Ruthanne R. Hyduke, M.A.* and James E. O'Connor, M.S.**
I. Introduction
Scenario: unsafe practices
Regulatory agencies
II. General Safety Guidelines
Hazard warning signs and labels
Safe work practices
Control of air flow
Training and record-keeping
III. Bloodborne Pathogens
Direct contact
Indirect contact
IV. Universal Precautions
Barriers
Other safe practice rules
VI. Communication of Hazards and
the Chemical Hygiene Plan
Introduction
Standard operating procedures
NFPA Hazard Identification (Diamond) System
VII. Personal Protective Equipment
(PPE)
Laboratory coats
Gloves
Dress code
Safety goggles, glasses, masks or full face shields
Vaccinations
Splash guards or shatter proof shields
First aid kits
Spill kits
Eyewash or facewash stations
Safety showers
Hoods and safety cabinets
Surgical masks
VIII. Fire and Electrical Safety
Protection
RACE
Other fire safety precautions
Fire extinguishers
Electrical safety precautions
IX. Ergonomics
Repetitive stress injuries
Lifting
Ruthanne R. Hyduke, M.A.
Ruthanne R. Hyduke, M.A.
Does this situation seem unlikely? When each employee in a facility takes the responsibility of keeping the entire office including the laboratory a safe place to work and every person is trained to follow safe practices as second nature, these incidences can be kept to a minimum. Until then, a situation such as the one above can occur.
This module is designed to remind everyone of the risks associated with working in the clinical laboratory, the precautions to be taken in infection control, and other risk management concepts. Many sets of rules, standards and guidelines dealing with risk management have been developed by federal, state, and local agencies and professional organizations. This module contains links to resources that cover all working laboratories. However, each individual must consult with their employer for any specific rules that govern their facility. The quiz on this module will cover only the content contained in this text. The links are provided as additional resources of information when improving a facilities' risk management program.
The field of health and safety continues to grow in complexity as more is learned about the hazards in our workplace. Today's highly technical clinical laboratory contains many biological fluids, chemicals, electronic instruments, and other sources of potential hazards. Each worker in the laboratory has the responsibility of keeping the laboratory a safe working place and of following the guidelines and safe practices outlined by the management.
Regulatory Agencies:
OSHA, the Occupational Safety and Health Administration, was created
in 1970 to help prevent employee work hazards. Consequently, it then
mandated two programs to assure the safety of clinical laboratory
personnel. The first deals with the occupational exposure to chemical
hazards and became law in 1991. The second deals with occupational
exposure to bloodborne pathogens and became law in 1992. In addition,
the Joint Commission of Accreditation of Healthcare Organizations and
the College of American Pathologists continually revise their
guidelines to provide more consideration for the health and safety of
the laboratory employee.
Today all physician offices and laboratories must have written policies and procedures that are customized for each facility. OSHA states that these policies and procedures must include rules for:
Ruthanne R. Hyduke, M.A.
Hazard warning signs and
labels
Prominant signs and labels must be posted in all laboratory
areas. These signs generally fall into four categories:
In addition, the National Fire Protection Agency (NFPA) requires the posting of the hazardous materials classification charts within the laboratory area. All hazards such as biohazards, radiation hazards, laser light, chemical hazards, explosive or flammable liquids, cryogenic hazards, compressed gas storage, noise hazards, and UV light must be posted with guidelines for handling these hazards available in a procedural manual on site. All employees must be educated on the meanings of these signs and labels.
Safe work practices
The safe work practices policies must include, but are not limited
to, guidelines for all of the following topics.
Hygiene: covers the safe use of chemicals and the use of universal precautions when the employee has the potential of being exposed to blood.
Dress Code: covers the use of personal protective equipment including laboratory clothing, gloves, eye and face protection, and respiratory protection.
Incident Reports: All exposure incidents require that an incident report be filed on employees within 24 hours of an accident and must be kept in the employee's permanent file.
