1. Research Safety Organization [Return to Table of Contents] a) Research Safety Committee The MGH Research Safety Committee will provide leadership and support for the management of workplace safety and health and compliance with applicable environmental regulations within the MGH research community. Representatives from the research community and various support department managers will interact within this forum to develop and implement policies and guidelines, share information, assess risks, raise staff awareness through the safety education program, and otherwise act to minimize risk and assure compliance with pertinent laws, standards and best practices. i) Goal The MGH Research Safety Committee s goal is to oversee and guide a comprehensive program that recognizes and effectively manages research-related risks to worker safety and health, physical property and the external environment. ii) Objectives Maintain an active membership consisting of representatives from the research community and hospital support departments. Appoint subcommittees or ad hoc groups to address special issues and concerns as necessary. Develop, implement and maintain policies and procedures to ensure safety, health and environmental protection while complying with federal, state and local laws and industry best practices. Maintain communication between the committee and the research community, assuring that lab groups are informed about hazards and regulatory requirements. Assure provision of general and department-specific education, training and consultation. Provide oversight and support through safety audit activities, particularly of high risk areas and activities, responding promptly to issues to assure safety and compliance. Encourage incident reporting and review safety audit and incident data for trends and sentinel events to assure experience-based safety programming and to provide the information needed to guide performance improvement. Maintain liaison as needed with outside agencies at the local, state, and federal level. Strive for continual program improvement. Issue regular reports on program status to the MGH Safety Committee. b) Support Department Responsibilities [Return to Table of Contents] i) Research Compliance Shares committee leadership. Assists in keeping the committee apprised of pertinent compliance and regulatory driven initiatives related to safety, health and environmental management. Contributes actively to all policy and training development.
Assists in disseminating information to the research community. Assists in identifying, planning and implementing committee initiatives, including but not limited to identifying non-compliant areas. Supports performance and process improvement activities. ii) Environmental Health and Safety (EH&S) Shares committee leadership. Supports and assists in coordinating an effective and comprehensive research safety management program. Supports development and implementation of general and lab-specific safety, health and environmental protection policies and practices. Provides technical support and consults on hazard-specific issues. Participates in hazard surveillance activities, particularly focusing on fire safety, chemical safety and hygiene, hazardous waste disposal and environmental protection. Acts as a liaison between regulatory agencies and the research community. Implements training programs covering its areas of technical responsibility for all research laboratory personnel. Collects and analyzes incident data to support program assessment and improvement. iii) Biosafety The MGH Biosafety Office (a division of MGH EH&S) provides oversight for research involving recombinant and synthetic nucleic acids, infectious agents, potentially infectious human and non-human materials and certain select agent toxins used in exempt amounts. The Biosafety Manager is a member of the Partner s Institutional Biosafety Committee - PIBC, and manages a program that assures that all protocols involving biological agents of interest to the PIBC receive proper committee review and risk assessment and that committee prescribed controls are fully and consistently implemented within respective research operations. iv) Research Space Management Group (RSMG) Is responsible to the Executive Committee on Research (ECOR) for all aspects of research space allocation, configuration and management. Manages the committee concerned with all policies, procedures, processes and initiatives related to research building emergency evacuation. Educates Principal Investigators (PIs) and their designated representatives regarding evacuation policy, the research Emergency Notification System (ENS) and lab-specific evacuation planning. Collects and maintains PI and alternate lab contact information for use with the research ENS. Coordinates and supports the laboratory surveillance program throughout the research community, including corrective actions as necessary.
