Chapter 2 Safety in the Clinical Chemistry Laboratory PDF

28 Chapter 2 Safety in the CliniCal ChemiStry laboratory INTRODUCTION ? TABLE 2-2 Relevant OSHA standards, includin...

28 Chapter 2 Safety in the CliniCal ChemiStry laboratory INTRODUCTION ? TABLE 2-2 Relevant OSHA standards, including their respective parts and titles, for clinical Safe laboratory practices are the responsibility of everyone who laboratories. enters the facility. Knowledge and common sense are important to ensuring that accidents are kept to a minimum. All laboratory staff 1910.94 Ventilation should develop an appreciation for safety because working safely 1910.101 Compressed gases is as much an attitude asit is a practice. 1910.120 Hazardous waste operations and emergency response (hazardous materials or haZmat teams) LABORATORY SAFETY 1910.134 Respiratory protection 1910 subpt L Fire protection There are several organizations actively involved in providing a 1910.157 Portable fire extinguishers safe environment for laboratory personnel. Examples of these 1910 subpt S Electrical organizations include state, federal, professional, and accrediting 1910.1030 Bloodborne pathogens agencies. Specific examples arelisted in Table 2-1 ?. 1910.1048 Formaldehyde 1910.1096 Ionizing radiation OCCUPATIONAL SAFETY AND 1910.1200 Hazard communication HEALTH ADMINISTRATION 1910.1450 Occupational exposure to hazardous chemicals in laboratories The Occupational Safety and Health Administration (OSHA) is 1910 subpt. Z Toxic and chemical hazards afederal agency within the Department of Labor that was created by Congress through Public Law 91-596 in 1970 and provides federally mandated policies and procedures to ensure safety in the workplace, including laboratories and health-care facilities. OSHA standards are Hazard Communication(29 CFR 1910.1200 for laboratories), found in the Code of Federal Regulations (CFR). The standard whichincludes Rightto Know, OSHA poster 2203, and safety most associated with clinical laboratories is identified as Standard 29 data sheets. In 1988 OSHA expanded this regulation to include CFR. This standard is divided into several sections that are identi-fied hospital workers. using a part number with a title (e.g., part number 1910.1450, Bloodborne Pathogens (29 CFR 1910.1030), published in 1991. titled Occupational Exposure to Hazardous Chemicals in Labora-tories1). OSHA issued the Bloodborne Pathogens Standard to protect work-ers Alist of clinically relevant sections and their respective part from this risk. numbers is shown in Table 2-2 ?. Detailed information for each part In 2001, in response to the Needlestick Safety and Prevention may be found in the Federal Register, Document 29 CFR. Act, OSHA revised Bloodborne pathogens, 29 CFR1910.1030, Four major OSHA standards have made a significant impact to include needlestick safety. on the safety practices in clinical laboratories: Occupational Exposureto Hazardous Chemicalsin Laboratories,29 CFR 1910.1450. ChECkpoInt! 2-1 Which Code of Federal Regulations (CFR) may assist ? TABLE 2-1 Organizations actively involved in a laboratory supervisor in developing a policy for the providing safety standards, guidelines, education, proper handling of patient specimens? and procedures for clinical laboratories. AACC American Association for Clinical Chemistry ASCP American Society for Clinical Pathology CAP College of American Pathologists CHEMICAL SAFETY CDC Centers for Disease Control and Prevention Chemical safety awareness is of paramount importance in the CLSI Clinical and Laboratory Standards Institute clinical laboratory. The CLS mayhandle several different types of DNV Det Norske Veritas (Hospital Accreditation chemicalsin a working day. Therefore, knowledge of the com-pounds, Organization) their associated hazards, and their proper handling is very EPA Environmental Protection Agency important in reducingthe extent of injury in caseof an accidental NFPA National Fire Protection Agency exposure. NIOSH National Institute for Occupational Safety and Health Chemical Hygiene Plan OSHA Occupational Safety and Health Administration OSHA mandated that each laboratory establish a chemical TJC The Joint Commission (formerly JCAHO, Joint Commission on Accreditation of Healthcare hygiene plan.2 This plan is designed to provide laboratory staff Organizations) withinformation necessary to safely handlechemicals.Severalspe-cific U.S. NRC United States Nuclear Regulatory Commission elements included in the chemical hygiene plan are listed in Box 2-1  Chapter 2 Safety in the CliniCal ChemiStry laboratory 29 body tissues also requires that the affected body tissue be flushed BOx 2-1 Specific Elements Included in the with water using a faucet or shower, after which a physician should OSHA Chemical Hygiene Plan evaluate the victim. Flushing should also last for at least 15 minutes. Chemical spills occur in laboratories and should be approached Glossary of terms with