WSH Council Healthcare Guidelines.pdf

Workplace Safety and Health GuidelinesHealthcare contents Foreword Introduction Managing Workplace Safety and Health in Healthcare 06 07 09 10 11 12 13 Workplace Safety and Health Policy Planning Implementation and Operation Recording and Reporting Occupational Injuries and Illnesses Investigation of Accidents, Occupational Illnesses and Incidents Checking and Corrective Action Management Review 53 54 56 61 63 64 69 77 40 44 47 50 30 31 32 33 35 Formaldehyde Solvents Mercury Natural Rubber Latex Biological and Infectious Hazards Infectious Diseases / Infectious Diseases Management Programme Bloodborne Pathogens Infectious Agents other than Bloodborne Pathogens Airborne Infections Infections Transmitted by Direct Contact Biological Matter Vegetable Matter Animal Proteins Physical Hazards Ergonomics Noise Vibration Ionising Radiation Non-ionising Radiation Sharps Specfic Hazards 16 19 20 26 28 Chemical Hazards Hazardous Chemical Management Programme Anaesthetic Waste Gases and Vapours Routes of Exposure and Sources of Leaks Sterilising and Disinfecting Agents Ethylene Oxide Colour Coding and Marking Protective Clothing and Equipment 125 Personal Protective Equipment (PPE) Programme 127 Respiratory Protection Programme Hazardous Waste Management 104 Types of Hazardous Waste Generated 105 Hazardous Waste Management Programme Facilities and General Safety Safety in Construction and Renovation 109 General / Material Handling and Storage / Welding and Cutting / Fire Safety / Electrical Safety Miscellaneous Emergency Response Planning 111 Emergency Response Plan 112 Fire 113 Chemical Spill or Leak 114 Pandemic Flu. Stress and Burnout Workplace Harassment and Violence Hazardous Drug Handling Details on Selected Work / Activity Area Maintenance of Facilities 118 Control of Hazardous Energy: Lockout / Tagout / Electrical Safety 119 Pressure Vessel Safety 120 Confined Spaces 122 Lighting 123 Signs. SARS and Emerging Infectious Diseases Indoor Air Quality (IAQ) and Ventilation 115 IAQ and Ventilation Management Programme 117 Safe Means of Access and Egress 128 First Aid Appendices 130 Appendix A – Occupational Diseases Reportable under Workplace Safety and Health Act and its Subsidiary Legislation 131 Appendix B – Examples of Infections and Routes of Transmission 132 Appendix C – Summary of Hazards in Healthcare by Location 136 Appendix D – Useful Links 137 Appendix E – Resources Acknowledgements .83 85 94 Psychosocial Hazards Shift Work and Overtime Work. For while we all readily identify with the aims of the WSHAC and recognise that healthcare professionals have an important role to play in reducing the unnecessary suffering and loss of lives among Singapore’s workforce. we have endeavoured to include the latest information available on the potential hazards and the best practices relating to their control and prevention. and healthcare work is no exception. We have also consulted local experts and key stakeholders and incorporated their useful comments and suggestions. Let us join hands to make every type of work in Singapore. Recognising that healthcare workers are exposed to a wide array of work-related safety and health risks. Our members represent the various healthcare institutions. We need workplace safety and health programmes in which workers and management take an active role. Indeed. Workplace Safety and Health Healthcare Advisory Sub-committee. industry-led Workplace Safety and Health Advisory Committee (WSHAC) deemed it necessary to establish. 5 (or 15. Of course. information alone is no substitute for putting knowledge into practice. We need personal discipline and commitment. professional bodies. safe and satisfying. Out of 238 reported cases of Severe Acute Respiratory Syndrome (SARS) in Singapore in 2003. since its inception in September 2005. The publication of this set of guidelines is part of our ongoing efforts to raise the awareness of Singapore’s healthcare workers to the myriad hazards they may be facing in their workplace. their dedication to the saving of others’ lives and the alleviation of others’ suffering may render healthcare workers particularly vulnerable to the dangers inherent in their work. As Chairman of the Healthcare Advisory Sub-committee and a member of the healthcare profession. academia and government. Workplace Safety and Health Advisory Committee March 2008 The WSHAC was stepped up to WSH Council with effect from 1 April 2008. the need to put our own house in order. the multisectoral. A/Prof Lim Meng Kin Chairman.8%) were healthcare professionals. In carefully compiling it. . 97 (or 40. We need to engender healthful habits and strong safety cultures. a Healthcare Advisory Sub-committee to spearhead efforts aimed at protecting and promoting workplace safety and health in Singapore’s burgeoning healthcare sector.workplace safety and health guidelines 3 Foreword Every type of work brings with it some safety or health concerns. Of the 33 who lost their lives. including our own. I consider these guidelines to be very timely. we realise too.2%) were healthcare workers. and productivity of healthcare workers. dental. The guidelines highlight common work hazards faced by healthcare workers and recommend best practices to control or prevent these hazards. kitchen. Together. the pace of work can be fast and the working hours long. laboratory. Bigger establishments have more functions. while smaller ones have specialised focus areas. and even death. The principles of safety and health management and information on the establishment of workplace safety and health programmes are also provided in the guidelines. wards. Providing a safe and healthy work environment will boost the wellbeing. There are many departments performing different functions within a healthcare facility. ranging from reception. To encourage and aid the workplace safety and health effort in the healthcare industry. central sterile supplies units. theatre sterile supply units. . In providing a high standard of service to patients. All these can be prevented. morale. Healthcare establishments can also be either government or privately owned. surgery. general medicine. absenteeism. let us work to establish a safe and healthy work environment for all healthcare workers. facility maintenance and medical records.4 healthcare Introduction In comparison to other industries. the healthcare industry is unique. Poor safety and health practices can contribute to illness. It is a professional industry that comprises both big establishments such as the major hospitals under the SingHealth and National Healthcare Group clusters as well as small and medium enterprises (SMEs) such as the general practitioners. radiography. productivity loss. the Workplace Safety and Health Council has produced a set of guidelines directed at healthcare workers. laundry. disability. workplace safety and health guidelines 5 managing workplace safety and health in healthcare . The management should develop a clear safety and health policy which communicates the healthcare facility’s overall safety and health objectives and how it seeks to achieve its commitment. • be appropriate to the nature and scale of the facility‘s WSH risks. biological safety. etc. Management review Checking and corrective action Implementation and operation Planning WSH Policy Figure 1 – Elements of a successful WSH management system1 Workplace Safety and Health Policy The leadership and commitment from management is the essential foundation for an effective WSH management system.6 healthcare Managing Workplace Safety and Health in Healthcare Continual Improvement A systematic approach where the management of workplace safety and health (WSH) goals are integrated with facility management objectives is essential to manage risks and prevent accidents and ill-health in a healthcare facility. which are presented in Figure 1 below. Workplace Safety and Health Act.) and other requirements to which the facility subscribes to.g. illhealth and incidents. workplace safety. • be available to interested parties. Each facility should have a safety and health programme that covers fire safety. Biological Agents and Toxins Act. and • be reviewed periodically to ensure its relevance to the facility. Regardless of the size of the facility. • include a commitment to the protection of the safety and health of all members of the facility by preventing work-related accidents. etc. continual improvement and compliance with current applicable legislation (e. The policy should: • be endorsed by the facility’s top management. the WSH management system should include 5 essential elements for it to be effective. • be effectively communicated to all employees with the intention that employees are made aware of their individual WSH obligations. 1 Source: SS506 – Part 1: Specifications . • be understood by all staff. money. so that the risks posed by these hazards are reduced through the implementation of effective control measures. and • allocation and provision of adequate resources (time. The procedures to conduct risk assessment should include: • identification of hazards. . • evaluation of the tolerability of residual risks (after the implementation of control measures). This will then form the basis of the WSH management system. the assessment of risks. Procedures should be established in the WSH management system for the ongoing identification of hazards. • evaluation of risks with existing (or proposed) control measures in place (taking into account the likelihood and severity of consequences) due to the hazards posed in the facility.). • identification of any additional risk control measures needed (using the hierarchy of controls as shown in Fig 2). Adequate and appropriate planning based on initial review. • defined responsibilities and clear performance criteria indicating what is to be done by whom and when. there needs to be an understanding of all significant WSH hazards within the organisation. subsequent reviews and other relevant data should include: • clearly defined WSH objectives (for the protection of safety and health of persons at work). and • evaluation of whether the risk control measures are sufficient to reduce the risk to a tolerable level. manpower etc.workplace safety and health guidelines 7 Planning A plan with clear objectives and standards is essential to maintaining a consistent approach in the implementation of a WSH management system. • selection of measurement criteria for confirming that the objectives are met. Together with the plan. and the implementation of necessary control measures. 8 healthcare All activities within the facility should be assessed and this information should be documented and kept up-to-date. • activities of all personnel having access to the facility (including volunteers.g. • emergency conditions (e. equipment maintenance). and • facilities at the workplace. Monitoring and Health Surveillance Personal Protective Equipment Most Preferred Least Preferred Figure 2 – Hierarchy of Controls . spillage of chemotherapeutic drugs during transport). Elimination Substitution Isolation and Engineering Controls Administrative Controls Safe Work Practises. • non-routine activities (e. testing of backup generator. These activities should include: • routine activities (e.g. disposal of biohazardous waste).g. whether provided by the facility or others. subcontractors and visitors). • regular safety and health programme review.workplace safety and health guidelines 9 Implementation and Operation All facilities. management system. use and maintenance of size of the facility and needs: personal protective equipment. big or small. The following can be included in the WSH • safe work procedures.). accidents and dangerous occurrences. processes or machinery). risk assessments and supporting programmes. • regular safety and health inspections. chemical spills. Training procedures should also take into account the responsibilities and abilities of these personnel. materials. These personnel should also be trained such that they are competent to perform their roles effectively. and • a safety and health committee • emergency procedures for the (members should be from different healthcare facility. All facilities should also have procedures for ensuring that pertinent WSH information is communicated to and from employees and other interested parties. should have the relevant procedures in place to address the following: • recordkeeping and notifications (includes incidents. airborne release of hazardous substances and natural disaster emergencies. risk assessments and training records). etc. depending on the • selection. Examples of these communications (but not limited to) include: • review of WSH policies. • management of change (modification or introduction of new work methods. • preventive maintenance programme (includes critical equipment and systems). illnesses. The roles and responsibilities of personnel who manage the WSH management system or are involved in any of its sub-elements should be clearly defined. noise or medical surveillance and action plans). documented and communicated in order to ensure its efficient implementation. and • WSH training for employees (includes induction and periodic training and assessment for competency). • exposure monitoring (includes chemical. • emergency response plans (includes fires. and • management of contractual / volunteer work. functional units). . g. • particulars of the employer. Accidents and Occupational Diseases • An accident in the course of work that results in: . or • A dangerous occurrence such as: . The duties of an employer include the reporting and keeping of records of accidents.the injured being given more than 3 consecutive days of medical rest. where it happened. incidents and occupational diseases.10 healthcare Recording and Reporting Occupational Injuries and Illnesses The Workplace Safety and Health (Incident Reporting) Regulations requires employers to report accidents.flooding. including what happened. If an employee is diagnosed with an occupational disease (please refer to Appendix A for a full list of reportable occupational diseases). .g. if applicable.collapse of structures or equipment. and. and organisation identification number (e. . .a fatality. organisation identification number (e. . dangerous occurrences and occupational diseases at workplaces. the employer is to submit the report within 10 days of receipt of the written diagnosis.hospitalisation for at least 24 hours. including the employer’s name. In the event of incidents outlined in the table below.an explosion or fire. and . • particulars of the occupier of the incident premises including the occupier’s name. Accounting and Corporate Regulatory Authority (ACRA) number) and contact details. iReport. Reportable Incidents. ACRA number if applicable).machinery damage. or . The following information is needed to submit the report through iReport: • particulars of the incident. • particulars of the injured or deceased (if applicable). the employer must submit the report within 10 days to the Ministry of Manpower (MOM) through the electronic reporting system. and how it happened. • the name and designation of the employee involved. Investigation of Accidents. The log should indicate the following: • whether the injury or illness was fatal. The procedures should include. • whether it is an injury or illness. type of information to capture and record keeping. and • updating of changes in documented procedures to reflect new change and communication to all employees. but should not be restricted to. • the date and time of the occurrence. occupational illnesses and incidents (when deemed to be of major concern). and • the time lost as a result of the injury or illness.workplace safety and health guidelines 11 Reports or notifications made under these regulations must be kept at the facility for a period of at least 3 years from the time of report. those that have led or could lead to serious harm. the following: • process for notification. These records can provide information on the effectiveness of existing WSH programmes. • type of events to be investigated e. Occupational Illnesses and Incidents After being notified of an accident or incident. • department where the employee is regularly employed.g. The purpose of having these procedures is to prevent further occurrence of such situations. • process of investigation (evidence collection through interviews and site visits to find out the root cause of the event). . Employee injuries and illnesses which are not reportable to MOM should be recorded and kept by the facility for tracking purposes. • identification and implementation of corrective or preventive actions. • review of follow-up actions for effectiveness. the management should review the information collected and decide on the next course of action. • brief description of the occurrence. A facility should develop and implement effective procedures for evaluating and investigating accidents. The audit results should be documented and communicated to the management and personnel responsible for follow up actions. Any changes in the documented procedures resulting from corrective and preventive actions should be documented and communicated to affected employees to ensure continuity. A review of an existing WSH management system should assess the performance against key indicators such as: • compliance to legislations.g. Procedures should be established for periodic audits of the WSH management system. WSH personnel should look out for unsafe acts and conditions above and beyond that reportable to MOM. implementation of control measures). incidents of ill-health. standards and WSH management systems / programmes. .12 healthcare Checking and Corrective Action All facilities should establish procedures to monitor and measure WSH performance on a regular basis for continual improvement. Following the WSH performance assessment. and • is effective in meeting the facility’s policy and objectives. Corrective or even preventive actions should be taken to eliminate the causes of actual and potential accidents or incidents of ill-health. such audits should be conducted by personnel without direct connection with the processes or activities being examined. • number of WSH related accidents. This is in order to determine whether the system: • conforms to what was specified in the procedures and documents. Checks on the WSH management system should be done through periodic reviews by the facility and by conducting regular audits of the system. • has been properly implemented and maintained. or • achievement of specific WSH objectives defined in the planning stage (e. Wherever possible. proposed improvements to the system and its connecting processes should be reviewed through the risk assessment process prior to implementation. . changing circumstances and need for continual improvement. the review should address potential changes to: • WSH policies. The results of periodic audits serve to help the management focus on areas of concern during such reviews. against each requirement of SS 506-1. In the light of audit results. Such reviews should be conducted at intervals set by the management and of duration suitable for the type of facility. typical inputs and typical outputs.workplace safety and health guidelines 13 Management Review The facility’s top management should review the WSH management system to ensure its continuing suitability. The Singapore Standard on OSH management system consists of the following parts: • Part 1 – Specification • Part 2 – General guidelines on the implementation of OSH management system • Part 3 – Requirement for chemical industry NOTE – Subsequent parts of this series would provide specific guidance on implementation for specific industries. • objectives. and / or • elements of the WSH management system or programme. Further information can be obtained from our references: • Singapore Standard: SS506 Occupational safety and health (OSH) management system SS 506-2 explains the underlying principles of SS 506-1. adequacy and effectiveness. and describes the intent. • International Labour Organisation (ILO): Guidelines on Occupational Safety and Health Management Systems – Copyright © 2001 ILO. • British Standard (BS) OHSAS 18001 : 1999 standard (now superseded by the BS OHSAS 18001 : 2007 edition). 14 healthcare specific hazards . shift work.g. radiation. orthophthalaldehyde (OPA). chemical and radioactive) generated by healthcare activities. • Biological / Infectious Hazards – Infectious / biological agents. slips and falls. • Physical Hazards – Agents or factors encountered within the workplace environment such as manual handling. cytotoxic. C viruses. extreme care must be taken during the preparation and administration. Workplace hazards presented in this section are categorised into the following sub-sections: • Chemical Hazards – Various forms of chemicals that are potentially toxic or irritating to the body system. including solutions and gases (e. viruses. workplace violence including physical assault and verbal abuse). infectious. glutaraldehyde. • Hazardous Waste Management – The management of the various types of wastes (e. sharps. discomfort or disease. stress. .g.g. formalin and solvents such as xylene. ethylene oxide. noise and vibration that can cause injuries. biological. mercury waste from amalgam removal. fungi or parasites that may be transmitted via contact with infected patients or contaminated body secretions / fluids (e. including disposal of their packaging. exposure to anaesthetic gases and chemotherapeutic agents). such as bacteria. toluene and acetone). hepatitis B. This section presents a general overview of both common hazards (e.g. strain.workplace safety and health guidelines 15 Specific Hazards The range of workplace hazards existing within healthcare facilities differs between the various types of healthcare establishments and is dependent on the size and range of medical services rendered. • Hazardous Drug Handling – Chemotherapeutic agents are used to treat and destroy malignant cells but can have the same effect on healthy cells. Therefore. anaesthetic waste gases and vapours. repetitive strain injuries.). emotional strain and / or interpersonal problems (e. sharp objects) and those that are specific to certain medical services (e. Mycobacterium tuberculosis. • Psychosocial Hazards – Factors and situations encountered or associated with one’s job or work environment that creates stress.g. human immunodeficiency virus (HIV).g. etc. used sharps. Hazardous Chemical Management Programme Where hazardous chemicals are used. handled or produced. These include: • the toxicity and physical properties of substances used. be defined. Policy and Strategy The policy statement should state explicitly the responsibility and commitment of the management to ensure the safe use of chemicals and the protection of employees against chemical hazards. • the routes of entry into the human body. The programme should include. The programme should be under the charge of a safety and health management team comprising of at least one senior management staff. • the nature and duration of exposure. It should cover all stages in the life cycle of the chemicals i. manufacture. The register should contain information on the inventory and location of such chemicals. which are purchased.e. should be kept. storage. To give effect to the policy. Written safe work procedures should be drawn up for implementation. • the aggregated effects of combined exposures. stored. used or handled. and • the susceptibility of the healthcare employees. handling and disposal. SDS should also be made available to persons who are exposed or liable to be exposed to hazardous chemicals. targets should be set and relevant records kept. the management should also outline a broad strategy on managing hazardous materials. objectives should 2 Register of Chemicals A register of all hazardous chemicals. Individual components can be delegated to responsible persons.16 healthcare Chemical Hazards Many factors can influence the risk of exposure to chemicals used in the healthcare facility. The hazardous chemical management programme should form part of the safety and health management system. a management programme should be established and implemented to safeguard the health and safety of persons who are liable to be exposed to these chemicals. transport. but not be limited to the following components. Previously known as Material Safety Data Sheet (MSDS) . • work practices. usage. Provision and Application of Safety Data Sheets (SDS)2 Management should study the information provided in the SDS and take the necessary measures to ensure the safe use of the hazardous chemicals. Safe Work Procedures Written procedures on any work involving hazardous chemicals should be established and documented. the hazards involved and the precautions to take. handled or stored. The label should indicate the identity of the chemical. vessel or machinery that is liable to produce or give off any hazardous substance or waste. A proper system of storage of hazardous chemicals should be established taking into consideration the properties of the chemicals. This should include proper labelling of waste by national or international codes. Transport of Chemicals Whenever hazardous chemicals are transported. compatibilities. Risk Assessment and Control Management should ensure that a suitable and sufficient assessment is made of the risks arising from the use of any hazardous chemicals. Warning signs or notices specifying the nature of the danger of the hazardous substances should be posted at areas where such substances are used. The safe work procedures should include the use of personal protective equipment and the safety and health precautions to be taken in the course of work. use and disposal of any hazardous chemicals.g. by licensed or approved waste collectors). proper waste transport and disposal facilities (e. transferring. Waste Disposal Operations that generate hazardous wastes should be governed by a hazardous waste management system. certain measures should be taken to ensure that the potential risks are adequately communicated to all who may come into contact with the chemicals in the course of the transport. The risk assessment should also be carried out for work on any process. and quantity of storage. Storage of Chemicals The potential hazards in chemical storage include catastrophic failure of a tank. operational and environmental conditions. whether within or outside a company. proper waste storage and treatment facilities. and proper emergency action plans to deal with any accidental release of hazardous wastes.workplace safety and health guidelines 17 Selection and Procurement Procedures A proper chemical selection and procurement approval procedure should be established. Labelling and Warning Signs All chemical containers should be labelled. . All new processes and chemical products should be investigated for known and potential hazards prior to acquisition or purchase. The procedures should cover dispensing. leak or fugitive emission from storage containers. Persons who are required to handle the chemical must be told of the potential hazards and the appropriate precautionary measures. Cabinets or rooms which are used to store such chemicals should be clearly labelled. A proper system of labelling should be followed. plant. A suitable personal protective equipment programme should be implemented taking the above elements into consideration. Employees exposed to such chemicals should be identified for regular medical examinations. Information and Training Employees who handle chemicals or may be affected by them should be informed of the hazard potential of these chemicals and the procedures for safe handling. face shields overalls. The procedures should also describe how the contaminated materials can be safely disposed. The results of examinations should be evaluated and medical records properly kept. personal protective equipment should be properly selected. spills. The results of monitoring should be correctly interpreted and records properly kept. For more information: refer to Protective Clothing and Equipment section on pg 125. aprons. where . Personal Protective Equipment Personal protective equipment (PPE) include respirators. explosions. Emergency Response Planning and First-Aid Emergency planning is needed to cope with chemical accidents such as fires. leaks or release of hazardous chemicals. minimisation of exposure and first aid. Further information can be obtained from our reference: • Ministry of Manpower (MOM): Guidelines on Prevention and Control of Chemical Hazards. The safety and health management team should review the overall policy. Emergency procedures should be established so that the source of release can be promptly rectified and the area of contamination contained and properly decontaminated. For more information: refer to Emergency Response Planning section on pg 111 and First Aid section on pg 128. planning and implementation of the hazard chemical management programme on a regular basis to ensure its effectiveness and relevance. gloves and boots. Monitoring and Management Review Regular workplace monitoring by competent persons should be carried out in areas where hazardous chemicals are used or given off. Anti-static PPE should be worn when handling materials with a low ignition point. A training programme should be instituted to ensure that the safe handling procedures are both known and understood by all concerned. correctly used or comfortably fitted and regularly maintained. Medical Surveillance A medical surveillance programme should be established. To ensure that employees are effectively protected. 