**Florida licensees, please note: This exercise will fulfill your state requirement for credit in Supervision / Administration.

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1 EDUCATIONAL COMMENTARY LABORATORY SAFETY UPDATE Educational commentary is provided through our affiliation with the American Society for Clinical Pathology (ASCP). To obtain FREE CME/CMLE credits click on Earn CE Credits under Continuing Education on the left side of the screen. **Florida licensees, please note: This exercise will fulfill your state requirement for credit in Supervision / Administration. LEARNING OBJECTIVES On completion of this exercise, the participant should be able to describe the rationale for changes in the Hazard Communication Act and outline major changes to the law. distinguish OSHA from the CDC by describing the differences in regulatory authority. describe the background for the creation of the Guidelines for Safe Work Practices in Human and Animal Medical Diagnostic Laboratories document by the CDC. explain the term safety climate. Introduction This commentary will outline two new documents that affect the practice of safety in clinical laboratories. The first is a revision of the Hazard Communication Act of 1983 published by the Occupational Safety and Health Administration (OSHA). Because OSHA is a governmental agency located within the U.S. Department of Labor, these new regulations are law, and compliance by clinical laboratories is mandated. The second document was published by the Centers for Disease Control and Prevention (CDC), also a governmental agency. The CDC, however, issues only recommendations. Although compliance is not required by law, CDC recommendations represent current science and sound judgment, making it best practice to comply. Revised Hazard Communication Standard In 2012, the Occupational Safety and Health Administration published a revised Hazard Communication Standard. 1 The original Hazard Communication Standard, published in 1983, gave workers the right to know what chemicals they were working with and how to protect themselves. The new standard of 2012 was revised to align with the United Nations global chemical labeling system, the Globally Harmonized System (GHS). This system was developed over several years through negotiations among experts from various countries, international organizations, and stakeholder groups. It is an international classification system for chemical hazards, labels, and safety data sheets.

2 The purpose of the revision is to reduce confusion about chemical hazards in the workplace. Workers, especially those with low literacy, should be better able to understand hazards with the new law. Chemicals will be classified according to health and physical hazards. Consistent labels and safety data sheets will be established for all chemicals made in the United States and abroad. It is hoped that the new law will make it safer for workers to do their jobs and easier for employers to stay competitive in the global marketplace. According to OSHA, the new law will prevent over 500 workplace illnesses or injuries and 43 deaths annually in the U.S. The major changes in the new Hazard Communication Act are: Hazard communication: The definitions of hazards have been changed to provide specific criteria for the classification of health and physical hazards. This should ensure consistency across manufacturers and improve accuracy in labels and safety data sheets. Chemical manufacturers will be required to include a label that provides a harmonized signal word (pictogram) and hazard statement for each hazard class and category. Safety data sheets: Formerly called material safety data sheets, all safety data sheets will be standardized to contain a specified 16-section format. In addition to the current training requirements, OSHA requires that employees be trained on the new label elements (pictograms) and safety data sheet format by December 31, Full compliance with the new law will not be required until There are nine pictograms under the globally harmonized system depicting health, safety, and environmental hazards (Table 1). The new Hazard Communication Standard (HCS) requires eight of these pictograms. Because OSHA does not govern environmental hazards, that pictogram is not required by the law.

3 Table 1. HCS Pictograms and Hazards Health Hazard Flame Exclamation Mark Carcinogen Mutagenicity Reproductive Toxicity Respiratory Sensitizer Target Organ Toxicity Aspiration Toxicity Flammables Pyrophorics Self-Heating Emits Flammable Gas Self-Reactives Organic Peroxides Irritant (skin and eye) Skin Sensitizer Acute Toxicity (harmful) Narcotic Effects Respiratory Tract Irritant Hazardous to Ozone Layer (Non Mandatory) Gas Cylinder Corrosion Exploding Bomb Gases under Pressure Flame over Circle Skin Corrosion/ burns Eye Damage Corrosive to Metals Environment (Non Mandatory) Explosives Self-Reactives Organic Peroxides Skull and Crossbones Oxidizers Aquatic Toxicity Acute Toxicity (fatal or toxic) Source: For more specific information about the new HCS, the reader is directed to the OSHA website at Guidelines for Safe Work Practices in Human and Animal Medical Diagnostic Laboratories Published in 2012 by the CDC, the Guidelines for Safe Work Practices in Human and Animal Medical Diagnostic Laboratories 2 updates the safety practices of the diagnostic medical laboratory based on the latest scientific knowledge. A panel of experts from a variety of laboratory agencies, organizations, and facilities developed this document. The recommendations cover all sections of the clinical laboratory (microbiology, chemistry, hematology, pathology) and animal diagnostic laboratories. This commentary will focus mainly on the recommendations for the most common sections found in physicians office laboratories. The purpose of this new set of recommendations was not to replace existing biosafety guidelines but to improve the safety of activities in diagnostic clinical laboratories and to raise laboratory workers awareness of safety issues. Another purpose of the document was to encourage laboratorians to create

