OSHA PROGRAM MANUAL for Medical Facilities About the Author Sheila Dunn, DA, MT (ASCP), holds a doctoral degree in clinical laboratory science from the Catholic University of America in Washington, DC. She has helped thousands of outpatient medical facilities comply with federal regulations such as CLIA and OSHA through her presentations at a nationwide seminar series. She has written more than 150 articles about regulatory issues and healthcare delivery systems and serves as an advisor to numerous companies. 14C HCPro, a division of BLR 75 Sylvan Street, Suite A-101 Danvers, MA 01923 Tel: 800/650-6787 Fax: 800/639-8511 www.hcmarketplace.com 2005 2014 HCPro, a division of BLR. All rights reserved, including right of reproduction. The author(s) and their agent(s) have made every reasonable effort in the preparation of this publication to ensure the accuracy of the information. However, the information in this book is sold without warranty, either expressed or implied. The authors, the editors, their agents, and the publishers will not be liable for any damages caused or alleged to be caused directly, indirectly, incidentally, or consequentially by the information in this publication. This publication cannot and does not provide specific information for a user s exact situation. Users of this publication should exercise their own judgment and, where appropriate, seek the assistance of legal counsel regarding their particular situation.
OSHA Program Manual for Medical Facilities is published by HCPro, a division of BLR. Copyright 2014 HCPro, a division of BLR. All rights reserved. Printed in the United States of America. 5 4 3 2 1 ISBN: 978-1-60146-743-0 No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, a division of BLR, or the Copyright Clearance Center (978-750-8400). Please notify us immediately if you have received an unauthorized copy. HCPro, a division of BLR, provides information resources for the healthcare industry. HCPro, a division of BLR, is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Sheila Dunn, DA, MT (ASCP), Author Jay Kumar, Senior Managing Editor Marge McFarlane, PhD, CHSP, CHFM, HEM, MEP, CHEP, Reviewer Mike Mirabello, Senior Graphic Artist Matt Sharpe, Senior Manager of Production Elizabeth Petersen, Vice President Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions. Arrangements can be made for quantity discounts. For more information, contact: HCPro, a division of BLR 75 Sylvan Street, Suite A-101 Danvers, MA 01923 Telephone: 800-650-6787 or 781-639-1872 Fax: 800-639-8511 E-mail: customerservice@hcpro.com Visit HCPro online at: www.hcpro.com and www.hcmarketplace.com 3/14 22065
Important Information About the Use of This Program This product is intended for use in one facility and is copyrighted for this purpose. Please do not copy the contents or print additional copies for use in other facilities or for teaching anyone other than your em ployees. This manual may not be transferred to another workplace without the written consent of HCPro, Inc. As an OSHA Program Manual owner, you may call or e-mail us anytime you have OSHA-related ques tions specific to your practice. HCPro also publishes a monthly newsletter, Medical Environment Update, to help you keep your OSHA Program Manual current from year to year. Should OSHA pass a revised or new regula tion, we will inform you of that change through Medical Environment Update. We will also provide forms, in structions, posters, and advice through this newsletter to help you keep your practice up to date and in compliance. Follow these steps to determine if your manual is up to date: 1. Check for the three-character code in the lower right-hand corner of the box on the title page of this manual. 2. Then log into your HCPro account on your Medical Environment Update subscription page at www.hcpro.com/login-3265. If you have not established a username/password or have forgotten it, you may retrieve it by clicking the link on this page. 3. Once logged in to the Medical Environment Update subscription page, find the most recent issue. 4. There you will find an update file. If the file has the same code as on the title page, your manual is up to date. 5. If the update code is different, open the file and choose from the appropriate pdf to download for your manual (medical or dental).you also have the choice of printing your update pages one-sided or twosided, depending on your printing capabilities. 6. Print the updated pages and replace the old pages. Should you have difficulty logging in or accessing the updated pages, contact HCPro customer service: Telephone: 800/650-6787 E-mail: customerservice@hcpro.com Thank you for your business. Let us know how we can help. HCPro, a division of BLR 75 Sylvan Street, Suite A-101 Danvers, MA 01923 Telephone: 800/650-6787 Fax: 800/639-8511 www.hcmarketplace.com i
