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

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

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

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

as an advisor to numerous companies.

10C

©2005–2010. HCPro, Inc. All rights reserved, including right of reproduction. The author(s) and their agent(s) have made every reasonable effort in the preparation of this publication to ensure the accuracy of the information. However, the information in this book is sold without warranty, either expressed or implied. The authors, the editors, their agents, and the publishers will not be liable for any damages caused or alleged to be caused directly, indirectly, incidentally, or consequentially by the information in this publication. This publication cannot and does not provide specific information for a user’s exact situation. Users of this publication should exercise their own judgment and, where appropriate, seek the assistance of legal counsel regarding their particular situation.

HCPro, Inc.P.O. Box 1168

Marblehead, MA 01945Tel: 800/650-6787Fax: 800/639-8511

www.hcmarketplace.com

OSHAPROGRAMMANUALfor Medical Facilities

OSHA Program Manual for Medical Facilities is published by HCPro, Inc.

Copyright © 2010 HCPro, Inc.

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, Inc., or the Copyright Clearance Center (978/750-8400). Please notify us immediately if you have received an unauthorized copy.

HCPro, Inc., provides information resources for the healthcare industry.

HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.

Sheila Dunn, DA, MT (ASCP), AuthorDavid A. LaHoda, Managing EditorOwen MacDonald, Executive EditorEmily Sheahan, Group PublisherMike Mirabello, Senior Graphic ArtistMatt Sharpe, Production SupervisorJean St. Pierre, Director of Operations

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, Inc.P.O. Box 1168Marblehead, MA 01945Telephone: 800/650-6787 or 781/639-1872Fax: 781/639-2982E-mail: customerservice@hcpro.com

Visit HCPro at its World Wide Web sites:www.hcpro.com and www.hcmarketplace.com

02/201021753

i

Important Information About the Use of This Program

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

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

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

this manual.

2. Then log into your HCPro account on your Medical Environment Update subscription page at www.hcpro.com/login-3265. If you have not established a username/password or have forgotten it, you may retrieve 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 chose from the appropriate pdf to download for your manual (medical or dental).You also have the choice of printing your update pages one­sided or two­sided, depending you your printing capabilities.

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

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

E­mail: customerservice@hcpro.com Once again, thank you for your business. Let us know how we can help.

David A. LaHodaManaging Editor

HCPro, Inc.P.O. Box 1168

Marblehead, MA 01945Telephone: 800/650­6787

Fax: 800/639­8511www.hcmarketplace.com

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.

ix

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

How to Customize this Program ................................................................. ii

What is Included in this Program ................................................................ vi

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

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

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

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

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

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

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

Page

Contents

x

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

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

Duties of the OSHA Safety Officer ............................................................... 2-2Accident/Incident Investigation & Reporting Procedure ........................... 2-3

Definition of an Accident and/or Incident ..............................................................................2-4When to Investigate an Accident or Incident ........................................................................2-4How to Document an Accident/Incident................................................................................2-4Correcting Unsafe Conditions ..............................................................................................2-4

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

Monthly Facility Review Checklist (Form 4) .........................................................................2-10Annual Facility Review Checklist (Form 5) ...........................................................................2-11Annual OSHA Program Manual (Exposure Control Plan) Review Form (Form 3) ...............2-14

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

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

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

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

Fire Risks During Surgery ....................................................................................................3-8Fire Drills ..............................................................................................................................3-8

Fire extinguisher supplement ...................................................................... Supplement

Contents

xi

Electrical Safety ............................................................................................ 3-9Physical Characteristics of a Safe Medical Facility ................................... 3-9

Automated External Defibrillators .........................................................................................3-9Air Quality .............................................................................................................................3-10

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

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

Systems Failure ............................................................................................. 3-17Evacuation Plan ............................................................................................ 3-17

Evacuation Procedures ........................................................................................................3-18Methods for Carrying Patients During an Evacuation ..................................................3-19

Evacuation Floor Plan ..........................................................................................................3-20Example Evacuation Floor Plan ...........................................................................................3-21

Emergency Preparedness Supplies ............................................................ 3-22Emergency Action Procedures .................................................................... 3-22

Bioterrorism: Suspicious Letters or Packages ......................................................................3-23What is a “Suspicious Package”? ................................................................................3-23

Bomb Threat .........................................................................................................................3-24If You Discover a Bomb or a Suspicious Item ..............................................................3-24Explosion ......................................................................................................................3-24

Civil Disturbance ..................................................................................................................3-25Earthquake ...........................................................................................................................3-25

If a Tremor Occurs when You Are Inside ......................................................................3-26After the Tremor Is Over ...............................................................................................3-26

Severe Weather ...................................................................................................................3-26Flood ............................................................................................................................3-26Hurricane ......................................................................................................................3-27Severe Thunderstorm or Tornado Warning ..................................................................3-27Tornado Safety Tips .....................................................................................................3-27Severe Thunderstorm or Tornado Watch .....................................................................3-28Toxic External Atmosphere ...........................................................................................3-28