2006.18 healthcare For more information: refer to Hazardous Waste Management section on pg 104. An appropriate monitoring strategy should be established and followed. appropriate. safety glasses. Levels of WAGs are higher when mask anaesthesia is used. The common agents used are nitrous oxide and halogenated agents such as isoflurane. • Anaesthetic nurses and assistants. . particularly if the mask does not fit the patient well. • Operating room personnel. Locations where Used / Found Healthcare workers can be exposed to waste anaesthetic gases and vapours in: • operating rooms. fatigue and impaired neuropsychological performance. Common symptoms of exposure include effects on the central nervous system such as mood disorders. occupational diseases such as hepatitis due to halothane. bronchial asthma due to enflurane and allergic contact eczema due to halothane or isoflurane can occur. Healthcare workers can be exposed to waste anaesthetic gases when they leak out from various sections of the anaesthetic circuits or when patients in the recovery room exhale the gases into the air. In ENT and dental surgery. • obstetric delivery rooms. Workers at Risk • Anaesthetists.workplace safety and health guidelines 19 Anaesthetic Waste Gases and Vapours Uses Anaesthetic gases are used to provide inhalation anaesthesia in adults and children undergoing surgery. • recovery rooms (post anaesthesia care units). • Surgeons and surgical staff. Effects of Exposure Exposure to high levels of waste anaesthetic gases (WAGs) may occur with the use of unscavenged systems and / or poor general ventilation. • intensive care units. • Medical technicians. • Dental nurses. • Emergency room staff. and • dental facilities. enflurane and halothane. otorhinolaryngologic (ENT) surgery and dental surgery. Exposures can be higher in paediatric surgery. headaches. desflurane. assistants and attendant staff. • Delivery room staff such as obstetric nurses. sevoflurane. • Radiology department personnel. • Post anaesthesia care nurses and staff. • Dentists. • Recovery room nurses and other staff. the close proximity of the surgeon and attendant staff to the patient’s mouth results in increased exposure to the exhaled anaesthetic vapours. Though rare. dental and obstetric procedures. • hoses. As there is a potential for effects on the neurological and reproductive systems with excessive exposure. the main sources of leaks include: • tank valves. Management Policy There should be a written policy in place stating the responsibility and commitment of management in protecting employees from exposure to waste anaesthetic gases. • spillage of liquid inhaled anaesthetics. and • improperly inflated tracheal tube and laryngeal mask airway cuffs. selected anaesthesia techniques and improper practices can also contribute to the escape of WAGs into the atmosphere of the operating room. • leaving vaporisers on after use. obstetric and dental facilities. departments. • high and low-pressure machine connections. In recovery rooms. and • Y-connectors. such as: • leaving gas flow control valves open. • defects in rubber and plastic tubing. • poorly fitted patient face masks. Management of Waste Anaesthetic Gases Anaesthetic gases are widely used in healthcare facilities. This policy should be communicated to all employees. a management system should be in place to ensure that employees are protected. • Identifying sources of leaking or waste anaesthetic gases. the main source of WAGs is from the vapours contained in the air that patients exhale. and • Personal sampling measurements of exposed staff. operating theatres and dental facilities. In operating theatres. • connections in the breathing circuit. such as obstetrics Control Measures The control of exposure to waste anaesthetic gases should follow . • reservoir bags. • ventilator bellows. Employees at increased risk for exposure to waste anaesthetic gases should be identified. Exposure to WAGs can be quantified by various means including: • Measuring airborne concentrations of WAGs. Risk Assessment Areas where anaesthetic gases are used or could be present should be identified and documented.20 healthcare Routes of Exposure and Sources of Leaks The main route of exposure is through inhalation. Specific policies with regard to the exposure to pregnant and lactating employees should also be present. In addition. workplace safety and health guidelines 21 the hierarchy of controls. The use of engineering controls is preferred, followed by safe work practices as the reduction of the hazard at source is generally the most effective. changes per hour or as stipulated by national regulations. Safe Work Practices Anaesthetic practices Exposure to higher levels of anaesthetic gases can occur during the induction and emergent phases of anaesthesia. Preparation of anaesthesia • An anaesthesia system should be chosen that minimises leakage and allows active scavenging of waste anaesthetic gases. • Use of a low flow or minimum flow system for fresh gas is preferred. • Before anaesthesia is administered, a complete inspection of the anaesthesia apparatus should be done daily before the first case and an abbreviated check before each case. • Face masks should be of an optimum size for proper fit and seal to minimise leakage. • Face masks should only be used if laryngeal or tracheal tubes cannot be used. • If tracheal tubes, laryngeal masks and other airway devices are used, they should be positioned precisely with the cuffs inflated adequately. • For intubation without a cuff, choose a tube size that induces minimum leakage. Induction of anaesthesia • Exposure to WAGs can be reduced by using either intravenous induction or a double mask system. Engineering Control Measures Scavenging system There should be an effective system to collect and dispose of anaesthetic gases in both operating and non-operating theatre settings. WAGs should be exhausted to the outside atmosphere. In the operating theatre, an active scavenging system attached to the site of overflow in the breathing circuit, with a minimum flow rate of 40 l/min is an effective means of reducing exposure to WAGs. The presence of a volumetric buffer regulation system is preferred. All gases in the anaesthetic system should be channelled to the exhaust and thence to the scavenging system. Reduction of leakages The amount of leakage in anaesthetic machines should be reduced to as low as practically possible. As far as possible, an automatic leakage detector should be installed, otherwise, regular tests for leaks should be performed and the results documented and acted upon. General ventilation There should be adequate ventilation in the operating theatres or other rooms where anaesthetic gases are used to ensure there is additional dilution ventilation of the WAGs. The rate of air change should be more than 15 air 22 healthcare • Check that the scavenging device is correctly connected before each patient is anaesthetised or whenever the apparatus is moved. • Start using the scavenging system during the induction phase of anaesthesia. • Turn on the supply of the anaesthetic gases after the face mask is placed in a leaktight position or after the tube is connected to the patient system. Maintenance of anaesthesia • In mask anaesthesia, the effectiveness of the seal of the mask should be checked constantly. • When patient is disconnected from the breathing system, the exhaust valve should be opened while the open end should be closed. Alternatively, the gas supply should be briefly cut off and the buffer balloon emptied of the anaesthetic gases via the scavenging system. Emergence from anaesthesia • Before removal of the mask or tube, oxygen should be administered at the end of anaesthesia at a high flow rate to flush anaesthetics out of the anaesthesia system and the patient’s lungs. • The washed out anaesthetic gases should be removed by the scavenging system. • The supply of anaesthetic gases should be turned off at the end of anaesthesia. Filling of vaporisers • Handling of anaesthetics such as filling of vaporisers should not be done in the recovery room. • Use safety devices when filling vaporisers to minimise the opportunity for spills of volatile anaesthetic agents. • Vaporisers should be filled in a well ventilated area. • Use of a closed system for filling of vaporisers is preferred. • Routine procedures for detection of leaks should be present. Maintenance Programme There should be a regular preventive maintenance programme of the following equipment by trained individuals: • the anaesthetic apparatus, hoses, connections, reservoir bags, etc.; • wall plugs; • anaesthetic gas piping; • anaesthetic gas scavenging systems; and • ventilation systems. During maintenance, points to note are: • care should be taken to assemble the equipment properly; • connectors should be close-fitting, gasspecfiic and appropriate to the specific anaesthetic equipment; • parts that are damaged or of inferior design should be replaced; workplace safety and health guidelines 23 • regular checks for the proper functioning of the scavenging system should be in place; and • records of maintenance should be kept. In addition, there should be an established, written maintenance plan and scheduling of maintenance for the various components of the airconditioning and exhausting systems. Administrative Measures Record keeping There should be adequate records kept of the following: • types of anaesthesia apparatus and types of volatile agents in use; • daily inspections of apparatus and scavenging systems in use; • written work instructions for proper use of anaesthetic apparatus, scavenging systems, procedures for filling of vaporisers, spill or leak management, safe work practices and maintenance of apparatus; • records of preventive maintenance and checks; • incident investigation reports; • action plans, if any; • monitoring records of WAGs, if available; and • medical surveillance results, if any. Training and education All staff handling or using volatile anaesthetic agents should be regularly trained in the following aspects: • health effects of exposure to these agents; • rationale of engineering control measures; • proper use of anaesthetic equipment; • safe work practices; • use of appropriate personal protective equipment; and • management of spills or leaks. The training should be updated whenever there is a change in equipment, processes or an incident occurs. Personal Protective Equipment (PPE) Personal protective equipment (PPE) should not be used as a substitute for engineering control measures, safe work practices or administrative controls in protecting employees from exposure to WAGs. In the event of a spill, PPE should be used in conjunction with engineering measures, safe work practices and administrative controls to contain and clean up the spill. Choice of appropriate PPE such as chemical resistant gowns, gloves, goggles and respirators depends on the type of agents used. Information in the Safety Data Sheets (SDS) should be consulted. For more information: refer to Protective Clothing and Equipment section on pg 125. There should be a written procedure in place for the containment. Seal and label the container. • collect spilt liquid and absorbent materials used and put in a tightly capped glass or plastic container. Data obtained from the monitoring can be used to assess effectiveness of control measures so as to ensure the lowest practicable levels of waste anaesthetic gases. Choice of method and sampling strategy would depend on the objective of the sampling and staff are advised to consult technical experts and manuals for the appropriate method. lactating and planning for a pregnancy. Medical surveillance The organisation may want to put in place a surveillance system for early detection of health effects from exposure to waste anaesthetic gases. clean up and disposal of large spills. consult the safety data sheet or the manufacturer. • ventilate the area where possible. Exposure records and biological tests of exposed staff should be properly kept and maintained.24 healthcare Management of Spills and Disposal of Liquid Anaesthetic Agents Spills of small amounts of liquid anaesthetic agents would probably evaporate at room temperature before a clean up can be initiated. the organisation should develop a policy regarding exposure of all staff particularly vulnerable workers such as those pregnant. Only adequately trained and equipped staff should be allowed to respond to such spills. Different methods and types of measurements can be used. Monitoring Monitoring exposure at the workplace Measuring the airborne levels of anaesthetic gases at the workplace is a method of evaluating workplace exposures. gloves. Reporting and record keeping There should be a reporting system in place so that staff exposed to WAGs can report incidents. • persons without personal protective equipment should not be present till the area is deemed safe by trained personnel. and • the container should be handed over to the proper waste disposal contractors and should be disposed of according to national or international regulations. Some general guidelines to minimise exposure of employees to waste liquid anaesthetic agents are: • wear appropriate personal protective equipment – chemical protective gowns. If you are unsure of the specific procedures and appropriate personal protective equipment. As WAGs may have effects on the reproductive system. respirator and goggles. . • annual questionnaire emphasising the above systems. • exposure and medical records of employees who may be exposed to anaesthetic agents should be properly kept and maintained. • Centers for Disease Control and Prevention.workplace safety and health guidelines 25 Suggested elements of the programme are: • baseline or pre-placement medical questionnaire including: . . 2007.past medical history with emphasis on hepatic (liver).past exposure to waste anaesthetic gases. neurological (nervous system). • appropriate laboratory / biological tests if necessary. etc. .. NIOSH): Waste Anesthetic Gases . cardiovascular (heart and circulation) and reproductive functions.medical evaluation including history and physical examination. Accessed 30 September 2007. and • the information in the surveillance system should be used to review working conditions and control measures. • Centers for Disease Control and Prevention. • incident reporting in the event there is exposure to high levels of anaesthetic agents such as spills or leaks. Occupational Safety and Health Administration (OSHA): Anaesthetic Gases: Guidelines For Workplace Exposures. • reproductive hazards policy – There should be a policy to address worker exposure and reproductive effects in both male and female employees. . Accessed 23 September 2007. 2000. . Accessed 22 September 2007. • case finding to allow for reporting of health effects by employees. National Institute for Occupational Safety and Health (CDC.suitable laboratory tests where applicable. 2001.a detailed occupational history. renal (kidney). Further information can be obtained from our references: • US Department of Labor. NIOSH): Control of Nitrous Oxide in Dental Operatories (1998). Accessed 23 September 2007. National Institute for Occupational Safety and Health (CDC. • International Social Security Association (ISSA): Safety in the Use of Anaesthetic Gases.Occupational Hazards in Hospitals. • a final medical review in the event that a worker requests for a job transfer or leaves the job. • maintenance of Safety Data Sheets (SDS) for all anaesthetic agents in use. . ortho-Phthalaldehyde (OPA) OPA (Trade name Cidex®) is a clear blue solution with little odour. nose and other 3 Parts per million . Exposure to such sterilising solutions can occur during the following activities: • activating and pouring sterilising solution into or out of a cleaning container system (e. Sonacide®. Common sterilising agents include glutaraldehyde. It may also be used as biological tissue fixative and as a component in X-ray film developers. • removing instruments from the container system. • opening the cleaning container system to immerse instruments to be disinfected. usually on the hands but occasionally on the face. and Omnicide®.. Glutaraldehyde Trade names of glutaraldehyde-based products include. such as filter or hose changes on automated processors that have not been pre-rinsed with water. Individuals who become sensitised to glutaraldehyde can develop dermatitis after contacting solutions containing as little as 0. Inhalation of vapours and aerosols can cause nose. It is a potential skin and respiratory sensitiser that may cause dermatitis with prolonged or repeated contact and may aggravate pre-existing bronchitis or asthma.g.26 healthcare Sterilising and Disinfecting Agents Healthcare facilities use a variety of sterilising solutions to sterilise / disinfect a variety of heat-sensitive instruments. giving rise to contact dermatitis.2 ppm3 (short term). • handling of soaked instruments. tissues resulting in symptoms such as stinging. glutaraldehyde acts as a contact allergen. • flushing out instrument parts with a syringe. • performing maintenance procedures. and dialysis equipment. • agitating the sterilising solution. ortho-phthalaldehyde (OPA) and ethylene oxide. with spray bottles to spray-wipe surfaces.1% glutaraldehyde. skin. • aerosolisation of solution. bronchoscopes.g. • cleaning up sterilising solution spills. • drying instrument interiors with compressed air. In addition. but not limited to. coughing and sneezing. Respiratory sensitisation can cause allergic rhinitis and asthmalike reactions. such as endoscopes. It is a potential irritant of the eyes. soaking basin in manual disinfecting operations and reservoir in automated processors). excessive tearing. the product stains proteins on surfaces to gray / black. e. Sporicidin®. The permissible exposure limit for glutaraldehyde is 0. throat and lung irritation. • rinsing the channels of instruments containing residual sterilising solution. Cidex®. Hospex®. In addition to causing respiratory effects. 2001. Use of personal protective equipment to prevent skin contact such as gloves (nitrile rubber gloves. • Occupational Safety and Health Service. Current as of 15 December 2007. Occupational Safety and Health Administration (OSHA): Best Practices for Safe Use of Glutaraldehyde in Health Care. . laboratory hoods) for open soaking. ANSI/AMMI 1996) for rooms where disinfection or sterilisation are carried out. butyl rubber gloves. National Institute for Occupational Safety and Health (CDC. theatre sterile supply units (TSSU). 2003. safety eyewear and fluid-resistant gowns or aprons. INC (SGNA): Guideline for the Use of High-Level Disinfectants and Sterilants for Reprocessing of Flexible Gastrointestinal Endoscopes.Occupational Hazards in Hospitals. Department for Labour.workplace safety and health guidelines 27 Control Measures Hierarchical approach Elimination / Substitution Engineering Controls Examples of control measures to reduce exposure Substituting with a less hazardous chemical. Further information can be obtained from our references: • US Department of Labor. Provision of general dilution ventilation (10 air changes per hour. Healthcare personnel at risk include those who work with cold sterilisation equipment (e. New Zealand Guidelines for the Provision of Facilities and General Safety and Health in the Healthcare Industry. NIOSH): Glutaraldehyde . 2006. • Centers for Disease Control and Prevention. sleeve protectors. within endoscopy department and operating theatres. 1997. Accessed 24 April 2007. Current as of 15 December 2007. • Society of Gastroenterology Nurses and Associates. Provision of local exhaust ventilation (e.g. central sterile supplies units (CSSU) and dental clinics). Safe Work Practices Administrative Controls Personal Protective Equipment Ensuring that all containers containing sterilising solution are covered at all times with tight-fitting lids. and 100% copolymer gloves may be used). Enclosure of soaking basins and processing units.g. Automation of the transfer of sterilising solution from drums into process containers using pumps and closed transfer lines. Provision of eyewash stations in all areas where sterilising solutions are handled. Current as of 15 December 2007. abdominal discomfort and diarrhoea. an established animal carcinogen and a human carcinogen (International Agency for Research on Cancer (IARC). renal dialysis units. and • intravenous leaching of ethylene oxide from inadequately aerated medical devices inserted intravenously. autoclaves. It is also a mutagen.g. blisters and dermatitis when it comes into contact with skin. headache. Less frequently reported effects include muscular weakness. central supply. and nervous system disorders. Ethylene oxide liquid has the capacity to cause burns. Because the odour of EtO cannot be detected below approximately 700 ppm. The permissible exposure limit for ethylene oxide is 1 ppm (long term). High vapour concentrations of ethylene oxide (in the order of 1000 ppm) can cause irritation and damage to the eyes and upper respiratory system. and may have adverse reproductive effects on humans. Healthcare personnel at risk include those who work in operating rooms. cough. Routes of exposure to ethylene oxide include: • inhalation of ethylene oxide gas in air.28 healthcare Ethylene Oxide Ethylene oxide (EtO) is commonly used as a sterilising agent for medical devices and equipment that are heat and moisture-sensitive and thus cannot be sterilised by steam. respiratory therapy departments and areas where ethylene oxide is used e. fatigue and pulmonary oedema. • oral – residual ethylene oxide in ingested material. Ethylene oxide is toxic in various body systems. 