care. Laboratory staff should be properly trained to respond A description of standard operating procedures in a safe manner. Every laboratory staff should have knowledge of Aninventory of all chemicals the chemicals being used, available resources, first aid procedures, Safety data sheets (SDSs) and the proper steps to assess the impact of a spill. Proper labeling and storage of chemicals Appropriate response to a chemical spill is dictated by the size Aninventory of personal protective equipment (PPE) of the spill. A small spill is typically described as a spill of less than A description of engineering controls ~30 mL(~1.0 oz), of toxic material,or upto ~3.8 L(~1 gal) of low-toxicity chemical. Large chemical spills are defined as spills Procedures for waste removal and disposal greater than one gallon or 20 to 30 mL of a chemical that is highly Requirements for employees physical and medical hazardous. Once the size of a spill is determined, the appropriate consultations response must beinitiated. Training requirements Small chemical spills can be managed bylaboratory staff. The Procedures for proper record keeping safety data sheets (described below) should be available and knowl-edge Designation of a chemical hygiene officer and safety of chemical National Fire Protection Association (NFPA committee 704-M) labels may be helpful. All laboratories should have a chemi-cal spill kit available. A commercial kit for most types of spills is available and is shown in Figure 2-2. All-purpose absorbents, for Operating Procedures example, kitty litter, vermiculite, and sand, are also useful. These materials are useful to form a dike to contain the spill. Before Specific operating protocols should be developed for proper dispo-sition cleaning up the spill, remember to wear appropriate personal of accidents in laboratories involving chemical spills. Acci-dents protective equipment (PPE). As a minimum, this includes gloves that involve chemicals splashed into the eyes require that the and protective eyewear. eyes be flushed immediately with copious amounts of water from Depending on the size and type of spill, protective clothing, an eyewash station, shown in Figure 2-1. The eyewash station protective foot covering, and a respirator may be needed. Pick up should be plumbed to a continuous source of water (60100F) any broken glass with tongs or some other mechanical device. Do and be handicapped accessible. Maintenance of eyewash devices not use your hands. Place absorbent material over the spill, making should include periodic flushing to ensure sufficient flow of water sure not to spread the liquid. Transfer all contaminated material and to minimize bacterial growth in the lines that could lead to eye into a plastic bag. Label the bag with the name of the hazardous infections. When chemicals, especially corrosives, are splashed into material. Finally, contact the appropriate hazardous spill team or the eyes, they should be rinsed for 15 minutes continuously and emergency health team. The incident should be documented, first without interruption using the eyewash station or under a faucet aid issues addressed, and an analysis of the incident initiated to if an eyewash device is unavailable. Chemical exposure to other FIgURE 2-1 Eyewash station with dual jet eye washers. FIgURE 2-2 Chemical spill kit. (From Sunheimer RL, Graves, L, Stockwin W. Clinical Laboratory Urinalysis and (From Sunheimer RL, Graves, L, Stockwin W. Clinical Laboratory Urinalysis and Body Fluids, 1st ed. Upper Saddle River, NJ: Pearson Education, 2015) Body Fluids, 1st ed. Upper Saddle River, NJ: Pearson Education, 2015 30 Chapter 2 Safety in the CliniCal ChemiStry laboratory as 704-M Identification System,coversthe nine classesof hazard-ous MINI-CASE 2.1 materials, asfollows: Bill is performing a toxicology procedure that requires Explosives the sample to be extracted with a combination of sodium Compressed gases hydroxide and diethyl ether. He did not realize that the Flammable liquids chemical reaction in that mixture of reagent and patient sample would cause an increase in pressure. When he Flammablesolids removed the screw cap, the liquid mixture was propelled Oxidizer materials into the atmosphere because of the pressure buildup. Bill Toxic materials experienced severe irritation to both eyes that required immediate attention. Radioactive materials 1. What did Bill do wrong? Corrosive materials Miscellaneous materials not classified by any other means Materials are identified using four small, diamond-shaped assess the appropriateness of the response and measures to pre-vent symbols grouped into alarge diamond shape, as shown in reoccurrence. Figure 2-3. The smaller diamonds are color coded to represent The response for a large chemical spill requires a higher level a specific health hazard, as shown in Table 2-3 ?. The degree of of expertise and coordination of the departments within an insti-tution. hazard is rated using a