Violence ................................................................................................................................3-28

Contents

xii

Violence Prevention Plan Introduction .................................................................................3-28Overview of Violence Prevention Plan Components ............................................................3-28

Violence Prevention Plan; Part 1 .................................................................................3-29Violence Prevention Plan; Part 2 .................................................................................3-36

More Sources for Prevention of Workplace Violence ...........................................................3-37

First Aid .......................................................................................................... 3-38Crash Kit/Cart Components ......................................................................... 3-41Drug-Free Workplace Program .................................................................... 3-43Service Animals ............................................................................................. 3-48Holiday Decorations ..................................................................................... 3-50

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

Safe Decorations and Displays Policy ........................................................ 3-52

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

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

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

Wrist and Hand Exercises ............................................................................................4-6Eye Strain .............................................................................................................................4-7

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

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

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

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

Bloodborne Pathogens ................................................................................. 5-6Epidemiology of Bloodborne Pathogens ..............................................................................5-6Update on AIDS in the Workplace ........................................................................................5-9Transmission of Bloodborne Pathogens ..............................................................................5-10

Contents

xiii

Exposure Determination ............................................................................... 5-10Personnel Who Are Occupationally Exposed .......................................................................5-10

Exposure Prone Procedures ........................................................................................5-11Bloodborne Pathogens Exposure Determination List #1 (Form 8) .......................................5-12Other Personnel Who Could Potentially Be Occupationally Exposed ..................................5-13Bloodborne Pathogens Exposure Determination List #2 (Form 9) .......................................5-14Employees Who Are Not Occupationally Exposed...............................................................5-15

Restricted Access Areas .............................................................................. 5-15Engineering/Work Practice Controls ........................................................... 5-15

Biohazard Labels ..................................................................................................................5-16Handwashing ........................................................................................................................5-16

When to Wash Hands ..................................................................................................5-18How to Wash Hands ....................................................................................................5-18Artificial Nails ................................................................................................................5-18

Sharps Safety .......................................................................................................................5-19What to Look for in Safety Devices ..............................................................................5-19Sharps Evaluation Procedure ......................................................................................5-20Use of Non-Safe Sharps ..............................................................................................5-21Phlebotomy Needles ....................................................................................................5-22

Sharps Containers ................................................................................................................5-22Sharps Container Maintenance ....................................................................................5-23Sharps Container Disposal Procedure .........................................................................5-23

Biohazardous Waste (See Tab 8) .........................................................................................5-24Laundry ................................................................................................................................5-24

Personal Protective Clothing & Equipment ................................................ 5-25PPE Strategy ........................................................................................................................5-25Locations of PPE ..................................................................................................................5-26

Gloves ..........................................................................................................................5-27When to Wear Gloves ..........................................................................................5-27How to Wear Gloves ............................................................................................5-27Latex Allergy ........................................................................................................5-28Preventing Allergic Reactions ..............................................................................5-29

Face Protection ............................................................................................................5-30Body Protection ............................................................................................................5-30Emergency Resuscitation Equipment ..........................................................................5-31

When to Wear PPE ..............................................................................................................5-31

Hepatitis B Vaccine ....................................................................................... 5-32Safety of the Hepatitis B Vaccine .........................................................................................5-33Documenting Employee Hepatitis Vaccines .........................................................................5-33Titering Employees after the Hepatitis B Vaccination ...........................................................5-34

How to Determine Employee Immunity ........................................................................5-34Testing Employees Vaccinated before the Titer Requirement ......................................5-35

Contents

xiv

Types of Hepatitis B Tests ............................................................................ 5-35Interpreting Hepatitis B Test Results ....................................................................................5-36

Post-exposure Evaluation & Follow-up ...................................................... 5-37What Is an Exposure? ..........................................................................................................5-37What to Do after an Occupational Exposure ........................................................................5-37Confidentiality of Post-exposure Procedures .......................................................................5-42Employee Counseling/Precautions .....................................................................................5-43

Occupational Exposure Management Resources ...................................... 5-43Accident Report/Sharps Injury (Form 14) .................................................... 5-44Post-exposure Checklist ............................................................................. 5-46Post-exposure Medical Evaluation Declination Form (Form 18) ............... 5-47Injection Safety .............................................................................................. 5-49

Information for Providers ......................................................................................................5-49

Frequently Asked Questions: Injection Safety FAQs for Providers ......... 5-50Overview ..............................................................................................................................5-50Injection Procedures .............................................................................................................5-52

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

Bloodborne Pathogens Resources ............................................................. 5-55Bloodborne Pathogens Violations in Physician Practices ........................ 5-56

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

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

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

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

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

TB Isolation Procedures for Cough Inducing & Aerosol-Generating Procedures.........6-9Respiratory Protection for Healthcare Workers: N-95 Respirators ..............................6-10

Seal Checking N-95 Respirators ..........................................................................6-10Employee TB Skin Testing (TST) .........................................................................................6-10

