osha program manual contents

ix

IntroductionImportant Information About the Use of This Program ............................. iHow to Customize this Program .................................................................. iiWhat Is Included in This Program ............................................................... vi

TAB 1: OSHA Jurisdictions & InspectionsA Quick Look at OSHA .................................................................................. 1-1

States with OSHA-Approved Plans ......................................................................................1-1OSHA Consultative Services Division ..................................................................................1-2OSHA’s Jurisdiction ..............................................................................................................1-2OSHA’s General Duty Clause ..............................................................................................1-2

Employee or Employer? ............................................................................... 1-3Employer Responsibilities Under OSHA ..............................................................................1-4

Overview of OSHA Standards ...................................................................... 1-4OSHA Inspections ......................................................................................... 1-5

Employee Complaints ..........................................................................................................1-5If an On-site OSHA Inspection Occurs .................................................................................1-6During the Inspection ...........................................................................................................1-7What OSHA Inspectors May Ask Employees .......................................................................1-7The Typical OSHA Inspection ...............................................................................................1-8The Closing Conference .......................................................................................................1-8

OSHA Sanctions ............................................................................................ 1-10Whistleblower Protection ............................................................................. 1-11Students and Volunteers .............................................................................. 1-13

OSHA PROGRAM MANUAL

Contents

Front Pocket OSHA Poster 3165: IT’S THE LAW! Laminated Eyewash Station Sign 4 Sample Biohazard Self-Adhesive Labels CD-ROM (MS Word for Windows 2000) with Master Record Forms (Tab 8) from this Manual

for Customization.

Page

x

Contents

TAB 2: Injury & Illness Prevention ProgramManagement Leadership and Employee Involvement..........................................................2-1Key Contacts for the OSHA Safety Program ........................................................................2-2Location of the OSHA Safety Program .................................................................................2-2

Duties of the OSHA Safety Officer ............................................................... 2-2Accident/Incident Investigation & Reporting Procedure ........................... 2-3

Definition of an Accident and/or Incident ..............................................................................2-4When to Investigate an Accident/Incident ............................................................................2-4How to Document an Accident/Incident................................................................................2-4Recording Accidents or Injuries for OSHA............................................................................2-4Correcting Unsafe or at Risk Conditions...............................................................................2-5

Recordkeeping Requirements ..................................................................... 2-5Equipment & Facility Records ..............................................................................................2-5Bloodborne Pathogens Records ..........................................................................................2-5Hazard Communication Records .........................................................................................2-6TB Records/Respiratory Protection Program .......................................................................2-6Employee Medical Records ..................................................................................................2-6Evaluating Exposure Incidents .............................................................................................2-6

Workplace Hazard Analysis ......................................................................... 2-7Employee Training ........................................................................................ 2-8

Checklist for an Effective Safety Training Session ...............................................................2-8Interactive Safety Training Exercises ...................................................................................2-9

General Safety .............................................................................................................2-9Fire Safety ....................................................................................................................2-9Bloodborne Pathogens Safety .....................................................................................2-10Chemical Safety ...........................................................................................................2-10TB Safety .....................................................................................................................2-10

Annual Employee Retraining ....................................................................... 2-10Bloodborne Pathogens Annual Training Contents................................................................2-11Respiratory Protection Annual Training Contents.................................................................2-12Hazard Communication Annual Training Contents...............................................................2-12

New Employee Orientation ........................................................................... 2-12Documenting Employee Training ................................................................ 2-13

OSHA Yearly Retraining .......................................................................................................2-13

Practical Ideas for Administering the OSHA Safety Program ................... 2-18Organizing OSHA Compliance Duties ......................................................... 2-18

2-1

OSHA Program Manual for Dental Facilities

TAB 2: OSHA PROGRAM ADMINISTRATION

INJURY & ILLNESS PREVENTION PLANManagement Leadership and Employee Involvement

It is the employer’s responsibility to have an effective safety program that complies with OSHA regulations.Employees must also be aware of their OSHA-mandated safety responsibilities contained within this customized program. Specific employee instructions and procedures for this plan are contained in the respective sections of this OSHA Program Manual.

The procedures, rules and regulations contained within this Manual are official policies of this organization and are intended for the protection of all employees. This practice communicates with employees regarding occupational safety and health policies, procedures and directives through:The job description for each employee, which requires them to report any perceived

hazard to the supervising dentist or OSHA Safety Officer upon discovery. Orientation training. Employees are given personal instructions about hazards and safety

requirements prior to job assignment.Annual OSHA retraining.Staff meetings. Health and safety issues are a permanent item on the agenda for these

meetings. Employees are asked to discuss safety and health issues, concerns and hazards. Suggestions are discussed and considered when evaluating the need for possible policy changes.

Specific memoranda, as necessary, to ensure that specific hazards and methods of avoiding them are understood.

OSHA Program Manual. This office requires that all employees follow the procedures and policies contained in the Manual.

The facility management is committed to keeping employees safe from occupational hazards. One way this is accomplished is by assuring that each new employee exposed to the hazards below is made aware of OSHA regulations for the potential hazards at this facility and how to follow them to ensure their individual safety:General safety hazardsFire and emergenciesBloodborne pathogensHazardous chemicalsTuberculosis and other respiratory diseases Ergonomic injuries

2-2


Every employee safety concern is investigated via mechanisms implemented by this facility. Employees are advised of any action taken as a result of the investigation and necessary changes are then incorporated into the OSHA Program Manual.

All employees must follow these policies in order to maintain a safe work place. Employees cannot opt to ignore OSHA requirements; these specific policies and procedures are mandated and strictly and consistently enforced. Violations will result in disciplinary action up to and including termination of employment. Employee compliance with these safety regulations is also evaluated annually as a part of their job performance review.

In all situations, employees are expected to use sound judgment to protect the health of fellow employees, patients and visitors to our facility.

Key Contacts for the OSHA Safety Program

One person, the OSHA Safety Officer, has overall responsibility for the day-to-day implementation and management of this Safety Program. The OSHA Safety Officer for this facility is:

__________________________________________ __________________________Name of OSHA Safety Officer Telephone number

__________________________________________ __________________________Name of Employer Telephone number

Location of the OSHA Program Manual

The OSHA Program Manual is available for employee review and is kept in the following location: ___________________________________________________________________________

Duties of the OSHA Safety OfficerThe OSHA Safety Officer:

1. Maintains, reviews and updates the OSHA Safety Program at least annually and as necessary, such as when:New employees are hired.New procedures are adopted that affect employee safety.Tasks or job duties are modified.Accident or incident trends so indicate.New hazardous chemicals are introduced.

2. Enforces the policies and procedures contained within this OSHA Program Manual. Makes management aware of safety issues and recommends remedial action for all unsafe situations.

2-3


3. Maintains and obtains all necessary personal protective clothing and equipment, engineering controls, labels and waste disposal containers as required by OSHA. Ensures that adequate supplies of these items are available in the appropriate sizes.

4. Secures all required medical actions in the event of an employee exposure.5. Maintains or ensures that all employee safety records including hepatitis B vaccination

and titer (if given after 2000) or declination post exposure follow-up and training records. 6. Verifies that employees are aware of the hazardous chemicals in the dental facility and

that they understand how to protect themselves from exposure to these chemicals.7. Facilitates and documents the training of:

New employees to orient them to hazards that may occur while performing their assigned work duties.

Current employees prior to starting new job assignments.Current employees whenever new substances, processes, procedures or

equipment are introduced into the workplace and represent a new hazard.Annual OSHA retraining.

8. Makes this OSHA Program Manual available to employees, OSHA and NIOSH representatives upon request.

9. Accompanies the OSHA Compliance Safety and Health Officer during an inspection. 10. Performs inspections and evaluations to identify, mitigate or eliminate workplace hazards:

Monthly Facility Review Checklist.Whenever new substances, processes, procedures, or equipment are introduced

to the workplace to determine if an occupational hazard exists and how to avoid or eliminate such hazards.

Whenever potential hazards are reported to the administrator or to the designated safety and health person identified by this plan.

Routinely, verifies that staff examine personal protective equipment for its effectiveness against bloodborne pathogens, sterilization equipment, hazardous chemicals, fire and emergency conditions. Hazardous conditions found during staff inspections are corrected prior to work being resumed unless the hazard can be effectively minimized (abated) until corrected. Emergency exits are cleared immediately if a hazardous condition is discovered. Inoperative fire safety equipment is repaired or replaced as soon as possible. All employees are advised of any inoperative fire safety equipment during the replacement or repair time period.

