Rodak's Hematology: Clinical Principles and Applications, 5th Ed.

CHAPTER 2. Safety in the hematology laboratory

Sheila A. Finch

OUTLINE

Standard Precautions

Applicable Safety Practices Required by the OSHA Standard

Housekeeping

Laundry

Hepatitis B Virus Vaccination

Training and Documentation

Regulated Medical Waste Management

Occupational Hazards

Fire Hazard

Chemical Hazards

Electrical Hazard

Needle Puncture

Developing a Safety Management Program

Planning Stage: Hazard Assessment and Regulatory Review

Safety Program Elements

Objectives

After completion of this chapter, the reader will be able to:

1. Define standard precautions and list infectious materials included in standard precautions.

2. Describe the safe practices required in the Occupational Exposure to Bloodborne Pathogens Standard.

3. Identify occupational hazards that exist in the hematology laboratory.

4. Describe appropriate methods to decontaminate work surfaces after contamination with blood or other potentially infectious material.

5. Identify the regulatory requirements of the Occupational Exposure to Hazardous Chemicals in Laboratories standard.

6. Describe the principles of a fire prevention program, including details such as the frequency of testing equipment.

7. Name the most important practice to prevent the spread of infection.

8. Given a written laboratory scenario, assess for safety hazards and recommend corrective action for any deficiencies or unsafe practices identified.

9. Select the proper class of fire extinguisher for a given type of fire.

10. Explain the purpose of Safety Data Sheets (SDSs), list information contained on SDSs, and determine when SDSs would be used in a laboratory activity.

11. Name the specific practice during which most needle stick injuries occur.

12. Describe elements of a safety management program.

CASE STUDY

After studying the material in this chapter, the reader should be able to respond to the following case study:

Hematology Services, Inc., had a proactive safety program. Quarterly safety audits were conducted by members of the safety committee. The following statements were recorded in the safety audit report. Which statements describe good work practices, and which statements represent deficiencies? List the corrective actions required for identified unsafe practices.

1. A hematology laboratory scientist was observed removing gloves and immediately left the laboratory for a meeting. She did not remove her laboratory coat.

2. Food was found in the specimen refrigerator.

3. Hematology laboratory employees were seen in the lunchroom, wearing laboratory coats.

4. Fire extinguishers were found every 75 feet of the laboratory.

5. Fire extinguishers were inspected quarterly and maintained annually.

6. Unlabeled bottles were found at a workstation.

7. A 1:10 solution of bleach was found near an automated hematology analyzer. Further investigation revealed that the bleach solution was made 6 months ago.

8. Gloves were worn by the staff receiving specimens.

9. Safety data sheets were obtained by fax.

10. Chemicals were stored alphabetically.

Many conditions in the laboratory have the potential for causing injury to staff and damage to the building or to the community. Patients’ specimens, needles, chemicals, electrical equipment, reagents, and glassware all are potential causes of accidents or injury. Managers and employees must be knowledgeable about safe work practices and incorporate these practices into the operation of the hematology laboratory. The key to prevention of accidents and laboratory-acquired infections is a well-defined safety program.

Safety is a broad subject and cannot be covered in one chapter. This chapter simply highlights some of the key safe practices that should be followed in the hematology laboratory. Omission of a safe practice from this chapter does not imply that it is not important or that it should not be considered in the development of a safety curriculum or a safety program.

Standard precautions

One of the greatest risks associated with the hematology laboratory is the exposure to blood and body fluids. In December 1991, the Occupational Safety and Health Administration (OSHA) issued the final rule for the Occupational Exposure to Bloodborne Pathogens Standard. The rule that specifies standard precautions to protect laboratory workers and other health care professionals became effective on March 6, 1992. Universal precautions was the original term; OSHA’s current terminology is standard precautions. Throughout this text, the term standard precautions is used to remind the reader that all blood, body fluids, and unfixed tissues are to be handled as though they were potentially infectious.

Standard precautions must be adopted by the laboratory. Standard precautions apply to blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, any body fluid with visible blood, any unidentified body fluid, unfixed slides, microhematocrit clay, and saliva from dental procedures. Adopting standard precautions lessens the risk of health care worker exposures to blood and body fluids, decreasing the risk of injury and illness.

Bloodborne pathogens are pathogenic microorganisms that, when present in human blood, can cause disease. They include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). This chapter does not cover the complete details of the standard; it discusses only the sections that apply directly to the hematology laboratory. Additional information can be found in the references at the end of this chapter.