How to Customize this Program To come into complete OSHA compliance, the information in this program must be customized to reflect the actual circumstances in your workplace. For easy tracking, initial and date when you complete an item. Item Initials Date Post the It s The Law poster in a place that is visible to all employees. This poster, OSHA #3165, is located in the front pocket of this manual. Hang the eyewash station sign located in the front pocket of this manual. Make sure it is clearly visible above or next to the eyewash. Designate the evacuation route, and post in several locations. Be sure to post the route in the reception area and break room. See Tab 3, page 3-18, 3-18A for details. Read each tabbed section and verify that the policies and procedures described apply to your practice. Remove or strike through any procedure you don t perform! ii
Item Initials Date Either cross through the unused procedures, and initial and date your deletion. OR Remove the pages from the manual. Throughout, fill in all blanks with information specific to your facility. A master listing of blanks is on pages iv v. Spaces to initial and date are provided on the master listing. Use the Monthly and Annual Checklists to organize your OSHA activities. Document all activities performed. See Tab 11 for master copies of all forms. Make photocopies of forms and logs that are used repeatedly. To customize any form, see the enclosed CD. Keep this manual up to date! Download updates and insert them into this manual immediately upon receipt of the current issue of Medical Environment Update Newsletter, which explains how to access the update Web page. iii
Master List of Program Items for Customization Throughout this OSHA Program Manual, blanks are included for you to fill in information specific to your facility.! The following pages contain blanks for you to customize. Enter your initials and the date you made the entry in the far right columns. This way when you do your annual review you can quickly tell if you need to update old information. Page Item Information Needed Initials Date 2-2 Facility Details Facility Name, Safety Officer Name, Phone Numbers, Safety Manual Location 2-7 Workplace Hazards Record other hazards found in facility 2-14 Annual Review Safety officers review of plan 3-2 Emergency Phone List Local contact phone numbers 3-17 Systems Failure Contact names and numbers 3-18 3-19 Evacuation Procedures How alarms and announcements will be made, employee duties in emergency, assembly location 3-20 Evacuation Route Evacuation route 3-22 Emergency Preparedness Supplies Items that will be kept on hand for emergencies 3-25 Civil Disturbance Assembly location 3-26 Severe Weather Safest location in building (Note: 3 blanks) 3-27 3-30 3-37 Workplace Violence Details of your Violence Prevention Plan (Note: 6 blanks and 2 lists that require checkmarks) 3-41 3-42 Crash Kit/Cart Components Items included in facility s crash kit/cart 3-43 3-47 Drug-Free Workplace Program Details of your Drug-Free Workplace Program (Note: if no options selected on 3-43, other customizations not necessary) Procedures performed in facility that could expose employees 5-11 Exposure Prone Procedures 5-12 BBP Determination List Employees who have definite risk of exposure (class I) 5-14 BBP Determination List Employees who have possible risk of exposure (class II) 5-15 Restricted Access Areas Restricted areas not listed in items 1-3 5-17 Handwashing Locations Locations handwashing takes place iv