Baseline Employee TST: The Two-Step Skin Test .......................................................6-11Two-Step TST Interpretation ................................................................................6-12

Interpreting the TST .....................................................................................................6-12

Contents

xv

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

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

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

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

Pandemic Influenza Plan .............................................................................. 6-21Pre-pandemic Influenza Planning ........................................................................................6-21Once A Pandemic Is Announced ..........................................................................................6-24OSHA Enforcement Procedures for 2009 H1N1 ..................................................................6-26

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

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

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

TAB 7: Hazardous Chemical SafetyA Quick Look at HazCom .............................................................................. 7-1

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

Material Safety Data Sheets ......................................................................... 7-2Examples of Substances Requiring MSDS ..........................................................................7-3Substances Not Requiring MSDS ........................................................................................7-3Information Required on MSDS ...........................................................................................7-3How to Get MSDS ................................................................................................................7-4Where to Keep MSDS ..........................................................................................................7-4

Classification of Hazardous Substances .................................................... 7-4Flammable & Combustible Liquids .......................................................................................7-5

Contents

xvi

Storage of Hazardous Substances .............................................................. 7-5Hazardous Chemicals with Permissible Exposure Limits (PEL) .............. 7-6Labeling Hazardous Substances ................................................................. 7-7

NFPA Label System .............................................................................................................7-7

Safety Tips for Working with Hazardous Substances ............................... 7-8Hazardous Chemical Waste Packaging & Disposal ................................... 7-9Medications Security & Disposal ................................................................. 7-10

Security for Prescription Drugs .............................................................................................7-10Security for Controlled Substances ......................................................................................7-10Disposal of Prescription Drugs .............................................................................................7-10Disposal of Hazardous Drugs ...............................................................................................7-10

Medical Consultation & Injury Evaluation .................................................. 7-11HazCom Recordkeeping ............................................................................... 7-11

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

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

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

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

Using Glutaraldehyde ...................................................................................................8-11Glutaraldehyde Spills ...................................................................................................8-12Sterilant Safety .............................................................................................................SupplementSources for Chemical Air Monitoring ............................................................................8-13Testing the Potency of Glutaraldehyde ........................................................................8-13Disposing of Glutaraldehyde ........................................................................................8-13

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

Decontaminating Vaginal Specula ........................................................................................8-15

Contents

xvii

Keeping Employees Safe During Instrument Disinfection ....................................................8-15Decontaminating Semi-Critical Patient Care Equipment ......................................................8-16Decontaminating Non-Critical Patient Care Equipment .......................................................8-16Decontaminating Personal Protective Equipment (PPE) .....................................................8-17

Eyewashes ..................................................................................................... 8-17Number & Placement of Eyewash Stations..........................................................................8-17Eyewash Maintenance .........................................................................................................8-18

Waste Disposal .............................................................................................. 8-19Biomedical Waste Disposal ..................................................................................................8-19Hazardous Waste Disposal ..................................................................................................8-20Waste Handling & Storage ...................................................................................................8-21

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

Effects of CD Exposure on Health ........................................................................................9-1Safe Work Practices .............................................................................................................9-2Clothing ................................................................................................................................9-2Drug Preparation & Administration .......................................................................................9-2

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

Caring for Patients Receiving CDs .......................................................................................9-4Waste Disposal ....................................................................................................................9-4Spill Clean-up .......................................................................................................................9-4

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

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

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

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

Surgical Gowns ............................................................................................................9-11Surgical Gloves ............................................................................................................9-12Face and Eye Protection ..............................................................................................9-12Headwear .....................................................................................................................9-13Shoe Covers ................................................................................................................9-13Surgical Drapes ............................................................................................................9-13

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

Transferring Sharps Safely ...................................................................................................9-14How to Use the Neutral Zone .......................................................................................9-14

Contents

xviii

Tips for Minimally Invasive Surgeries ...........................................................................9-15Safety Techniques for Operating on Patients Infected with Known Bloodborne Disease .........................................................................................9-15

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

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

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

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

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

Safe Vaccine Handling and Storage ............................................................ 9-26Waste Anesthetic Gases ............................................................................... 9-29

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

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

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

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

General Safety .............................................................................................................10-3Fire Safety ....................................................................................................................10-3Bloodborne Pathogens Safety .....................................................................................10-3Chemical Safety ...........................................................................................................10-3TB Safety .....................................................................................................................10-4

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

Contents

xix

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

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

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

TAB 11: Master Record FormsGeneral Equipment and Facility Records

Safety Report .......................................................................................................................Form 1Autoclave Log .......................................................................................................................Form 2Annual OSHA Program Manual Review ...............................................................................Form 3Monthly Facility Review Checklist ........................................................................................Form 4Annual Facility Review Checklist ..........................................................................................Form 5Fire Drill Evaluation Form .....................................................................................................Form 5-AEmployee Fire Drill Participation Sign-up Sheet ..................................................................Form 5-BRisk Assessment for Workplace Violence ............................................................................Form 6Housekeeping Schedule ......................................................................................................Form 7Emergency Telephone List ...................................................................................................Form 7-A

