osha program manual for medical facilities march 2015...

Dear HCPro Customer:

Enclosed is your latest supplement to the OSHA Program Manual for Medical Facilities. This supplement is designed tokeep your product up to date. Your next supplement will be in May 2015.

If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 ore-mail [email protected]. At HCPro, customer comments and suggestions are very important to us—let usknow how we can serve you better.

Please insert these new and revised pages as indicated, and keep these filing instructions at the front of your book.

FILING INSTRUCTIONS

Rev. 3/15 OPMFMF Supplement to OSHA Program Manual for Medical Facilities

VISIT www.hcmarketplace.com for the latest compliance and training information.

Remove Insert Reason for Change

Title page Title page updated

vii/viii vii/viii Master List of Program Items for Customization—updated

xix/xx xix/xx OSHA Program Manual Contents—updated

Tab 7 Contents Tab 7 Contents updated

7-1 through 7-14 7-1 through 7-21 Tab 7: The Hazard Communication Standard—updated

March 2015 Revisions

About the AuthorMarge McFarlane, PhD, MT (ASCP), CHSP, CHFM, HEM, MEP, CHEP, is an independent safety consultant

with more than 38 years of healthcare experience. She has provided education, emergency management

and safety plan review, life safety, and infection prevention facility surveys for healthcare and businesses

in Wisconsin and across the nation since 2005. She is the author of The Compliance Guide to the OSHA

GHS Standard for Hazardous Chemical Labeling, 2014 and the OSHA Training Handbook for Healthcare

Facilities, Second Edition, 2014. 15C

©2005–2015 HCPro, a division of BLR. All rights reserved, including right of reproduction. The author(s) and their agent(s) have made every reasonable effort in the preparation of this publication to ensure the accuracy of the information. However, the information in this book is sold without warranty, either expressed or implied. The authors, the editors, their agents, and the publishers will not be liable for any damages caused or alleged to be caused directly, indirectly, incidentally, or consequentially by the information in this publication. This publication cannot and does not provide specific information for a user’s exact situation. Users of this publication should exercise their own judgment and, where appropriate, seek the assistance of legal counsel regarding their particular situation.

HCPro, a division of BLR75 Sylvan Street, Suite A-101

Danvers, MA 01923Tel: 800/650-6787Fax: 800/639-8511

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OSHAPROGRAMMANUALfor Medical Facilities

OSHA Program Manual for Medical Facilities is published by HCPro, a division of BLR.

Copyright © 2015 HCPro, a division of BLR.

All rights reserved. Printed in the United States of America. 5 4 3 2 1

ISBN: 978-1-60146-743-0

No part of this publication may be reproduced, in any form or by any means, without prior written consent of

HCPro, a division of BLR, or the Copyright Clearance Center (978-750-8400). Please notify us immediately

if you have received an unauthorized copy.

HCPro, a division of BLR, provides information resources for the healthcare industry.

HCPro, a division of BLR, is not affiliated in any way with The Joint Commission, which owns the JCAHO

and Joint Commission trademarks.

Marge McFarlane, PhD, MT (ASCP), CHSP, CHFM, HEM, MEP, CHEP, Author

Sheila Dunn, DA, MT (ASCP), Contributing Editor

John Palmer, Managing Editor

Mike Mirabello, Fulfillment Specialist

Glenn Stefanovics, Content Management Specialist

Matt Sharpe, Senior Manager of Production

Elizabeth Petersen, Vice President

Advice given is general. Readers should consult professional counsel for specific legal, ethical, or

clinical questions.

Arrangements can be made for quantity discounts. For more information, contact:

HCPro, a division of BLR

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Danvers, MA 01923

Telephone: 800-650-6787 or 781-639-1872

Fax: 800-639-8511

E-mail: [email protected]

Visit HCPro online at: www.hcpro.com and www.hcmarketplace.com

3/15

Master List of Program Items for Customization

Throughout this OSHA Program Manual, blanks are included for you to fill in information specific to your facility.

The following pages contain “blanks” for you to customize. Enter your initials and the date you made the entry in the far right columns. This way when you do your annual review you can quickly tell if you need to update old information.

Page Item Information Needed Initials Date 22 Key Contacts for the

OSHA Safety ProgramSafety officer name, employer name, phone numbers, safety manual location

28 Workplace Hazards Record other hazards found in facility216 Annual Review Safety officers review of plan 32 Emergency Phone List Local contact phone numbers318 Systems Failure Contact names and numbers319320

Evacuation Procedures How alarms and announcements will be made, employee duties in emergency, assembly location

321 Evacuation Route Evacuation route323 Emergency

Preparedness SuppliesItems that will be kept on hand for emergencies

326 Civil Disturbance Assembly location328329

Severe Weather Safest location in building (Note: 3 blanks)

332 – 339

Workplace Violence Details of your Violence Prevention Plan (Note: 6 blanks and 2 lists that require checkmarks)

343 Crash Kit/Cart Components

Items included in facility’s crash kit/cart

343 – 347

DrugFree Workplace Program

Details of your DrugFree Workplace Pro gram (Note: if no options selected on 3-43, other customizations not necessary)

350 – 353

Holiday Decorations A review of the combustible decorations allowed at your facility (Note: this assessment is not required)

510 Exposure Prone Procedures

Procedures performed in facility that could expose employees

511 BBP Determination List Employees who have definite risk of exposure (class I)

513 BBP Determination List Employees who have possible risk of exposure (class II)

514 Restricted Access Areas

Restricted areas not listed in items 1–3

vii

Page Item Information Needed Initials Date 516 Handwashing Locations Locations handwashing takes place520 Sharps Recapping Instances when recapping is allowed521 Safety Sharps Instances when safety sharps are not used523 Laundry How biohazardous laundry is cleaned, or

if only disposables are used525 PPE Locations PPE provided in facility and its locations530 When to Wear PPE If tasks not already listed are performed in

facility, add to table533 Hepatitis Vaccinations The provider and location for HBV vaccine543 BBP Post exposure

Testing Who does medical evaluation and lab testing in case of an employee exposure

65 TB Risk Assessment Previous year data on TB from health department and facility

67 Early TB Identification Procedures to ID active TB patients and where they are referred for treatment

69 Managing TB Patients Where suspected TB patients will wait and where they will be transferred to

610 N95 Masks Medical Air Purifying Respirators (PAPRs)

Will the facility provide N95 masks or not Will the facility provide PAPRs or not