Page Item Information Needed Initials Date 5-21 Sharps Recapping Instances when recapping is allowed 5-22 Safety Sharps Instances when safety sharps are not used 5-24 Laundry How biohazardous laundry is cleaned, or if only disposables are used 5-26 PPE Locations PPE provided in facility and its locations 5-31 When to Wear PPE If tasks not already listed are performed in facility, add to table 5-33 Hepatitis Vaccinations The provider and location for HBV vaccine 5-43 BBP Post -exposure Testing Who does medical evaluation and lab testing in case of an employee exposure 6-5 TB Risk Assessment Previous year data on TB from health department and facility 6-7 Early TB Identification Procedures to ID active TB patients and where they are referred for treatment 6-9 Managing TB Patients Where suspected TB patients will wait and where they will be transferred to 6-10 N-95 Masks Will the facility provide N-95 masks or not 6-15 TST Record Each employee s TST details 6-18 Employee TB Infections Where employees with positive TST or symptoms of TB will be referred 6-19 TB Exposure Log Only fill in if employee is exposed to TB 6-21 Pre-pandemic Influenza Individual to be response coordinator, local Planning key agencies, and contact information 6-22 Pre-pandemic Influenza Communication plan, name of PR, and Planning (con t) educational coordinators 6-23 Influenza Staff Shortage Number of staff needed and who will cover 6-24 Influenza Reporting Frequency of reporting, who will review reports 7-11 Chemical Exposure Facility name and phone for exposure medical follow-up 8-2 Bleach Contact Time If you use bleach for decontamination, check and document state specific contact time 8-3 Housekeeping Your cleaning methods and frequency Schedule 8-18 Eyewash Stations Location and types of eyewashes 8-19 Biohazardous Waste Company name and phone number of who picks up your biohazardous waste 10-8 10-9 New Employee Orientation Copy master from Tab 11, or CD-ROM, and use for new hires 10-18 Annual Employee Training Record Copy master from Tab 11, or CD-ROM, and use to document annual retraining v
What Is Included in this Program Contents at a Glance Occupational Safety and Health Administration (OSHA) regulations protect employees from unsafe working conditions. This includes on-the-job exposure to infectious diseases, such as HIV, hepatitis and tuberculosis, and hazardous substances such as glutaraldehyde. This OSHA Program Manual is intended to help outpatient medical facilities develop their particular policies and procedures in order to achieve compliance with the major federal OSHA regulations that impact medical practices. Here s what you ll find inside: TAB 1: What Is OSHA? This first section provides a quick look at OSHA, including what types of people and workplaces are protected under the agency s jurisdiction, and what to expect from an OSHA inspection. TAB 2: OSHA Program Administration Tab 2 introduces medical facilities to administration of an OSHA Program Manual, including appointing an OSHA Safety Officer, establishing the duties and authority of the OSHA Safety Officer, and organizing compliance duties. TAB 3: General Facility Safety This section provides an overview of the general workplace requirements applicable to ambulatory medical facilities, including fire safety, electrical safety, exits and building evacuation, workplace violence, and an emergency action plan. TAB 4: Ergonomics in the Medical Workplace Find out how to protect employees from repetitive motion disorders in the workplace in this section. Though OSHA s Ergonomics Standard was rescinded, Tab 4 provides commonsense measures to prevent the musculoskeletal disorders most frequently found in healthcare employees. TAB 5: Bloodborne Pathogens Exposure Control Plan Behind Tab 5 is a fill-in-the-blanks Exposure Control Plan for compliance with OSHA s Bloodborne Pathogens Standard (29 CFR 1910.1030). Once customized, this becomes your facility s policies to protect healthcare employees from occupationally acquired exposure to certain infectious organisms such as the human immunodeficiency virus (HIV) and hepatitis viruses (especially hepatitis B and C). The Bloodborne Pathogens Standard has been in effect since 1992, and was amended January 18, 2001 to include the requirement for sharps with built-in safety features. vi
TAB 6: TB/Infection Control Tab 6 contains a fill-in-the-blanks TB Exposure Control Plan to protect employees from occupational exposure to Mycobacterium tuberculosis. It also contains measures to protect employees from respiratory infections, such as influenza, and a Pandemic Flu Plan. TAB 7: Hazardous Chemical Safety Everything you need to know to comply with OSHA s Hazard Communication Standard (29 CFR 1910.1200) is in this section. This Standard (also called the Right To Know ) has been in effect since 1987 for all medical facilities, and is designed to protect employees from on-the-job exposure to hazardous chemicals. TAB 8: Decontamination Tab 8 covers all aspects of decontamination in a medical practice, including