UPDATE - HCProcontent.hcpro.com/manuals/meu/OSHASPM_17F_2017_supp.pdf · 10-1 through 10-18 10-1 through 10-18 Tab 10: Employee Training—updated Tab 11 Contents Tab 11 Contents

Dear HCPro Customer:

Enclosed is your latest supplement to the OSHA Program Manual for Medical Facilities. This supplement is designed to keep your product up to date. Your next supplement will be in Sepetmber 2017. If you have any questions about your subscription, please contact our Customer Service department at 800-650-6787 or e-mail [email protected]. At HCPro, customer comments and suggestions are very important to us—let us know 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.

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June 2017 Revisions


Enclosed is your latest supplement to the OSHA Program Manual for Medical Facilities. This supplement is designed to keep your product up to date. Your next supplement will be in September 2016.

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

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

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May 2016 Revisions


Enclosed is your latest supplement to the OSHA Program Manual for Medical Facilities. This supplement isdesigned to keep your product up to date.

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

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UPDATE to

a division of BLR

About the AuthorMarge McFarlane, PhD, MT (ASCP), CHSP, CHFM, CJCP, 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. 17F

©2005–2017 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 BLR35 Village Road, Suite 200

Middleton, MA 01949Tel: 800/650-6787Fax: 800/639-8511

www.hcmarketplace.com

OSHAPROGRAMMANUALfor Medical Facilities

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

Copyright © 2017 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, CJCP, HEM, MEP, CHEP, Author

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

Jay Kumar, Associate Product ManagerMike Mirabello, Fulfillment Specialist

Susan Robinson, 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

35 Village Road, Suite 200

Middleton, MA 01949

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

6/17

Contents

xxiii

Radiation Safety Guidelines for Personnel .......................................................................... 9-21Radiation Safety Policies for the Facility ............................................................................. 9-22Ionizing Radiation Exposure Limits ..................................................................................... 9-22Special Precautions for Pregnant Workers ......................................................................... 9-23Low-level Radioactive Waste Disposal ............................................................................... 9-23NRC Notification, Reports, and Record ............................................................................... 9-23NRC Resources and Publications ....................................................................................... 9-24

Working Safely with Cryogenic Liquids ..................................................... 9-25Precautions for Handling Liquid Nitrogen ............................................................................ 9-25Storing Liquid Nitrogen ........................................................................................................ 9-26Personal Protective Equipment ........................................................................................... 9-26Liquid Nitrogen Disposal ..................................................................................................... 9-26Steps to Take if There Is Accidental Exposure ..................................................................... 9-27

First Aid (cryogenic burns) .......................................................................................... 9-27First Aid (anoxia) ......................................................................................................... 9-27

Safe Vaccine Handling and Storage ............................................................ 9-28Waste Anesthetic Gases .............................................................................. 9-30

Where Exposures Occur ..................................................................................................... 9-31Preventing Exposures ......................................................................................................... 9-31

Controls ....................................................................................................................... 9-32Medical Surveillance ........................................................................................................... 9-32Recordkeeping .................................................................................................................... 9-33More Information ................................................................................................................. 9-33

TAB 10: Employee TrainingA Quick Look at the Employee Training Program ..................................... 10-1Training Format ............................................................................................ 10-1

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

General Safety ............................................................................................................. 10-3Fire Safety ................................................................................................................... 10-3Bloodborne Pathogens Safety ..................................................................................... 10-3Chemical Safety ........................................................................................................... 10-3TB Safety ..................................................................................................................... 10-4Infection Prevention ..................................................................................................... 10-4

Annual Employee Training ........................................................................... 10-5Bloodborne Pathogens Annual Training Contents ............................................................... 10-6Respiratory Protection Annual Training Contents ................................................................ 10-6Hazard Communication Annual Training Contents .............................................................. 10-7

New Employee Orientation .......................................................................... 10-7New Employee OSHA Orientation Checklist (Form 26) ...................................................... 10-8

Sample Tests with Answer Keys ................................................................. 10-10OSHA Annual Training: Sample Essay Test Questions (Form 28) ....................................... 10-11OSHA Annual Training: Sample Essay Test—Answer Key ................................................. 10-12

Contents

xxiv

OSHA Annual Training: Sample Multiple Choice Test Questions (Form 29) ....................... 10-13OSHA Annual Training: Sample Multiple Choice Test—Answer Key .................................. 10-15OSHA Annual Training: Sample True/False Test Questions (Form 30) ................................ 10-16OSHA Annual Training: Sample True/False Test—Answer Key ........................................... 10-17

Documenting Employee Training ................................................................ 10-17Annual Safety Training Record (Form 27) ................................................... 10-18

TAB 11: Master Record FormsGeneral Equipment and Facility Records

Safety Report ....................................................................................................................... Form 1Autoclave Log ...................................................................................................................... Form 2Eyewash Station Weekly Check Log ................................................................................... Form 2-AAnnual OSHA Program (Exposure Control Plan) Review ................................................... Form 3Weekly Facility Review Checklist ........................................................................................ Form 4-AMonthly Facility Review Checklist ....................................................................................... Form 4-BAnnual Facility Review Checklist ......................................................................................... Form 5Fire Drill Evaluation Form .................................................................................................... Form 5-AEmployee Fire Drill Participation Sign-up Sheet ................................................................. Form 5-BRisk Assessment for Workplace Violence ............................................................................ Form 6Housekeeping Schedule ...................................................................................................... Form 7Emergency Telephone List .................................................................................................. Form 7-AHealthcare Facility Slip, Trip, and Fall Hazard Checklist ..................................................... Form 7-B

