General Safety

TJUHBB POL 04.001

PURPOSE

To describe the policies for ensuring the safety and security of personnel and properties in the Neuropathology Biorepository.

Principle

To promote a productive and safe working environment all laboratory personnel, including residents, fellows, students and volunteers, will be given an orientation prior to working in the laboratory.

The supervisor is responsible for the proper orientation and training of all persons working in the laboratory. This orientation will include basic rules for working in the laboratory as well as specific guidelines regarding how Hospital safety policies apply to the Molecular and Genomic Pathology Laboratory. To aid orientation form MGEN_24-1 will be used and stored in the laboratory until the end of employment in the Molecular and Genomic Pathology Laboratory.

Additionally, within 90 days of employment all employees, fellows, residents, students and volunteers must complete safety training relevant to their duties as outlined by Clinical Laboratory policy 11.01. All should be familiar with the following plans: Fire, Electrical, Chemical Hygiene, Internal Disaster Plan, External Disaster Plan, Laboratory Evacuation Plan, Biological Terrorist Thread, Ergonomics, Equipment Safety, Radiation Safety (if necessary), the Infection Control Program and any other policy relevant to their duties. The supervisor is responsible for ensuring that all persons working in the laboratory have fulfilled this requirement.

This policy is in addition to the requirement for the generic orientation specified in Clinical Laboratory policy 9.03.

Laboratory Safety Checklist

POLICY

SAFETY
Lab personnel should take an active role in establishing and maintaining a safe working environment. A yearly safety meeting is held to discuss more biorepository specific safety procedures including personal and laboratory safety, fire prevention and control, biohazard handling and disposal, chemical handling and disposal, accident reporting, handling of compressed gases, and disaster plan. Safety procedures are included in the training of new laboratory staff. Documentation of training, yearly review and testing of safety procedures are maintained in the safety training log. Additionally, as a component of the laboratory quality assurance program which is updated monthly and reviewed quarterly with all staff, ongoing safety issues are discussed.

SECURITY

• A. Each staff member must wear a TJUH ID card during working hours.
• B. The laboratory door is kept locked when no one is in the laboratory.
• C. Personal possessions should be kept in assigned lockers.
• D. "Restricted Area, Authorized Personnel Only" signs are posted outside the door.
• E. Inform the security officer if any unauthorized personnel acting in a suspicious manner are seen.
• F. Patient files and log books are kept in the biorepository and can only be reviewed by authorized personnel.

LABORATORY EVACUATION
Evacuation signs are posted throughout the Laboratory and should be reviewed with all employees as part of their orientation process. In the event of an emergency situation, where in the laboratory or a section of the laboratory must be evacuated; the process must be carried out in an orderly manner. Laboratory management or other authority (i.e. fire department, police department, and hospital security or environmental safety) must declare a true evacuation situation. In situations that are life threatening, the evacuation may begin in the absence of formal declaration.

Upon notification of the need to evacuate, employees must leave the laboratory area via the nearest emergency exit (do not use elevators). The evacuation should be in accordance with the directions given at the time of notification. In the event there are disabled employees working in the vicinity, they must be notified and assisted in leaving the work area immediately. If the disabled employee cannot be evacuated, notify the authority in charge of the evacuation as to the location of the disabled employee.

Do not re-enter the evacuated area unless authorized by the party in-charge of the evacuation. Evacuation Plan

FIRE PREVENTION

• Smoking is prohibited throughout the lab and in all hospital buildings, including outside stairways.
• Place flammable rubbish in authorized receptacles.
• Maintain good housekeeping conditions throughout the laboratory with particular emphasis to all closet and storage space.
• Store rags and cloths permeated with oils or chemicals in metal containers with lids in specified areas.
• Turn off gas and electrical equipment when not in use or at closing time.
• Do not obstruct fire towers and exits.
• Always be aware of nearest exit to your area of work.
• Know the location of fire exits, fire alarm boxes and fire extinguishers on the floors where you work.

FIRE SAFETY
Upon discovery of a fire condition, employees and staff (including Physicians and Licensed Independent Practitioners) who are at the Fire Scene shall follow the procedures outlined by the RACE acronym:

• R: RESCUE anyone from immediate danger.