chemical and biological spills and waste, and routine disinfection and sterilization of medical instruments. TAB 9: Specialty Services This section includes safety considerations for specialty services such as x-rays, laser and other ambulatory surgery, compressed gas handling, laboratory testing, and administration of chemotherapy. This section may or may not be applicable to your practice. Please disregard information on any services that are not performed in your facility. TAB 10: Employee Training Tab 10 describes the types and amount of employee training necessary for medical employees. TAB 11: Master Record Forms This section contains master copies of Record Forms that will be needed repeatedly, from Equipment and Facility Records, to Bloodborne Pathogens, TB and HazCom Records, to Employee Training Records. Be sure to photocopy the original form before removing it from this section. These forms are also included on the CD-ROM in the front pocket of this OSHA Program Manual. TAB 12: OSHA Regulations & Key Contacts Tab 12 contains copies of actual OSHA regulations pertinent to ambulatory medical facilities and key contacts for selected Federal agencies. OSHA Regulations that Are Not Included in this Safety Program The following OSHA Standards are not addressed in this manual, since they do not apply to the activities in typical ambulatory medical facilities: Chemical Hygiene Standard (*29 CFR 1910.1450). Laboratories within medical facilities that use hazardous chemicals in bulk amounts must comply with this regulation. vii
Formaldehyde Standard (*29 CFR 1910.1048). Medical facilities that work with bulk quantities of formaldehyde (pouring it into specimen containers and/or processing specimens contained in formalin) may be required to comply with this regulation. Hazardous Waste Operations and Emergency Response (HAZWOPER) (29 CFR 1910.120), applies to workplaces that store, treat and dispose of large volumes of hazardous waste, or respond to emergencies caused by the uncontrolled release of infectious material. viii
OSHA PROGRAM MANUAL Contents Front Pocket OSHA Poster 3165: IT S THE LAW! Laminated Eyewash Station Sign 4 Sample Biohazard Self-Adhesive Labels CD-ROM (MS Word for Windows 2000) with Master Record Forms (Tab 11) from this Manual for Customization. Introduction Page Important Information About the Use of This Program... i How to Customize This Program... ii What Is Included in This Program... vi TAB 1: What Is OSHA? A Quick Look at OSHA... 1-1 States with OSHA-Approved Plans... 1-1 OSHA Consultative Services Division... 1-2 OSHA s Jurisdiction... 1-2 OSHA s General Duty Clause... 1-2 Employee or Employer?... 1-3 Employers Responsibility Under OSHA... 1-4 Overview of OSHA Standards... 1-5 OSHA Inspections... 1-5 Employee Complaints... 1-6 If an On-site OSHA Inspection Occurs... 1-6 During the Inspection... 1-7 What OSHA Inspectors May Ask Employees... 1-8 The Typical OSHA Inspection... 1-8 The Closing Conference... 1-9 OSHA Sanctions... 1-10 Whistleblower Protection... 1-12 Students and Volunteers... 1-14 ix
Contents TAB 2: OSHA Program Administration Injury and Illness Prevention Plan Flowchart... Reverse Side of TOC Injury and Illness Prevention Plan... 2-1 Management Leadership and Employee Involvement... 2-1 Key Contacts for the OSHA Program Manual... 2-1 Location of the OSHA Manual Program... 2-2 Duties of the OSHA Safety Officer... 2-2 Accident/Incident Investigation & Reporting Procedure... 2-4 Definition of an Accident and/or Incident... 2-4 When to Investigate an Accident and/or Incident... 2-4 How to Document an Accident and/or Incident... 2-4 Recording Accidents or Injuries for OSHA... 2-4 Correcting Unsafe or At-Risk Conditions... 2-5 Recordkeeping Requirements... 2-5 Workplace Hazard Analysis... 2-7 Practical Ideas for Involving Employees... 2-8 Organizing OSHA Compliance Duties... 2-9 Weekly Facility Review Checklist... 2-10 Monthly Facility Review Checklist... 2-11 Annual Facility Review Checklist... 2-12 Annual OSHA Safety Program Review... 2-15 TAB 3: General Facility Safety Keeping Employees Safe... 3-1 Important Phone Numbers & Contacts...3-1 Emergency Phone List... 3-2 Fire Safety... 3-3 Automatic Sprinkler Systems... 3-3 Fire Alarms... 3-3 Fire Procedures: Immediate Actions... 3-3 Building Evacuation... 3-4 Fire Extinguishers... 3-4 Purchase the Right Extinguisher... 3-5 How Many Fire Extinguishers to Have & Where to Put Them... 3-6 To Use a Fire Extinguisher: Think PASS... 3-7 When to Extinguish Fires with a Portable Fire Extinguisher... 3-7 When NOT to Extinguish Fires and to Evacuate... 3-7 Fire Extinguisher Inspections... 3-7 Fire Extinguisher Maintenance... 3-8 Fire Risks During Surgery... 3-8 Fire Extinguisher Supplement... Supplement Fire Drills... 3-9 Electrical Safety... 3-9 x
