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Dear HCPro Customer:
Enclosed is your latest supplement to the OSHA Program Manual for Medical Facilities. This supplement is designed to keep your product up to date. Your next supplement will be in May 2017. If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 or e-mail [email protected]. At HCPro, customer comments and suggestions are very important to us—let us know how we can serve you better.
Please insert these new and revised pages as indicated, and keep these filing instructions at the front of your book.
FILING INSTRUCTIONS
Rev. 12/16 OPMFMF Supplement to OSHA Program Manual for Medical Facilities
VISIT www.hcmarketplace.com for the latest compliance and training information.
Remove Insert Reason for ChangeTitle page Title page updated
xiii/xiv xiii/xiv OSHA Program Manual Contents—updated
2-11 through 2-16 2-11 through 2-16 Tab 2: OSHA Program Administration—updated
Tab 11 Contents Tab 11 Contents updated
Form 2, Form 2A, Form 4-A, Form 2, Form 2A, Forms 4-A, Tab 11: Master Record Forms—updated Form 4-B, Form 5, Form 5-B, Form 4-B, Form 5, Form 5-B,Form 7-A, Form 8, Form 9, Form 7-A, Form 8, Form 9,Form 9-A, Form 9-A1, Form 14, Form 9-A, Form 9-A1, Form 14,Form 19 Form 19
December 2016 Revisions
Dear HCPro Customer:
Enclosed is your latest supplement to the OSHA Program Manual for Medical Facilities. This supplement is designed to keep your product up to date. Your next supplement will be in September 2016.
If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 or e-mail [email protected]. At HCPro, customer comments and suggestions are very important to us—let us know how we can serve you better.
Please insert these new and revised pages as indicated, and keep these fi ling instructions at the front of your book.
FILING INSTRUCTIONS
Rev. 5/16 OPMFMF Supplement to OSHA Program Manual for Medical Facilities
VISIT www.hcmarketplace.com for the latest compliance and training information.
Remove Insert Reason for ChangeTitle page Title page updated
vii/viii vii/viii Master List of Program Items for Customization—updated
xxi/xxii xxi/xxii OSHA Program Manual Contents—updated
Tab 8 Contents Tab 8 Contents updated
8-1 through 8-26 8-1 through 8-24 Tab 8: Decontamination—updated
May 2016 Revisions
Dear HCPro Customer:
Enclosed is your latest supplement to the OSHA Program Manual for Medical Facilities. This supplement isdesigned to keep your product up to date.
If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 or e-mail [email protected]. At HCPro, customer comments and suggestions are veryimportant to us—let us know how we can serve you better.
February 2014 Revisions
Rev. 2/14 OPMFMF (22056)
Please insert these new and revised pages as indicated, and keep these filing instructions at the front of your book.
Remove Insert Reason for ChangeTitle page Title pages updated
i through xx i through xx Front Matter—updated
Tab 5 Contents Tab 5 Contents updated
5-1 through 5-57 5-1 through 5-57 Tab 5: Bloodborne Pathogens Exposure Control Plan—updated
FILING INSTRUCTIONS
Supplement to OSHA Program Manual for Medical Facilities
VISIT www.blr.com for the latest compliance and training information.
UPDATE to
a division of BLR
About the AuthorMarge McFarlane, PhD, MT (ASCP), CHSP, CHFM, CJCP, HEM, MEP, CHEP, is an independent safety consultant with more than 38 years of healthcare experience. She has provided education, emergency management and safety plan review, life safety, and infection prevention facility surveys for healthcare and businesses in Wisconsin and across the nation since 2005. She is the author of The Compliance Guide to the OSHA GHS Standard for Hazardous Chemical Labeling, 2014 and the OSHA Training Handbook for Healthcare Facilities, Second Edition, 2014. 16L
©2005–2016 HCPro, a division of BLR. All rights reserved, including right of reproduction. The author(s) and their agent(s) have made every reasonable effort in the preparation of this publication to ensure the accuracy of the information. However, the information in this book is sold without warranty, either expressed or implied. The authors, the editors, their agents, and the publishers will not be liable for any damages caused or alleged to be caused directly, indirectly, incidentally, or consequentially by the information in this publication. This publication cannot and does not provide specific information for a user’s exact situation. Users of this publication should exercise their own judgment and, where appropriate, seek the assistance of legal counsel regarding their particular situation.
HCPro, a division of BLR35 Village Road, Suite 200
Middleton, MA 01949Tel: 800/650-6787Fax: 800/639-8511
www.hcmarketplace.com
OSHAPROGRAMMANUALfor Medical Facilities
OSHA Program Manual for Medical Facilities is published by HCPro, a division of BLR.
Copyright © 2016 HCPro, a division of BLR.
All rights reserved. Printed in the United States of America. 5 4 3 2 1
ISBN: 978-1-60146-743-0
No part of this publication may be reproduced, in any form or by any means, without prior written consent of
HCPro, a division of BLR, or the Copyright Clearance Center (978-750-8400). Please notify us immediately
if you have received an unauthorized copy.
HCPro, a division of BLR, provides information resources for the healthcare industry.
HCPro, a division of BLR, is not affiliated in any way with The Joint Commission, which owns the JCAHO
and Joint Commission trademarks.
Marge McFarlane, PhD, MT (ASCP), CHSP, CHFM, CJCP, HEM, MEP, CHEP, Author
Sheila Dunn, DA, MT (ASCP), Contributing Editor
John Palmer, Managing Editor
Mike Mirabello, Fulfillment Specialist
Susan Robinson, Content Management Specialist
Matt Sharpe, Senior Manager of Production
Elizabeth Petersen, Vice President
Advice given is general. Readers should consult professional counsel for specific legal, ethical, or
clinical questions.
Arrangements can be made for quantity discounts. For more information, contact:
HCPro, a division of BLR
35 Village Road, Suite 200
Middleton, MA 01949
Telephone: 800-650-6787 or 781-639-1872
Fax: 800-639-8511
E-mail: [email protected]
Visit HCPro online at: www.hcpro.com and www.hcmarketplace.com
12/16
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 you keep your OSHA Program Manual current from year to year. Should OSHA pass a revised or new regula tion, we will inform you of that change through Medical Environment Update. We will also provide forms, in structions, posters, and advice through this newsletter to help you keep your practice up to date and in compliance.
Follow these steps to determine if your manual is up to date:1. Check for the 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 it by clicking the link on this page.
3. Once logged in to the Medical Environment Update subscription page, find the most recent issue. 4. There you will find an update file. If the file has the same code as on the title page, your manual is up
to date.5. If the update code is different, open the file and choose from the appropriate pdf to download for your
manual (medical or dental).You also have the choice of printing your update pages onesided or twosided, depending on your printing capabilities.
6. Print the updated pages and replace the old pages.
Should you have difficulty logging in or accessing the updated pages, contact HCPro customer service: Telephone: 8006506787 Email: [email protected]
Thank you for your business. Let us know how we can help.
HCPro, a division of BLR35 Village Road, Suite 200
Middleton, MA 01949Telephone: 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 Available as downloads: Master Record Forms (Tab 11) from this Manual
for Customization.
