This article is the second of a two-part series discussing current strategies for ensuring Occupational Safety and Health Administration (OSHA) compliance in the healthcare environment. This second article focuses on hazards in patient care areas including bloodborne pathogens, personal protective equipment, and ergonomics and safe patient handling.

Ensuring OSHA compliance in a hospital setting is complex and can be a daunting task.  This is largely due to the wide range of activities and work environment settings within hospitals.  But there are other reasons including the constant need to do more with less, prescriptive training and record-keeping requirements, and difficulty in integrating compliance into routine work.  In addition to ensuring employee and patient safety and well-being, maintaining OSHA compliance is vital to lowering worker’s compensation costs and reducing risks to hospital brand.

When Might You See OSHA in Your Hospital?

An OSHA inspector may visit your hospital for several reasons.  The most common reason today is a Programmed (i.e., Planned) Inspection, which accounts for over 60% of all inspections. Typical triggers of a Programmed Inspection are high injury and illness statistics on OSHA 300 logs (either for the whole sector or by employer within a sector), a specific event, or when a specific hazard is targeted.  OSHA may also inspect your hospital in response to a complaint (usually filed by an employee) or more commonly as part of a construction contractor investigation.  You can minimize the risk of an OSHA inspection by paying careful attention to the requirements for recordable injuries and illness. First, ensure you’re not over-reporting (or under-reporting) by including non-reportable incidents in your logs, and then compare your report to industry norms.  If your averages are higher than the national average, then you should proactively investigate and put in place a plan for improvement. Though ergonomic injuries can be a major contributor to recordable injuries and illnesses, there are several other important classes of injuries that you must determine through careful analysis of your injury and illness logs to improve your rates. A careful analysis of your injury and illness rates and characteristics often yields several trends that can be followed up on.

OSHA has begun a more targeted and aggressive enforcement according to an April 22, 2010, OSHA press release, “For many employers, investing in job safety only happens when they have adequate incentives to comply with OSHA requirements. Higher penalties and more aggressive, targeted enforcement will provide a greater deterrent…” It’s important for your hospital to understand where your OSHA vulnerabilities lie to assure you address those vulnerabilities. The table below illustrates the top OSHA citations by number of citations.

OSHA Top Hospital Violations in 2009
OSHA Standard	# Cited
Bloodborne pathogens	79
Electrical safety	49
The control of hazardous energy (lockout/tagout)	22
Respiratory protection	19
Forms	18
Maintenance, safeguards, and operational features for exit routes	14
Personal protective equipment	14
Permit-required confined spaces	14
Hazard communication	13
Walking / Working Surfaces (Fall Protection)	12
Asbestos	10

Common Hazards in Patient Care Areas 

Bloodborne Pathogens Standard and Needlestick Safety and Prevention Act

Bloodborne pathogens (BBP) was the most frequently cited standard in hospitals for fiscal year 2009. The standard applies to all employees with occupational exposure to blood or other potentially infectious material (OPIM), including body fluids mixed with blood, pleural fluid, saliva, etc. Some of the core requirements of the Bloodborne Pathogens standard are:

• Exposure Control Plan
• Engineering controls and “safer medical devices”
• Waste handling and containment
• Hazard communication and training
• Hepatitis B vaccine
• Exposure response and follow-up
• Record-keeping and Sharps Injury Log

The following are some of the most common violations under the Bloodborne Pathogens Standard.

Exposure Control Plan - Review and update your written Exposure Control Plan annually.

Hazard Communication and Training – Training must be conducted annually and documented. Review your training program to ensure it is of high quality and incorporates input from staff on hazards and risks. Verify that documentation is complete and readily accessible.

Waste Handling and Storage - Waste containment is a more visible area of compliance and violations will be easily spotted by an OSHA inspector. Ensure you have the proper labels / signage, access to waste containers is not blocked, infectious waste bags are inside containers, and containers are not over-flowing.  Also keep in mind that several states have additional regulations pertaining to management and disposal of biological waste and sharps.

Sharps Injuries – You must have a procedure for implementing and evaluating (product review, trial period) safer medical devices, including a mechanism for gathering employee feedback which is key to minimizing risks.  The Needlestick Safety and Prevention Act also requires that you establish and maintain a sharps injury log for recording percutaneous injuries from contaminated sharps. The Sharps Log must contain, at a minimum, information about the injury, the type and brand of device involved in the injury (if known), the department or work area where the exposure occurred, and an explanation of how the incident occurred. The log must be recorded and maintained in such a manner so as to protect the confidentiality of the injured employee (e.g., removal of personal identifiers).

When an injury does occur, the proper documentation must be completed in accordance with the Bloodborne Pathogen Standard requirements.   For performance improvement and program development, ensure that you are collecting enough data that will allow you to track and trend injuries.    For example, if your data reveals that you have many injury prevention features yet there are still a high number of injuries, this could indicate a lack of training or insufficient review of the technology.