Applicable safety practices required by the OSHA standard

The following standards are applicable in a hematology laboratory and must be enforced:

1. Hand washing is one of the most important safety practices. Hands must be washed with soap and water. If water is not readily available, alcohol hand gels (minimum 62% alcohol) may be used. Hands must be thoroughly dried. The proper technique for hand washing is as follows:

a. Wet hands and wrists thoroughly under running water.

b. Apply germicidal soap and rub hands vigorously for at least 15 seconds, including between the fingers and around and over the fingernails (Figure 2-1A).

c. Rinse hands thoroughly under running water in a downward flow from wrist to fingertips (Figure 2-1B).

d. Dry hands with a paper towel (Figure 2-1C). Use the paper towel to turn off the faucet handles (Figure 2-1D).

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FIGURE 2-1 Proper hand washing technique. A, Wet hands thoroughly under running water, apply soap, and rub hands vigorously for at least 15 seconds. B, Rinse hands thoroughly under running water in a downward flow from wrist to fingertips. C, Dry hands with a paper towel. D, Turn off faucet with paper towel. Source: (From Young AP, Proctor DB: Kinn’s the medical assistant, ed 11, St Louis, 2011, Saunders.)

Hands must be washed:

a. Whenever there is visible contamination with blood or body fluids

b. After completion of work

c. After gloves are removed and between glove changes

d. Before leaving the laboratory

e. Before and after eating and drinking, smoking, applying cosmetics or lip balm, changing a contact lens, and using the lavatory

f. Before and after all other activities that entail hand contact with mucous membranes, eyes, or breaks in skin

2. Eating, drinking, smoking, and applying cosmetics or lip balm must be prohibited in the laboratory work area.

3. Hands, pens, and other fomites must be kept away from the mouth and all mucous membranes.

4. Food and drink, including oral medications and tolerance-testing beverages, must not be kept in the same refrigerator as laboratory specimens or reagents or where potentially infectious materials are stored or tested.

5. Mouth pipetting must be prohibited.

6. Needles and other sharp objects contaminated with blood and other potentially infectious materials should not be manipulated in any way. Such manipulation includes resheathing, bending, clipping, or removing the sharp object. Resheathing or recapping is permitted only when there are no other alternatives or when the recapping is required by specific medical procedures. Recapping is permitted by use of a method other than the traditional two-handed procedure. The one-handed method or a resheathing device is often used. Documentation in the exposure control plan should identify the specific procedure in which resheathing is permitted.

7. Contaminated sharps (including, but not limited to, needles, blades, pipettes, syringes with needles, and glass slides) must be placed in a puncture-resistant container that is appropriately labeled with the universal biohazard symbol (Figure 2-2) or a red container that adheres to the standard. The container must be leakproof (Figure 2-3).

8. Procedures such as removing caps when checking for clots, filling hemacytometer chambers, making slides, discarding specimens, making dilutions, and pouring specimens or fluids must be performed so that splashing, spraying, or production of droplets of the specimen being manipulated is prevented. These procedures may be performed behind a barrier, such as a plastic shield, or protective eyewear should be worn (Figure 2-4).

9. Personal protective clothing and equipment must be provided to the laboratory staff. The most common forms of personal protective equipment are described in the following section:

a. Outer coverings, including gowns, laboratory coats, and sleeve protectors, should be worn when there is a chance of splashing or spilling on work clothing. The outer covering must be made of fluid-resistant material, must be long-sleeved, and must remain buttoned at all times. If contamination occurs, the personal protective equipment should be removed immediately and treated as infectious material.

Cloth laboratory coats may be worn if they are fluid resistant. If cloth coats are worn, the coats must be laundered inside the laboratory or hospital or by a contracted laundry service. Laboratory coats used in the laboratory while performing laboratory analysis are considered personal protective equipment and are not to be taken home.

All protective clothing should be removed before leaving the laboratory; it should not be worn into public areas. Public areas include, but are not limited to, break rooms, storage areas, bathrooms, cafeterias, offices, and meeting places outside the laboratory.

A second laboratory coat can be made available for use in public areas. A common practice is to have a different-colored laboratory coat that can be worn in public areas. This second laboratory coat could be laundered by the employee.

b. Gloves must be worn when the potential for contact with blood or body fluids exists (including when removing and handling bagged biohazardous material and when decontaminating bench tops) and when venipuncture or skin puncture is performed. One of the limitations of gloves is that they do not prevent needle sticks or other puncture wounds. Provision of gloves to laboratory staff must accommodate latex allergies. Alternative gloves must be readily accessible to any laboratory employee with a latex allergy. Gloves must be changed after each contact with a patient, when there is visible contamination, and when physical damage occurs. Gloves should not be worn when “clean” devices, such as a copy machine or a “clean” telephone, are used. Gloves must not be worn again or washed. After one glove is removed, the second glove can be removed by sliding the index finger of the ungloved hand between the glove and the hand and slipping the second glove off. This technique prevents contamination of the “clean” hand by the “dirty” second glove (Figure 2-5).1 Contaminated gloves should be disposed of according to applicable federal or state regulations.

c. Eyewear, including face shields, goggles, and masks, should be used when there is potential for aerosol mists, splashes, or sprays to mucous membranes (mouth, eyes, or nose). Removing caps from specimen tubes, working at an automated hematology analyzer, and centrifuging specimens are examples of tasks that could produce an aerosol mist.

