OSHAWatch
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Update Your Safety Manual
Hazard Analysis, Waste Disposal,
Cytotoxic Drugs Recommendations
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January/February 2007
Volume 9, No.1
Inside:
Take 5 Training Tip..................3
In the News ..............................4
Q
uality America is all about making
compliance easy for our OSHA Watch
subscribers. With every issue of this
newsletter we give you exclusive access
to our website where you can
download updates for your OSHA Safety
Manual. Password information to get to these
important updates is located on the back page
of each newsletter.
Beginning
with this
issue of
OSHA
Watch, we’re
expanding
our Safety
Manual
updates by
giving you
solid
information
on why these
updates are
important.
E
Beginning with this issue of OSHA Watch, we’re
expanding this service by giving you solid
information on why these updates are
important. Did a new regulation pass? Does a
certain OSHA policy or procedure need
clarification? Has a Public Health Service alert
been issued that should become part of your
safety program? Whatever the reason, we’ll focus
each issue on telling you what’s new and why it’s
important, in addition to giving you the pages
to add to your OSHA manual.
This issue of OSHA Watch updates three
important areas in your Safety Manual:
Hazard Analysis: A Great Tool for Managing
Your OSHA Program
Ask the Expert ..........................6
OSHA Manual Update.............8
SAFETY SHORTS
Good News: Human-to-human
transmission of H5N1 flu has yet to
occur in the U.S.
Bad News: Fewer than 40% of
healthcare workers received the flu
vaccine during the last flu season.
[ MORE ON BACK PAGE ]
EE
FR Alerts!
H
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To receive breaking
OSHA news, go to
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Newsletter”on the top
right corner.
Every OSHA Safety Officer has concerns.
How would our practice do if OSHA walked in
the door? What if an employee were injured
performing a procedure that isn’t addressed in our
OSHA manual?
continued on next page
We Make Compliance Easy!
1
Update Your Safety Manual
Hazard Analysis, Waste Disposal, Cytotoxic Drugs Recommendations cont’d
Think about all
the tasks your
employees
perform every
day: suturing,
laser surgery,
phlebotomy,
giving injections,
decontaminating
instruments, the
list goes on. All
have risks...
2
In a recent Quality America
teleconference, “Administering Your
OSHA Program,” we helped
participants with a Hazard
Analysis–listing all the procedures
performed in their facility, then ensuring
that the hazards associated with those
procedures are controlled by their
OSHA program.
We have amended the Hazardous Waste
Disposal sub-section in the Waste
Disposal section of Quality America’s
OSHA Safety Manual (Tab 8) to better
describe EPA-listed hazardous wastes. A
handy table lets you see clearly which
requirements apply at your facility based
upon your hazardous waste generator
status.
Think about all the tasks your
employees perform every day: suturing,
laser surgery, phlebotomy, giving
injections, decontaminating instruments,
and the list goes on. All have risks, some
from splashes or punctures with
infectious fluids, some from hazardous
chemical exposures. Other procedures
carry unique hazards, such as respiratory
and eye damage from lasers.
Cytotoxic Drugs: Glove
Recommendations
A Hazard Analysis is located in Quality
America’s OSHA Safety Program
Manual under the OSHA Program
Administration section (Tab 2). We’ve
revised this document to better stipulate
how each section of the manual
addresses all the potential hazards in
your medical facility.
This is the big picture view of your
OSHA program, so please read it
carefully and be sure that it includes all
procedures performed in your practice.
Then, sit back, relax and be confident
that you’ve covered all the bases!
Hazardous Waste Disposal: New
Legislation from EPA
New legislation from the Environmental
Protection Agency (EPA) classifies
hazardous waste and requires that you
begin using a new hazardous waste
record, the Uniform Hazardous Waste
Manifest.
The National Institute for
Occupational Safety and Health
(NIOSH) alert, “Preventing
Occupational Exposures to
Antineoplastic and Other Hazardous
Drugs in Health Care Settings,”
contains safety recommendations to
help workers who prepare and
administer
cytotoxic drugs
avoid
contamination.