Infection Control: policies must be in place for the protection of all employees including transfer personnel or couriers and those processing the samples. Work surfaces that come in contact with any hazards or have the potential to become contaminated must be cleaned on a daily basis with a disinfectant such as dilute bleach (0.5% sodium hypochlorite). Should accidents occur, all work surfaces must be decontaminated first with a spill kit using the manufacturer's instructions and then with a disinfectant such as the one mentioned above.
Hazard containment/Waste management: Each employer must develop a protocol for the processing of regulated waste material. Separate containers must be used for "dry" and "wet" materials and sharps (needles, scalpel blades). Some institutions require that waste materials be autoclaved before disposal; others dispose of their waste by incineration.
Control of air flow
The air flow within a laboratory environment should be controlled to
contain any hazardous materials. Disruption of the airflow may result
in the production of aerosols and the transmission of airborne
materials into unwanted areas of the facility. If any of the air flow
systems is disrupted for any length of time, employees must stop
working with any hazardous materials, contain the hazards, and leave
the laboratory area.
Training and Record-keeping
It is the responsibility of the employer to provide training for
all new employees on bloodborne pathogens and chemical hygiene
regulations. Many health care agencies also require training in fire
safety. This education may be in the form of videos, discussions, or
demonstrations and should be provided for employees annually.
Employees may be expected to take and pass quizzes covering the
material which can then be kept in the employees permanent file.
James E. O'Connor, M.S.
The organisms that most commonly come to mind when referring to bloodborne pathogens are the Hepatitis B virus (HBV) and the Human Immunodeficiency Virus (HIV). It should be remembered that body fluids and body secretions are also potentially hazardous specimens and the laboratory worker must exercise great caution and good laboratory practices when working with these specimens as well.
Exposure to blood, body fluids, and body secretions can occur by direct contact as well as indirect contact.Direct contact occurs through:
Indirect contact can occur when the outside of containers and specimen vouchers are contaminated with blood, serum, body fluids, etc.
Since the potential for infectivity of patient's blood and body fluids is not routinely known, it is essential that all laboratory workers conform to blood and body fluid precautions on all patients. These "universal precautions" should be followed regardless of any lack of evidence of the patient's infectious Internally Peer Reviewed.James E. O'Connor, M.S.
Barriers
Other safe practice rules:
Other "Universal Precautions" that should be followed in the proper
operation of a clinical laboratory or physician's office laboratory
are:
1. Never pipet by mouth and never blow out pipets that contain infectious material or other liquids.
2. Avoid using syringes whenever possible and dispose needles without recapping, bending, or cutting, in rigid puncture-resistant containers clearly marked as biohazardous.
3. Disinfect and decontaminate all work surfaces and devices where biologic materials are handled at completion of work. Sodium hypochlorite (0.5%) or some other proper disinfectant can be used. All spills should be immediately disinfected with 0.5% sodium hypochlorite. Contact should occur for at least 15 minutes.
4. No warning labels are to be used on patient specimens.
5. Properly dispose of contaminated laboratory supplies (biohazardous waste). All contaminated supplies may be incinerated or autoclaved prior to being discarded.
6. Obtain immediate treatment for accidental and inappropriate contact with biohazards, such as a needle stick. The incident should be reported to the supervisor so that appropriate prophylactic measures can be taken.
7. Strongly encourage frequent hand washing for 15 seconds in the laboratory. Employees must wash hands before leaving the laboratory.
8. All tubes should be inspected for cracks before centrifuging.
9. Employers must provide HBV vaccinations for all employees at no cost to the employee.
James E. O'Connor, M.S.
Tuberculosis is transmitted by inhaling contaminated air containing M. tuberculosis. This organism is passed from person to person by infectious aerosols or droplet nuclei produced by coughing, sneezing, talking, etc. The major symptoms of tuberculosis are a chronic productive cough lasting three weeks or more, fever, chest pain, night sweats, loss of weight, fatigue, anorexia, and hemoptysis (blood in the sputum).
