucous membranes,
unless otherwise indicated, and for other patient care or diagnostic procedures that do not
require the use of sterile gloves.

 Change gloves between patients

 Do not wash or disinfect surgical or examination gloves for reuse. Washing with surfactants
may cause “wicking” i.e., the enhanced penetration of liquids through undetected holes in the
glove. Some disinfecting agents may cause deterioration of latex, as does lanolin, which is
found in many hand creams.

54
  Use general purpose rubber household gloves for housekeeping chores involving potential
blood contact and for instrument cleaning and decontamination procedures. Utility gloves
may be decontaminated and reused, but should be discarded if they are peeling, cracked, or
discolored, or if they have punctures, tears, or other evidence of deterioration.

Gloves must be used:

 If the skin of the healthcare worker is cut, abraded, or chapped

 When examining abraded or non-intact skin or patients with active bleeding
 During invasive procedures
 During housekeeping and cleaning involving body fluids
 During decontaminating procedures
 When performing phlebotomy, processing and/or testing blood or other potentially infectious
specimens
 During all surgical or dental procedures

Eyewear: Protective eyewear is used in this facility when indicated; goggles face shields, or glasses
with solid side shields. IF a procedure presents a danger of splashing or if a manufacturer
recommends that goggles be worn when using their product, the employee must wear goggles.

 Protective eyewear, other than prescription glasses, shall be removed prior to exiting the
treatment area.
 Goggles and face shields will be cleaned and decontaminated after each use.

Masks: Mask are used in this facility when indicated.

 Contaminated masks will be replaced immediately or as soon as is feasible.

 Contaminated masks will be placed in the biohazardous waste container located in each
treatment area

Gowns, Aprons, Lab Coats: Gowns are worn to protect street wear and the arm and neck areas
from contamination. They may be worn until or unless they become soiled, damaged, or wet, at
which time they must immediately be removed and replaced.

Protective laboratory coats, gowns, and aprons will be removed and replaced as soon as they
become visibly damaged or contaminated. Disposable gowns should be properly disposed of by
placing them into the appropriate container based on whether or not they are contaminated. If
coats, gowns, and aprons are reusable, they will be placed into the laundry container. The employer
will clean them either in-house or by a commercial laundry. No employee will take personal
protective equipment home.

Resuscitation Equipment
Pocket masks, resuscitation bags, and/or other ventilation devices are kept:
55
Scrubbing Instruments
When scrubbing instruments, our employees will:
_____ Don gown, gloves and face protection. If scrubbing sharps, use puncture-
resistant gloves.
_____ Scrub with the brush and the instrument in a container of water, both
completely submerged beneath the surface of the water while scrubbing

Latex Allergy
This practice will reduce the potential for latex allergy by using low powder or powder- free
gloves by keeping the facility very clean. Alternatives, including nitrile or vinyl gloves, will be
offered to employees who are allergic to latex.

 Symptoms: Irritation, dermatitis, asthma, shock

 Diagnosis: History and physical, scratch testing and/or blood tests
 Treatment: Avoidance of latex-containing items

Annual Bloodborne Pathogen Exposure Control Plan Review

We have reviewed our Bloodborne Pathogen Exposure Control Plan and

56
______ performed and documented our safer sharps evaluation

______ listed safety devices and conventional sharps in use

______ found that it is still applicable as written

______ updated the Exposure Risk Groups

______ added new policies and procedures as needed

____________________________________________ ___________________
Safety Coordinator Date

____________________________________________ ____________________
Practice Manager Date

____________________________________________ ___________________
Safety Coordinator Date

____________________________________________ ____________________
Practice Manager Date

____________________________________________ ___________________
Safety Coordinator Date

____________________________________________ ____________________
Practice Manager Date

Exam Room #_______ Cleaning Log Facility Name:_____________________________

Exam tables and all surfaces wiped down with Sani-Cloth, supplies stocked, room neat
and organized
57
 Staff member cleaning room, must initial on each day. If room is not used, please fill in as “N/A”

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

STERILIZATION
Instruments, requiring high-level disinfection or sterilization will be processed according to the
manufacture’s guidelines, using the autoclave or an appropriate EPA-approved chemical such as
Cidex, Metricide, Omnicide, etc.

BIOHAZARDOUS LABELING

58
Biohazardous warnings, either the internationally recognized biohazard symbol or bright orange-red
coloring, will be used to alert persons of potential contamination of:

 Containers of contaminate waste

 Containers used to store, transport, or ship blood or other potentially infections materials
o Refrigerators, freezers and other containers used to store, transport, or ship blood
and/or other potentially infectious materials
o Sharps containers

HANDLING EMERGENCIES INVOLVING OCCUPATIONAL EXPOSURE

Accidents/Spills
 Blood and other potentially infectious materials
 Isolate area where spill occurs – place hazard sign in front of spill or have another
employee stay at spill site to warn others.
 Put on gloves, mask, eyewear, and fluid-proof gown.
 Apply the absorbed material in the spill kit to absorb the fluid.
 Place the absorbed material and all disposable clean-up items in the biohazard bag.
 Clean area where spill occurred with: (1) soap and water, then with (2) disinfectant.
 Place the biohazard bag into the central biohazard container.
 Remove and dispose of disposable personal protective equipment and clean and
disinfect non-disposable items.
 Wash hands with soap and running water.

Alternative method:
 Retrieve spill kit.
 Put on heavy-duty utility gloves.
 Saturate the area with diluted bleach and leave for 10 minutes.
 Remove any broken glass using a mechanical pickup and discard in sharps container.
 Wipe up excess materials in regulated trash.
 Disinfect the area.
 Disinfect and remove gloves.
 Wash hands

Sharps and contaminated broken glass or other sharp materials must be placed in the
biohazard container. These items are never to be picked up by the hand, even when wearing
gloves. Always use forceps or scoop and brush.

Emergencies Involving Patient Care

CPR- Always use the provided CPR device.

Unexpected bleeding; airway obstruction; etc.

59
  The patient must be cared for immediately in these events.

 If treatment results in blood or other body fluids contaminating any area of the
employee’s skin or eyes or mucous membranes, these are to be washed with soap and
running water as soon as possible.

Reporting of Accidents and Emergencies

 Employee must report any and all such emergency occurrences to either the employer
or the Safety Coordinator as soon as feasible.
 All incidents that involve having to treat a patient without appropriate personal
protective equipment must be documented and placed in this manual.