Bloodborne Pathogens RecordsBloodborne Pathogens Exposure Determination List #1......................................................Form 8Bloodborne Pathogens Exposure Determination List #2......................................................Form 9Bloodborne Pathogens PPE Checklist .................................................................................Form 9-ABloodborne Pathogens Compliance Checklist: ECP, Training, and Records .......................Form 9-BSafety Needle/Syringe Evaluation ........................................................................................Form 10Phlebotomy Device Evaluation.............................................................................................Form 11Generic Safety Device Evaluation ........................................................................................Form 12Sharps Disposal Container Locations ..................................................................................Form 12-ASharps Evaluation Results Form ..........................................................................................Form 13

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

Contents

xx

Hazard Communication Records Hazardous Substances List ..................................................................................................Form 19MSDS Request Letter ..........................................................................................................Form 20

TB/Infection Control Records TB Risk Assessment Results Form ......................................................................................Form 21TST Record ..........................................................................................................................Form 22TST Declination Form ..........................................................................................................Form 23TB Exposure Log ..................................................................................................................Form 24Influenza Vaccine Log ..........................................................................................................Form 25Influenza Vaccine Declination Form .....................................................................................Form 25-ADeclination of H1N1 Influenza Vaccination ..........................................................................Form 25-B

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

TAB 12: OSHA Regulations & Key ContactsOSHA Regulations

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

Additional OSHA ResourcesHealthcare Worker Vaccination Recommendations .............................................................12-42Suggested Work Restrictions for Employees .......................................................................12-44

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

TAB 9: SPECIALTY SERVICES

Contents

About This Section ........................................................................................... 9-1Working Safely with Cytotoxic Drugs ............................................................ 9-1

Effects of CD Exposure on Health ..........................................................................................9-1Safe Work Practices ...............................................................................................................9-2Clothing ...................................................................................................................................9-2Drug Preparation & Administration .........................................................................................9-2

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

Caring for Patients Receiving CDs .........................................................................................9-4Waste Disposal .......................................................................................................................9-4Spill Clean-up .........................................................................................................................9-4

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

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

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

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

Surgical Gowns ...............................................................................................................9-11Surgical Gloves ...............................................................................................................9-12Face and Eye Protection .................................................................................................9-12Headwear ........................................................................................................................9-13Shoe Covers ...................................................................................................................9-13Surgical Drapes ..............................................................................................................9-13

Page

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

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

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

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

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

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

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

Safe Vaccine Handling and Storage ............................................................... 9-26Waste Anesthetic Gases .................................................................................. 9-29

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

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

Contents

9-15

OSHA Program Manual for Medical Facilities

Tips for Minimally Invasive Surgeries

Although surgeries that begin as minimally invasive always have the potential to become an open procedure, there are some precautions to take, including the use of the NZ:Pass trocars, needles, and other short sharps through the use of the NZ.Pass long laparoscopic instruments that don’t fit in the NZ (e.g., sharp pointed

scissors) handle first and tip down.Place long-pointed cautery needles, hollow-bore needles, or other long sharps

into sleeve ports, on request, using two hands (preferably one person’s hands), then angle the handle toward the surgeon’s waiting hand.

Use shielded rather than exposed trocars and shielded needle systems wherever possible; blunt trocars may afford additional protection.

Avoid sprayback; use trocar valves to protect anesthesia personnel as well as the surgical team.

Periodically suction cautery smoke and laser plume to protect employees and the patient from toxic gases.

Safety Techniques for Operating on Patients Infected with Known Bloodborne Pathogens

Develop an exposure prevention plan pre-operatively.Limit access to the room to necessary personnel; crowding makes the risk of

exposure higher.Discuss any possible deviation from the usual techniques with the surgical team.Strive to use minimal sharps during the procedure if possible.Use safe sharp management and if scalpels are required, use disposable ones.Use a smoke evacuator with electrocautery as well as laser.Consider covering the neck area for additional protection. This is especially

important for men who shave every day.Focus on safety with every hand motion and think before acting or speaking when

sharps are in use.

Preventing Surgical Fires

There are approximately 100 fires reported annually in the perioperative setting, and that includes traditional ORs as well as other areas “where invasive procedures are performed such as cardiac catheterization labs, endoscopy suites, ambulatory surgery centers, eye centers, and emergency departments,” according to HCPro’s OR Surgical Fire Training Guide. Fires in such settings, whether reported or not, pose significant danger not only to the patient but also surgical team workers, making them both patient safety and occupational safety concerns.

9-16

OSHA Program Manual for Medical Facilities

Surgical fires cannot occur without three elements being present: a heat source, fuel, and an oxidizer.

Electrocautery units, including hand-activated battery cautery units, are the most common heat sources associated with surgical fires. Other heat sources to be aware of include but are not limited to medical lasers, fibro-optic cords, lenses, light sources, and even high-speed drills.