Contents Physical Characteristics of a Safe Medical Facility... 3-10 Automated External Defibrillators... 3-10 Air Quality... 3-10 Mold... 3-11 Mold Remediation... 3-12 Aisles... 3-13 Emergency Lighting... 3-14 Employee Dress Code... 3-14 Exits, Means of Egress... 3-14 Exit Doors... 3-15 Exit Signs... 3-15 Floors... 3-16 Lighting... 3-16 Noise... 3-16 Portable Space Heaters... 3-17 Restricted Access Areas... 3-17 Sinks... 3-17 Storage... 3-17 Systems Failure... 3-18 Evacuation Plan... 3-18 Evacuation Procedures... 3-19 Methods for Carrying Patients During an Evacuation... 3-20 Evacuation Floor Plan... 3-21 Example Evacuation Floor Plan... 3-22 Emergency Preparedness Supplies... 3-23 Emergency Action Procedures... 3-23 Bioterrorism: Suspicious Letters or Packages... 3-24 What Is a Suspicious Package?... 3-24 Bomb Threat... 3-25 If You Discover a Bomb or a Suspicious Item... 3-26 Explosion... 3-26 Civil Disturbance... 3-26 Earthquake... 3-27 If a Tremor Occurs when You Are Inside... 3-27 After the Tremor Is Over... 3-27 Severe Weather... 3-28 Flood... 3-28 Hurricane... 3-28 Severe Thunderstorm or Tornado Warning... 3-28 Tornado Safety Tips... 3-29 Severe Thunderstorm or Tornado Watch... 3-29 Toxic External Atmosphere... 3-29 Violence... 3-30 Violence Prevention Plan Introduction... 3-30 Overview of Violence Prevention Plan Components... 3-31 Violence Prevention Plan; Part 1... 3-31 Violence Prevention Plan; Part 2... 3-38 More Sources for Prevention of Workplace Violence... 3-39 xi
Contents First Aid... 3-40 Crash Kit/Cart Components... 3-43 Drug-Free Workplace Program... 3-43 Service Animals... 3-48 Holiday Decorations... 3-50 Sample Checklist: Spot Check Your Facility s Holiday Decorations...3-50 Safe Decorations and Displays Policy... 3-52 Slip, Trip, and Fall Prevention... 3-54 Contaminants on the Floor...3-54 Poor Drainage: Pipes and Drains...3-54 Indoor Walking Surface Irregularities...3-54 Outdoor Walking Surface Irregularities...3-55 Weather Conditions: Ice and Snow...3-55 Inadequate Lighting...3-55 Stairs and Handrails...3-55 Stepstools and Ladders...3-56 Tripping Hazards: Clutter, Including Loose Cords, Hoses, Wires, Medical Tubing...3-56 Improper Use of Floor Mats and Runners...3-56 Healthcare Facility Slip, Trip, and Fall Hazard Checklist...3-57 TAB 4: Ergonomics in the Medical Workplace A Quick Look at Ergonomics... 4-1 Common Musculoskeletal Disorders... 4-2 Back Injuries...4-3 Techniques to Reduce Injury...4-4 Fatigue...4-5 Repetitive Stress Injuries/Wrist Injuries...4-6 Wrist and Hand Exercises...4-6 Eye Strain...4-8 Why Prevent CVS?...4-8 Symptoms of CVS...4-8 Other Suggestions for Relieving Eye Strain...4-9 Selecting Equipment... 4-10 TAB 5: Bloodborne Pathogens Exposure Control Plan Exposure Control Plan Introduction... 5-1 Overview of Bloodborne Pathogens Standard Components... 5-2 A Quick Look at Occupational Exposure... 5-3 Industries Subject to the Bloodborne Pathogens Standard... 5-3 Universal/Standard Precautions... 5-4 Other Potentially Infectious Materials (OPIM)... 5-4 Implementing Universal/Standard Precautions... 5-5 xii
Contents Bloodborne Pathogens... 5-6 Epidemiology of Bloodborne Pathogens of Concern to Healthcare Workers... 5-6 Update on AIDS in the Workplace... 5-9 Transmission of Bloodborne Pathogens... 5-9 Exposure Determination... 5-9 Personnel Who Are Occupationally Exposed... 5-9 Exposure Prone Procedures... 5-10 Bloodborne Pathogens Exposure Determination List #1 (Form 8)... 5-12 Other Personnel Who Could Potentially Be Occupationally Exposed... 5-12 Bloodborne Pathogens Exposure Determination List #2 (Form 9)... 5-13 Employees Who Are Not Occupationally Exposed... 5-14 Restricted Access Areas... 5-14 Engineering/Work Practice Controls... 5-14 Biohazard Labels... 5-15 Handwashing... 5-15 When to Wash Hands... 5-17 How to Wash Hands... 5-17 Artificial Nails... 5-17 Sharps Safety... 5-18 What to Look for in Safety Devices... 5-18 Sharps Evaluation Procedure... 5-19 Use of Non-Safe Sharps... 5-20 Phlebotomy Needles... 5-21 Sharps Containers... 5-21 Sharps Container Maintenance... 5-22 Sharps Container Disposal Procedure... 