v) Radiation Safety Led by the MGH Radiation Safety Officer (RSO), the Radiation Safety Office ensures the safe use of radioactive materials and machine-produced sources of ionizing radiation. Administers MGH s Radioactive Materials License and Radioisotope Use Permits in conjunction with the Radiation Safety Committee. Implements policies and procedures for safe use of radioactive material and investigates any deviation from approved radiation safety practice. Provides training and exposure monitoring for radioactivity users and ancillary staff to keep exposures as low as reasonably achievable (ALARA). Monitors and actively works to minimize the environmental impact of radiation use, both inside and outside of the hospital. May suspend radioactive material use in cases of significant non-compliance with policies and regulations or in cases presenting a clear and present danger. vi) Occupational Health (OHS) The Occupational Health Service (OHS) provides occupational health care to the Partners HealthCare System workforce and promotes and supports the protection of employee health and safety in the work environment. The health care provided focuses on prevention and treatment of medical conditions associated with the work environment and/or job duties. Examples of occupational health care include TB testing after exposure to TB, evaluation and treatment of back pain after lifting, and treatment after experiencing a needlestick. The care provided by OHS does not include primary and episodic health care unrelated to an employee s job-related activities. OHS services include: pre-placement and return to work clearances immunizations and TB testing medical evaluation for respirator use evaluation and treatment of work-related injuries and exposures work site evaluations fitness for duty assessments work accommodation assessments vii) Police and Security (P&S) The purpose of the MGH Research Security Program is to protect people and assets from criminal activity and workplace violence. This program seeks to proactively identify trends and patterns of general and high security risks and develop, implement and maintain effective safeguards. While it is the primary goal of Police and Security to provide a safe and secure environment, they cannot do it alone. Providing a safe workplace for staff and visitors is a shared responsibility with all who work at MGH. Employees are advised to remain aware of their surroundings and report suspicious or inappropriate activity to the Police and Security Department. Employees are also advised to immediately report theft, threats, harassment, potential physical violence, disturbances, accidents (with or without injury), bomb threat, or an inappropriate or disruptive individual as soon as possible. c) Research Community Safety Responsibilities [Return to Table of Contents]
i) Department/Unit Chiefs Accept ultimate responsibility for implementing and enforcing safety, health and environmental requirements applicable to your laboratory operations. Either directly or through a designee, determine the best approach to safety coverage for the department. Use the safety coordinator roles described in sections c) iii through c) v below as sufficient for your department s structure and needs. Note: In recognition of the significant variability among departments research operations, this section is intended to provide maximum flexibility in organizing safety coverage within a department. Through the safety coordinator positions described below, the intent is to have each department represented on the Research Safety Committee while providing capable safety oversight and support throughout all research laboratories and associated spaces at all MGH research sites. Departments may utilize PIs, management staff or other appropriately experienced personnel to fill their safety coordinator roles and may even combine roles for assignment to one individual, depending on their circumstances. The endpoint in assigning safety coordinators is to assure adequate coverage for all sites where the department operates and to provide sufficient coverage for each individual laboratory at each site. Assure compliance with relevant safety, health and environmental protection requirements by all personnel. Assure each individual s completion of annual training requirements. (The time of an employee s performance evaluation is a good time to complete such a review.) Identify a department representative as the Department/Unit Safety Coordinator and assign this individual to the MGH Research Safety Committee ii) Principal Investigators Assume responsibility for the general safety of all personnel in your respective operations by assuring that all workplace hazards are continually and proactively identified and effectively managed and that staff comply with applicable environmental protection requirements. Assure that safe work practices are consistently followed. When responsible, designate a person(s) to serve as Department/Unit Safety Coordinator whose duties are detailed below. Develop and implement department-specific and protocol-specific safety policies and practices to address lab-specific risks and to supplement the more general guidance provided by the hospital s safety program. Assure that all lab employees are properly trained in safe work practices, including nontechnical staff who must be at least advised of risks and their location and the measures they must take to avoid them. Assure that hazardous conditions and practices are reported to the appropriate support department when necessary. Provide personal protective equipment as needed.