xiii
IntroductionImportant Information About the Use of This Program ............................ iHow to Customize This Program ................................................................ iiiMaster List of Program Items for Customization ....................................... viiWhat Is Included in This Program ............................................................... ix
TAB 1: What Is OSHA?A Quick Look at OSHA .................................................................................. 1-1
States with OSHA-Approved Plans ..................................................................................... 1-1
OSHA Consultative Services Division ................................................................................. 1-2
OSHA’s Jurisdiction ............................................................................................................. 1-2
OSHA’s General Duty Clause .............................................................................................. 1-2
Employee or Employer.................................................................................. 1-4Employer Responsibilities Under OSHA ............................................................................. 1-5
Overview of OSHA Standards ...................................................................... 1-5
OSHA Inspections ......................................................................................... 1-6Employee Complaints .......................................................................................................... 1-6
If an On-site OSHA Inspection Occurs ................................................................................ 1-7
During the Inspection .......................................................................................................... 1-8
What OSHA Inspectors May Ask Employees ...................................................................... 1-8
The Typical OSHA Inspection .............................................................................................. 1-9
The Closing Conference ...................................................................................................... 1-10
OSHA Sanctions ............................................................................................ 1-11
Whistleblower Protection ............................................................................. 1-13
Students and Volunteers ............................................................................... 1-15
Page
Contents
xiv
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 Safety Program ........................................................................ 2-2Location of the OSHA Manual Program .............................................................................. 2-2
Duties of the OSHA Safety Officer .............................................................. 2-2Accident/Incident Investigation & Reporting Procedure .......................... 2-4
Definition of an Accident/Incident or Near-Miss Event ........................................................ 2-4When to Investigate an Accident/Incident ........................................................................... 2-4How to Document an Accident/Incident ............................................................................... 2-5Recording Accidents or Injuries for OSHA ........................................................................... 2-5Correcting Unsafe or At-Risk Conditions .............................................................................. 2-5
Recordkeeping Requirements ..................................................................... 2-6Equipment & Facility Records ............................................................................................. 2-6Bloodborne Pathogens Records ......................................................................................... 2-6Hazard Communication Records ........................................................................................ 2-6TB Records ......................................................................................................................... 2-6Training Records ................................................................................................................. 2-7Employee Medical Records ................................................................................................. 2-7Evaluating Exposure Incidents ............................................................................................ 2-8
OSHA Focus on Healthcare ......................................................................... 2-8Workplace Hazard Analysis ........................................................................ 2-9Practical Ideas for Involving Employees ................................................... 2-10Organizing OSHA Compliance Duties ........................................................ 2-11Weekly Facility Review Checklist ............................................................... 2-12Monthly Facility Review Checklist .............................................................. 2-13Annual Facility Review Checklist ............................................................... 2-14Annual OSHA Safety Program (Includes Exposure Control Plan, Hazard Communication Program, and Respiratory Protection Plan) Review ... 2-17
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 ................................................................................. 3-5
Contents
xv
How Many Fire Extinguishers to Have & Where to Put Them ..................................... 3-6To Use a Fire Extinguisher: Think “PASS” .................................................................. 3-7When 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 .................................................................................... 3-8
Fire Risks During Surgery ................................................................................................... 3-8
Fire Extinguisher Supplement ..................................................................... Supplement
Fire Drills ............................................................................................................................. 3-9
Electrical Safety ............................................................................................ 3-9Physical Characteristics of a Safe Medical Facility ................................... 3-10
Automated External Defibrillators ........................................................................................ 3-10Air Quality ............................................................................................................................. 3-10
Mold ............................................................................................................................. 3-11Mold Remediation ............................................................................................... 3-12
Aisles ................................................................................................................................... 3-13Emergency Lighting ............................................................................................................. 3-14Employee Dress Code ......................................................................................................... 3-14Exits, Means of Egress ........................................................................................................ 3-14Exit Doors ............................................................................................................................ 3-15Exit Signs ............................................................................................................................. 3-15Floors ................................................................................................................................... 3-16Lighting ................................................................................................................................ 3-16Noise .................................................................................................................................... 3-16Portable Space Heaters ....................................................................................................... 3-17Restricted Access Areas ...................................................................................................... 3-17Sinks .................................................................................................................................... 3-17Storage ................................................................................................................................ 3-17
Systems Failure ............................................................................................. 3-18Evacuation Plan ............................................................................................ 3-18
Evacuation Procedures ........................................................................................................ 3-19Methods for Carrying Patients During an Evacuation .................................................. 3-20
Evacuation Floor Plan .......................................................................................................... 3-21Example Evacuation Floor Plan .......................................................................................... 3-22
Emergency Preparedness Supplies ........................................................... 3-23Emergency Action Procedures ................................................................... 3-23
Bioterrorism: Suspicious Letters or Packages ..................................................................... 3-24What Is a “Suspicious Package”? ................................................................................ 3-24
Bomb Threat ........................................................................................................................ 3-25If You Discover a Bomb or a Suspicious Item .............................................................. 3-26Explosion ..................................................................................................................... 3-26
Civil Disturbance .................................................................................................................. 3-26Earthquake ........................................................................................................................... 3-27
If a Tremor Occurs when You Are Inside ..................................................................... 3-27After the Tremor Is Over .............................................................................................. 3-27
Severe Weather ................................................................................................................... 3-28Flood ............................................................................................................................ 3-28Hurricane ..................................................................................................................... 3-28
Contents
xvi
Severe Thunderstorm or Tornado Warning ................................................................. 3-28Tornado Safety Tips ..................................................................................................... 3-29Severe Thunderstorm or Tornado Watch ..................................................................... 3-29Toxic External Atmosphere .......................................................................................... 3-29
Violence ................................................................................................................................ 3-30OSHA’s Jurisdiction Over Workplace Violence ........................................................... 3-30Prevalence of Violence ............................................................................................... 3-30Identifying Situations with the Potential for Violence .................................................... 3-32Violence Prevention Plan Introduction ........................................................................ 3-32Overview of Violence Prevention Plan Components ................................................... 3-33 Part 1 .................................................................................................................... 3-33
Workplace Violence Program Checklists .................................................... 3-35Part 2 .................................................................................................................. 3-38.9
More Sources for Prevention of Workplace Violence ................................................... 3-39
First Aid .......................................................................................................... 3-40Crash Kit/Cart Components ......................................................................... 3-43Drug-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 ........................................................ 3-52Slip, Trip, and Fall Prevention ...................................................................... 3-54
Contaminants on the Floor ...................................................................................................3-54Poor Drainage: Pipes and Drains .........................................................................................3-54Indoor Walking Surface Irregularities ...................................................................................3-54Outdoor Walking Surface Irregularities ................................................................................3-55Weather Conditions: Ice and Snow ......................................................................................3-55Inadequate Lighting ..............................................................................................................3-55Stairs and Handrails .............................................................................................................3-55Stepstools and Ladders........................................................................................................3-56Tripping Hazards: Clutter, Including Loose Cords, Hoses, Wires, Medical Tubing ..............3-56Improper Use of Floor Mats and Runners ............................................................................3-56Healthcare Facility Slip, Trip, and Fall Hazard Checklist ......................................................3-57
TAB 4: Ergonomics in the Medical WorkplaceA Quick Look at Ergonomics ....................................................................... 4-1Common Musculoskeletal Disorders .......................................................... 4-2
Back Injuries .........................................................................................................................4-3Techniques to Reduce Injury ........................................................................................4-4
Fatigue .................................................................................................................................4-5Repetitive Stress Injuries/Wrist Injuries ................................................................................4-6
Wrist and Hand Exercises ............................................................................................4-6Eye Strain .............................................................................................................................4-8
Why Prevent CVS? ......................................................................................................4-8Symptoms of CVS ........................................................................................................4-8Other Suggestions for Relieving Eye Strain .................................................................4-9
Selecting Equipment ..................................................................................... 4-10
Contents
xvii
TAB 5: Bloodborne Pathogens Exposure Control PlanExposure Control Plan Introduction ........................................................... 5-1Overview of Bloodborne Pathogens Standard Components .................... 5-2A Quick Look at Occupational Exposure .................................................... 5-3Industries Subject to the Bloodborne Pathogens Standard ..................... 5-3Universal/Standard Precautions .................................................................. 5-4
Other Potentially Infectious Materials (OPIM) ..................................................................... 5-4Implementing Universal/Standard Precautions ................................................................... 5-5
Bloodborne Pathogens ................................................................................ 5-6Epidemiology of Bloodborne Pathogens of Concern to Healthcare Workers ...................... 5-6Update on AIDS in the Workplace ....................................................................................... 5-9Transmission of Bloodborne Pathogens .............................................................................. 5-9
Exposure Determination .............................................................................. 5-9Personnel Who Are Occupationally Exposed ...................................................................... 5-9