Annual Facility Review Checklist.

Accident/Incident Investigation & Reporting ProcedureAll occupational injuries or illnesses are investigated with the objective of determining the facts that led to the incident, not with the objective of assigning blame. After the facts are gathered , the OSHA Safety Officer evaluates the cause and determines how the incident happened and what can be done to prevent similar incidents in the future.This procedure identifies an effective accident/incident investigation and reporting process in order to:

2-4


Identify underlying causes and potential hazards.Ensure adequacy of current systems.Recommend corrective actions to reduce risk and prevent recurrence.Raise awareness of potential workplace hazards in the workplace.Demonstrate concern for health and safety.Meet legislative requirements [i.e., OSH Act, Worker’s Compensation Act.] Identify developing trends that can be analyzed to pinpoint particular or recurring

problems, regardless of the outcome of the incident.

Definition of an Accident and/or Incident

For the purposes of this program, an accident and/or incident is defined as any unplanned or undesired event which:Results in harm to one or more individuals.Causes property damage.Has the potential for injury or dollar loss.

When to Investigate an Accident/Incident

The OSHA Safety Officer conducts an accident or incident investigation when:There is evidence of a work-related injury/illness.An accident/incident occurs in with property damage.Conditions are recognized as being potentially hazardous or unsafe to others.

How to Document an Accident/Incident

Two forms may be used for incident investigation: Incident Report/Sharps Injury LogSafety Report - Use to record staff meetings or Safety Committee meeting minutes when

safety issues are discussed

Master copies of both forms are located behind Tab 8: Master Record Forms.

Recording Accidents or Injuries for OSHA

Federal OSHA requires the recording and posting of incidents or injuries resulting in loss of work days, work restrictions, and treatment beyond first aid (e.g. OSHA logs 300, 300A, 301) except for small businesses with no more than 10 employees and certain exempt business types. Dental practices and laboratories are exempt from the OSHA recordkeeping requirement. State-administered OSHA programs, however, may have different recording exemptions. Finally, even exempt businesses can be required to record injuries if requested by state or federal labor departments for statistical purposes such as the U.S. Bureau of Labor Statistics.

2-5


Correcting Unsafe or at Risk Conditions

Unsafe or at-risk conditions, work practices, and procedures are corrected in a timely manner based on the potential severity of the hazard. Our policy is to lessen the impact of all hazards and unsafe work practices, but if the hazard cannot be corrected (mitigated) upon discovery, employees are instructed on how to avoid the hazard or protect themselves from the hazard, or are removed from the area where the hazard is found.

Recordkeeping RequirementsFederal agencies assume that “if something wasn’t written down, it wasn’t done.” The records needed for OSHA purposes are located behind Tab 8: Master Record Forms and are summarized below.

Equipment & Facility Records

Safety Report……………………………………... For employee safety concerns and staff meeting minutes

Autoclave Log…………………………………….. Weekly, or as indicatedNew Employee OSHA Orientation Checklist…………………………………………... When new staff is addedAnnual Employee Training Record……………... Annually OSHA Annual Retraining (sample test)………… Annually

Annual OSHA Safety Program Review…………Annually to update manual includes Exposure Control Plan, Hazard Communication Plan and Respiratory Protection Plans

Monthly Facility Review Checklist………………. Monthly to ensure ongoing complianceAnnual Facility Review Checklist………………… Annually to ensure ongoing complianceHousekeeping Schedule…………………………. Initially and as part of the annual reviewFire Drill Report ………………………….............. Annually

Bloodborne Pathogens Records

Exposure Determination List..…………………… Initially, and when new clinical staff or processes are added

Sharps Evaluation Forms……………………….. AnnuallyIncident Report/Sharps Injury Log………………. For employee sharps injuries and other incidentsHBV Employee Vaccination Record…………….. To document employees’ HBV vaccination statusHBV Vaccination Declination Form……………… When an employee declines HBV vaccinationPost Exposure Checklist……………….…………. To document employee post exposure follow-up and

treatment

Post Exposure Medical Evaluation Declination Form………………………………………………...

When employees decline medical treatment

Source Patient Testing Consent Form…………… Use to obtain consent from a source patient after an exposure incident such as a needlestick or splash

2-6


Hazard Communication Records

OSHA Hazardous Substances List…………….. Initially, and when a new hazardous chemical is introduced

TB Records/Respiratory Protection Program

Annual TB Risk Assessment……………………... AnnuallyTB Skin Test Record……………………………… As indicatedTB Skin Test Declination Form……….………….. As indicatedTB Exposure Log………………………………….. As indicatedRespirator Fit Testing Log………………………… As indicated

Employee Medical Records

The OSHA Safety Officer assembles a medical record for each employee who could experience occupational exposure to blood and other potentially infectious material. These employees are listed on Exposure Determination List #1 and #2 located behind Tab 8: Master Record Forms (Form 7 and 8). Employee’s medical records consist of:Name and social security number.Hepatitis B vaccination records, including the date of vaccination/titer and any medical

records relative to the employee’s ability to receive vaccination or declination form.When applicable, post exposure records containing a copy of exam results, medical

testing, follow-up procedures after the exposure including the Incident Report/Sharps Injury Log, (Form 11 located behind Tab 8).

When applicable, a copy of the healthcare professional’s written evaluation report for any exposure incident (due within 15 days of the completion of the evaluation).

When applicable, a copy of information sent to the evaluating physician for the exposure incident.

Maintain medical records for exposed employees in strict confidence. Release of these records, whether within or outside of the workplace, may be made available only with the employee’s written consent, except for those records that are required by law. Keep these records for the length of employment plus 30 years.

Employers must inform employees, (or anyone with written consent from the employee) upon their request and within 15 working days, of the existence, location and availability of their training records or confidential medical and exposure records. Employers also must provide these records to employees upon request. Copies of hepatitis B vaccination records or their medical record for employees who have worked for less than one year need not be retained if they are given to the employee upon termination of employment.

If an employer plans to stop doing business and there is no successor employer to receive and maintain these records, the employer must notify employees of their right of access to their records at least three months before the employer ceases to do business.

2-7


Evaluating Exposure Incidents

The OSHA Safety Officer reviews the circumstances surrounding all exposure incidents by examining the Incident Report/Sharps Injury Log to determine:Engineering controls in use at the time.Work practices in use at the time.A description of the device/implement in use at the time.Protective equipment in use at the time of the incident. Location of the incident.Procedure being performed at the time of the incident.Training that the employee had received prior to the incident.

Based on this information, the OSHA Safety Officer determines if revisions to this OSHA Exposure Control Plan are needed and makes appropriate changes.

Workplace Hazard Analysis Hazards in each workplace must be identified so that they can be mitigated before accidents occur. A workplace hazard analysis identifies where interventions are needed, e.g., eye protection, lifting programs, etc.

Management has assessed risks associated with the general facility as well as all tasks performed at this site and determined that the standards below apply. Individual safety and health programs for each of these standards are located behind the designated Tabs in this Manual. These standards are:

General Facility Safety (Tab 3): Fire, Electrical, Emergency Evacuation Program, Workplace Violence.

Ergonomics (Tab 4): While no longer an OSHA standard, ergonomic findings can be cited by OSHA under the General Duty Clause.

Bloodborne Pathogens (Tab 5): This section specifies:- Employees who could be exposed to bloodborne pathogens- Tasks performed that could expose an employee to bloodborne pathogens, and

which PPE is required when performing these tasks- Areas in the facility where access is restricted- Areas where PPE and handwashing facilities are located

Hazard Communication and Radiation Safety (Tab 6): Describes how to handle and store hazardous substances, which are listed on the Hazardous Substances List (Form 17). Includes:

- Glutaraldehyde/peroxide-based high-level disinfectants- Gas cylinders- Lasers

2-8


- Beryllium alloys- Nitrous oxide- Silica- Mercury - X-rays

Infection Control (Tab 7): contains a facility TB risk assessment, steps to take to identify potential TB patients, and procedures for avoiding TB transmission (while no longer a Federal OSHA standard, Individual State OSHA plans may have specific TB and infectious disease standards). Also includes a Pandemic Influenza Plan.