2007). • skin. eye or mucous membrane contact with the liquid or with ethylene oxide absorbed in solid materials. workers can be exposed to high concentration of this compound unknowingly. . nausea and recurrent vomiting. hoarseness. workplace safety and health guidelines 29 Control Measures Hierarchical approach Engineering Controls Examples of control measures to reduce exposure Store supply cylinders in a ventilated enclosure (either a ventilated cabinet or a hood that covers the point where the cylinder is connected to the steriliser supply line). Administrative Controls Sterilising operations should be centralised and access to steriliser rooms should be restricted. Provision of real-time monitoring devices with audio and visual alarm for ethylene oxide sterilising facilities. tubing. laboratory hoods) for sterilisers using cartridges or glass ampules. Floor drains should have a cover with an anti-siphon air gap. at the junction of the vacuum pump discharge line with the floor drain. Provision of general dilution ventilation for rooms where sterilisation is carried out. Provision of appropriate local exhaust ventilation (e. Further information can be obtained from our reference: • Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health (CDC. valves.Engineering Controls and Work Practices. and the enclosure should be exhausted to a dedicated ventilation system. July 1989. Personal Protective Equipment Provision of proper personal protective equipment to prevent skin or inhalation exposures. . Dedicated exhaust ventilation should be provided for the enclosures. NIOSH): Current Intelligent Bulletin 52: Ethylene Oxide Sterilizers in Health Care Facilities . Current as of 15 December 2007. should be enclosed.g. and piping connections for all steriliser units. Have a maintenance plan which includes regular checks of door gaskets. The air gap. The steriliser should be enclosed either in a mechanical access room or a cabinet. Local exhaust ventilation sufficient to effectively remove ethylene oxide should be as close as possible to the top of the steriliser door. surgeons / dentists and pathologists etc. Safe Work Practices Administrative Controls Personal Protective Equipment Ensuring that all containers containing formalin are covered at all times with tight-fitting lids. histopathology laboratories and operating theatres. e. Formaldehyde is often combined with methanol and water to make formalin. Formaldehyde vapour is an irritant to the eyes and the respiratory tract. operating theatres. it can cause both primary irritation and sensitisation dermatitis. In liquid or solution form. Healthcare personnel at risk include laboratory technicians. The permissible exposure limit of formaldehyde is 0. where formaldehyde is used.3 ppm (short term). nurses. Provision of eyewash station in all areas where formalin is handled. Provision of traps in floor drains. Formaldehyde is recommended to be handled as a known carcinogen (International Agency for Research on Cancer (IARC). butyl rubber gloves. Provision of spill-absorbent bags for emergencies. pathology laboratories or dialysis centres. Use of personal protective equipment to prevent skin contact such as respirators.30 healthcare Formaldehyde Formaldehyde is a tissue sterilising agent and preservative often used in dialysis units.g. face shields. Purchasing small quantities of formaldehyde in plastic containers for ease of handling and safety. fluid-resistant aprons and boots.. . 2006) in the workplace. Control Measures Hierarchical approach Engineering Controls Examples of control measures to reduce exposure Provision of local exhaust ventilation over work stations using formalin or specimens preserved in formalin. gloves (nitrile rubber gloves. and 100% copolymer gloves may be used). Use protective equipment to prevent skin contact and inhalation such as gloves. Healthcare personnel at risk include laboratory technicians. Provision of local exhaust ventilation and enclosure of solvent vapour sources for controlling exposures to solvents in laboratories. cleaning agents and paints used in equipment maintenance workshops. toluene and alcohols. nausea. Long-term exposure to some solvents has been associated with cancer. goggles. Many solvents act as central nervous system depressants. adverse reproductive effects. respirator (for organic vapours) rubber aprons. Examples include xylene. and the upper respiratory tract. cardiovascular problems. Provision of warning signs and labelling of solvent containers with information on the hazards of exposure to solvents and the precautions to take. mainly reagents used in medical laboratories. cleaning agents used in housekeeping and renovation works. skin. dizziness. workshop technicians. central nervous system and hematopoietic system. contractors and housekeeping staff. Dentists. weakness. surgeons and their assistants can also be exposed to volatile organic compounds and solvents such as methacrylate and chloroform. Solvents may also irritate eyes. kidneys. Control Measures Hierarchical approach Elimination / Substitution Engineering Controls Examples of control measures to reduce exposure Substituting hazardous solvents with less hazardous alternatives. and other symptoms.workplace safety and health guidelines 31 Solvents There are a wide range of solvents used in healthcare facilities. Most solvents can be absorbed through the skin or by inhalation and ingestion. Administrative Controls Personal Protective Equipment . and boots. causing headaches. Prolonged contact may result in defatting and dehydration of the skin. and damage to the liver. digestive disturbances. the element can also be absorbed through the skin. Administrative Controls . Control Measures Hierarchical approach Engineering Controls Examples of control measures to reduce exposure Provision of exhaust systems to prevent the accumulation or recirculation of mercury vapours in equipment maintenance rooms / biomedical workshops. and marked renal damage. tremors. This syndrome is characterised by emotional instability and irritability.025 mg/m3 (long term). Exposure to short-term high levels of mercury can produce severe respiratory irritation. named for the makers of felt hats who used mercury in processing. Exposure to mercury in the hospital is usually the result of an accidental spill arising from breakage of mercurycontaining equipment and apparatus. Long-term exposure to low levels of mercury results in the classic mad hatter syndrome. Mercury has also been reported as a cause of sensitisation dermatitis. Provision of mercury spill clean-up kits and training for emergency response staff. Although inhalation is the major route of entry for mercury. blood pressure apparatus and sphygmomanometers.32 healthcare Mercury Mercury can be found in equipment such as thermometers. The permissible exposure limit for mercury vapour is 0. anorexia. excessive salivation. and weight loss. inflammation of the gums. Mercury is also used in dental amalgams. Establishing emergency procedures for handling mercury contamination including procedures for cleanup and for respirator selection. gingivitis. • Kitchen staff. clinical areas. autopsy rooms. dental dams. become airborne and inhaled. nurses and related staff. ICUs. Exposure Situations / Procedures • Healthcare workers in direct patient care where the use of gloves is required and NRL gloves are used – clinics. pathologists. rubber bands. . laboratory staff. • Workers with atopic allergic diseases. dentists. offices. also known as accelerators. kiwi and chestnut. are added to latex in the processing phase. Healthcare workers are also exposed by direct contact to NRL or chemicals in rubbers and plastics. toilets and other general facilities. security staff. operating theatres. • Workers with history of certain food allergies such as banana. In powdered NRL gloves. Chemicals. • Workers with past history of multiple surgical procedures. sphygmomanometers. wards. anaesthesia masks. waste disposal staff. – kitchens. the proteins are easily carried on the cornstarch powder. clinical and research laboratories.. • Rubber containing consumer products e. Workers at Risk • Healthcare workers using NRL gloves particularly the powdered type – doctors. avocado. catheters. stress balls.workplace safety and health guidelines 33 Natural Rubber Latex A number of proteins that make up natural rubber latex (NRL) can cause the development of occupational asthma and dermatitis in people exposed to them.g. stethoscopes etc. washing up and other utility gloves. • Stretchy rubber products pose a higher risk than dry rubber products. dithiocarbamates and mercaptobenzothiazoles (MBT). Chemicals most likely to cause reactions are thiurams. drains. • Use of rubber containing equipment such as IV bungs. research staff. erasers etc. • Centers for Disease Control and Prevention.uk/latex/index. National Institute for Occupational Safety and Health (CDC. . In non-clinical tasks. provide appropriate non-latex gloves. NIOSH): NIOSH Alert: Preventing Allergic Reactions to Natural Rubber Latex in the Workplace (1997). Provision of appropriate latex-free personal protective equipment. powder free gloves. Further information can be obtained from our references: • Health and Safety Executive (HSE). http://www. Administrative Controls Personal Protective Equipment Education and awareness.htm.hse. gov. Accessed 1 July 2007.34 healthcare Control Measures Hierarchical approach Elimination / Substitution Examples of control measures to reduce exposure Substitute natural rubber latex gloves with alternatives such as vinyl or other non-latex gloves. Use low protein. Accessed 1 July 2007. UK: Latex allergies website. All areas where there is potential exposure to biological hazards. laundry and portering and so on. mumps. measles. varicella zoster (VZV). • immune status of healthcare worker. should be included. rubella. injection. dermatitis and asthma. Management Policy and Strategy The policy is a written statement of a facility’s intent to provide a safe and healthy environment and should enlist the support of employees in achieving its aims. setting health and safety standards and developing policies. . Infectious Disease Management Programme Facilities should implement a health and safety management programme for infectious diseases to protect the health of healthcare workers. • duration of exposure. exposure to animals and vegetable matter can cause allergies. HIV. Infectious Diseases Healthcare workers are exposed to infectious agents by inhalation. but ultimate responsibility for health and safety cannot be delegated. • availability of post-exposure prophylaxis where applicable. operating theatres. • availability of vaccines. gastrointestinal infections and scabies. Mycobacterium tuberculosis. As infectious agents have the potential to multiply. healthcare workers and supporting staff are exposed to various infections such as Hepatitis B. • virulence of the infectious organisms. There should be systems and procedures in place for ensuring health and safety of its employees. cleaning. sterilising departments. The policy should detail the health and safety responsibilities within the facility. Factors determining whether the healthcare worker gets the infection are: • how the infection is spread. Specific functions such as carrying out risk assessments may be delegated down the management line .workplace safety and health guidelines 35 Biological and Infectious Hazards In treating and caring for patients. Hepatitis C. clinics. ingestion or physical contact. • how well the organism survives in the environment. In addition. • dose of the organisms. breaking the chain of transmission is important in the control of infection. housekeeping. This means taking an active role in carrying out risk assessments. together with monitoring of standards and enforcement of compliance. such as wards. and • reviewing the risk assessment if the nature of work changes or if there is a change in the process. non-routine work. The safe work procedures should include the correct use of appropriate personal . • vulnerable persons such as expectant mothers and those with impaired immune systems. A risk assessment is a means of determining the risk associated with exposure to a particular hazard or work. volunteers. patient care areas. • documentation of findings and control measures selected as well as any other steps necessary to reduce exposure to risk. • emergency situations. The coverage of the risk assessments should include: Safe Work Procedures There should be written procedures on any work where there is exposure to infectious matter and should include emergency areas. • likelihood of harm arising. mortuary waste disposal and biomedical maintenance. • non-routine work. engineering control measures. Documentation of risk assessments and controls should be kept up-to-date. The steps in doing a risk assessment include: • hazard identification. laundry and maintenance of contaminated equipment. • determining workers at risk and how harm could arise. housekeeping and laundry. • routine work. and • all facilities at your workplace. This register should also include information on the staff who may be exposed and the areas in which they work. • activities of personnel with access to the facility such as visitors.36 healthcare Register of Work Activities A register of all processes related to infection control should be documented including routine. administrative measures and personal protective equipment. These should be reviewed periodically or whenever there is a change in the nature of the process. assessment of adequacy of existing precautions. Risks should be controlled at source and control measures should follow the hierarchy of controls viz elimination or substitution. housekeeping. disposal of infectious matter. subcontractors and workers. Risk Assessment and Risk Control Management should ensure that suitable and sufficient risk assessments are made of all activities where there is handling or exposure to infectious agents. operating theatres. substances or equipment used or on the occurrence of an incident or an occupational disease. laboratories. The components are hand hygiene. gloves and boots. correctly used. Environmental Infection Control Certain infections can be transferred by direct contact with contaminated surfaces. Personal Protective Equipment Personal protective equipment (PPE) includes respirators. aerosolisation of highly infectious organisms. fluid resistant gowns. eye or face shield and proper handling of potentially contaminated equipment. mask.workplace safety and health guidelines 37 protective equipment and the safety and health precautions to be taken in the course of work. excretions except sweat. secretions. Existing programmes such as infection control programme. . To ensure that employees are effectively protected. comfortably fitted and regularly maintained. body fluids. non-intact skin and mucous membranes may contain transmissible infectious agents. overalls. A suitable personal protective equipment programme should be implemented taking into account the above elements. transport and disposal of such wastes. aprons. face shields. For more information: refer to Protective Clothing and Equipment section on pg 125. risk group of the organisms. The use of standard precautions applies to all patients in any health care setting. safety glasses. use of personal protective equipment (PPE) such as gloves. Maintaining a clean environment by good housekeeping would also reduce disease transmission. The extent of PPE used depends on the risk of healthcare workers – patient interaction. treatment. There should be a programme for cleaning and decontaminating clinical contact areas in order to reduce transfer of infections to healthcare workers and other patients. contact. other concomitant hazards and the nature of work. spills of organisms outside of biological safety cabinets. Selection of PPE should be based on transmission routes of infection. airborne and droplet precautions can be incorporated into the infectious disease management programme. TB infection control. It is based on the premise that blood. For more information: refer to Hazardous Waste Management section on pg 104. accidents or emergencies that might occur such as sharps injuries. The plan should describe what needs to be done. Emergency Planning Emergency planning is required for incidents. proper storage. Healthcare workers should ensure that PPE’s are not brought out of clinical or laboratory areas. Disposal Operations where biological / infectious wastes are generated should be governed by a waste management system that should include proper labelling according to national or international codes. standard precautions for prevention of bloodborne infections. personal protective equipment should be properly selected. and proper waste disposal. Information in the records should include type of work.38 healthcare for example: emergency procedures. All records should be properly kept and maintained for at least 5 years. The programme should also address whether a healthcare worker should be restricted from work and determine when he / she would be fit to return to work. Treatment given would depend on the nature and type of infection exposed to. Records A facility should keep exposure records of its employees who work with more hazardous organisms in the laboratories or in clinical areas. Post-Exposure Programme A post-exposure programme should be implemented to cope with employees who are infected with or occupationally exposed to infectious diseases. systematic collection. and guide implementation of interventions and evaluation of the effectiveness of those interventions. Case Finding A facility should have a system for active case finding of healthcare workers with clusters of fever symptoms. For more information: refer to Emergency Response Planning section on pg 111. Where required by current legislation. A system should be put in place to detect early signs of work-related ill health in employees exposed to certain health risks and to act on the results. location of work done. decontamination and cleaning. and any specific incidents or exposures that occurred. Emerging infectious diseases is another area that should be catered for. Health Surveillance Surveillance is defined as the ongoing. and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality and to improve health. influenza. Vaccinations (Immunoprophylaxis) Employees at increased risk of exposure to vaccine-preventable infections . A systematic epidemiologic investigation should be done to determine commonalities in persons. occupational diseases should be reported to MOM. and time. Such a programme should incorporate knowledge of the epidemiology of such infections and include inputs from an infectious disease consultant in accordance to the institution’s policy or any other regulatory guidelines. interpretation. first aid procedures. occupational asthma. or single cases of sharps injuries. varicella zoster and rubella might benefit from the implementation of a vaccination programme. dermatitis and other occupational diseases. analysis. such as Hepatitis B. use of safety equipment and appropriate PPE. place. gastrointestinal or other symptoms. Education and Training All employees should be given suitable and sufficient information about the biological agents they could be exposed to. the precautions to take.workplace safety and health guidelines 39 Monitoring and Review Information on occurrence of infectious diseases should be monitored and analysed with regard to frequency. emergency and first aid procedures. usage of personal protective equipment. planning and implementation of the infectious disease management programme regularly to ensure it effectiveness and relevance. health effects and absenteeism as well as to the performance of the safety and health management system. . They should also be informed of the results of the risk assessment. The safety and health management team should review the overall policy. post-exposure prophylaxis and reporting procedures for occupational accidents and diseases. A health and safety training programme should be implemented to ensure that safe work procedures are known and understood by all staff. and the risks created by the exposure. vaccinations. infection control policies. 40 healthcare Bloodborne Pathogens Healthcare workers are potentially exposed to bloodborne pathogens such as Hepatitis B. Hepatitis C and HIV/AIDS are the most common infections that can be transmitted to healthcare workers by blood and bodily fluids. • Surgery e.e. research laboratories. and • Repair of medical and dental equipment. nose. • Venepuncture e. Exposure Situations / Procedures • Procedures resulting in a percutaneous injury or contact of mucosal membrane or non-intact skin with infected blood. in wards. • Nurses. waste holding and treatment areas.g. clinics. in emergency departments. animal facilities. • Disposal of biohazardous waste e. • Ambulance and related staff. in clinical laboratories. • Biomedical technicians and engineers.g. Hepatitis B.g. • Transport of injured patients who have open bleeding wounds. operating theatres. The main routes of exposure are by percutaneous inoculation or permucosal means i.g. wards. • Laboratory workers. • Post-mortem procedures – autopsy rooms. Hepatitis C and HIV from needlestick injures or cuts from other sharp objects contaminated with an infected patient’s blood or through contact of the eyes. in wards. • Phlebotomists. non-intact skin or mucous membranes (due to spills and splashes). mouth or non-intact skin with an infected patient’s blood or bodily fluids. laboratories. tissues or bodily fluids such as needlestick or sharps injuries. . • Laboratory work e. operating theatres. • Resuscitation e. • Waste handling and disposal workers. clinics and operating theatres. • Emergency room staff.g. spills or splashes and human bites. Workers at Risk • Doctors. contact of an open wound. in operating theatres. • Mortuary staff. procedures for administration of medications to confused or combative patients. • Explore other routes of medication delivery e. • Consider substitution of non-needle systems for certain types of blood prick tests. • Proper sharps disposal containers placed in convenient locations. Engineering Controls • Safety engineered sharps or needles with built-in sharps injury prevention features. smoking and the application of cosmetics in areas where there is a risk of contamination. cuts and abrasions. • Blunt tipped suture needles where appropriate. • Use standard precautions: .Safe handling of needles and sharps: • No recapping.workplace safety and health guidelines 41 Control Measures Hierarchical approach Elimination / Substitution Examples of control measures to reduce exposure • Eliminate use of needles or sharps for IV drug delivery. Safe Work Practices • General safe work practices: .cover all breaks in exposed skin by using waterproof dressings and suitable gloves.prohibit eating. bending.Hand hygiene before and after procedures. drinking. . • Review specimen collection procedures. . • Needleless IV delivery systems.g. especially in the presence of blood and body fluids. breaking needles. • Consider use of alternative IV delivery systems. • Blunt-ended scissors. . . . oral.prevent puncture wounds. Proper management of spills and other forms of contamination. • Control contamination of surfaces: .Avoiding hand-to-hand passage of sharp instruments by using a basin or neutral zone.Dispose of glass ampoules properly as soon as withdrawal of contents is completed.Substituting endoscopic surgery for open surgery where possible.Using instruments. .Containment of the infectious agents. . . punctureresistant plastic containers.Use appropriate sharps containers i.Proper patient handling techniques for phlebotomy on uncooperative patients.Basic principles of aseptic technique for the preparation and administration of parenteral medications.Use of appropriate decontamination procedures by heat or chemical means. and load/unload needles and scalpels. to grasp needles.Prevention of contamination of injection equipment and medication. • Safe handling and disposal of waste: . .Use of single-dose vials is preferred over multipledose vials. . • Work in operating theatres: .42 healthcare Hierarchical approach Examples of control measures to reduce exposure • Safe injection practices: .Giving verbal announcements when passing sharps. rather than fingers. .e. retract tissue. . disposable needle and syringe for each injection given. single-use. . .Use of a sterile. .Using alternative cutting methods such as blunt electrocautery and laser devices when appropriate. . . .Using round-tipped scalpel blades instead of sharptipped blades. . • Screening for HBV. HCV and HIV and exposure prone procedures. 