10. Phlebotomy trays should be appropriately labeled to indicate potentially infectious materials. Specimens should be placed into a secondary container, such as a resealable biohazard-labeled bag.

11. If a pneumatic tube system is used to transport specimens, the specimens should be transported in the appropriate tube (primary containment), and placed into a special self-sealing leakproof bag appropriately labeled with the biohazard symbol (secondary containment). Requisition forms should be placed outside of the secondary container to prevent contamination if the specimen leaks. Foam inserts for the pneumatic tube system carrier prevent shifting of the sample during transport and also act as a shock absorber, thus decreasing the risk of breakage.

When specimens are received in the laboratory, they should be handled by an employee wearing gloves, a laboratory coat, and other protective clothing, in accordance with the type and condition of specimen. Contaminated containers or requisitions must be decontaminated or replaced before being sent to the work area.

12. When equipment used to process specimens becomes visibly contaminated or requires maintenance or service, it must be decontaminated, whether service is performed within the laboratory or by a manufacturer repair service. Decontamination of equipment consists of a minimum of flushing the lines and wiping the exterior and interior of the equipment. If it is difficult to decontaminate the equipment, it must be labeled with the biohazard symbol to indicate potentially infectious material. Routine cleaning should be performed on equipment that has the potential for receiving splashes or sprays, such as inside the lid of the microhematocrit centrifuge.

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FIGURE 2-2 Biohazard symbol.

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FIGURE 2-3 Examples of sharps disposal systems. A, Molded foot pedal cart with hinged or slide top lid. B, In-room system wall enclosures. C, Multipurpose container with horizontal drop lid. D, Phlebotomy containers. Source: (Courtesy Covidien, Mansfield, MA.)

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FIGURE 2-4 Examples of safety shields. A, Face shield. B, Adjustable swing arm shield. Source: (Courtesy Steve Kasper.)

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FIGURE 2-5 Removal of gloves. A, Using one hand, grasp the outside of the other glove and slowly pull it off the hand, turning it inside out as you remove it. B, Scrunch the removed glove into a ball. C, Place the index and middle finger of the ungloved hand on the inside of the other glove. D, Pull the second glove off of the hand, turning it inside out as it is removed and enclosing the balled-up glove. Source: (From Bonewit-West K: Clinical procedures for medical assistants, ed 9, St Louis, 2015, Saunders.)

Housekeeping

Blood and other potentially infectious materials can contaminate work surfaces easily. Contamination can be caused by splashes, poor work practices, and droplets of blood on the work surface. To prevent contamination, all work surfaces should be cleaned when procedures are completed and whenever the bench area or floor becomes visibly contaminated. An appropriate disinfectant solution is household bleach, used in a 1:10 volume/volume dilution (10%), which can be made by adding 10 mL of bleach to 90 mL of water or 1½ cups of bleach to 1 gallon of water to achieve the recommended concentration of chlorine (5500 ppm). Because this solution is not stable, it must be made fresh daily. The container of 1:10 solution of bleach should be labeled properly with the name of the solution, the date and time prepared, the date and time of expiration (24 hours), and the initials of the preparer. Bleach is not recommended for aluminum surfaces. Other solutions used to decontaminate include, but are not limited to, a phenol-based disinfectant such as Amphyl®, tuberculocidal disinfectants, and 70% ethanol. All paper towels used in the decontamination process should be disposed of as biohazardous waste. Documentation of the disinfection of work areas and equipment after each shift is required.

Laundry

If nondisposable laboratory coats are used, they must be placed in appropriate containers for transport to the laundry at the facility or to a contract service and not taken to the employee’s home.

Hepatitis B virus vaccination

Laboratory employees should receive the HBV vaccination series at no cost before or within 10 days after beginning work in the laboratory. An employee must sign a release form if he or she refuses the series. The employee can request and receive the hepatitis vaccination series at any time, however. If an exposure incident (needle puncture or exposure to skin, eye, face, or mucous membrane) occurs, postexposure evaluation and follow-up, including prophylaxis and medical consultation, should be made available at no cost to the employee. Employees should be encouraged to report all exposure incidents, and such reporting should be enforced as standard policy.