Other Hazards in This Facility:____________________________________________________________________________________________________________________________________________

Employees who perform tasks that put them at risk for exposure to bloodborne pathogens or hazardous chemicals have been trained, understand and follow the policies and procedures in this OSHA Program Manual.

Workplace hazards are reviewed and can be assessed through the following mechanisms: Weekly Facility Review Checklist (Form 4A)Monthly Facility Review Checklist (Form 4B). Annual Facility Review Checklist (Form 5). Incident Report/Sharps Injury Log (Form 11).Safety Report for employee concerns (Form 1).Observation of near-misses and at-risk behaviors.

Workplace hazards are reviewed:

Whenever new substances, processes or procedures are introduced.When previously unidentified hazards are recognized.When incidents occur or workplace conditions warrant a review.

Once a potential hazard is identified, the OSHA Safety Officer records the changes to the procedures contained in the appropriate Tab of this Manual.

Employee TrainingThe OSHA Safety Officer is responsible for overseeing the employee training program, which involves annual retraining as well as new employee orientation. It is also suggested, but not required, to conduct a brief, interactive session devoted to a safety issue at every staff meeting.

A dentist or other qualified medical professional (dental assistant, hygenist, etc.) may provide the training, as long as he/she is competent in addressing questions pertaining to OSHA compliance.

Training sessions are provided during work hours at no cost to the employee. Material appropriate in content and vocabulary to the educational level, literacy and language background of employees is used, such as videos or lectures.

2-9


Educational formats, such as live presentations, interactive or noninteractive computer programs, or videos, may be used to fulfill employee training requirements. However, a qualified person must be available to answer questions during a discussion period specifically for all types of bloodborne pathogens training. A telephone hotline may suffice in fulfilling this requirement, according to January 17, 2008, OSHA interpretation letters; however, voice mail, e-mail, paging systems, or other methods that don’t guarantee an immediate response are not compliant. For more details on the interactive requirement, search for “Clarification on trainer requirements and access to trainer under OSHA’s bloodborne pathogens standard” at www.osha.gov or call the HCPro OSHA consultation line at (800) 650-6787.

The training must contain information that none of these formats can accomplish, such as:Where the OSHA Program Manual and MSDS (SDS) binder are located in the facility.Where fire extinguishers, eyewash stations and exit doors are located in the facility.Where personal protective equipment is located in the facility.Where employees and patients meet after a building evacuation.

Checklist for an Effective Safety Training Session

The following eight tips help lead to a more effective presentation:

Plan the event – Set objectives, limit the focus of your talk, and project your belief in the subject matter.

Involve management – The training program will only achieve its objectives if management is committed to employee safety. Have a member of management in attendance to clarify policies.

Be creative – Use audio, visual, role plays and hands-on material to increase employees’ retention of the information. Use techniques that best communicate to your specific employees.

Demonstrate – Use props in cases where it’s more effective to demonstrate the use of an item than explain it.

Keep it moving – The most effective speakers move throughout the room. Create activities, which allow audience participation from the front row to the last.

Use employees as teachers – Let the audience relate the subject matter back to their own real world experiences. Listen to the examples offered and expand on them.

Help employees buy into the process – The best training information is worthless if employees do not see how it will benefit them. Use specific on-site examples to show the relevance of the program to their own safety.

Head off opposition – Use off-the-job examples if the group is resistant to someone telling them how to do their work. Off-the-job examples drive the point across in a much less threatening way.

2-10


Interactive Safety Training Exercises

A good safety program involves not only management commitment but employee involvement. Employees will retain more information and practice safety procedures if safety training is interesting and interactive. The following suggestions can be included in employees’ annual training or can serve to reinforce management’s commitment to this OSHA Safety Program at staff meetings.

General SafetyDemonstrate the location and operation of the eyewash(s).Demonstrate the location of circuit breakers and describe procedures used in the event of

electrical shock injury.State the location of compressed gas cylinders and describe precautions regarding their

use.Describe hazards of radioactive materials and precautions regarding their use.

Fire SafetyState location of fire alarms and extinguisher(s) and demonstrate or describe their use. Identify location of evacuation routes from the building.Explain procedures to follow in the event of a fire (RACE).Participate in a fire drill.

Bloodborne Pathogens SafetyDescribe the protocol for cleaning up splashes and sprays of saliva.Describe the protocol for disposal of sharps/used needles. Locate the Exposure Control Plan.Demonstrate aseptic removal of gloves.Describe when protective apparel is used.

Chemical Safety Locate the MSDS (SDS) binder and look up a hazardous chemical with which you work.

Then:- State the primary route of entry for this chemical (skin, lungs, eyes, etc.).- Discuss the symptoms of overexposure to this chemical.- Identify the protective equipment and ventilation that is required when working with

this chemical.- Locate the protective equipment in the area. State location of replacements.- State the emergency first aid procedures for the chemical.

State the location of the chemical spill kit.Demonstrate how to clean up a chemical spill.Demonstrate how to use safety glasses while developing x-rays and while mixing,

pouring or diluting chemicals. (Note: this hazard is eliminated with the use of digital films)Show how to use the silver separator for x-ray developer and fixing solutions. (Note: this

2-11


hazard is eliminated with the use of digital films)Describe how to manage scrap amalgam in an air tight container prior to collection by a

metal refining company.Show how to shut off the oxygen tank valve.Demonstrate the proper use of the nitrous oxide equipment:

- Instruct on the hazards of recreational use of nitrous oxide - Instruct on the teratogenic effects of nitrous oxide

TB SafetyConduct a role-play for exactly what action to take when a potential TB patient enters the

facility. Discuss the effectiveness of current policies.

Annual Employee Retraining OSHA requires annual training for employees covered under the Bloodborne Pathogens and Respiratory Protection standards. HCPro also strongly recommends annual retraining on the Hazard Communication Standard (“Right To Know”) now with the focus of the “Right to Understand” since the OSHA changes passed in 2012. All employees need to know the new chemical labeling and hazard rating information prior to December 2013. (Refer to Tab 6 for the latest updates).

It also makes sense to include miscellaneous safety procedures, such as, violence prevention and fire safety. At least once per year, all employees should be shown the location and proper use of fire extinguishers, fire alarms and exit routes. Training Topic Who Must Attend When to TrainTraining and Annual Retraining on Bloodborne Pathogens

Employees named on either of the Exposure Determination Lists.

• Before potential on-the-job exposure• Annually• Provide abbreviated training for affected

em ployees whenever a new procedure is adopted that involves potential exposure

Annual Retraining on Respiratory Protection

Employees required to wear a respirator.

• Before potential on-the-job exposure

• Annually

• When changes in the workplace or the type of respirator render previous training obsolete

• When employee’s knowledge or use of the respirator indicates retraining is needed

Training and Annual Retraining* on Hazard Communication

New and current employees who are exposed to hazardous chemicals in the normal course of their duties.

• Before potential on-the-job exposure • Annually • Employees who face exposure whenever

a new hazardous chemical is introduced in the workplace

2-12


* HCPro recommends employees complete HazCom training both initially and then annually. Although minimum legal requirements do not dictate annual retraining for employees, we strongly recommend annual training for those working with hazardous substances. Chemicals are always being added or eliminated from the workplace, so it makes sense to refresh your staff by training each year.

Bloodborne Pathogens Annual Training ContentsAccess to this OSHA Program Manual which includes written policies for OSHA

compliance. The OSHA Program Manual also includes an Exposure Control Plan for the Bloodborne Pathogens Standard.

An explanation of the signs and labels used in this workplace.A general explanation of the modes of transmission, epidemiology and symptoms of

bloodborne diseases (HBV, HCV, HIV).An explanation of methods to recognize tasks that may involve exposure to blood or

other potentially infectious materials and the practices to prevent or reduce exposure.A discussion of the limitations of the above practices to prevent or reduce exposure to

bloodborne pathogens. Information on the types, proper use, location, removal, decontamination and disposal of

personal protective equipment (PPE). Information about the free hepatitis B vaccine, including its efficacy, safety, benefits.An explanation of what constitutes an exposure incident and the procedure to follow if an

exposure event occurs. Information about the type of post exposure follow-up provided by this facility. An opportunity for employees to ask questions of the person conducting training.