2000. • Education and awareness: . • Gloves. Administrative Controls • Management policy on healthcare workers infectious for HBV. • Rubber boots or plastic overshoes where the flooring / ground is likely to be contaminated. • Eye protection such as face shields / goggles / safety spectacles / visors where splashes are possible. HCV and HIV for healthcare workers especially those performing exposure prone procedures: . Personal Protective Equipment Use appropriate personal protective equipment such as: • Impervious gowns.Proper cleaning and decontamination of equipment.Staff should be aware of the hazards of bloodborne infections and trained in safe work practices. Further information can be obtained from our reference: • Ministry of Health (MOH) Singapore: Guidelines for Preventing Transmission of Bloodborne Infections in a Healthcare Setting.workplace safety and health guidelines 43 Hierarchical approach Examples of control measures to reduce exposure • Maintenance: . • Infection control practices for special lumbar procedures.Counselling for above workers. individuals with infections such as SARS. infectious diseases. usually over short distances. • Mortuary workers and autopsy room staff. This usually happens when infected patients cough. TB. autopsy etc. induction. performance of laryngeal swabs. Exposure Situations / Procedures • High risk situations where there is aerosolisation of patient’s respiratory secretions such as endotracheal intubation.e. • Clinical and research laboratory workers. surgical procedures. Mycobacterium tuberculosis (TB). influenza. Group A Streptococcus. Workers at Risk • Healthcare workers in direct patient care particularly departments of respiratory medicine. • Caring for infective patients i. areas involving care of immunocompromised patients. viruses. • Dental procedures. • Dental healthcare workers including dentists.44 healthcare Infectious Agents other than Bloodborne Pathogens Pathogens of various classes such as bacteria. cardiopulmonary resuscitation. assistants and technicians. emergency care. • Generation of aerosols of infected laboratory samples. sputum . adenovirus. Some organisms can also be transmitted by multiple routes.. Mycoplasma pneumoniae. The main modes of transmission are described below together with the appropriate preventive measures to be taken. sneeze or talk and healthcare workers inhale the particles. parasites. Bordetella pertussis and Neisseria meningitidis. rhinovirus. It is important to note that not all organisms are transmitted from person to person. fungi. The routes of infection vary with the organism and type of infection. influenza etc. Droplet Infections Such infections are spread when respiratory droplets (usually more than 5µm in diameter) carrying infectious pathogens transmit infections when they travel directly from the respiratory tract of the infectious individual to the mucosal surfaces of the susceptible recipient. cough induction by chest physiotherapy.. prions can cause infections. bronchoscopy. Examples of infections spread in this way are SARS-CoV. congestion.Use of fluid resistant mask for close contact with infectious patient. .Adhere to the proper sequence of removing PPE. . or increased production of respiratory secretions when entering a healthcare facility. rhinorrhea.workplace safety and health guidelines 45 Control Measures Hierarchical approach Engineering Controls Examples of control measures to reduce exposure • Negative pressure rooms are desirable. Safe Work Practices • Droplet precautions: . .Used with any patients and accompanying persons with undiagnosed transmissible respiratory infections. .Cohorting of patients if single room is unavailable – to discuss with infectious disease consultant.Single patient room for patient preferred. • A respiratory hygiene / cough etiquette programme should be: . • Patients to wear a fluid resistant mask (if tolerated) when being transported outside the room and to follow respiratory hygiene / cough etiquette. .Change protective attire and perform hand hygiene between contact with patients in the same room. . .Spatial separation of more than 1 metre between beds in multi-bed wards.Keep curtain drawn between beds in multi-bed wards. .Mask to be donned on entry to room. • Consider use of microbiological safety cabinets for laboratory work such as immunomagnetic separation and innoculation of biochemical test kits that may generate aerosols. .Applied to those with cough. patients and visitors. • Source control measures such as covering the mouth / nose with a tissue when coughing and prompt disposal of used tissues. of persons with respiratory infections in common waiting areas when possible. ideally more than 1 metre. • Impervious gowns. . • Spatial separation. • Eye protection such as face shields / goggles / safety spectacles / visors where splashes are possible. • Rubber boots or plastic overshoes where the flooring / ground is likely to be contaminated.46 healthcare Hierarchical approach Examples of control measures to reduce exposure . • Use of surgical masks (fluid resistant).Elements of a respiratory hygiene / cough etiquette programme are: • Education of healthcare facility staff. • Signs of instructions (as below). • Hand hygiene after contact with respiratory secretions. Administrative Controls Personal Protective Equipment • Education and training on hazards and effects as well as safe work practices. • Gloves. • Using surgical masks on the coughing person when tolerated. . infectious diseases and emergency care.. Healthcare workers can become infected when they inhale the infectious particles. rhinovirus. physicians’ offices. norovirus and rotavirus has also been demonstrated. • Dental procedures. particularly if using an oscillating saw. influenza. Workers at Risk • Healthcare workers in direct patient care particularly departments of respiratory medicine. • Respiratory and infectious disease departments. and • Ambulance crew. • Aerosolisation of infected laboratory samples. • Clinical and research laboratory workers. Microorganisms can be carried by air currents and be dispersed over longer distances and infect individuals who are not in the vicinity of infected individuals. surgical procedures and autopsy etc. Limited airborne transmission of SARSCoV. rubeola virus (measles) and varicella zoster (chickenpox). • Dental healthcare workers including dentists. influenza. performance of laryngeal swabs. bronchoscopy. cough induction by chest physiotherapy. • Emergency room staff. cardiopulmonary resuscitation. • Emergency departments. TB. Such infections include Mycobacterium tuberculosis (TB). • Outpatient clinics. • Biological waste handlers including cleaners. • Housekeeping staff. and areas involving care of immunocompromised patients. sputum induction. Variola (smallpox) can also be transmitted by this route under certain conditions. • Performing post mortems of infected patients. • Mortuary workers and autopsy room staff. assistants and technicians. Exposure Situations / Procedures • High risk situations where there is aerosolisation of patient’s respiratory secretions such as endotracheal intubation. • Caring for infective patients such as individuals with infections such as SARS.workplace safety and health guidelines 47 Airborne Infections Airborne infections are transmitted when the infectious aerosols (such as airborne droplet nuclei or small particles) are small enough to remain airborne for a longer time and distance. • Surgical staff. Maintain a distance of at least 1 metre between symptomatic and non-symptomatic patients in the waiting room. • Laminar flow. • Adhere to the proper sequence of personal protective equipment removal. .48 healthcare Control Measures Hierarchical approach Engineering Controls Examples of control measures to reduce exposure • Ventilation design.air pressure should be checked visually daily with the use of smoke tubes or flutter strips.at least 12 air changes per hour (new facility) or 6 air changes per hour (old / existing facilities). • Use of high efficiency particulate air (HEPA) filters. a single room is preferable. . rhinorrhea. • Use of airborne infection isolation rooms [AIIR] (negative pressure to the atmosphere). • Use standard precautions: .Used with any patients and accompanying persons with undiagnosed transmissible respiratory infections. • In airborne infection isolation rooms (AIIR): . pocket resuscitation masks with one way valves. congestion. . and other ventilation devices. separate infectious patients such as those with cough or sneezing in a separate enclosed room away from others. or increased production of respiratory secretions when entering a healthcare facility. • Implementation of a respiratory hygiene / cough etiquette programme which should be: . Safe Work Practices • Proper hand hygiene between contact with patients.Applied to those with cough. .In waiting rooms. • Use of biological safety cabinets in the laboratory when performing aerosol generating tests. • During resuscitation: Use of mouthpieces. • Appropriate eye protection such as safety goggles or face shields depending on the risk.Education of healthcare facility staff. • Appropriate gloves. • Rubber boots or plastic overshoes where the flooring / ground is likely to be contaminated. .Hand hygiene after contact with respiratory secretions. . . ideally more than 1 metre. of persons with respiratory infections in common waiting areas when possible.Biological safety cabinets should be used for laboratory work where necessary. . .Spatial separation. .The type and specifications of such cabinets would depend on the risk level of the microbiological agents and procedure being performed. .Signs of instructions (as below). patients and visitors.Source control measures such as covering the mouth / nose with a tissue when coughing and prompt disposal of used tissues. Administrative Controls Personal Protective Equipment • Education and training on hazards and effects as well as safe work practices.Refer to the Respiratory Protection Programme section on page 127 for details.Using surgical masks on the coughing person when tolerated.workplace safety and health guidelines 49 Hierarchical approach Examples of control measures to reduce exposure • Elements of a respiratory hygiene / cough etiquette programme are: . • Fit-tested particulate respirator N95 or higher. • Safety equipment: . • Impervious aprons. . E. For more examples of infections and routes of transmission: refer to Appendix B . Workers at Risk • Healthcare workers caring for infectious patients. • Dental healthcare staff such as dentists. bodily fluids and body parts. • Maintenance of contaminated biomedical equipment. respiratory secretions and excretions of patients. Clostridium difficile. • Dental procedures. and direct skin contact with infected patients.50 healthcare Infections Transmitted by Direct Contact Healthcare workers can become infected when they come into direct contact with blood. Infections transmitted by direct contact include gastrointestinal infections such as Salmonella typhi. • Biomedical technicians and engineers. • Emergency departments. • Waste handling and disposal staff. • Operating theatres. Norovirus. assistants. technicians. coli O157. ringworm. dental nurses. • Operating theatre staff. Exposure Situations / Procedures Caring for infectious patients without using proper barrier precautions: • Wards. scabies (mites). Campylobacter jejuni. urine and vomit. • Clinical and research laboratory staff. orf. skin and soft tissue infections such as Staphylococcus aureus. Hepatitis A. • Housekeeping and laundry. • Outpatient clinics or physicians’ offices. • Waste handling and disposal. . • Clinical and research laboratories. herpes simplex virus (HSV). excreta such as faeces. and viral respiratory tract infections such as respiratory syncytial virus (RSV). • Housekeeping staff. Not using proper barrier precautions in the following situations: • Performing post mortems of infected patients. Methicillin resistant Staphylococcus aureus (MRSA). • Maintaining a distance of at least 1 metre between symptomatic and non-symptomatic patients in the waiting room. • When removing PPE. • Proper cleaning and disinfection of shared toys between patient use (in paediatrics). • Keep nails short and discourage use of artificial nails. pocket resuscitation masks with one way valves. • Laboratory coats should be washed separately from other clothes. • Proper cleaning and disinfection of biomedical equipment such as endoscopes.workplace safety and health guidelines 51 Control Measures Hierarchical approach Engineering Controls Examples of control measures to reduce exposure • Isolation of patients in a single room is preferable. • Proper containment and disposal of contaminated waste and PPE. and other ventilation devices. • During resuscitation: Use of a mouthpiece. • Proper labelling of bags of used PPE. Safe Work Practices • Use standard precautions. • Use of disposable protective sheaths / sleeves for patient care devices where appropriate. • Proper hand hygiene after contact with each patient. gloves should be removed last. patient care equipment like thermometers and glucose monitoring devices. ideally should not be brought home. . put on PPE on entry to the room. • Segregation of used disposable and non-disposable PPE. • Adhere to the proper sequence of PPE removal. surgical instruments. • When nursing a patient on contact precautions. • Hand hygiene should be performed following removal of gloves. • Impervious aprons. • Rubber boots or plastic overshoes where the flooring / ground is likely to be contaminated.52 healthcare Hierarchical approach Administrative Controls Personal Protective Equipment Examples of control measures to reduce exposure • Education and training on hazards and effects as well as safe work practices. • Appropriate gloves. • Appropriate eye protection such as safety goggles or face shields. . Exposure Situations / Procedures • Use of cereal flours in food preparation such as sifting or addition of flour. this might occur in the kitchens and animal research facilities. Vegetable Matter Workers exposed to vegetable matter such as wheat. dermatitis and occupational asthma. . soybean. • Gloves. • Apron. • Animal husbandry workers. Workers at Risk • Kitchen aides and cooks. local exhaust ventilation. Personal Protective Equipment • Appropriate respirators. buckwheat and other cereal flours. Safe Work Practices • Transfer flour or animal feed in such a way to minimise generation of dust. • Wet cleaning of dusty areas. • Non-slip shoes. Control Measures Hierarchical approach Engineering Controls Examples of control measures to reduce exposure • Consider enclosing the weighing and sifting process. Mode of Exposure Workers are exposed to vegetable proteins through direct contact or by inhalation. • Automate the sifting process. • Transfer of animal feed to smaller containers.workplace safety and health guidelines 53 Biological Matter Exposure to certain animal and vegetable proteins can cause allergies. raw cotton fibres and other vegetable proteins can develop asthma or dermatitis. • Implement a Respiratory Protection Programme if respirators are used (see page 127). safe work practices and use of appropriate PPE. fit-tested if necessary. • Use of local exhaust ventilation together with enclosure for sifting process. In the healthcare setting. The organisation should assess the exposure risk and implement control measures such as improved ventilation. Exposure Situations / Procedures • Handling animals in animal research facilities. . • Kitchen workers. • Working at biomedical research facilities. Control Measures Hierarchical approach Engineering Controls Examples of control measures to reduce exposure • Ensure proper ventilation. • Use of cell lines in research laboratories. Administrative Controls • Education and awareness. • Biomedical researchers. air flow and sufficient air exchange. • Animal researchers. In the kitchens. • Use of biological safety cabinets where appropriate.54 healthcare Animal Proteins Researchers and veterinary workers who handle animals may develop occupational asthma or dermatitis due to inhalation of or direct contact with animal proteins found in fur. Workers at Risk • Animal husbandry workers. Safe Work Practices • Standard precautions. • Cover all open wounds with waterproof plaster. • Use of animal tissues / parts in research laboratories. • Personal protective equipment and laboratory coats should not be worn outside the working areas. dried secretions and excreta of animal. employees can be exposed to animal proteins as they handle fish and meats in food preparation. • Local Exhaust Ventilation (LEV) and well designed ventilation in animal housing areas. • Implement a Respiratory Protection Programme if respirators are used (see page 127). • Handling various meats in food preparation. • Centers for Disease Prevention and Control (CDC). • Gloves. UK : Biological Agents: Managing the Risks in Laboratories and Healthcare Premises. • Workplace Safety and Health (Risk Management) Regulations. 2003. Current as of 15 December 2007. • Appropriate shoes. • Ministry of Health (MOH) Singapore: Guidelines for Preventing Transmission of Bloodborne Infections in a Healthcare Setting. 2000. 2006. • Impervious aprons. .workplace safety and health guidelines 55 Hierarchical approach Personal Protective Equipment Examples of control measures to reduce exposure • Respirators where appropriate (fit-tested). • Centers for Disease Prevention and Control (CDC). • Eye protection. • World Health Organisation (WHO): WHO Laboratory Biosafety Manual 3rd edition. USA: Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Current as of 15 December 2007. Further information can be obtained from our references: • Health and Safety Executive (HSE). 2007. 2005. USA: Guidelines for Infection Control in Dental Healthcare Settings. Accessed 2 July 2007. • lifting patients who cannot support their own weight or who are overweight. • multiple lifts per shift.g.bending – lateral or side bending. • working beyond one’s physical capabilities. laundry. kneeling.. • distance to be moved. trying to stop a patient / resident from falling or picking patient / resident up from floor or bed. • employee exposure to ergonomic stressors in healthcare workplaces occurs not only during patienthandling tasks but also while performing other tasks as well in the kitchen. • done in awkward postures e.g. Adjusting the work environment and work practices can prevent injuries before they occur.g. and the distance the patient / resident is from the employee. Increased ergonomic risk can occur from patient handling tasks which are: • repetitive e. squatting. . • done using a great deal of force e. pushing chairs or gurneys across elevation changes or up ramps. the equipment and the work task. . repeatedly cranking manual adjustments for beds.. for example during the transportation of equipment. moving food carts or other .56 healthcare Physical Hazards Ergonomics Ergonomics is the science of fitting the job to the worker.. no available staff to help. .reaching above shoulder height.twisting of the back. bending over. lifting or transferring patients / residents. reaching across beds to lift patients / residents. or leaning over a bed. Healthcare employees are at risk when handling. The use of inappropriately designed equipment or tools can contribute to the development of musculoskeletal disorders as it would require the worker to adopt awkward postures when using it. • awkward postures: . Other hazards include: • overexertion – e. the design of equipment and work tasks to conform to the capability of the worker.fixed awkward postures can contribute to development of musculoskeletal disorders. manually lifting immobile patients / residents alone.g. and housekeeping areas of facilities. engineering. (it is more stressful to reach away from the body to lift or pull a patient / resident).. • lifting heavy objects e. • lifting alone.g. Musculoskeletal disorders can result from a mismatch between the capabilities of the workers. or chair to car. use team lifts or use mechanical assistance. Patients / residents are slid rather than lifted. Control Measures Handling. They usually involve multiple staff members to help do the lifting. • slip sheets / roller sheets: Help to reduce friction while laterally transferring patients / residents or repositioning patients / residents in bed and to help reduce the force workers need to exert to move the patient / resident. bed to chair. Avoid hand cranked beds. • wheelchairs with removable arms to allow for easier lateral transfers. This type of device helps prevent back injuries in staff. and during housekeeping tasks.workplace safety and health guidelines 57 heavy carts. and are totally mechanical. using hand tools. This is often done with the help of a draw sheet. especially useful with height adjustable beds. Two or more persons may be deployed to lift heavy loads. which can lead to wrist / shoulder musculoskeletal disorders such as strain or repetitive motion injuries. • training on when and how to use mechanical assistance. When lifting patients or loads: • never transfer patients when off balance. These beds can be kept low to the ground for patient / resident safety and then raised up for interaction with staff. pouring liquids out of heavy pots or containers. These include: • sliding boards / patient slides: A slick board used under patients / resident to help reduce the need for lifting during the transfer of patient / resident from . • height adjustable electric beds that have height controls to allow for easy transfers from bed height to wheelchair height. Boards and sheets can be used to help move patients. • never lift alone. Some new lateral transfer systems do not require any lifting by staff. Lifting or Transferring Patients Mechanical lifting equipment can help lift patients who cannot support their own weight and these include: • overhead track mounted patient lifters built into the ceiling can be used to move patients from room to room without manual lifting. • avoiding awkward postures while lifting or moving patients. • lateral transfer devices: Devices used to laterally transfer the patient / resident for example from bed to gurney. or similar device. • avoid heavy lifting especially with spine rotated. reaching into deep sinks or containers. • lift loads close to the body. particularly fallen patients / resident. The worker should adopt proper lifting techniques and use assist devices and other equipment to reduce excessive lifting hazards. • limit the number of allowed lifts per employee per day. and housekeeping when possible that have side openings to allow for easy disposal without reaching into and pulling bags up and out. • installing chutes and dumpsters at or below grade level. • using spring-loaded platforms to help lift items such as laundry. • ensure that passageways are unobstructed. hampers. or other carts well maintained to minimise the amount of force exerted while using these items. low rolling resistance wheels. • using handles to move carts rather than the side of the cart to prevent the accidental smashing of hands and fingers. Keep arms close to your body and push with your whole body not just your arms. The bags should be able to slide off the cart without lifting. or • removing objects to be washed into a smaller container on the counter for scrubbing or soaking and replacing back in the sink for final rinse. • keeping floors clean and well maintained. laundry or other kinds of bags by: • using handling bags for laundry. • using carts with large. • attach handles to equipment to help with the transfer process. • push rather than pull equipment when possible. . gurneys. keeping work at a comfortable uniform level. • pushing rather than pulling whenever possible. or have wheels attached to the equipment. • getting help with heavy or bulky loads. Reaching and Lifting Tasks Limit excessive reaching and back flexion when reaching into deep sinks or containers by: • placing an object such as a plastic basin in the bottom of the sink to raise the surface up while washing items in the sink. Limit reaching or lifting hazards when lifting trash. laundry. • get help when moving heavy or bulky equipment or equipment that you cannot see over. housekeeping or other carts by: • keeping carts.58 healthcare Transferring or moving items or objects: • place equipment on a rolling device if possible to allow for easier transport. • limiting the size and weight of these bags and provide handles to further decrease lifting hazards. • do not transport multiple items alone. These can usually roll easily over mixed flooring as well as gaps between elevators and hallways. • keeping handles of devices to be pushed at waist to chest height. • placing receptacles in unobstructed and easy to reach places. garbage. Limit reaching and pushing hazards from moving heavy dietary. arms. • have minimal tool weight. Hand tools should: • be properly designed. and support by providing resources are essential to the success of an ergonomics programme.g. of maintenance workers by choosing hand tools carefully. Management Policy and Support Management polices defining clear goals and responsibilities. • allow the wrist to remain straight while doing finger intensive tasks. Employees should be involved as they are a vital source of information about hazards in their workplace. . These solutions could involve the use of equipment or a change in work practices or both. • monitoring and review. The key elements of a successful ergonomics programme include: • management policy and support. The aim is to identify: • manual handling hazards. and leads to greater acceptance when changes are made in the workplace. • tasks and processes with high ergonomic risks. • education and training. • avoiding awkward postures while cleaning (e. and shoulders. • have minimal vibration or use vibration dampening devices and vibration-dampening gloves. • risk assessment and risk control. Ergonomics Programme An effective ergonomics programme should include management leadership and employee participation. • avoiding tight and static grip and using padded non-slip handles. • have padded non-slip handles. Handtools Limit strains and sprains of the wrists.workplace safety and health guidelines 59 Housekeeping Tasks Employees can reduce ergonomic hazards during housekeeping by: • using carts to transport supplies rather than carrying. twisting and bending). and fit to the user. This enhances worker motivation and job satisfaction. Implementation of ergonomic solutions should follow the hierarchy of controls. The previous pages have identified typical high risk tasks and activities in healthcare as well as suggested control measures. • reporting system and investigation process. • alternating tasks or rotate employees through stressful tasks. Select ergonomic tools such as ergonomic knives or bent-handled pliers. Risk Assessment and Control A risk assessment for ergonomic risks should be done for all existing and new work activities. . Monitoring and Review In addition. risk of hazard after improvement must be established and areas where further improvement is needed should be followed up. and . All improvement measures should be evaluated for their effectiveness to help sustain the effort to reduce injuries and illnesses.reviews. . Periodic review of ergonomic control measures should be carried out to ensure that such measures remain effective. .employee surveys.insurance company reports. 2002. There should be procedures for the investigation of the incident / accident.osha. Improvement measures should be evaluated if they introduce new problems. Occupational Safety and Health Administration (OSHA): Hospital E-tool: http://www. Training on Safe Manual Handling and Lifting Techniques Provision of training ensures that employees and managers can recognise potential ergonomic issues in the workplace and understand measures that are available to minimise the risk of injury. reporting of the investigation findings and implementation of action plan by the various personnel or departments. . • US Department of Labor. .accident and near-miss investigation reports.html Current as of 15 December 2007. Training on safe manual handling and lifting techniques should be included in induction training for new employees and form part of the regular refresher courses. a surveillance system should also be put in place to systematically identify ergonomic concerns in the workplace by analysing: . Further information can be obtained from our references: • Singapore Standard: CP 92: Code of Practice for Manual Handling.observations of workplace conditions.gov/ SLTC/etools/hospital/index. This is important for continuous improvement and long-term success of the programme. . .active case finding. Active case finding and observation of trends should prompt management to review the presence of possible ergonomic risks and implement control measures if the risk is elevated.reports of workers’ compensation claims.60 healthcare Reporting System and Investigation Process A system for prompt reporting of injuries and musculoskeletal diseases should be established.injury and illness information.employee interviews. . A decibel is the sound level reading obtained on the A scale of a sound level meter at slow response. workshops. Impact (impulse) noise is noise at intervals of more than one second. laundry staff. • Provision of suitable personal hearing protectors to all persons exposed to excessive noise and ensuring their usage. • Provision of enclosures with acoustical foam lining for noisy compressors and equipment.workplace safety and health guidelines 61 Noise In a healthcare facility. nurses and doctors / dentists working in orthotics. Healthcare personnel at risk include workshop technicians. . interference with speech communication and with perception of warning signs. plaster rooms and dental centres / clinics. annoyance and extra-auditory effects. laundry areas. orthotics. Employees should not be exposed to impact noise exceeding 140 dBAs. disruption of job performance. excessive noise levels can be encountered in compressor rooms. acoustic trauma. plaster rooms and dental centres / clinics. • Acoustical treatment of walls to reduce noise reflection. facilities management staff. Control Measures Hierarchical approach Elimination / Substitution Engineering Controls Examples of control measures to reduce exposure • Replacement of metal-to-metal contact with synthetic material-to-metal contact. The A scale contains the frequency range of the human ear. Administrative Controls Personal Protective Equipment • Limiting persons’ exposure time to excessive noise through job rotation. Prolonged exposure to excessive noise can cause noise-induced hearing loss (NIHL). Noise exposure limits are expressed in decibels (dBAs). other detrimental effects of excessive noise exposure include tinnitus. • Application of vibration damping to noisy machines using springs or elastomers. such as engineering and administrative controls to minimise the risk from noise.g. • record keeping e. • implementation of reasonably practicable noise control measures. including management. . • provision of suitable personal hearing protectors to all persons exposed to excessive noise and ensuring their usage. documenting the measures taken to protect employees from noise. The basic hearing conservation programme should include: • monitoring of noise exposure levels for identification of noise hazard and evaluation of the risks involved. Current as of 15 December 2007. 