scale of 0 to 4, with 4 indicating the most Alarge chemical spill typically requires evacuation of the serious risk. Chemical labels on the original containers must not be area. The doors to the affected room should be closed to contain removed or defaced. For chemicals not in their original container, the vapors or gases. Appropriate notification of external response the labeling information should include the following: crews depends on the nature and size of the chemical spill. For example, a spill may require a response from the fire department, Identification of the hazardous chemical hazardous material (HAZMAT) team, or an institutional safety Route of body entry department. Be prepared to provide the responding teams with Health hazard the necessary information about the spill (e.g., name of chemical(s) Physical hazard and approximate quantity of material spilled). Finally, do not reen-ter the area until advised by an appropriate authority that it is safe Target organ(s) affected to return. Policies for avoiding unnecessary chemical exposure must be defined. Activities such as smoking, eating, drinking, and apply-ing cosmetics must be prohibited in all workstations. Wearing of proper footwear must be enforced. No sandals, canvas shoes, or any open-toed footwear should be allowed. Staff with long hair or loose clothing and jewelry should be reminded that these items must be secured. Contact lenses should not be worn in the labora-tory because they prevent proper washing of the eyes in case of a chemical splash. Also, plastic contact lenses may be damaged by organic vapors, which may lead to chronic eye infections. Hand-washing after handling chemicals and before leaving the laboratory should be emphasized. Safety data sheets (SDSs) are documents that provide information about chemical substances. They consist of several sectionsincluding identification, composition, hazards, first aid, firefighting concerns, and safe handlingthat are relevant to the chemical being used. SDSs must be obtained for all chemicals and FIgURE 2-3 NFPA 704-M identification system must be located in an area that is available to all laboratory person-nel using diamond-shaped symbol. at any time. The format of the SDS has been standardized by the American National Standards Institute (ANSI), which makes the document easier to interpret.2 ChECkpoInt! 2-2 The container for a chemical received in the clinical lab-oratory Identifying and Labeling Chemicals reveals a symbol with a capital letter W with a Proper labeling of chemicals is described in OSHA regulation 29 line drawn through it in the white diamond of the NFPA CFR 1910.1450. The actual labeling system used is adopted from 704-m identification designation. Whatinformation does the hazard identification system developed by the National Fire this disclose to the laboratory staff Protection Agency (NFPA).3 This identification system, referred to  Chapter 2 Safety in the CliniCal ChemiStry laboratory 31 ? TABLE 2-3 NFPA 704-M identification system of BOx 2-2 Examples of Poor Chemical warning labels for chemical hazards. Storage Practice Color Codes Interpretations Chemicals are stored in random order BlueHealth Hazard 4deadly Chemicals are stored in alphabetical order 3extreme danger 2hazardous Chemicals are stored by poorly chosen categories 1slightly hazardous Chemicals are stored in a hood while the hood is in use 0normal material for other purposes RedFire Hazard Flammables are stored in domestic or household-type Flash points 4below 73F refrigerators 3below 100F Food is stored beside chemicals in the refrigerator 2below 200F Chemicals are stored on shelves above eye level 1above 200F One bottle of a chemical is sitting on top of a second 0will not burn bottle of the chemical yellowreactivity 4may detonate Shelves are overcrowded 3shock and heat may detonate Shelving on which chemicals are stored is not strong 2violent chemical change enough to support chemicals 1unstable if heated Shelves are not securely fastened to a permanent 0stable structure WhiteSpecific Hazard Oxidizer oXy Corrosive COR Inventory control is poor or nonexistent Acid ACID There are containers with no labels or inappropriate Alkali ALK labels Use no water Containers are stored on the floor Radiation Caps on containers are missing, not on properly, or badly deteriorated Storage and Chemical Inventory Box 2-2. Examples of problems with storing chemicals alphabeti-cally A chemical inventory should be conducted on an annual basis. An are shown in Table 2-4 ?.4 accuratelisting of all chemicalsand their hazardsshould beavail-able Categorical storage of chemicals is a safe approach for sepa-rating at all times. During the inventory process, the technologist potentially reactive chemicals. Eachchemical mustbe stored should pay particular attention to the following: in its respective hazardouscategory. For example,inorganic acids Keep only the amount of chemicals that is needed. Less is