Personal Protective Equipment (PPE) - Hospitals are required to establish clear criteria for the use of PPE and provide staff training on recognizing risks. Additionally, you are required to provide appropriate PPE that is accessible to staff within a reasonable distance.

To assess compliance, managers should conduct inspections to verify that appropriate types and sizes of PPE are being stored and are accessible.  Interview staff to determine if they can locate PPE.  If not, this could be an indicator that it is not being used. These exercises will also serve to promote a culture of safety within your organization.

Ergonomics and Safe Patient Handling

Ergonomics issues can be cited under the General Duty Clause. Before issuing a citation, OSHA will consider:

• Whether an ergonomic hazard exists.
• Whether that hazard is recognized.
• Whether the hazard is causing, or is likely to cause, serious physical harm to employees.
• Whether a feasible means exists to reduce the hazard.

OSHA has proposed adding a separate column on the OSHA 300 log for employers to record work-related musculoskeletal disorders (MSDs). The proposed rule will not change existing requirements for when and under what circumstances employers must record musculoskeletal injuries on their injury and illness logs, but it will better highlight the data. It is possible that this move could be a prelude to new ergonomics rulemaking and increased enforcement.

An effective ergonomics program includes:

Hazards in the Clinical Laboratory Environment

Formaldehyde

OSHA has prescriptive requirements for labeling and this is a common vulnerability for many hospitals. Labels must include the chemical name, hazard warning, and must state “Caution: Cancer Causing Agent”. Labeling the outside of a storage cabinet is not sufficient; the container itself must be labeled.

Hospitals are required to conduct monitoring for employee exposure to formaldehyde for specific exposure limits (permissible exposure limit and short-term exposure limit). This includes employees in clinical and pathology laboratories. Often, employers will not monitor “all” of the procedures required by OSHA. Specifically, ensure that “waste dumping procedures” have appropriate exposure determination and monitoring data. 

Training is required annually for anyone working with a certain concentration of formaldehyde or with a certain exposure to formaldehyde.

Hazardous Spill Response

Any employee responsible for responding to a hazardous spill must have specialized training. Hospitals must provide spill kits and appropriate PPE including respirators. Often, hospitals seem to be vulnerable in training requirements and written procedures for chemical spill response.

Medical and First Aid – Eye Washes

Inspections should be conducted routinely to verify that eye washes are available and accessible (not blocked or covered).  Also ensure that eyewashes are in close proximity (e.g., within about 10 seconds) from where injurious chemicals are stored and used.

Compliance Strategies

We recommend a hazard and risk assessment as the first step toward ensuring OSHA compliance for hazards in patient care areas. Don’t assume that your Environmental Rounds (Hazard Surveillance) will spot these types of issues – dedicate a separate survey that involves hospital personnel who perform both typical and high hazard tasks.  Based on our experience conducting OSHA compliance gap analyses for hospitals, we recommend the following to ensure OSHA compliance:

• Review your training programs carefully.  They should be of high quality and contain input from staff on site-specific conditions and hazards.  Ensure training records are complete and current, since this is the first thing an OSHA inspector will review.
• Many standards have very prescriptive requirements for written policies. Ensure the necessary policies in your hospital are in place and current.
• Ensure you have a system of defined responsibilities in place to maintain compliance.  Almost invariably, when programs do not have “program owners” there are lapses in safety and/or compliance.
• Don’t depend on occasional hazard assessments to point out deficiencies, but rather put this responsibility in the hands of several people who have operational responsibilities. Ask for regular reports from these people (with metrics if applicable).
• Assure you use topical experts when developing safety procedures.

OSHA compliance can often be a problem in hospitals because of the wide range of activities taking place across many departments.  A dedicated effort is often necessary to ensure continuous compliance, but the effort can help prevent a serious injury, reduce workers’ compensation costs, and reduce risk to brand name.  Fortunately, many of the review and improvement mechanisms already exist in hospitals to ensure Joint Commission compliance, and with a little additional effort and a trained eye they can be applied to ensuring OSHA compliance as well. 

Achieving a safer workplace and OSHA compliance may seem like a formidable task, but if tackled methodically using the results of the hazard and risk assessment it is very doable. The high cost of employee injury and illnesses, non-compliance, and staff and patient well being is more than worth the effort to improve safety performance. 

Bryan Connors, M.S., C.I.H., H.E.M., is a Senior Scientist / Healthcare Practice Leader at EH&E. He has extensive program management experience in environmental health and safety programs in the healthcare and biotechnology sectors, including nearly 10 years of direct program management responsibilities in several tertiary care hospitals. For more information, contact Bryan at bconnors@eheinc.com.

Gena Koufos, M.S., RN, is a Staff Scientist at EH&E. Gena has worked with a variety of clients and hospitals as part of the Healthcare Group at EH&E. She has been involved in projects related to Joint Commission compliance, development of a hospital-wide hazardous drug and safety program, as well as OSHA and state Department of Public Health (DPH) program assessment and compliance assistance. For more information contact Gena at gkoufos@eheinc.com.