Employer’s Responsibility
When an incident such as the one listed above occurs where an employee must treat a
patient without appropriate personal protective equipment, the circumstances shall be
investigated and documented in order to determine whether changes can be instituted to
prevent such occurrences in the future.

60
 LAUNDRY
Contaminated laundry (gowns, lab coats, towels, etc.) will be placed in leak-proof containers and will
not be sorted or rinsed prior to placement into the container. Laundry containers are labeled with
the biohazard symbol or are color-coded red. If the container becomes contaminated on the outside,
it will be placed in another labeled leak-proof container.

Employees who have contact with contaminated laundry will wear protective gloves. In the event
the laundry contains blood-soaked items, the handler will also wear a fluid-resistant gown. A sharps
container will be kept in the laundry room.

No employee may wear or transport out of this facility any contaminated laundry. (ITEMS MAY NOT
BE TAKEN HOME FOR CLEANING.)

1. _______ This office sends all laundry to __________________________________________

2. _______ This office utilizes an in-office washer and dryer. Employees responsible for laundry will
be properly trained. Contaminated laundry items will not be sorted or rinsed prior to placement
in the washing machine. Heavy-duty utility gloves will be worn when doing the laundry. If the
laundry contains blood-soaked items, a fluid-resistant gown will also be worn. Depending upon
the volume of laundry and degree of contamination, the washing
3. _______ This practice uses disposable items.

The CDC recommends a temperature of at least 72⁰C (160⁰F) for 25 minutes. Lower temperatures
are effective only if bleach (50-150 ppm) or another appropriate chemical is used. Commercial dry
cleaning renders soiled fabrics fee of pathogen transmission.

61
Dear ___________________________:

The office of ______________________________________________utilized your laundry service for

cleaning our contaminated linens.

Following the OSHA guidelines for contaminated linens (29 CFR 1910, 1030); we will be placing our
laundry items in fluid-resistant containers or bags with biohazard symbol attached. Our office follows
Universal Precautions when handling contaminated linens. For the protection of your employees, if
you have not already done so, you need to make them aware of the risks associated with bloodborne
pathogens, and proper procedures and protective equipment to use when handling these items.

Sincerely,

______________________________________________

Signed by employer

Hepatitis B Infection Control

62
The Hepatitis B vaccination or declination is offered and completed upon hire. These records are
kept within the respective Baptist Corporate Employee Health offices. Please see below for a list of
contacts:

Employee Health Services Contact Information

Director: Lesley Heckaman 901-226-4542 901-226-4583
Facility Employee Health Phone Fax
Nurse
BMH-Booneville Doris Box 662-720-5262 662-720-5245
100 Hospital Street
Booneville, MS 38829
BMH-Collierville Lynne Lancaster 901-861-8880 901-861-8882
5000 W. Poplar Ave. Dianne Dowdy 901-861-8632
Collierville, TN 38017

BMH-Desoto Helen McBroom 662-772-2169 662-772-2168

7601 Southcrest Pkwy. Kathy Vinton 662-772-3116
Southaven, MS 38671
BMH-Germantown Rehab Jamie Cardot 901-757-3407 901-751-6148
2100 Exeter Rd.
Germantown, TN 38138
BMH-Golden Triangle Johnny Judson 662-244-2100 662-244-2160
2520 Fifth St. North
Columbus, MS 39701
BMH-Huntingdon Teresa Brawner 731-986-7204 731-986-7008
631 R.B. Wilson Dr.
Huntingdon, TN 28344
NEA Baptist Ashley May House 870-972-7156 870-972-7385
3024 Stadium Blvd.
Jonesboro, AR 72401
BMH-Memphis (East) Denese Bryant 901-226-4542 901-226-4583
6019 Walnut Grove Rd. Beth Oliver 901-226-3870
Memphis, TN 38120 Ginger Coleman 901-226-5021

BMH-North Mississippi Linnie Maples 662-232-8272 662-513-1179

2301 S. Lamar Blvd.
Oxford, MS 38655

BMH-Restorative Care Becky Fowler 901-226-0575

Hospital
MH-Tipton (Covington) Christy Coker 901-475-5419 901-475-5418
1995 Highway 51 S.
Covington, TN. 38019
Trinity Home Care & Jill Anderson 901-415-3431 901-415-3427
Hospice

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BMH-Union City Robbie Taylor 731-884-8623 731-884-8633
1201 Bishop St.
Union City, TN 38261
BMH-Union County (New Sonya Thompson 662-538-2164 662-538-2664
Albany)
200 Highway 30 West
New Albany, MS. 38652
BMH-Hospital for Women Beverly Reed 901-227-9348 901-227-9157
6225 Humphreys Blvd. Michelle Thomas 901-227-9155
Memphis, TN 38120

Minor Medical Centers Janie Basford 662-893-1199 662-893-1166

Medical Alternatives Denese Bryant 901-226-4542 901-226-4583

Baptist Home Medical Gayle Beckler 901-373-8485 901-937-2168

Equipment
Baptist College of Health Adonna Caldwell 901-226-4542 901-226-4583
Sciences
Corporate Building Denese Bryant 901-226-4542 901-226-4583

64
 Tuberculosis Infection Control
The Tuberculosis screening process is completed upon hire. These records are kept within the
respective Baptist Corporate Employee Health offices. Please see below for a list of contacts:

Employee Health Services Contact Information

Director: Lesley Heckaman 901-226-4542 901-226-4583
Facility Employee Health Phone Fax
Nurse
BMH-Booneville Doris Box 662-720-5262 662-720-5245
100 Hospital Street
Booneville, MS 38829
BMH-Collierville Lynne Lancaster 901-861-8880 901-861-8882
5000 W. Poplar Ave. Dianne Dowdy 901-861-8632
Collierville, TN 38017

BMH-Desoto Helen McBroom 662-772-2169 662-772-2168

7601 Southcrest Pkwy. Kathy Vinton 662-772-3116
Southaven, MS 38671
BMH-Germantown Rehab Jamie Cardot 901-757-3407 901-751-6148
2100 Exeter Rd.
Germantown, TN 38138
BMH-Golden Triangle Johnny Judson 662-244-2100 662-244-2160
2520 Fifth St. North
Columbus, MS 39701
BMH-Huntingdon Teresa Brawner 731-986-7204 731-986-7008
631 R.B. Wilson Dr.
Huntingdon, TN 28344
NEA Baptist Ashley May House 870-972-7156 870-972-7385
3024 Stadium Blvd.
Jonesboro, AR 72401
BMH-Memphis (East) Denese Bryant 901-226-4542 901-226-4583
6019 Walnut Grove Rd. Beth Oliver 901-226-3870
Memphis, TN 38120 Ginger Coleman 901-226-5021