We updated
the Cytotoxic
Drugs section
of Quality
America’s
OSHA Safety
Manual
(Tab 9) to
recommend double-gloving with
chemotherapy-specific gloves when
handling antineoplastic drugs. We also
updated information on Biological
Safety Cabinets (BSC) and closedsystem transfer devices.
We encourage you to download these
important updates today. See page 8 for
your username and password.
www.quality-america.com • 1-800-946-9956
Take 5 Training Tip
Start the year off right: Get back to the basics with a fire safety refresher. Write each letter of
the A.R.A.C.E. and P.A.S.S. acronyms on an index card (use different colors if you would like
to distinguish the A’s). Hand out one card to each staff member at your next meeting. Ask
employees to explain what the letter stands for. Then discuss when and how to use each
procedure.
If you see smoke or fire, act quickly following the “A.R.A.C.E.” procedure:
Announce “Code Red.”
Rescue those in immediate danger.
Alarm. Activate the fire alarm. Call 911 and give exact location of fire, your name and
type of fire (if known). Always let the operator hang up first. During the “Take
5”exercise, ask the employee to state the location of the fire alarm(s) in your building.
Contain the fire by closing all doors and windows.
Extinguish or Evacuate. Describe the evacuation route and have the employee physically go
and retrieve the fire extinguisher(s).
To put out a fire with a portable extinguisher, a person must be able to activate the extinguisher
and use it effectively. Attempting to fight even a small fire carries risk. Fires can increase in size
and intensity in seconds, blocking the exit path and creating breathing hazards.
Hand the extinguisher to each employee as they describe and demonstrate how they would
accomplish each step in the P.A.S.S. approach below. Don’t actually pull the pin or squeeze the
discharge handle unless you have another extinguisher available (ABC rated extinguishers will
NOT hold a charge after partial use). Also, if you do decide to actually discharge the
extinguisher, make sure you do this outside (ABC extinguishers leave a residue that can
harm sensitive equipment, like computers, and is mildly corrosive to many metals like
aluminum, copper and steel). If staff physically discharge the unit, position everyone
upwind to keep them from inhaling the dry chemical agent in ABC extinguishers.
Have staff demonstrate how to use a fire extinguisher using the “P.A.S.S.” technique:
Pull the activation pin.
Aim the nozzle at the base of the fire.
Squeeze the handle to release the extinguishing agent.
Sweep the stream over the base of the fire.
Wrap up the training by discussing when to evacuate instead of extinguishing the fire, such as:
If the fire involves flammable solvents.
If it has spread more than 60 square feet.
If the fire is partially hidden behind a wall or ceiling.
If it cannot be reached from a standing position.
If, due to smoke, the fire cannot be fought without respiratory protection.
If the heat makes it difficult to approach.
For more information reference pages 3-3 to 3-8 and 3-16 to 3-18 of the Quality America
Safety Program Manual.
Sources:
1. www.ou.edu/oupd/fireprim.htm
2. http://firedept.ci.lubbock.tx.us/firemarshal/fmoweb2/FireExtinguishers/fireextinguishers.html
OSHA Watch Update January/February 2007
3
Why Don’t We Do It In Our Sleeves
in the
You feel a sneeze or cough coming on.
There’s not a tissue in sight. What
should you do? Most people
automatically put their hands in front
of their mouths and noses to stop
germs from getting into the air. But
this technique puts the germs on their
hands, which then spreads them to
telephones, doorknobs and
other surfaces. Other people
touch these surfaces and voila!
Colds and flu spread quickly
through schools, workplaces
and entire cities.
NEWS
Want to train staff on proper cough
techniques? A humorous five-minute
video, produced by an ENT physician
and the Maine Medical Association, is
fun to watch and will actually make
people change the way they cough and
sneeze.
Source: www.coughsafe.com/index.html
Discard Tube Holders After Each
Phlebotomy
OSHA cited Quest Diagnostics
Laboratory in 2004 for reusing blood
tube holders, specifically, the BD
"Pronto” auto-release blood collection
device. After contesting OSHA’s
penalty of several thousand dollars,
Quest finally lost the battle in
November when an Administrative
Law Judge upheld OSHA’s citation.
The judge cited two Quest accident
reports documenting accidental
needlesticks sustained by
phlebotomists from the back end of
needles.