2003. • training and educating all persons involved in HCP. 2003. to increase their awareness of noise hazards and their prevention. • Ministry of Manpower (MOM): Hearing Conservation Programme Guidelines. • Singapore Standard: CP 99: Code of Practice for Industrial Noise Control. • evaluation of HCP to determine its effectiveness and areas for improvements.62 healthcare The control of excessive noise can be supported by establishing an effective hearing conservation programme (HCP) whenever employee noise exposures equal or exceed eight hour time weighted average (TWA) sound level of 85 dBAs. • annual audiometric examinations to determine the effectiveness of HCP in preventing NIHL and for detection of early hearing impairment. • Ministry of Manpower (MOM): Guidelines on Noise and Vibration Control. Further information can be obtained from our references: • Workplace Safety and Health (Noise) Regulations. HCP team members and all employees who are exposed to excessive noise. Intense vibration may be transmitted to persons who operate certain vehicles.workplace safety and health guidelines 63 Vibration Noisy processes are often associated with vibration. dental ultrasonic scalers and vibrators. the exposure must be controlled and maintained within limits to protect them from adverse health effects. Further information can be obtained from our reference: • Ministry of Manpower (MOM): Guidelines on Noise and Vibration Control. doctors and nurses working in orthotics. • Designing work breaks to avoid long periods of vibration exposure. • Ensuring that all equipment and hand tools are maintained in good condition. operating theatres and dental centres / clinics and cleaners. Healthcare personnel at risk include workshop technicians. Where persons are exposed to whole body or hand-arm vibration. Control Measures Hierarchical approach Elimination / Substitution Safe Work Practices Administrative Controls Examples of control measures to reduce exposure • Procuring low vibration equipment and tools in replacement of high-vibration ones. bone drills / saws in operating theatres).g. dentists. 2003. equipment (e. . grinders and cutters in prosthesis workshop) and hand held tools (e.g. • Provision of information and training to affected personnel on the hazard. signs of injury and ways to minimise risk and report any symptoms. plaster rooms. bystanders and members of the public who are near an irradiating machine in operation or radionuclide sources.vomiting. The amount of exposure depends on the amount of radiation. radioactive materials used in nuclear medicine and other ionising radiation generating devices. • Radiation monitoring equipment should be used to monitor the working environment. . .64 healthcare Ionising Radiation The Radiation Protection Act and its Regulations for ionising radiation covers radioactive materials and ionising radiation generating apparatus used in the healthcare industry. healthcare establishments need to apply for the appropriate licenses from the Centre for Radiation Protection and Nuclear Science. The radioactive wastes generated are also governed by these legislations. The effects of radiation exposure include: • Deterministic effects: . .e.bone marrow suppression. . Exposure to radiation can occur in the following situations: • unprotected employees. • badly maintained machinery and improperly designed facility / room. • Stochastic effects: Cancer: Genetic effects may lead to congenital defects in the employee’s offspring (i. • exposure may come from patients undergoing nuclear medicine procedures. • exposure may also result from handling of radioactive spills. distance from the source and type of shielding in place.nausea. and . Large whole-body exposures cause .weakness. • spent sources of radioactive materials or contaminated materials which are not properly stored or handled. Radiation Exposure in Healthcare Healthcare employees may be exposed to ionising radiation from portable and fixed X-ray machines. .death.diarrhoea. hereditary effects). To own and to use the radioactive materials and the apparatus.temporary or permanent sterilisation. .erythema and dermatitis. duration of exposure. • employees can be exposed to radioactive isotopes or specimens and excreta of humans and animals who have received radioisotopes. Exposure Monitoring • Thermoluminescent dosimetry badges or their equivalent should be used for long-term monitoring of personnel. National Environment Agency (NEA-CRPNS). .cataract. workplace safety and health guidelines 65 • Appropriate personnel monitoring equipment. such as film badges. • Establish a preventive and corrective maintenance programme for X-ray machines with specific personnel responsible for assuring proper maintenance of the X-ray machines. or film rings. handled or stored. pocket chambers. • Use lead glass as a barrier to protect against radiation exposure when procedures must be done close to the patient. Safe Work Practices • Give adequate warning to surrounding staff or members of the public before operating X-ray machines. • Provide lead shields for syringes or vials containing radioisotopes. should be used to monitor healthcare workers who may be exposed to radiation hazards. pocket dosimeters. those that can operate with a smaller electric current should be considered. • Records of the radiation exposure of the employees should be kept and the employee should be advised of his individual exposures as according to licensing conditions. • Establish a contamination monitoring plan for all work areas where radioactive materials are used. . Engineering Controls • Operate the X-ray and other (portable) irradiation devices with adequate shielding in accordance to the Radiation Protection Act and Regulations. Control Measures Hierarchical approach Elimination / Substitution Examples of control measures to reduce exposure • When purchasing new X-ray machines. • Use advanced (digital) screen / material so that X-ray operating at a smaller electric current can still give the same picture quality. shielded from radiation exposure. • Use lead strips during fluoroscopic procedures. • Some procedures like those that use remote fluoroscopy can be run from control panels in an adjacent room. 66 healthcare Hierarchical approach Examples of control measures to reduce exposure • Implement safe work procedures for cleaning up of contaminated work areas. • Establish guidelines to manage patients who are undergoing nuclear medicine procedures. Personal Protective Equipment • Provision of proper personal protective equipment e. lead gloves. • There should be a separate storage area for radioactive sources. These licences are only issued to qualified medical practitioners who have the necessary knowledge on the safe use of these apparatus. • Provide proper cleaning agents for cleaning of work areas and hands. leads aprons.g. Administrative Controls • Medical establishments need to obtain appropriate licenses to own irradiating apparatus and radioactive materials. appropriate licences need to be obtained from the regulatory authority. thyroid shields and lead goggles. This area should be adequately shielded. . • To use radioactive materials (for medical purposes). • To operate an irradiation apparatus. These licences are only issued to qualified / relevant medical practitioners who have the necessary knowledge on the safe use of these materials. appropriate licences need to be obtained from the regulatory authority. • Document and retain inventories of radioactive materials. Only authorised personnel should have access to such a storage area. Healthcare establishments are advised to consult NEA-CRPNS on matters relating to the disposal of such waste.workplace safety and health guidelines 67 Radioactive Waste Management Unusable radioactive materials and articles / things contaminated by radioactive materials are generally considered radioactive waste. In addition. This area should be adequately shielded. • Only authorised personnel should have access to such storage areas. • Healthcare establishments should establish a safety committee or a radiation safety officer to be responsible for the disposal of radioactive waste. . written consent from NEA-CRPNS is needed before the disposal can be carried out. Two main types of radioactive waste can be found in the healthcare establishments: • low level radioactive waste (solid and liquid). Disposal of radioactive waste from any healthcare establishment requires approval from the establishment’s internal committee or officer responsible for radiation safety. Radiation protection legislations do not allow such waste to be disposed of or accumulated without the approval of the DirectorGeneral for Environment Protection. Control Measures Hierarchical approach Safe Work Practices Administrative Controls Examples of control measures to reduce exposure • There should be a separate storage area for radioactive waste. • spent sealed sources (solid). Safety and Security. http://app.org/unscear/index.htm • Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) Radiation Health Series.energy.nea. http://www.html • The International Commission on Radiological Protection (ICRP) http://www. 2007. http://hss.sg/cms/htdocs/article.cfm • US Department of Energy (DOE). Office of Health.iaea.unscear.eu/energy/nuclear/radioprotection/publication_en.ncrponline.html • National Council on Radiation Protection and Measurements (NCRP) http://www. • Radiation Protection (Ionising Radiation) Regulations.au/publications/Codes/rhs.icrp.europa.arpansa.org/Publications/index. Nuclear Safety and Environment Online Approved DOE Technical Standards.gov.asp?pid=2885 • European Commission Energy – Nuclear Issues.gov/nuclearsafety/techstds/standard/standard.html All URLs on this page were current as of 15 March 2008. . http://ec.gov.org • International Atomic Energy Agency http://www.68 healthcare Further information can be obtained from our references: • Radiation Protection Act. • Disposal of Radioactive Waste.org/ • United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) http://www. Continuous lasers in this class operate at a power of less than 0. Laser beam should be kept away from any flammable liquid. Class IV – This class of laser has the highest energy. Many laser pointers belong to this class.005 W. The electric current used to generate the beam is a potential shock hazard.001 W. which is the aversion response time. Continuous lasers in this class operate at a power of less than 0.5 W. a laser can have various properties. Direct beam exposure can cause burns to the skin. gases or any flammable object that can emit flammable vapour. • Magnetic Resonance Imaging (MRI) apparatus. Exposure usually occurs from unintentional operation and / or when proper controls are not in effect. Continuous lasers in this class operate at a power in the range 0. The four classes of lasers are: Class I – The least-hazardous class. Laser A laser is a device that emits intense coherent light through a special mechanism called stimulated emission. Class IIIb – This is considered as a high power laser. Considered incapable of providing damaging levels of laser emissions. resulting in possibly blindness. . May extend across the whole electromagnetic spectrum and are hazardous when viewed intrabeam. Exposure to Lasers in Healthcare Exposure of healthcare workers to lasers can occur in the operating rooms during excision and cauterisation of tissues. Used in laser printers and compact disc players. It also extends across the whole electromagnetic spectrum. Class IIIa – This class of laser is dangerous under direct or reflected vision. This class includes lasers that emit both invisible and visible electromagnetic spectrum. Lasers in this class are used in physiotherapy treatments and for research purposes. Class II – Applies only to visible laser emissions and may be viewed directly for time periods of less than or equal to 0. Healthcare establishments need to obtain the appropriate licenses to own and / or to operate such irradiating apparatus.workplace safety and health guidelines 69 Non-ionising Radiation The Radiation Protection Act and Regulations for non-ionising radiation apply to the following types of medical irradiating devices: • high power lasers. Some laser pointers and laser barcode scanners belong to this class. Class 4 lasers are used for laser displays.25 seconds. skin. where Class IIIb and Class IV lasers are most often used. and eye hazards. Fire is another major concern when using lasers. and to the eyes. laser surgery and cutting metals. • medical ultrasound apparatus. As a light source. • ultraviolet sunlamps.001 – 0. depending on the purpose for which it is designed and calibrated. It presents significant fire. • All doors to operating rooms that house lasers should contain safety interlocks which shutdown the laser system if anyone enters the room. Only qualified personnel (with the appropriate licences) should maintain the system. Classifications of lasers should coincide with actual power output. all windows in laser surgical areas to protect employees outside the surgical area. . Safe Work Practices • Establish a preventive and corrective maintenance programme for laser machines with specific personnel responsible for assuring proper maintenance of this equipment. • Laser operators should check the laser system before each procedure and during extended procedures. Only personnel trained in laser technology should make measurements. or if alterations have been made to the laser system that may have changed its classification. • Adequately insulate / ground laser systems. • Attach bleeders and proper grounding to the system. especially those with high voltage capacitance. • Cover or black out. Administrative Controls • Ensure all personnel using such equipment are trained in the proper usage. Only personnel with the appropriate licence are allowed to use Class IIIb and Class IV laser devices. Maintenance may only be done according to written standard operating procedures.70 healthcare Control Measures Hierarchical approach Engineering Controls Examples of control measures to reduce exposure • Use portable smoke evacuators and room suction systems. Generally. if the laser system has not been classified. • Provide warning signs in areas where exposure to lasers is likely. power measurement is required when the manufacturer’s information is not available. • Provision of skin covers and / or “sun screen” creams is recommended for ultraviolet lasers (200-400nm). consideration should be given to flame resistant materials). Further information can be obtained from our references: • Radiation Protection Act. . e. For Class IV lasers.g. 2007. gloves (tightly woven fabrics and opaque gloves provide the best protection) and laser protective eyewear (wavelength of the laser is the most important factor in determining the type of eye protection to be used). • Radiation Protection (Non-ionising Radiation) Regulations. protective clothing (laboratory jacket or coat can provide protection for the arms.workplace safety and health guidelines 71 Hierarchical approach Personal Protective Equipment Examples of control measures to reduce exposure • Provision of proper personal protective equipment. healthcare workers may be exposed to laser or electro-surgical smoke. . Although there has been no documented transmission of infectious disease through surgical smoke. and absorbers as infectious waste and dispose of them appropriately. bio-aerosols. Note that the laser beam may ignite the plume or biological vapours. and creates visual problems for the surgeon. • Consider all tubing. dead and live cellular material (including blood fragments). The smoke may act as a vector for cancerous cells which may be inhaled by the surgical team and other exposed individuals. • Keep the smoke evacuator or room suction hose nozzle inlet as close as possible (within 1 diameter of the suction hose) to the surgical site to effectively capture airborne contaminants. At high concentrations the smoke causes ocular and upper respiratory tract irritation in healthcare workers. the thermal destruction of tissue creates smoke as a by-product. Consequently. the potential for generating infectious viral fragments. • Keep smoke evacuator ON (activated) at all times when airborne particles are produced during all surgical or other procedures. • Inspect smoke evacuator systems regularly to prevent possible leaks. and formaldehyde. The smoke has unpleasant odours and has been shown to have mutagenic potential. Control Measures Hierarchical approach Engineering Controls Safe Work Practices Examples of control measures to reduce exposure • Use portable smoke evacuators and room suction systems. hydrogen cyanide. particularly following treatment of venereal warts. and viruses. Potential Hazards Research has shown that the laser smoke plume can contain toxic gases and vapours such as benzene. • Install new filters and tubing before each procedure. filter.72 healthcare Exposure to Laser Plume in Healthcare During surgical procedures that use a laser or electro-surgical unit. may exist. body fluids. Standard Precautions are based on the principle that all blood. excretions except sweat. * Excerpt from Centers for Disease Control and Prevention. NIOSH): Hazard Controls . secretions. Current as of 15 December 2007.html. gloves and laser protective eyewear. 1996.gov/ncidod/dhqp/gl_isolation_ standard.* 4 For details on Standard Precautions. Standard Precautions include a group of infection prevention practices that apply to all patients.cdc.Control of Smoke from Laser / Electric Surgical Procedures. National Institute for Occupational Safety and Health (CDC. http://www. regardless of suspected or confirmed infection status.workplace safety and health guidelines 73 Hierarchical approach Examples of control measures to reduce exposure • Practice Standard Precautions4. in any setting in which healthcare is delivered. nonintact skin. 2000” published by Ministry of Health. . Current as of 15 December 2007. Personal Protective Equipment • Provision of proper personal protective equipment e.g. Singapore. Further information can be obtained from our reference: • Centers for Disease Control and Prevention. and mucus membranes may contain transmissible infectious agents. refer to “Guidelines for Preventing Transmission of Bloodbourne Infections in a Healthcare Setting. 74 healthcare Medical Ultrasound Medical Ultrasound apparatus are used for diagnostic. • Radiation Protection (Non-ionising Radiation) Regulations. Since these apparatus are electrical devices. Control Measures Hierarchical approach Safe Work Practices Examples of control measures to reduce exposure • To implement an inspection plan to detect any possible wear and tear which exposes any current conducting part on the apparatus. Further information can be obtained from our references: • Radiation Protection Act. 2007. • To put in place quality control procedures and testing programme to ensure apparatus performance specifications are met. • Guidelines on the Use of Ultrasound in Medicine (Academy of Medicine. • A license is needed to possess / own such apparatus. therapeutic and surgery purposes. Administrative Controls • Only qualified personnel are allowed to operate this apparatus. . care must be taken to avoid any possible electric shock and electrocution. Singapore). They emit ultrasound at acoustic frequencies above 16 kHz. • Proper warning signs to alert people of the generation of radiofrequency radiation. • A license is needed to possess / own such apparatus. • Radiation Protection (Non-ionising Radiation) Regulations. • Only qualified personnel are allowed to operate this apparatus. In addition. care must be taken to avoid any possible electric shock and electrocution. 2007. Control Measures Hierarchical approach Safe Work Practices Examples of control measures to reduce exposure • To implement an inspection plan to detect any possible wear and tear which exposes any current conducting part on the apparatus. • Proper warning signs to alert people of the high magnetic field in the vicinity and its dangers. strong magnetic fields may propel small objects and lead to physical injury if there is no proper shielding. Since this apparatus is an electrical device. .workplace safety and health guidelines 75 Magnetic Resonance Imaging Magnetic resonance imaging (MRI) apparatus emit strong magnetic fields and radiofrequency radiation for the purpose of imaging or spectroscopy of the human body. Administrative Controls Further information can be obtained from our references: • Radiation Protection Act. Strong magnetic fields may have harmful effect on the human body. • To implement an inspection plan to detect any possible wear and tear which exposes any current conducting part on the apparatus. Personal Protective Equipment • Provision of proper personal protective equipment e. Since these apparatus are electrical devices. Further information can be obtained from our references: • Radiation Protection Act. Control Measures Hierarchical approach Engineering Controls Safe Work Practices Examples of control measures to reduce exposure • Ensure that the appropriate safety features are built into the apparatus. Administrative Controls • Only qualified personnel are allowed to operate this apparatus. • A license is needed to possess / own such apparatus.g. . • To put in place quality control procedures and testing programmes to ensure apparatus performance specifications are met. • Radiation Protection (Non-ionising Radiation) Regulations. care must be taken to avoid any possible electric shock and electrocution. 