3/14/2016. Putting the Pieces Together: Safety Regulations and Guidelines. Objectives. Piece This Together

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1 Putting the Pieces Together: Safety Regulations and Guidelines Dan Scungio, MT (ASCP), SLS, CQA (ASQ) Objectives Explore the agencies that affect lab safety regulations. Review safety subject areas and tie the regulations and guidelines together. Connect the pieces of the safety puzzle together to form a complete picture for your laboratory. Piece This Together 1

2 Polling Question Which agency accredits your laboratory? CAP TJC CMS Other Not sure Federal Regulatory Agencies EPA Environmental Protection Agency DOT Department of Transportation DOL Department of Labor ADA Americans with Disabilities Act BLS Bureau of Labor Services FDA Food and Drug Administration Other Safety Guideline Sources CAP College of American Pathologists CDC Centers for Disease Control and Prevention NIOSH National Institute for Occupational Safety and Health CLSI Clinical and Laboratory Standards Institute IATA International Air Transportation Association TJC The Joint Commission ISO International Organization for Standardization NFPA National Fire Protection Association 2

3 OSHA Regulations that affect laboratory 1981: Hearing Conservation 1983: Hazard Communication 1990: Chemical Hygiene 1991: Bloodborne Pathogens 2007: Payment for PPE 2009: Adoption of GHS CAP College of American Pathologists Lab accreditation Proficiency testing Polling Question Which agency accredits your hospital? TJC DNV HFAP Other Not sure or N/A 3

4 The Joint Commission Hospital Accreditation Laboratory Accreditation Changes in 2015 DNV Interpretive-Guidelines_18c.pdf CLSI NCCLS Accredited by ANSI Volunteers Consensus process 4

5 EPA/DOT Federal regulatory agencies EPA Lab waste Manifests/Shipping papers DOT Material transport Couriers ISO ISO ISO 15189:2012 ISO 15190:2003 CMS Deemed status State agency inspection 42 CFR 482 5

6 Visit These Web Sites! Putting the Pieces Together Bloodborne Pathogens CAP = OSHA + CLSI + CDC BBP Standard BMBL5 MMWR M29 GP17 6

7 Bloodborne Pathogens Risk Assessments: Job classification Regular exposure Some exposure No exposure Technologist X Phlebotomist X Laboratory clerk X Secretary X Task Assessments: Bloodborne Pathogens Task Additional protective equipment Engineering controls Removing blood tube tops None Plastic shield Phlebotomy None Sharps container Processing samples Mask None Plating TB cultures Gown and mask Biohazard safety hood Class II Bloodborne Pathogens 7

8 Bloodborne Pathogens Personal Electronic Devices: Put The Pieces Together Is the exposure control plan, available, current and has it been reviewed within the last year? Have employees been offered the Hepatitis B vaccine free of charge within 10 days of hire? Have policies and procedures been developed regarding the reporting of all occupational injuries and illnesses that require medical treatment? Are the entryways to the lab marked with "biohazard" or "authorized personnel only?" Is there biohazard signage on specimen refrigerators/freezers? Put The Pieces Together Do employees refrain from eating, drinking, gum chewing, smoking, applying cosmetics and lip balm, or manipulating contact lenses in the work area? Have employees responsible for shipping diagnostic and infectious specimens been trained in accordance with the Department of Transportation (DOT) regulations? Are there documented procedures detailing procurement, transportation, and handling of patient specimens to ensure that they are submitted in an appropriately and well-constructed container with a secure lid to prevent leakage during transport? Does the lab have a documented tuberculosis exposure control plan? 8

9 Chemical Hygiene CAP = OSHA + NFPA + CLSI Hazard Communication Standard Chemical Hygiene Standard Flammable Storage GP17 Chemical Hygiene Chemical Hygiene Plan Safety Data Sheets Chemical Labeling PPE First Aid/Spills Chemical Storage Chemical Hygiene The Final GHS Deadline: June 1, 2016 Are You Ready? 9