Exposure Prone Procedures ....................................................................................... 5-10Bloodborne Pathogens Exposure Determination List #1 (Form 8) ...................................... 5-12Other Personnel Who Could Potentially Be Occupationally Exposed ................................. 5-12Bloodborne Pathogens Exposure Determination List #2 (Form 9) ...................................... 5-13Employees Who Are Not Occupationally Exposed .............................................................. 5-14
Restricted Access Areas .............................................................................. 5-14Engineering/Work Practice Controls ........................................................... 5-14
Biohazard Labels ................................................................................................................. 5-15Handwashing ....................................................................................................................... 5-15
When to Wash Hands .................................................................................................. 5-17How to Wash Hands .................................................................................................... 5-17Artificial Nails ............................................................................................................... 5-17
Sharps Safety ...................................................................................................................... 5-18What to Look for in Safety Devices ............................................................................. 5-18Sharps Evaluation Procedure ...................................................................................... 5-19Use of Non-Safe Sharps .............................................................................................. 5-20Phlebotomy Needles ................................................................................................... 5-21
Sharps Containers ............................................................................................................... 5-21Sharps Container Maintenance ................................................................................... 5-22Sharps Container Disposal Procedure ........................................................................ 5-22
Biohazardous Waste (See Tab 8) ........................................................................................ 5-23Laundry ................................................................................................................................ 5-23
Personal Protective Clothing & Equipment ............................................... 5-24PPE Strategy ....................................................................................................................... 5-24Locations of PPE ................................................................................................................. 5-25
Gloves ......................................................................................................................... 5-26When to Wear Gloves ......................................................................................... 5-26How to Wear Gloves ........................................................................................... 5-26Latex Allergy ....................................................................................................... 5-27Preventing Allergic Reactions ............................................................................. 5-28
Contents
xviii
Face Protection ........................................................................................................... 5-29Body Protection ........................................................................................................... 5-29Emergency Resuscitation Equipment ......................................................................... 5-30
When to Wear PPE .............................................................................................................. 5-30
Hepatitis B Vaccine ....................................................................................... 5-31Safety of the Hepatitis B Vaccine ......................................................................................... 5-32Documenting Employee Hepatitis Vaccines ........................................................................ 5-32Titering Employees after the Hepatitis B Vaccination .......................................................... 5-33
How to Determine Employee Immunity ....................................................................... 5-33Testing Employees Vaccinated before the Titer Requirement ..................................... 5-34
Types of Hepatitis B Tests ........................................................................... 5-34Interpreting Hepatitis B Test Results .................................................................................... 5-35
New Employee Hepatitis B Virus Vaccination Flow Chart ........................ Supplement
Post-exposure Evaluation & Follow-up ...................................................... 5-37What Is an Exposure? .......................................................................................................... 5-37What to Do after an Occupational Exposure ....................................................................... 5-37For HCV Exposures ............................................................................................................ 5-39For HBV Exposures ............................................................................................................. 5-39For HIV Exposures .............................................................................................................. 5-40When to Get Expert Consultation for HIV Post-exposure Prophylaxis ................................ 5-41Confidentiality of Post-exposure Procedures ...................................................................... 5-41Employee Counseling/Precautions ..................................................................................... 5-42
Occupational Exposure Management Resources ..................................... 5-42Incident Report/Sharps Injury (Form 14) .................................................... 5-43Post-exposure Checklist (Form 17) ............................................................. 5-45Post-exposure Medical Evaluation Declination Form (Form 18) .............. 5-46Injection Safety ............................................................................................. 5-47
Information for Providers ..................................................................................................... 5-47
Frequently Asked Questions: Injection Safety FAQs for Providers ........ 5-48Overview ............................................................................................................................. 5-48Injection Procedures ............................................................................................................ 5-50
Infection Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens ..................... Supplement
Infection Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens (fingerstick, blood glucose sampling) ........................................................ Supplement
Bloodborne Pathogens Resources ............................................................. 5-53
Contents
xix
TAB 6: TB/Infection Prevention and 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 .............................................. 6-4TB Risk Assessment ........................................................................................................... 6-4
TB Risk Assessment Results Form (Form 20) ............................................................ 6-5Early Identification of Patients with Active TB ..................................................................... 6-6
Symptoms of TB ........................................................................................................... 6-6Handout: Cover Your Cough/Clean Your Hands ................................................................. 6-8Managing Patients with Suspected or Confirmed TB ........................................................... 6-9
TB Isolation Procedures for Cough Inducing and Aerosol-Generating Procedures .... 6-9Respiratory Protection for Healthcare Workers: N-95 Respirators or Medical Powered Air Purifying Respirators (PAPRs) ................ 6-10
Seal Checking N-95 Respirators ......................................................................... 6-10Medical PAPRs ................................................................................................... 6-10
Employee TB Skin Testing (TST) ........................................................................................ 6-11Baseline Employee TST: The Two-Step Skin Test ...................................................... 6-12
Two-Step TST Interpretation ................................................................................ 6-12Interpreting the TST ..................................................................................................... 6-13
False Positive/False Negative TB Tests .............................................................. 6-13Workers Who Have Had BCG Vaccination .......................................................... 6-14
Periodic Retesting of Employees ................................................................................ 6-14Recording TST Results ............................................................................................... 6-14TST Record (Form 21) ................................................................................................ 6-15TST Declination (Form 22) .......................................................................................... 6-16
Evaluation and 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 and Skin Test Conversions ........................................... 6-17TB Exposure Log (Form 23) ......................................................................................... 6-19Decontaminating Patient Care Area and Equipment.................................................... 6-20
Employee Training ............................................................................................................... 6-20
Pandemic Influenza Plan and Other Infectious Diseases ........................ 6-21Pre-pandemic Planning ....................................................................................................... 6-21Once a Pandemic Is Announced .......................................................................................... 6-24OSHA Enforcement for a Pandemic .................................................................................... 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 Resources .......................................................................................................... 6-29
Multidrug-Resistant Organisms (MDRO) .................................................... 6-29CDC Classification of MDRO Threats ................................................................................ 6-29MDRO Prevention and Control ............................................................................................ 6-31
Contents
xx
Colonization vs. Infection .................................................................................................... 6-31MDRO Transmission ........................................................................................................... 6-32Patient Precautions ............................................................................................................. 6-32
Hand Hygiene ............................................................................................................. 6-33Contact Precautions .................................................................................................... 6-33
Environmental Cleaning ...................................................................................................... 6-34Infected Employees ............................................................................................................. 6-35MDRO Resources ............................................................................................................... 6-36
Pertussis and Worker Vaccination ............................................................. 6-36Supplement: How Antibiotic Resistance Happens ................................... 6-38Supplement: Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care ......................................................... S1–S10
TAB 7: The Hazard Communication StandardA Quick Look at HazCom ............................................................................. 7-1
Determining Which Chemicals Are Hazardous ................................................................... 7-2Routes of Exposure to Hazardous Chemicals ..................................................................... 7-3
Safety Data Sheets ....................................................................................... 7-4Examples of Chemicals Requiring an SDS .......................................................................... 7-4Chemicals Not Requiring an SDS ....................................................................................... 7-4SDS Flowchart Determination .............................................................................................. 7-5Information Required on SDSs ............................................................................................ 7-5How to Get SDSs ................................................................................................................ 7-11Where to Keep SDSs .......................................................................................................... 7-12
Classification of Hazardous Chemicals ..................................................... 7-12Flammable Liquids ..............................................................................................................7-13
Storage of Hazardous Chemicals ............................................................... 7-13Hazardous Chemicals With Permissible Exposure Limits (PELs) ........... 7-14Labeling Hazardous Chemicals .................................................................. 7-15
HazCom Pictograms and Hazard Statements ..................................................................... 7-15Pictograms .......................................................................................................................... 7-15NFPA Label System ............................................................................................................ 7-16
Safety Tips for Working with Hazardous Chemicals ................................. 7-17Hazardous Chemical Waste Packaging and Disposal ............................... 7-18Medications Security and Disposal ............................................................ 7-19
Security for Prescription Drugs ............................................................................................ 7-19Security for Controlled Chemicals ........................................................................................ 7-19Disposal of Prescription Drugs ............................................................................................. 7-19Disposal of Hazardous Drugs .............................................................................................. 7-19
Medical Consultation and Injury Evaluation .............................................. 7-20HazCom Recordkeeping .............................................................................. 7-20
Contents
xxi
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 ................................................................................. 8-4BBP Spill Clean-up Procedures .......................................................................................... 8-4Spills That Contain Broken Glass or Sharp Objects ............................................................ 8-5Chemical Spill Clean-up Procedures ................................................................................... 8-5Chemical Exposure to Skin ................................................................................................. 8-6Mercury Spills ...................................................................................................................... 8-6Cytotoxic Drug Spill Clean-up ............................................................................................. 8-7
Decontamination of Medical Instruments & Equipment ........................... 8-7When to Sterilize ................................................................................................................. 8-7Precleaning Instruments Prior to High-level Disinfection or Sterilization ............................. 8-8Sterilization .......................................................................................................................... 8-10Quality Checks for Sterilization ........................................................................................... 8-10High-level Disinfecting ......................................................................................................... 8-11
Using Glutaraldehyde ................................................................................................... 8-12Glutaraldehyde Spills .................................................................................................. 8-14Sources for Chemical Air Monitoring ........................................................................... 8-15Testing the Potency of Glutaraldehyde ....................................................................... 8-15Disposing of Glutaraldehyde ....................................................................................... 8-15