615 TST Record Each employee’s TST details618 Employee TB Infections Where employees with positive TST or

symptoms of TB will be referred619 TB Exposure Log Only fill in if employee is exposed to TB621 Prepandemic Planning Individual to be response coordinator, local

key agencies, and contact information622 Prepandemic Planning

(con’t)Communication plan, name of PR, and educational coordinators

624 Influenza Staff Shortage

Number of staff needed and who will cover

625 Influenza Reporting Frequency of reporting, who will review reports

720 Chemical Exposure Facility name and phone for exposure medical followup

82 Bleach Contact Time If you use bleach for decontamination, check and document state specific contact time

83 Housekeeping Schedule

Your cleaning methods and frequency

819 Eyewash Stations Location and types of eyewashes821 Biohazardous Waste Company name and phone number of

who picks up your biohazardous waste108 109

New Employee Orientation

Copy master from Tab 11, or CDROM, and use for new hires

1018 Annual Employee Training Record

Copy master from Tab 11, or CDROM, and use to document annual retraining

viii

Contents

xix

TAB 6: TB/Infection Prevention and Control PlanA Quick Look At TB ...................................................................................... 6-1

TB Transmission .................................................................................................................. 61Risk Factors for Developing Active TB ................................................................................. 62

TB Exposure Control Plan Policy ................................................................ 6-3Overview: How to Protect Staff from Contracting TB at Work .............................................. 64TB Risk Assessment ........................................................................................................... 64

TB Risk Assessment Results Form (Form 20) ............................................................ 65Early Identification of Patients with Active TB ..................................................................... 66

Symptoms of TB ........................................................................................................... 66Handout: Cover Your Cough/Clean Your Hands ................................................................. 68Managing Patients with Suspected or Confirmed TB ........................................................... 69

TB Isolation Procedures for Cough Inducing and AerosolGenerating Procedures .... 69Respiratory Protection for Healthcare Workers: N95 Respirators or Medical Powered Air Purifying Respirators (PAPRs) ................ 610

Seal Checking N95 Respirators ......................................................................... 610Medical PAPRs ................................................................................................... 610

Employee TB Skin Testing (TST) ........................................................................................ 611Baseline Employee TST: The TwoStep Skin Test ...................................................... 612

TwoStep TST Interpretation ................................................................................ 612Interpreting the TST ..................................................................................................... 613

False Positive/False Negative TB Tests .............................................................. 613Workers Who Have Had BCG Vaccination .......................................................... 614

Periodic Retesting of Employees ................................................................................ 614Recording TST Results ............................................................................................... 614TST Record (Form 21) ................................................................................................ 615TST Declination (Form 22) .......................................................................................... 616

Evaluation and Management of Healthcare Employees Exposed to TB ............................. 617Employees with Symptoms of TB ................................................................................ 617Employees Who Have Been Exposed to a Known TB Patient .................................... 617Positive Employee Skin Tests and Skin Test Conversions ........................................... 617TB Exposure Log (Form 23) ......................................................................................... 619Decontaminating Patient Care Area and Equipment.................................................... 620

Employee Training ............................................................................................................... 620

Pandemic Influenza Plan and Other Infectious Diseases ........................ 6-21Prepandemic Planning ....................................................................................................... 621Once a Pandemic Is Announced .......................................................................................... 624OSHA Enforcement for a Pandemic .................................................................................... 626

Identifying Very High and High Exposure Risks .......................................................... 626Dealing with N95 Respirator Shortages ...................................................................... 627Prioritize Your Facility’s Use of N95 Respirators ......................................................... 627Documentation ............................................................................................................ 628

Pandemic Resources .......................................................................................................... 629

Multidrug-Resistant Organisms (MDRO) .................................................... 6-29CDC Classification of MDRO Threats ................................................................................ 629MDRO Prevention and Control ............................................................................................ 631

Contents

xx

Colonization vs. Infection .................................................................................................... 631MDRO Transmission ........................................................................................................... 632Patient Precautions ............................................................................................................. 632

Hand Hygiene ............................................................................................................. 633Contact Precautions .................................................................................................... 633

Environmental Cleaning ...................................................................................................... 634Infected Employees ............................................................................................................. 635MDRO Resources ............................................................................................................... 636

Pertussis and Worker Vaccination ............................................................. 6-36Supplement: How Antibiotic Resistance Happens ................................... 6-38Supplement: Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care ......................................................... S1–S10

TAB 7: The Hazard Communication StandardA Quick Look at HazCom ............................................................................. 7-1

Determining Which Chemicals Are Hazardous ................................................................... 72Routes of Exposure to Hazardous Chemicals ..................................................................... 73

Safety Data Sheets ....................................................................................... 7-4Examples of Chemicals Requiring an SDS .......................................................................... 74Chemicals Not Requiring an SDS ....................................................................................... 74SDS Flowchart Determination .............................................................................................. 75Information Required on SDSs ............................................................................................ 75How to Get SDSs ................................................................................................................ 711Where to Keep SDSs .......................................................................................................... 712

Classification of Hazardous Chemicals ..................................................... 7-12Flammable Liquids ..............................................................................................................713

Storage of Hazardous Chemicals ............................................................... 7-13Hazardous Chemicals With Permissible Exposure Limits (PELs) ........... 7-14Labeling Hazardous Chemicals .................................................................. 7-15

HazCom Pictograms and Hazard Statements ..................................................................... 715Pictograms .......................................................................................................................... 715NFPA Label System ............................................................................................................ 716

Safety Tips for Working with Hazardous Chemicals ................................. 7-17Hazardous Chemical Waste Packaging and Disposal ............................... 7-18Medications Security and Disposal ............................................................ 7-19

Security for Prescription Drugs ............................................................................................ 719Security for Controlled Chemicals ........................................................................................ 719Disposal of Prescription Drugs ............................................................................................. 719Disposal of Hazardous Drugs .............................................................................................. 719

Medical Consultation and Injury Evaluation .............................................. 7-20HazCom Recordkeeping .............................................................................. 7-20

TAB 7: THE HAZARD COMMUNICATION STANDARD

Contents

A Quick Look at HazCom ................................................................................ 7-1Determining Which Chemicals Are Hazardous ...................................................................... 7-2Routes of Exposure to Hazardous Chemicals ....................................................................... 7-3