5-22 Biohazardous Waste (See Tab 8)... 5-23 Laundry... 5-23 Personal Protective Clothing & Equipment... 5-24 PPE Strategy... 5-24 Locations of PPE... 5-25 Gloves... 5-26 When to Wear Gloves... 5-26 How to Wear Gloves... 5-26 Latex Allergy... 5-27 Preventing Allergic Reactions... 5-28 Face Protection... 5-29 Body Protection... 5-29 Emergency Resuscitation Equipment... 5-30 When to Wear PPE... 5-30 Hepatitis B Vaccine... 5-31 Safety of the Hepatitis B Vaccine... 5-32 Documenting Employee Hepatitis Vaccines... 5-32 Titering Employees after the Hepatitis B Vaccination... 5-33 How to Determine Employee Immunity... 5-33 Testing Employees Vaccinated before the Titer Requirement... 5-34 xiii
Contents Types of Hepatitis B Tests... 5-34 Interpreting Hepatitis B Test Results... 5-35 New Employee Hepatitis B Virus Vaccination Flow Chart... Supplement Post-exposure Evaluation & Follow-up... 5-37 What Is an Exposure?... 5-37 What to Do after an Occupational Exposure... 5-37 For HCV Exposures... 5-39 For HBV Exposures... 5-39 For HIV Exposures... 5-40 When to Get Expert Consultation for HIV Post-exposure Prophylaxis... 5-41 Confidentiality of Post-exposure Procedures... 5-41 Employee Counseling/Precautions... 5-42 Occupational Exposure Management Resources... 5-42 Incident Report/Sharps Injury (Form 14)... 5-43 Post-exposure Checklist... 5-45 Post-exposure Medical Evaluation Declination Form (Form 18)... 5-46 Injection Safety... 5-47 Information for Providers... 5-47 Frequently Asked Questions: Injection Safety FAQs for Providers... 5-48 Overview... 5-48 Injection Procedures... 5-50 Infection Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens... Supplement Infection Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens (fingerstick, blood glucose sampling)... Supplement Bloodborne Pathogens Resources... 5-53 TAB 6: TB/Infection Control Plan A Quick Look at TB... 6-1 TB Transmission... 6-1 Risk Factors for Developing Active TB... 6-2 TB Exposure Control Plan Policy... 6-3 Overview: How to Protect Staff from Contracting TB at Work... 6-3 TB Risk Assessment... 6-4 TB Risk Assessment Results Form (Form 21)... 6-5 Early Identification of Patients with Active TB... 6-6 Symptoms of TB... 6-6 Managing Patients with Suspected or Confirmed TB... 6-9 TB Isolation Procedures for Cough-Inducing & Aerosol-Generating Procedures... 6-9 Respiratory Protection for Healthcare Workers: N-95 Respirators... 6-10 Seal Checking N-95 Respirators... 6-10 xiv
Contents Employee TB Skin Testing (TST)... 6-10 Baseline Employee TST: The Two-Step Skin Test... 6-11 Two-Step TST Interpretation... 6-12 Interpreting the TST... 6-12 False Positive/False Negative TB Tests... 6-12 Workers Who Have Had BCG Vaccination... 6-13 Periodic Retesting of Employees... 6-13 Recording TST Results... 6-14 TST Record (Form 22)... 6-15 TST Declination (Form 23)... 6-16 Evaluation & Management of Healthcare Employees Exposed to TB... 6-17 Employees with Symptoms of TB... 6-17 Employees Who Have Been Exposed to a Known TB Patient... 6-17 Positive Employee Skin Tests & Skin Test Conversions... 6-17 TB Exposure Log (Form 24)... 6-19 Decontaminating Patient Care Area and Equipment... 6-20 Employee Training... 6-20 Pandemic Influenza Plan... 6-21 Pre-pandemic Influenza Planning... 6-21 Once a Pandemic Is Announced... 6-24 OSHA Enforcement for H1N1 Influenza... 6-26 Identifying Very High and High Exposure Risks... 6-26 Dealing with N95 Respirator Shortages... 6-27 Prioritize Your Facility s Use of N95 Respirators... 6-27 Documentation... 6-28 Pandemic Influenza Resources... 6-29 MRSA Prevention and Control... 6-29 MRSA Transmission... 6-30 Patient Precautions... 6-30 Hand Hygiene... 6-31 Contact Precautions... 6-31 Environmental Cleaning... 6-32 Infected Employees... 6-33 MRSA Resources... 6-33 Pertussis and Worker Vaccination... 6-34 Supplement: Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care... S1-S10 TAB 7: The Hazard Communication Standard A Quick Look at HazCom... 7-1 Determining Which Chemicals Are Hazardous... 7-1 Routes of Exposure to Hazardous Substances... 7-2 Material Safety Data Sheets/Safety Data Sheets... 7-3 Examples of Substances Requiring MSDS (SDS)... 7-3 Substances Not Requiring MSDS (SDS)... 7-3 MSDS (SDS) Flowchart Determination... 7-4 xv