Cleaning Transvaginal and Transrectal Ultrasound Probes ................................................ 8-16Disinfect Transvaginal and Transrectal Probes After Each Use .................................. 8-16Cleaning Ultrasound Transducers ............................................................................... 8-16
Decontaminating Vaginal Specula ....................................................................................... 8-17Step 1: Contain & Transport ....................................................................................... 8-17Step 2: Clean ............................................................................................................. 8-17Step 3: Disinfect or Sterilize ....................................................................................... 8-17
Keeping Employees Safe During Instrument Disinfection ................................................... 8-18Decontaminating Semi-critical Patient Care Equipment ...................................................... 8-18Decontaminating Non-critical Patient Care Equipment ....................................................... 8-18Decontaminating Personal Protective Equipment (PPE) .................................................... 8-19
Eyewash Stations ......................................................................................... 8-19Number & Placement of Eyewash Stations ......................................................................... 8-20Eyewash Maintenance ........................................................................................................ 8-21
Waste Disposal ............................................................................................. 8-21Biomedical Waste Disposal ................................................................................................. 8-21Hazardous Waste Disposal ................................................................................................. 8-22Waste Handling & Storage .................................................................................................. 8-24
Contents
xxii
TAB 9: Specialty ServicesAbout this Section ........................................................................................ 9-1Working Safely with Antineoplastic and Hazardous Drugs ...................... 9-1
NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2014 ... 9-2NIOSH Hazardous Drug List for Healthcare ........................................................................ 9-3Effects of Hazardous Drug (HD) Exposure on Health .......................................................... 9-3Safe Work Practices ............................................................................................................. 9-3Clothing ............................................................................................................................... 9-3Sample List of Drugs that Should be Handled as Hazardous ............................................. 9-4Drug Preparation and Administration .................................................................................. 9-5Cleaning the Drug Preparation Area ................................................................................... 9-6Caring for Patients Receiving HDs ...................................................................................... 9-6Waste Disposal .................................................................................................................... 9-6Spill Clean-up ....................................................................................................................... 9-7
Suggested Spill Kit Components .................................................................................. 9-7Receiving Antineoplastic and Hazardous Drugs ................................................................. 9-8Storage of Antineoplastic and Hazardous Drugs ................................................................. 9-8Transport of Antineoplastic and Hazardous Drugs ............................................................... 9-8Employee Training ............................................................................................................... 9-8Employee Medical Surveillance .......................................................................................... 9-9Employee Exposure ............................................................................................................ 9-9
Gas Cylinder Safety ...................................................................................... 9-10Electrosurgical Safety ................................................................................. 9-11
Safe Work Practices ............................................................................................................ 9-13
Surgical Safety .............................................................................................. 9-13General PPE Indications for Surgery .................................................................................. 9-13
Surgical Gowns ........................................................................................................... 9-14Surgical Gloves ........................................................................................................... 9-14Face and Eye Protection ............................................................................................. 9-15Headwear .................................................................................................................... 9-15Shoe Covers ................................................................................................................ 9-15Surgical Drapes ............................................................................................................ 9-15
Safe Sharp Strategies for the Surgical Setting .................................................................... 9-15Scalpels ....................................................................................................................... 9-15Suture Needles ........................................................................................................... 9-16
Transferring Sharps Safely .................................................................................................. 9-16How to Use the Neutral Zone (NZ) .............................................................................. 9-17Tips for Minimally Invasive Surgeries .......................................................................... 9-17Safety Techniques for Operating on Patients Infected with Known Bloodborne Pathogens ................................................................................................. 9-17
Preventing Surgical Fires .................................................................................................... 9-18
Laboratory Safety .......................................................................................... 9-19Laboratory Specimen Transport ........................................................................................... 9-20
Radiation Safety ............................................................................................ 9-20Regulation of the Medical Use of Nuclear By-products ....................................................... 9-20The “ALARA” Principle ........................................................................................................ 9-21
Contents
xxiii
Radiation Safety Guidelines for Personnel .......................................................................... 9-21Radiation Safety Policies for the Facility ............................................................................. 9-22Ionizing Radiation Exposure Limits ..................................................................................... 9-22Special Precautions for Pregnant Workers ......................................................................... 9-23Low-level Radioactive Waste Disposal ............................................................................... 9-23NRC Notification, Reports, and Record ............................................................................... 9-23NRC Resources and Publications ....................................................................................... 9-24
Working Safely with Cryogenic Liquids ..................................................... 9-25Precautions for Handling Liquid Nitrogen ............................................................................ 9-25Storing Liquid Nitrogen ........................................................................................................ 9-26Personal Protective Equipment ........................................................................................... 9-26Liquid Nitrogen Disposal ..................................................................................................... 9-26Steps to Take if There Is Accidental Exposure ..................................................................... 9-27
First Aid (cryogenic burns) .......................................................................................... 9-27First Aid (anoxia) ......................................................................................................... 9-27
Safe Vaccine Handling and Storage ............................................................ 9-28Waste Anesthetic Gases .............................................................................. 9-30
Where Exposures Occur ..................................................................................................... 9-31Preventing Exposures ......................................................................................................... 9-31
Controls ....................................................................................................................... 9-32Medical Surveillance ........................................................................................................... 9-32Recordkeeping .................................................................................................................... 9-33More Information ................................................................................................................. 9-33
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 ............................................................... 10-6Respiratory Protection Annual Training Contents ................................................................ 10-6Hazard Communication Annual Training Contents .............................................................. 10-7
New Employee Orientation .......................................................................... 10-7New Employee OSHA Orientation Checklist (Form 26) ...................................................... 10-8
Sample Tests with Answer Keys ................................................................. 10-10OSHA Annual Retraining: Sample Essay Test Questions (Form 28) ................................... 10-11OSHA Annual Retraining: Sample Essay Test—Answer Key .............................................. 10-12OSHA Annual Retraining: Sample Multiple Choice Test Questions (Form 29) .................... 10-13
Contents
xxiv
OSHA Annual Retraining: Sample Multiple Choice Test—Answer Key ............................... 10-15OSHA Annual Retraining: Sample True/False Test Questions (Form 30) ............................ 10-16OSHA Annual 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 2Eyewash Station Weekly Check Log ................................................................................... Form 2-AAnnual OSHA Program (Exposure Control Plan) Review ................................................... Form 3Weekly Facility Review Checklist ........................................................................................ Form 4-AMonthly Facility Review Checklist ....................................................................................... Form 4-BAnnual 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-AHealthcare Facility Slip, Trip, and Fall Hazard Checklist ..................................................... Form 7-B
Bloodborne Pathogens RecordsBloodborne Pathogens Exposure Determination List #1 ..................................................... Form 8Bloodborne Pathogens Exposure Determination List #2 ..................................................... Form 9Bloodborne Pathogens PPE Compliance Checklist ............................................................ Form 9-AFailure to Use PPE .............................................................................................................. Form 9-A-1Bloodborne 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 13Exposure Prevention Checklist ............................................................................................ Form 13-A
Bloodborne Pathogens Employee Medical RecordsIncident 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
Hazard Communication Records Hazardous Substances List ................................................................................................. Form 19
TB/Infection Control Records TB Risk Assessment Results Form ..................................................................................... Form 20TST Record ......................................................................................................................... Form 21TST Declination Form .......................................................................................................... Form 22TB Exposure Log ................................................................................................................. Form 23Influenza Vaccine Log .......................................................................................................... Form 24Influenza Vaccine Declination Form .................................................................................... Form 25-AChecklist for Infection Prevention for Outpatient Settings ................................................... Form 25-B List of Infection Prevention Contact Persons and Roles/Responsibilities ................................ Form 25-C
Training RecordsNew Employee OSHA Orientation Checklist ....................................................................... Form 26Annual Employee Training Record ...................................................................................... Form 27OSHA Annual Retraining (Sample Essay Test) ................................................................... Form 28 OSHA Annual Retraining (Sample Multiple Choice Test) .................................................... Form 29OSHA Annual Retraining (Sample True/False Test) ............................................................ Form 30Respiratory Protection Training Record ............................................................................... Form 31Qualitative Respirator Fit Test Report .................................................................................. Form 31-AChecklist for Decreasing Surgical Fire Risks ....................................................................... Form 32
TAB 12: OSHA Regulations & Key ResourcesOSHA 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 (Revised 2011) ................................... 12-42Suggested Work Restrictions for Employees ...................................................................... 12-44
Acronyms used in the OSHA Program Manual ......................................... 12-48
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Contents
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OSHA Program Manual for Medical Facilities
During staff meetings, encourage employees to bring up any concerns about their safety on the job. Listen to their responses and encourage discussion.
When an employee states a concern, show interest and ask for more details. Regardless of whether that concern is high on your priority list or not, address it and resolve either to fix the problem or allay the employee’s fears.
Bring this OSHA Program Manual for to staff meetings to reinforce the fact that your practice has a tangible program that contains policies to ensure staff safety.
Take 5 minutes at these same meetings to do a safety-related demonstration, such as showing how to remove exam gloves without splashing your colleagues, how to clean up a biohazardous spill, how to locate and read an MSDS (SDS), etc. These short exercises reinforce the commitment to safety. One approach is to have different employees demonstrate a safety topic to their peers each month.
Practice evacuation drills for fire, violent behavior, and other emergencies that could potentially occur. After the drill, critique the staff’s performance and amend the emergency plan, if necessary. Ensure that staff are trained on the changes.
Finally, the ultimate goal of an OSHA Safety Officer should be zero non-compliance and minimal exposure incidents. Make sure that employees know exactly what safety measures to take. Employees should know that using appropriate work practices and wearing appropriate protective gear is not optional. Employees should expect consistent enforcement of safety policies and know what happens if there is non-compliance. Disciplinary actions should be fair and consistent: Follow an unheeded verbal warning with a written warning. If no corrective action follows, take further disciplinary action and/or termination.