Respiratory Protection Annual Training ContentsWhere the written respiratory protection plan is located and how to access it.An explanation of the requirements of the plan including identification of the program

administrator, respirator selection, medical evaluations, and fit testing.An explanation why the respirator is necessary and how improper fit, usage, or

maintenance can compromise the protective effect of the respirator.An explanation on the limitations and capabilities of the respirator.How to use the respirator effectively in emergency situations, including malfunctions. How to inspect, put on and remove, use, and check the seals of the respirator.What the procedures are for maintenance and storage of the respirator.How to recognize medical signs and symptoms limit or prevent respirators use.

Hazard Communication Annual Training ContentsWhere the Hazard Communication program, including MSDS (SDS), is located and how

to access the program.How to protect employees from the hazardous substances they work with (including

precautions to take and protective clothing and equipment to use).Proper labeling of hazardous chemicals.

2-13


How to read and interpret MSDS (SDS) and labels.How to recognize if they have been exposed (such as visual appearance or smell).How to clean up a chemical spill.What to do if exposure occurs.How to report an incident or exposure.

New Employee OrientationIn addition to annual retraining, employees must be trained initially about OSHA regulations as they pertain specifically to the workplace. Use Form 19, the New Employee OSHA Orientation Checklist located in Tab 8: Master Record Forms of this manual.

It’s important not to assume that even employees with a clinical background will know how to protect themselves from hazards in your workplace because general safety knowledge may not transfer to a current work situation.

Documenting Employee Training Document annual employee retraining on Form 20, the Annual Employee Training Record. Document new employee safety training on Form 19, the New Employee OSHA Orientation Checklist. Master copies of these forms can be found behind Tab 8: Master Record Forms.

Retain all training records for at least three years.

OSHA ANNUAL RETRAININGSample Test Questions

1. What does OSHA stand for?

O___________________________________ S___________________________________H___________________________________ A___________________________________

2. List 3 bloodborne pathogens:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________

2-14


3. Name 3 ways employees can be infected by bloodborne pathogens on the job:

_____________________________________________________________________________________________________________________________________________________________________________________________________________________

Circle the most appropriate response.

4. Name one way employees can be infected with bloodborne pathogens on the job:

a. Handling contaminated instruments.b. Being exposed to patients who are coughing.c. Working with glutaraldehyde.d. Helping an older patient from the waiting area to the operatory.

5. OSHA’s standard protects America’s healthcare workers against this most common bloodborne pathogen:

a. HIVb. Hepatitis Cc. Tuberculosisd. Syphilis

6. Which of the following is most likely to cause an actual infection after a needlestick with an infected patient, i.e., transmission occurs most easily?

a. HIVb. Hepatitis Bc. Hepatitis Cd. Hepatitis A

7. When performing a procedure where blood is likely to splash or spray, one must wear:

a. Gloves, gown, goggles.b. Gloves, gown, mask.c. Gloves, gown, full face shield.d. Gloves, lab coat, mask, goggles.

8. Which of the following does not require an MSDS (SDS)?

a. Clorox bleach used in 1:10 dilution to clean surfaces.b. High-level disinfectants (Cidex, Metricide, etc.) used to soak instruments.c. Household products containing hazard warning labels that are used differently than

at home.d. Household products with hazardous warning labels that are used exactly as they are

used at home and with the same frequency.

2-15


9. Which of the following is not true about eyewashes?

a. Employees must be able to reach eyewashes in 10 seconds.b. A squeeze-bottle mounted over a sink is ideal.c. The eyewash must be able to flush the eyes with tepid water for at least 15 minutes.d. An eyewash must have a visible sign.e. All of the above are true.

10. Which of the following is true about biohazardous waste containers?

a. Containers must be leakproof.b. Containers must contain the biohazard symbol.c. Containers must be located at the point of waste generation.d. All are true.e. None are true.

2-16


Mark True or False

___ 1. An employee can be dismissed from their job for not following the safety policies in the OSHA Safety Program.

___ 2. An employee can sign a declination form to be excused from wearing gloves when working with blood or saliva.

___ 3. It is an OSHA violation to put biohazardous trash in regular wastebaskets or cans.___ 4. Needlesticks don’t need to be reported unless the patient is known to have HIV or

hepatitis.___ 5. An employee can be infected with HIV by a splash or spray of patient saliva to his

intact skin.

2-17


Sample Test - Answer Key

1. OSHA stands for the:

Occupational Safety and Health Administration

2. Three bloodborne pathogens are:

1. Hepatitis B2. Hepatitis C3. HIV

3. Ways employees can be infected on the job are:

- Splashes or sprays to non-intact skin or pre-existing skin lesion- Needlesticks- Sharps injuries from broken glass, scalpels, burs, etc.- Mucous membrane contact through sprays, splashes, rubbing into eyes, nose,

mouth, etc.

4. a5. b6. b7. c8. d9. b10. d11. T12. F13. T14. F15. F

2-18


Practical Ideas for Administering the OSHA Safety ProgramAn employee complaint is the number one reason for an OSHA inspector to show up at a dental facility’s door. In fact, most OSHA inspections of dental offices have been initiated by an employee complaint.

Whether it’s the disgruntled employee who sees his complaint as a way to retaliate against a supervisor or a system he perceives as being “wrong,” or a person who has consistently received a deaf ear from management about a perceived hazard, OSHA will come. OSHA inspectors once in the facility, rarely, if ever, leave your facility without reviewing other OSHA required records.

You can nip potential complaints to OSHA in the bud. Here are some practical suggestions for doing this–the best part is that they don’t cost a penny. Try some or all of them to reduce your real or perceived liability:During every staff meeting, encourage employees to bring up any concerns about their

safety on the job. Listen to their responses and encourage discussions!When an employee states a concern, show interest and ask for more details. Regardless

of whether that concern is your top priority or not, address it and resolve either to fix the problem or allay the employee’s fears.

Bring this OSHA Program Manual to staff meetings to reinforce the fact that your practice has a tangible program that contains policies to ensure staff safety.

Take five minutes at these same meetings to do a safety-related demonstration, such as showing how to remove exam gloves without splashing colleagues, how to clean up a biohazardous spill, how to locate and read a MSDS (SDS), etc. These short exercises reinforce your commitment to safety. Allow employees the opportunity to present these topics at safety meetings. Practice evacuation drills for fire, violent behavior, and other emergencies that could potentially occur in your area. After the drill, critique the staff’s performance and amend your emergency plans.

Finally, the ultimate goal for an OSHA Safety Officer is zero non-compliance and minimal exposure incidents. Make sure employees know exactly what safety measures to take. Be sure that employees know that using safe work practices and wearing appropriate protective gear is not optional. Make sure employees 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, Inc., 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 (Helpful tool for annual review of overall safety program)

2-19


4. An Annual OSHA Safety Program Review Form (mandatory) These forms are located behind Tab 8: Master Record Forms (Forms 4A, 4B, 5, and 3). Use them to document and organize compliance duties.

This facility identifies the need for new engineering controls, changes to the current ones in use (e.g., sharps containers, work practices, sharps devices, protective equipment or clothing), or in employee training, through:Review of employee injury records.Verbal or written communication (complaints or suggestions) from employees.Sharps evaluation forms.Staff/committee meetings.

If it is determined that revisions need to be made, the OSHA Safety Officer ensures implementation of the recommendations by making changes to this OSHA Safety Program. For this purpose, use the Annual OSHA Program Review Form located behind Tab 8: Master Record Forms (Form 3).