BMH-North Mississippi Linnie Maples 662-232-8272 662-513-1179

2301 S. Lamar Blvd.
Oxford, MS 38655

BMH-Restorative Care Becky Fowler 901-226-0575

Hospital
MH-Tipton (Covington) Christy Coker 901-475-5419 901-475-5418
1995 Highway 51 S.
Covington, TN. 38019
Trinity Home Care & Jill Anderson 901-415-3431 901-415-3427
Hospice

65
BMH-Union City Robbie Taylor 731-884-8623 731-884-8633
1201 Bishop St.
Union City, TN 38261
BMH-Union County (New Sonya Thompson 662-538-2164 662-538-2664
Albany)
200 Highway 30 West
New Albany, MS. 38652
BMH-Hospital for Women Beverly Reed 901-227-9348 901-227-9157
6225 Humphreys Blvd. Michelle Thomas 901-227-9155
Memphis, TN 38120

Minor Medical Centers Janie Basford 662-893-1199 662-893-1166

Medical Alternatives Denese Bryant 901-226-4542 901-226-4583

Baptist Home Medical Gayle Beckler 901-373-8485 901-937-2168

Equipment
Baptist College of Health Adonna Caldwell 901-226-4542 901-226-4583
Sciences
Corporate Building Denese Bryant 901-226-4542 901-226-4583

66
 HAZARD COMMUNICATION PROGRAM 2013

Across the United States, some 30,000,000 workers are exposed to as many as 650,000 hazardous
chemicals in more than 3,000,000 worksites. OSHA’s Hazard Communications Standard (HCS) has
been very successful in protecting those employees from such exposures.

The original HCS was implemented on November 25, 1983 and revised in February 1994 to include all
workers and to accommodate new technologies. On March 26, 2012, OSHA published in the Federal
Register a new Hazard Communication Standard, revised to improve employee safety and to comply
with the United Nations Globally Harmonized System.

“(1) The purpose of this section is to ensure that the hazards of all chemicals produced or imported
are classified, and that information concerning the classified hazards is transmitted to employers and
employees. The requirements of this section are intended to be consistent with the provisions of the
United Nations Globally Harmonized System of Classification and Labeling of Chemicals (GHS),
Revision 3. The transmittal of information is to be accomplished by means of comprehensive hazard
communication programs, which are to include container labeling and other forms of warning, safety
data sheets and employee training.”

Under the standard, manufacturers and importers of chemicals are required to:
 Classify the potential hazards of all chemicals they produce and distribute,
 Fulfill all labeling requirements on the containers they ship to customers, and to
 Provide Safety Data Sheets with the first shipment to each customer.

Employers are required by this standard to:

 Ensure a compliant labeling for chemicals in the workplace,
 Maintain a current list of hazardous chemicals,
 Provide access to Safety Data Sheets (SDSs), and to
 Inform and train employees about the chemicals to which they may be exposed, especially
on understanding SDSs and recognizing pictograms.

HAZARD COMMUNICATION POLICY

The Safety Coordinator is charged with overall responsibility for our Hazard Communication Program,
in compliance with OSHA Hazard Communication Standard, Title 29, Federal Regulations Code
1910.1200. The Safety Coordinator has the full support and authority of the employer to ensure that
compliance is maintained in this office.
This practice will follow all employer requirements in this standard on hazardous chemicals. The
following policy explains in detail just how this practice will comply with the Hazardous
Communication Standard, including instructions and other helpful information.

The Hazard Communication Standard included in this section requires employees and employers to
come into compliance with its standards. This includes:

1) Ensuring that all containers are properly labeled

2) Establishing a list of hazardous chemicals in the workplace
67
 3) Maintaining Safety Data Sheets for all hazardous chemicals
4) Establishing workplace safety practices
5) Providing necessary personal protective equipment
6) Providing training for all employees at risk for exposure to hazardous chemicals

Our Hazard Communications Program teaches the hazardous nature of the substances with which we
work, proper and safe handling procedures, and the steps employees must take to protect
themselves from harm during normal working conditions or in an emergency situation in the
workplace.

This office provides written materials, including copies of the official standard and written methods of
compliance. These materials are available upon request from the Safety Coordinator. Initial and
annual chemical safety training is provided for all employees who may come into contact with
hazardous chemicals.

LABELING AND OTHER FORMS OF WARNING

This practice will ensure that every hazardous chemical bears the appropriate labeling and warnings
as prescribed in the Hazardous Communication Standard. Labels and other forms of warning for
each incoming hazardous chemical will be inspected by the Safety Coordinator for compliance with
the standard and to insure that proper forms of warning are posted. Anytime incoming chemicals
are not fully and adequately labeled, the Safety Coordinator will complete the labeling according to
the regulation. No one in this practice will deface or damage labels in any way.

Labels are used to warn employees who may have contact with containers of the potential hazard
posed by their contents. The Safety Coordinator will ensure that all containers and chemicals in this
practice are labeled, whether they are hazardous or not. Manufactured products in their original
containers are already labeled, and have hazard information such as “Flammable,” “Eye Irritant,” etc.
The challenge lies with secondary unmarked containers, which must be labeled before being put into
use.

Chemicals in the manufacturer’s containers must have the following information:

 Product identifier
 Signal word
 Hazard statement(s)
 Pictogram(s)
 Precautionary statement(s) and
 Name, address, and telephone number for the manufacturer, importer, or other responsible
party.
Chemicals that are not in the original container also require labels. The labels must be in English,
legible, and prominently displayed. A label must be affixed to the outside of the container and
comply with one of the following:
a. Requirements for shipped containers as listed above, or
b. Product identifier and words, pictures, symbols or a combination thereof which provide
general information about the hazards of the chemicals and which may be combined with
other information available (SDS) to provide more specific information concerning the
physical and health hazards to employees.

68
Instructions: Clearly print this information on labels and cover them with clear waterproof tape, if
needed, for permanency. A photocopy of the original label may be used as the label for an
unmarked bottle if it can be done without defacing the original label. No label on incoming
containers of hazardous chemicals shall be removed or defaced. The labels must be legible and
prominently displayed on the container. If employees do not understand English, the employer may
add the information in the appropriate language in addition to (not instead of) English.