Training and documentation

Hematology staff should be properly educated in epidemiology and symptoms of bloodborne diseases, modes of transmission of bloodborne diseases, use of protective equipment, work practices, ways to recognize tasks and other activities that may result in an exposure, and the location of the written exposure plan for the laboratory. Education should be documented and should occur when new methods, equipment, or procedures are introduced; at the time of initial assignment to the laboratory; and at least annually thereafter.

Regulated medical waste management

Specimens from the hematology laboratory are identified as regulated waste. There are different categories of regulated medical waste, and state and local regulations for disposal of medical waste must be followed. OSHA regulates some aspects of regulated medical waste such as needle handling, occupational exposure, labeling of containers, employee training, and storing of the waste. The Occupational Exposure to Bloodborne Pathogens Standard provides information on the handling of regulated medical waste. Detailed disposal guidelines are specific to the state disposal standards. When two regulations conflict, the more stringent standard is followed.

Occupational hazards

Four important occupational hazards in the laboratory are discussed in this chapter: fire hazard, chemical hazards, electrical hazard, and needle puncture. There are other hazards to be considered when a safety management program is developed, and the reader is referred to the Department of Labor section of the Code of Federal Regulations for detailed regulations.2

Fire hazard

Because of the numerous flammable and combustible chemicals used in the laboratory, fire is a potential hazard. Complying with standards established by the National Fire Protection Association, OSHA, the Joint Commission, the College of American Pathologists, and other organizations can minimize the dangers. A good fire safety/prevention plan is necessary and should consist of the following:

1. Enforcement of a no-smoking policy.

2. Installation of appropriate fire extinguishers. Several types of extinguishers, most of which are multipurpose, are available for use for specific types of fires.

3. Placement of fire extinguishers every 75 feet. A distinct system for marking the locations of fire extinguishers enables quick access when they are needed. Fire extinguishers should be checked monthly and maintained annually. Not all fire extinguishers are alike. Each fire extinguisher is rated for the type of fire that it can suppress. It is important to use the correct fire extinguisher for the given class of fire. Hematology laboratory staff should be trained to recognize the class of extinguisher and use a fire extinguisher properly. Table 2-1 summarizes the fire extinguisher classifications. The fire extinguishers used in the laboratory are portable extinguishers and are not designed to fight large fires. In the event of a fire in the laboratory, the local fire department must be contacted immediately.

4. Placement of adequate fire detection and suppression systems (alarms, smoke detectors, sprinklers), which should be tested every 3 months.

5. Placement of manual fire alarm boxes near the exit doors. Travel distance should not exceed 200 feet.

6. Written fire prevention and response procedures, commonly referred to as the fire response plan. All staff in the laboratory should be knowledgeable about the procedures. Employees should be given assignments for specific responsibilities in case of fire, including responsibilities for patient care, if applicable. Total count of employees in the laboratory should be known for any given day, and a buddy system should be developed in case evacuation is necessary. Equipment shutdown procedures should be addressed in the plan, as should responsibility for implementation of those procedures.

7. Fire drills, which should be conducted so that response to a fire situation is routine and not a panic response. Frequency of fire drills varies by type of occupancy of the building and by accrediting agency. Overall governance can be by the local or state fire marshall. All laboratory employees should participate in the fire drills. Proper documentation should be maintained to verify that all phases of the fire response plan were activated. If patients are in areas adjacent to the hematology laboratory, evacuation can be simulated, rather than evacuating actual patients. The entire evacuation route should be walked to verify the exit routes and clearance of the corridors. A summary of the laboratory’s fire response plan can be copied onto a quick reference card and attached to workers’ identification badges to be readily available in a fire situation.

8. Written storage requirements for any flammable or combustible chemicals stored in the laboratory. Chemicals should be arranged according to hazard class and not alphabetically. A master chemical inventory should be maintained and revised when new chemicals are added or deleted from the laboratory procedures.

9. A well-organized fire safety training program. This program should be completed by all employees. Activities that require walking evacuation routes and locating fire exit boxes in the laboratory area should be scheduled. Types of fires likely to occur and use of the fire extinguisher should be discussed. Local fire departments may request a tour of the laboratory or facility to become familiar with the potential fire hazards prior to an actual fire occurring in the laboratory.

TABLE 2-1

Fire Extinguisher Classifications and Use

Class/Type of Extinguisher

Type of Fire

A

Ordinary combustibles such as wood, cloth, or paper.

B

Flammable liquids, gases, or grease.

C

Energized (plugged-in) electrical fires. Examples are fires involving equipment, computers, fuse boxes, or circuit breakers.