TAB 2: OSHA PROGRAM ADMINISTRATION

Contents

INJURY & ILLNESS PREVENTION PLAN ....................................................... 2-1Management Leadership and Employee Involvement............................................................2-1Key Contacts for the OSHA Safety Manual ............................................................................2-2Location of the OSHA Safety Program ...................................................................................2-2

Duties of the OSHA Safety Officer .................................................................. 2-2Accident/Incident Investigation & Reporting Procedure .............................. 2-3

Definition of an Accident and/or Incident ................................................................................2-4When to Investigate an Accident/Incident ...............................................................................2-4How to Document an Accident/Incident ..................................................................................2-4Recording Accidents or Injuries for OSHA ..............................................................................2-4Correcting Unsafe or at Risk Conditions .................................................................................2-5

Recordkeeping Requirements ........................................................................ 2-5Equipment & Facility Records .................................................................................................2-5Bloodborne Pathogens Records .............................................................................................2-5Hazard Communication Records ............................................................................................2-6TB Records/Respiratory Protection Program .........................................................................2-6Employee Medical Records ....................................................................................................2-6Evaluating Exposure Incidents ...............................................................................................2-7

Workplace Hazard Analysis ............................................................................. 2-7Employee Training ........................................................................................... 2-8

Checklist for an Effective Safety Training Session .................................................................2-9Interactive Safety Training Exercises ......................................................................................2-10

General Safety ................................................................................................................2-10Fire Safety .......................................................................................................................2-10Bloodborne Pathogens Safety ........................................................................................2-10Chemical Safety ..............................................................................................................2-10TB Safety ........................................................................................................................2-11

Annual Employee Retraining .......................................................................... 2-11Bloodborne Pathogens Annual Training Contents ..................................................................2-12Respiraotry Protection Annual Training Contents ...................................................................2-12Hazard Communication Annual Training Contents .................................................................2-12

Page

New Employee Orientation .............................................................................. 2-12Documenting Employee Training ................................................................... 2-13

OSHA Annual Retraining ........................................................................................................2-13

Practical Ideas for Administering the OSHA Safety Program ...................... 2-18

Contents


Form 1

SAFETY REPORT

Use to record discussions from employee or patient complaints/concerns and staff meeting or Safety Committee meetings.

Date: __________ Venue: Staff Meeting Complaint/Concern Other: ___________________________________

Employee(s) Present: ______________________________________________________________________

______________________________________________________________________

Safety Issue: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Further Action Needed? Yes No

Action Taken:__________________________________________________________________________________________________________________________________________________________________________________________________________________

Resolution: __________________________________________________________________________________________________________________________________________________________________________________________________________________


EYEwASh STATION wEEkLY ChECk LOG

Eyewash stations require weekly checks to be compliant with the American National Standards Institute, 2009 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 (within one second) – Flow removes eyepiece covers – Water flows evenly, in a steady stream from both eyepieces – If the eyewash is designed with a mixing value, ensure that the water temperature

is between 60-100 F.

Flush. Run the station for three minutes to flush stagnant water from the line.

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 inspection/ disinfection

Notes Initial

*Document annually required testing here or on a separate log of all eyewash stations in the facility.

Form 2-A


Form 3

ANNUAL OShA SAFETY PROGRAM (INCLUDES EXPOSURE CONTROL

PLAN, hAzARD COMMUNICATION PROGRAM AND RESPIRATORY PROTECTION PLAN) REVIEw

Date Reviewed By Page # of Changes Summary of Revisions*

*Include evaluations of sharps containers, safety needles, etc.


Form 4-A

wEEkLY FACILITY REVIEw ChECkLIST

Mark 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 readable?

_____ 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.)

_____ 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) 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 occupationally 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 7.)

_____ Have the exam/treatment rooms been inspected for outdated supplies?

Date: __________________ OSHA Safety Officer: __________________________________


Form 4-B

MONThLY FACILITY REVIEw ChECkLIST

Mark 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?

_____ 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 cleansers available 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 sec every month?

Administration_____

Have all new employees completed a “New Employee OSHA Orientation” checklist? (Reference Form 26.)

_____Is the MSDS (SDS) binder and the Master Hazardous Substances List up to date, reflecting any new chemicals brought into use this month? (Reference Form 19, MSDS (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: __________________________________


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. (annual testing

of backup lights/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). _____ 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. (record review shows the extinguishers were inspected during each of the last twelve months).

_____ Panic buttons, or public address systems, are in working order. _____ The worksite is maintained in a clean and sanitary condition. _____ Restricted areas (lab, decontamination room, biohazardous waste storage, etc.) are

designated with signage. Break Room_____ The break area is free of contamination from blood or other potentially infectious

materials (OPIMs). _____ Employees discard PPE before entering the break area. _____ The break area is free from hazardous chemicals unless properly segregated. Check-in/Reception_____ An up-to-date emergency contact list is posted or present. (Reference Tab 3)

_____ The reception area is free of contamination from blood and OPIMs. _____ Employees discard PPE before entering the reception area. _____ 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 20)

_____ All new employees received initial OSHA training and completed a New Employee Orientation Checklist (if previously trained) and this training is documented. (Reference

Form 19)


Form 5

(Annual Facility Review Checklist, page 2 of 3)_____ Employees are trained on the proper precautions, and how to properly don, doff and

use, the PPE necessary for their job duties. (Reference Forms 19, 20)

_____ All employees participated in at least one fire drill this year or signed Safety Committee/Staff meeting minutes where they reviewed the fire drill discussion/results.

_____ Employees have been trained on how to respond in the event of a fire (R.A.C.E.). (Reference Forms 19, 20)

_____ Employees have been properly trained on how to use a fire extinguisher (P.A.S.S.) (Reference Forms 19, 20)

_____ All OSHA training records from the last three (3) years are available (Reference Forms 19, 20)

_____ Exposure Determination Lists #1 and #2 document all employees with risk for exposure. (Reference Forms 7, 8)

_____ The facility has documented all needlesticks and other sharps injuries which occurred this year using the Incidents/Sharps Injury Log (Reference Form 11 )

_____ All employee incidents, 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, 11)

_____ In areas where trends were noted above or safer sharps have not yet been imple-mented frontline employees have been included in the evaluation of new safety devices for possible future implementation. Evaluations have been documented, and evaluation forms are retained. (Reference Forms 9, 10)

_____ Hepatitis B vaccination records (or declination forms) are available for all employees. (Reference Forms 12, 13)

_____ 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 11, 14, 15, 16)

_____ 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 17)

_____ MSDS (SDS) binder(s) are in the proper location (accessible to employees). _____ MSDS (SDS) are present for all hazardous chemicals in the facility, including fire

extinguishing chemicals. (Reference MSDS (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 , incompatible chemicals are segregated, etc.) and are disposed of properly.

_____ Chemicals are labeled legibly with contents and hazards clearly identified. Labels match the identity on the corresponding MSDS (SDS). (Reference Form 17, MSDS (SDS) binder)

_____ Appropriate PPE (gloves, respirators, goggles/face-shields, aprons) is available/accessible for handling hazardous chemicals. (Reference MSDS (SDS) binder)

_____ All items are stored at least 18 inches from the ceiling in sprinklered areas.


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 ANSI 2009, Eyewash Standards._____ Universal Precautions are used when handling all blood or 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 medical 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 seal). _____ PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is

available in the correct sizes and amounts, worn consistently and functions properly. _____ Sharps containers are in the proper locations, secure 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 2/3 full. _____ The most effective engineering controls are available, being used 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. _____ Appropriate PPE (rubber, nitrile or vinyl gloves, respirators, goggles/face shields,

aprons) available, consistently worn 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. Labels match the identity on the corresponding MSDS (SDS). (Reference Form 17, MSDS (SDS) binder)

_____ Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in an explosion-proof flammable cabinet, incompatible chemicals are segregated, 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, are properly labeled for the chemical and biohazards present.

Comments (explain any “No” answer): ________________________________________________________________________________________________________________________________________________________

Date: __________ OSHA Safety Officer*: __________________________________________* Note: Also document this annual OSHA safety program review on Form 3.


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: _______________________________________________________________


Form 5-B

EMPLOYEE FIRE DRILLPARTICIPATION SIGN-UP ShEET

Date: ___________________

Participating Employees

1. 16.2. 17.3. 18.4. 19.5. 20.6. 21.7. 22.8. 23.9. 24.10. 25.11. 26.12. 27.13. 28.14. 29.15. 30.

Non-participating Employees

Name Date Safety Minutes/Fire Plan Reviewed

OSHA Safety Officer: ____________________________________________________


Form 9-A

ShARPS DISPOSAL CONTAINER LOCATIONS

Use to periodically monitor compliance for sharps disposal container locations.

Container placement, along with work practices, allows sharps disposal as soon as possible—preferably without needing to put the device down and pick it up again.

Containers are within arm’s reach and below eye level at their point of use.

Wall-mounted containers allow workers to access or view the opening of the container.

No furniture or other objects create obstacles between the worker’s path and the container.

Container placement does not cause unnecessary movement when holding the sharp during disposal.

The following locations are avoided for container placement:

– In the corners of rooms

– On the backs of room doors

– Near light switches or room environmental controls

– In areas in which people might sit or lie beneath the container

– Under cabinets

– Inside cabinet doors

– Under sinks

– Where the container is subject to impact and dislodgment by pedestrian traffic, moving equipment, gurneys, wheelchairs, or swinging doors

Placement due to security and safety precautions such as pediatric, geriatric, mental health, and correctional settings does not impair safe access by workers.