If a chemical is transferred into a temporary container, and the container is only for immediate use
by the person who transferred it, no labels are required for the portable container. Signs, placards,
process sheets or other written materials may be used to identify individual stationary process
containers.

CHEMICAL LIST
This practice will maintain a list of all hazardous chemicals used in this practice. This list will include
the following information: chemical identifier used on the Safety Data Sheet (SDS), manufacturer’s
name, and notation about the presence of the SDS. The Safety Coordinator is responsible for keeping
the list current by adding chemicals as they are acquired by the practice. Some chemicals that are
not hazardous may be included in our OSHA program to improve safety for employees and patients.

One comprehensive list, or a separate list for each location in the practice, will be compiled and
reviewed periodically. Every bottle, carton, and gas cylinder will be inspected, and every container
that bears any hazardous warning will be included in this list.

The Safety Coordinator will place the chemical list in the binder with the SDSs, using the list as the
index. The last column on the index is a check-off list. When the Safety Data Sheet for each listed
hazardous material has been received, the Safety Coordinator will note it in that column.

PHARMACEUTICALS

Pharmaceutical products are covered if they meet OSHA hazard criteria and are liquids, semi-solids
(creams, ointments, and lotions), powders and aerosols. OSHA hazard classes cover both health
hazards (e.g., highly toxic, sensitizer, etc.) and physical hazards (e.g., flammable liquid, etc.) In
particular, any drugs which are in gel, powder, liquid or aerosol form require an MSDS sheet, as well
as drugs which have been changed from their original solid form prior to patient administration, such
as by crushing. (Ref: HazCom Standard 29 CFR 1910.1200 (g) (1)).

EXEMPTIONS

Exemptions under the consumer product clause continue to raise concerns. On July 8, 2004, OSHA
responded to a request for clarification on how the HCS relates to certain products. The standard
exempts “consumer products” under certain conditions. The response later, available at
www.osha.gov, confirms this by stating:

69
“The consumer products exemption applies when a product is defined as a “consumer product” by
the Consumer Safety Act … and “the employer can show that it is used in the workplace for the
purpose intended by the chemical manufacturer or importer of the product and its use results in a
duration and frequency of exposure which is not greater than the range of exposures that could
reasonably be experienced by consumers when used for the purpose intended (29 CFR 1910.1200 (b)
(6) (ix)”….. The term “consumer product” means any article, or component part thereof, produced or
distributed for sale to a consumer for use in or around a permanent or temporary household or
residence, a school, in recreation, or otherwise, or for the personal use, consumption, or enjoyment
of a consumer…..”

OSHA considers office chemicals such as White-Out, cleaning products such as Pledge, and copier
chemicals to be exempt under the provisions of the rule as consumer products. Consumer products,
which are generally not hazardous chemicals as defined by the HCS, fall under the provisions of the
standard only when they are used with greater frequency or duration than a normal consumer, or for
“uses not intended by the manufacturer….”

The HCS also exempts:

 Hazardous waste and hazardous substances that are part of remedial or removal action under
the EPA
 Tobacco or tobacco products
 Wood or wood products if the only hazard is flammability or combustibility
 Articles (solids)
 Food and alcohol in retail establishments or for personal consumption by employees
 Drugs in solid, final form for administration to the patient
 Over-the-counter drugs; drugs for personal consumption by employees
 Cosmetics in retail establishments or for personal use by employees
 Nuisance particles that do not pose any physical or health hazards covered by the standard
 Radiation (ionizing and non-ionizing)
 Biological hazards
PHARMACEUTICALS

The following pharmaceuticals are exempted:

 Pharmaceuticals which are received sealed, remain sealed, and go home with the patient
sealed (samples, dispensed products if sealed),
 Tablets and capsules which remain tablets and capsules (are not pulverized or broken apart
for administration in the practice)
 Any medication that is in solid final form for direct administration to the patient

The Safety Coordinator will check all new chemicals received regarding hazards and M requirement.
If someone other than the Safety Coordinator receives new chemicals, that person should notify the
Safety Coordinator as soon as possible to ensure that proper SDSs are obtained and filed and that
employees can be trained in their use and hazards if necessary.

After the chemical list is completed and checked, SDSs (Safety Data Sheets) are obtained for each
product from the manufacturer or from the distributor who sold the product. Many may also be
obtained online.

70
 SAFETY DATA SHEETS INTERNET RESOURCES
SDSs: www.micromedex.com/products/dolphin/
http.//hq.msdsonline.com/pssworldmed/search/Default.aspx
Service: www.netmsds.com

INTERNALLY PRODUCED HAZARDOUS MATERIALS

Biohazardous medical waste, chemical waste and/or compressed air, and handling and disposal of
the biohazardous wastes are covered under the waste section of the Bloodborne Pathogen Program.

EMPLOYEE INFORMATION AND TRAINING

Information and training as required by Section (h) of the standard will be provided to all employees
at the time of initial assignment, whenever a new hazard is introduced into their work area, and
annually thereafter. Employees will be trained to know the chemical’s effect on the body, how to
detect an overexposure, what personal protective equipment or procedures are needed when
handling the chemical, how to properly and safely clean up an accidental spill, and how to read and
understand the SDS.

Training will be provided annually for all employees. Written records of the training will be kept in
this manual or in personnel files. Training will be provided by our SC utilizing such aids and methods
as: verbal instruction, demonstration of handling certain chemicals, protective equipment use,
interpretation of labels and wall charts, and question and answer sessions.

Training will be provided by this practice, as required by OSHA, at the following times and under the
following conditions. This training may include seminar presentations, videos, written materials and
test. Time will be allotted for employee questions.
 During normal working hours and at no cost to the employee
 For all employees, full time or part time, at potential risk for hazardous chemical exposure
 When new hazardous materials and associated information are received
 Whenever safe handling and emergency procedures are modified
 Annually as a refresher training for all employees using hazardous materials
 For new employees before their initial assignment
 For contract workers

In the unlikely event that an employee will be involved in a non-routine task, that employee will be
informed of the hazard involved, and trained at specific training sessions prior to performing the
task.