Source: Phlebotomy Today
www.phlebotomy.com/Newsletter.html
Asthma Risks at Work
Several common substances in the
indoor healthcare environment can
cause or trigger asthma, including the
disinfectant glutaraldehyde, latex and
4
biological allergens, formaldehyde and
the sterilizing agent ethylene oxide.
The 87-page “Risks to Asthma Posed
by Indoor Health Care Environments:
A Guide to Identifying and Reducing
Problematic Exposures,” suggests ways
to mitigate exposure for the 10-20% of
adult-onset asthma cases that are due
to workplace exposures.
Source: Health Care Without Harm.
Oct. 18, 2006
www.noharm.org/details.cfm?type=document
&ID=1315
Suture Needle Injury Stats
Suture needles cause 51% of sharps
injuries in surgical settings while scalpel
blades rank a distant second, with 12%
of injuries. Sharp-tip suture needles
account for 54,000 sharps injuries per
year, mostly by needles used to suture
muscle or fascia, for which blunt suture
needles could be substituted. U.S.
hospitals end up spending about $36.3
million per year to test and treat victims
of these types of sharps injuries-an
expense that could be avoided by
implementing blunt suture needles where
applicable.
Source: International Healthcare Worker
Safety Center Fact Sheet: “Percutaneous
Injuries from Suture Needles,”
www.healthsystem.virginia.edu/internet/epinet/
SUTURE-NEEDLES-INJURIES-info.pdf
Long Work Hours = More
Needlesticks
Three years ago in OSHA Watch we
reported on the new Accreditation
Council for Graduate Medical
Education (ACGME) restrictions
limiting work hours for interns and
residents to 30 consecutive and 80
total hours each week. Residents were
also required to have one day off a
week. But that’s not happening.
In the year after the limits were
imposed, 83% of interns reported
working hours that, for at least one
month, violated the ACGME rules.
www.quality-america.com • 1-800-946-9956
And medical centers not complying
are reporting more needlestick
injuries. Lapses in concentration and
fatigue are likely responsible for the
61% increase in needlesticks following
an overnight shift.
giving an epidural anesthetic intravenously
to a 16-year-old patient who was in labor,
instead of penicillin, which had been
prescribed IV for a strep infection. If
convicted, she faces a $25,000 fine and
up to three years in prison.
Source: JAMA, 296:1055-1070. 2006
Coming Clean About Medical Errors
Anyone would be uncomfortable
’fessing up to a medical error, and
physicians are no exception. When
asked how they would disclose an
error, most physicians said they would
be more likely to report it if the
mistake were obvious to the patient.
∑ • 56% chose statements that ∑ ∑ ∑
mentioned the adverse event but ∑
not the error.
∑ • 19% would not volunteer any ∑
information about the error's ∑ ∑
cause.
∑ • 63% of physicians would not ∑ ∑
provide specific information ∑ ∑
about preventing future errors.
∑ • 42% would explicitly state that ∑
an error occurred.
Surgical specialists are less likely (19%)
than medical specialists (58%) to
explicitly tell a patient about a medical
error.
Source: Archives of Internal Medicine, Vol.
166 No. 15. Aug. 14/28, 2006
Nurse Faces Criminal Charges for
Medication Error
Nurses and hospital associations are
outraged that a Wisconsin nurse was
charged with a felony after mistakenly
This landmark case implies that healthcare
workers are at risk for criminal charges if
they make an unintentional error. The
American Nursing Association believes
that criminal indictment will have a
chilling effect on the willingness of
registered nurses and other healthcare
professionals to report errors for fear of
prosecution–not to mention its effect on
staff morale and nursing recruitment efforts.
Source: Wisconsin State Journal. Nov. 3, 2006
Decorations Ease Needle Phobia
Most kids put up a real fuss about
needles: 57% cry, 55% have trouble
sitting still, and 14% actually try to run
away. So, the University of New Mexico
Health Sciences Center added butterflies,
fish, smiley faces and flowers to syringes
in the hopes that decorations will make
the doctor’s office a lot less scary.
The decorated needles reduced aversion to
needles by 68%, fear by 53% and anxiety
by 53%. Even adults liked them: 95%
preferred the decorated syringes to the
non-decorated ones; 100% of the children
did. The same results occurred with
decorated IV bags and scalpels.