Bloodborne Pathogens RecordsBloodborne Pathogens Exposure Determination List #1 ..................................................... Form 8Bloodborne Pathogens Exposure Determination List #2 ..................................................... Form 9Bloodborne Pathogens PPE Compliance Checklist ............................................................ Form 9-AFailure to Use PPE .............................................................................................................. Form 9-A-1Bloodborne Pathogens Compliance Checklist: ECP, Training, and Records ...................... Form 9-BSafety Needle/Syringe Evaluation ....................................................................................... Form 10Phlebotomy Device Evaluation ............................................................................................ Form 11Generic Safety Device Evaluation ....................................................................................... Form 12Sharps Disposal Container Locations .................................................................................. Form 12-ASharps Evaluation Results ................................................................................................... Form 13Exposure Prevention Checklist ............................................................................................ Form 13-A

Bloodborne Pathogens Employee Medical RecordsIncident Report/Sharps Injury ............................................................................................... Form 14Sharps Injury Log ................................................................................................................. Form 14-AHBV Vaccination Declination Form ...................................................................................... Form 15HBV Employee Vaccination Form ........................................................................................ Form 16Post-exposure Checklist ...................................................................................................... Form 17Post-exposure Medical Evaluation Declination Form .......................................................... Form 18Source Patient Testing Consent Form ................................................................................. Form 18-A

Hazard Communication Records Hazardous Substances List ................................................................................................. Form 19

TB/Infection Control Records TB Risk Assessment Results Form ..................................................................................... Form 20TST Record ......................................................................................................................... Form 21TST Declination Form .......................................................................................................... Form 22TB Exposure Log ................................................................................................................. Form 23Influenza Vaccine Log .......................................................................................................... Form 24Influenza Vaccine Declination Form .................................................................................... Form 25-AChecklist for Infection Prevention for Outpatient Settings ................................................... Form 25-B List of Infection Prevention Contact Persons and Roles/Responsibilities ................................ Form 25-C

Training RecordsNew Employee OSHA Orientation Checklist ....................................................................... Form 26Annual Employee Training Record ...................................................................................... Form 27OSHA Annual Training (Sample Essay Test) ....................................................................... Form 28 OSHA Annual Training (Sample Multiple Choice Test) ........................................................ Form 29OSHA Annual Training (Sample True/False Test) ............................................................... Form 30Respiratory Protection Training Record ............................................................................... Form 31Qualitative Respirator Fit Test Report for N-95 Masks ........................................................ Form 31-AChecklist for Decreasing Surgical Fire Risks ....................................................................... Form 32

TAB 12: OSHA Regulations & Key ResourcesOSHA Regulations

Bloodborne Pathogens Standard ........................................................................................ 12-1Amended Bloodborne Pathogens Standard (Sharps Safety) .............................................. 12-13Hazard Communication Standard ........................................................................................ 12-14Exit Routes, Emergency Action Plans, and Fire Prevention Plans ...................................... 12-29Ionizing Radiation ................................................................................................................ 12-33Table of Other OSHA Standards for Outpatient Medical Facilities ...................................... 12-41

Additional OSHA ResourcesHealthcare Worker Vaccination Recommendations (Revised 2011) ................................... 12-42Suggested Work Restrictions for Employees ...................................................................... 12-44

Acronyms used in the OSHA Program Manual ......................................... 12-48

xxv

Contents

TAB 10: EMPLOYEE TRAINING

Contents

A Quick Look at the Employee Training Program ......................................... 10-1Training Format ................................................................................................ 10-1

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

General Safety ................................................................................................................10-3Fire Safety .......................................................................................................................10-3Bloodborne Pathogens Safety ........................................................................................10-3Chemical Safety ..............................................................................................................10-3TB Safety ........................................................................................................................10-4Infection Prevention ........................................................................................................10-4

Annual Employee Training .............................................................................. 10-5Bloodborne Pathogens Annual Training Contents ..................................................................10-6Respiratory Protection Annual Training Contents....................................................................10-6Hazard Communication Annual Training Contents .................................................................10-7

New Employee Orientation .............................................................................. 10-7New Employee OSHA Orientation Checklist (Form 26) ..........................................................10-8

Sample Tests with Answer Keys ..................................................................... 10-10OSHA Annual Training: Sample Essay Test Questions (Form 28) .........................................10-11OSHA Annual Training: Sample Essay Test—Answer Key .....................................................10-12OSHA Annual Training: Sample Multiple Choice Test Questions (Form 29) ...........................10-13OSHA Annual Training: Sample Multiple Choice Test—Answer Key ......................................10-15OSHA Annual Training: Sample True/False Test Questions (Form 30) ..................................10-16OSHA Annual Training: Sample True/False Test—Answer Key .............................................10-17

Documenting Employee Training ................................................................... 10-17Annual Employee Training Record (Form 27) ............................................... 10-18

Page

10-1

OSHA Program Manual for Medical Facilities

EMPLOYEE TRAININGA Quick Look at the Employee Training Program

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

A physician or other qualified medical professional (nurse, medical assistant, laboratory technologist, etc.) may provide the training, as long as he/she is competent in addressing questions pertaining to OSHA compliance. An infection prevention background is helpful, especially for bloodborne pathogens and TB training.

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.

Training Format

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.

The training must contain information that none of these formats can accomplish, such as:

▪ Where the OSHA manual and 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

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Checklist for an Effective Safety Training Session

Safety presentations, are a challenge to keep entertaining. Employees may not expect to be amused or involved.

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 accident 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.

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 Program Manual at staff meetings.

10-3


General Safety

▪ Demonstrate 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. ▪ Discuss protocols for avoiding slips, trips and falls. ▪ Discuss the ban on the use of extension cords in this facility. ▪ Discuss how to prevent and report workplace violence. ▪ Disuses the severe weather and bomb threat policy.

Fire Safety

▪ State location of fire extinguisher(s) and demonstrate/describe their use (PASS). ▪ State location of fire alarms, if any. ▪ Identify location of evacuation routes from the building and where to meet. ▪ Explain procedures to follow in the event of a fire (R.A.C.E.). ▪ Participate in a mock fire drill.

Bloodborne Pathogens Safety

▪ Describe the protocol for cleaning up a blood spill. ▪ Describe the protocol for disposal of sharps/used needles. ▪ Locate the Exposure Control Plan. ▪ Demonstrate aseptic removal of gloves. ▪ Describe when personal protective equipment is used/required.