Installation height of containers is within an ergonomically acceptable range (i.e., 52–56 inches for standing disposal; 38–42 inches for seated disposal).

Containers are visible by placement, color, and signage.

Container fill status is visible under current lighting conditions and before sharps are placed in the container.

Container safety features, security measures, and design aesthetics do not impair container recognition, fill status, warning labels, disposal opening, or access.


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

Log on page 2) Chemical injury: ______________________________ (Attach MSDS

(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?)______________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

(Use reverse if necessary)

Engineering controls/work practices/protective equipment/safety devices in use at the time of the incident: __________________________________________________________witness/person familiar with incident: ___________________________________________Resolution:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

(Use reverse if necessary)

OShA safety officer signature: ________________________ Date reviewed: __________Supervisor signature: ________________________________ Date reviewed: __________

*2nd page used only when indicated above.

Form 11


Form 11

(Incident Report/Sharps Injury, page 2 of 2 – use only when indicated on page 1)

EXPOSURE LOGRoute 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: ________________________

Patient Name: ________________Age: ______ Sex: ________

(or use patient sticker)

ShARPS INJURY LOGType/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 11-A


hBV EMPLOYEE VACCINATION FORM

Date: _____________ Healthcare provider: ______________________________

Employee name: _______________________________________________________

hepatitis B vaccine: (check one)

Immune from previous vaccination or other reason (attach vaccination records from previous employer or other test results)

Declined (attach hBV Vaccination Declination Form)

Contraindicated (attach signed medical opinion)

Immune (attach test results)

Accepted (complete table below)

Dose Date Administered by Comments/ Exp Date, LOT # and MFG of Vaccine

1

2

3

Titer Attach lab results**If employee was not immune, repeat the series of three hepatitis B vaccinations and titer again.

Employee is a responder.

Employee is a non-responder and has been counseled about the need for prophylaxis for any known or probable parenteral exposure to HBsAg-positive blood. See comments.

Comments:___________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Form 13


POST-EXPOSURE ChECkLISTDate Post-exposure Follow-up

Incident Report/Sharps Injury Log completed.Obtain consent from source patient and test for HBV, HCV, and HIV.*Obtain consent from exposed employee and test for HBV, HCV and HIV.* +

Exposed employee offered the HBV vaccination again, if initially declined.Employee referred to healthcare provider and given:

– A copy of the Bloodborne Pathogens Standard.– A copy of the Incident Report/Sharps Injury Log.– Results of the source individual’s testing (if applicable).– Exposed employee’s medical record relevant to this incident (SSN,

HBV status, test results).Healthcare provider given the source individual’s test results.Written opinion from healthcare provider received within 15 days of the evaluation must include: 1. Whether HBV vaccination was recommended and whether or not the

employee received the first shot in the series. 2. Verification that the employee has been informed of the results of the

evaluation and told of any medical conditions resulting from exposure requiring further evaluation and treatment.

All added findings or diagnoses must be kept confidential and not included in the written opinion, which goes to the employer. Any further information about the results of the employee’s evaluation and medical conditions must be conveyed to the employee only and not included in the written opinion that goes to the employer. Employee medical record (including written opinion above) is stored in a confidential** location and is not made available to employee’s employer.Circumstances of the exposure incident are reviewed to determine whether modifications are needed to bloodborne pathogens policies and procedures.

* Obtain as soon as feasible. These are not sequential but concurrent steps.

+ Can be declined via declination form. If the employee does not give consent for HIV serological testing during collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days; if the exposed employee elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible.

** The employee must give specific written consent for anyone to see his/her record. Maintain this confidential medical record for the length of employment plus 30 years.

Form 14


Form 17

hA

zAR

DO

US

SUB

STA

NC

ES L

IST

Che

mic

alN

ame

Loca

tion

In

Faci

lity

Man

ufac

ture

r Nam

e/A

ddre

ssw

hat C

hem

ical

Is U

sed

for

MSD

S(S

DS)

? (Y

*/N)

*A m

aste

r cop

y of

this

form

is a

lso

loca

ted

in H

cPro

’s M

SD

S (S

DS

) bin

der.

File

in m

ain

MS

DS

(SD

S) fi

le o

r bin

der.

Pos

t cop

y at

site

loca

tion.


NEw EMPLOYEE OShA ORIENTATION ChECkLIST

(1 of 2 pages)

Employee name: _______________________________________Date: _________________

Please mark “Y” to denote employee understanding, “N” if more information is needed, or “NA” if the item is not applicable to the employee’s responsibilities.

OShA BLOODBORNE PAThOGENS STANDARDThe new employee knows:

_____ Where the OSHA Safety Manuel is located._____ How bloodborne pathogens are transmitted (needlesticks, cuts, splashes, sprays)._____ The signs and of the symptoms of HBV, HCV and HIV infection._____ Which body fluids encountered in this practice are potentially infectious._____ When, where and how to wash hands._____ Where eyewashes are located and how to use them._____ How to properly handle and dispose of sharps._____ Where sharps containers are located._____ What is considered biohazardous waste and where containers are located._____ When and how to close sharps containers and biohazardous waste containers and

transport them to the storage area._____ That restricted access areas indicated by biohazard labeling should only be entered

by trained and authorized personnel._____ How to properly package and store laboratory specimens._____ How to clean up biohazardous spills. _____ Where utility gloves are located and when to use them._____ How and when to wear the proper PPE to protect against potentially infectious

body fluids. _____ What to do with soiled, reusable PPE (care, maintenance, cleaning)._____ When to change exam gloves. Knows to wash hands after removing gloves._____ How to remove gloves safely._____ Where, when and how to use disinfectant cleansers based on the Housekeeping

Schedule located in Tab 5._____ How to operate the autoclave (including spore strip testing)._____ What constitutes an on-the-job exposure and what to do if an exposure occurs._____ That the hepatitis B vaccine is safe and available free of charge in this workplace._____ That a titer will be performed after the hepatitis B vaccination series to verify its efficacy.

Form 18


(New Employee OShA Orientation Checklist, page 2 of 2)

hAzARD COMMUNICATIONThe new employee knows:

_____ What hazardous chemicals exist in the practice (review master list)._____ How to work safely with the above chemicals._____ Where Material Safety Data Sheets (MSDS)/Safety Data Sheets (SDS) are located

and how to read one._____ How to recognize signs of chemical exposure and what to do if exposure occurs._____ How and where to sterilize or disinfect instruments and equipment._____ How to work safely with dental x-rays.

Other: ____________________________________________________________________.

EMERGENCIESThe new employee knows:

_____ Location of written emergency procedures and emergency telephone numbers._____ Exit routes and evacuation procedures._____ Where fire extinguishers are located and what to do in the event of a fire._____ Protocols for reporting workplace violence.

Other: ____________________________________________________________________.

RESPIRATORY PROTECTION PLAN_____ Influenza vaccination and protection protocols._____ Incidence of TB in the community and related protocols.

Form 18


ANNUAL EMPLOYEE TRAINING RECORD

Type of training*: ____________________________ Date: ___________________

Subjects covered**: ______________________________________________________________________________________________________________________

Trainer: __________________________ Title/Qualifications: _________________

I have read and understood the safety procedures outlined in our Exposure Control Plan and Hazard Communication Plan. After the training session, I was given the opportunity to ask questions to clarify the material. I will, to the best of my abilities, make every effort to practice these safety policies in order to reduce health risks to my coworkers, our patients and myself.

Date Employee name/Job title (please print) Employee signature

*Video, Seminar, etc. If employee attended a seminar, attach seminar description to this form.** Bloodborne Pathogens, HazCom, fire safety, radiation, etc.

Form 19


INFLUENzA VACCINE DECLINATION FORM

My employer or affiliated health facility, ___________________________, has recommended I receive influenza vaccination in order to protect myself and the patients I serve.

I acknowledge that I am aware of the following facts:

• Influenza is a serious respiratory disease that kills an average of 36,000 persons and hospitalizes more than 200,000 persons in the United States each year.

• Influenza vaccination is recommended for me and all other healthcare workers to prevent influenza disease and its complications, including death.

• If I contract influenza, I will shed the virus for 24–48 hours before influenza symptoms appear. My shedding the virus can spread influenza infection to patients in this facility.