Safety Data Sheets .......................................................................................... 7-4Examples of Chemicals Requiring an SDS ............................................................................ 7-4Chemicals Not Requiring an SDS .......................................................................................... 7-4SDS Flowchart Determination ................................................................................................ 7-5Information Required on SDSs .............................................................................................. 7-5How to Get SDSs ................................................................................................................... 7-11Where to Keep SDSs ............................................................................................................. 7-12

Classification of Hazardous Chemicals ........................................................ 7-12Flammable Liquids .................................................................................................................7-13

Storage of Hazardous Chemicals .................................................................. 7-13Hazardous Chemicals With Permissible Exposure Limits (PELs) .............. 7-14Labeling Hazardous Chemicals ..................................................................... 7-15

HazCom Pictograms and Hazard Statements ....................................................................... 7-15Pictograms ............................................................................................................................. 7-15NFPA Label System ............................................................................................................... 7-16

Safety Tips for Working with Hazardous Chemicals .................................... 7-17Hazardous Chemical Waste Packaging and Disposal .................................. 7-18Medications Security and Disposal ............................................................... 7-19

Security for Prescription Drugs .............................................................................................. 7-19Security for Controlled Chemicals .......................................................................................... 7-19Disposal of Prescription Drugs ............................................................................................... 7-19Disposal of Hazardous Drugs ................................................................................................ 7-19

Medical Consultation and Injury Evaluation ................................................. 7-20HazCom Recordkeeping ................................................................................. 7-20

Page

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OSHA Program Manual for Medical Facilities

THE HAZARD COMMUNICATION STANDARD

A Quick Look at HazComOSHA’s Hazard Communication Standard (HazCom) has been in effect since May 1988, and is also called the “Right to Know” Standard. Its intent is to protect healthcare workers from hazardous substances in the workplace. The HazCom Standard May 2012 updates align the OSHA standard with the United Nations’ Globally Harmonized System (GHS) for chemical classification and labeling. While the basic requirements of HazCom are still in place, the intent was to provide employees the right to “understand” the hazards of the chemicals in their workplace. The purpose of the GHS is to ensure quality and consistency of labeling by using pictograms, signal words, and hazard and precautionary statements in an international economy. GHS is meant to unify all the different and sometimes conflicting systems of labeling and identifying hazardous chemicals throughout the world, thereby reducing trade barriers. The advantages of the GHS as stated by OSHA include:Reduced confusion about hazard classificationsIncreased understanding about safety precautions to take, approved use, proper

storage and disposal of chemicals and mixturesIncreased downstream risk management by increasing understanding of the risks

of hazardous chemicalsFacilitated training with uniform safety data sheets (SDSs) and well-defined hazard

classesEnhanced worker understanding, especially for low-literacy workers and those

workers where English is a second languageImproved worker safetyEnhanced international trade

The GHS update adds appendices to the Hazard Communications Standard that better define health and physical hazards, require that mixtures of chemicals be assessed for hazards, and require that a pictogram for each hazard class be placed on the label of each chemical container received or each secondary container used in the workplace.

There are key elements of the original Hazard Communication Standard that are still in effect. This includes the need for a written Hazard Communication Plan that is reviewed annually. Other items that remain include:An accurate, frequently updated list of chemicals in the facilityA safety data sheet (SDS) (formerly a material safety data sheet (MSDS)) for

each hazardous chemical that is readily accessible at all times

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Training for all workers before they are potentially exposed to hazardous chemicals and when new chemical hazards are introduced

Identification and training on required Personal Protective Equipment (PPE) Knowledge of signs and symptoms of exposure to hazardous chemicals in their areaProper segregation and storage of all chemicalsSpill kits/emergency equipment for each class of hazardous chemicalEmergency response and first aid proceduresMedical evaluation protocols in cases of overexposureArchiving MSDSs and SDSs no longer in use for 30 years

To ensure that information about the dangers of hazardous chemicals used in this facility are known by all affected employees, this Hazard Communication program has been established and requires the transition to the use of uniformly formatted SDSs and new labeling requirements for all for all hazardous chemicals. These standardized SDSs are to be fully implemented by December 2015 and all existing MSDSs will be replaced as soon as SDSs are available.

Until that time either the current MSDS or the new SDS is acceptable as long as employees are trained on the information currently available in the healthcare facility. Although the initial training was completed by December 2013, all employers must continue to maintain the updated SDSs, review the current hazard communication program and update it as new health/risk Information becomes available. Additional training will be needed to ensure that all employees understand the meaning of the new labels and pictograms.

Determining Which Chemicals Are Hazardous

Chemical exposure may cause or contribute to many serious health problems such as heart ailments; central nervous system, kidney and lung damage; sterility; cancer; burns; and rashes. Some chemicals may also be physical safety hazards and have the potential to cause fires, explosions, and other serious accidents.

To determine whether any chemical in a medical practice needs an SDS, use the following criteria:

1. Is the chemical hazardous?2. Are employees exposed to it?

Check all locations for chemicals, liquid or aerosol drugs and medications (tablet and capsule forms are exempt), disinfectants, and x-ray developers. (Note that the use of digital films eliminates the need for hazardous developer and fixer chemicals.)

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Examine the label of each to see if a statement is present, such as “flammable,” “danger,” or “warning.” The pictograms on the new labels will indicate if the chemical is a health hazard, an irritant/sensitizer, corrosive, oxidizer or toxic. If a hazard statement and/or pictogram is present, the chemical is considered hazardous by OSHA and is regulated under the HazCom Standard. By June 1, 2015, all labels from chemical manufacturers will be required to have a product identifier, pictograms, a signal word, hazard and precautionary statements, and supplier identification. Distributors, however, have until December 1, 2015, to comply with the new labeling requirements and to use up stock with the old labels.

Determine whether employees are involved with the products in such a way that they could be exposed. For instance, do employees administer medications to patients or do they simply give the bottles to patients to take home? If the latter is the case, then you do NOT need an SDS for that medication, since there is no chance of employee injury.

If employees administer or handle a particular product check the product label or package insert that accompanies it. If there is a health, flammability or “warning,” or “danger” listing, then an SDS is required. Imagine an employee accidentally getting the solution in their eye or on their skin. What would need to be done in this instance? The answer is on the SDS in Section 4 (first aid measures). Any employee handling that product would need to know what to do.