Contents Information Required on MSDS (SDS)... 7-4 How to Get MSDS (SDS)... 7-5 Where to Keep MSDS (SDS)... 7-5 Classification of Hazardous Substances... 7-6 Flammable & Combustible Liquids... 7-6 Storage of Hazardous Substances... 7-7 Hazardous Chemicals with Permissible Exposure Limits (PEL)... 7-8 Labeling Hazardous Substances... 7-8 HazCom Pictograms and Hazard Statements... 7-8 Pictograms... 7-9 NFPA Label System... 7-10 Safety Tips for Working with Hazardous Substances... 7-10 Hazardous Chemical Waste Packaging & Disposal... 7-11 Medications Security & Disposal... 7-12 Security for Prescription Drugs... 7-12 Security for Controlled Substances... 7-12 Disposal of Prescription Drugs... 7-13 Disposal of Hazardous Drugs... 7-13 Medical Consultation & Injury Evaluation... 7-13 HazCom Recordkeeping... 7-14 TAB 8: Decontamination A Quick Look at Decontamination... 8-1 Routine Housekeeping Procedures... 8-1 Decontaminating Work Surfaces... 8-1 Sample Housekeeping Schedule (Form 7)... 8-3 Spill Containment Plan... 8-4 Spill Clean-up Procedures... 8-4 Spills That Contain Broken Glass or Sharp Objects... 8-5 Chemical Spill Clean-up Procedures... 8-5 Chemical Exposure to Skin... 8-5 Mercury Spills... 8-6 Cytotoxic Drug Spill Clean-up... 8-6 Decontamination of Medical Instruments & Equipment... 8-7 When to Sterilize... 8-7 Precleaning Instruments Prior to High-Level Disinfection or Sterilization... 8-8 Sterilization... 8-9 Quality Checks for Sterilization... 8-9 High-Level Disinfecting... 8-10 Using Glutaraldehyde... 8-11 Sterilant Safety... Supplement Glutaraldehyde Spills... 8-13 Sources for Chemical Air Monitoring... 8-14 xvi
Contents Testing the Potency of Glutaraldehyde... 8-14 Disposing of Glutaraldehyde... 8-14 Cleaning Transvaginal and Transrectal Ultrasound Probes... 8-14 Disinfect Transvaginal and Transrectal Probes After Each Use... 8-15 Cleaning Ultrasound Transducers... 8-15 Decontaminating Vaginal Specula... 8-15 Keeping Employees Safe During Instrument Disinfection... 8-16 Decontaminating Semi-critical Patient Care Equipment... 8-16 Decontaminating Non-critical Patient Care Equipment... 8-17 Decontaminating Personal Protective Equipment (PPE)... 8-18 Eyewashes... 8-18 Number & Placement of Eyewash Stations... 8-18 Eyewash Maintenance... 8-19 Waste Disposal... 8-20 Biomedical Waste Disposal... 8-20 Hazardous Waste Disposal... 8-21 Waste Handling & Storage... 8-23 TAB 9: Specialty Services About this Section... 9-1 Working Safely with Cytotoxic Drugs... 9-1 NIOSH Hazardous Drug List for Healthcare... 9-1 Effects of CD Exposure on Health... 9-1 Safe Work Practices... 9-2 Clothing... 9-2 Drug Preparation & Administration... 9-2 Sample List of Drugs that Should be Handled as Hazardous... Supplement Selecting Biological Safety Cabinets (BSC)... 9-3 Cleaning the Drug Preparation Area... 9-4 Caring for Patients Receiving CDs... 9-4 Waste Disposal... 9-4 Spill Clean-up... 9-5 Suggested Spill Kit Components... 9-5 CD Receiving... 9-6 CD Storage... 9-6 CD Transport... 9-6 Employee Training... 9-6 Employee Medical Surveillance... 9-7 Employee Exposure... 9-7 Gas Cylinder Safety... 9-7 Electrosurgical Safety (Laser, LEEPs)... 9-9 Safe Work Practices... 9-10 Surgical Safety... 9-11 General PPE Indications for Surgery... 9-11 Surgical Gowns... 9-11 xvii
Contents Surgical Gloves... 9-12 Face and Eye Protection... 9-12 Headwear... 9-13 Shoe Covers... 9-13 Surgical Drapes... 9-13 Safe Sharp Strategies for the Surgical Setting... 9-13 Scalpels... 9-13 Suture Needles... 9-13 Transferring Sharps Safely... 9-14 How to Use the Neutral Zone (NZ)... 9-14 Tips for Minimally Invasive Surgeries... 9-15 Safety Techniques for Operating on Patients Infected with Known Bloodborne Pathogens... 9-15 Preventing Surgical Fires... 9-15 Laboratory Safety... 9-16 Laboratory Specimen Transport... 9-17 Radiation Safety... 9-18 Regulation of the Medical Use of Nuclear By-products... 9-18 The ALARA Principle... 9-18 Radiation Safety Guidelines for Personnel... 9-19 Radiation Safety Policies for the Facility... 9-19 Ionizing Radiation Exposure Limits... 9-20 Special Precautions for Pregnant Workers... 9-20 Low-level Radioactive Waste Disposal... 9-21 NRC Notification, Reports, and Record... 9-21 NRC Resources and Publications... 9-22 Working Safely with Cryogenic Liquids... 9-23 Precautions for Handling Liquid Nitrogen... 9-23 Storing Liquid Nitrogen... 9-24 Personal Protective Equipment... 9-24 Liquid Nitrogen Disposal... 9-24 Steps to Take if There Is Accidental Exposure... 9-25 First Aid (cryogenic burns)... 9-25 First Aid (anoxia)... 9-25 Safe Vaccine Handling and Storage... 9-26 Waste Anesthetic Gases... 9-28 Where Exposures Occur... 9-29 Preventing Exposures... 9-29 Controls... 9-30 Medical Surveillance... 9-30 Recordkeeping... 9-31 More Information... 9-31 TAB 10: Employee Training A Quick Look at the Employee Training Program... 10-1 Training Format... 10-1 Checklist for an Effective Safety Training Session... 10-2 xviii