Fuels for surgical fires are also common in the OR. “Virtually everything used in a OR burns or will fuel a fire, from the patient’s own body to the supplies used while performing various surgical procedures,” according to the OR Surgical Fire Training Guide. The list of fuels includes linens and drapes, both paper and plastic, and a host of other supplies used during surgery such as sponges, lap pads, dressings, tapes, and plastic tubing and connectors. Prep solutions, skin degreasers, aerosols, and tinctures also increase fire risks.

Of course, oxygen is the most common surgical setting oxidizer. While ambient room air contains 21% oxygen, most procedures provide the patient with higher concentra-tions through face masks, nasal cannula, or endotrachial tubes, according to the Training Guide.

The Master Record Forms tab of this OSHA Program Manual has a checklist for decreasing surgical fire risks. See Form 32.

ResourcesFor more detailed information on the preventing and suppressing of surgical fires, how to evacuate an OR suite or facility during a fire, communications during the emergency, and training staff members, see these resources:

1. OR Surgical Fire Training Guide, HCPro, Inc.2. OR Surgical Fire Training Video, HCPro, Inc.

Laboratory Safety A laboratory is an area where testing of patient blood or other potentially infectious materials (OPIM) is performed.

Since a laboratory is a high-risk area, take the following safety precautions:Do not allow smoking, eating, drinking, or application of cosmetics in the area

where testing of patient blood or OPIM is performed.Do not use glass capillary tubes. Wear face and body protection (masks, goggles, gowns, and gloves) when

removing the stoppers from vacuum tubes, since this activity often generates

9-17

OSHA Program Manual for Medical Facilities

sprays of infectious material. Alternatively, perform this task behind a plexiglas barrier or use a safety device to prevent splashes from occurring.

Use safety needles to collect blood specimens. Use a new plastic vacuum tube holder for each phlebotomy. Discard the vacuum tube holder and the attached needle (with safety device activated) into the sharps container.

Do not place food or drinks in lab refrigerators.Do not wear sandals or shoes with open toes or heels in the laboratory unless

protective shoe covers are worn.Control hair, beards, neckties, and jewelry to avoid contact with moving

instruments and specimens.Do not pipette by mouth; use mechanical pipettes or bulbs.Do not leave specimens “standing around.” Dispose as soon as possible after

testing.Treat serum-based reagents as possible sources of hepatitis and HIV. This

includes reagents labeled “hepatitis antigen negative,” since hepatitis testing does not detect all levels of hepatitis antigen. Use rubber bulbs or other safety devices when pipetting these serum products.

Do not work in a crowded or messy area. Organize your work area; keep it clean.Never operate a centrifuge without a cover. Recent models are built with this

safety feature included and will not function when open. Fit centrifuges with safety cups. Cover all tubes with caps or parafilm. During centrifugation, if unusual noises are heard, stop and check the load for balance or breakage. Wipe the inside of the centrifuge with 10% bleach or other appropriate disinfectant at the end of each work shift and whenever blood spills occur.

Clean broken glass with mechanical devices such as forceps or spill kits, not hands.

Only properly trained individuals may operate autoclaves. Open the autoclave only when the steam valve is off, the temperature is normal, and the pressure is zero. Loosen caps of containers before autoclaving for procedures such as preparation of sterile distilled water. When autoclaving waste material such as culture plates, use a “double bag” and place the bag in a larger container to avoid spillage into the autoclave chamber.

Laboratory Specimen Transport

Place patient specimens in clean, dry containers with secure lids. Transport specimens in a secondary container that bears the biohazard symbol, such as an impervious plastic bag or a container with a securely locked lid, which prevents leakage during storage and transport.

9-18

OSHA Program Manual for Medical Facilities

Radiation SafetyFacilities performing x-rays must be in compliance with any applicable state regulations. The Nuclear Regulatory Commission (NRC) has primary responsibility for licensing and regulating nuclear materials.

Some states, called agreement states, have contracted with NRC to regulate their own nuclear materials. These states are Alabama, Arizona, Arkansas, California, Colorado, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Mississippi, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Oregon, Rhode Island, South Carolina, Tennessee, Texas, Utah and Wyoming.

OSHA regulates occupational exposure to ionizing and nonionizing radiation [29 C.F.R. § 1910.96 and 29 C.F.R, (see Tab 12: OSHA Regulations and Key Contacts)] from sources such as radiographic systems, radiographic/fluoroscopic systems, and CT scanners. OSHA’s regulation provides that radiation exposure should not exceed permissible exposure limits, that warning signs and labels be posted outside regulated areas and on containers of regulated materials, and that employees working in regulated areas be monitored for exposure levels. Compliance with NRC regulations or the regulations of an agreement state is automatic compliance with OSHA’s ionizing radiation regulation.