Organizing OSHA Compliance DutiesTo help organize a busy OSHA Safety Officer’s efforts to get a facility in compliance and keep it there, HCPro offers four useful tools:
1. A Weekly Facility Review Checklist (highly recommended).2. A Monthly Facility Review Checklist (highly recommended).3. An Annual Facility Review Checklist (highly recommended to assist in the annual
assessment of the facility safety program).4. An Annual OSHA Program Manual Review Form (mandatory and includes the
Exposure Control Plan, the Hazard Communications Plan and the Respiratory Protection Plan).
These forms are located on the following pages, as well as behind Tab 11: Master Record Forms. These forms document and organize compliance duties.
If it is determined that revisions need to be made, the OSHA Safety Officer ensures implementation of the recommendations and makes changes to the OSHA Program Manual. For this purpose, use the Annual OSHA Program Manual Review Form located on page 2-14 and behind Tab 11: Master Record Forms (Form 3).
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OSHA Program Manual for Medical Facilities
WEEKLY FACILITY REVIEW CHECKLISTMark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered “No” to any question, explain on the reverse of this form.
Facility
_____Are all secondary containers, such as spray bottles and chemical bottles, properly labeled and legible, including the required OSHA pictograms?
_____Are all sharps containers filled below the “fill” line (or 2/3 full) and secure and positioned firmly so that they cannot be knocked over?
_____Are biohazard waste bags/storage bins in the proper locations (in every area where blood or OPIM is encountered) and functioning properly?
_____ Is the biohazard storage area clean, secure and orderly?
_____Is the autoclave working properly? Are weekly biological indicator test records complete? (Reference Form 2.)
_____Are scavenging systems for waste anesthetic gas (hoses, bags, masks, and connections) inspected for cracks and leaks?
_____
Is the eyewash station functioning properly? (Run water for several minutes and inspect /disinfect eyepieces; see Tab 5 for details.) (See weekly eyewash station log, Form 2A)
_____ Are exit signs visible and illuminated where required?
_____ Are all exit hallways unobstructed with exit doors unlocked from the inside?
_____
Do ALL facility exits have clear and unobstructed (by snow/ice, trash bins, containers, etc.) paths to the street or public way? (It is important to check secondary facility exits.)
Administration
_____
Have hepatitis B vaccinations been made available to unvaccinated new hires with occupational exposure to bloodborne pathogens after training and within 10 working days of initial assignment or has an OSHA declination form been signed?
_____Have tuberculin skin tests (TST) been made available to new hires before exposures to patients with TB or within 10 working days of initial assignment?
_____Is the exam/treatment room set-up and clean-up procedure consistently followed? (Reference Form 6.)
_____ Have the exam/treatment rooms been inspected for outdated supplies?
Date: ________________ OSHA Safety Officer: ______________________________
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OSHA Program Manual for Medical Facilities
MONTHLY FACILITY REVIEW CHECKLISTMark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered “No” to any question, explain on the reverse of this form.
Facility
_____Are compressed gas cylinders securely fastened in an upright condition? Are empty or unused gas cylinders capped and properly labeled and segregated from each other?
_____ Are exit doors free of blockage, clearly marked, and unlocked?
_____Are fire extinguishers fully charged, accessible, inspected and in their designated places?
_____ Are all floors and carpets dry and free of tripping hazards?
_____Are stored items not stacked higher than 5 feet (unless a stepstool is available), stable, and located more than 3 feet from any heat source?
_____Are PPE (gowns, face shields, gloves, shoe covers, etc.) and respirators (N95s) in the proper location, available in the correct sizes and amounts, and functioning properly?
_____ Are hand sanitizers available, in date and in the proper locations?
_____ Are all chemicals labeled legibly so contents and hazards are clearly identified?
_____ Are chemical and biohazard spill kits available and within their expiration date?
_____ Are all first aid kit/crash cart components within their expiration dates?
____Do emergency backup lights/batteries have documented testing for 30 seconds every month?
Administration
_____Have all new employees completed a “New Employee OSHA Orientation” checklist? (Reference Form 26.)
_____Is the SDS binder and the Master Hazardous Substances List up to date, reflecting any new chemicals brought into use this month? (Reference Form 19, (SDS Binder.)
_____
Do the Exposure Determination Lists #1 and #2 reflect new employees with occupational exposure? Have employees who left the facility been removed? Have employees whose job duties changed been added/deleted? (Reference Form 8, 9.)
_____Has a new clinical procedure been implemented which requires face, body, or hand protection? If so, has the PPE table (Tab 5) been updated?
Date: __________________ OSHA Safety Officer: __________________________________
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OSHA Program Manual for Medical Facilities
ANNUAL FACILITY REVIEW CHECKLIST(1 of 3 Pages)
Mark Yes (Y), No (N) or Not Applicable (NA) for the following OSHA requirements. Explain any “No” responses in the space provided at the end of this form.
General Facility Safety
_____The most current OSHA poster, “It’s the Law” (or state equivalent poster) is visible to all employees.
_____ Exit doors are free of blockage, clearly marked and unlocked.
_____Exit signs are properly lit and backup lights/batteries are functioning. The 90-minute annual testing of backup lights with batteries is documented.
_____ If your facility has 10 or more employees, a written evacuation plan/route is posted. _____ Medical equipment cords have grounded 3-pronged plugs. _____ _____
Extension cords are being used properly (not as permanent wiring). Extension cords are not plugged into each other (daisy-chained).
_____Electrical cords are managed to prevent tripping hazards (not placed under rugs or across doorways).
_____ Electrical cords are in good condition (no frays, defects, etc.). _____ The fire alarm is in proper working order, if present. _____ An appropriate number of fire extinguishers are present/accessible.
_____
The fire extinguishers have been inspected and tagged within the last 12 months and are fully charged. A record review shows that the extinguishers were inspected during each month of the last 12 months.
_____ Panic buttons, or public address systems, are in working order, if present. _____ The worksite is maintained in a clean and sanitary condition. _____ Restricted areas (lab, decontamination room, etc.) are designated with signage.
Break Room
_____The break area is free of contamination from blood and other potentially infectious materials (OPIMs).
_____ Employees discard PPE before entering the break area (before leaving exam rooms).
_____ The break area is free from hazardous chemicals.
Check-in/Reception_____ An up-to-date emergency contact list is posted or present. (Reference Form 7-A)
_____ The reception area is free of contamination from blood and OPIMs. _____ Employees discard PPE before entering the reception area (before leaving exam rooms). _____ The reception area is free from hazardous chemicals. Administration Area
_____
All employees have undergone OSHA annual retraining on bloodborne pathogens, hazard communication and TB in the last 12 months and this training is documented. (Reference Form 27)
_____
All new employees received initial OSHA training (if not previously trained) or completed a New Employee Orientation Checklist (if previously trained) and this training is documented. (Reference Form 26)
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OSHA Program Manual for Medical Facilities
(Annual Facility Review Checklist, page 2 of 3)
_____Employees are trained on the proper precautions, and how to properly don and use, the PPE necessary for their job duties. (Reference Forms 26, 27)
_____
All employees participated in at least one fire drill this year or have signed Safety Committee/staff meeting minutes where they reviewed the fire drill discussion and results. (Reference Forms 5-A, 5-B)
_____Employees have been trained on how to respond in the event of a fire (R.A.C.E.). (Reference Forms 26, 27)
_____Employees have been properly trained on how to use a fire extinguisher (P.A.S.S.). (Reference Forms 26, 27)
_____ All OSHA training records from the last three (3) years are available. (Reference Forms 26, 27)
_____Exposure Determination Lists #1 and #2 document all employees with risk for exposure. (Reference Forms 8, 9)
_____The facility has documented all needlesticks and other sharps injuries which occurred this year using the Incident/Sharps Injury Log (Reference Form 14)
_____
All employee accidents, near-misses, injuries and complaints (check Safety Report and Incident/Sharps Injury Logs) were examined for trends. The need to change engineering controls, policies or procedures was evaluated. (Reference Forms 1, 14)
_____
In areas where trends were noted above or safer sharps have not yet been implemented frontline employees have evaluated new safety devices for possible future implementation. Evaluations have been documented, and evaluation forms are retained. (Reference Forms 10, 11, 12, 13)
_____Hepatitis B vaccination records (or declination forms) are available for all employees. (Reference Forms 15, 16)
_____
Employee post-exposure medical records (for all employees who sustained a needle-stick or other BBP or chemical exposure) are complete and located in a confidential area. Records are available from the last 30 years. (Reference Forms 14, 17, 18, 18-A)
_____
Engineering controls are functioning effectively (protective shields have not been removed or broken, and all parts are functioning as intended). Any fume hoods or biological cabinets have been certified as required by the manufacturer.