Assure that required medical monitoring is identified through Occupational Health and provided as needed. Review the status of required training for each employee (most managers do this during annual performance reviews) and ensure personnel are not only in compliance but also maintaining their training competency. iii) Department/Unit Safety Coordinator Serve as a member of the MGH Research Safety Committee. Assign site safety coordinators and lab safety coordinators per the department s safety coverage plan to assist as needed. Function as a safety monitor and coordinator for the department and as a liaison to the Environmental Health and Safety Department and other safety management groups. Assist lab personnel in department-specific protocol development and training. Assure that the department has a current department-specific fire plan that is followed during each activation of the building fire alarm system. Assure that department-specific chemical hygiene practices are developed as needed and followed. Assure that eyewash stations are checked and flushed weekly by someone in each lab and this is documented on the tag attached to each fixture. Assure that fire extinguishers are checked monthly by someone in each lab and documented on the tag attached to each unit. Assure that biological safety cabinets, chemical fume hoods, laminar flow benches and other lab equipment requiring periodic maintenance and certification are up to date and that deficiencies are corrected. Assure that all personnel satisfy their initial and continuing safety training requirements. Assist in planning and training for laboratory emergencies such as fire, flood, spills, and power outages. Assure fire doors are not obstructed or blocked open and corridors are clear of all storage. Assure storage, especially of hazardous materials, is appropriate and labs are not cluttered. Assure adequate personal protective equipment is available and properly used. Interface with the safety surveillance team on its rounds activities. Respond to safety surveillance team suggestions for improving workplace safety. Assure that staff understands and complies with institutional procedures for disposal of biological, chemical, and radioactive waste. Promulgate timely information from the Research Safety Committee back to the work areas. Assist when necessary with training functions. Familiarize new group members with laboratory safety devices, procedures, and policies. Arrange for the correction of observed safety problems within the group. If corrections cannot be made easily, the safety coordinator will notify their research director and/or the MGH Safety Office.
iv) Site Safety Coordinator 1 Work in conjunction with the Department/Unit Safety Coordinator. Develop and implement laboratory-specific and protocol-specific safety policies and practices to address lab-specific risks and to supplement the more general guidance provided by the hospital s safety program. Assure that all employees are properly trained in safe work practices. Assure that hazardous conditions and practices are reported to the Environmental Health & Safety department when necessary. Provide personal protective equipment when needed. Assure that required medical monitoring is identified through Occupational Health and provided as needed. v) Lab Safety Coordinator 2 Work in conjunction with the Department/Unit Safety Coordinator and the Site Safety Coordinator Develop and implement PI laboratory-specific and protocol-specific safety policies and practices to address lab-specific risks and to supplement the more general guidance provided by the hospital s safety program. Assure that all employees are properly trained in safe work practices. Assure that hazardous conditions and practices are reported to the Environmental Health & Safety department when necessary. Provide personal protective equipment when needed. Assure that required medical monitoring is identified through Occupational Health and provided as needed. vi) Lab Personnel Participate actively in required safety education and training upon hire and routinely thereafter, as required by hospital policy. Maintain knowledge of, comply with, and adhere to all safety policies and procedures to ensure a safe working environment for yourself and others. Use all equipment safely. Exercise prudence in the use of all chemical materials. Consult safety data sheets when necessary and always know the hazards of any chemicals used. Take appropriate precautions with all workplace risks. Use personal protective equipment as prescribed by specific work procedures. 1 The appointment of a Site Safety Coordinators is at the discretion of the Department/Unit Coordinator. For smaller departments, this position may not be necessary. 2 The appointment of a Lab Safety Coordinators is at the discretion of the Department/Unit Coordinator. For smaller departments, this position may not be necessary.
Immediately report all unsafe conditions which you cannot correct yourself to a safety coordinator, supervisor or a member of the Environmental Health & Safety Department. Immediately report any accidents or near accidents including fires and/or personal injury in which you were involved to a supervisor or safety coordinator. File timely, complete and accurate incident reports and enlist the assistance of a supervisor as necessary. Remain prepared to respond to emergencies effectively and according to established protocols. Participate in inspections, safety reviews, and accident analyses, as necessary.