Sources:
1. Journal of Family Practice. Aug.2006
2. Yahoo Survey on Pediatric Fear of Needles:
biz.yahoo.com/prnews/061016/sfm051.html?.v=66
3. The Albuquerque Tribune. Less Fear is
Decorated Needle’s Point. Aug. 19, 2006
www.grantland.net
OSHA Watch Update January/February 2007
5
Q
Cleaning Ultrasound Probes, Safe Suture Needles,
Scrubs in the Clinic, Food and Drinks at the Front Desk
Reporting Fires to OSHA
Q. If a fire breaks out in our OR, are
we required to report it to OSHA?
ask the
A. Not unless three or more employees
are hospitalized because
of injuries from the
fire. Any work-related
fatality must also be
reported to OSHA.
EXPERT
Cleaning Ultrasound Probes
Q. We use transvaginal ultrasound
probes covered with condoms. Can you
tell me how to clean the probe after
each patient? Our doctors believe it is
sufficient to just spray the probe with a
disinfectant and wipe it clean.
Dr. Sheila Dunn
A. Since the probe touches patient
mucous membranes, which are capable
of transmitting bloodborne pathogens,
you must use a chemical sterilant, such
as glutaraldehyde. Note also that
several studies confirm that latex
condoms often fail (6.9%) and that
visual inspection is inadequate 5% of
the time. To substantiate this practice,
check out the Guidelines for Cleaning
and Preparing Endocavitary
Ultrasound Transducers Between
Patients from the American Institute of
Ultrasound in Medicine at
www.aium.org/publications/statements
/_statementSelected.asp?statement=27
Sample Meds
Q. How should sample medications be
stored?
A. First, restrict access to the area
where prescription drug samples are
stored. Store samples by therapeutic
class rather than alphabetically, to
reduce the danger of serious dispensing
6
errors. Read the labels to be sure that
samples are stored at the correct
temperature, light and humidity.
Periodically monitor and discard
expired medications.
Safe Suture Needles
Q. The only area where we haven’t
converted to safety sharps in our
practice is for suture needles. Blunt
suture needles don’t work for stitching
up skin wounds. If OSHA inspects us,
will using non-safe sutures be a
violation?
A. OSHA requires us to look at
alternative ways to perform a
procedure in addition to safety
alternatives. Since blunt suture needles
don’t work in your circumstances,
consider sharpless techniques such as
skin adhesives, electrocautery, tissue
stapling and minimally invasive
instrumentation. Some products to
check out are Steri-Strip™ Adhesive
Skin Closures and Precise™ Skin
Staplers, both manufactured by 3M.
Removing Needles from Syringes
Q. Is it okay to remove a safety needle
from the syringe to dispose in a sharps
container if the needle isn’t
contaminated?
A. If the needle is used for a procedure
where it will never become
contaminated (such as when drawing
up meds and changing the needle
before patient administration), save
some money and don’t use a safety
needle for such procedures. If a needle
is contaminated, OSHA’s Bloodborne
Pathogens Standard prohibits its
removal “unless the employer can
demonstrate that no alternative is
feasible or that such action is required
www.quality-america.com • 1-800-946-9956
answer
by a specific medical or dental
procedure.”
Bottom Line: An uncontaminated
needle can be removed from a syringe
for disposal, BUT indicate this
procedure in your OSHA Safety
Manual. If the procedure isn’t
documented, an OSHA inspector
would assume that discarded needles in
sharps containers are contaminated and
would issue a citation.
OPIMs might splash or spray, you must
be provided with a fluid resistant gown
to wear over your scrubs as PPE. From
what you describe, scrubs are simply a
“uniform” in your clinic, not PPE, so
your employer is not legally obligated to
wash them and, according solely to
OSHA, you could wear them home.
PPE must be washed by the employer
and can’t be worn home. Remember,
employers can set policies above and
beyond what OSHA requires. It sounds
like that's true in your case.
Lab Coats
Q. Do lab coats have to have cuffed
sleeves and be fluid resistant?