better. such as hydrochloric acid (HCl) and sulfuric acid (H2SO4) should bestored asa group and should not bestored with caustic bases, If possible, purchase chemicals in plastic containers to avoid such as sodium hydroxide (NaOH) and ammonium hydroxide breaking glass. (NH4OH). Chemicals classified as oxidizing compounds, such as Rotate your chemical inventory and note expiration dates. potassiumdichromateandsilver nitrate,can bestoredtogether but Dispose of chemicalsif not used within a yearespecially away from other compounds. Chemical compatibility charts are peroxide-forming compounds. available that outline general classes of incompatible chemicals.4 Make sure all secondary containers are properly labeled. Flammablechemicals mustbestoredin an appropriate safety cabinet (see section Safety Cabinets, below) and should not be If possible, relocate corrosive, flammable, and reactive chemi-cals mixedin with other classes of compounds. Volatile or flammable to below eye level. liquids should neverbestoredin refrigeratorsthat are not designed Proper storage of hazardous materialsin the laboratory is very to accommodate hazardsthe solvents maycreate. If the laboratory important. Several examples of poor storage practices are shown in has corrosive or flammable chemicals that require refrigeration, ? TABLE 2-4 Problems associated with storing chemicals alphabetically. Chemical Combinations Problems Acetic acid + acetaldehyde Small amounts of acetic acid will cause the acetaldehyde to polymerize, releasing a large amount of heat Ammonium nitrate + aceticacid mixture will ignite, especially if an acid is concentrated Hydrogen peroxide + ferrous sulfide Vigorous reaction, highly exothermic Lead perchlorate + methanol Explosive mixture if agitated Potassiumcyanide + potassium nitrite Potentially explosive mixture if heated 32 Chapter 2 Safety in the CliniCal ChemiStry laboratory lead azide, are primary high explosives that may detonate when MINI-CASE 2-2 heated or shaken. Heavy-metal azides are formed when solutions or reagents containing sodium azide are exposed to heavy metals Brenda, a CLS working in the chemistry laboratory, was or their salts. Heavy-metal azides can accumulate under certain asked to clean out a closet storage area where chemicals circumstances, for example, in metal pipelines, and thus lead to vio-lent had been stored and came upon a bottle of concentrated explosions. Anhydrous and monohydrate perchloric acid are hydrochloric acid. note: this mini-Case will require the explosive, but the usual aqueous solutions are stable in the absence reader to search for the information online (Internet) and/ of organic compounds. The crystalline form of the acid, which is or in appropriate reference books. Here are sources to explosive and shock sensitive, can precipitate on a hood surface. assist you in your search: https://www.msdsonline.com Information regarding the explosive nature of chemicals may be and https://www.osha.gov. found in their accompanying SDS. 1. What are the nfpa 704-m placard designations for concentrated hydrochloric acid? Include health haz-ard, Cryogenic Material fire/flammability, reactivity, and special hazard. Cryogenic liquids (cryogens) are liquefied gases that are kept in 2. What is the physical appearance of the concentrated their liquid stateat verylow temperatures. The wordcryogenicmeans hydrochloric acid? producing, or related to, low temperatures, and all cryogenic 3. Where can you look for information regarding the liquids are extremely cold. Cryogenic liquids have boiling points safety issues for concentrated hydrochloric acid? below -150C (-238F). Carbondioxideand nitrous oxide, which 4. What important information about concentrated have slightly higher boiling points, are sometimes included in this hydrochloric acid should be the focus for Brenda? category. All cryogenic liquids are gases at normal temperatures 5. What specific steps should be taken to properly han-dle, and pressures. These gases must be cooled below room tempera-ture use, and dispose of this bottle of concentrated before an increase in pressure can liquefy them. Various cryo-gens hydrochloric acid? become liquids under different conditions of temperature and pressure, but all have two properties in common: (1) They are extremely cold and (2) small amounts of liquid can expand into very large volumes of gas. there areseveral manufacturers that distribute explosion-proof and The vapors and gases released from cryogenic liquids also corrosion-proof refrigerators. These units are designed to comply remain very cold. They often condense the moisture in air, creat-ing with NFPA and OSHA specifications. a highly visible fog. In poorly insulated containers, some cryo-genic Transferring chemicals from one container to another can liquids actually condense the surrounding area, forming a result in an accident or overexposure. Therefore, care must be liquid-air mixture. Cryogenic liquids are