In 95% of patients with tuberculosis, the cell-mediated immune system is able to contain the disease at the initial site of infection in the lungs and this local infection heals without consequence. Therefore, infection has occurred but the disease remains "latent". The patient is not infectious, that is, not able to spread the disease to others. In 5% of TB cases, the disease is "active". These people usually have some or all of the symptoms mentioned above and often have an abnormal chest x-ray as well. Patients with "active" disease are infectious and must be isolated until the disease is controlled.
Most of the time the physician does not know on preliminary examination that his patient may have active tuberculosis until x-rays and PPD skin tests are performed. It is prudent to screen all patients for cough or determine if they have been exposed to relatives or other individuals with tuberculosis. However, if the physician is suspicious that his patient may have active tuberculosis (presents many of the symptoms previously described) or poses a higher index of suspicion, such as an immigrant from SE Asia, an IV drug abuser, a homeless individual or an immunocompromised patient (ex. AIDS patient), then the patient should wear a surgical mask and be placed in a TB isolation room with the door closed to reduce the chances of producing aerosols.
Ideally the TB isolation rooms should have a negative air pressure to direct airflow away from adjoining rooms or hallways. Contaminated air should be exhausted to the outside of the building.
Early morning sputum is the best specimen for culture. The ideal situation is to collect three to five consecutive early morning sputum specimens (at least 10 mL each) by the "deep cough" technique so as to collect drainage from deep down in the lung. Sometimes patients cannot cough up sputum and the inhalation of hot saline vapor is necessary for inducing sputum production.
During coughing and cough inducing procedures, the patient should be kept isolated until coughing subsides. Staff exposed to patients during coughing and specimen collection should wear respiratory protective devices, such as N95 or High-Efficiency Particulate Air (HEPA) respirators.
Once the expectorated or induced sputum is obtained it is placed in a regular sterile sputum cup and sent immediately to the clinical laboratory for processing, cultivation, isolation and identification of mycobacteria utilizing the proper OSHA TB safety regulations.
TB isolation rooms should be kept empty until properly ventilated (1 hour) and then cleaned by routine office procedures.
Ruthanne R. Hyduke, M.A.
NFPA Diamond
OSHA mandated that laboratories must have a chemical hygiene plan developed and in place as of January 31, 1991. This plan provides for the protection and education of all employees in the facility and must include:
1. Glossary of safety terms
2. Standard operating procedures for use of chemicals
3. Material Safety Data Sheets (MSDSs) for all chemicals
4. An inventory of chemicals updated annually
5. Appropriate chemical storage information
6. Chemical labeling requirements
7. A description of environmental monitoring
8. Maintenance of safety devices
9. Availability of required personal protective equipment (PPE) for all employees
10. Waste removal and disposal procedures
11. Housekeeping protocol for working with hazardous chemicals
12. Requirements for employee physicals and consultations
13. Education/training requirements of employees
14. Recordkeeping requirements
15. Appointment of a Safety Officer and Committee
16. Any other information deemed necessary to assure a safe working environment.
Standard operating procedures
Each facility must develop procedures for handling accidents and
chemical spills. In general, if chemicals have come in contact with
the eyes or skin, the areas must be flushed with copious amounts of
water first and then followed with medical attention. The eyewashing
procedure requires a minimum of 15 minutes of washing. Some skin
contact with chemicals may require neutralization as part of the
washing process. For example, acid burns may be neutralized by the
application of a paste of sodium bicarbonate (baking soda) to the
affected area. Thus, sodium bicarbonate should be available as part
of the laboratory first-aid kit.
To help assure protection of the employee, each employer must develop some rules for avoiding unnecessary chemical exposure. These rules might include, but not be limited to the rules that follow:
In the laboratory work area:
1. Smoking, eating, and drinking are prohibited.
2. Do not store any food or drinks in any laboratory refrigerators especially those that store chemicals or biological hazards.