Routes of Exposure to Hazardous Chemicals

The safest way to prevent chemical injury is to know the routes of entry that each chemical may take into the body and take precautions to ensure that contact is not made. In general, routes of exposure of a substance fall into one of the following categories:

1. Inhalation. Many occupational exposures result from breathing chemical vapors. These substances may affect the respiratory track or pass from the lungs to other organs by way of the blood stream or lymphatic system. The type and severity of the effect depends on the nature of the chemical, the amount of chemical absorbed, the rate of absorption, individual susceptibility, and other factors.

2. Ingestion. This route of exposure may occur if the worker is not using preventive measures such as gloves and proper handwashing techniques, or is eating food or consuming drink in the work area. This mode of exposure is far less common in medical surroundings than inhalation.

3. Skin Contact. This is a frequent mode of chemical exposure, often resulting in localized irritation. A wide variety of substances can penetrate the skin and produce skin hypersensitivity, including latex, formaldehyde and phenols. Skin is abundantly supplied with blood vessels, which facilitate the absorption of chemicals into the body.

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4. Eye Contact. Eyes are very sensitive to contact with most chemicals, resulting in irritation. Eyes are vascular organs and rapidly absorb many chemicals. Alkaline materials, phenols, and strong acids are particularly corrosive and can cause permanent loss of vision.

5. Injection. This route of exposure can occur inadvertently through mechanical injury from glass or metal contaminated with chemicals, or when toxic chemicals are handled in syringes with needles.

Safety Data SheetsA key requirement for compliance with HazCom is the availability of SDSs for hazardous chemicals. An SDS contains emergency, precautionary and general information about hazardous chemicals and chemical mixtures.

Compile a master list of all hazardous substances using the Hazardous Substances List behind Tab 11: Master Record Forms (Form 19) in this OSHA Program Manual.

Examples of Chemicals Requiring an SDS

Drugs and pharmaceuticals except those in solid, “final form” (tablets, pills, capsules) for direct administration to the patient. Tablets or pills designed to be dissolved or crushed by employees prior to administration are not in “final form” and require an SDS. Package inserts and the Physicians’ Desk Reference cannot substitute for manufacturers’ SDS.

A product containing a hazard warning that is available commercially to the general public. Chemicals such as bleach, chemotherapy drugs, some injectable drugs, alcohol hand sanitizer, disinfectants and glutaraldehyde DO require an SDS.

Chemicals Not Requiring an SDSAny product that does not bear a hazard warning.

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Information Required on an SDS

Safety data sheets will have a specified 16-section standard format and include the following information.

Section 1: IdentificationThis section:Lists the chemical name as well as any other common names by which the

product is knownIdentifies the recommended uses for the productIdentifies any restrictions on use as recommended by the supplier/manufacturerGives the chemical manufacturer or supplier address and contact information

Example: isopropyl alcohol, 70%,is frequently used in healthcare as a topical antiseptic Other listed names for this chemical include 2-propanol, isopropanol, rubbing

alcohol, or IPAIdentified uses include cleaning of skin prior to procedures, as in venipuncture

or injection. Identified restrictions include not using isopropyl alcohol on internal wounds or for

drinking (ingestion).

YES

YES

YES

YES NO

NO

NO

NO

Is the chemical (drug) labeled as hazardous or dangerous?

Can employees be exposed to it?

Is the chemical used according to the label instructions?

Is the chemical (drug) a common consumer (household) product, and is it used with the same frequency as a

consumer would use it?

MSDS not required. MSDS is required.

SDS flowchart determination

Source: A Common Sense Approach to Chemical Safety for Medical and Dental Settings, Quality America.

SDS is requiredSDS is not required

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Section 2: Hazard(s) identificationThis section identifies all of the different hazards of a chemical and the appropriate warning information associated with each of those hazards. This section changed from a performance-based orientation to a specific criteria for the classification of health and physical hazards. The information will also provide specific criteria for the classification of mixtures. GHS will require that mixtures are classified by the percentage of each component included, and a revised hazard rating be provided. These specific criteria will help to ensure the evaluations of hazardous effects are consistent across manufacturers, and that labels and SDSs are more accurate as a result. The information will include all the information that will be required on the container label:The hazard classification of the chemical, i.e. flammable liquidSignal word (Danger or Warning): a single word to indicate the relative severity

of the hazard“Danger” is used for more severe hazards, while “warning” is used for less

severe hazardsHazard statement(s) describes the nature of the hazards and the degree of

hazard, i.e., may cause liver or kidney damagePictograms for each hazard class: a symbol intended to convey specific

information regarding the hazard of a chemicalPrecautionary statement(s) related to minimizing or preventing adverse effects

resulting from exposure and improper storage or handling of a chemicalDescription of any hazards not otherwise classified or of unknown toxicity. This is

a change from previous HazCom information, as the statement of acute toxicity would be relative to the percentage of the ingredients in the mixture, and is not just a statement about that ingredient alone.

Examples of chemicals that fall into this category include simple asphyxiates and/or combustible dust.

Example: isopropyl alcohol, 70%:- Hazard classification: flammable liquid, eye irritation- Signal word: Danger- Hazard statements: Highly flammable liquid and vapor- Causes serious eye irritation- Causes mild skin irritation- May cause drowsiness or dizziness- Pictogram: flame and irritant (exclamation mark)- Precautionary statements:

o Keep away from heat/sparks/open flame. No smoking. o Do not breathe vapors

- In case of fire, use dry chemical (BC) or carbon dioxide extinguisher

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Section 3: Composition/information on ingredients This section lists the chemical identity and common names; percentage of each ingredient if it is a mixture; chemical listing (unique identifiers); and impurities or stabilizers, which are also classified and contribute to the hazard classification of the product. A statement that a chemical is claimed as a trade secret or is proprietary would be made in this section.

Section 4: First-aid measuresThis section lists the signs and symptoms, acute and delayed effects of exposure to the chemical. This is key information and required for employee training. This section lists first aid measures for skin and eye exposure, as well as inhalation and ingestion. Required treatment listed in this section might include the use of an eyewash station for a corrosive or caustic chemical, or the need to move to fresh air and get medical attention.

Example: isopropyl alcohol, 70%, Symptoms of isopropyl alcohol poisoning or overexposure include flushing, headache, dizziness, central nervous system depression, nausea, vomiting, and loss of consciousness. Poisoning/overexposure can occur from ingestion, inhalation, absorption, or consumption of isopropyl alcohol.