classified as compressed taken to avoid these situations. A bottle should never be held by gases according North American Industrial Classification System its neck, butinstead should be grippedfirmly aroundits body with (NAICS) 325120, which replaced the Standard Industrial Classi-fication one or both hands, depending on the size of the bottle. Acids must Code 2813. Everyone who works with cryogenic liquids be diluted slowly by adding them to water while mixing. Never must be aware of their hazards and know how to handle them add waterto a concentratedacid. Transferringvolatile orflamma-ble safely. chemicals should be carried outin an OSHA-approved fume Cryogenic liquids such asliquid nitrogen, helium, and oxygen hood. Also, safety glasses should be worn whenever transferring are, by definition, extremely cold. Contact of exposed skin to cryo-genic chemicalsfrom one container to another. Acids,caustic materi-als, liquids can produce a painful burn. A splash of cryogenic and strong oxidizing agents should be mixedin the sink. This liquid in the eye can cause loss of vision. Whenever handling cryo-genic provides waterfor cooling and confinement of the reagent in case liquids, always wear proper personal protective equipment, of a spill. including alab coat that is buttoned, heavy gloves, and a face shield Transporting chemicals throughout the laboratory can be haz-ardous. or safety goggles. Hazards associated with cryogens include the For safe transport of any chemical, placeit in a secondary following: container. Chemicalsin glassbottlesshould betransported in rub-ber or plastic containers that protect them from breakage and, in Fire or explosion the event of breakage, help to contain the spill. Usea cart to move Asphyxiation heavycontainersor multiplenumbers of containersfrom onearea Pressure buildup of the laboratory to another. Embrittlement of material Potentially Explosive Compounds Tissue damage Laboratory staff must be aware of any chemicals that have the potentialto explode or detonate. Anexplosivechemicalis a chemi-cal Formaldehyde that causes a sudden release of pressure, gas, or heat when Formaldehyde (formalin) is a colorless liquid with a characteristic subjected to shock, pressure, or high temperatures. Dried picric pungent odor and is routinely used in laboratories for tissue pro-cessing. acid mayexplodeif its container is dropped. Azides,specifically The primary deleterious health effects of formaldehyd  Chapter 2 Safety in the CliniCal ChemiStry laboratory 33 exposure are respiratory cancer, dermatitis, sensory irritation (eye, ChECkpoInt! 2-3 nose, and throat), and sensitization. In addition to inhalation haz-ards, solutions of formaldehyde can damage skin and eye tissue Charlotte, a CLS, began organizing the chemical storage immediately on contact. OSHA and specific state guidelines have area and was placing the chemicals in alphabetical order. been established to assist laboratories in handling and disposing She placed a container of acetic acid next to a container of this chemical. of ammonium nitrate. 1. What recommendation would you make to Charlotte Safety Cabinets for a safer method to store these chemicals? Limit the amount of flammable materials that you need to store. 2. What reason would you provide as a rationale for not OSHA defines the maximum amount of flammable and com-bustible storing acetic acid next to ammonium nitrate? liquids that can be stored in any laboratory with NFPA-approved flammable storage cabinets. These limits may be modified by local fire departments. The regulations are defined by the solvents classification. The classification of flammable sol-vents MINI-CASE 2-3 is defined in terms of flash points, with Class IA and IB solvents being the most combustible. Large amounts of volatile Tom was transferring a serum sample using a 5.0 mL volu-metric solvents must be stored in a safety cabinet that is approved by glass pipette to a 250 mL glass volumetric flask NFPA and meets OSHA standards. The cabinet should be properly containing 6N nitric acid. When Tom was finished, he vented, and the use of self-closing doors is encouraged. inadvertently left the glass pipette in the flask. Afew min-utes later, as Tom turned and reached for another flask, he Chemical Waste struck the glass pipette, which caused the flask to tip over, spilling the solution onto the bench, floor, his shoes, lab Disposal of chemical waste is the responsibility of individual lab-oratories. coat, and pants. Tom was wearing alab coat, unbuttoned, The responsibility and liability start when the original with no eyewear, and he was using a pipetting bulb to chemical is brought into or madein the laboratory and continues aspirate the serum sample. until the waste has been completely destroyed. The Resource Con-servation 1. Identify safety practices Tom chose to ignore. and Recovery Act (RCRA), passed by Congress in 1976, dictates this cradle-to-grave responsibility and liability. It