A. Only if they're being used as PPE
(Personal Protective Equipment). If
your staff are just wearing lab coats as
part of their uniform, then they don't
need to be fluid resistant. If, however,
lab coats are worn only as PPE, when
the worker could be splashed or sprayed
with an infectious material, then they
do need to be fluid resistant. Cuffs are
nice, but not absolutely necessary.
Sleeves could be tucked inside gloves
when lab coats are being used as PPE.
Scrubs in the Clinic
Q. What is the regulation regarding
changing scrubs before leaving the
clinic? I am told we must change out of
them because of the bloodborne
pathogens regulations, but we are
seldom around blood. Also, we are told
that the scrubs must be professionally
washed. Is this a requirement?
A. OSHA does not consider scrubs to
be Personal Protective Equipment (PPE)
because the fabric is permeable to blood
and other potentially infectious
materials (OPIMs). When you are
performing procedures where blood or
OSHA Watch Update January/February 2007
Food and Drinks at the Front Desk
Q. We’ve restricted food and beverages
from the appointment desk area, but
employees are rebelling! Isn’t this an
OSHA regulation?
A. According to the Bloodborne
Pathogens Standard, the front office is
not an area that can be “reasonably
anticipated” for splashes or sprays of
blood or OPIMs to occur (unless lab
specimens are handled in this area). If
your reception desk area is reserved for
only clerical functions, front office
employees can have food/drink at their
workstations, based solely on OSHA
regulations. Keep in mind,
though, that OSHA
standards represent the
minimum requirements
for employee safety and
each office has the option to
make more stringent dress codes
and policies for behavior. I sure
wouldn’t want a reception area to smell
like a sardine sandwich! That said, most
medical and dental practices allow eating
only in the break room, but drinking is
another story. I bet you could quell the
rebellion by allowing beverages. Just hope
someone doesn’t bring in fermented
barley juice!
7
SAFETY SHORTS:
A quick look back at news from 2006
First, the Good News
Coming soon to healthcare facilities: Antimicrobial
gloves containing chlorhexidine that reduce
transmission of multidrug resistant organisms, such
as MRSA, by 90-100%.
Also coming: Surgical sponges tagged with radio
frequency. Before sewing up, a handheld wandscanning device detects tagged surgical sponges that
may have inadvertently been left in the patient.
This one beats them all. While we sometimes infer
that OSHA is heavy handed, most of the time,
OSHA’s worker safety regulations do save lives.
This literally was the case last spring when an OSHA
inspector in Ohio, acting on an anonymous
complaint, made a surprise visit to a construction
site of a preschool and noticed that the structure
wasn’t braced properly. He issued a stop-work order
and removed the workers just minutes before the
roof fell in and the walls collapsed.
Now for the Not-So-Good News
Last winter, the owner of Comfort and Caring
Home Health Company was arrested for preparing
to give bogus flu shots consisting of purified water.
Doctors’ offices lag way behind hospitals in safety
sharp product conversions in all categories, but
especially for syringes (45% versus 79%).
OSHA Manual
UPDATES
Hazard Analysis, Waste Disposal, Cytotoxic Drugs
Quality America has updated and improved Tabs 2, 8, and 9 of
the OSHA Safety Program Manual. In Tab 2, the Hazard
Analysis was revised to explain how each section of the Manual
thoroughly addresses potential hazards in your facility. In Tab 8
we updated the Waste Disposal section based upon new
manifesting requirements. Tab 9 includes the latest precautions to
take when working with Cytotoxic Drugs. Here’s how to get
these updates for your Manual.
Medical & Dental Practices
1. Go to www.quality-america.com/oshawatch
2. Enter username and password below:
Username: qualityamerica
Password: startright
3. Click each link to download updates.
4. Print and replace old pages with new.
©1999-2007 Quality America ®, Inc. All rights reserved. No part of this
publication may be reproduced, stored in any retrieval system, or transmitted in
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otherwise–without the prior written permission of the publisher, Quality
America ®, Inc. OSHA Watch offers easy and economic alternatives for
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PO Box 8787 • Asheville, NC 28814
www.quality-america.com
Dr. Sheila Dunn, President & CEO
PO Box 8787 • Asheville, NC 28814
1-800-946-9956
www.quality-america.com
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