(a) Methods and observations that may be used to detect the presence or release of a hazardous
chemical in the work area (such as monitoring conducted by the employer, continuous
monitoring devices, visual appearance or odor of hazardous chemicals when being released,
etc.);
(b) The physical and health hazards of the chemicals in the work area;
(c) The measure employees can take to protect themselves from the hazards, including specific
procedures the employer has implemented to protect employees from exposure to hazardous

71
 chemicals, such as appropriate work practices, emergency procedures and personal protective
equipment to be used;
(d) General safety instructions on the handling, cleanup, and disposal of hazardous chemicals;
and
(e) The details of the hazard communication program developed by the employer including an
explanation of the labeling system and the SDS, and how employees can obtain and use the
appropriate hazard information.

WORK HAZARD CONTROLS

Employees in the facility will use hazardous chemicals only in well-ventilated areas and while wearing
personal protective equipment indicated by the SDS. The SDS includes requirements for employees
to wear gloves, gown and face protection (goggles plus mask, or full-face shield). This practice has
substituted lower-hazard chemicals for higher-hazard chemicals, and will continue to do so.

All employees will clean the work surfaces and wash their hands following the use of hazardous
chemicals.

No eating, drinking, applying cosmetics or contact lenses, or storing food or beverages will be
allowed in areas where hazardous chemicals are stored or used.

Spilled chemicals will be cleaned up according to our spill clean-up procedure or the SDS if the SDS
clean-up instructions are more stringent. The absorbed materials will be discarded according to
information found in the SDS.

GENERAL EFFECTS OF CHEMICALS

Short-term (acute) effects may include:

 Burns from flammable materials
 Eyes, nose, throat, lung irritation, or injury
 Dry skin or dermatitis
 Nausea (sick feeling)
 Fever
 Unconsciousness
 Death
 Nervous system effects (i.e., dizziness, headache, highs)
 Vomiting
Long-term (chronic) effects may include:
 Sensitization
 Birth Defects
 Damage to liver, kidney, stomach, central nervous system, muscles, brain, blood, bones, and
lungs
 Cancer
 Reproductive effects
 Death
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 DISPOSAL

OSHA does not govern chemical disposal. The Environmental Protection Agency (EPA) and the
Resource Conservation and Recovery Act (RCRA) do. When SDSs are vague, contact the waste
removal service for guidance.

Many waste removal services recommend packaging chemicals separately from the biohazardous
waste, and labeling it “Chemical Waste”. The waste removal company can then process it
appropriately. This includes silver and mercury.

CHEMICAL SPILL

Spill Clean-up Procedures

1. Isolate the area and seek assistance.
2. If the spill is chemical, get the SDS Sheet and read how to clean up the spill.
3. Retrieve the spill kit*.
4. Put on the appropriate personal protective equipment: face protection, gown, and heavy-
duty gloves.
5. Pour absorbent on the spill, using enough that the spill becomes manageable in a solid form.
A special spill kit, or powdered sulfur, must be used to clean up mercury.
6. Using the broom and scoop in the chemical spill kit, sweep up the spill and dispose it
according to SDS directions or, if it is a biohazardous spill, dispose of it in a red bag.
7. Clean the area with soap and water.
8. If the spill is potentially biohazardous, spray the area with a hospital grade disinfectant using
the spray-wipe-spray technique.

*The Spill Kit should contain the following items: Absorbent; Personal Protective Equipment (face
shield, gown, gloves), small broom and dust pan, bags for disposal, paper towels for cleaning,
disinfectant.

EPA CLEANUP TIPS FOR BROKEN CFL BULBS

Compact fluorescent light (CFL) bulbs are quickly replacing traditional incandescent light bulbs.
(Rumor has it that the incandescent bulbs are going the way of 8-tracks.) Although CFLs are said to
be twice as efficient as incandescent ones, they do break. And when they break, they release a tiny
bit of mercury. Here are the latest tips from the Environmental Protections Agency (EPA) for cleaning
up broken CFLs.

1. Remove all human and pets from the room.

2. Air the room for 5-10 minutes by opening a window or door to the outside.
3. Shut off the central forced air heating and cooling system.
4. Collect materials for cleaning up the broken bulb.
5. Carefully clean up all broken glass and visible powder.
6. Place debris (including items used for cleanup) in a sealable container.
7. Place the sealed container in an outdoor trash can.
8. Continue to air the room for several hours, with the HVAC off.

73
 STORAGE AND HANDLING OF HAZARDOUS CHEMICALS

Chemicals will be stored in cool, dry areas at temperatures between 67◦F and 94◦F, unless the
manufacturer notes otherwise. Storage areas should be constructed so that shelving is fixed securely
to the floor or wall and should be away from direct sunlight, high heat and humidity, and ignition.
Access to the storage area should be limited to authorized personnel only.

Chemicals will be stored in properly labeled containers with special attention given to hazard
warnings. These warnings will alert employees using the chemicals not to store incompatible
materials in the same area. Chemicals need to be stored by their potential hazard, not
alphabetically. These hazard classes are as follow: Health Hazard, Carcinogen, Compressed Gas,
Corrosive, Flammable, Moderate Poison, Non-Hazardous, Radioactive, Sever Poison, Water Reactive,
and Oxidizers.

Large volumes of flammables must be stored in special storage areas. Water reactive chemicals need
dry storage. Strong oxidizers will be separated from other chemicals. Compressed gas cylinders will
be secured and supported.

Each employee should read the manufacturer’s or supplier’s directions before using any product, and
note the possible hazards (both physical and health hazards) of the product. The proper information
should be on the label for products containing hazardous chemicals.

74
 EYEWASH STATIONS
An employer who employs anyone to perform procedures that may cause splashes or spills of
hazardous chemicals to the eyes must have an eyewash station. This includes any employer with x-
ray equipment in use. See 1910.151©; 1926.50(q)

Requirements for eyewash stations focus on chemicals that are “corrosive.” For offices that have any
chemical listed as “corrosive”, eye wash station is mandatory. Hand-held squeeze bottles are not
acceptable. The affected individual must be able to access the eyewash station within 10 seconds,
activate it with one motion, and have both hands free to hold both eyelids open while flushing with a
continuous flow of clean water for 15 minutes.

The eyewash stations must be easily accessible to the laboratory and x-ray room, and must be
unobstructed for ease of use for employees who are performing those tasks that may result in
splashes of hazardous chemicals to the eyes. It must be located within 10 seconds from the potential
hazard.

The American National Standards Institute (ANSI) requires a 3-minute flushing weekly. Because of
the potential danger of bacterial growth in the device, it is recommended that you flush the device
for 15 minutes weekly.

The eyewash station must be approved by the ANSI. It must be operational with one hand
movement, have a continuous flow of clean tepid water and for the water to continue to flow for at
least 15 minutes, while the employee is hands free, holding both her eyelids open.