_____The Hazardous Substances List contains all hazardous chemicals in the facility (check for new chemicals recently brought into use). (Reference Form 19)
_____ SDS binder(s) are in the proper location (accessible to employees).
_____SDS are present for all hazardous chemicals in the facility, including fire extinguishing chemicals. (Reference SDS binder)
_____ TB skin test (TST) records are on file for all employees. (Reference Forms 22, 23)
_____ The annual TB risk assessment has been performed. (Reference Form 21)
_____The contents (type and number of items) of the first aid kit have been reviewed and are considered adequate for emergencies anticipated in the facility.
Storage Area
_____Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in a flammable cabinet etc.) and are disposed of properly.
_____ Chemicals are labeled legibly with contents and hazards clearly identified. Labels and pictograms match the identity on the corresponding SDS. (Reference Form 19, SDS binder)
_____ Appropriate PPE (gloves, respirators, goggles/face-shields, aprons) is available/accessible for handling hazardous chemicals. (Reference SDS binder)
_____ All items are stored at least 18 inches from the ceiling.
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OSHA Program Manual for Medical Facilities
(Annual Facility Review Checklist, page 3 of 3)Exam Rooms/Clinical Areas
_____All eyewash stations are in proper working order. Annual maintenance and testing is documented per the ANSI 2009 or 2014 Eyewash Standards, ANSI 358.1.
_____Universal Precautions/Standard Precautions are used when handling all blood and Other Potentially Infectious Materials (OPIMs).
_____Handwashing facilities (sinks with soap or alcohol gels) are available in all areas where biohazards and patients are encountered.
_____The biohazard symbol/label is used to indicate the potential presence of BBPs for all blood & OPIMs.
_____Contaminated items and regulated waste are placed into approved biohazard bags and containers displaying the biohazard symbol.
_____Biohazard waste bags/storage bins are located in every area where blood or OPIM are encountered and functioning properly (i.e. they can be securely closed).
_____PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is available in the correct sizes and amounts, and functions properly.
_____Sharps containers are in the proper locations and positioned firmly so that they cannot be knocked over.
_____Sharps containers are replaced as soon as they reach the “fill line” and not filled past ⅔ full.
_____The most effective engineering controls are available and functioning correctly (i.e. safety needles, sharps containers, fume hoods, splash shields)
_____Employees decontaminate and clean work surfaces as soon as contaminated and at the end of every shift with an appropriate disinfectant.
Cleaning/Decontamination Room
_____PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is available in the correct sizes and amounts, and functions properly.
_____Is appropriate PPE (rubber or vinyl gloves, respirators, goggles/face shields, aprons) available and accessible for handling hazardous chemicals in the workplace.
_____Employees decontaminate and clean work surfaces as soon as contaminated and at the end of every shift with an appropriate disinfectant.
_____Chemicals are labeled legibly with contents and hazards clearly identified. The GHS labels match the identity on the corresponding SDS. (Reference Form 19, SDS binder)
_____
Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in an explosion-proof flammable cabinet etc.) and are disposed of properly.
_____
Soaking basins or reservoirs used for decontamination of instruments have tight fitting covers to reduce evaporation of hazardous vapors and are properly labeled for chemical and biohazards.
Comments (explain any “No” answer): _____________________________________________________________________________________________________________________________________________________________________________________________________
Date: __________ OSHA Safety Officer*: __________________________________________* Note: Also document this annual OSHA Program Manual review on Form 3.
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 2-A Eyewash Station Weekly Check Log........... Use weekly to record performance of emergency eyewash stations.
Form 3 Annual OSHA Program Manual Review…...Use annually to document that this manual was reviewed and updated.
Form 4-A Weekly Facility Review Checklist............... Use weekly (optional form).
Form 4-B 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.
Form 7-B Healthcare Facility Slip, Trip, and Fall Hazard Checklist....................................
Use 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-A1 Failure to Use PPE..................................... Use to investigate incident.
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.
Form 13-A Exposure Prevention Checklist Use periodically to monitor compliance for sharps disposal container locations
Bloodborne Pathogens Employee Medical Records
Form 14 Incident Report/Sharps Injury….......... 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.
TB/Infection Control Records
Form 20 TB Risk Assessment Results Form…......... Use annually.
Form 21 TST Record……………..………..……......... Use as indicated, based on your facility’s risk assessment.
Form 22 TST Declination Form………….…...…........ Use when an employee declines receiving a TB skin test.
Form 23 TB Exposure Log……………….…...…........ Use as indicated when employees are exposed to a known TB patient.
Contents
Form 24 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 Checklist for Infection Prevention for Outpatient Settings......................................... Use initially and at least annually thereafter.
Form 25-C List of Infection Prevention Contact Persons and Roles/Responsibilities..............................
Use initially and whenever infection prevention roles and responsibilities change.
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 Annual Retraining (Sample Essay Test)…………..………........
Use annually.
Form 29 OSHA Annual Retraining (Sample Multiple Choice Test)……..…........
Use annually.
Form 30 OSHA Annual Retraining (Sample True/False Test)….…….…............
Use annually.
Form 31 Respirator Protection Training Record….... Use annually.
Form 31-A Qualitative Respirator Fit Test Report……... Use annually when requiring a respirator or when changing respirator selection.
Form 32 Checklist for Decreasing Surgical Fire Risks….................................................
Use annually.
Contents
OSHA Program Manual for Medical Facilities
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OSHA Program Manual for Medical Facilities
EYEWASH STATION WEEKLY CHECK LOGEyewash stations require weekly checks to be compliant with the American National Standards Institute, 2009 or 2014 edition, which OSHA may reference during an inspection. If your eyewash station does not have a weekly log already attached to the fixture, use this log to check the proper functioning of the station and to flush out stagnant water. Keep a separate log for each station and inspect for:
• Access and signage. Eyewash stations must be easily identifiable and unobstructed.
• Operation. Turn on the station and check that:–– The station activates easily with foot or one-handed control–– Flow removes eyepiece covers–– Water flows evenly, in a steady stream from both eyepieces–– If the eyewash is designed with a mixing valve, ensure the water temperature is
between 60-100 degrees F (tepid).–– Water flows continuously “hands-free”
• Flush. Run the station for up to three minutes to flush stagnant water from the line. Flush until the water is clear.
• Eyepiece presence and disinfection. Observe that both eyepieces are present and not cracked or damaged. Periodically rinse eyepieces with 10% bleach solution, flush with water for 15 seconds, and replace.
Date (weekly)
Access,signage Operation Flush Eyepiece
disinfection Notes Initial
Form 2-A
OSHA Program Manual for Medical Facilities
Form 4-A
WEEKLY FACILITY REVIEW CHECKLISTMark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered “No” to any question, explain on the reverse of this form.
Facility
_____Are all secondary containers, such as spray bottles and chemical bottles, properly labeled and legible, including the required OSHA pictograms?
_____Are all sharps containers filled below the “fill” line (or 2/3 full) and secure and positioned firmly so that they cannot be knocked over?
_____Are biohazard waste bags/storage bins in the proper locations (in every area where blood or OPIM is encountered) and functioning properly?
_____ Is the biohazard storage area clean, secure and orderly?
_____Is the autoclave working properly? Are weekly biological indicator test records complete? (Reference Form 2.)
_____Are scavenging systems for waste anesthetic gas (hoses, bags, masks, and connections) inspected for cracks and leaks?
_____
Is the eyewash station functioning properly? (Run water for several minutes and inspect /disinfect eyepieces; see Tab 5 for details.) (See weekly eyewash station log, Form 2A)
_____ Are exit signs visible and illuminated where required?
_____ Are all exit hallways unobstructed with exit doors unlocked from the inside?
_____
Do ALL facility exits have clear and unobstructed (by snow/ice, trash bins, containers, etc.) paths to the street or public way? (It is important to check secondary facility exits.)
Administration
_____
Have hepatitis B vaccinations been made available to unvaccinated new hires with occupational exposure to bloodborne pathogens after training and within 10 working days of initial assignment or has an OSHA declination form been signed?
_____Have tuberculin skin tests (TST) been made available to new hires before exposures to patients with TB or within 10 working days of initial assignment?
_____Is the exam/treatment room set-up and clean-up procedure consistently followed? (Reference Form 6.)
_____ Have the exam/treatment rooms been inspected for outdated supplies?
Date: ________________ OSHA Safety Officer: ______________________________
OSHA Program Manual for Medical Facilities
Form 4-B
MONTHLY FACILITY REVIEW CHECKLISTMark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered “No” to any question, explain on the reverse of this form.
Facility
_____Are compressed gas cylinders securely fastened in an upright condition? Are empty or unused gas cylinders capped and properly labeled and segregated from each other?
_____ Are exit doors free of blockage, clearly marked, and unlocked?
_____Are fire extinguishers fully charged, accessible, inspected and in their designated places?
_____ Are all floors and carpets dry and free of tripping hazards?
_____Are stored items not stacked higher than 5 feet (unless a stepstool is available), stable, and located more than 3 feet from any heat source?