2007. protective eyewear.76 healthcare Ultraviolet Sunlamps These are apparatus that emit ultraviolet radiation (λ = 180 – 400 nm) to induce skin tanning or other cosmetic effects. suture and injection needles. workers’ compensation claims. Examples include scalpels and blades. Health Surveillance There should be a system in place to monitor work-related ill health in sharps exposed employees. safe work procedures. biological matter and chemicals. Prevention • Vaccinations . responsibilities and resources is vital for a successful programme. a vaccination programme should be implemented. at source and control measures should follow the hierarchy of controls namely eliminations or substitutions. employee surveys and workplace observations.A system should be set up to report and investigate all cases of sharps injuries and near-misses.Where certain occupational infections due to sharps injuries can be prevented by vaccinations. a post exposure programme should be in place to cope with injured employees who have been exposed to occupational infections. lacerations or puncture wounds. administrative measures including education and training. Involvement of employees is important as they are most familiar with the hazards at the workplace. Identification of Hazards Areas and processes where there is a risk of sharps injuries should be systematically identified from information from injury and illness data. knives. near miss investigation reports. Risk Assessment and Risk Control The risks should ideally be controlled . employee interviews. For more information: refer to Biological and Infectious Hazards section on page 35. incident reporting and investigation .workplace safety and health guidelines 77 Sharps ‘Sharps’ are objects that have a thin cutting edge or point able to cause injuries such as cuts. as well as broken glass and porcelain. machinery and cutting devices. engineering control measures. insurance company reports. and use of appropriate personal protective equipment. Treatment given would depend on what the exposure was. Post-Exposure Programme In the event that a sharps injury does occur. • Case finding. and address fitness to work. This system should also ensure that legislative Management System An effective sharps management programme should have the following elements: Management Policy and Strategy Management support with the provision of clear goals. laundries.Records of sharps exposures. .wards. For more information: refer to Biological and Infectious Hazards section on page 35 . cutting devices and . . blades.waste disposal staff.laboratory staff.mortuaries. health effects should be analysed by management to ensure that the safety and health policy and procedures remain effective and relevant. • Education and training . bodily fluids. • Handling sharps in: . infection control policies. HIV and other infections could occur. Results of such investigations and the controls implemented should also be documented. .Information on sharps injuries. infections such as hepatitis B.nursing staff. . and .78 healthcare requirements for reporting are met.All employees working in areas where there is potential for sharps exposure should be trained in the proper use of sharps. suture and injection needles. • Record keeping .kitchens. and .radiologic and radiotherapy facilities.waste storage and treatment areas. hepatitis C.kitchen staff.clinics. mechanism.laboratory staff. Reporting of any occupational disease that occurs as a result of sharps exposure is required under the current Workplace Safety and Health Act. • Monitoring and review . The sharps could also be contaminated by chemicals such as solvents. Such documentation should be kept for at least 5 years or longer where appropriate. interventions and any worker followup should be properly kept and maintained. The training programme should also ensure that safe work procedures are known and understood by all staff. .engineering workshops.waste storage and treatment areas. vaccinations. and . machinery in: . . • Handling of broken glass and porcelain by: . If the sharp objects are contaminated by either human or animal blood. • Use of knives. .clinical and research laboratories and facilities. location. post-exposure prophylaxis and reporting procedures for occupational accidents and diseases. and machinery in: . usage of personal protective equipment where appropriate. Exposure Situations / Procedures • Use of scalpels. .pharmacy and drug preparation areas. . .operating theatres. . cutting devices and equipment.housekeeping staff. secretions and excrement. oral. Housekeeping staff. Safe Work Practices In clinical areas: • Avoid recapping of syringes. Control Measures Hierarchical approach Elimination / Substitution Examples of control measures to reduce exposure • Reduce and / or eliminate use of sharps where possible. Waste disposal staff. • Set up instrument trays with uniform orientation of all sharps. and radioactive material.. e. • • • • • • • • Nurses. • TCM practitioners. • Consider needless intravenous delivery systems. Laboratory staff. . soft tissue etc. muscle.workplace safety and health guidelines 79 disinfectants. Workers at Risk • Doctors. Pharmacy and related staff.. Kitchen staff. For more information: refer to Hazardous Waste Management section on page 104. e. meat slicers and vegetable slicers. • Dentists. resulting in adverse health effects. • If recapping cannot be avoided. Radiologic and radiotherapy staff.g. • Separate sharp from non-sharp equipment using instruments such as forceps. • Separate used from un-used sharps. • Use an alternative method of food preparation if available. topical etc. food mixers. • Consider use of blunt-tip suture needles where applicable. Patient care staff.g. Engineering Controls • Use guarding for kitchen equipment such as mincers. use one handed recapping techniques with assistive devices. • Use sharps with safety features. cytotoxic and other hazardous drugs. • Consider alternative methods of medication delivery. • Never over fill sharps containers. • Wash and clean sharp tools separately from other instruments or utensils. • Use instruments for retraction of tissues. • Use forceps / instruments for suturing and not hands. in addition to the above: • Use verbal warnings before passing sharp instruments. • Use instruments such as receptacle / tray / container / forceps or other devices to pass sharps. • Do not reach into moving parts of machines with fingers. In the kitchen and other areas where there are machines: • Ensure safety guards are in place before using the machine. • Locate disposal containers close to immediate work area. • Kitchens – Knives: . • Refrain from wearing loose or frayed clothing. • Use labelled puncture proof containers for disposal. • Clean or maintain the machine only when power has been shut down.80 healthcare Hierarchical approach Examples of control measures to reduce exposure • Use forceps to sort and dispose of sharp contaminated devices.Use the right knife for the task at hand. • Use containers designed to exclude hands / fingers. • Do not remove safety guarding or interlocks installed on machines. . • Follow manufacturer’s or supplier’s instructions when operating the machine. In the operating theatre. . Personal Protective Equipment • Wear mesh gloves when using knives when appropriate. Food and Beverage. • Establish an improved reporting system for sharps injuries and their follow-up.Use a flat surface or cutting board. deboning or cutting. • Implement a prompt post exposure programme for injured healthcare workers. USA: Sharps Injury Prevention Program Workbook.Ensure that the knife is sharp. • Curl the fingers of the other hand over the object that is being cut.Cut away from the body when trimming. • Training and education in safe work practices (standard precautions) at induction for new workers and periodically for all healthcare workers. Further information can be obtained from our references: • Workplace Safety and Health Council (WSHC): Workplace Safety and Health Guidelines . . 2008. Administrative Measures • Establish a vaccination policy for all healthcare staff against vaccine preventable bloodborne infections. Current as of 15 December 2007.Store knives properly in a proper rack in a visible place. • Use armoured gloves in operating theatres when working with sharp objects.workplace safety and health guidelines 81 Hierarchical approach Examples of control measures to reduce exposure . .Hotels. • Centers for Disease Prevention and Control (CDC). . access to counselling or emotional support for work related incidents should be made available to your employees. lack of control over workload. A simple definition of psychosocial hazards could be ‘those aspects of the design and management of work. or agreement on. continually subject to deadlines. higher uncertainty. continuous exposure to people through work. interpersonal conflict. overtime work. under use of skills. fragmented or meaningless work. high levels of time pressure. organisational objectives. Should the need arise. night shifts. Issue No. Social or physical isolation. pacing. suitability or maintenance. poor relationships with superiors. long or unsociable hours. lack of social support. Low participation in decision making. . workplace aggression and violence and increased patient acuity. stress and burnout. Due to the complex nature of their work. Work overload or under load. machine pacing. science and technology as well as having to meet international standards in patient care and clinical quality. shift work. low levels of support for problem solving and personal development. unpredictable hours. and its social and organisational contexts. poor lighting. involvement in direct patient care and time pressures make them more vulnerable to psychosocial threats to their well-being. Some of the common psychosocial hazards at the workplace include issues relating to shift work. etc. that have the potential for causing psychological or physical harm’.. Shift working. lack of definition of.82 healthcare Psychosocial Hazards Healthcare workers work in a milieu of constant change due to rapid advances in medicine. poor environmental conditions such as lack of space. Towards the Development of a Psychosocial Risk Management Toolkit (PRIMAT) The Global Occupational Health Network Newsletter. Inadequate equipment availability. 10 -2006. excessive noise. The table below summarises the types of psychosocial risk factors and gives some examples: Psychosocial Risk Factors and Examples5 Job Content Lack of variety or short work cycles. inflexible work schedules. Workload and Work Pace Work Schedule Control Environment and Equipment Organisational culture and Function Interpersonal Relationships at Work 5 Stavroula Leka. Poor communication. For more information: refer to Indoor Air Quality and Ventilation section on page 115 and Lighting section on page 122. • Disruption of family and social life. • Physical and mental health effects. Stress and Burnout Occurrence Shift work. . • Training and education on health and safety effects of shift work and techniques for recognition and reduction of stress. The development of work-related stress is often a result of the complex interplay of multiple psychosocial hazards. and • A regular exercise regime is recommended. • Increased risk of injuries / accidents.workplace safety and health guidelines 83 Shift Work. • Consider sleeping on a set schedule and obtaining sufficient sleep. Effects of Exposure Shift work • Disturbance of circadian rhythm (biological clock). Organisational changes • Shift design and schedules can be adjusted so that staff have sufficient rest days. • Fatigue and burnout. • Sleep deprivation. • Facilities: . Buy-in from senior management is important for the success of the programme.Provision of adequate meal breaks.Provide rest facilities for all staff. • Allow time for relaxation. . Staff Stress Management • As far as possible. Stress and burnout could be a long term result of shift work and extended work times. overtime and extended work times are an inherent part of the healthcare system. Psychosocial Hazard Management System The organisation should develop a policy to reduce workers’ exposures to work-related stress. Management of shift work can be dealt with holistically in the programme for work-related stress. adhere to regular eating patterns and good nutrition.A work environment with adequate lighting and ventilation is important for all shifts. . Control Measures There are two levels at which changes can be made to mitigate the effects of shift work. Overtime Work. Allan Toomingas. • Centers for Disease Control and Prevention. • Evaluation of risk: . . Regular debriefing sessions after severe and emotionally taxing events are also helpful in monitoring the psychosocial environment. . • Hans-Martin Hasselhorn. The effectiveness of the solutions could be evaluated by follow-up surveys. existing records such as sickness absence. • Monitor and review: .organisational change. 10: Psychosocial Factors and Mental Health at Work. and . Focus groups can be set up to explore possible solutions and the results communicated to the all employees. Issue No.control. The key areas of work that should be assessed include: . 1999. Monica Lagerström: Occupational Health for Healthcare Workers: A Practical Guide. employee turnover and productivity records could also be reviewed. .demands.This can be done through a survey questionnaire.An action plan should be developed by both management and employees to address psychosocial hazards identified.84 healthcare Programme for managing psychosocial exposures: • Identify the hazards. .The risk level can be evaluated based on the information in the previous 2 steps.support.The milestones in the action plan should be monitored. • Health and Safety Executive (HSE). Accessed 20 October 2007. • Identify at risk employees: . 2006. A number of standardised questionnaires are available. In addition. • Record findings: . . Current as of 15 December 2007.roles. NIOSH): Stress at Work. Current as of 15 December 2007. Further information can be obtained from our references: • World Health Organisation (WHO): The Global Occupational Health Network Newsletter.relationships. National Institute for Occupational Safety and Health (CDC. UK: Tackling Stress: The Management Standards Approach. 1999. workplace safety and health guidelines 85 Workplace Harassment and Violence Workplace aggression and violence is a recognised hazard, but the true extent may not be known as it is likely to be under-reported. • management commitment and employee participation in a violence prevention programme; • Analysis of worksites: - A risk assessment of the workplace should be done to identify the hazards and assess the severity of the risk. A review of the injury and illness records, compensation claims and screening surveys for workplace violence would also form part or the risk assessment; • Safety and health training of healthcare workers should include: - conflict resolution; - recognising and managing assaults; and - awareness of workplace violence; • Record keeping: - Incident reports - All healthcare workers should be encouraged to report incidents of workplace aggression and violence. This report should also include action plans to prevent reoccurrence; • Evaluation of the programme: - The programme should be evaluated regularly to ensure a safe and secure workplace for all staff. Occurrence and Risk Factors Workplace aggression and violence can range from verbal abuse, use of profanities and physical assaults. Aggression and violence can occur between staff, patient to staff and public to staff. Effects of Exposure • Psychological trauma; • Physical injuries. Hazard Management System A system should be put in place to reduce exposure of healthcare workers to violence and abuse. The components should include: • a clear policy known to management and employees and is understood by all staff, should be clearly communicated to both patients and accompanying persons; • clearly defined protocols for dealing with at-risk situations where staff is subject to either physical abuse, verbal intimidation or threats; 86 healthcare Control Measures Hierarchical approach Engineering Controls Administrative Controls Examples of control measures to reduce exposure • The design of the working environment could be improved such as providing physical security measures; • Staffing schedules can be adjusted to ensure that staff do not work alone and to minimise patient waiting time; • Movement of the public in hospitals should be controlled. Further information can be obtained from our references: • US Department of Labor, Occupational Safety and Health Administration (OSHA): Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers, 2004. Accessed 20 October 2007. • Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (CDC, NIOSH): Violence: Occupational Hazards in Hospitals, 2002. Current as of 15 December 2007. • Health and Safety Executive (HSE), UK: Workplace Violence. Accessed 20 October 2007. workplace safety and health guidelines 87 Hazardous Drug Handling Hazardous drugs are drugs or chemicals that demonstrate one or more of the following characteristics in either humans or animals: carcinogenicity, teratogenicity or other developmental toxicity, reproductive toxicity, organ toxicity at low doses, genotoxicity or where the structure and toxicity profiles of new drugs mimic existing drugs determined hazardous by the above criteria. Commonly, this would include cytotoxic and anti-neoplastic drugs, anti-virals as well as new bio-engineered drugs. Although the drugs kill or damage cancer cells, they also damage normal cells. This coupled with the increasing use and complexity of chemotherapy as well as the unknown effects of new drugs such as nanotechnology has lead to concern over the risks to healthcare workers involved in the preparation, handling, administration and disposal of these drugs. Such drugs administered to patients may also be excreted unmetabolised in their urine, resulting in exposure to nurses, attendants, housekeeping and waste disposal staff. Exposure Situations / Procedures Hazardous drugs are commonly administered by injection as single doses or as a continuous infusion. Some drugs can also be given orally as tablets, capsules or as liquids. The potential for exposure exists during various tasks, such as drug reconstitution and mixing, connecting and disconnecting intravenous tubing, and disposing of waste equipment or patient waste. Drugs can be found in the air, on work surfaces, clothes, medical equipment and in patient urine and faeces. The common routes of exposure are through skin and mucous membrane contact (in spills and splashes) and inhalation (e.g. overpressurising vials), but ingestion (eating or drinking in contaminated areas) or injection (needlestick injuries) can also occur. Some of the areas where exposure could occur include: • hospitals; • hospices; • oncology units; • pharmacies; • wards; • reception and delivery areas; • infusion centres; and • laundry areas. Effects Some studies have shown that exposure to these drugs can cause acute health effects such as skin and eye irritation and chronic health effects including adverse reproductive outcomes such as infertility, miscarriage, birth defects and possibly leukaemia and other cancers. • facility staff receiving and transporting stock. Workers at Risk • pharmacists and pharmacy technicians. It should cover all areas where there is potential exposure to hazardous drugs such as wards. bed clothes. The policy should detail the health and safety responsibilities within the organisation and should include systems and procedures in place for ensuring health and safety of its employees. • nurses and nursing assistants. laundry and portering. • disposal of patient waste.88 healthcare Activities where exposure could occur: • drug reconstitution and mixing. • connecting and disconnecting intravenous tubing. Management Policy The policy is a written statement of the organisation’s intent to provide a safe and healthy environment. • operating room staff. bedding. It should enlist the support of employees in achieving its aims. • hospital attendants and transport staff. logistics.The system should include management of the movement of the drugs . A risk assessment is a means of determining the risk associated with exposure to a particular hazard or work. waste disposal. spill control to medical surveillance. a management system should be in place to protect the health and safety of healthcare and other workers coming into contact with these drugs. • disposal of waste equipment. all institutions should develop and maintain their own list of hazardous drugs in use. • biological waste handlers / cleaners / environmental services staff. • housekeeping. Risk Assessment Management should ensure that suitable and sufficient risk assessments are made of all activities where there is handling or exposure to hazardous drugs. pharmacies. and • laundering of contaminated bed linen and patient clothing. There should be periodic review of the health and safety management system. clinics. • laundry staff handling contaminated linen. • determining workers at risk and how harm could arise. etc. from entry into the facility through preparation and administration. • maintenance of equipment. cleaning. equipment maintenance and housekeeping. • doctors. operating theatres. The policy should be communicated to all employees. The steps in conducting a risk assessment include: • hazard identification. Health and Safety Management System for Use of Hazardous Drugs Due to the potent nature of these drugs and their potential for harm. Risks should be controlled at source and control measures should follow the hierarchy of controls such as elimination or substitution. assessment of adequacy of existing precautions. • control exposure at source. such as: • organising work to reduce the quantities of drugs used. subcontractors and workers. • documentation of findings and control measures selected as well as any other steps necessary to reduce exposure risk. • use totally enclosed systems as the first choice for controlling exposure to carcinogens. Documentation of risk assessments and controls should be kept up to date. • vulnerable persons such as new and expectant mothers and those with impaired immune systems. • non-routine work. safe work practices. • arranging for the safe handling. storage and transport of cytotoxic drugs and waste material containing or contaminated by them. Exposure Control Measures to control exposure should be applied in the following order: Safe Work Procedures There should be written procedures on any work where there is exposure to . • emergency situations. prohibiting eating. and • all facilities at your workplace. • using good hygiene practices and providing suitable welfare facilities e. including use of adequate ventilation systems and appropriate organisational measures. young and trainee workers. • training all staff who may be involved in handling cytotoxic drugs or cleaning areas likely to be contaminated. volunteers. engineering control measures. unless this is not reasonably practicable.workplace safety and health guidelines 89 • likelihood of harm arising. • reviewing the risk assessment if the nature of work changes or if there is a change in the process. The coverage of the risk assessments should include: • routine work. • activities of personnel with access to the facility such as visitors. The broad measures described above will include more specific controls. administrative measures and personal protective equipment. the number of employees potentially exposed and their duration of exposure. • issue personal protective equipment where adequate control of exposure cannot be achieved by other measures alone. drinking and smoking in areas where drugs are handled and providing washing facilities. to the minimum.g. on the risks and the precautions to be taken. . waste disposal and biomedical maintenance. Gloves should be changed regularly or when integrity is breached. gloves and boots.spill control. • Safe work practices relating to both drug manipulation techniques and to general hygiene practices – such as not permitting eating or drinking in areas where drugs are handled e.worn correctly. etc. personal protective equipment should be properly selected. trainees etc. • Effective protection can only be achieved if the PPE chosen is: .compatible with other PPE in use.storage of drugs. laundry. • Gloves: .labelling of drugs. . a safe drug handling programme should be established and this should incorporate: • Policies and procedures defining: . • Eye and face protection: Personal Protective Equipment • Personal protective equipment (PPE) . aprons. correctly used.suited to the wearer and environment.Note that no glove material will offer unlimited protection from cytotoxic drugs. • Procedures and training for handling hazardous drugs safely.g. .suitable for the task. young workers. and methods of control other than protective gloves are not reasonably practicable. torn. administering. The safe work procedures should include the use of appropriate safety equipment.Where contact with cytotoxic drugs is possible. • Employers need to ensure that employees are trained in the use of PPE and that the equipment is adequately maintained.personnel issues (vulnerable workers such as expectant workers. .in good condition. overalls. and using all equipment and personal protective equipment properly. pharmacies. . personal protective equipment and techniques on safe handling of such drugs as well as the safety and health precautions to be taken in the course of work. cleaning up spills. and disposing of hazardous drugs. • Selection of PPE should be based on routes of potential exposure to hazardous drugs and other concomitant hazards and the nature of work. . damaged. In addition. • To ensure that employees are effectively protected. face shields. mortuary. .detailed procedures for preparing..presence of hazardous drugs. safety glasses. includes respirators. . comfortably fitted and regularly maintained. the pharmacy or clinic. . protective gloves must be provided for employees. . operating theatres.90 healthcare hazardous drugs and this should include: patient care areas.). particularly where cytotoxic drugs are being handled outside an enclosed system and there is a risk of splashing. . • Respiratory protection: . use of safety equipment and appropriate personal protective equipment.A suitable personal protective equipment programme should be implemented taking the above elements into consideration. they should be washed out with water or an eye wash bottle containing water or normal saline.Manipulation of oral or topical medicines containing cytotoxic drugs should be avoided if possible. treatment. that includes emergency procedures. particularly if a spill occurs outside the biological safety cabinets. Any drugs that come into direct contact with the skin should be washed off with soap and water and medical advice should be obtained. . Surgical masks will not protect against the inhalation of fine dust or aerosols. tasks such as dividing or crushing tablets should be restricted to a controlled environment. . respiratory protective equipment (RPE) should be considered if exposure to powders or aerosols is possible. If drugs come into direct contact with the eye. decontamination and cleaning.workplace safety and health guidelines 91 . and proper waste disposal. Carrying out these procedures in wards or clinics should be actively discouraged. Disposal Operations where hazardous drugs are generated including contaminated patient waste should be governed by a waste management system that includes proper labelling according to national or international codes. However. Emergency Planning Policies. first aid procedures. The plan should describe what needs to be done. For more information: refer to Hazardous Waste Management section on page 104. Appropriate personal protective equipment should also be used when cleaning up spills. if it is not reasonably practicable to control exposure using total enclosure / local exhaust ventilation. a respiratory protection programme should also be in place to manage the use such equipment. If this is unavoidable. A number of options are available including a face shield or visor. proper storage. ideally within a pharmacy department. For more . Medical advice should be obtained. plans and procedures are required for incidents such as spills and splashes.Eye and face protection is relevant.If respirators are used. For more information: refer to Protective Clothing and Equipment section on page 125. transport and disposal of such wastes. goggles and safety spectacles. Proper spill kits and clean up kits should be placed within easy reach where possible exposures might occur and staff should be trained in their use.Preparation of cytotoxic drugs should be carried out in a suitable safety cabinet or pharmaceutical isolator. • laboratory tests including complete blood counts. The elements of such a programme would include: • questionnaires on reproductive and general health at the time of employment and periodically. • workers with significant change in health status detected should also be on a follow-up programme. post-exposure monitoring and reporting procedures for occupational accidents and diseases. However. ventilation. If there are significant health changes.evaluate current preventive measures. the precautions they should take. it is a good practice to monitor the workplace for exposure. These monitoring techniques can also help confirm . there is currently no recognised standard against which test data can be compared against. They should also be informed of the results of the risk assessment. • workers who have significant exposure to spills and splashes should also be on the monitoring programme. Health Surveillance Education and Training All employees should be given suitable and