ABC

Multipurpose for type A, B, and C fires.

Chemical hazards

Some of the chemicals used in the hematology laboratory are considered hazardous and are governed by the Occupational Exposure to Hazardous Chemicals in Laboratories Standard. This regulation requires laboratories to develop a chemical hygiene plan that outlines safe work practices to minimize exposures to hazardous chemicals. The full text of this regulation can be found in 29 CFR (Code of Federal Regulations) 1910.1450.2

General principles that should be followed in working with chemicals are as follows:

1. Label all chemicals properly, including chemicals in secondary containers, with the name and concentration of the chemical, preparation or fill date, expiration date (time, if applicable), initials of preparer (if done in-house), and chemical hazards (e.g., poisonous, corrosive, flammable). Do not use a chemical that is not properly labeled as to the identity or content.

2. Follow all handling and storage requirements for the chemical.

3. Store alcohol and other flammable chemicals in approved safety cans or storage cabinets at least 5 feet away from a heat source (e.g., Bunsen burners, paraffin baths). Limit the quantity of flammable chemicals stored on the workbench to 2 working days’ supply. Do not store chemicals in a hood or in any area where they could react with other chemicals.

4. Use adequate ventilation, such as fume hoods, when working with hazardous chemicals.

5. Use personal protective equipment, such as gloves (e.g., nitrile, polyvinyl chloride, rubber—as appropriate for the chemical in use), rubber aprons, and face shields. Safety showers and eye wash stations should be available every 100 feet or within 10 seconds of travel distance from every work area where the hazardous chemicals are used.

6. Use bottle carriers for glass bottles containing more than 500 mL of hazardous chemical.

7. Use alcohol-based solvents, rather than xylene or other particularly hazardous substances, to clean microscope objectives.

8. The wearing of contact lenses should not be permitted when an employee is working with xylene, acetone, alcohols, formaldehyde, and other solvents. Many lenses are permeable to chemical fumes. Contact lenses can make it difficult to wash the eyes adequately in the event of a splash.

9. Spill response procedures should be included in the chemical safety procedures, and all employees must receive training in these procedures. Absorbent material should be available for spill response. Multiple spill response kits and absorbent material should be stored in various areas and rooms rather than only in the area where they are likely to be needed. This prevents the need to walk through the spilled chemical to obtain the kit.

10. Safety Data Sheets (SDS), formerly known as Material Safety Data Sheets (MSDS), are written by the manufacturers of chemicals to provide information on the chemicals that cannot be put on a label. In 2012, the Hazard Communication Standard (29 CFR 1910.1200(g)) was revised to align with the United Nations Globally Harmonized System (GHS) of Classification and Labeling of Chemicals. The significant revisions required the use of new labeling elements and a standardized format for Safety Data Sheets (SDS). The standardized information on the SDS uses a 16-section format, and the implementation date is June 1, 2015. The OSHA website on Hazard Communication Safety Data Sheets specifies the content for the 16 sections of the SDS as follows:3

• Section 1. Identification includes product identifier, manufacturer or distributor (name, address, emergency phone number), recommended use, and restrictions on use.

• Section 2. Hazard(s) identification includes all hazards of the chemical and required label information.

• Section 3. Composition/information on ingredients includes information on chemical ingredients and trade secret claims.

• Section 4. First-aid measures includes symptoms, acute and delayed effects, and required treatment.

• Section 5. Firefighting measures provides extinguishing techniques and equipment and chemical hazards from fire.

• Section 6. Accidental release measures lists emergency procedures, protective equipment, and methods of containment and cleanup.

• Section 7. Handling and storage lists precautions for safe handling and storage and incompatibilities with other chemicals.

• Section 8. Exposure controls and personal protection lists OSHA’s permissible exposure limits, threshold limit values, engineering controls, and personal protective equipment.

• Section 9. Physical and chemical properties includes properties such as boiling point, vapor pressure, evaporation rate, appearance, and odor.

• Section 10. Stability and reactivity lists chemical stability and the possibility of hazardous reactions.

• Section 11. Toxicological information lists the routes of exposure, related symptoms, acute and chronic effects, and measures of toxicity.

• Section 12. Ecological information (nonmandatory) provides information to evaluate the environmental impact if chemical was released.

• Section 13. Disposal consideration (nonmandatory) provides guidance on proper disposal practices and recycling or reclamation of the chemical.

• Section 14. Transport information (nonmandatory) provides classification information for shipping and transporting the chemical.

• Section 15. Regulatory information (nonmandatory) lists safety, health, and environmental regulations for the chemical that are not listed in the other sections.

• Section 16. Other information includes the date of SDS preparation or last revision.