This practice will install eyewash stations as needed. We will maintain proper use by following the
manufacturer’s instructions, checking for proper functioning daily, and cleaning as needed.

Our eyewash station(s) area located______________________________________________

Approved by_____________________________

75
 EYEWASH INSPECTION AND MONITORING RECORD

Location:__________________________________ Months/YR: __________________

1. Test the flow of water through the eyewash each week (bump test).
2. Once each week, flush the eyewash by allowing water to flow through it for at least three
minutes, but preferably for fifteen minutes.
3. Record the results and initial.

Month/Week Bump Test Flush Initials Corrective Action

Month:
Wk.1
2
3
4
5
Month:
Wk. 1
2
3
4
5
Month:
Wk. 1
2
3
4
5
Month:
Wk. 1
2
3
4
5

76
 WORKPLACE HAZARD ASSESSMENT

INSTRUCTIONS FOR
COMPLETING HAZARD
ASSESSMENT

The Safety Coordinator shall conduct an initial Workplace Hazard Assessment for this facility and
subsequent Hazard Assessments as needed. Input from all employees will be welcome. The goal of
this process is to reduce the rate of occupational illnesses and injuries.

Each potential hazard must be assessed using the Hazard Assessment forms. Hazards that are
observed during the assessment will be recorded in the “Hazards Observed” section. Assessment of
hazards will be done without regard to available controls, such as personal protective equipment,
which will be documented in the “Current Controls” section.

Frontline workers will be given the opportunity to participate in the hazard assessment and in
choosing and implementing controls. For each hazard observed, the Safety Coordinator shall
document current and suggested hazard controls. Suggestions will be recorded in the “Suggested
Controls/Comments” section.

The Safety Coordinator and management will use the hazard assessment, documentation of
occupational illnesses and injuries, and input from employees to thoroughly assess potential hazards
and to propose appropriate hazard controls. These findings will be used to develop and maintain a
facility-specific safety and health program.

To complete the Hazard Assessment:

1. Carefully evaluate each hazard in the first column.
2. Place an N in the second column if the hazard is not present in your workplace. No further
actions needed. Write NA in the two columns for controls.
3. Place a Y in the second column if the hazard is present – even if controls are in place.
4. If the answer is yes, list the controls that are in placed in the third column. Write “none” if no
controls are in place.
5. If the hazard is present but the controls listed are less than optimal, write suggestions for
additional or better controls in the last column.

OSHA requires this to be done one time, with the findings being used to implement corrections if
indicated. If extensive corrections are needed, it is wise to repeat the Hazard Assessment to evaluate
the effectiveness of those changes.

77
 WORKSITE HAZARD ASSESSMENT
Practice:__________________________________ Date: _______________ Signature __________________

HAZARD YES/ CONTROLS IN PLACE SUGGESTED CONTROLS

NO /COMMENTS
I. BLOODBORNE PATOGENS
A. Invasive procedures
B. Collecting/handling patient body fluids,
laboratory controls, etc.
C. Changing dressings
D. Handling soiled linen/biohazardous
wastes
E. Handling contaminated instruments
F. Administering injections, starting IVs,
removing sutures
G. Examination of body orifices
H. Catheterization/
cauterization/lacerations
I. X-ray of open wounds or oral cavity N/A
J. Cleaning contaminated surfaces
K. Food or beverages in or near
contaminated area
L. Presence/use of sharps without safety
devices
M. Sharps containers overfilled
HAZARD YES/ CONTROLS IN PLACE SUGGESTED
NO CONTROLS/COMMENTS
N. Open sharps containers on moveable
carts
O. Unsealed sharps containers
78
 transported
II. FIRE SAFETY/EVACUATION
A. Unmarked exits
B. Exits blocked (inside or outside)
III. ELECTRICAL
A. Outlets overloaded
B. Inoperable switches or outlets
C. 3-prong plug in 2-prong outlet
D. Outlets near water without a GFCI
E. Damaged equipment
F. Damaged wiring
G. Excessive extension cords
H. Unlabeled or inaccessible breakers
I. Broken or missing outlet covers
HAZARD YES/ CONTROLS IN PLACE SUGGESTED
NO CONTROLS/COMMENTS
IV. LOGOUT/TAGOUT
A. Electrical power to machines should be
locked out for maintenance or repair
B. Appropriate signage is needed to warn
employees anytime a piece of
equipment should not be reactivated
V. MACHINE GUARDING
A. Unsafe machinery
B. Unsafe work practices
C. Unprotected fan blades
VI. WALKING AND WORKING
79
 SURFACES
A. Slip or trip hazards
B. Obstacles in halls
VII. LASER/RADIATION/MRI
A. Laser procedures performed
1. Reflective surfaces present in the
room during laser procedures
2. Flammable (alcohol, 02, anesthetic
gases, etc.) present during laser
procedures
3. Goggles available
B. Radiology procedures performed
HAZARD YES/ CONTROLS IN PLACE SUGGESTED
NO CONTROLS/COMMENTS
1. Unsafe equipment
2. Unsafe work practices
C. Improper sharps disposal
VIII. HAZARDOUS CHEMICALS
1.SDS Book Available
IX. ERGONIMICS
A. Assisting patients:
1. Between wheelchair and exam
table or dental chair
2. Other
B. Awkward positions/posture
C. Pushing
1. Wheelchairs/Carts

80
 2. Other
D. Telephone usage more than 4 hrs./day
with no break
E. Computer terminal activities longer
than 4 hrs./day with no break
F. Other repetitive motions
HAZARD YES/ CONTROLS IN PLACE SUGGESTED
NO CONTROLS/COMMENTS
1. Dental hygiene procedures
2. Ultrasonic procedures
G. Poor lighting
H. Limited space for work movements
I. Excessive static standing
J. Reaching/stooping/bending/twisting/
squatting/required
X. RECORD KEEPING
A. Written Hazard Exposure Control Plan
B. Poster(s) displayed
I certify that this assessment was performed as documented on each of the previous pages.