Regulation of the Medical Use of Nuclear By-products

NRC requires any facility that uses, produces, transfers, receives, acquires, owns, or possesses nuclear materials to:

1. Obtain a license to operate. 2. Comply with safety regulations-occupational dose limits, record keeping,

notification requirements, the creation of a radiation safety committee and designation of a radiation safety committee and designation of a radiation safety officer, maintenance of records, and submission of reports to NRC if a radiation incident occurs.

3. Properly dispose of radioactive waste. 4. Be subject to NRC inspections and enforcement actions.

The “ALARA” Principle

The main philosophy of a radiation safety program and of much of NRC’s regulations is to keep radiation exposure “As Low As Reasonably Achievable” (ALARA). All authorized users are expected to be committed to keeping exposure limits below the mandated levels.

TAB 10: EMPLOYEE TRAINING

Contents

A Quick Look at the Employee Training Program ......................................... 10-1Training Format ................................................................................................ 10-1

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

General Safety ................................................................................................................10-3Fire Safety .......................................................................................................................10-3Bloodborne Pathogens Safety ........................................................................................10-3Chemical Safety ..............................................................................................................10-3TB Safety ........................................................................................................................10-4

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

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

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

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

Page

10-1

OSHA Program Manual for Medical Facilities

EMPLOYEE TRAINING

A Quick Look at the Employee Training ProgramThe OSHA Safety Officer is responsible for overseeing your facility’s employee training program, which involves yearly retraining as well as new employee orientation. It is suggested, but not required, to conduct a brief, interactive session devoted to a safety issue at every staff meeting. A physician or other qualified medical professional (nurse, medical assistant, laboratory technologist, etc.) may provide the training, as long as he/she is competent in address-ing questions pertaining to OSHA compliance. An infection control background is helpful, especially for bloodborne pathogens and TB training. Training sessions are provided during work hours at no cost to the employee. Material appropriate in content and vocabulary to the educational level, literacy, and language background of employees is used, such as videos or lectures.

Training FormatEducational formats, such as live presentations, interactive or noninteractive computer programs, or videos, may be used to fulfill employee training requirements. However, a qualified person must be available to answer questions during a discussion period specifically for all types of bloodborne pathogens training. A telephone hotline may suffice in fulfilling this requirement, according to January 17, 2008, OSHA interpretation letters; however, voice mail, e-mail, paging systems, or other methods that don’t guarantee an immediate response are not compliant. For more details on the interactive requirement, search for “Clarification on trainer requirements and access to trainer under OSHA’s bloodborne pathogens standard” at www.osha.gov or call the HCPro OSHA consultation line at (800) 650-6787. The training must contain information that none of these formats can accomplish, such as:

Where the OSHA manual and MSDS binder are located in the facilityWhere fire extinguishers, eyewash stations, and exit doors are located in

the facilityWhere personal protective equipment is located in the facility

10-2

OSHA Program Manual for Medical Facilities

Checklist for an Effective Safety Training Session

Safety presentations, as we all know, are not often very entertaining. Employees rarely expect to be amused or involved.

The following eight tips help lead to a more effective presentation:

Plan the event – Set objectives, limit the focus of your talk, and project your belief in the subject matter.

Involve management – The training program will only achieve its objectives if management is committed to employee safety. Have a member of management in attendance to clarify policies.

Be creative – Use audio, visual, role plays and hands-on material to increase employees’ retention of the information. Use techniques that best communicate to your specific employees.

Demonstrate – Use props in cases where it’s more effective to demonstrate the use of an item than explain it.

Keep it moving – The most effective speakers move throughout the room. Create activities, which allow audience participation from the front row to the last.

Use employees as teachers – Let the audience relate the subject matter back to their own real world experiences. Listen to the examples offered and expand on them.

Help employees buy into the process – The best training information is worthless if employees do not see how it will benefit them. Use specific on-site accident examples to show the relevance of the program to their own safety.

Head off opposition – Use off-the-job examples if the group is resistant to someone telling them how to do their work. Off-the-job examples drive the point across in a much less threatening way.

Interactive Safety Training Exercises

A good safety program involves not only management commitment but employee involvement. Employees will retain more information and practice safety procedures if safety training is interesting and interactive. The following suggestions can be included in employees’ annual training or can serve to reinforce management’s commitment to this OSHA Program Manual at staff meetings.

TAB 11: MASTER RECORD FORMS

Contents

General Equipment and Facility Records

Form 1 Safety Report…………………..…................ Use to document employee complaints; staff meeting minutes.

Form 2 Autoclave Log…………………..………........ Use weekly, or as indicated to record performance of biological indicator tests.

Form 3 Annual OSHA Program Manual Review…...Use annually to document that this manual was reviewed and updated.

Form 4 Monthly Facility Review Checklist............... Use monthly (optional form).

Form 5 Annual Facility Review Checklist……......... Use annually.

Form 5-A Fire Drill Evaluation Form…………….......... Use at least once per year.

Form 5-B Employee Fire Drill Participation Sign-Up Sheet …………………………........

Use at least once per year.

Form 6 Risk Assessment for Workplace Violence… Use initially and as needed.