3. Do not apply cosmetics even lip balm.
4. Pull back and secure long hair.
5. Wear only approved clothing.
6. Wear shoes that cover the entire foot and are not made of canvas.
7. Always wear safety glasses when handling chemicals. Do not wear contact lenses. Never manipulate contact lenses.
8. Pipetting by mouth is absolutely prohibited.
9. Keep hands away from hair, mouth, eyes, nose, and face while working in the laboratory.
10. Wash hands thoroughly after handling any chemicals.
11. Wash hands thoroughly before handling non-laboratory equipment and before leaving the laboratory.
12. Dispose of all chipped or cracked glassware because they could break easily and spill chemicals.
13. Rinse all used glassware thoroughly before putting with other glassware to soak.
14. Clean work area thoroughly when the testing is completed.
Some guidelines for the storage of chemicals include:
OSHA guidelines require that chemicals remain in the original containers with the original labels kept intact. When portions of the chemical are removed from the original container, the label on the new container must include the origin of the chemical and all hazards that the chemical might pose. The NFPA requires that all chemicals with a hazard rating of 2 or greater (4 is the rating of greatest hazard) must be labeled with their diamond system. That means that even common chemicals like the diluted bleach used for cleaning require the regulatory labeling.
NFPA hazard identification (diamond) system
This system consists of four small, diamond-shaped symbols grouped into a larger diamond shape. The left diamond is blue and represents the health hazard of the chemical. The top diamond is red and identifies the degree of flamability. The right diamond is yellow and indicates a reactivity-stability hazard. The bottom diamond is white and is used for provision of special hazard information. The degree of hazard of the chemical is rated on a scale of 1 to 4 with 4 indicating the greatest hazard. All chemicals with a rating of 2 or greater in any of the areas must be labeled with this system.
Physician office laboratories that handle cytotoxic drugs are required to have special procedures on handling these agents. Biosafety hoods must be provided, and employees trained and monitored in their use of the hoods. In addition, the hoods themselves must be monitored annually to assure that they are operating correctly and that the minimum air flow across the face of the hood is met.
Formaldehyde and gluteraldehyde, chemicals that are often found in medical facilities are also covered under this standard. Baseline monitoring is usually recommended for documenting potential employee exposure to these chemicals. Radioactive chemicals, which are now used rarely in the clinical laboratory, also require special monitoring and disposal procedures.
In addition to chemicals, the Hazard Communication Standard covers gas tanks such as oxygen, CO2, and others. Tanks, both full and empty, must be stored upright on a stand and/or chained to a wall or stationary object preferably in an area away from the laboratory. Generally, these tanks are color coded and marked by the NFPA diamond system.
An employee's knowledge of the properties of the chemicals in use in the laboratory and of the proper handling techniques greatly reduces the potential of dangerous situations. All chemicals should be handled carefully, and, when in heavy containers, placed on a cart for transport from one area to another. Glass containers should be placed in protective plastic carriers for safer transport. In the event of a chemical accident, the spill must be contained and an appropriate spill kit used to clean up the area. Many of these kits are available commercially; and each comes with directions for its appropriate use.
Remember to keep all reagent/chemical bottles and containers clearly labeled. When moving a chemical to a different container, it is best to first label the new container appropriately thus avoiding the possibility of having an unlabeled chemical in the laboratory.
The U.S. Environmental Protection Agency (EPA) controls the disposal of all non-radioactive chemicals. However, many local fire departments and/or municipal governments have their own regulations for proper disposal. Each laboratory safety officer should consult these local regulations when developing the policies for their laboratory.
According to OSHA regulations, when information such as new toxicity data, new disposal methods, cleanup methods or other information becomes available and a company sends you an updated MSDS, all employees must be informed of the changes. The education of employees on the proper storage and use of chemicals is necessary to help them avoid dangers such as burns, explosions, fires, and exposure to toxic fumes.
<Ruthanne R. Hyduke, M.A.
1. Lab coats must be:
2. Gloves must:
3. Dress code
4. Safety goggles or glasses, masks, or full face shields must be provided for the employees. They should be worn while working in the laboratory. Several models can be worn over prescription glasses.