• If I become infected with influenza, even when my symptoms are mild, I can spread severe illness to others.

• I understand that the strains of virus that cause influenza infection change almost every year, which is why a different influenza vaccine is recommended each year.

• I cannot get the influenza disease from the influenza vaccine.• The consequences of my refusing to be vaccinated could endanger my health and

the health of those with whom I have contact, including

– patients in this healthcare setting– my coworkers– my family– my community

Despite these facts, I am choosing to decline influenza vaccination right now for the following reasons: ____________________________________________________

___________________________________________________________________

I understand that I may change my mind at any time and accept influenza vaccination, if vaccine is available.

I have read and fully understand the information on this declination form.

_________________________________ __________Employee signature Date

________________________________Employee printed name

Adapted from Immunization Action Coalitionwww.immunize.org/catg.d/p4068.pdf

Form 25-A


Form 25-B

Section I. Administrative Policies and Facility PracticesPractice

PerformedIf answer is No, document

plan for remediation1. Facility PoliciesWritten infection prevention policies and procedures are available, current, and based on evidence-based guidelines (e.g., CDC/HICPAC), regulations, or standards (Note: Policies and procedures should be appropriate for the services provided by the facility and should extend beyond OSHA bloodborne pathogen training.)

Yes No

Infection prevention policies and procedures are reassessed at least annually or according to state or federal requirements

Yes No

Supplies necessary for adherence to Standard Precautions are readily available (Note: This includes hand hygiene products, personal protective equipment, and injection equipment.)

Yes No

2. General Infection Prevention Education and TrainingHealthcare personnel (HCP) receive job-specific training on infection prevention policies and procedures upon hire and at least annually or according to state or federal requirements (Note: This includes those employed by outside agencies and available by contract or on a volunteer basis to the facility.)

Yes No

Competency and compliance with job-specific infection prevention policies and procedures are documented both upon hire and through annual evaluations/assessments

Yes No

3. Occupational health HCP are trained on the OSHA Bloodborne Pathogens standard upon hire and at least annually

Yes No

The facility maintains a log of needlesticks, sharps injuries, and other employee exposure events

Yes No

Following an exposure event, post-exposure evaluation and follow-up, including prophylaxis as appropriate, are available at no cost to employees and are supervised by a licensed healthcare professional

Yes No

Hepatitis B vaccination is available at no cost to all employees who are at risk of occupational exposure

Yes No

Post-vaccination screening for protective levels of hepatitis B surface antibody is conducted after third vaccine dose is administered

Yes No

All HCP are offered annual influenza vaccination at no cost Yes NoAll HCP who have potential for exposure to tuberculosis (TB) are screened for TB upon hire and annually (if negative)

Yes No

ChECkLIST FOR INFECTION PREVENTION FOR OUTPATIENT SETTINGS


Form 25-B

The facility has a respiratory protection program that details required worksite-specific procedures and elements for required respirator use

Yes No

Respiratory fit testing is provided at least annually to appropriate HCP

Yes No

Facility has written protocols for managing/preventing job-related and community-acquired infections or important ex posures in HCP, including notification of appropriate infection prevention and occupational health personnel when applicable

Yes No

4. Surveillance and Disease Reporting An updated list of diseases reportable to the public health authority is readily available to all personnel

Yes No

The facility can demonstrate compliance with mandatory reporting requirements for notifiable diseases, healthcare-associated infections, and for potential outbreaks

Yes No

5. hand hygiene The facility provides supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-based hand rub) and ensures that they are readily accessible to HCP in patient care areasHCP are educated regarding appropriate indications for hand washing with soap and water versus hand rubbing with alcohol-based hand rub (Note: Soap and water should be used when bare hands are visibly soiled [e.g., blood, body fluids] or after caring for a patient with known or suspected infectious diarrhea [e.g., Clostridium difficile or norovirus]. In all other situations, alcohol-based hand rub may be used.)

Yes No

The facility periodically monitors and records adherence to hand hygiene and provides feedback to personnel regarding their performance

Yes No

6. Personal Protective Equipment (PPE)The facility has sufficient and appropriate PPE available and readily accessible to HCP

Yes No

HCP receive training on proper selection and use of PPE Yes No7. Injection Safety Medication purchasing decisions at the facility reflect selec tion of vial sizes that most appropriately fit the procedure needs of the facility and limit need for sharing of multi-dose vials

Yes No

Injections are required to be prepared using aseptic tech nique in a clean area free from contamination or contact with blood, body fluids, or contaminated equipment

Yes No

Facility has policies and procedures to track HCP access to controlled substances to prevent narcotics theft/diversion

Yes No

(Infection Prevention Checklist, page 2 of 8)


Form 25-B

8. Respiratory hygiene/Cough Etiquette The facility has policies and procedures to contain respir atory secretions in persons who have signs and symptoms of a respiratory infection, beginning at point of entry to the facility and continuing through the duration of the visit. Policies include:

Yes No

Posting signs at entrances (with instructions to patients with symptoms of respiratory infection to cover their mouths/noses when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after hands have been in contact with respiratory secretions).

Yes No

Providing tissues and no-touch receptacles for disposal of tissues.

Yes No

Providing resources for performing hand hygiene in or near waiting areas.

Yes No

Offering face masks to coughing patients and other symptomatic persons upon entry to the facility.

Yes No

Providing space and encouraging persons with symptoms of respiratory infections to sit as far away from others as possible. If available, facilities may wish to place these patients in a separate area while waiting for care.

Yes No

The facility educates HCP on the importance of infection prevention measures to contain respiratory secretions to prevent the spread of respiratory pathogens when examining and caring for patients with signs and symptoms of a respiratory infection.

Yes No

9. Environmental Cleaning Facility has written policies and procedures for routine cleaning and disinfection of environmental services, including identification of responsible personnel

Yes No

Environmental services staff receive job-specific training and competency validation at hire and when procedures/policies change

Yes No

Training and equipment are available to ensure that HCP wear appropriate PPE to preclude exposure to infectious agents or chemicals (PPE can include gloves, gowns, masks, and eye protection)

Yes No

Cleaning procedures are periodically monitored and assessed to ensure that they are consistently and correctly performed

Yes No

The facility has a policy/procedure for decontamination of spills of blood or other body fluids

Yes No

10. Reprocessing of Reusable Instruments and Devices Facility has policies and procedures to ensure that reusable medical devices are cleaned and reprocessed appropriately prior to use on another patient (Note: This includes clear delineation of responsibility among HCP.)

Yes No

Policies, procedures, and manufacturer reprocessing instruc tions for reusable medical devices used in the facility are available in the reprocessing area(s)

Yes No



Form 25-B

HCP responsible for reprocessing reusable medical devices are appropriately trained and competencies are regularly documented (at least annually and when new equipment is introduced)

Yes No

Training and equipment are available to ensure that HCP wear appropriate PPE to prevent exposure to infectious agents or chemicals (PPE can include gloves, gowns, masks, and eye protection) (Note: The exact type of PPE depends on infectious or chemical agent and anticipated type of exposure.)

Yes No

The above basic information allows for a general assessment of policies and procedures related to reprocessing of reusable medical devices. Ambulatory facilities that are providing on-site sterilization or high-level disinfection of reusable medical equipment should refer to the more detailed checklists related to sterilization and high-level disinfection in separate sections of this document devoted to those issues.

Critical items (e.g., surgical instruments) are objects that enter sterile tissue or the vascular system and must be sterile prior to use (see Sterilization Section).

Semi-critical items (e.g., endoscopes for upper endoscopy and colonoscopy, vaginal probes) are objects that contact mucous membranes or non-intact skin and require, at a minimum, high-level disinfection prior to reuse (see High-level Disinfection Section).

Non-critical items (e.g., blood pressure cuffs) are objects that may come in contact with intact skin but not mucous membranes and should undergo cleaning and low- or intermediate-level disinfection depending on the nature and degree of contamination.

Single-use devices (SUD) are labeled by the manufacturer for a single use and do not have reprocessing instructions. They may not be reprocessed for reuse except by entities that have complied with FDA regulatory requirements and have received FDA clearance to reprocess specific SUDs.

Note: Pre-cleaning must always be performed prior to sterilization and/or disinfection.