_________________________________________________________________ _______________________________
Employer Date

81
 PERSONAL PROTECTIVE HAZARD ASSESSMENT
Practice:__________________________________ Date: _______________ Signature ___________________________________

Applicable Task Required Personal

Protective Equipment
Yes No Gloves –Specify Gown Face Protection-Specify Other
(medical, utility or (shield, goggles, or mask)
puncture-resistant)
Hazardous Chemicals
Cleaning instruments/Surfaces
Chemotherapy (cancer)
Mixing/Pouring x-ray chemicals
Misc. chemical procedures
Radiation
Taking x-rays of wounds
Intraoral x-rays
Processing x-rays
Laser procedure
Tuberculosis
Care of TB patients
Cough-inducing procedures
Ergonomics
Phone/keyboard duty >4 hrs.
with no break
Repetitive motion
Awkward position
Heavy lifting

I certify that this assessment was performed as documented.

_______________________________________________________ ______________________________

Employer Date

82
 SAFETY DATA SHEETS (SDSs)
The Safety Data Sheet is the document prepared by the manufacturer to describe the chemical and to inform
the user of any hazards and needed safety precautions. The Safety Coordinator is responsible for obtaining SDSs
for all hazardous chemicals and for making them available to all users.

Enforcement remains an important focus for protecting employers. During the year of October 2010 –
September 2011, OSHA issued over 200 citations to 115 health service employers for violations of the HCS,
making it the second most frequently cited OSHA standard. Almost $1,000,000 (one million dollars!) was
assessed in penalties.

The manufacture or importer has the responsibility and accountability for the accuracy of information on Safety
Data Sheets. Employers are required to make the SDS available to employees. Manufactures and importers
have the primary responsibility for distributing SDS to clients, but most healthcare employers get their chemicals
from distributors, who in this case must provide SDSs.

To improve reliability of the information on the SDS and to make emergency information easier to find, OSHA
now stipulates the order in which information must be placed on all ADSs. The order of information begins on
page 9.

The manufactures update SDSs are necessary. The manufacturer, importer, or distributor is responsible for
sending SDSs to clients. Updated SDSs will replace outdated ones in the SDS library as they are received. If the
new SDS indicates hazards that were not on the original one, the new SDS must be posted in a prominent place
for two weeks before filing it with the others. This is our way of informing the employees about the new
hazards. The Safety Coordinator is ultimately responsible for the accuracy of the lists. Old MSDS sheets,
including those for discontinued chemicals, must be kept for at least 30 years.

All employees have access to our SDSs at all times. Our SDSs are stored:

_________electronically *

_________ in a binder located ___________________________________________________

If there is a discrepancy between the information on the label and the information on the SDS, the SDS will
prevail. The Safety Coordinator will obtain SDSs for new hazardous chemicals as they are acquired from the
supplier, the manufacturer, or the Internet.

When a new product comes into the workplace, all employees need to be informed of the new hazards
associated with the chemicals in this product. The safety Coordinator will provide training prior to any
employee working with the new chemical.

We will maintain SDSs for most general customer products that are currently in use. If we discontinue using a
hazardous chemical (e.g., mercury, formaldehyde, or glutaraldehyde) we will date the SDS and keep it for 30
more years. If an employee has an over-exposure or any type of reaction to any chemical, a copy of the SDS will
be placed in the employee medical file and kept for the duration of employment pus 30 years.

83
 New Chemical Labeling Requirements
Pictogram: a symbol plus other graphic elements, such as a border, background pattern, or color that is
intended to convey specific information about the hazards of a chemical. Each pictogram consists of a different
symbol on a white background within a red square frame set on a point (i.e. a red diamond). There are nine
pictograms under the GHS. However, only eight pictograms are required under the HCS.

Hazard Communication Standard Pictograms and Hazards

Health Hazard Flame Exclamation Mark

 Carcinogen  Flammables  Irritant (skin and eye)

 Mutagenicity  Pyrophorics  Skin Sensitizer
 Reproductive Toxicity  Self-Heating  Acute Toxicity
 Respiratory Sensitizer  Emits Flammable Gas  Narcotic Effects
 Target Organ Toxicity  Self-Reactives  Respiratory Tract
 Aspiration Toxicity  Organic Peroxides Irritant
 Hazardous to Ozone
Layer (Non-Mandatory)
Gas Cylinder Corrosion Exploding Bomb

 Gases Under Pressure  Skin Corrosion/Burns  Explosives

 Eye Damage  Self-Reactives
 Corrosive to Metals  Organic Peroxides
Flame Over Circle Environment Skull and Crossbones
(Non-Mandatory)

 Oxidizers  Acute Toxicity (fatal or

 Aquatic Toxicity toxic)
 Signal word: a single word used to indicate the relative level of severity of hazard and alert the reader
to a potential hazard on the label. The signal words used are “Danger” and “Warning.” “Danger” is for
the more severe hazards, while “Warning” is used for less severe hazards.
 Hazard Statement: a statement assigned to a hazard class and category that describes the nature of the
hazards of a chemical, including, where appropriate, the degree of the hazard.

 Precautionary Statement: a phrase that describes recommended measures to be taken to minimize or

prevent adverse effects resulting from exposure to a hazardous chemical or improper storage or
handling of a hazardous chemical.

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 Label Format

PRODUCT IDENTIFIER HAZARD PICTOGRAMS

CODE
Product Name

SUPPLIER IDENTIFICATION
Company Name
Street Address SIGNAL WORD*
City State
Postal Code Country
Danger
Emergency Phone Number

PRECAUTIONARY STATEMENTS HAZARD STATEMENT

Keep container tightly closed. Store in a cool, well Highly flammable liquid and vapor.
ventilated place that is locked. May cause liver and kidney damage.

Keep away from heat/sparks/open flame. No smoking.

Only use non-sparking tools. SUPPLEMENTAL INFORMATION

Use explosion-proof electrical equipment.
Directions for use
Take precautionary measure against static discharge.

Ground and bond container and receiving equipment.

Fill weight:
Do not breathe vapors. Lot Number:
Gross weight:
Wear Protective gloves. Fill weight:
Expiration date:
Do not eat, drink or smoke when using this product.

Wash hands thoroughly after handling.

Dispose of in accordance with local, regional, national,

international regulations as specified.

In Case of Fire: use dry chemical (BC) or Carbon dioxide

(CO2) fire extinguisher to extinguish.

First Aid
If exposed call Poison Control.
If on skin (on hair): Take off immediately any
contaminated clothing. Rinse skin with water.