5. Vaccinations against the hepatitis B virus must be provided for all employees.
6. Splash guards or shatterproof safety shields must be provided and used whenever the employee might encounter aerosols or other splashes. For example, employees should always open tubes of blood with a splash guard between their face and the tube of blood.
7. First aid kits must be available for the treatment of minor skin abrasions in the work area. The employer must also consider whether his employees need formal training in first aid and CPR.
8. Spill kits must be available for the containment and clean up of any laboratory spills. There are many spill kits available commercially and each comes with directions for their appropriate use.
9. Eyewash or facewash stations must be located within the laboratory, and the employees trained on how to use them. These should be checked weekly for correct operation. When a splash to the eyes has occurred, the eye should be washed for at least 15 minutes which means that many portable eyewash facilities would not be adequate.
10. Safety showers must be mounted within the laboratory area. They should have a large ring on a chain that can be easily found even when employees have their eyes closed. In addition, showers should be mounted high enough that employees can stand under them when needed. Showers must be checked annually for correct operation.
11. Chemical fume hoods or biological safety cabinets must be provided whenever the employee works with hazardous or volatile chemicals or with pathogens.
12. Surgical masks should be worn by patients suspected of having "active" tuberculosis. Staff exposed to patients during coughing and specimen collection should wear Respiratory Protective Devices, such as N95 or High-Efficiency Particulate Air (HEPA) respirators.
Ruthanne R. Hyduke, M.A.
RACE
In the event of a fire or other hazardous situation (major
chemical spills and electrical problems), all employees must remember
the RACE acronym for appropriate action:
Rescue: Move all people in the vicinity of the hazard beyond a fire door.
Alert: Notify the fire department through either a phone call or by pulling the appropriate alarm. When phoning, be prepared to give your name and the location and extent of the hazard. Also alert other personnel in the area and tell them what they should do to help you.
Confine: Try to keep the hazard in one location by closing all doors and windows. Turn off all gas supplies, remove all flammables, and assure that all smoke doors are closed. Disconnect all electrical equipment where appropriate.
Extinguish a fire with an approved fire extinguisher only from a point of safety. Never turn your back on the fire; move the extinguisher back and forth at the base of the fire.
Other fire safety precautions that employees must know include:
All health care employees need to attend fire safety training provided by a local fire or safety agency. This training is best when it provides hands-on practice of the use of fire extinguishers.
Fire extinguishers
Fire extinguishers are labeled with letters that indicate what kind
of fire they can be used on:
Class A Extinguishers can be used on ordinary combustibles such as
wood, cloth, and paper.
Class B extinguishers can be used on flammable liquids and gases.
Class
C extinguishers are used on fires that involve an electrical
supply.
In addition there are many multipurpose or combination extinguishers available. Consult your local fire department for the appropriate extinguisher to have in your particular work areas.
Electrical Safety Precautions
Employees must use precautionary measures when working with
electrical equipment. Some equipment requires special precautions
that are often suggested in the manual accompanying the instrument.
OSHA requires that all grounded circuitry meet the regulations
of the National Electrical Code pulished by the NFPA.The
electrical safety precautions that employees must consider
include:
1. Never overload circuits.
2. Power strips with their own fuses or circuit breakers may be used where multiple outlets are needed.
3. Never use extension cords. If one is needed on a temporary basis, the cord must be less than 12 feet in length, UL approved, and have only one outlet at the end.
4. Be sure all equipment is grounded by using three prong plugs only. Check the ground on all outlets annually.
5. Keep hands dry when working with electrical equipment. If liquids spill an electrical equipment, unplug immediately if it can be done safely and dry the equipment with a hair dryer.
6. Never use electrical equipment when any "problem conditions" occur such as:
7. Never use a Class A or ABC extinguishers on an electrical fire.
Ruthanne R. Hyduke, M.A.