_____Are PPE (gowns, face shields, gloves, shoe covers, etc.) and respirators (N95s) in the proper location, available in the correct sizes and amounts, and functioning properly?
_____ Are hand sanitizers available, in date and in the proper locations?
_____ Are all chemicals labeled legibly so contents and hazards are clearly identified?
_____ Are chemical and biohazard spill kits available and within their expiration date?
_____ Are all first aid kit/crash cart components within their expiration dates?
____Do emergency backup lights/batteries have documented testing for 30 seconds every month?
Administration
_____Have all new employees completed a “New Employee OSHA Orientation” checklist? (Reference Form 26.)
_____Is the SDS binder and the Master Hazardous Substances List up to date, reflecting any new chemicals brought into use this month? (Reference Form 19, (SDS Binder.)
_____
Do the Exposure Determination Lists #1 and #2 reflect new employees with occupational exposure? Have employees who left the facility been removed? Have employees whose job duties changed been added/deleted? (Reference Form 8, 9.)
_____Has a new clinical procedure been implemented which requires face, body, or hand protection? If so, has the PPE table (Tab 5) been updated?
Date: __________________ OSHA Safety Officer: __________________________________
OSHA Program Manual for Medical Facilities
Form 5
ANNUAL FACILITY REVIEW CHECKLIST(1 of 3 Pages)
Mark Yes (Y), No (N) or Not Applicable (NA) for the following OSHA requirements. Explain any “No” responses in the space provided at the end of this form.
General Facility Safety
_____The most current OSHA poster, “It’s the Law” (or state equivalent poster) is visible to all employees.
_____ Exit doors are free of blockage, clearly marked and unlocked.
_____Exit signs are properly lit and backup lights/batteries are functioning. The 90-minute annual testing of backup lights with batteries is documented.
_____ If your facility has 10 or more employees, a written evacuation plan/route is posted. _____ Medical equipment cords have grounded 3-pronged plugs. _____ _____
Extension cords are being used properly (not as permanent wiring). Extension cords are not plugged into each other (daisy-chained).
_____Electrical cords are managed to prevent tripping hazards (not placed under rugs or across doorways).
_____ Electrical cords are in good condition (no frays, defects, etc.). _____ The fire alarm is in proper working order, if present. _____ An appropriate number of fire extinguishers are present/accessible.
_____
The fire extinguishers have been inspected and tagged within the last 12 months and are fully charged. A record review shows that the extinguishers were inspected during each month of the last 12 months.
_____ Panic buttons, or public address systems, are in working order, if present. _____ The worksite is maintained in a clean and sanitary condition. _____ Restricted areas (lab, decontamination room, etc.) are designated with signage.
Break Room
_____The break area is free of contamination from blood and other potentially infectious materials (OPIMs).
_____ Employees discard PPE before entering the break area (before leaving exam rooms).
_____ The break area is free from hazardous chemicals.
Check-in/Reception
_____ An up-to-date emergency contact list is posted or present. (Reference Form 7-A)
_____ The reception area is free of contamination from blood and OPIMs.
_____ Employees discard PPE before entering the reception area (before leaving exam rooms).
_____ The reception area is free from hazardous chemicals. Administration Area
_____
All employees have undergone OSHA annual retraining on bloodborne pathogens, hazard communication and TB in the last 12 months and this training is documented. (Reference Form 27)
_____
All new employees received initial OSHA training (if not previously trained) or completed a New Employee Orientation Checklist (if previously trained) and this training is documented. (Reference Form 26)
OSHA Program Manual for Medical Facilities
Form 5
(Annual Facility Review Checklist, page 2 of 3)
_____Employees are trained on the proper precautions, and how to properly don and use, the PPE necessary for their job duties. (Reference Forms 26, 27)
_____
All employees participated in at least one fire drill this year or have signed Safety Committee/staff meeting minutes where they reviewed the fire drill discussion and results. (Reference Forms 5-A, 5-B)
_____Employees have been trained on how to respond in the event of a fire (R.A.C.E.). (Reference Forms 26, 27)
_____Employees have been properly trained on how to use a fire extinguisher (P.A.S.S.). (Reference Forms 26, 27)
_____ All OSHA training records from the last three (3) years are available. (Reference Forms 26, 27)
_____Exposure Determination Lists #1 and #2 document all employees with risk for exposure. (Reference Forms 8, 9)
_____The facility has documented all needlesticks and other sharps injuries which occurred this year using the Incident/Sharps Injury Log (Reference Form 14)
_____
All employee accidents, near-misses, injuries and complaints (check Safety Report and Incident/Sharps Injury Logs) were examined for trends. The need to change engineering controls, policies or procedures was evaluated. (Reference Forms 1, 14)
_____
In areas where trends were noted above or safer sharps have not yet been implemented front-line employees have evaluated new safety devices for possible future implementation. Evalua-tions have been documented, and evaluation forms are retained. (Reference Forms 10, 11, 12, 13)
_____Hepatitis B vaccination records (or declination forms) are available for all employees. (Reference Forms 15, 16)
_____
Employee post-exposure medical records (for all employees who sustained a needlestick or other BBP or chemical exposure) are complete and located in a confidential area. Records are available from the last 30 years. (Reference Forms 14, 17, 18, 18-A)
_____
Engineering controls are functioning effectively (protective shields have not been removed or broken, and all parts are functioning as intended). Any fume hoods or biological cabinets have been certified as required by the manufacturer.
_____The Hazardous Substances List contains all hazardous chemicals in the facility (check for new chemicals recently brought into use). (Reference Form 19)
_____ SDS binder(s) are in the proper location (accessible to employees).
_____SDS are present for all hazardous chemicals in the facility, including fire extinguishing chemicals. (Reference SDS binder)
_____ TB skin test (TST) records are on file for all employees. (Reference Forms 22, 23)
_____ The annual TB risk assessment has been performed. (Reference Form 21)
_____The contents (type and number of items) of the first aid kit have been reviewed and are considered adequate for emergencies anticipated in the facility.
Storage Area
_____
Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in a flammable cabinet etc.) and are disposed of properly.
_____Chemicals are labeled legibly with contents and hazards clearly identified. Labels and pictograms match the identity on the corresponding SDS. (Reference Form 19, SDS binder)
_____ Appropriate PPE (gloves, respirators, goggles/face-shields, aprons) is available/accessible for handling hazardous chemicals. (Reference SDS binder)
_____ All items are stored at least 18 inches from the ceiling.
OSHA Program Manual for Medical Facilities
Form 5
(Annual Facility Review Checklist, page 3 of 3)
Exam Rooms/Clinical Areas
_____All eyewash stations are in proper working order. Annual maintenance and testing is documented per the ANSI 2009 or 2014 Eyewash Standards, ANSI 358.1.
_____Universal Precautions/Standard Precautions are used when handling all blood and Other Potentially Infectious Materials (OPIMs).
_____Handwashing facilities (sinks with soap or alcohol gels) are available in all areas where biohazards and patients are encountered.
_____The biohazard symbol/label is used to indicate the potential presence of BBPs for all blood & OPIMs.
_____Contaminated items and regulated waste are placed into approved biohazard bags and containers displaying the biohazard symbol.
_____Biohazard waste bags/storage bins are located in every area where blood or OPIM are encountered and functioning properly (i.e. they can be securely closed).
_____PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is available in the correct sizes and amounts, and functions properly.
_____Sharps containers are in the proper locations and positioned firmly so that they cannot be knocked over.
_____Sharps containers are replaced as soon as they reach the “fill line” and not filled past ⅔ full.
_____The most effective engineering controls are available and functioning correctly (i.e. safety needles, sharps containers, fume hoods, splash shields)
_____Employees decontaminate and clean work surfaces as soon as contaminated and at the end of every shift with an appropriate disinfectant.
Cleaning/Decontamination Room
_____PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is available in the correct sizes and amounts, and functions properly.
_____Is appropriate PPE (rubber or vinyl gloves, respirators, goggles/face shields, aprons) available and accessible for handling hazardous chemicals in the workplace.
_____Employees decontaminate and clean work surfaces as soon as contaminated and at the end of every shift with an appropriate disinfectant.
_____Chemicals are labeled legibly with contents and hazards clearly identified. The GHS labels match the identity on the corresponding SDS. (Reference Form 19, SDS binder)
_____
Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in an explosion-proof flammable cabinet etc.) and are disposed of properly.
_____
Soaking basins or reservoirs used for decontamination of instruments have tight fitting covers to reduce evaporation of hazardous vapors and are properly labeled for chemical and biohazards.
Comments (explain any “No” answer): ____________________________________________________________________________________________________________________________________________________________
Date: __________ OSHA Safety Officer*: __________________________________________* Note: Also document this annual OSHA safety program review on Form 3.