Contents Interactive Safety Training Exercises... 10-2 General Safety... 10-3 Fire Safety... 10-3 Bloodborne Pathogens Safety... 10-3 Chemical Safety... 10-3 TB Safety... 10-4 Annual Employee Retraining... 10-5 Bloodborne Pathogens Annual Training Contents... 10-6 Respiratory Protection Annual Training Contents... 10-6 Hazard Communication Annual Training Contents... 10-7 New Employee Orientation... 10-7 New Employee OSHA Orientation Checklist (Form 26)... 10-8 Sample Tests with Answer Keys... 10-10 OSHA Annual Retraining: Sample Essay Test Questions (Form 28)... 10-11 OSHA Annual Retraining: Sample Essay Test Answer Key... 10-12 OSHA Annual Retraining: Sample Multiple Choice Test Questions (Form 29)... 10-13 OSHA Annual Retraining: Sample Multiple Choice Test Answer Key... 10-15 OSHA Annual Retraining: Sample True/False Test Questions (Form 30)... 10-16 OSHA Annual Retraining: Sample True/False Test Answer Key... 10-17 Documenting Employee Training... 10-17 Annual Safety Training Record (Form 27)... 10-18 TAB 11: Master Record Forms General Equipment and Facility Records Safety Report... Form 1 Autoclave Log... Form 2 Eyewash Station Weekly Check Log... Form 2-A Annual OSHA Program (Exposure Control Plan) Review... Form 3 Weekly Facility Review Checklist... Form 4-A Monthly Facility Review Checklist... Form 4-B Annual Facility Review Checklist... Form 5 Fire Drill Evaluation Form... Form 5-A Employee Fire Drill Participation Sign-up Sheet... Form 5-B Risk Assessment for Workplace Violence... Form 6 Housekeeping Schedule... Form 7 Emergency Telephone List... Form 7-A Healthcare Facility Slip, Trip, and Fall Hazard Checklist... Form 7-B Bloodborne Pathogens Records Bloodborne Pathogens Exposure Determination List #1... Form 8 Bloodborne Pathogens Exposure Determination List #2... Form 9 Bloodborne Pathogens PPE Compliance Checklist... Form 9-A Failure to Use PPE... Form 9-A-1 Bloodborne Pathogens Compliance Checklist: ECP, Training, and Records... Form 9-B Safety Needle/Syringe Evaluation... Form 10 Phlebotomy Device Evaluation... Form 11 Generic Safety Device Evaluation... Form 12 Sharps Disposal Container Locations... Form 12-A xix
Contents Sharps Evaluation Results... Form 13 Exposure Prevention Checklist... Form 13-A Bloodborne Pathogens Employee Medical Records Incident Report/Sharps Injury... Form 14 Sharps Injury Log... Form 14-A HBV Vaccination Declination Form... Form 15 HBV Employee Vaccination Form... Form 16 Post-exposure Checklist... Form 17 Post-exposure Medical Evaluation Declination Form... Form 18 Source Patient Testing Consent Form... Form 18-A Hazard Communication Records Hazardous Substances List... Form 19 TB/Infection Control Records TB Risk Assessment Results Form... Form 20 TST Record... Form 21 TST Declination Form... Form 22 TB Exposure Log... Form 23 Influenza Vaccine Log... Form 24 Influenza Vaccine Declination Form (Seasonal and H1N1)... Form 25-A Checklist for Infection Prevention for Outpatient Settings... Form 25-B List of Infection Prevention Contact Persons and Roles/Responsibilities... Form 25-C Training Records New Employee OSHA Orientation Checklist... Form 26 Annual Employee Training Record... Form 27 OSHA Annual Retraining (Sample Essay Test)... Form 28 OSHA Annual Retraining (Sample Multiple Choice Test)... Form 29 OSHA Annual Retraining (Sample True/False Test)... Form 30 Respiratory Protection Training Record... Form 31 Qualitative Respirator Fit Test Report... Form 31-A Checklist for Decreasing Surgical Fire Risks... Form 32 TAB 12: OSHA Regulations & Key Contacts OSHA Regulations Bloodborne Pathogens Standard... 12-1 Amended Bloodborne Pathogens Standard (Sharps Safety)... 12-13 Hazard Communication Standard... 12-14 Exit Routes, Emergency Action Plans, and Fire Prevention Plans... 12-29 Ionizing Radiation... 12-33 Table of Other OSHA Standards for Outpatient Medical Facilities... 12-41 Additional OSHA Resources Healthcare Worker Vaccination Recommendations (Revised 2011)... 12-42 Suggested Work Restrictions for Employees... 12-44 Key Contacts State OSHA Consultative Services Directory... 12-48 Directory of States with Approved OSHA Plans... 12-51 Acronyms used in the OSHA Program Manual... 12-53 xx