4 and foster a culture of safety in their laboratories. The document describes a culture of safety as an environment in which laboratory safety becomes an integral and obvious priority to the total organization, starting at the top. The laboratory manager must direct employees to identify potential hazards in the workplace and devise methods to minimize or eliminate these risks. The safety climate requires a constant mindfulness of risk and prevention and the participation of all employees. Routes of exposure The primary routes of exposure to laboratory-associated infections (LAIs) are as follows: Percutaneous injuries with needles or other contaminated sharps Spills and splashes onto skin or mucous membranes Ingestion or exposure through contact with an open wound or touching mouth or eyes with fingers or other contaminated objects Inhalation of infectious aerosols The first three routes are fairly easy to detect but they account for less than 20% of all reported LAIs. 3 A recent report found that a specific event causing an LAI was apparent in only 50% of cases, suggesting unsuspected infectious aerosols can play a large role in LAIs. 4 One study reported that the most frequent causes of injury leading to exposures in the chemistry laboratory were needlesticks, acid or alkali spills, glass cuts, splashes in the eye, and bruises and cuts. 5 In the hematology laboratory, the most likely causes of exposures are needle punctures, aerosols from centrifuges or removal of tube stoppers, tube breakage, and contaminated gloves. In non-microbiology areas of the laboratory, the primary mistake may be assuming that a specimen does not contain infectious agents and then working without attention to risk. It is imperative to remember the concept of universal or standard precautions that states that all samples should be treated as potentially infectious. Risk Assessment The CDC recommends that every facility conduct its own risk assessment to determine hazards in the workplace and develop ways to reduce or eliminate the risk. The process of risk assessment is shown in Figure 1. Identifying potential biologic hazards in the laboratory is the first step in risk assessment. Information may be gathered from a variety of sources, such as walkabouts, benchmarking, interviews, detailed inspections, incident reviews, and facility design. Interventions or controls to eliminate or reduce risk may be engineering controls, safe work practices, or use of personal protective equipment. Although risk assessment is mainly the responsibility of the laboratory manager, all employees should be encouraged to participate in the process to create a greater awareness. The CDC document contains several charts, checklists, and examples to help explain and simplify the process.

5 Figure 1. Risk assessment for biologic hazards Source: Risks in the Chemistry Laboratory Below are a few examples of risks inherent to chemistry instruments. Others are listed in the CDC document. Most new instruments contain closed-system sampling devices that help decrease risk if used properly. Be aware of sampling probes or robotic arms that move quickly and could cause skin punctures; those that deliver fluid rapidly can cause aerosols. Always follow manufacturer s directions when operating instruments. Keep covers closed and safety shields in place when instruments are in operation, if possible. Always wear disposable gloves and use gauze pads with impermeable plastic coating on one side if operation of an instrument requires wiping sample probes after sampling. Fill sample cups and aliquot tubes using mechanical devices, such as transfer pipettes; never pour. Collect instrument waste into a waste container that contains fresh concentrated household bleach in sufficient quantity to achieve a final concentration of 10% bleach when the container is full.

6 Risks in the Hematology Laboratory A hematology instrument incurs the same types of risks as listed previously for chemistry instruments. The following are examples of other types of risk inherent in hematology: Microscope parts such as eyepieces, stage, and focus knobs that may become contaminated should be disinfected daily with a noncorrosive disinfectant. Avoid waving slides in the air or using electric fans to dry slides unless working under a biologic safety cabinet. Use plastic disposable Wintrobe tubes instead of glass capillary tubes for buffy coat smears to avoid cutting glass. Use plastic capillary tubes instead of glass for microhematocrit testing to avoid tube breakage in the hand. Use caution when using glass hemocytometers and glass cover slips to avoid punctures from broken glass. Plastic versions are available and reliable. Phlebotomy Risks Examples of risks specific to phlebotomy are listed below. Evaluate, select, and use needlestick prevention devices that provide optimal protection against injuries. Those using the device should be involved in the selection, and re-evaluation should be done annually. Make sure sharps disposal containers are easily accessible in patient rooms and phlebotomy stations. They should be emptied promptly when three-fourths full. When patient specimens are transported from the phlebotomy station to another part of the laboratory, they should be placed in a secondary container that has a tight-fitting lid or is impermeable to spills. Ensure all infection control policies are adhered to with patients and in the phlebotomy area. Disinfect any item touched with used gloves with a 1:10 solution of bleach. Conclusion Guidelines for Safe Work Practices in Human and Animal Medical Diagnostic Laboratories is a lengthy document, and the above is only a brief summary. For more specific information about this recommendation, the reader is directed to the CDC website,

7 References 1. Department of Labor, Occupational Safety and Health Administration. Hazard Communication, Final Rule. Federal Register. 29 CFR, Parts 1910, , Centers for Disease Control and Prevention. Guidelines for safe work practices in human and animal medical diagnostic laboratories. MMWR Morb Mortal Wkly Rep. 2012;61(01): Collins CH. Laboratory-Acquired Infections: History, Incidence, Causes, and Prevention. 3rd ed. London: Butterworth-Heinemann, Ltd; Harding AL, Byers KB. Epidemiology of laboratory-associated infections. In: Fleming DO, Hunt DL, eds. Biological Safety: Principles and Practices. 3rd ed. Washington, DC: ASM Press; 2000: Pragay DA, Howard SF, Gill ES. Clinical laboratory accidents and some recommended remedies. Clin Chem. 1980;26: ASCP 2012