Form 7 Housekeeping Schedule………..……......... Use initially.

Form 7-A Emergency Telephone List……..……......... Use initially and as needed.

Bloodborne Pathogens Records

Form 8 Bloodborne Pathogens Exposure Determination List #1…………………......... Use initially, and whenever new clinical staff is added.

Form 9 Bloodborne Pathogens Exposure Determination List #2………………..…....... Use initially, and whenever new clinical staff is added.

Form 9-A Bloodborne Pathogens PPE Compliance Checklist…………..…….......... Use initially, and whenever new clinical staff is added.

Form 9-B Bloodborne Pathogens Compliance Checklist: ECP, Training and Records……. Use initially, and whenever new clinical staff is added.

Form 10 Safety Needle/Syringe Evaluation............... Use initially, and whenever new safety devices are under consideration.

Form 11 Phlebotomy Device Evaluation…................ Use initially, and whenever new safety devices are under consideration.

Form 12 Generic Safety Device Evaluation……........ Use initially, and whenever new safety devices are under consideration.

Form 12-A Sharps Disposal Container Locations..........Use periodically to monitor compliance for sharps disposal container locations.

Form 13 Sharps Evaluation Results Form.............… Use initially, and whenever new safety devices are under consideration.

Bloodborne Pathogens Employee Medical Records

Form 14 Accident Report/Sharps Injury Log….......... Use when an employee injury occurs, including sharps injuries and other bloodborne pathogens exposures.

Form 15 HBV Vaccination Declination Form……....... Use when an employee is given the hepatitis B vaccine or declines this vaccine.

Form 16 HBV Employee Vaccination Form…….........Use when an employee is given the hepatitis B vaccine or declines this vaccine.

Form 17 Post-exposure Checklist…………….…........Use to document that all required actions were taken after a sharps injury or employee exposure to bloodborne pathogens.

Form 18 Post-exposure Medical Evaluation Declination Form………………….................

Use to document a particular employee refusing post exposure testing and treatment.

Form 18-A Source Patient Testing Consent Form…….. Use to obtain consent from a source patient after an exposure incident such as a needlestick.

Hazard Communication Records

Form 19 Hazardous Substances List…….……......... Use initially to list all hazardous chemicals in your facility and when a new hazardous chemical is introduced.

Form 20 MSDS Request Letter…………..…….......... Use when a new hazardous chemical is intro duced to document attempts to procure a MSDS.

TB / Infection Control Records

Form 21 TB Risk Assessment Results Form…......... Use annually.

Form 22 TST Record……………..………..……......... Use as indicated, based on your facility’s risk assessment.

Form 23 TST Declination Form………….…...…........ Use when an employee declines receiving a TB skin test.

Form 24 TB Exposure Log……………….…...…........ As indicated when employees are exposed to a known TB patient.

Form 25 Influenza Vaccine Log………....………........ Use annually to vaccinate all employees.

Form 25-A Influenza Vaccine Declination Form….......... Use when an employee declines this vaccine.

Form 25-B Declination of H1N1 Influenza Vaccination... Use when an employee declines this vaccine.

Contents

Training Records

Form 26 New Employee OSHA Orientation Checklist…................................

Use to document initial OSHA training when new staff members are added.

Form 27 Annual Employee Training Record….......... Use annually.

Form 28 OSHA Yearly Retraining (Sample Essay Test)…………..………........

Use annually.

Form 29 OSHA Yearly Retraining (Sample Multiple Choice Test)……..…........

Use annually.

Form 30 OSHA Yearly Retraining (Sample True/False Test)….…….…............

Use annually.

Form 31 Respirator Protection Training Record….... Use annually.

Form 32 Checklist for Decreasing Surgical Fire Risks….................................................

Use annually.

Contents

OSHA Program Manual for Medical Facilities

Form 9-B

BLOODBORNE PATHOGENS COMPLIANCE CHECKLIST:

ECP, TRAINING, AND RECORDS Use this checklist to periodically monitor compliance with the exposure control plan and

training and records sections of the Bloodborne Pathogens standard, 1910.1030.

Section Requirements Compliance

Exposure control plan (ECP)(c)(1)(i) This facility has a written ECP for employers with occupational

exposure to blood or other potentially infectious material (OPIM).Yes No

(c)(1)(iii) A copy of the ECP is accessible to all employees. Yes No

(c)(1); (c)(2)(i)(C); (c)(2)(ii)

An exposure determination has been completed for work classifications or individual employees with occupational exposure to blood or OPIM.

Yes No

(c)(1)(ii)(A) The tasks of each employee are closely checked to identify any potential exposure to blood or other infectious products.

Yes No

(c)(1); (c)(2)(ii) Determining whether tasks are subject to occupational exposure is done as if personal protective equipment (PPE) is not used.

Yes No

(c)(1)(ii)(C) The exposure control plan includes the procedure for the evaluation of circumstances surrounding exposure incidents.

