COMPLIANCE

Where’s your lab safety manual?

By Dan Scungio, MT (ASCP), SLS, CQA (ASQ)  bio

Laboratory leadership should be committed to providing a safe working environment, and they should believe their employees have a right to know about health hazards associated with their work in the department. In order for employees to make knowledgeable decisions about the personal risks of work in the lab, a comprehensive Laboratory Safety Manual should be established to include policies, procedures, and responsibilities designed to maintain an awareness of potentially hazardous conditions in the workplace and to train employees in appropriate safe working conditions.

The Lab Safety Manual can be policies and procedures on paper, or it can be in an electronic format. Either way, all lab staff should have easy access to the manual at all times. It should not be hidden away in a locked office. Make sure staff are given information about how to access all lab safety policies and procedures. Safety policies should be approved by the lab medical director (or designee), and they should remain under document control at all times. Make sure staff have read policies as part of the training process, and ensure training occurs for new procedures as well.

There is no firm guidance or set of regulations that define what policies must be in the manual. However, many regulatory agencies (OSHA, CAP, etc.) do require specific written safety plans and procedures. For instance, OSHA states that every laboratory needs an Exposure Control Plan in order to comply with the Bloodborne Pathogens standard. The agency’s Chemical Hygiene standard expects a written Chemical Hygiene Plan which details chemical safety practices, assesses chemical hazards, and designates a Chemical Hygiene Officer.

The College of American Pathologists (CAP), a lab accrediting agency, has other expectations for written lab safety procedures. Adequate policies should be available detailing laboratory fire prevention and control. The fire safety plan should include information about fire response, drills, and the use of fire-fighting equipment. CAP also requires a tuberculosis exposure control plan for those labs where employees may be exposed to patients or tuberculosis samples that are considered potentially infectious.

Other necessary lab safety procedures are mandated by multiple organizations. A comprehensive lab emergency management and evacuation plan is needed so that staff can effectively respond to different types of disaster situations. Instructions about the selection and proper use of Personal Protective Equipment (PPE) is required as well. If radioactive materials are handled in the department, specific policies are needed to ensure adequate training and radiation detection are performed. Lastly, waste management procedures should detail the proper disposal of lab refuse into the various possible waste streams.

Some specialty safety procedures may be necessary depending on the types of equipment or testing that occurs in the department. If liquid nitrogen is used, be sure to detail the safe handling of those containers (as well as other compressed gases if applicable). Ultraviolet light sources also require particular safety practices.

There may be a wide variety of safety policies, procedures, and job aids in the laboratory safety manual, but they should never sit in a binder untouched or unseen. The safety manual should be kept up to date, and it should be reviewed by staff on a regular basis. Choose specific policies and create continuing education, competencies, or even quizzes and games for staff to help maintain the awareness of these important documents. If created well and used regularly, the laboratory safety manual can be a powerful tool to help you improve and maintain the safety management of the laboratory.


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