Lifting
All employees should be given instructions on the proper way to lift
heavy objects even though this may not be a routine part of their
job. These instructions might include:
Ruthanne R. Hyduke, M.A. and James E. O'Connor, M.S.
Autoclave |
sterilize by use of steam pressure to destroy microbial life. |
Blood |
human blood, human blood components, and products made from human blood. |
Bloodborne Pathogen |
any pathogenic microorganisms that are present in human blood and can cause disease in humans. |
Clinical Laboratory |
a workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials. |
Contaminated |
the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface. |
Decontamination |
the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens to the point where they are no longer capable of transmitting infectious particles. |
Exposure Incident |
the contact of specific eye, mouth, other mucous membrane, non-intact skin, or parenteral sites with blood or other potentially infectious materials during the performance of an employee's duties. |
HBV |
hepatitis B virus; one of the micro-organisms considered to be a bloodborne pathogen. |
HIV |
human immunodeficiency virus; one of the micro-organisms considered to be a bloodborne pathogen. |
Incineration |
destruction of regulated waste by burning. |
Laundry |
any clothing or other fabric (e.g., bedding) that is worn in the presence of bloodborne pathogens and has the potential of becoming "comtaminated." |
MSDS |
material safety data sheet; provides information about chemicals to comply with the OSHA "Hazard Communication" Rule. |
NFPA |
National Fire Protection Agency. |
Parenteral |
piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions. |
PPE |
Personal protective equipment; specialized clothing or equipment worn by an employee for protection against a hazard. |
Regulated Waste |
- liquid or semi-liquid blood or other potentially infectious materials (PIMs). -contaminated items that might release blood or PIMs. - items caked with dried blood or PIMs. -contaminated sharps. -pathological and microbiological wastes. |
Risk Management |
the development of rules, regulations, equipment, and training that help provide a safe environment for all employees. ("Safety") |
RSIs |
Repetitive Stress Injuries; injuries caused by the repetition of a certain motion. (Example carpal tunnel syndrome from computer work) |
Sharps |
-any object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires. -are of most concern when "contaminated". |
Sterilize |
the use of physical or chemical means to destroy all microbial life including highly resistant bacterial endospores. |
Universal Precautions |
an approach to infection control where all human blood and body fluids are treated as if known to be infectious for bloodborne pathogens. |
Work Practice Controls |
rules that reduce the likelihood of exposure by altering the manner that a task is performed. Example prohibiting the recapping of needles. |
Ruthanne R. Hyduke, M.A.
Ruthanne R. Hyduke, M.A.
Section I Chemical Identity: This section provides the common and chemical name for any chemical substance. It must be cross-referenced to the name found on the label.
Section II Hazardous Ingredients: Where there are mixtures of chemicals, the hazardous chemical must be identified with the list of other chemicals found in the compound. Carcinogens must be identified if they are present in the mixture at levels of 0.1% or greater.
Section III Physical and Chemical Characteristics: The physical and chemical characteristics such as boiling and freezing points, density, vapor pressure, specific gravity, solubility, volatility, appearance and odor must be listed.
Section IV Fire and Explosion Data: The compound's and/or chemical's potential for explosion and the conditions under which it could ignite or explode must be listed.
Section V Reactivity Data: This section lists other chemicals that this one may react with to produce hazardous situations.
Section VI Health Hazards: This section must include the signs and symptoms of exposure, any medical conditions that are aggravated by exposure, the specific types of hazard (carcinogen, corrosive, toxin, etc.) that the chemical presents, and the route of entry of the chemical into the body.
Section VII Precautions for Safe Handling and Use: This section must describe the hygiene practices, precautions to be taken during repair and maintenance of equipment using this chemical, and procedures for cleaning spills and leaks of the chemical. Some manufacturers may also include waste disposal instructions for the chemical.
Section VIII Control Measures: This section describes the control measures that must be taken when using this chemical such as personal protective equipment, safe handling procedures, and other engineering controls.
Material Safety Data Sheet