Chemical Safety

▪ Locate the 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 where replacements are

located.

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▪ 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. ▪ Discuss the new GHS pictograms, labeling format and sections of the SDS.

TB Safety

▪ Conduct a role play for exactly what action to take when a potential TB patient enters the facility. Discuss the effectiveness of current policies.

Infection Prevention

▪ Discuss safe injection practices – one needle/one syringe/one time. ▪ Discuss labeling and expiration dates for medication vials. ▪ Identify the difference between Standard Precautions and transmission

precautions.

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Annual Employee Training

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” and now under the GHS update, “Right to Understand”).It also makes sense to include miscellaneous safety procedures, such as workplace 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 Train

Annual Retraining on Bloodborne Pathogens

Employees named on either Exposure Determination List.

• Before potential on-the-job exposure.

• Annually.

• Provide abbreviated training for affected employees whenever a new procedure is adopted that involves potential exposure to bloodborne pathogens.

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.

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 to hazardous chemicals.

• Annually.

• Employees who face exposure whenever a new hazardous chemical is introduced in the workplace.

• All employees on the GHS update regarding pictograms, new labeling requirements and SDS format.

* 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.

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Bloodborne Pathogens Annual Training Contents

▪ Access to this OSHA Program Manual (and instructions for how to access in the future), which includes written policies for OSHA compliance. The OSHA Program Manual also includes an Exposure Control Plan for both the Bloodborne Pathogens Standard. Finally, the OSHA Program Manual includes copies of the following regulations: the Bloodborne Pathogens Standard and the Hazard Communication 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. (This includes a discussion on the required use of safety sharps.)

▪ A discussion of the limitations of the above practices to prevent or reduce exposure to bloodborne pathogens. (This includes a discussion on which sharps in the facility are not safety sharps and a reminder to bring the use of any nonsafety sharps to the OSHA Safety Officer for inclusion with the annual sharps review process.)

▪ Information on the types, proper use, location, removal, decontamination, and disposal of personal protective equipment (PPE). A reminder that PPE MUST be worn for each task where there is reasonably anticipated exposure to blood or body fluids.

▪ Information about the free hepatitis B vaccine, including its efficacy, safety, and 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 the

training session.

Respiratory Protection Annual Training Contents

▪ Where 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 situations

in which the respirator malfunctions.

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▪ 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 that may limit or prevent the

effective use of respirators. Hazard Communication Annual Training Contents

▪ Where the Hazard Communication program, including 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. ▪ How to read and interpret SDS pictograms, hazard warnings and labels. ▪ How to recognize if they have been exposed (such as visual appearance,

dizziness, or smell, etc.) ▪ How to clean up a chemical spill. ▪ What to do if exposure occurs. ▪ How to report an accident or exposure.

New Employee Orientation

In addition to annual retraining, employees must be trained initially about OSHA regula-tions as they pertain specifically to the workplace. Use the New Employee OSHA Orientation Checklist on the next page for this purpose, and behind Tab 11: Master Record Forms (Form 26).

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.

In addition to annual retraining, employees must be trained initially about OSHA regulations as they pertain specifically to the workplace:

Training Topic Who Must Attend When to Train

New Employee Orientation: All OSHA Safety Issues

New employees and employees who have

transferred from another location or department.

Within 10 days of commencing work.

10-8


NEW EMPLOYEE OSHA ORIENTATION CHECKLIST

(1 of 3 pages)

Note: A master copy of this form (2 pages) can be found behind Tab 11: Master Record Forms (Form 26).

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 Program Manual 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_____ How to properly handle and dispose of sharps to prevent needle stick injuries_____ 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 8: Decontamination._____ 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

10-9


(New Employee OSHA Orientation Checklist, page 2 of 3)

Hazard CommunicationThe new employee knows:_____ What hazardous chemicals exist in the practice (review master list)_____ How to work safely with the above chemicals, including use of PPE__________

Where Safety Data Sheets (SDS) are located and how to read oneWhat the OSHA pictograms and hazard warnings on chemical labels mean

__________

How to recognize signs of chemical exposure and what to do if exposure occursWhere the eyewashes are and how to use them

Other: __________________________________________________________________________.

TB/Respiratory ProtectionThe new employee knows:_____ How TB is transmitted and policies for identifying potential TB patients._____ The practice’s relative risk of encountering patients with TB (refer to TB Risk

Assessment Result Form)._____ What to do if an active TB patient enters the practice._____ That initial TB skin testing (TST) must be performed._____ Influenza vaccination and protection protocols.

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

(RACE/PASS)_____ Protocols for responding to and reporting workplace violence

Other: __________________________________________________________________________.

10-10



General Safety/Infection PreventionThe new employee knows:_____ How to report workplace injuries_____ How to report potential safety issues_____ That extension cords cannot be used with patient equipment_____ How to handle patients safely (ergonomically) to prevent injury_____ How to prevent slips, trips and falls

_____ How to implement standard precautions, transmission/droplet/airborne precautions, including knowledge of multidrug resistant organisms (MDROs)

_____ How and where to sterilize or disinfect instruments and equipment

Sample Tests with Answer Keys

The following pages contain sample essay, multiple choice, and True/False questions that could be used for annual retraining. Answer keys are also provided.

10-11


OSHA ANNUAL TRAININGSample Essay Test Questions

Note: A master copy of this test can be found behind Tab 11: Master Record Forms (Form 28).