First aid:Eyes: Rinse with plenty of water for 15 minutes and seek medical attention.Inhalation: Move person to fresh air and keep at rest. If breathing is difficult, give

oxygen. If not breathing, give artificial respiration. Get medical attention.Skin: Flush with plenty of water for at least 15 minutes while removing

contaminated clothing and wash using soap. Get medical attention.Ingestion: Do not induce vomiting! Never give anything by mouth to an unconscious

person. If conscious, wash out mouth with water. Get medical attention.

Section 5: Firefighting measures This section lists suitable (and unsuitable) extinguishing media (agents like water, dry chemical, or foam), precautions, and special PPE for firefighters, as well as specific hazards arising from products of combustion (fire). Toxic byproducts from the fire and the chemical would be listed here.

Example: isopropyl alcohol, 70%,Is flammable in the presence of spark or flame. Use water spray, alcohol-resistant

foam, dry chemical, or carbon dioxide.Firefighters are to wear self-contained breathing apparatus and full protective

clothing, including eye protection and boots.Gives off toxic fumes (carbon oxides) under fire conditions. (This section also

references the Stability and Reactivity information in Section 10.)

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Section 6: Accidental release measures This section references emergency response precautions and personal protective equipment needed. Appropriate procedures for cleanup of spills, leaks, or releases are listed here. It differentiates between protocols for large and small spills, where the spill volume has an impact on the level of the hazard. It will give recommendations for evacuations, methods of containment, and cleanup procedures.

Example: isopropyl alcohol, 70%,Protective Equipment: For large spills, wear chemical safety glasses or goggles,

nitrile gloves, and a lab coat or apron. (Section 8 is where one would find the PPE recommendations.)

An eyewash station or quick drench shower is recommended, since isopropyl alcohol is a severe eye hazard.

Environmental Precautions: Prevent spillage from entering drains.Methods and materials for containment and cleanup: Neutralize spill. Absorb spill

with noncombustible absorbent material, then place in a suitable container for disposal. Clean surfaces thoroughly with water to remove residual contamination. Dispose of waste in accordance with local, state, and federal regulations.

Section 7: Handling and storage This section lists precautions for safe handling, storage, and use. It includes incompatibilities—that is, how this chemical needs to be stored away from certain other chemicals.

Quick note: If one mixes ammonia with bleach, the result is chlorine gas. Inhaled chlorine gas turns into acid in the lungs. Not a recommended process, yet some facilities and laboratories like to store all their chemicals alphabetically because it looked more orderly.

Example: isopropyl alcohol, 70%,Precautions for safe handling: See Section 8 for recommendations on the use of PPE. Use with adequate ventilation. Wash thoroughly after using. Keep container closed when not in use.

Conditions for safe storage, including any incompatibilities: Store in cool, dry, well-ventilated area. Store away from oxidizing agents (bleach) and aluminum. (What this tells me is that I should never store isopropyl alcohol in an aluminum container.) See also Section 10 for incompatible materials.

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Section 8: Exposure controls/personal protectionThis section lists any regulatory exposure limits, use of personal protective equipment (PPE), work practice controls, and ventilation requirements used to minimize exposures. There are several agencies that have developed occupational exposure limits for an 8-hour workday. OSHA has Permissible Exposure Limits (PELs) which have the force of law but are somewhat outdated. National Institute for Occupational Safety and Health (NIOSH) has Recommended Exposure Limits (RELs), and the American Conference of Governmental Industrial Hygienists (ACGIH) has published Threshold Limit Values (TLVs). The NIOSH and ACGIH limits are guidelines but have the advantage of being updated as additional hazards of chemicals become known.

Example: isopropyl alcohol, 70%,OSHA PEL = 400 ppm.NIOSH REL = 400 ppmACGIH TLV = 200 ppm

These are average exposures over an 8-hour workday where the average worker would not suffer health effects. Many of these exposures were developed for industrial settings and not healthcare.

Personal Protective Equipment:Eyes: wear chemical safety glasses or goggles. (Remember that isopropyl alcohol

is a severe eye irritant.)Inhalation: provide local exhaust.Skin: wear nitrile or rubber gloves, apron or lab coat.Other: provide eyewash stations, showers, and washing facilities.

Section 9: Physical and chemical propertiesThis section lists the properties of the chemical such as vapor pressure, specific gravity, color, odor, pH, appearance, and physical hazards of the chemical, i.e., flammability and explosive limits. This is the beginning of more technical information, but it is helpful to know what the chemical looks like (solid, liquid, green, yellow, or clear) as well as whether it has a characteristic smell.

Quick note: While smell is not an approved way to detect the extent of chemical exposure, some hazardous chemicals have good warning properties. Formalin, glutaraldehyde, bleach, and hand sanitizer all have a distinct smell. Other chemicals like ethylene oxide (a known carcinogen used for gas sterilization) have no odor at all.

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Example: isopropyl alcohol, 70%,Some of the recognizable characteristics include:Appearance: Clear, colorless liquidOdor: Alcohol-likeOdor threshold: 22 ppm (that means one can readily smell isopropyl alcohol)Solubility: readily soluble in water (that means it mixes readily with water).

Section 10: Stability and reactivity This section discusses the risks of explosion of the product in the presence of sparks, shocks, and fire. It also lists incompatible materials and conditions to avoid (like high temperature).

Example: isopropyl alcohol, 70%,Isopropyl alcohol is chemically stable. Conditions to avoid include heat, flames,

and sparks. Extremes of temperature and direct sunlight. Sunlight can warm the liquid, giving off vapors that readily ignite in the presence of a spark or flame.

Incompatible materials include aluminum, acids, and oxidizing agents such as bleach.

Section 11: Toxicological information This section discusses routes of exposure, symptoms, delayed and immediate effects, listing as to whether the chemical is toxic, a carcinogen or reproductive hazard including the OSHA permissible exposure level, any limits recommended by the manufacturer, NIOSH, ACGIH, International Agency for Research on Cancer (IARC), National Toxicology Program (NTP), and Agency for Toxic Substances and Disease Registry (ATSDR). These last three agencies report on chemicals that are stated to be toxic, carcinogens, mutagens, or reproductive hazards.

Example: isopropyl alcohol, 70%,All of the references listed indicate that isopropyl is not classifiable as a human carcinogen.