sufficient information about the hazardous drugs they could be exposed to and the risks created by this exposure. A medical surveillance programme should be in place to monitor the health of workers exposed to hazardous drugs. Where there is exposure to cancer-causing drugs. A health and safety training programme should be implemented to ensure that safe work procedures are known and understood by all staff. Performing serial measurements and observing trends in the data can be useful to help demonstrate that control measures are still adequate or the need to review them. Surveillance Monitoring Exposure at the Workplace Monitoring exposure can include any periodic test or measurement which helps to confirm the ongoing effectiveness of controls. restoration of adequate control if there is a failure of the measures put in place. urinalysis and any other relevant tests such as liver function and renal function done at employment and periodically during employment. engineering control measures (biological safety cabinets.92 healthcare information: refer to Emergency Response Planning section on page 111 and First Aid section on page 128. closed system transfer devices and IV infusion systems). emergency and first aid procedures. • physical examination of healthcare staff at time of employment and periodically where indicated by either the questionnaire or laboratory tests. usage of personal protective equipment. the employer should: . • results of questionnaires and tests should be monitored for trends that may be a sign of health effects due to exposure. containment. • develop or refine a plan to prevent further worker exposure. location of work done. . Reporting of occupational diseases is required under the current legislation. Such records should be properly kept and maintained.workplace safety and health guidelines 93 . Record Keeping and Reporting A facility should keep exposure records of its employees who work with hazardous drugs. • offer alternative duty or reassignment to affected worker. Information in the records should include type of work. and any specific incidents or exposures that occurred. • work practices.compare performance with recommended standards.perform environmental sampling where possible. respiratory protection. non-permeable gowns. . Documentation should be kept for at least 5 years. • personal protective equipment policies and employee compliance and use. • availability of appropriate personal protective equipment such as double gloves. • continue ongoing medical surveillance of all workers at risk. unpacking and transporting vials to work areas. • Consider dedicated emergency exhaust fan powerful enough to quickly purge airborne contaminants in the event of a spill. • Proper labelling. • protective clothing. handling. safe work practices and use of personal protective equipment. Personal protective equipment (PPE) – use appropriate PPEs such as: • chemotherapy gloves when receiving.94 healthcare Details on Selected Work / Activity Area Receiving and Storage Areas The main hazard is spills from damaged containers or when handling intact containers. Administrative Controls Personal Protective Equipment • Education and training of staff on hazards. • eye and face protection. • Observe for potential cracks / damaged containers / leakage. Hierarchical approach Engineering Controls Examples of control measures to reduce exposure • Sufficient general exhaust ventilation. . effects. Safe Work Practices • Store and transport in closed containers. • Cover all cuts / lacerations with plasters. • Follow the proper sequence of removing personal protective equipment (PPE). Examples of control measures to reduce exposure • Prepare drugs in ventilated cabinets. Safe Work Procedures • Wash hands before putting on gloves . Access to the preparation areas should be limited. Preparing Hazardous Drugs Hierarchical approach Engineering Controls The job tasks should be coordinated for effective control of exposures to workers. • Consider using closed system transfer devices. Administrative Controls • Prepare hazardous drugs in a centralised area where possible. . In addition. Ideally use a totally enclosed cabinet. a spill control programme should be in place in the event of spills and splashes. counting of tablets should also be done in a biological safety cabinet if this is likely to produce dust such as non-coated tablets. • Seal and wipe all waste containers inside a ventilated cabinet before removal for disposal. • Seal the finished product in a container before removing from ventilated cabinet. glovebags and needleless systems for transfer of drugs from primary packaging to dosing systems (to be done inside a ventilated cabinet). • Dispose all PPE immediately after use. • Remove all outer gloves and sleeve covers and bag for disposal while still inside a ventilated cabinet. • Ensure the availability of Safety Data Sheets (SDS). • Compounding of drugs. • Train all staff in safe work practices and use of proper equipment.workplace safety and health guidelines 95 Drug Preparation and Administration The hazard analysis should include a review of the whole process. . • Use appropriate respirators if ventilated cabinets are not available. • Ensure latex free gloves are available for those with latex allergy. • Dispose PPE immediately after use according to nation regulations. elastic or knit cuffs.. For more information: refer to Hazardous Waste Management section on page 104. long sleeves. • Change gloves regularly according to recommendations on Safety Data Sheet and / or when integrity is breached. handling vials / finished products. labelling or disposing of hazardous waste.96 healthcare Hierarchical approach Personal Protective Equipment Examples of control measures to reduce exposure • Use proper personal protective equipment (PPE). • Consider using disposable sleeve covers to protect wrist area. • Use chemotherapy gloves or double gloving when opening drug packaging. • Use eye and face protection if aerosolisation is anticipated. torn damaged etc. • Use proper disposable gowns made of polyethylenecoated polypropylene with closed fronts. • Flush tubing at end of infusion before removing IV bag and tubing. lines and pumps clean of hazardous drugs. • Double-bag all chemotherapy waste bags. • Put the emergency spill kit at hand or near by while administering the drugs. • Place disposable items in a purple chemotherapy waste container and close lid. • Dispose IV bag and line intact in accordance with pharmacy instructions or legislative regulations. • Dispose PPE immediately after use according to national regulations. • Place plastic backed absorbent pads under IV line to catch leakages. • Do not remove IV tubing from bag containing hazardous drugs beside patient’s bed. IV bags. • Tape IV tubing connection sites.workplace safety and health guidelines 97 Administration of Hazardous Drugs Hierarchical approach Engineering Controls Examples of control measures to reduce exposure • Administer drugs by using needleless and closed systems. • Place sterile gauze under push sites. . For more information: refer to Hazardous Waste Management section on page 104. • Use Luer-lock fittings. • Observe standard precautions. • Remove protective clothing in the proper sequence. • Wipe all syringes. Safe Work Procedures • Carry an emergency spill kit while transporting hazardous drugs from preparation to administration areas. . • Double glove if using latex gloves. • Chemical splash goggles or equivalent safety glasses. elastic or knit cuffs. • Ensure latex free gloves are available for those with latex allergy. • Restrict the number of staff who are allowed to administer hazardous drugs. • Appropriate respirators should be used if handling aerosolised drugs or if aerosolisation is expected. • Check Luer-lock fittings for leaks. . damaged etc. Personal Protective Equipment • Chemotherapy / latex gloves when handling and administering hazardous drugs. For more information: refer to Hazardous Waste Management section on page 104. • Use proper disposable gowns made of polyethylenecoated polypropylene with closed fronts. • Change gloves regularly and when integrity is breached. torn.98 healthcare Hierarchical approach Administrative Controls Examples of control measures to reduce exposure • Train staff on the proper safe work procedures and proper use of personal protective equipment. long sleeves. • Prime IV line inside ventilated cabinet if using hazardous drugs if not primed with non-drug solution. • Dispose PPE immediately after use according to national regulations. A workplan should be in place for regular testing of HEPA filters. gloves and shoes. eye and face protection.Safety protocols and procedures should be developed for safe work practices when conducting routine maintenance. • Selection should be based on needs such as aseptic drug preparation and worker’s safety and health considerations.Ensure proper disposal of used filtration media according to national regulations.workplace safety and health guidelines 99 Ventilated Cabinets / Biological Safety Cabinets • Preparation of hazardous drugs should be done in a dedicated cabinet. .Maintenance staff should be trained in hazards. use of non-recycled air. proper work procedures and work practices. For more information: . proper disposal and personal protective equipment (PPE) use. Spill Control There should be policies and procedures to manage spills which include: • A respiratory protection programme. including lockout / tagout procedures. laminar flow.servicing and upgrades) . .g.Appropriate personal protective equipment should be provided including gowns. • Selection criteria should include the design of airflow and exhaust so there is sufficient flowrate. Non-routine maintenance (e. Maintenance of Ventilated / Biological Safety Cabinets Routine maintenance .The same precautions for routine maintenance should also apply. etc. leak tests and other performance characteristics. . • Standard operating procedure in the event that personnel are also contaminated. signages. . • There should be real time monitoring of cabinet performance. refer to Hazardous Waste Management section on page 104. respirators and face protection. . • Establish standard operational procedures (SOPs) in the event of personnel contamination. For more information: refer to Hazardous Waste Management section on page 104. • Proper warning signs. Personal Protective Equipment • Appropriate personal protective equipment such as gloves. • Restrict access by untrained workers. • Dispose personal protective equipment immediately after use according to national regulations.100 healthcare Hierarchical approach Safe Work Procedures Examples of control measures to reduce exposure • Correct selection and use of materials in spill kit. • Staff should be educated and trained in safe work practices. • Use of appropriate personal protective equipment. • Include respiratory protection programme. • Proper disposal of contaminated materials/equipment according to NEA regulations on hazardous waste. • Spill handling drills. Administrative Controls • Education and training on safe work practices. gowns and footwear. For more information: refer to the reference at the end of this section on page 103. • Proper handling of spills. • Locate spill kits in immediate vicinity of potential spill areas. When full. Administrative Controls .workplace safety and health guidelines 101 Medical Waste Disposal Identify all possible types of waste generated by preparation of and administration of hazardous medications such as partially filled vials. unused IV medications. Decontaminating and Housekeeping Cleaning and Decontaminating Hierarchical approach Engineering Controls Safe Work Procedures Examples of control measures to reduce exposure • Ensure sufficient ventilation to prevent build up of hazardous airborne drug concentrations. eye protection such as safety glasses with side shields or face shields should be worn. Do not place needles and sharps contaminated with cytotoxic wastes into infectious disease containers. • A schedule of regular cleaning activities for work surfaces and equipment that might become contaminated e. Put needles.g. gowns. undispensed products. needles and syringes. empty vials and sharps (preferably as one unit) in puncture proof plastic waste containers. gloves. • Storage and use of hazardous drugs in unventilated areas such as unventilated storage closets or rooms should be discouraged. gloves. Personal Protective Equipment • Where there is a risk of splashing. • There should be protocols for proper storage of hazardous drugs according to NEA and other international guidelines. tubing into purple cytotoxic waste bags. trolleys and carts etc should be in place. Radioactive waste should be placed in red bags for disposal by licensed NEA contractors. • Work surfaces should be cleaned with an appropriate deactivating agent before and at the end of each activity and at the end of each work shift. Routine Cleaning. gowns. the container should be placed in purple cytotoxics bag. Incinerate at regulated medical waste facility – use licensed NEA disposal contractors for biohazardous waste (see NEA guide). bed linen and contaminated materials from spill cleanups. underpads. Put syringes. • Procedure for removal of gloves: . • Reuseable items such as glassware or other contaminated items should be washed twice with detergent by a trained employee wearing double latex gloves and a gown. • Use disposable fluid resistant gowns if necessary.Remove outer gloves and gown by turning them inside out and placing them in a purple bag. • Gloves should be chemically resistant to decontaminating or cleaning agent used. • Dispose PPE immediately after use according to national regulations. footwear etc. • Wash hands with soap and water after removal of gloves.102 healthcare Hierarchical approach Examples of control measures to reduce exposure • Use appropriate gloves according to Safety Data Sheets (SDS) and glove selection guidelines.. • Linen contaminated with hazardous drugs or excreta from patients who have received hazardous drugs in the last 48 hours should be placed in specially marked and labelled laundry bags which are then placed in another impervious bag (double bagging). gloves. • Ensure availability of latex-free gloves for those with latex allergy. • Contents of laundry bag should be pre-washed and then added to other laundry for a second wash. .Repeat the procedure with the inner glove. For more information: refer to Hazardous Waste Management section on page 104. • Excreta contaminated with blood should be handled following standard precautions. • Use double gloves. . Housekeeping Hierarchical approach Safe Work Procedures Examples of control measures to reduce exposure • Use appropriate PPE such as gowns. eye and face protection. Occupational Safety and Health Administration (OSHA): OSHA Technical Manual. Personal Protective Equipment Further information can be obtained from our references: • US Department of Labor. • Centers for Disease Control and Prevention. . Current as of 15 December 2007. • Use face shields where splashing may occur. Section VI Chapter 2: Controlling Occupational Exposure to Hazardous Drugs. • Linen personnel should wear latex gloves and gowns when handling prewashed material. please refer to pharmaceutical waste disposal guideline published by National Environment Agency (NEA). NIOSH): Medical Surveillance for Healthcare Workers Exposed to Hazardous Drugs. Accessed 3 July 2007. • Use appropriate gloves. double glove if handling linens. • For proper disposal of medication waste. National Institute for Occupational Safety and Health (CDC. For more information: refer to Hazardous Waste Management section on page 104. • Centers for Disease Control and Prevention. • National Environment Agency (NEA): Control of Hazardous Substances. • Health and Safety Executive (HSE). Accessed 3 July 2007.workplace safety and health guidelines 103 Hierarchical approach Administrative Controls Examples of control measures to reduce exposure • Educate and train all nursing. National Institute for Occupational Safety and Health (CDC. • Suitable latex free gloves should be made available for those with latex allergies. • Use fluid resistant disposable gowns which should be changed whenever contaminated. housekeeping and biological waste disposal staff on effects of exposure to hazardous drugs and the precautions to take. • Dispose PPE immediately after use according to national regulations. Current as of 15 December 2007. faeces or urine from patients who had received hazardous drugs within the last 48 hours up to the last 7 days. NIOSH): Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Healthcare Settings. • National Environment Agency (NEA): Control of Toxic Wastes. Accessed 3 July 2007. Accessed 1 July 2007. HK: Safe Handling of Cytotoxic Drugs. . Pharmaceutical wastes are also commonly found in healthcare facilities. Much of the waste is hazardous and must therefore be packaged. Beside biohazardous waste. waste water from laundries and floor washing and other substances that do not pose any significant contamination risk in handling. Such wastes could be disposed of as general household waste by general waste contractors at public waste disposal facilities if they are not contaminated with biohazardous or toxic waste. routine clinical waste. pharmaceutical waste. contaminated sharps and other contaminated waste from treatment areas are considered as biohazardous wastes which need special handling and disposal by licensed biohazardous waste contractors. Lassa fever) infections. in addition. Waste that is heavily soiled with the patient’s blood or body fluid should also be treated as potentially infectious. cytotoxic waste. they could be either disposed of through special waste incinerators or as general waste. expired cytotoxic drugs and waste materials which are contaminated with cytotoxic drugs during the preparation and administration of cytotoxic therapy are also required to be properly handled and incinerated by approved biohazardous waste incinerators.g. Infectious waste. Infectious waste is defined as waste that is capable of causing an infectious disease. Infectious waste. radioactive waste. pathological waste. transferred.g. pathological organs and other waste from patients with Biosafety Level III (e. and disposed of properly to protect both the persons handling it and the environment. food waste. spent photographic developing solutions and spent solvents. Depending on the nature of the pharmaceutical waste. Infectious waste includes sharps. contaminated sharps. Chemical wastes include discarded solid. microbiological cultures. chemical waste and general waste. These wastes should be segregated as biohazardous and nonhazardous waste for special disposal by licensed toxic waste contractors. pathological waste. liquid and gaseous chemicals from diagnostic and experimental work and from cleaning. Hepatitis B) and IV (e. housekeeping disinfecting and engineering services such as used lubricating oil. Types of Hazardous Waste Generated Wastes from healthcare facilities include infectious waste. packing materials. General wastes generated in healthcare facilities may include office waste.104 healthcare Hazardous Waste Management Healthcare facilities generate diverse wastes that require proper disposal. may need pre-treatment before it is disposed of as biohazardous waste. The responsibilities of personnel should be described in these procedures. Safe Work Procedures Written procedures on treatment of all types of wastes generated by the healthcare facility should be established and documented. Identification of Hazardous Waste This includes designation of the waste that should be managed as biohazardous and segregation of biohazardous waste from nonbiohazardous waste. such as the generation. The hazardous waste management programme should form part of the safety and health management system. . A transport and disposal flowchart from the generation site to the disposal site can be drawn up to provide clarity on the sources of wastes. collection. treatment and safe disposal of hazardous waste. The hazardous waste management programme should include the following elements: Packaging of Waste Colour-coded disposal bags must be used to segregate wastes that need special handling and disposal.workplace safety and health guidelines 105 Hazardous Waste Management Programme The management of all healthcare facilities should develop a hazardous waste management programme suitable for the size of the facility and types of wastes generated. The management should also appoint person/s within the facility with the responsibility for maintenance and management of waste transfer and disposal documentation. 106 healthcare Type of waste Sharps or breakable objects present? No Yes Puncture resistant container required? No Yes Colour code Examples Biohazardous only Yellow Yellow • Gauzes soiled with bodily fluids • Used syringes and tubings contaminated with bodily fluids • Partially filled glass vials of hazardous drugs Cytotoxics No No Purple • Expired cytotoxic drugs • Disposable gloves. creams and ointments) General waste Yes / No If Black practicable . bench wipes and gowns used during chemotherapeutic drugs preparation Biohazardous contaminated with cytotoxics Yes Yes Purple • Used syringes and tubings for administering chemotherapeutic drugs • Glass vials with cytotoxic drug residue Radioactive No No Red • Disposal gloves and bench wipes used in the preparation of radioactive materials Biohazardous and Yes contaminated with radioactive materials Yes Red followed • Used syringes by yellow (after for administering the radioactive radioactive isotopes to patients material has decayed to the safe level) • Empty antibiotics and vaccines vials • General pharmaceutics (vitamin tablets. the associated safety and health hazards and recommended personal protective equipment during handling. All waste generated by healthcare institutions must be disposed of in accordance to legal requirements. . Disposal The management should identify off-site hazardous waste collectors licensed by NEA to collect and dispose of the various types of hazardous wastes.workplace safety and health guidelines 107 Storage All hazardous wastes stored should be quantified and tracked.g. A register of all the wastes that are being generated and stored should be kept. Further information can be obtained from our references: • Singapore Standard: CP 100: Code of Practice for Hazardous Waste Management. All containers used for storing hazardous wastes should be clearly labelled with the type of wastes. handling. safe handling techniques and disposal procedure). packaging. Such waste must be segregated into hazardous and nonhazardous waste so that it can be safely disposed of by the respective licensed waste contractors. especially infectious waste should be properly trained to ensure that they are equipped with the appropriate knowledge (potential health hazards and precautions to take. • source of waste e. • date ready for disposal. Staff Training All personnel involved in the generation. storage and disposal of hazardous wastes. The management should develop a licensed hazardous waste collector assessment programme to verify the capability and competency of potential off-site hazardous waste contractors in handling their wastes. For more information: refer to Emergency Response Planning section on page 111. The register should include: • type and quantity. 2004. and where possible. department or unit. Contingency Measures for Emergency Situations The management should establish emergency response plans and procedures to deal with on-site incidents involving hazardous wastes and provide adequate hazardous material response equipment. • appointed licensed collector. 