1. Name two OSHA regulations that impact medical practices:

__________________________________________________________________________________________________________________________

2. What does OSHA stand for?

O____________________________ S____________________________H____________________________ A____________________________

3. List 3 bloodborne pathogens:

_______________________________________________________________________________________________________________________________________________________________________________________

4. Check all infectious body fluids for which OSHA requires universal/standard precautions:

___ Urine___ Pleural fluid___ Vomit___ Saliva ___ Blood___ Feces___ Semen___ Vaginal secretions___ Tears___ Amniotic fluid

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

__________________________________________________________________________________________________________________________________________________________________________________________

10-12


OSHA ANNUAL TRAININGSample Essay Test - Answer Key

1. Two regulations that impact medical practices are:1. Bloodborne Pathogens2. Hazard Communication

2. OSHA stands for the: Occupational Safety and Health Administration

3. Three bloodborne pathogens are:1. Hepatitis B2. Hepatitis C3. HIV

4. Potentially infectious substances include the following:- Pleural fluid - Blood- Semen - Vaginal secretions - Amniotic fluid- Saliva (in dental procedures only)- Any body fluid visibly contaminated with blood

5. 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, slides, etc.- Mucous membrane contact through sprays, splashes, rubbing into eyes, nose,

mouth, etc.

10-13


OSHA ANNUAL TRAININGSample Multiple Choice Test Questions


Circle the most appropriate response.

1. Which OSHA regulation does not impact medical practices?

a. OSH Act General Duty Clauseb. CLIAc. Hazard Communication d. Bloodborne Pathogens

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

a. Handling urine specimens.b. Being exposed to patients who are coughing.c. Working with cleaning chemicals.d. Collecting blood samples from patients.

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

a. HIVb. Hepatitis Cc. Tuberculosisd. Syphilis

4. 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

5. 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.

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6. Universal/Standard Precautions implies that:

a. Healthcare workers should treat the blood and body fluids of all patients as if they are infected with HIV or hepatitis.

b. Healthcare workers should be cautious with all patients’ blood and body fluids.c. All patients’ blood and body fluid must be disposed of in red bags.d. None of the above.

7. Which of the following procedures are considered high risk for tuberculosis?

a. Drawing blood.b. Urine testing.c. Aerosolized administration of medication.d. Suture removal.

8. Which of the following does not require a 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.

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.

10-15


OSHA ANNUAL TRAININGSample Multiple Choice Test - Answer Key

1. b

2. d

3. b

4. b

5. c

6. a

7. c

8. d

9. b

10. d

10-16


OSHA ANNUAL TRAINING Sample True/False Test Questions


Mark True or False

___ 1. Sample antibiotics in pill form that are given to patients require a SDS.___ 2. An employee can be dismissed from their job for not following the safety

policies in the OSHA Program Manual. ___ 3. An employee must wear gloves when working with blood or other potentially

infectious body fluids.___ 4. It is an OSHA violation to put regular trash in biohazardous red bags.___ 5. It is an OSHA violation to put biohazardous trash in regular wastebaskets or

cans.___ 6. Needlesticks don’t need to be reported unless the patient is known to have

HIV or hepatitis.___ 7. Solutions of bleach must be made up fresh daily.___ 8. An employee can be infected with HIV by a splash or spray of patient blood

to his eyes, nose or lips.___ 9. An employee can be infected with HIV by a splash or spray of patient blood

to his intact skin.___ 10. A patient who is likely to have active TB has had a productive cough for at

least three weeks.

10-17


OSHA ANNUAL TRAININGOSHA Sample True/False Test - Answer Key

1. F

2. T

3. T

4. F

5. T

6. F

7. T

8. T

9. F

10. T

Documenting Employee Training Document annual employee retraining on the Annual Training Record (page 10-18). Document new employee safety training on the New Employee OSHA Orientation Checklist (page 10-8), also behind Tab 11: Master Record Forms (Form 26).

Retain all training records for at least three years.

10-18


ANNUAL EMPLOYEE TRAINING RECORDNote: A master copy of this form can be found behind Tab 11: Master Record Forms (Form 27)

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, TB, fire safety, emergency procedures, infection prevention, etc.

TAB 11: MASTER RECORD FORMS

Contents

General Equipment and Facility Records

Form 1 Safety Report…………………..…................ Use to document employee complaints; staff meeting minutes.

Form 2 Autoclave Log…………………..………........ Use weekly or as indicated to record performance of biological indicator tests.

Form 2-A Eyewash Station Weekly Check Log........... Use weekly to record performance of emergency eyewash stations.

Form 3 Annual OSHA Program Manual Review…...Use annually to document that this manual was reviewed and updated.

Form 4-A Weekly Facility Review Checklist............... Use weekly (optional form).

Form 4-B Monthly Facility Review Checklist............... Use monthly (optional form).

Form 5 Annual Facility Review Checklist……......... Use annually.

Form 5-A Fire Drill Evaluation Form…………….......... Use at least once per year.

Form 5-B Employee Fire Drill Participation Sign-up Sheet …………………………........

Use at least once per year.

Form 6 Risk Assessment for Workplace Violence… Use initially and as needed.

Form 7 Housekeeping Schedule………..……......... Use initially.

Form 7-A Emergency Telephone List……..……......... Use initially and as needed.

Form 7-B Healthcare Facility Slip, Trip, and Fall Hazard Checklist....................................

Use as needed.

Bloodborne Pathogens Records

Form 8 Bloodborne Pathogens Exposure Determination List #1…………………......... Use initially and whenever new clinical staff is added.

Form 9 Bloodborne Pathogens Exposure Determination List #2………………..…....... Use initially and whenever new clinical staff is added.

Form 9-A Bloodborne Pathogens PPE Compliance Checklist…………..…….......... Use initially and whenever new clinical staff is added.

Form 9-A1 Failure to Use PPE..................................... Use to investigate incident.

Form 9-B Bloodborne Pathogens Compliance Checklist: ECP, Training, and Records……. Use initially and whenever new clinical staff is added.

Form 10 Safety Needle/Syringe Evaluation............... Use initially and whenever new safety devices are under consideration.

Form 11 Phlebotomy Device Evaluation…................ Use initially and whenever new safety devices are under consideration.

Form 12 Generic Safety Device Evaluation……........ Use initially and whenever new safety devices are under consideration.

Form 12-A Sharps Disposal Container Locations..........Use periodically to monitor compliance for sharps disposal container locations.

Form 13 Sharps Evaluation Results Form.............… Use initially and whenever new safety devices are under consideration.