Signs and symptoms of exposure:Skin: irritation, redness, and itchinessEyes: irritation, redness, watering eyes, and itchinessRespiratory: irritation, coughing, wheezing, dizziness, drowsinessIngestion: irritation, nausea, vomiting, diarrhea, dizziness, drowsinessChronic toxicity: may cause damage to kidneys, liver, skin, central nervous systemReproductive toxicity: Classified as a reproductive system/toxin/female and a

developmental toxin

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Section 12: Ecological information This section lists any environmental impacts if known. This section is not enforceable by OSHA, but included in SDS and indicates if the product is hazardous to the aquatic environment through acute (immediate) or chronic (long-term) aquatic toxicity, or if it is hazardous to the ozone layer.

Section 13: Disposal considerations This section indicates that users should review how to handle, manage, and dispose of the chemical waste according to applicable federal, state, and local regulations. This section is also not enforced by OSHA.

Example: isopropyl alcohol, 70%,Isopropyl alcohol may still be flammable even as a waste product. Local and state regulations would need to be consulted to determine the appropriate method of disposal.

Quick note: Some states allow flammable liquids to be recycled and used for fuel blending. Check with local and state vendors to see if that option is available in your area.

Section 14: Transport information This section lists shipping and labeling requirements for the Department of Transportation (DOT), Transportation of Dangerous Goods (Canada), the International Maritime Dangerous Goods Code, and the International Air Transport Association. All of the agencies have agreed to use the UN Code for identification of the chemical.

Section 15: Regulatory information This section lists the safety, health, and environmental reporting regulations specific for the product not otherwise listed on the SDS. This information may include any national or regional regulatory information from the Department of Transportation, the Environmental Protection Agency, or Consumer Product Safety Commission regulations.

Section 16: Other information This section includes the date of preparation or last revision. The revisions or changes may be listed here. How to Get SDSs

SDSs are available free of charge from the manufacturer or distributor of the chemicals and may be sent with the shipment. SDSs are also available over the Internet at the manufacturer’s or distributor’s website.

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Where to Keep SDSs

File SDSs in the binder accompanying the OSHA Program Manual. Copies of SDSs may also be kept at each location where the hazardous chemical is used, if it is distant from the central location. Be sure employees know where SDSs are kept and that they have easy access to them.

It is permissible to have your SDS files online or on a computer if employees can readily access the files in the workplace. Be sure to train employees on how to access the SDS file and that there are no barriers to online access such as password-locked computers. Identify backup measures in the written Hazard Communication Plan in case the online system goes down.

Classification of Hazardous ChemicalsChemicals often used in medical facilities are classified as:1. Health Hazards:

a. Acutely Toxic. A term that can be applied to almost any substance in quantity. A substance is considered toxic if serious biologic effects may follow inhalation, ingestion, or skin contact with relatively small amounts.

b. Sensitizer/irritant. These substances cause little or no reaction upon initial contact, but may cause a marked reaction after subsequent exposures.This category may include some adhesives, detergents and high level disinfectants.

c. Carcinogen, mutagen, teratogen. Mercury and lead are examples of “teratogenic substances” which can cause malformation of a fetus. Women who are pregnant or trying to become pregnant should be aware of teratogens in their workplace.

d. Corrosive. Corrosive substances destroy tissue and cause permanent changes in the tissue, such as scarring. Common corrosive agents may include ammonia and acids. The use of corrosive chemicals requires ready access to an eyewash station.

2. Physical Hazards:a. Flammable. GHS revised the definition of flammable liquids to include

any liquid with a flash point below 140 degrees F. OSHA no longer has a “combustible” category. Common flammable items are acetone and alcohol. Note that NFPA 30 still uses the former definitions for flammable and combustible. This could be the basis for miscommunication in the event of a fire or emergency.

b. Oxidizers. Chemicals that give off oxygen when heated are classified as oxidizers. These chemicals do not cause fires but contribute oxygen to the fire triangle. Bleach is an oxidizer that may be present in dental offices.

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c. Gases under pressure. Cylinders of oxygen, carbon dioxide or nitrous oxide may be found in many dental offices. If tipped over or dropped, these cylinders can become missiles.

Flammable Liquids

The adoption of GHS includes a revision of the definition of flammable liquids to include any liquid with a flashpoint below 140 degrees F. The flash points are divided into 4 categories and eliminates the combustible class previously used. It is important to note that the NFPA 30, Flammable and Combustible Liquids Code used by fire fighters has not changed the definitions and still uses Class I ABC for flammable liquids and Class II and III for combustible liquids. NFPA publishes consensus codes and standards while Haz Com with the GHS is a federal OSHA Labor law. It is easy to see where one needs to be clear about which standard is being referenced as a GHS Category 2 is flammable whereas NFPA Class II is combustible.

Flammables Have Flashpoints Below 140°F (GHS)Category Flash Point Boiling Point Examples

1 <73° F <95°F acetaldehyde, ethyl ether, cyclohexane.2 <73° F >95°F acetone, benzene, toluene, and alcohol

hand sanitizers.3 >73° F <140°F hydrazine, styrene, and turpentine.4 >140°F <199.4°F acetic acid, naptha, and stoddard solvent.

Storage of Hazardous ChemicalsRead all chemical labels carefully to determine other factors for the proper use and storage of hazardous liquids such as ignition temperature, explosive limits (LEL or UEL), vapor pressure, specific gravity, and vapor density. Purchase chemicals in a volume that will be consumed before the expiration date.

OSHA does not require the use of flammable storage cabinets unless the total amount of flammable reaches a given amount. The amount of liquid that may be stored outside of a cabinet in any one fire area of a building cannot exceed: 25 gallons of Category 1 liquids in containers. 120 gallons of Category 2, 3, or 4 liquids in containers.

Not more than 60 gallons of Category 1 liquids may be stored in a storage cabinet. Also, not more than three such cabinets may be located in a single fire area.

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Local authorities and insurance companies may require the use of flammable storage cabinets in quantities less than that of OSHA.

The exceptions to this rule are medicines, beverages, foodstuffs, cosmetics, and other common consumer products, when packaged according to commonly accepted practices.

Hazardous Chemicals with Permissible Exposure Limits (PELs)Some chemicals frequently used in medical facilities that have recommended or required employee exposure limits are shown below. Most medical offices will not be required to monitor these levels since exposures are well below these limits. For instance, medical facilities that store small vials of formaldehyde to transport tissue for pathology testing would certainly fall below the established limits. Glutaraldehyde, which is often used as a high-level disinfectant in medical practices should also remain well below the permissible exposure limits when diluted in a tightly covered container. Safety measures for glutaraldehyde are discussed in detail in Tab 8: Decontamination.