Yes No

(c)(1)(iv) The facility reviews and updates the ECP at least annually and whenever necessary to reflect new or modified tasks and procedures that affect occupational exposure, and to reflect new or revised employee positions with occupational exposure.

Yes No

(c)(1)(iv)(A) The exposure control plan reflects changes in technology that eliminate or reduce exposures to bloodborne pathogens and documents annual consideration and implementation of safer medical devices.

Yes No

(c)(1)(v) The input of nonmanagerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls is documented in the exposure control plan.

Yes No

Training and records(g)(2)(i)–(vi) Bloodborne pathogens training is provided: 1) to all exposed

employees, 2) at no cost, 3) during working hours, 4) before exposure may occur, 5) annually, 6) when new procedures are introduced, and 7) with material appropriate to the education, literacy level, and language of employees.

Yes No

Persons who are not employees but who work in this facility (e.g., janitorial and temporary service staff, contract employees, and support service personnel) have been informed of the bloodborne pathogens program and the use of PPE.

Yes No

OSHA Program Manual for Medical Facilities

Form 9-B

Section Requirements ComplianceAll exposed salaried physicians have undergone training in the facility’s bloodborne pathogens program and have been offered hepatitis B virus (HBV) immunization.

Yes No

(g)(2)(vii) The training program contains at a minimum the elements listed in sections (A)-(M).

Yes No

(g)(2)(vii)(N) Training sessions provide an opportunity for questions and discussion between the trainer and the worker.

.Yes No

(g)(2)(viii) The trainer is knowledgeable about the subject matter and relates training content to the workplace in a realistic way.

Yes No

(h)(2)(i)(A-D) Training records include the dates of the training sessions, the contents or a summary of the training session, the names and qualifications of the people conducting the training, and the names and job titles of everyone attending the training sessions.

Yes No

(h)(2)(ii) Training records are maintained for three years from the date of the session.

Yes No

(h)(3)(i)–(iii) Training records and medical records of exposed employees are available in accordance with OSHA regulations.

Yes No

(h)(4)(i)–(ii) A policy is in effect governing the transfer of training and medical records if the business closes.

Yes No

(h)(1)(i) This facility maintains medical records for each employee who has had occupational exposure.

Yes No

(h)(1)(ii)(A–E) Medical records include Social Security numbers and HBV vaccination status, including the dates of all HBV vaccinations and medical records relative to the employee’s ability to receive vaccination.

Yes No

Medical records include a copy of the healthcare professional’s written opinions pertaining to employee exams, medical testing, and follow-up procedures. A copy of the information provided to the healthcare professional by the employer should also be included.

Yes No

(h)(1)(iii) The organization keeps the records and does not disclose them without the employee’s written permission.

Yes No

(h)(1)(iv) The organization maintains medical records for at least the duration of employment plus 30 years.

Yes No

(Bloodborne Pathogens Compliance Checklist, page 2 of 2)

OSHA Program Manual for Medical Facilities

CHECKLIST FOR DECREASING SURGICAL FIRE RISKS

This list provides surgical teams with one way to double-check for surgical fire risks.

Treat any “no” answer as potential increased risk during surgery.

Employee knowledgeDo operating room (OR) staff members understand the fire risks associated with surgery?

Yes No

Do surgical teams know how to extinguish an OR fire? Yes NoDo OR staff members know how to alert facility emergency personnel and the fire department if a fire occurs?

Yes No

Do employees know how to evacuate the OR with the patient if necessary? Yes NoPreparing for surgeryDid the appropriate department inspect the electrosurgical device/surgical laser and associated equipment for proper operation before surgery?

Yes No

Did the appropriate department inspect anesthesia equipment, including tubing, before the surgery?

Yes No

Do staff members allow prepping agents to evaporate before surgery? Yes NoDo surgical teams clean up any pools of prepping agents before surgery? Yes NoAre surgical drapes and the patient’s gown free of pockets that might trap oxygen?

Yes No

Do staff members properly place the oxygen tubes and masks to avoid leaks and the creation of air pockets?

Yes No

Are patient’s hair and facial hair near the surgical site coated with a water-based jelly to prevent burning?

Yes No

Did staff members inform the patient ahead of time not to put oily or greasy cosmetic products in the hair and on the face before surgery?

Yes No

During surgeryDoes the surgeon put the electrosurgical device/surgical laser in its holster or otherwise deactivate it when not in use?

Yes No

Do surgeons use the electrosurgical device/surgical laser at its lowest practical setting?

Yes No

Does the electrosurgical device/surgical laser feature an audible activation sound?

Yes No

Do surgeons avoid supplying 100% oxygen to the patient during the surgery? Yes NoDo surgeons discontinue the use of oxygen before using an electrosurgical device/surgical laser?

Yes No

Is sterile water or saline solution available to put out a fire? Yes NoIs a portable fire extinguisher available in or near the OR? Yes No

Source: September 2003 Healthcare Life Safety Compliance, HCPro, Inc.

Form 32