A SDS management system should be considered to track the incoming SDSs received in the laboratory. A notice should be posted to alert the hematology staff when new or revised SDSs have been received. SDSs may be obtained electronically by means of computer, fax, or Internet. If an electronic device is used in the laboratory to receive and store SDSs, each employee must be trained on the use of the device. The training must include emergency procedures in case of power outages or malfunctions of the device. The device must be reliable and readily accessible during the hours of operation. In the event of emergency, hard copies of the SDSs must be accessible to medical staff. SDSs are required to be kept for 30 years after employment of the last employee who used the chemicals in the work area, and they should be documented with the date when the chemical was no longer used in the laboratory.

Electrical hazard

Electrical equipment and outlets are other sources of hazard. Faulty wiring may cause fires or serious injury. Guidelines include the following:

1. Equipment must be grounded or double insulated. (Grounded equipment has a three-pronged plug.)

2. Use of “cheater” adapters (adapters that allow three-pronged plugs to fit into a two-pronged outlet) should be prohibited.

3. Use of gang plugs (plugs that allow several cords to be plugged into one outlet) should be prohibited.

4. Use of extension cords should be avoided.

5. Equipment with loose plugs or frayed cords should not be used.

6. Stepping on cords, rolling heavy equipment over cords, and other abuse of cords should be prohibited.

7. When cords are unplugged, the plug, not the cord, should be pulled.

8. Equipment that causes shock or a tingling sensation should be turned off, the instrument unplugged and identified as defective, and the problem reported.

9. Before repair or adjustment of electrical equipment is attempted, the following should be done:

a. Unplug the equipment.

b. Make sure the hands are dry.

c. Remove jewelry.

Needle puncture

Needle puncture is a serious occupational hazard for laboratory personnel. Needle-handling procedures should be written and followed, with special attention to phlebotomy procedures and disposal of contaminated needles (Chapter 3). Other items that can cause a puncture similar to a needle puncture include sedimentation rate tubes, applicator sticks, capillary tubes, glass slides, and transfer pipettes.

Disposal procedures should be followed and enforced. The most frequent cause of a needle puncture or a puncture from other sharp objects is improper disposal. Failure to check sharps containers on a regular basis and to replace them when they are no more than three-quarters full encourages overstuffing, which sometimes leads to injury. Portable bedside containers are available for personnel when performing venipunctures or skin punctures. Wall-mounted needle disposal containers also are available and make disposal convenient. All needle punctures should be reported to the health services or proper authorities within the institution.

Developing a safety management program

Every accredited laboratory is required to have a safety management program. A safety management program is one that identifies the guidelines necessary to provide a safe working environment free from recognizable hazards that can cause harm or injury. Many medical laboratory scientists assume positions as supervisors or laboratory safety officers. Responsibilities in these positions require knowledge of the safety principles and the development, implementation, and maintenance of a laboratory safety program. This section provides an overview of the elements that should be considered in developing a safety program.

Planning stage: Hazard assessment and regulatory review

Assessment of the hazards found in the laboratory and awareness of the standards and regulations that govern laboratories is a required step in the development of a safety program. Taking the time to become knowledgeable about the regulations and standards that relate to the procedures performed in the hematology laboratory is an essential first step. Examples of the regulatory agencies that have standards, requirements, and guidelines that are applicable to hematology laboratories are given in . Sorting through the regulatory maze can be challenging, but the government agencies and voluntary standards organizations are willing to assist employers in complying with their standards. Box 2-1

BOX 2-1

Government Regulatory Agencies Providing Laboratory Safety Standards

Department of labor: 29 code of federal regulations part 1910

Hazard Communication Standard (right to know): 29 CFR 1910.1200

Occupational Exposure to Bloodborne Pathogens Standard: 29 CFR 1910.1030

Occupational Exposure to Hazardous Chemicals in Laboratories Standard: 29 CFR 1910.1450

Formaldehyde Standard: 29 CFR 1910.1048

Air Contaminants: Permissible Exposure Limits: 29 CFR 1910.1000

Occupational Noise Level Standard: 29 CFR 1910.95

Hazardous Waste Operations and Emergency Response Standard: 29 CFR 1910.120

Personal Protective Equipment: 29 CFR 1910.132

Eye and Face Protection: 29 CFR 1910.133

Respiratory Protection: 29 CFR 1910.134

Medical waste standards regulated by the state

State medical waste standards

Department of the interior, environmental protection agency: 40 code of federal regulations parts 200-399

Resource Conservation and Recovery Act (RCRA)

Clean Air Act

Clean Water Act

Toxic Substances Control Act (TSCA)

Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA)

Superfund Amendments and Reauthorization Act (SARA)

SARA Title III: Community Right to Know Act

Voluntary agencies/accrediting agencies/other government agencies

The Joint Commission

College of American Pathologists (CAP)

State public health departments

Centers for Disease Control and Prevention (CDC)

Clinical and Laboratory Standards Institute

National Fire Protection Association (NFPA)

Department of Transportation (DOT): Regulated Medical Waste Shipment Regulations: 49 CFR 100-185

CFR, Code of Federal Regulations.