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 WORKPLACE HAZARDOUS CHEMICAL LIST
Practice _________________________________ SIC Code ___________________________

Address _________________________________

Chemical Manufacturer SDS on File

(Common Name)
Alcohol, Isopropyl Cumberland-Swan X

List Prepared ___________________________________Reviewed/Updated_____________

Date Date

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 BIOHAZARDOUS WASTE
This office observes all OSHA regulations concerning the handling of contaminated waste. Contaminated wastes
include the following: blood or other potentially infectious body fluids; saliva in dental procedures; items which
would release these fluids if compressed; items which are coated with fried blood or other potentially infectious
materials and are capable of releasing these materials during handling; contaminated sharps; pathological and
microbiological waste containing blood or other body fluids include saliva.

Protocol for waste handling in this facility is as follows:

 All contaminated sharps are to be placed in the sharps container at the location where they are used.
These containers will be tightly closed and removed when contents reach the fill line.
 All wastes will be separated into contaminated and non-contaminated types.
 Non-contaminated waste is placed in the regular trash can. IF IN DOUBT, PLACE THE ITEM IN THE RED
CONTAINER.
 Contaminated wastes, including grossly contaminated gloves, are to be placed in the biohazardous
containers located in each treatment area. Do NOT carry these items back to the central sterilization
area; dispose of them where they are used. These containers must be closeable, leak-proof and properly
labeled. Close lid prior to transporting for pick-up.
 Contaminated wastes are filled sharps containers may NOT be placed with the regular trash for removal
from this facility.

HOUSEKEEPING
In keeping with the concept of Universal Precautions, the Safety Coordinator will ensure that the worksite is
maintained in a clean and sanitary condition.

Equipment: Each worker will use an EPA or FDA-approved disinfectant to clean and decontaminate all
equipment and environmental work surfaces after he/she has used them and made contact with blood or other
potentially infectious materials.

Work Surfaces: Each worker is responsible for using EPA or FDA-approved disinfectant to decontaminate work
surfaces anytime the surfaces become contaminated with blood or other potentially infectious materials, before
lunch breaks and at the end of each shift. Work surfaces include countertops, mobile med carts, etc. This will be
done at least twice a day: before lunch and at the end of the day, following the disinfectant manufacturer’s
contact time requirement.

Protective Coverings: Protective coverings such as plastic wrap, aluminum foil, or imperviously backed
absorbent paper used to cover equipment or environmental surfaces shall be removed and replaced as soon as
feasible when they become obviously contaminated and at the end of the work shift by the staff member
working in that area.

Trash Cans: All bins, pails, cans, and similar receptacles which have a reasonable likelihood for becoming
contaminated with blood or other potentially infectious materials will be inspected, cleaned, and
decontaminated daily by the Safety Coordinator or as soon as feasible upon visible contamination.
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As our disinfectant we use:

_____ a hospital disinfectant that is EPA-approved and tuberculocidal and used at the recommended dilutions

_____a disinfectant with HV and HBV efficacy that is EPA-approved and used at the recommended dilutions

_____ a 5.25% solution of sodium hypochlorite (household bleach) diluted between 1:10 and 1:100 with water
and prepared fresh daily

General housekeeping, such as dusting, sweeping and floor mopping, vacuuming carpet, cleaning bathrooms,
and emptying trash is done on an as-needed basis. Bins, pails, cans, and similar receptacles will be cleaned and
disinfected when visibly contaminated.

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 Medical Waste Disposal Guide
Item Regulated Routine Trash Sharps
Waste Container
Band-Aid /Cotton Balls/ Gauze –slightly X
soiled
Band-Aids/Cotton Balls/ Gauze- X
saturated
Blades/Razors X
Blood or Blood Products X
Capillary Tubes X
Culture Plates, Tubes X
Disposable Gown – damaged or slightly X
soiled
Disposable Gown - saturated X
Disposable Vaginal Speculums X
Exam Table Paper X
Glass Blood Collection Tubes X
Glass Slides X
Gloves - not visibly soiled X
Gloves – visibly soiled X
Lancets X
Laser Masks X
Masks – damaged or soiled X
Needles X
Pap Smear Brushes X
Pipettes, Glass X
Sharps Container X
Throat Swab X
Tissue, Unfixed X
Urine Specimens - Bloody X

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 NEW EMPLOYEE TRAINING FORM

NAME: DATE:
(PLEASE PRINT)
SIGNATURE:
General Workplace Safety
I have been trained on this facility’s Fire/Emergency Plan and I agree to comply with the requirements. I
understand that management is concerned about employee safety in this facility and acknowledge that my job
description requires me to immediately report any safety concerns I have to
I have had the opportunity to ask questions and have them answered to my satisfaction.
Bloodborne Exposure Training
Prior to assignment to any task or job which could result in exposure to blood and/or other bodily fluids, I had
the opportunity to review this facility’s Bloodborne Exposure Control written plan. My training, which occurred
prior to being assigned to any task that could result in a bloodborne exposure included, but was not limited to,
symptoms of bloodborne diseases, modes of transmission and the use of Universal Precautions, specific work
practice controls, engineering controls and appropriate Personal Protective Equipment to reduce the risk of
exposure. I understand and agree to comply with all procedures and policies set forth in the plan and have had
the opportunity to ask questions and have had them answered to my satisfaction. I will report any concerns
and/or bloodborne exposure incidents to Employee Health immediately. Because my job puts me at risk of
exposure to bloodborne pathogens, the Hepatitis B vaccination series was offered to me at no charge within the
first 10 days of employment.
Hazard Communications
I have been made aware of this facility’s written policy on hazard communications and have had the opportunity
to read the plans. I have been trained on appropriate container labeling, the use of Personal Protective
Equipment and the location and use of Material Safety Data Sheets (MSDS). 1 was trained prior to any task which
could put me at risk of any chemical exposure. To the best of my ability, I will comply with this facility’s Hazard
Communications requirements. I will immediately report any concerns I might have about over-exposure to
chemical liquids, vapors or gas to the Safety Coordinator
Biomedical Waste Management
I have been trained on this facility’s biomedical waste management plan. I have had the opportunity to review
the written plan and to ask questions and have them answered to my satisfaction. Training was conducted prior
to any assignment that could result in exposure to biohazardous materials. The training included, but was not
limited to, the definition of biomedical waste generated in this facility, proper handling and disposal of
biomedical waste, appropriate use of Personal Protective Equipment, the contingency plan for cleaning any
biohazardous waste spill, and on-site storage requirements.

TRAINER(S):

Training appropriate to this employee’s job description was completed successfully. He/she had the opportunity to
ask specific questions about job safety and/or health concerns. I have answered these questions to the best of my
ability. He/she was advised to report any future safety or health concerns to

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