10 Put The Pieces Together Is the Chemical Hygiene Plan available and current? Is there annual review and evaluation of the effectiveness of the Chemical Hygiene Plan? Are the SDS accessible at all times to all employees? Has the chemical inventory been performed and updated in the last 12 months? Is there a list of carcinogens, mutagens, and teratogens? Are all manufactured chemical containers labeled with the appropriate chemical identity and hazard warning information? Put The Pieces Together Are transfer containers of chemicals properly labeled with a HMIS label or plain label with the name of the chemical, concentration, route of entry, health hazard, physical hazard, target organs affected, lab name, lot # and expiration date? Are chemicals stored away from heat, sunlight or reactive substances, and below shoulder level? Are flammable liquids stored in an appropriate flammable storage cabinet or room? Is environmental monitoring performed and documented where appropriate? Put The Pieces Together Are chemical spill kits/materials maintained and available for use? If no expiration date exists, is there an indication of the date the kit was placed in service? Does spill kit appear ready for use? (i.e. no physical changes noted- clumps, discoloration inside or outside of packaging). Have employees been trained in spill clean up procedures? Has the Target Organ poster been placed so that it is visible to all employees? 10

11 Fire/Electrical/Gas Safety CAP = NFPA + CLSI + (OSHA) NFPA 2013 Standards GP17 NEC plus local code Fire/Electrical/Gas Safety Physical Environment Policies Fire Safety Plan Records Put the Pieces Together Are all compressed gas cylinders chained to the wall or otherwise secured in a non-tip base? Are cylinders transported via hand truck or other stabilizing device? Are cylinders legibly marked to clearly identify the gas in the cylinders? Are cylinders equipped with a pressure regulator designed and marked for its maximum pressure, and Is the regulator system equipped with two gauges to show both the cylinder pressure and the outlet pressure? Are valve protectors placed on cylinders when they are not in use or connected for use? 11

12 Put the Pieces Together Is electrical equipment grounded with the use of three pronged plugs? Are electrical cords free of any frayed edges and are extension cords prohibited from use? Are multi-plug adapters prohibited? Are electrical outlets located near wet locations, such as sinks, protected by a ground-fault circuit interrupter (GFCI)? Have employees been trained in how to handle shock injuries? Are electrical panels kept cleared within three feet in front of breaker panels? Are electrical circuit breakers and panels labeled with a current listing of equipment powered by each unit? Put the Pieces Together Is there a fire pull station located near the laboratory? Is there an automatic fire detection system, and can the fire alarm be heard from inside the laboratory? Does each room larger than 1000 ft2, or in which major fire hazards exist, have at least 2 exit access doors remote from each other, one of which opens directly into an exit route? Are all fire extinguishers easily accessible and not blocked? Have all employees received fire extinguisher training including the opportunity to actually handle the extinguisher in a real or simulated practice? Have fire extinguishers been serviced with in the past year? Do employees know what the acronyms RACE and PASS stand for? Have periodic fire drills been completed and documented? Has each employee performed at least one full evacuation to the triage emergency meeting area annually? Waste Management CAP = EPA + DOT + OSHA + CLSI RCRA hazardous waste regulations PHMSA Bloodborne Pathogens Standard GP05 12

13 Waste Management Waste Management Plan Records Manifests Satellite Accumulation Areas Central Accumulation Areas Waste Audits Put the Pieces Together Is all waste disposed of properly according to federal state and local authorities? Is there a waste management plan? Are there documented cradle-to-grave protocols in place where appropriate? Have employees been trained as to what can be discharged down the sewer? (Ask employee what they pour down sinks) Does the facility have a discharge permit or letter of acknowledgement from the wastewater treatment facility? Is the laboratory discharge to the sewer routinely monitored? Put the Pieces Together Is there a program to reduce the volume of hazardous waste that is generated by the laboratory? As a small quantity generator is waste stored less than 180 days? If the facility has to transport waste more than 200 miles for disposal, is the waste stored 270 days or less? Are incompatible wastes and/or materials separated or protected by physical means such as a wall or cabinet? Are waste management records (manifests, waste analysis results, inspection records, training records) retained on-site for at least three years? 13

14 Complete The Puzzle Tool #1: Chart Complete The Puzzle Tool #2: Lab safety audit Complete The Puzzle Tool #2: Lab safety audit 14

15 Complete The Puzzle Put it all together- on a regular basis References Know your resources Internal External Questions? Did You Piece it Together? 15

16 Putting the Pieces Together: Safety Regulations and Guidelines Dan Scungio, MT (ASCP), SLS, CQA (ASQ) 16