Safety program elements

A proactive program should include the following elements:

• Written safety plan. Written policies and procedures should be developed that explain the steps to be taken for all of the occupational and environmental hazards that exist in the hematology laboratory.

• Training programs. Conducted annually for all employees. New employees should receive safety information on the first day that they are assigned to the hematology laboratory.

• Job safety analysis. Identifies all of the tasks performed in the hematology laboratory, the steps involved in performing the procedures, and the risk associated with the procedures.

• Safety awareness program. Promotes a team approach and encourages employees to take an active part in the safety program.

• Risk assessment. Proactive risk assessment (identification) of all the potential safety, occupational, or environmental hazards that exist in the laboratory should be conducted at least annually and when a new risk is added to the laboratory. After the risk assessment is conducted, goals, policies, and procedures should be developed to prevent the hazard from injuring a laboratory employee. Some common risks are exposure to bloodborne pathogens; exposure to chemicals; needle punctures; slips, trips, and falls; and ergonomics issues.

• Safety audits and follow-up. A safety checklist should be developed for the hematology laboratory for use during scheduled and unscheduled safety audits. Any unsafe practices should be corrected. Actions taken to correct the unsafe practice should be documented and monitored to verify the actions are effective in correcting the practice.

• Reporting and investigating of all accidents, “near misses,” or unsafe conditions. The causes of all incidents should be reviewed and corrective action taken, if necessary.

• Emergency drill and evaluation. Periodic drills for all potential internal and external disasters should be conducted. Drills should address the potential accident or disaster event before it occurs and test the preparedness of the hematology personnel for an emergency situation. Planning for disaster events and practicing the response to a disaster event reduce the panic that results when the correct response procedure is not followed.

• Emergency management plan. Emergencies, sometimes called disasters (anything that prevents normal operation of the laboratory) do not occur only in the hospital-based laboratories. Freestanding laboratories, physician office laboratories, and university laboratories can be affected by emergencies that occur in the building or in the community. Emergency planning is crucial to being able to experience an emergency situation and recover enough to continue the daily operation of the laboratory. In addition to the safety risk assessment, a hazard vulnerability analysis should be conducted. Hazard vulnerability analysis helps to identify all of the potential emergencies that may have an impact on the laboratory. Emergencies such as a utility failure—loss of power, water, or telephones—can have a great impact on the laboratory’s ability to perform procedures. Emergencies in the community, such as a terrorist attack, plane crash, severe weather, flood, or civil disturbances, can affect the laboratory employee’s ability to get to work and can affect transportation of crucial supplies or equipment. When the potential emergencies are identified, policies and procedures should be developed and practiced so that the laboratory employee knows the backup procedures and can implement them quickly during an emergency or disaster situation. The emergency management plan should cover the four phases of response to an emergency, as follows:

1. Mitigation includes measures to prevent or reduce the adverse effects of the emergency.

2. Preparedness includes the design of procedures, identification of resources that may be used, and training in the procedures.

3. Response includes the actions that will be taken when responding to the emergency.

4. Recovery includes the procedures to assess damage, evaluate response, and replenish supplies so that the laboratory can return to normal operation.

An example of an emergency management plan is shown in . Box 2-2

BOX 2-2

Emergency Management Activities: Planning for Response to a Fire

Mitigation tools

Fire alarm pull box

Emergency code to notify workers

Smoke detectors

Fire/smoke doors

Audible and visual alarms

Fire exit lights

Sprinkler system

Preparedness activities

Training of workers

Fire drills

Fire response procedure development

Annual and monthly fire extinguisher checks

Response activities

Fire response plan implementation

Assignment of specific tasks during the actual event

Recovery activities

Communication of “all clear”

Documentation of response to the fire

Damage assessment

Financial accounting of response activities

Replenishment of supplies

Stress debriefing for employees

The key to prevention of accidents and laboratory-acquired infections is a well-defined safety program that also includes:

• Safety committee/department safety meetings to communicate safety policies to the employees.

• Review of equipment and supplies purchased for the laboratory for code compliance and safety features.

• Annual evaluation of the safety program for review of goals and performance as well as a review of the regulations to assess compliance in the laboratory.

Summary

• The responsibility of a medical laboratory professional is to perform analytical procedures accurately, precisely, and safely.