Form 13-A Exposure Prevention Checklist Use periodically to monitor compliance for sharps disposal container locations

Bloodborne Pathogens Employee Medical Records

Form 14 Incident Report/Sharps Injury….......... Use when an employee injury occurs, including sharps injuries and other bloodborne pathogens exposures.

Form 15 HBV Vaccination Declination Form……....... Use when an employee is given the hepatitis B vaccine or declines this vaccine.

Form 16 HBV Employee Vaccination Form…….........Use when an employee is given the hepatitis B vaccine or declines this vaccine.

Form 17 Post-exposure Checklist…………….…........Use to document that all required actions were taken after a sharps injury or employee exposure to bloodborne pathogens.

Form 18 Post-exposure Medical Evaluation Declination Form………………….................

Use to document a particular employee refusing post- exposure testing and treatment.

Form 18-A Source Patient Testing Consent Form…….. Use to obtain consent from a source patient after an exposure incident such as a needlestick.

Hazard Communication Records

Form 19 Hazardous Substances List…….……......... Use initially to list all hazardous chemicals in your facility and when a new hazardous chemical is introduced.

TB/Infection Control Records

Form 20 TB Risk Assessment Results Form…......... Use annually.

Form 21 TST Record……………..………..……......... Use as indicated, based on your facility’s risk assessment.

Form 22 TST Declination Form………….…...…........ Use when an employee declines receiving a TB skin test.

Form 23 TB Exposure Log……………….…...…........ Use as indicated when employees are exposed to a known TB patient.

Contents

Form 24 Influenza Vaccine Log………....………........ Use annually to vaccinate all employees.

Form 25-A Influenza Vaccine Declination Form….......... Use when an employee declines this vaccine.

Form 25-B Checklist for Infection Prevention for Outpatient Settings......................................... Use initially and at least annually thereafter.

Form 25-C List of Infection Prevention Contact Persons and Roles/Responsibilities..............................

Use initially and whenever infection prevention roles and responsibilities change.

Training Records

Form 26 New Employee OSHA Orientation Checklist…................................

Use to document initial OSHA training when new staff members are added.

Form 27 Annual Employee Training Record….......... Use annually.

Form 28 OSHA Annual Training (Sample Essay Test)…………..………........

Use annually.

Form 29 OSHA Annual Training (Sample Multiple Choice Test)……..…........

Use annually.

Form 30 OSHA Annual Training (Sample True/False Test)….…….…............

Use annually.

Form 31 Respirator Protection Training Record….... Use annually.

Form 31-A Qualitative Respirator Fit Test Report for N-95 Masks……...……...……...…….……...

Use annually when requiring a respirator or when changing respirator selection.

Form 32 Checklist for Decreasing Surgical Fire Risks….................................................

Use annually.

Contents


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Form 25-A

INFLUENZA VACCINE DECLINATION FORM

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

I acknowledge that I am aware of the following facts:

• Influenza is a serious respiratory disease that kills thousands of people in the United States each year.

• Influenza vaccination is recommended for me and all other healthcare workers to protect this facility’s patients from influenza, its complications and death.

• If I contract influenza, I can shed the virus for 24 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 if my symptoms are mild or non-existent, I can spread it to others and they can become seriously ill.

• I understand that the strains of virus that cause influenza infection change almost every year and, even if they don’t change, my immunity declines over time. This is why vaccination against influenza is recommended each year.

• I understand that I cannot get influenza from the influenza vaccine.• The consequences of my refusing to be vaccinated could have life-threatening

consequences to my health and the health of those with whom I have contact, including

– all 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 still is available.

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

_________________________________ __________Employee signature Date

________________________________Employee printed name

Reference: CDC, Prevention and Control of Influenza Vaccines-Recommendation of ACIP at www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html

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


Form 25-B

Section I. Administrative Policies and Facility PracticesPractice

PerformedIf answer is No, document plan for corrective action

1. 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 per state or federal requirements, and updated if appropriate.

Yes No

At least one individual trained in infection prevention is employed by or regularly available (e.g., by contract) to manage the facility’s infection control program. Note: Examples of training may include: Successful completion of initial and/or recertification exams developed by the Certification Board for Infection Control & Epidemiology; participation in infection control courses organized by the state or recognized professional societies (e.g., APIC, SHEA).

Yes No

Facility has system for early detection and management of potentially infectious persons at initial points of patient encounter. Note: System may include taking a travel and occupational history, as appropriate, and elements described under respiratory hygiene/cough etiquette.

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

Facility has an exposure control plan that is tailored to the specific requirements of the facility (e.g., addresses potential hazards posed by specific services provided by the facility). Note: A model template, which includes a guide for creating an exposure control plan that meets the requirements of the OSHA Bloodborne Pathogens Standard is available at: www. osha.gov/Publications/osha3186.pdf

Yes No

2. General Infection Prevention Education and TrainingHealthcare personnel (HCP) receive job-specific competency-based training on infection prevention policies and procedures upon hire and at least annually or per 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

CHECKLIST FOR INFECTION PREVENTION FOR OUTPATIENT SETTINGS

https://www.osha.gov/Publications/osha3186.pdf

https://www.osha.gov/Publications/osha3186.pdf


Practice Performed

If answer is No, document plan for corrective action

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 have repeat testing, If appropriate based on the facility-level risk assessment. Note: For more information, facilities should refer to the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_ cid=rr5417a1_e

Yes No

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 exposures in HCP, including notification of appropriate infection prevention and occupational health personnel when applicable. 1. Work-exclusion policies that encourage reporting of illnesses and do not penalize with loss of wages, benefits, or job status. 2. Education of personnel on prompt reporting of illness to supervisor.

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 knowledge and compliance with mandatory reporting requirements for notifiable diseases, healthcare-associated infections, and for potential outbreaks.

Yes No

Form 25-B

(Infection Prevention Checklist, page 2 of 12)

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_cid=rr5417a1_e

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_cid=rr5417a1_e


Practice Performed


Patients who have undergone procedures at the facility are educated regarding signs and symptoms of infection that may be associated with the procedure and instructed to notify the facility if such signs or symptoms occur.