OSHA Program Manual for Medical Facilities
Form 5-A
FIRE DRILL EVALUATION FORM
Date: ________________ Announced Unannounced (check one)
Time to complete drill (minutes): __________
Staff learned of simulated fire by: ___________________________________________
Name of person discovering “Fire Flag” or simulated problem: ____________________
Mark Y, N or N/A___ Was fire signal (Code Red) audible to all employees and patients?___ Were employees aware of the location of the closest fire alarm pull station?___ Were patients evacuated promptly, safely and without undue panic?___ Did all employees perform their assigned responsibilities (e.g., shut off medical
gas canisters in use, check restrooms, close doors and windows, call roll after evacuation)?
___ Was the posted evacuation route used?___ Did staff meet at the designated assembly site outside the office?___ Was the evacuation route adequate?___ Was the fire department alerted (in fact or in simulation)?___ Were the office doors and windows closed?___ Were attempts made to contain or extinguish the fire versus evacuating the building? Was this the right decision? _____ ___ If employees attempted to extinguish the fire, did they use the proper technique? (PASS)___ Were fire extinguishers in the correct locations, charged and in working order?___ Did a staff member meet and direct the emergency response team?___ Were patient records isolated or protected?___ Were "wounded" patients and staff members adequately triaged? ___ Did the staff act as a "team"?
Comments/Critique:_____________________________________________________________________________________________________________________________________________________
Recommendations:_____________________________________________________________________________________________________________________________________________________
OSHA Safety Officer: _______________________________________________________________
OSHA Program Manual for Medical Facilities
Form 5-B
EMPLOYEE FIRE DRILLPARTICIPATION SIGN-UP SHEET
Date: ___________________
Participating Employees
Non-participating EmployeesName Date Safety Minutes/Fire Plan Reviewed
OSHA Safety Officer: ____________________________________________________
OSHA Program Manual for Medical Facilities
Form 7-A
EMERGENCY PHONE LIST
Keep this emergency phone list current and easily available.
Name Telephone Number
OSHA1-800-321-OSHA (6742)
TTY 1-877-889-5627
Rescue squad
Police department
Fire department
Hospital emergency room
Public health department
Equipment repair
Infectious waste disposal carrier
Safety officer
Structural failure
Poison control center
Electrician
Sprinkler company
Heating/air conditioning repair
Fire extinguisher company
Elevator inspector
Gas/fuel company (if gas or fuel heat)
Compressed Gas Distributor
OSHA Program Manual for Medical Facilities
Form 8
BLOODBORNE PATHOGENSEXPOSURE DETERMINATION LIST #1
Employees with Definite Risk of Exposure (Class I)
Job Title Department/Location Date/Revision
OSHA Program Manual for Medical Facilities
Form 9
BLOODBORNE PATHOGENS EXPOSURE DETERMINATION LIST #2
Employees with Possible Risk of Exposure (Class Il)
Job Title Employee Name Tasks Performed
OSHA Program Manual for Medical Facilities
Form 9-A
BLOODBORNE PATHOGENS PPE COMPLIANCE CHECKLIST
Use this checklist to periodically monitor compliance with the personal protective equipment (PPE) sections of the bloodborne pathogens (BBP) standard, 1910.1030.
Section Requirements Compliance
(d)(3)(i) The facility provides appropriate PPE to all exposed personnel at no cost and in appropriate sizes.
Yes No
(d)(3)(ii) All employees covered under the standard receive training in the proper use, types, and locations of PPE.
Yes No
(d)(3)(ii) The employer makes sure that employees use appropriate PPE. Yes No
(d)(3)(ii) If a rare situation arises in which the use of PPE might prevent safe healthcare or causes increased hazards to the employee or a coworker, the facility documents the situation and investigates.
Yes No
(d)(3)(iii) Alternative gloves (e.g., hypoallergenic, latex-free) are readily available to employees who may have allergies to the gloves that are normally available.
Yes No
(d)(3)(iv) The employer cleans, launders, disposes of, repairs, and replaces PPE and clothing at no cost to the employee.
Yes No
(d)(3)(vi) If blood or other potentially infectious materials penetrates a garment, employees should remove the clothing immediately or as soon as possible.
Yes No
(d)(3)(vii) Employees remove all PPE before leaving work areas. Yes No
(d)(3)(viii) When employees remove PPE, they place it into a designated area or container for storage, washing, decontamination, or disposal.
Yes No
(d)(3)(ix)
Employees wear gloves when they anticipate coming into contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin. They also wear gloves when performing vascular access procedures and when handling or touching contaminated items or surfaces.
Yes No
(d)(3)(x)
Employees wear masks and goggles whenever there is a reasonable likelihood that splashes, spray, blood droplets, or other potentially infectious materials may enter their eyes, nose, or mouth.
Yes No
(d)(3)(xi) Employees wear gowns, aprons, lab coats and clinic jackets, or similar outer garments, whenever they anticipate a reasonable likelihood of exposure.
Yes No
(d)(3)(xii) Employees wear surgical caps or hoods and shoe covers or boots in instances when gross contamination can reasonably be anticipated (e.g., during orthopedic surgery).
Yes No
OSHA Program Manual for Medical Facilities
Form 9-A1
FAILURE TO USE PPEEmployees may not decide to routinely decline the use of PPE due to inconvenience or personal preferences. Use this form, however, to investigate rare occasions when PPE was declined because use would:
• Prevent the delivery of health care or public safety services; or
• Pose an increased hazard to the employee’s safety or that of coworker(s)
Procedure/Task/ Location Type of PPE Reason for declining
PPE use Employee name Date
Summary of investigation:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Investigator: ______________________________________________________________________________
Date of improvement or action: _________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
OSHA Program Manual for Medical Facilities
Form 14
INCIDENT REPORT/SHARPS INJURY(1 of 2* Pages)
Complete this report for incidents and accidents. Document employee injuries that require more than simple first aid.
Situation/procedure: __________________________________________________________Date of incident: ________________________ Time of incident: ______________________Exact location of incident: _____________________________________________________Type of incident: (Check ALL that apply!) Near miss. Patient safety concern. Non-employee injury. Body part involved:_____________________ Employee injury. Body part involved: ________________________ Sharps injury. (Fill out Exposure and Sharps Injury on page 2) Splash/spray to mucous membrane or non-intact skin. (Fill out Exposure on
page 2) Chemical injury: ______________________________ (Attach SDS.) (Name of substance) Other. Specify: ____________________________________________
Employee name: _____________________ Employee title: ___________________Circumstances of the incident: (What happened? How did it happen? Who was involved? What caused the incident?)______________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
Engineering controls/work practices/protective equipment/safety devices in use at the time of the incident: __________________________________________________________Witness/person familiar with incident: ___________________________________________Resolution:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.
OSHA safety officer signature: ________________________ Date reviewed: __________Supervisor signature: ________________________________ Date reviewed: __________
*2nd page used only when indicated above.
(Use reverse if necessary)
(Use reverse if necessary)
OSHA Program Manual for Medical Facilities
Form 14
(Incident Report/Sharps Injury, page 2 of 2 – use only when indicated on page 1)
EXPOSURERoute of exposure:
Sharps injury Splash to* _________________. Spray to* __________________.
*Designate abraded skin, eye, mouth, etc.
Source patient name/description:
Please refer to patient info below:
Source individual’s name is not available. Explain: __________________________ ________________________________.
Was source individual tested** for:
HIV Yes NoHIV test dateHepatitis B Yes NoHBV test dateHepatitis C Yes NoHCV test date
**Obtain proper written consent, if required in your state, prior to testing. If source patient is already known to be positive for HIV, HBV, or HCV, new testing is not required.
Date/time _________________ employee sent to ____________________________ for evaluation and follow up. If declined, attach Post-Exposure Medical Evaluation Declination (Form 18).
Complete and attach: Post-exposure Checklist (Form 17) File original Form 14 with all supporting attachments in confidential employee medical record.
Maintain this record for the duration of employment plus 30 years.
Employee name: _______________________ Date of incident: ________________________
SHARPS INJURYType/brand name of device involved in the exposure: ____________________________.
Did the device in use have engineered sharps injury protection? Yes No
If no, does the injured employee believe a protective mechanism could have prevented the injury? Yes No
Was the device used properly? Yes No
Was the protective mechanism activated? Yes No
Did the exposure occur: Before activation? During activation? After activation?
When/how did the exposure incident occur? During use of sharp Between steps of a multi-step procedure After use and before disposal of sharp While putting sharp into disposal container Sharp left in inappropriate place Overfilled sharps container Disassembling Other _______________________________.
Does the exposed employee believe other controls (procedural, administrative, etc.) could have prevented the injury? Yes No
Comments: ___________________________________________________________________________________________________________.Transfer the information in this box to the Sharps Injury Log, Form 14-A
Patient Name: ________________Age: ______ Sex: ________
(or use patient sticker)
OSHA Program Manual for Medical Facilities
Form 19
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