• Safe practices must be incorporated into all laboratory procedures and should be followed by every employee.

• The laboratory must adopt standard precautions that require that all human blood, body fluids, and unfixed tissues be treated as if they were infectious.

• One of the most important safety practices is hand washing.

• Occupational hazards in the laboratory include fire, chemical and electrical hazards, and needle puncture.

• Some commonsense rules of safety are as follows:

• Be knowledgeable about the procedures being performed. If in doubt, ask for further instructions.

• Wear protective clothing and use protective equipment when required.

• Clean up spills immediately, if the substance is low hazard and the spill is small; otherwise, contact hazardous materials team (internal or vendor) for spill reporting and appropriate spill management.

• Keep workstations clean and corridors free from obstruction.

• Report injuries and unsafe conditions. Review accidents and incidents to determine their fundamental cause. Take corrective action to prevent further injuries.

• Maintain a proactive safety management program.

Now that you have completed this chapter, go back and read again the case study at the beginning and respond to the questions presented.

Review questions

Answers can be found in the Appendix.

1. Standard precautions apply to all of the following except:

a. Blood

b. Cerebrospinal fluid

c. Semen

d. Concentrated acids

2. The most important practice in preventing the spread of disease is:

a. Wearing masks during patient contact

b. Proper hand washing

c. Wearing disposable laboratory coats

d. Identifying specimens from known or suspected HIV- and HBV-infected patients with a red label

3. The appropriate dilution of bleach to be used in laboratory disinfection is:

a. 1:2

b. 1:5

c. 1:10

d. 1:100

4. How frequently should fire alarms and sprinkler systems be tested?

a. Weekly

b. Monthly

c. Quarterly

d. Annually

5. Where should alcohol and other flammable chemicals be stored?

a. In an approved safety can or storage cabinet away from heat sources

b. Under a hood and arranged alphabetically for ease of identification in an emergency

c. In a refrigerator at 2° C to 8° C to reduce volatilization

d. On a low shelf in an area protected from light

6. The most frequent cause of needle punctures is:

a. Patient movement during venipuncture

b. Improper disposal of phlebotomy equipment

c. Inattention during removal of needle after venipuncture

d. Failure to attach needle firmly to syringe or tube holder

7. Under which of the following circumstances would a SDS be helpful?

a. A phlebotomist has experienced a needle puncture with a clean needle.

b. A fire extinguisher failed during routine testing.

c. A pregnant laboratory employee has asked whether she needs to be concerned about working with a given reagent.

d. During a safety inspection, an aged microscope power supply is found to have a frayed power cord.

8. It is a busy evening in the City Hospital hematology department. One staff member called in sick, and there was a major auto accident that has one staff member tied up in the blood bank all evening. Mary, the medical laboratory scientist covering hematology, is in a hurry to get a stat sample on the analyzer but needs to pour off an aliquot for another department. She is wearing gloves and a lab coat. She carefully covers the stopper of the well-mixed ethylenediaminetetraacetic acid (EDTA) tube with a gauze square and tilts the stopper toward her so it opens away from her. She pours off about 1 mL into a prelabeled tube, replaces the stopper of the EDTA tube, and puts it in the sample rack and sets it on the conveyor. She then brings the poured sample off to the other department. How would you assess Mary’s safety practice?

a. Mary was careful and followed all appropriate procedures.

b. Mary should have used a shield when opening the tube.

c. Mary should have poured the sample into a sterile tube.

d. Mary should have wiped the tube with alcohol after replacing the stopper.

9. What class fire extinguisher would be appropriate to use on a fire in a chemical cabinet?

a. Class A

b. Class B

c. Class C

d. Class D

10. According to OSHA standards, laboratory coats must be all of the following except:

a. Water resistant

b. Made of cloth fabric that can be readily laundered

c. Long-sleeved

d. Worn fully buttoned

11. Which one of the following would NOT be part of a safety management plan?

a. Job safety analysis

b. Risk assessment of potential safety hazards

c. Mechanism for reporting accidents

d. Budget for engineering controls and personal protective equipment

References

1.  Garza D, Becan-McBride K. Phlebotomy handbook. 8th ed. Upper Saddle River, NJ : Pearson Education, Inc. 2010.

2.  United States Department of Labor. 29 Code of Federal Regulations Part 1910. Available at Available at: http://www.osha.gov/law-regs.xhtml Accessed 22.11.13.

3.  United States Department of Labor. Occupational Safety and Health Administration, Hazard Communication Safety Data Sheets. Available at: https://www.osha.gov/Publications/HazComm_QuickCard_SafetyData.xhtml Accessed 20.10.13.