Chemical Exposure LimitFormaldehyde 0.75 part per million (ppm) over 8 hours or 2 ppm over a

15 minute period.Glutaraldehyde There is no OSHA PEL. 0.2 ppm NIOSH REL;

ACGIH 0.05 ppm ceiling concentration.Ethylene Oxide (EtO) 1 ppm over 8 hours or 5 ppm over a 15-minute period.Nitrous Oxide 25 ppm.Mercury 0.1 mg/m3 over an 8-hour shift.

If there is any question whether employee exposure exceeds permissible limits, contact a local industrial hygiene company to test the HVAC system. These companies will ensure that your workplace air supply system has an adequate number of air changes per hour to reduce or eliminate employee exposure to these chemicals. For circumstances where exposure limits in your workplace fluctuate or reach permissible limits, provide clip-on monitoring badges for employees. Companies that supply air monitoring badges are listed in Tab 8: Decontamination.

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Ensure that anesthesia equipment is services and monitored for leakage per the manufacturer’s recommendations.

Labeling Hazardous Chemicals

HazCom Pictograms and Hazard Statements

Hazardous chemicals are labeled appropriately when bought from the manufacturer, so there is no need to re-label them upon receipt. The label must include:

Identity or contents.Chemical name and the common or trade name of the contents.Pictogram (s)Signal word, “danger” or “warning”Hazard and precautionary statements about storage use, first aid, and

emergency procedures.The name, address, and phone number of the chemical supplier.

Be sure to label, tag, or mark containers of any chemical that has been transferred to a secondary, unlabeled container with the contents, the dilution, and any hazardous warning, including specific effects of the chemical and target organs affected.

Advise the OSHA Safety Officer if there are unlabeled containers in the workplace or if a label has become illegible. The OSHA Safety Officer ensures that labels are replaced when deteriorated or illegible.

Pictograms

These pictograms must include the red diamond with the black picture and text. OSHA feels that these pictograms will be more readily understood than other means of hazard labeling.

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Health Hazard

• Carcinogen• Mutagenicity• Reproductive Toxicity• Respiratory Sensitizer• Target Organ Toxicity• Aspiration Toxicity

Flame

• Flammables• Pyrophorics• Self-Heating• Emits Flammable Gas• Self-Reactives• Organic Peroxides

Exclamation Mark

• Irritant (skin and eye)• Skin Sensitizer• Acute Toxicity• Narcotic Effects• Respiratory Tract Irritant• Hazardous to Ozone Layer (Non-Mandatory)

Gas Cylinder

• Gases Under Pressure

Corrosion

• Skin Corrosion/Burns• Eye Damage• Corrosive to Metals

Exploding Bomb

• Explosives• Self-Reactives• Organic Peroxides

Flame Over Circle

• Oxidizers

Environment(Non-Mandatory)

• Aquatic Toxicity

Skull and Crossbones

• Acute Toxicity (fatal or toxic)

The new pictograms can be downloaded from the OSHA website: www.osha.gov/dsg/hazcom/pictograms.

NFPA Label System

NFPA or other custom labels can be used until June 2015 when the next phase of the revised Haz Com Standard goes into effect. Until then, either the NFPA system or the pictograms and new labeling system may be used as long as workers understand both labeling systems. While OSHA never specifically mandated the National Fire Protection Association’s (NFPA) standard hazard identification system (see the diamond-shaped, color-coded symbol below), some dental facilities have adopted it to standardize hazard labels. The NFPA system offers hazard assessments for health (blue quadrant), flammability (red quadrant), reactivity/stability (yellow quadrant), and special hazards (white quadrant) at a glance.

0 = minimal 1 = slight 2 = moderate 3 = serious 4 = severe

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♦ The top diamond is RED and contains the flammability hazard rating.

♦ The right diamond is YELLOW and indi cates the reactivity rating of the chemical.

♦ The left diamond is BLUE and indicates the health hazard rating.

♦ The bottom diamond is WHITE and focuses attention on any special hazards of the chemical, such as oxidizer, water reactive, corrosive or carcinogen.

Note: the GHS labeling system uses “1” as the most severe hazard and “4” as the least severe hazard.

Safety Tips for Working with Hazardous ChemicalsAll employees working with hazardous substances are provided with personal protective equipment (PPE) according to specific OSHA standards or, where indicated, by the SDS in section 8. These employees receive education regarding when PPE is necessary; how to properly don, doff, adjust, and wear it; the limitations of PPE; and the proper care, maintenance, useful life, and disposal of PPE.

Other general safety rules for working with chemicals are:

Avoid direct contact with hands, face, and clothing, including shoes.Never taste or smell a chemical.Do not smoke, drink, or eat in chemical use and storage areas.Never use any chemical from an unlabeled container.Keep ap propriate safety devices available for employees who work with, or in

the vicinity of, hazardous chemicals. For example, if a substance could cause eye damage, an emergency eyewash must be available in close proximity to the workstation. Specifications for the types of eyewashes required and their locations are located behind Tab 8: Decontamination.

If flammable liquids or vapors are present, the proper fire extinguishers must be present and readily accessible.

quality-america.com 1-800-946-9956

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Labeling Hazardous Substances

Hazardous chemicals are labeled appropriately when bought from the manufacturer, so there is no need to relabel them upon receipt. The label must include:

Identity or contents.

Chemical name and common or trade name of the contents.

Hazard warnings, including words, pictures, symbols, or combinations that convey the health

and/or physical hazards of the container’s contents; these warnings must be specific as to the

effect of the chemical and specific target organs involved.

The name, address, and phone number of the chemical manufacturer.

Be sure to label, tag, or mark containers of any chemical that has been transferred to a secondary,

unlabeled container with the contents, dilution, and any hazardous warning, including specific effects of

the chemical and target organs affected.

Advise the OSHA safety officer if there are unlabeled containers or if a label has become illegible. The

OSHA safety officer assures that labels are replaced when deteriorated or illegible.

NFPA Label System

Although OSHA does not specifically mandate the National Fire Protection Association’s (NFPA) standard hazard identification system (see the diamond-shaped, color-coded symbol below), some

dental facilities may wish to adopt it to standardize hazard labels. The NFPA system offers hazard

assessments for health (blue quadrant), flammability (red quadrant), reactivity/stability (yellow quadrant), and special hazards (white quadrant) at a glance.