estab-lished 2. What is the appropriate course of action for Tom to a system for managing nonhazardous and hazardous solid follow in response to the chemical spill? wastes in an environmentally sound manner. Specifically, it pro-vides for the management of hazardous wastes from the point of origin to the point of final disposal. RCRA also promotes resource recovery and waste minimization.5 In addition, each laboratory BIOHAZARDS: UNIVERSAL must comply with all local, state Department of Environmental PRECAUTIONS Conservation (DEC), and U.S. Environmental Protection Agency Exposure-Control Plan (EPA) mandates.6 OSHA requires all laboratories to develop and implement an Laboratories are identified by RCRA as waste generators exposure-control plan.7 This plan is designed to help prevent and thereby require a permit for proper waste disposal. Labo-ratories accidental exposure of laboratory personnel to bloodborne patho-gens. are considered small-quantity waste generators and are Bloodborne pathogens are pathogenic microorganisms that therefore governed by the policies and procedures appropriate are present in human blood and can cause disease in humans. These to the corresponding permit. Pouring chemicals down the sink pathogens include, but are not limited to, hepatitis B virus (HBV) drain should not be done without authorization from the labora-torys and human immunodeficiency virus (HIV). The exposure-control environmental health and safety officer. Any hazardous, plan also includes procedures for the proper handling and disposal corrosive, or flammable materials are prohibited from being dis-posed of all medical waste produced by the laboratory. The exposure-control of by pouring down sink drains. This includes chemicals plan should include sections on the following: (1) purpose, such as (2) scope, (3) references, (4) definition of terms, (5) delineation of Organic solvents with a boiling point of less than 50C responsibilities, and (6) detailed procedural steps. Hydrocarbons OSHA guidelines for this plan require that the employer place each employee into one of three groups, defined asfollows: Halogenated hydrocarbons GroupI: Ajob classification in which all employees face Nitro compounds occupational exposure to blood or other potentially infec-tious Mercaptan materials. Freon Group II: Ajob classification in which some employees face Azidesand peroxides occupational exposure to blood or other potentially infectious Concentrated acids and bases materials. Thejob description for this group represents dutie  34 Chapter 2 Safety in the CliniCal ChemiStry laboratory that put the employee at risk for possible exposure to human or weeping dermatitis should refrain from all direct patient care and blood or other potentially infectious materials. from handling patient-care equipment until the condition resolves. Group III: Ajob classification in which employees will not Pregnant health-care workers are not known to be at greater face any occupational exposure to blood or other potentially risk of contracting HIV infection than health-care workers who infectious materials. are not pregnant; however, if a health-care worker develops HIV infection during pregnancy, the infant is at risk of infec-tion Employees in groups I and II require OSHA bloodborne resulting from perinatal transmission. Because of this risk, pathogen training at the outset of their employment and annu-ally pregnant health-care workers should be especially familiar with thereafter. Also,these employees must be offered vaccination and strictly adhere to precautions to minimize the risk of HIV against hepatitis B within 10 working days of initial assignment to transmission.10 a position involving possible exposure. Group III employees do not require OSHA training. How-ever, if a group III employee assumes a job assignment that will Hand Hygiene Practices result in possible exposure to bloodborne pathogens, then he or Transmission of pathogens most often occurs via the contami-nated she must be offered the hepatitis vaccination and is required to hands of health-care workers. Accordingly, hand hygiene attend an OSHA training session before beginning job duties. (i.e., hand washing with soap and water or use of a waterless, alco-hol-based hand rub) has long been considered one of the most Biological Hazards important infection control measures for preventing the transmis-sion of infectious agents. Laboratory personnel must be aware of potential sources of The CDC recommends vigorous rubbing together of all lath-ered exposure to infectious agents such as HBV and HIV. Examples of surfaces for at least 15 seconds, followed by rinsing in a flow-ing exposure sources include the following: stream of water, as shown in Box 2-3.11 If hands are visibly Centrifuge accidents soiled, more time may be required. Hand hygiene is still necessary Needle punctures after gloves are removed because gloves may become perforated and bacteria can