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 areas

Yes No

HCP are educated regarding appropriate indications for hand washing with soap and water versus hand rubbing with alcohol-based hand rub upon hire and annually. (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 noro virus]. 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 upon hire, annually and when new equipment or protocols are introduced.

Yes No

Facility routinely audits (monitors and documents) adherence to proper PPE selection and use.

Yes No

Facility provides feedback from audits to personnel regarding their performance with selection and use of PPE.

Yes No

7. 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

HCP who prepare and/or administer parenteral medications receive training on safe injection practices:

i. Upon hire, prior to being allowed to prepare and/or administer parenteral medications

ii. Annuallyiii. When new equipment or protocols are introduced

Yes No

Facility routinely audits (monitors and documents) adherence to safe injection practices.

Yes No

Form 25-B



Form 25-B

Practice Performed


Facility provides feedback from audits to personnel regarding their adherence to safe injection practices.

Yes No

Facility has policies and procedures to track HCP access to controlled substances to prevent narcotics theft/diversion. Note: Policies and procedures should address: how data are reviewed, how facility would respond to unusual access patterns, how facility would assess risk to patients if tampering (alteration or substitution) is suspected or identified, and who the facility would contact if diversion is suspected or identified.

Yes No NA

(this facility does not

prepare or administer controlled

substances)

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, annually 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



Form 25-B

Practice Performed


Cleaning procedures are periodically monitored and assessed to ensure that they are consistently and correctly performed, feedback is provided to personnel regarding their adherence to cleaning and disinfection procedures.

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 for cleaning and disinfection of equipment including, non-critical equipment, mobile devices, and other electronics (e.g., point-of-care devices) that might not be reprocessed in a centralized reprocessing area.

Yes No

The individual(s) in charge of infection prevention at the facility is consulted whenever new devices or products will be purchased or introduced to ensure implementation of appropriate reprocessing policies and procedures.

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

HCP responsible for reprocessing reusable medical devices are appropriately trained and competencies are regularly documented (upon hire, prior to being allowed to reprocess devices and at least annually and when new equipment is introduced or policies/procedures change).

Yes No

Facility routinely audits (monitors and documents) adherence to reprocessing procedures.

Yes No

Facility provides feedback from audits to personnel regarding their adherence to reprocessing procedures

Yes No

Facility has protocols to ensure that HCP can readily identify devices that have been properly reprocessed and are ready for patient use (e.g., tagging system, storage in designated area).

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



Form 25-B

Practice Performed


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 performed per 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 reprocessing equipment (e.g., automated endoscope reprocessors, steam autoclave) is performed by qualified personnel in accordance with manufacturer instructions; confirm maintenance records are available.

Yes No NA

(Reprocess-ing equip-ment is not used at the

facility)

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. If a respirator is used, it is removed and discarded (or reprocessed if reusable) after leaving the patient room or care area and closing the door.

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



Form 25-B

Practice Performed


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

Yes No

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

Yes No

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

NA (Facility does not use multi-dose vials or discards them after

single patient use)

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

NA

If used for more than one patient, the point-of-care testing meter is cleaned and disinfected after every use per 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

NA



Form 25-B

Practice Performed


5. Environmental CleaningEnvironmental surfaces, with an emphasis on surfaces in proximity to the patient and those that are frequently touched (high-touch surfaces), are cleaned and then disinfected with an EPA-registered disinfectant.

Note: If environmental services are performed by contract personnel, facility should verify that appropriate EPA-registered products are provided by contracting company.

Yes No

High-touch surfaces in rooms where surgical or other invasive procedures (e.g., endoscopy, spinal injections) are performed are cleaned and then disinfected with an EPA registered disinfectant after each procedure.

Yes No

NA

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 per manufacturer instructions (Note: If the manufacturer does not provide such instructions, the device may not be suitable for multi-patient use.)

Yes No

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

Yes No

Reusable medical devices are cleaned, reprocessed (disinfection or sterilization) and maintained per the 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



Form 25-B

Practice Performed


Single-use devices are discarded after use and not used for more than one patient unless they have been appropriately reprocessed as described in the note below.

Note: If the facility elects to reuse single-use devices, these devices must be reprocessed prior to reuse by a third-party reprocessor that it 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:i. Adequate space is allotted for reprocessing activities.

A workflow pattern is followed such that devices clearly flow from high contamination areas to clean/sterile areas (i.e., there is clear separation between soiled and clean workspaces).

Yes No

Adequate time for reprocessing is allowed to ensure adherence to all steps recommended by the device manufacturer, including drying and proper storage.

Note: Facilities should have an adequate supply of instruments for the volume of procedures performed and should schedule procedures to allow sufficient time for all reprocessing steps.

Yes No

Enzymatic cleaner or detergent is used for pre-cleaning and discarded per 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 a load number that indicates the sterilizer used, the cycle or load number, and the date of sterilization, and if applicable, the expiration date.

Yes No

NA

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

Yes No

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

Yes No



Form 25-B

Practice Performed


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

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

Yes No

The facility has a process to perform initial cleaning of devices (to prevent soiled materials from becoming dried onto devices) prior to transport to the off-site reprocessing facility.

Yes No

NA

8. High-Level Disinfection of Reusable Instruments and DevicesFlexible endoscopes are inspected for damage and leak-tested as part of each reprocessing cycle. Any device that fails the leak test is removed from clinical use and repaired.

Yes No

Items are thoroughly cleaned per manufacturer instructions and visually inspected for residual soil prior to high-level disinfection.

Note: Cleaning may be manual (i.e., using friction) and/or mechanical (e.g., with ultrasonic cleaners, washer-disinfector, washer-sterilizers).

(Note: For lumened instruments, device channels and lumens must be cleaned using appropriately sized cleaning brushes.)

Yes No

Cleaning is performed as soon as practical after use (e.g., at the point of use) to prevent soiled materials from becoming dried onto instruments.