• A: ALARM: Pull the nearest fire alarm pull station and call Jefferson Security at 811 or 77, or call 911 in areas not serviced by Jefferson Security. Give exact location and details of fire.

• C: CONFINE by closing doors in the fire area to contain smoke and heat.

• E: EVACUATE: Evacuate away from smoke and heat.

• EXTINGUISH: Extinguish small fires.
  All employees and staff should know how to use a fire extinguisher. The acronym PASS is used to remember steps to properly use a fire extinguisher:

• P: Pull the pin between the extinguisher’s handles.

• A: Aim the nozzle at the base of the fire. You should stand 6-10 feet away from fire.

• S: Squeeze the handle of the fire extinguisher.

• S: Sweep the nozzle from side to side across the base of the fire.
  Upon activation of a Code Red, all employees and staff (including Physicians and Licensed Independent Practitioners) who are away from the Fire Scene shall do the following:

Prepare to accept patients from the Fire Scene or near the Fire Scene if evacuation is required (especially for areas directly adjacent to the Fire Scene). Be cognizant that the fire situation may affect the ability to effectively care for patients away from the Fire Scene.
Be aware of any additional instructions given via the Public Address System.
Keep patients and visitors in rooms if possible until directed to do otherwise.
Keep all identified smoke barrier doors closed. Prepare to evacuate if directed.
DO NOT use Elevators.
In addition to the above, upon activation of a Code Red, Physicians and Licensed Independent Practitioners are specifically requested to:
• In a patient area, go to the nurses’ station to be available for response to a medical emergency.
• Assist other staff in moving patients and visitors to safety, and evacuate with the other staff as conditions dictate.

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OUTLAWED APPLIANCES

The University Safety Committee prohibits the use of toaster oven type appliances in all campus workplaces. Microwave ovens are acceptable alternatives for the toaster.

Equipment with two-pronged plugs should not be used in a laboratory due to the high risk associated with electrical grounding hazards.

ELECTRICAL SAFETY
Operator Responsibilities

• Avoid use of extension cords and two-prong plugs.
• Never operate electrical equipment with wet hands.
• Perform a visual inspection of equipment for frayed or damaged power cords, broken or malfunctioning switches, pilot lights, etc.
• Notify the supervisor immediately if any abnormal conditions are found which affect the safety of the equipment.
• Immediately turn off and unplug the power cord from any equipment that produces an electrical shock when touched. Notify both the supervisor and the biomedical staff.

Supervisor Responsibilities

• Instruct all employees of the safety procedures that should be followed.
• The supervisors periodically inspect all electrical equipment for safety hazards.
• The supervisor should immediately contact the biomedical staff when a safety hazard exists which they cannot readily rectify.

Biomedical Instrumentation Responsibilities

The QA staff annually performs certain physical checks on all electrical laboratory equipment initially and after major repairs. These include checking the grounding, polarity, insulation, leakage current, physical condition of the power cord and plug, and a check of current leakage to the environment. These electrical checks are performed in accordance with the National Fire Protection Association's Electrical Code (NFPA #76bt). The code specifies that grounding resistance should be less than 0.15 ohms, leakage current in forward and reverse conditions should be less than 500 uA, and leakage to the environment should be less than 500uA.

INTERNAL AND EXTERNAL DISASTER PLANS
Laboratory personnel are knowledgeable and trained to handle internal and external disasters.

Internal emergencies includes fire, biohazard/chemical exposure, job-related injury, etc. The external disaster usually is electricity turn-off, fire, weather conditions (e.g., flood and hurricane), nature disasters (earthquake), and terrorism attack, etc.

When encountering a disaster, follow institutional guidelines and standard procedures for evacuation and medical assistance.

Revisions

POL ID	Date Revised	Author	Summary of Changes
POL 04.001	08/05/2016	Patel, Miraj	Policy finalized

Version & Approval

Version	Category	Approval	Date
04.001	Administration	Stephen Peiper, MD	08/05/2016