multiply rapidly on gloved hands. Spilling infectious material on bench surfaces Cuts and scratches from contaminated glassware Removing stoppers from blood drawing tubes BOx 2-3 Hand Hygiene Procedure Universal precautions* is a practice described by the Hand wash procedure Comments National Institute for Occupational Safety and Health (NIOSH) in which every clinical laboratory should treat all human blood 1. Turn on water faucet to Water that is too hot can and other potentially infectious materials as if they were known a cool temperature. affect skin integrity. to contain infectious agents such as HBV, HIV, and other blood-borne 2. Place hands under water. To aid soap activation. pathogens.8 Examples of infectious materialsinclude 3. Dispense one pump Excessive volume of soap blood, serum, plasma, blood products, vaginal secretions, semen, action volume of soap. product may cause drying cerebrospinal fluid, and synovial fluid. Universal precautions do of hands, and dry cracked not apply to feces, nasal secretion, saliva (except in dental set-tings), hands may harbor bacteria, sputum, sweat, tears, urine, and vomit unless it contains viruses, and fungi. visible blood. Hands and other skin surfaces should be washed 4. Rubbing briskly, wash The focus of good hand immediately and thoroughly if contaminated with blood or other all surfaces of hands, washing technique is to body fluids. Hands should be washed immediately after gloves including between initiate mechanical removal areremoved.9 fingers, for at least of dirt and microorganisms, Mouthpieces, resuscitation bags, and other ventilation devices 15 seconds. using friction and rinsing should be available for use in areas in which the need for resusci-tation under running water. is predictable to minimize the need for emergency mouth-to-mouth 5. Rinse thoroughly under To reduce skin irritation resuscitation, although saliva has not been implicated in running water. from soap residue HIV transmission. Health-care workers who have exudative lesions 6. Pat hands dry with paper towels, discard-ing * The CDC hasreplaced the term Universal Precautions with the terms standard the paper towels in precautionsand transmission-based precautionsfor health-care workers. The difference a waste container. between the three is shown below: 7. If using a hand-operated All faucet handles are con-sidered Universal precautions: for fluids liable to have blood or that are visibly faucet, use a contaminated. bloody dry paper towel to turn Standard precautions: for all body substances except sweat off the faucet. Transmission-based precautions: specific for new microbes  Chapter 2 Safety in the CliniCal ChemiStry laboratory 35 Individuals will wash their hands immediately or as soon as pos-sible after removal of gloves or other PPE and after hand con-tact with blood or other potentially infectious materials. Hands are to be washed between all patient contacts; before eat-ing, drinking, smoking, applying cosmetics or lip balm, manip-ulating contact lenses, and handling of personal devices (e.g., book bags and cell phones); and after using the restroom. Needlestick Regulations OSHA updated 29 CFR 1910.1030 to include the Needlestick Safety and Prevention Act,12, 13 which requires that needles used for withdrawing blood musthave a built-in safety feature or mechanism that effectively reduces the risk of an exposure inci-dent. All laboratories must provide the appropriate devices and monitortheir useas part of a quality-assuranceprogram. The Centers for Disease Control and Prevention (CDC) FIgURE 2-4 Personal protective equipment (PPE) reported that implementing the following measures might prevent including gloves, face shield, and safety goggles needlestickinjuries:14 with side shield. (From Sunheimer RL, Graves, L, Stockwin W. Clinical Laboratory Urinalysis and Usesafe and effective alternatives to needles. Body Fluids, 1st ed. Upper Saddle River, NJ: Pearson Education; 2015) Participate in the selection and evaluation of needle safety devices. Use only devices equipped with safety mechanisms. protein from the rubber tree or the chemicals used in the produc-tion Do notrecap needles. of latex. NIOSH has recommended that employers provide gloves with reduced protein content (e.g., latex-free and powder or Implement a plan that will ensure safe handling and disposal cornstarch-free gloves). Also, every employee should be provided of needles. with continuing education and training materialsabout latex aller-gies, Immediately dispose of used needles in the proper sharps dis-posal and high-risk employees should be periodically screened for containers. allergy symptoms. Communicate needlestick hazards to your employees. Gloves are also available to protect employees from expo-sure to chemicals (e.g., acids, bases, and solvents). Glove materials Participate in infection-control training. highly rated for handling acids and bases include nitrile, neoprene, and natural rubber. Nitrile and neoprene-based gloves are also very ChECkpoInt! 