Yes No

NA

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

Yes No

NACleaning brushes are disposable or if reusable, cleaned and high-level disinfected or sterilized (per manufacturer instructions) after each use

Yes No

NA

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 (e.g., automated endoscope reprocessor) 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



Form 25-B

Practice Performed


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 according to manufacturer’s instructions.

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

Facility maintains a log for each endoscopy procedure which includes: patient’s name and medical record number (if available), procedure, date, endoscopist, system used to reprocess the endoscope (if more than one system could be used in the reprocessing area), and serial number or other identifier of the endoscope used.

Yes No

The facility has a process to perform initial cleaning of devices (to prevent soiled materials from becoming dried onto devices) prior to transport to the off-site reprocessing facility.

Yes No

Source: Adapted with permission from the CDC’s Infection Prevention Checklist for Outpatient Settings: Minimum Expectations for Safe Care. 2016 –version 2.3



Form 25-C

Contact Person(s)[a] (Names/Titles)

Contact Information Roles/Responsibilities

Phone: Pager: E-mail:

• Infection prevention personnel/consultant • Assists with infection control plan development, update/revision, and

implementation ○ Including a protocol for transferring patients who require Airborne

Precautions (if applicable)


• Educate and train facility staff (including Environmental Services/housekeeping) • Assess for competency of jobs/tasks (examples provided):

○ Hand hygiene performance/compliance ○ Proper use of PPE ○ Environmental cleaning/disinfection ○ Triage/screening, taking vital signs ○ Phlebotomy service

• Determine when to implement enhanced respiratory screening measures • Ensure facility sick leave policies are in place and followed


• Collect, manage, and analyze HAI data for surveillance purposes • Prepare and distribute surveillance reports • Notifies state and local health departments of reportable diseases/conditions

and outbreaks


• Provides fit-testing for N-95 respirators (if used in facility) and appropriate respiratory protection training to facility staff


• Assess patients presenting with symptoms of active infection (may be notified by registration staff upon patient arrival)

• Determine patient placement as needed


• Environmental Services (ES) /housekeeping staff • Responsible for (specify tasks, examples provided):

○ Ensure supplies are restocked ○ Daily cleaning of patient-care areas ○ Disinfect bathrooms as needed ○ Cleaning large spills of blood or other potentially infectious materials[b]

○ Empty regular trash and dispose regulated waste accordingly


• Clean/disinfect areas and/or surfaces that require more frequent cleaning or are not routinely cleaned by ES/housekeeping staff (specify areas/surfaces and specific situations, examples provided):

○ Medication preparation area after each patient encounter ○ Patient-care devices after each use ○ Exam rooms and/or chemotherapy suite after each patient encounter

(e.g., change paper covering exam table, clean chemotherapy chair) ○ Patient-care areas after contamination with body fluids[c]


• Monitor medication/vaccine refrigerator temperature log • Ensure alternative storage method is in place in the event of power failure

(specify method)

[a] Several roles/tasks may be performed by the same person, e.g., Infection Prevention personnel, or by more than one person.[b] Cleaning/disinfection of spills of blood or other potentially infectious materials should be assigned to personnel trained to handle

such situation; this may include facility staff other than ES/housekeeping staff.[c] Ensure this task is assigned to personnel who are available to respond in a timely manner; in some facilities,

ES/housekeeping staff may be better equipped to handle this type of cleaning/disinfection.

LIST OF INFECTION PREVENTION CONTACT PERSONS AND ROLES/RESPONSIBILITIES

Source: Basic Infection Control and Prevention Plan for Outpatient Oncology Settings, CDC 2011.


Form 26

NEW EMPLOYEE OSHA ORIENTATION CHECKLIST

(1 of 3 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 Program Manual 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_____ How to properly handle and dispose of sharps to prevent needle stick injuries_____ 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 8: Decontamination._____ 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 26


Hazard CommunicationThe new employee knows:_____ What hazardous chemicals exist in the practice (review master list)_____ How to work safely with the above chemicals, including use of PPE__________

Where Safety Data Sheets (SDS) are located and how to read oneWhat the OSHA pictograms and hazard warnings on chemical labels mean

__________

How to recognize signs of chemical exposure and what to do if exposure occursWhere the eyewashes are and how to use them

Other: __________________________________________________________________________.

TB/Respiratory ProtectionThe new employee knows:_____ How TB is transmitted and policies for identifying potential TB patients._____ The practice’s relative risk of encountering patients with TB (refer to TB Risk

Assessment Result Form)._____ What to do if an active TB patient enters the practice._____ That initial TB skin testing (TST) must be performed._____ Influenza vaccination and protection protocols.

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

(RACE/PASS)_____ Protocols for responding to and reporting workplace violence

Other: __________________________________________________________________________.


Form 26


General Safety/Infection PreventionThe new employee knows:_____ How to report workplace injuries_____ How to report potential safety issues_____ That extension cords cannot be used with patient equipment_____ How to handle patients safely (ergonomically) to prevent injury_____ How to prevent slips, trips and falls

_____ How to implement standard precautions, transmission/droplet/airborne precautions, including knowledge of multidrug resistant organisms (MDROs)

_____ How and where to sterilize or disinfect instruments and equipment


Form 27

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, TB, fire safety, emergency procedures, infection prevention, etc.


Form 28

OSHA ANNUAL TRAININGSample Essay Test Questions

1. Name two OSHA regulations that impact medical practices:

__________________________________________________________________________________________________________________________

2. What does OSHA stand for?

O____________________________ S____________________________H____________________________ A____________________________

3. List 3 bloodborne pathogens:

_______________________________________________________________________________________________________________________________________________________________________________________

4. Check all infectious body fluids for which OSHA requires universal/standard precautions:

___ Urine___ Pleural fluid___ Vomit___ Saliva ___ Blood___ Feces___ Semen___ Vaginal secretions___ Tears___ Amniotic fluid

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

__________________________________________________________________________________________________________________________________________________________________________________________


Form 29

OSHA ANNUAL TRAININGSample Multiple Choice Test Questions

Circle the most appropriate response.