In addition, each quadrant shows the magnitude of severity, graded from 0 to 4:

0 = minimal 1 = slight 2 = moderate 3 = serious 4 = severe

♦ The top diamond is RED and contains the flammability hazard rating.

♦ The right diamond is YELLOW and indicates the reactivity rating of the chemical.

♦ The left diamond is BLUE and indicates the health hazard rating.

♦ The bottom diamond is WHITE and focuses attention on any special hazards of the chemical, such as oxidizer, water reactive, or corrosive.

Safety Tips for Working with Hazardous Substances

All employees working with hazardous substances are provided with personal protective

equipment (PPE) according to specific OSHA standards or, where indicated, by material safety

data sheets. These employees receive education regarding when PPE is necessary; how to

properly don, doff, adjust, and wear it; the limitations of PPE; and the proper care, maintenance, useful life, and disposal of PPE.

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Hazardous Chemical Waste Packaging and DisposalRead the SDS carefully for guidance on disposal of hazardous chemicals. The Resource Conservation and Recovery Act (RCRA) statutes of the Environmental Protection Agency (EPA) affect the handling of chemical hazardous waste (not infectious waste). Most physician offices are affected by RCRA (or its state-administered counterpart) because they generate chemical hazardous waste, although those that generate less than 100 kg (about 27 gallons) per month are classified as very small-quantity generators that are conditionally exempt from RCRA.

Facilities that generate between 100 kg and 1,000 kg per month are considered small-quantity generators and must obtain a 12-digit EPA identification number. Hazardous wastes must be tracked from the time it is generated until its disposal with a manifest system (cradle to grave) and shipped in EPA-approved hazardous waste trucks.

Typical healthcare hazardous wastes are:

Acetone methanolEthyl etherPotassium cyanideNitrous oxideEpinephrine base*MercuryFormaldehydeTolueneSilver

Regardless of your RCRA classification, do not discharge pollutants into the water/sewer system without first verifying with local publicly owned treatment works that it meets your state’s criteria for discharge. For more information about disposing of chemical hazardous waste, see the Hazardous Waste Disposal section in Tab 8, or contact your state or local Environmental Protection Agency office.

* In October 2007 the EPA determined the scope of the epinephrine hazardous waste listing is only epinephrine base, and does not include epinephrine salts. Most, if not all, of the epinephrine used in medical applications is one of several epinephrine salts. The EPA statement applies to the federal level only. As most states implement their own EPA programs, some may regulate epinephrine salts more stringently than the federal regulations. Therefore, we recommend you contact your state agency to determine the regulation in your state, especially if your facility is located in California, Minnesota,, Michigan, Oregon, Rhode Island, or Washington (where laws are typically stricter than the federal regulations.) Find your state contact information at http://www.epa.gov/osw/wyl/stateprograms.htm.

See Tab 9: Specialty Services for disposal of cytotoxic drugs and radioactive mater ials. For instructions about cleaning up large volume spills, see Tab 8: Decontamination.

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Medications Security and DisposalThis information is not specifically required by OSHA, but is included in this section because of the fact that some prescription drugs are considered hazardous substances and require SDSs.

Security for Prescription Drugs

Store all prescription drugs, including samples and prescription pads, in a secured area with controlled access to minimize the risk of theft or unauthorized use.

Security for Controlled Substances

Keep Drug Enforcement Administration (DEA) ordering forms and controlled substances in a secure and locked area. Limit access to these forms and drugs to specific staff selected by management.

Maintain a record of the date, name, strength, and amount of controlled drugs ordered.

Keep a dispensing record that includes date, patient name, drug name and strength of drug, amount dispensed, physician name, and name and signature of person who dispensed the drug.

Take inventory at regular intervals and resolve discrepancies between the inventory record and the dispensing record.

Disposal of Prescription Drugs

Check prescription drugs periodically for expiration.Remove expired drugs from stock. Check package insert or SDS for any special disposal requirements. Document how expired drugs are disposed of after removal from stock (e.g.,

sharps containers or pharmaceutical collection containers, etc.).

Disposal of Hazardous Drugs

Special handling may be required for toxins, biological and cytotoxic drugs, see Tab 9: Specialty Services. As above, check the SDS and have proper disposal containers available.

Appoint one staff person to have overall responsibility for ensuring proper disposal of expired medications.

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Medical Consultation and Injury EvaluationEmployees who need medical attention due to a chemical exposure will use the health services at the following facility:

_____________________________________ _________________________ Name of healthcare facility Telephone number

If an employee requests evaluation by a personal physician, that request will be honored. Medical evaluations and consultations are performed by or under the supervision of a licensed physician without cost to the employee, without loss of pay, and at a reasonable time and place.

Employees will be medically evaluated when:

Signs and symptoms are consistent with a chemical exposure.Environmental monitoring reveals an exposure level above the proper threshold, if

appropriate (formaldehyde, etc.).

Record chemical exposures on the Incident Report/Sharps Injury Log located behind Tab 11: Master Record Forms (Form 14).

The OSHA Safety Officer will provide the following information to the referring physician:

Identity of the hazardous chemical to which the employee was exposed.A description of the conditions under which exposure occurred.A description of the signs and symptoms of exposure.A copy of the SDS for the chemical involved.

HazCom RecordkeepingOSHA’s Hazard Communication Standard requires that records of employee exposures to hazardous chemicals are kept for 30 years plus the length of employment. There’s no need to keep them in your SDS binder that is accessible to employees if they take up too much space. Archiving or filing SDS that are no longer in use meet the intent of the Hazard Communication Standard.

Effective Dates: The table below summarizes the phase-in dates required under the revised Hazard Communication Standard (HCS):

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Effective Completion Date Requirement(s) Who

December 1, 2013 Train employees on the new label elements and SDS format.

Employers

June 1, 2015*

December 1, 2015

Compliance with all modified provisions of this final rule, except:

The Distributor shall not ship containers labeled by the chemical manufacturer or im-porter unless it is a GHS label

Chemical manufacturers, importers, distributors and employers

June 1, 2016 Update alternative workplace labeling and hazard com muni-cation program as necessary, and provide additional em ployee training for newly identi fied physical or health hazards.

Employers

Transition Period to the effective completion dates noted above

May comply with either 29 CFR 1910.1200 (the final standard), or the current standard, or both

Chemical manufacturers, importers, distributors, and employers

osha program manual for medical facilities march 2015...

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