2-4 good for handling organic solvents. For guidance on proper selec-tion of gloves, refer to the MAPA Spontex, Inc. (Columbia, TN) What is the term that describes the following? Every clin-ical chemical resistance guide at the following website: http://www laboratory should treat all human blood and other.spontexusa.com. potentially infectious material as if they were known to contain infectious agents such a HBV, HIV, and other Eyewear bloodborne pathogens. Laboratory staff often do not properly protect their eyes while handling hazardous materials. Workers who wear glasses often feel safe and do not believe that additional eyewear is neces-sary. Personal Protective Equipment Conventional or prescription eyeglasses are not impervious to Personal protective equipment (PPE) is specialized clothing or chemicals, and therefore proper eyewear is recommended. Proper equipment worn by an employee for protection against a hazard. eyewear is described as glasses or goggles that provide protection General work clothes (e.g., uniforms, pants, shirts, or blouses) are to the sides of the face as well as the front. The lenses must also be not intended to function as protection against a hazard and are not impervious to chemicals. Another acceptable face-and-eye protec-tion considered to be personal protective equipment. Several examples device is the face shield. of PPE are shown in Figure 2-4. Respirators gloves Respirators are required for selected laboratory procedures. Most The routine use of gloves to protect laboratory staff against expo-sure notable is the handling of pathogenic microorganisms such as to bloodborne pathogens was mandated by OSHA in 1991.7 strains of Mycobacterium tuberculosis.15Respirators should contain As laboratory staff began wearing gloves on a daily basis for pro-longed high-efficiency particulate air (HEPA) filters if no other engi-neering periods of time, reports of skin sensitivities traceable to controls are available. Handling of certain chemicals the plastic gloves increased. Skin sensitivities may be due to either may require the use of a respirator. The SDS accompanying th  36 Chapter 2 Safety in the CliniCal ChemiStry laboratory chemical should indicate whether a respirator is required. Filtration lighter than glass and (2) plastics can be incinerated, thus reduc-ing respirators will require the use of one or two cartridges designed to waste downstream. Laboratory staff must remember that filter out hazardous chemical vapors. Strict adherence to all safety when switching to plasticware, especially blood collection tubes, recommendations is necessary when handling hazardous materials they must review the manufacturers instructions. requiring the use of any type of respirator. Laboratory Coats and Footwear ChECkpoInt! 2.5 Employers must provide proper laboratory coats to each employee. True or False: It is acceptable to wear comfortable sandals Characteristics of proper laboratory coats include the following: with exposed toes in a clinical laboratory. They must have cuffed sleeves and be full length. They should remain buttoned to avoid contaminating street clothes. Biosafety Levels The materialshould beresistantto liquids. The CDC and NationalInstitutes of Health(NIH) have developed The construction of lab coats resistant to liquids includes lay-ers criteria for handlinginfectious materials.Thesecriteria are classi-fied of polypropylene, spun bonded filaments, and meltblown into four biosafety levels: biosafety level 1 (BSL1) through polypropylene microfibers. BSL4.16 Table 2-5 ? provides a portion of the information con-tained in the referencecited. Knowledgeof BSLsis required when A spun bonded filament refers to the process of producing questions arise regarding proper useand functional parameters of filaments or webs from polypropylene and other organic sub-stances laboratory hoods. that will possess positive features such as restricting fluids from passing through. Meltblown polypropylene is a thermally Toxic Substances bonded ultrafine fiber that has been self-bonded and forms a three-dimensional random microporous structure. This material Toxic substances pose a potentially significant andlong-lasting risk is impervious to the passage of liquids through the fibers. to alllaboratory personnel.Chemicals in this group havethe poten-tial Laboratory staff should wear footwear that is comfortable to affect the offspring of female workers. Theterm xenobiotic and safe. The shoe material should be nonporous. No open-toed refers to a substance that is foreign to a living organism and is shoes, sandals, or flip-flops should be worn in the laboratory. usually harmful. Theroutes of entry for xenobiotic substances include the following: Engineered Controls Pulmonary An engineered control is defined as safety equipment that isolates Oral or removes the bloodborne pathogen hazard from the workplace Tra