1. Which OSHA regulation does not impact medical practices?

a. OSH Act General Duty Clauseb. CLIAc. Hazard Communication d. Bloodborne Pathogens

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

a. Handling urine specimens.b. Being exposed to patients who are coughing.c. Working with cleaning chemicals.d. Collecting blood samples from patients.

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

a. HIVb. Hepatitis Cc. Tuberculosisd. Syphilis

4. 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

5. 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.


Form 29

6. Universal/Standard Precautions implies that:

a. Healthcare workers should treat the blood and body fluids of all patients as if they are infected with HIV or hepatitis.

b. Healthcare workers should be cautious with all patients’ blood and body fluids.c. All patients’ blood and body fluid must be disposed of in red bags.d. None of the above.

7. Which of the following procedures are considered high risk for tuberculosis?

a. Drawing blood.b. Urine testing.c. Aerosolized administration of medication.d. Suture removal.

8. Which of the following does not require a 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.

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.


Form 30

OSHA ANNUAL TRAINING Sample True/False Test Questions

Mark True or False

___ 1. Sample antibiotics in pill form that are given to patients require a SDS.___ 2. An employee can be dismissed from their job for not following the safety

policies in the OSHA Program Manual. ___ 3. An employee must wear gloves when working with blood or other potentially

infectious body fluids.___ 4. It is an OSHA violation to put regular trash in biohazardous red bags.___ 5. It is an OSHA violation to put biohazardous trash in regular wastebaskets or

cans.___ 6. Needlesticks don’t need to be reported unless the patient is known to have

HIV or hepatitis.___ 7. Solutions of bleach must be made up fresh daily.___ 8. An employee can be infected with HIV by a splash or spray of patient blood

to his eyes, nose or lips.___ 9. An employee can be infected with HIV by a splash or spray of patient blood

to his intact skin.___ 10. A patient who is likely to have active TB has had a productive cough for at

least three weeks.


Form 31-A

QUALITATIVE RESPIRATOR FIT TEST REPORT for N-95 MASKS

It is the responsibility of the employer to follow and comply with requirements for the written program, medical clearances, fit testing and training following 29CFR1910.134 (including Appendix A and B1). It also is the responsibility of the employer to follow the recommendations of the manufacture of the respirator and fit testing kits.

Employer: __________________________________________________________________________________

Subject’s Name: __________________________________ DOB: __________________________________

Medical evaluation current: _________________________________________________________________

Respirator make: _________________________________ Model: __________________________________ Mask Size: q S q M q L Cartridge type: _______________________________________

The respirator must be donned by the participant without assistance.

Test Agent: q Saccharin q Bitrex Sensitivity check: q Bitrex squeezes __________ q Saccharin squeezes __________ (No eating/smoking/drinking/chewing gum 15 min prior to test)

Fitting: q Positive pressure seal check q Negative pressure seal check

Appropriate PPE worn during the fit test procedure: _________________________________________The mask will be worn for 5 min. prior to the test: ___________________________________________Facial hair cannot cross the seal of the facepiece: ___________________________________________

The respirator shall not be adjusted once the fit-test exercises begin.

Exercises: All exercises are 1 minute eachq Normal breathing q Deep breathing q Turning head side to side q Moving head up and down q Talking/counting reciting q Bending over at waistq Grimacing for 15 sec. q Normal breathing

If the participant has difficulty breathing at any point, stop the test and fail the test.

q Pass q Fail

Subject’s signature: ___________________________________ Date: _______________________________

Tester’s signature: ____________________________________ Date: _______________________________

Source: Source: www.OSHA.gov


CHECKLIST FOR DECREASING SURGICAL FIRE RISKS

This list provides surgical teams with one way to double-check for surgical fire risks.

Treat any “no” answer as potential increased risk during surgery.

Employee knowledgeDo operating room (OR) staff members understand the fire risks associated with surgery (fuel, heat and oxygen)?

Yes No

Do surgical teams know how to extinguish an OR fire? Yes NoDo OR staff members know how to alert facility emergency personnel and the fire department if a fire occurs?

Yes No

Do employees know how to evacuate the OR with the patient if necessary? Yes NoPreparing for surgeryIs there a timeout prior to the procedure to discuss fire risks? Yes NoDid the appropriate department inspect the electrosurgical device/surgical laser and associated equipment for proper operation before surgery?

Yes No

Did the appropriate department inspect anesthesia equipment, including tubing, before the surgery?

Yes No

Do staff members allow prepping agents to evaporate before surgery? Yes NoDo surgical teams clean up any pools of prepping agents before surgery? Yes NoAre surgical drapes and the patient’s gown free of pockets that might trap oxygen?

Yes No

Do staff members properly place the oxygen tubes and masks to avoid leaks and the creation of air pockets?

Yes No

Are patient’s hair and facial hair near the surgical site coated with a water-based jelly to prevent burning?

Yes No

Did staff members inform the patient ahead of time not to put oily or greasy cosmetic products in the hair and on the face before surgery?

Yes No

During surgeryDoes the surgeon put the electrosurgical device/surgical laser in its holster or otherwise deactivate it when not in use?

Yes No

Do surgeons use the electrosurgical device/surgical laser at its lowest practical setting?

Yes No

Does the electrosurgical device/surgical laser feature an audible activation sound?

Yes No

Do surgeons avoid supplying 100% oxygen to the patient during the surgery? Yes NoDo surgeons discontinue the use of oxygen before using an electrosurgical device/surgical laser?

Yes No

Is sterile water or saline solution available to put out a fire? Yes NoIs a portable fire extinguisher available in or near the OR? Yes No

Source: September 2003 Healthcare Life Safety Compliance, HCPro and AORN 2014

Form 32

Documents

UPDATE - HCProcontent.hcpro.com/manuals/meu/OSHASPM_17F_2017_supp.pdf · 10-1 through 10-18 10-1 through 10-18 Tab 10: Employee Training—updated Tab 11 Contents Tab 11 Contents