Practice Performed

If answer is No, document plan for remediation

11. Sterilization of Reusable Instruments and DevicesAll reusable critical instruments and devices are sterilized prior to reuse

Yes No

Routine maintenance for sterilization equipment is per formed according to manufacturer instruction (confirm maintenance records are available)

Yes No

Policies and procedures are in place outlining facility re sponse (i.e., recall of device and risk assessment) in the event of a reprocessing error/failure

Yes No

12. high-Level Disinfection of Reusable Instruments and Devices All reusable semi-critical items receive at least high-level disinfection prior to reuse

Yes No

The facility has a system in place to identify which instrument (e.g., endoscope) was used on a patient via a log for each procedure

Yes No

Routine maintenance for high-level disinfection equipment is performed according to manufacturer instruction; confirm maintenance records are available

Yes No


Source: Adapted with permission from the CDC’s Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care.


Form 25-B

Section II. Personnel and Patient-care ObservationsPractice

PerformedIf answer is No, document

plan for remediation1. hand hygiene performed correctly: Before contact with the patient or their immediate care environment (even if gloves are worn)

Yes No

Before exiting the patient’s care area after touching the patient or the patient’s immediate environment (even if gloves are worn)

Yes No

Before performing an aseptic task (e.g., insertion of IV or preparing an injection) (even if gloves are worn)

Yes No

After contact with blood, body fluids, or contaminated surfaces (even if gloves are worn)

Yes No

When hands move from a contaminated body site to a clean body site during patient care (even if gloves are worn)

Yes No

2. PPE is correctly used: PPE is removed and discarded prior to leaving the patient’s room or care area

Yes No

Hand hygiene is performed immediately after removal of PPE Yes NoGloves:HCP wear gloves for potential contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated equipment

Yes No

HCP do not wear the same pair of gloves for the care of more than one patient

Yes No

HCP do not wash gloves for the purpose of reuse Yes NoGowns:HCP wear gowns to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated

Yes No

HCP do not wear the same gown for the care of more than one patient

Yes No

Facial protection:HCP wear mouth, nose, and eye protection during procedures that are likely to generate splashes or sprays of blood or other body fluids

Yes No

HCP wear a face mask (e.g., surgical mask) when placing a catheter or injecting material into the epidural or subdural space (e.g., during myelogram, epidural, or spinal anesthesia)

Yes No

3. Injection safety Needles and syringes are used for only one patient (this includes manufactured prefilled syringes and cartridge devices such as insulin pens)

Yes No

The rubber septum on a medication vial is disinfected with alcohol prior to piercing

Yes No

Medication vials are entered with a new needle and a new syringe, even when obtaining additional doses for the same patient

Yes No



Form 25-B

Single-dose (single-use) medication vials, ampules, and bags or bottles of intravenous solution are used for only one patient

Yes No

Medication administration tubing and connectors are used for only one patient

Yes No

Multi-dose vials are dated by HCP when they are first opened and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial (Note: This is different from the expiration date printed on the vial.)

Yes No

Multi-dose vials are dedicated to individual patients whenever possible.

Yes No

Multi-dose vials to be used for more than one patient are kept in a centralized medication area and do not enter the immediate patient treatment area (e.g., operating room, patient room/cubicle) (Note: If multi-dose vials enter the immediate patient treatment area, they should be dedicated for single-patient use and discarded immediately after use.)

Yes No

All sharps are disposed of in a puncture-resistant sharps container

Yes No

Filled sharps containers are disposed of in accordance with state-regulated medical waste rules

Yes No

All controlled substances (e.g., Schedule II, III, IV, V drugs) are kept locked within a secure area

Yes No

4. Point-of-Care Testing (e.g., blood glucose meters, INR monitor)New single-use, auto-disabling lancing device is used for each patient (Note: Lancet holder devices are not suitable for multi-patient use.)

Yes No

If used for more than one patient, the point-of-care testing meter is cleaned and disinfected after every use according to manufacturer’s instructions (Note: If the manufacturer does not provide instructions for cleaning and disinfection, then the testing meter should not be used for more than one patient.)

Yes No

5. Environmental CleaningEnvironmental surfaces, with an emphasis on surfaces in proxi mity to the patient and those that are frequently touched, are cleaned and then disinfected with an EPA-registered disinfectant

Yes No

Cleaners and disinfectants are used in accordance with manufacturer’s instructions (e.g., dilution, storage, shelf life, contact time)

Yes No

6. Reprocessing of Reusable Instruments and Devices Reusable medical devices are cleaned, reprocessed (disinfection or sterilization), and maintained according to manufacturer instructions (Note: If the manufacturer does not provide such instructions, the device may not be suitable for multi-patient use.)

Yes No



Form 25-B

Single-use devices are discarded after use and not used for more than one patient. (Note: If the facility elects to reuse single-use devices, these devices must be reprocessed prior to reuse by a third-party reprocessor that is registered with the FDA as a third-party reprocessor and cleared by the FDA to reprocess the specific device in question. The facility should have documentation from the third-party reprocessor confirming this is the case.)

Yes No

Reprocessing area has a work flow pattern such that devices clearly flow from high-contamination areas to clean/sterile areas (i.e., there is clear separation between soiled and clean work spaces)

Yes No

Medical devices are stored in a manner to protect from damage and contamination

Yes No

7. Sterilization of Reusable Instruments and Devices Items are thoroughly pre-cleaned according to manufacturer instructions and visually inspected for residual soil prior to sterilization (Note: For lumened instruments, device channels and lumens must be cleaned using appropriately sized cleaning brushes.)

Yes No

Enzymatic cleaner or detergent is used for pre-cleaning and discarded according to manufacturer’s instructions (typically after each use)

Yes No

Cleaning brushes are disposable or cleaned and high-level disinfected or sterilized (per manufacturer’s instructions) after each use

Yes No

After pre-cleaning, instruments are appropriately wrapped/packaged for sterilization (e.g., package system selected is compatible with the sterilization process being performed, hinged instruments are open, instruments are disassembled if indicated by the manufacturer)

Yes No

A chemical indicator (process indicator) is placed correctly in the instrument packs in every load

Yes No

A biological indicator is used at least weekly for each sterilizer and with every load containing implantable items

Yes No

For dynamic air removal–type sterilizers, a Bowie-Dick test is performed each day the sterilizer is used to verify efficacy of air removal

Yes No

Sterile packs are labeled with the sterilizer used, the cycle or load number, and the date of sterilization

Yes No

Logs for each sterilizer cycle are current and include results from each load

Yes No

After sterilization, medical devices and instruments are stored so that sterility is not compromised

Yes No

Sterile packages are inspected for integrity and compromised packages are reprocessed prior to use

Yes No

Immediate-use steam sterilization (flash sterilization), if performed, is only done in circumstances in which routine sterilization procedures cannot be performed

Yes No



Form 25-B

Instruments that are flash-sterilized are used immediately and not stored

Yes No

8. high-Level Disinfection of Reusable Instruments and DevicesFlexible endoscopes are inspected for damage and leak-tested as part of each reprocessing cycle

Yes No

Items are thoroughly pre-cleaned according to manufacturer instructions and visually inspected for residual soil prior to high-level disinfection (Note: For lumened instruments, device channels and lumens must be cleaned using appropriately sized cleaning brushes.)

Yes No

Enzymatic cleaner or detergent is used and discarded according to manufacturer instructions (typically after each use)

Yes No

Cleaning brushes are disposable or cleaned and high-level disinfected or sterilized (per manufacturer instructions) after each use

Yes No

For chemicals used in high-level disinfection, manufacturer instructions are followed for:

– Preparation Yes No– Testing for appropriate concentration Yes No– Replacement (i.e., prior to expiration or loss of efficacy) Yes No

If automated reprocessing equipment is used, proper connectors are used to ensure that channels and lumens are appropriately disinfected

Yes No

Devices are disinfected for the appropriate length of time as specified by manufacturer instructions

Yes No

Devices are disinfected at the appropriate temperature as specified by manufacturer instructions

Yes No

After high-level disinfection, devices are rinsed with sterile water, filtered water, or tap water followed by a rinse with 70%–90% ethyl or isopropyl alcohol

Yes No

Devices are dried thoroughly prior to reuse (Note: Lumened instruments [e.g., endoscopes] require flushing channels with alcohol and forcing air through channels.)

Yes No

After high-level disinfection, devices are stored in a manner to protect from damage or contamination (Note: Endoscopes should be hung in a vertical position.)

Yes No


Source: Adapted with permission from the CDC’s Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care.

osha program manual contents

Documents