108 healthcare facilities and general safety . • Training of workers on the use of fire fighting equipment should be conducted. • A Hot Work Permit System should be implemented and hot work permits should be completed and posted at the work location. All materials should be properly stored and all waste materials properly disposed.workplace safety and health guidelines 109 Safety in Construction and Renovation General • Prior to commencement of works. • Fire extinguishers should be adequately provided at work areas where welding and cutting works are being carried out. Fire Safety • An adequate number of fire extinguishers should be provided. They should be properly tagged and inspected. . Material Handling and Storage • Proper housekeeping should be maintained within the construction site and its surroundings. • Junction boxes and panels should be properly covered. Electrical Safety • Temporary lightings should be in place for access areas and locations where works are being carried out. Welding and Cutting • Compressed gas cylinders should be properly secured and kept in an upright position at all times. • Safety Data Sheets (SDS) for construction materials should be made easily accessible to all workers. as well as to the hospital’s employees affected by the construction and renovation works. • Fire alarm systems within the facility should be properly set to allow hot work to be carried out without accidental activation. risk assessment should be carried out for all construction and renovation works. emergency plans and safety procedures to be followed. • Site-specific protocols related to construction safety and health should be established for specialised areas within the facility. • Temporary construction partitions should be smoke tight and made of non-combustible materials. • All staff should be briefed on the intended construction works to be carried out. • Security measures should be put in place to prevent unauthorised entry into the construction site. . • Contingency plans should be developed for emergency responses to power failures. • Proper identification tags should be provided for all construction workers.110 healthcare Miscellaneous • Ladders and scaffolds should be of sound construction. Further information can be obtained from our reference: • Workplace Safety and Health (Construction) Regulations. fire alarm systems etc. water supply disruptions and fires. • All floor openings should be properly covered.) should be periodically reviewed. • Notification policy for deactivating life safety devices (smoke detectors. Procedures for protection of records vital to the facility should be established. It is the responsibility of the management to establish and maintain plans and procedures to identify the potential for and responses to incidents and emergency situations.g. to prevent accidents and loss of life and property. It should include procedures for all possible emergencies that the healthcare facility may encounter and should be placed under the charge of an emergency response team.workplace safety and health guidelines 111 Emergency Response Planning Planning and preparing for emergencies is an essential part of hazard prevention and control. for both during and after office hours. Singapore Civil Defence Force (SCDF) and National Environment Agency (NEA)). implement and execute contingency Protection of Vital Records and Equipment Designated employees should be trained in emergency shut-down or lock-out procedures for critical equipment prior to evacuation.g. It should detail the chains of command or responsibility. Emergency Planning and Response Committee An emergency planning and response committee should be set up to create. The emergency response plan should form part of the safety and health management system. Emergency Evacuation Procedures The evacuation procedures for inpatients. out patients. Ministry of Health (MOH) and Ministry of Manpower (MOM)) and the community should be established. employees and on-site contractors should be elaborated. the communication network and “alerting” procedures. regulatory agencies (e. roles and responsibilities of designated employees. It should detail the various evacuation routes and assembly areas for partial or full evacuation. Communication with external emergency agencies (e. . Corporate Policy This policy should emphasise the importance of emergency response planning and affirms management support for the emergency response initiative. Emergency Response Plan An effective emergency response plan should include the following characteristics. These plans and procedures should also be frequently reviewed and updated. to be used during an emergency. Incident Command System A command and control system to coordinate actions during an emergency should be established. plans in times of emergencies. . The employees should be aware of their role in the event of any emergency situation and fire evacuation. selfcontained breathing apparatus) • identity of person to contact. and in responding and reporting on fire emergencies. • process of reporting fires and smoke. (including evacuation plan) that is accessible and available to employees. shut-down procedures. Results and findings from practice drills should be recorded and reviewed by the management. The plan should include the following: • employees must be trained to recognise fire alarms. Fire Each healthcare facility should have a designated Fire Safety Officer as required by the Fire Safety Bureau. The healthcare facility should have a written fire response plan. • rescue and medical duties for employees performing the duties. Regular Review and Updating The emergency response plan should be regularly reviewed and updated. a competent person should be present to operate fire safety devices such as fire extinguishers. • procedures for employees who must remain to operate critical equipment before they evacuate. • procedures and schedules for equipment maintenance. • fire protection equipment and systems available to control ignition sources. and usage of emergency equipment (e. Where a Fire Safety Officer is not mandated by law. • emergency escape procedures and escape routes. Fire drills should be conducted periodically and documented.112 healthcare Training Training for all levels of employees within the organisation should include evacuation procedures and routes. Practice drills should be carried out according to a pre-determined schedule.g. All employees must be aware of the workplace emergency and fire evacuation plan. including designation and contact number. • procedures that account for all employees after evacuation. workplace safety and health guidelines 113 Chemical Spill or Leak Each healthcare facility should have an appointed chemical spill response team. All employees must be aware of the chemical spill response plan. • procedures for those employees who must remain to operate critical equipment before they evacuate. and protective equipment. Practice drills should be conducted periodically and documented. It is the responsibility of each healthcare employee using chemicals and chemical products to become familiar with this plan.g. Paper towels and sponges may be used as absorbent type cleanup aids but this should be done cautiously. Contaminated residues should be collected in a suitable. • procedures for initial containment of the spill and possible fire if the chemical is flammable. The training should also include familiarisation with areas covered by the teams. All personnel working with hazardous chemical including “response teams” must be trained in the appropriate spillage procedures. The employees working in areas where hazardous chemicals are used or handled (e. TSSU) should be aware of their role in the event of an emergency situation. These kits should be located strategically around the department area. • procedures for packaging and disposal of contaminated chemicals and spill response equipment. • identity and contact number of appointed chemical emergency response team leader and its members. earth or sodium bicarbonate to contain / absorb the spillage should be considered. for example sand. • procedures for administering first aid treatment to personnel exposed to chemical. These cleanup supplies should be consistent with the hazards and quantities of substances used. laboratories. The plan should include the following: • process of reporting chemical spill. The team should prepare a Chemical Spill Response Plan which should include the appropriate specific procedures and response equipment for dealing with a chemical spill. The training should include the use of any special equipment and personal protective equipment. clearly labelled container prior to disposal as “contaminated” or “special waste”. neutralisers. The training must be recorded and personnel should be retrained at appropriate intervals. CSSU. absorbants. • procedures for the evacuation of nonessential personnel. • provision of chemical spill response kit and personal protective equipment for chemical emergency response team. Commercial spill kits are available that have instructions. Sponges should be chemical resistant. Use of suitable materials. . Paper used to clean up oxidisers can later ignite and appropriate gloves should be worn when cleaning toxic materials with towels. It is anticipated that a pandemic flu may result in the next infectious disease outbreak. the organisation should have measures in the event that an outbreak of infectious disease occurs. the emergence of severe acute respiratory syndrome (SARS) due to a novel SARS coronavirus resulted in a global outbreak of this disease.114 healthcare Pandemic Flu. Organisations are advised to refer to the MOH documents for further information and consult the MOH website regularly for updates. The Ministry of Health (MOH) has a detailed and comprehensive pandemic response and readiness plan available on its website for healthcare organisations. . This highlighted the need for adequate protection of healthcare workers and the development of contingency plans to deal with future outbreaks and emerging infectious diseases. SARS and Emerging Infectious Diseases In 2003. As part of the emergency planning response. 42% of the probable cases were healthcare workers. In Singapore. of whom over half were nurses. monomers. • Documentation of Ventilation Systems in Place Documents showing the layout . ozone from copy machines. offgassing of various building materials. The programme should include but should not be limited to the following components. cements. markers. radon. soil gas (found in the soil as a result of decaying matter). tobacco smoke. but are not limited to. Indoor Air Quality and Ventilation Management Programme The management. building vermin. leakage from underground storage tanks. cooking. together with the facilities management team. Good indoor air quality improves productivity at the workplace. volatile organic compounds (VOC) from various solvents. All dust. vehicle or building exhaust returning into the building by re-entrainment. Building pollutants may include. poor indoor air quality could lead to losses in productivity as a result of comfort problems. should implement a management plan to ensure that good quality indoor air is achieved in all workplaces within your healthcare facility. leakage or spills. • Written Policy on Indoor Air Quality and Ventilation The policy statement should state explicitly the responsibility and commitment of management to achieve good indoor air quality for all occupants in the healthcare facility. The pollutants may be brought into the building from outside or may come from the building itself. filtration. fumes. fungal spores. dust. All workplaces within your healthcare facility should be ventilated by natural or mechanical means (e. any of the following: pollen. Individual components can be delegated to responsible persons.workplace safety and health guidelines 115 Indoor Air Quality and Ventilation Indoor Air Quality (IAQ) refers to the quality of indoor air as it relates to pollutants that may be airborne in the building. Employees should also be protected from inhalation of any contaminants in the workplace. On the other hand. mechanical extraction systems or a combination of these. ill health and sickness-absenteeism. and glues. wet and damp areas in ductwork where ideal conditions cause pathogens to grow.g. cooling tower that encourages microbial growth. standing water on roofs and in ducts that encourages microbial and fungal growth. ACMV) to provide a constant and sufficient supply of fresh air for all employees. steam or other airborne contaminants which arise as a result of any process or in the course of work should be removed at the source. This can be achieved through elimination or isolation of people from the contamination and implementation of control measures such as dilution ventilation. toners. air-conditioning mechanical ventilation. should be conducted by the competent persons if deemed necessary for the investigation so that adjustments or alterations can be made. and any environmental or biological sampling. humidifiers and other ACMV and building system components should be conducted to detect any microbial growth or contamination.use of personal protective equipment. • Regular Inspections and Air Monitoring Regular walk-through inspections of the premises and the ventilation systems. • National Environment Agency (NEA): Guidelines for Good Indoor Air Quality in Office Premises. • Records The following records should be maintained for reference and audit checks: . . . This documentation should aid the facilities management team to locate major building system equipment and the areas they serve.types of ventilation systems that are used and how they operate.IAQ and ventilation systems inspection records.Incidents investigation reports. . . a written maintenance plan and scheduling of maintenance for the various components of the air-conditioning and exhaust systems. Operation and Maintenance of Local Exhaust Ventilation Systems. should be conducted by a competent person. Further information can be obtained from our references: • Ministry of Manpower (MOM): Guidelines on Design. Checks on ductwork.control measures to ensure proper ventilation during building cleaning. • Preventive Maintenance Regime There should be established. maintenance and when handling chemicals and other harmful agents. A checklist listing the major systems and equipment needed to be inspected can be used during inspection.Employee complaints detailing signs or symptoms that may be caused by building related illness. Current as of 15 December 2007. Indoor air monitoring.g. and . 1996.Action plans to rectify any problem areas identified through investigation of complaint or incident. . • Training and Information The employees who are involved in building system operation and maintenance must be provided with training on the following: .116 healthcare and location of the air-conditioning and / or mechanical ventilating (ACMV) system and other forms of extraction systems (e. downdraft tables and biological hoods) of your facility should be kept. the main design plan should be updated. including ACMV. Feedback from occupants on the conditions in the building and the operation of the ACMV system can be obtained during inspection to identify possible irregularities. The maintenance plan should include reasonable and appropriate measures to avoid degradation of the air quality during renovation and construction works. Where changes are made to any system. workplace safety and health guidelines 117 Safe Means of Access and Egress • Safe means of access should be provided to and from: - the workplace; and - all work-related areas at a workplace. • All means of access and egress should be free from obstructions. • Handrails should be provided at access and egress areas where appropriate to prevent slipping. • Exit signs should be posted and properly lit. • All means of access or egress should be properly maintained. Further information can be obtained from our reference: • Workplace Safety and Health (Construction) Regulations. 118 healthcare Maintenance of Facilities Control of Hazardous Energy: Lockout / Tagout Maintenance and repair work on hazardous machinery or electrical installations have led to serious or fatal accidents in the past when such machinery or installations were not properly deactivated or de-energised. A few accidents had also occurred when such machinery or installation were inadvertently activated when workers were still carrying out the servicing or repair. Employers of the servicing / repair workers should establish and implement lock-out procedures for the inspection, cleaning, repair or maintenance of any machinery, equipment or electrical installation that, if inadvertently activated or energised, could cause bodily injury. Such lock-out arrangements are often supplemented with a tag-out system to ensure a clear warning system is in place against inadvertent activation while work is still being carried out on the machinery or installation. Every person carrying out the inspection, cleaning, repair or maintenance of such machinery, equipment or electrical installation must be fully instructed on the lock-out and tag out procedures for that work before commencing the work. It is important that any cleaning, servicing, maintenance or repair of hazardous machinery and electrical installation be carried out by competent personnel who are well instructed and familiar with the proper procedures, including the necessary lock-out and tag out procedures. Hence, such work should always be carried out by agents or suppliers of the machinery or electrical installation. Electrical Safety Electricity is a common source of energy widely used to power and run many types of equipment and appliances. When work is carried out with an electric powered tool or on an electrical circuit, the worker is exposed to the risks of electrical hazards. An accident involving electricity can cause a range of injuries including electric shock, electrical burns, loss of muscle control and thermal burns. In an electric shock, voltage as low as 50 volts applied between two parts of the human body can cause a current to flow that can block natural electrical signals between the brain and the muscles. This may result in effects including stopping the heart from beating properly, preventing the person from breathing and causing muscle spasms. At high voltage or when the current flows through the body for more than a few fractions of a second, the current can result in deep electrical burns that are permanently disabling. People who receive an electric shock often get painful muscle spasms that workplace safety and health guidelines 119 can be strong enough to break bones or dislocate joints. People can also receive thermal burns when they get too near hot surfaces from overloaded, faulty or shorted electrical equipment or if they are involved in an electrical explosion. Electrical appliances and equipment are generally safe for use if they are designed and manufactured to acceptable electrical standards and codes, and that have been maintained in such a condition. Most electrical appliances are built with safeguards to prevent any overcurrent or earth leakage from reaching a dangerous level to injure a person. It is important that such safeguards are maintained to be in good working condition to provide the protection. Before operating any electrical equipment or appliances, a visual inspection should be carried out to detect any defects or deterioration to the equipment such as inadequate wiring, exposed electrical parts or wires, bad insulation, overloading of the circuit from plugging too many appliances into the same source (main socket), wetness and spilled chemicals. Any necessary repair, maintenance or servicing of the equipment work should always be carried out by competent persons such as the agents or suppliers of the equipment. Another common source of electrical hazards is the electrical installation. Electrical installations must be installed in accordance with Singapore Standard CP5: Code of Practice for Electrical Installations. Such installations as well as repairs, maintenance and inspections should always be carried out by the electrical workers licensed by the Energy Market Authority. Pressure Vessel Safety Autoclaves, jacketed steam sterilizers, air receivers and steam boilers are pressure vessels which can potentially explode and result in serious or fatal accidents and cause major property damage if they fail while in operation. These pressure vessels are used in hospitals and other healthcare facilities. Owners of these pressure vessels should ensure the integrity of these pressure vessels to prevent any mishap by using pressure vessels that are designed and fabricated in accordance to internationally acceptable codes and standards such as the American Society of Mechnical Engineer’s (ASME) Code and the British Standards. These pressure vessels must be examined and certified fit for service by Authorised Examiners before they are first being put into use. Jacketed steam sterilisers, steam receivers and air receivers are required to have mandatory periodic inspections by Authorised Examiner once every 24 months. Steam boilers must be reinspected by Authorised Examiner once every 12 months interval. The list of Authorised Examiners, Guidelines for the Registration of Pressure Vessels in Workplaces by the Authorised Examiner and Guidelines to sp. • provide ventilation equipment. pressure vessels should also be regularly serviced and maintained to ensure the equipment is functioning properly.gov. The certification examinations are conducted by the Singapore Marine Academy of the Singapore Polytechnic. Confined Spaces A confined space is any space large enough that an employee can bodily enter and perform assigned work.mom. Owners should always consult an Authorised Examiner and engage a competent boiler contractor for any repair carried out on a pressure vessel. Employers requiring their staff to work in confined spaces are required to implement a programme for controlling.edu.120 healthcare Local Fabricators of Pressure Vessels are available at the MOM website at: http://www. contains or has the potential to contain hazardous atmospheric hazards capable of causing death or serious physical injury. has restricted means for entry or . • identify and evaluate the hazards before employee enters the confined space. Operators of steam boilers are required by law to be certified Steam Boilers Attendants before they can operate them. or ventilating the permit space.html All operators of the pressure vessels must be trained on its safe operating procedures and be provided with all the necessary protective equipment. • provide communication equipment. • provide lighting equipment needed to enable to employees to see well enough to do their work and to exit the space quickly in an emergency. and verifying that conditions in the permit space are acceptable. isolating the permit space. • provide personal protective equipment where necessary. exit and is not designed for continuous employee occupancy. protecting employee from permit space hazards and for regulating employee’s entry into permit spaces. providing pedestrian and vehicular barriers.sg/SPweb/ appmanager/home/default?_ nfpb=true&_pageLabel=SP_BI_C_ Courses Besides the statutory inspections. and where appropriate. Safe work procedures and protective equipment shall be ensured and provided for employees: • implement measures necessary to prevent unauthorised entry. inerting. • providing testing and monitoring equipment. flushing. • provide barriers and shields. purging.sg/publish/ momportal/en/communities/workplace_ safety_and_health. The details can be found at the website of the Continuing Education Centre of Singapore Polytechnic at: http://www. • policies and procedures to specify acceptable entry conditions. Further information can be obtained from our references: • Singapore Standard: CP 84: 2000 Code of Practice for Entry into and Safe Working in Confined Spaces. and entry supervisor should be clearly defined and documented.workplace safety and health guidelines 121 • provide equipment for safe ingress and egress by authorised entrants. attendants. The duties of all authorised entrants. The employer should certify that the training has been accomplished before assigning the employee to work in this area. • provide rescue equipment and any other equipment necessary for safe entry and rescue. . The employer should provide training to those employees working in such areas so that they can perform the work safely. .122 healthcare Lighting The level of lighting provided and its distribution within workplaces have a major impact on how quickly. Recommended illuminance based on CP 531: Type of healthcare premises / activity Operating theatre Pre-op and recovery room Intensive care (simple examination) Endoscopy room Sterilisation / disinfection rooms Autopsy rooms and mortuaries Dental surgical rooms (general lighting) Dialysis rooms Wards (general lighting) Maintained Illuminance (lux) 1000 500 300 300 300 500 500 500 100 All exits. Measurement of lighting level should be carried out as part of the facilities maintenance programme to ensure adequate lighting is provided and a smooth transition between work areas with different lighting requirements. should be lit and be provided with additional emergency lighting where necessary. both normal and emergency. is provided for all work areas within your healthcare facility. The management should ensure that suitable lighting. depending on the type of task being carried out. safely and comfortably employees are able to carry out their tasks. Adequate and uniform lighting help to reduce visual fatigue and provide for the health and safety of all employees in the workplace. These lighting values should follow the values set out for healthcare in Singapore Standard CP 531-1:2006 Code of Practice for lighting of work places – Indoor. Further information can be obtained from our reference: • Singapore Standard: CP 531-1: 2006 Code of Practice for Lighting of Work Places – Indoor. Outdoor areas such as walkways should be satisfactorily lit for work and access during hours of darkness to provide safety and security to both visitors and employees. • mandatory action signs. to be conversant in identifying the safety signs and know what they need to do when they see a safety sign. Fire open ignition source and smoking prohibited P009 Do not operate .g. Safety signs of appropriate size (25 cm x 25 cm) should be displayed in such positions which can be clearly seen by persons working or entering into an area. radioactive. respiratory. safety signs which encapsulate appropriate colour and various geometric shapes with addition of a graphical symbol.workplace safety and health guidelines 123 Signs. • fire safety signs. doctors. tell us a general safety message. Generally. therapist. It is therefore important for healthcare workers. Safety signs can be classified into the following five main categories according to its functions: • prohibition signs. • means of escape and emergency equipment signs (safe condition signs). e. flammable. explosive and biological hazards exist. by engineering controls and safe systems of work. machinery. The areas that require putting up of safety signs can include those where chemical. The following are examples of common safety signs used in workplaces: Prohibition Signs P002 No smoking P003 No open flame. etc. nurses. Colour Coding and Marking Suitable safety signs are to be provided whenever there is a risk that has not been avoided or controlled by other means. cleaners. noise. • warning signs. radiation. 124 healthcare Mandatory Action Signs M002 Wear eye protection M004 Wear hearing protection M006 Wear hand protection M007 Wear foot protection Warning Signs W009 Warning: Biological hazard W012 Warning: Flammable material W013 Warning: Toxic hazard W015 Warning: Electrical hazard Fire Safety Signs F001 Fire extinguisher F002 Fire hose reel F006 Fire emergency telephone Safe Condition Signs E002 Emergency exit (right hand) E003 First aid E004 Emergency telephone Further information can be obtained from our references: • Singapore Standard: SS 508: Part 3: 2004 Specification for Graphical Symbols Safety Colours and Safety Signs.Safety Signs.Part 5: Signs with Specific Safety Meanings. Including Fire Safety Signs . • British Standard: BS 5499-5: 2002 Graphical Symbols and Signs . . Where there are authorised visitors. Personal Protective Equipment (PPE) Programme This programme should address: Hazards in the Healthcare Facility The management should conduct a suitable and sufficient assessment of the risks to health from exposure to all forms of hazards present in the workplace.g. to places of work where conditions require the use of particular protective clothing or equipment. Selection of PPE The personal protective clothing and equipment selected should be appropriate for the type of hazard and the conditions under which it is used. including contractors. If protective clothing or equipment needs to be used. This is to provide them with reasonable protection against all forms of risk or danger they may encounter when carrying out work in the workplace. Different sizes of clothing and appropriate types of equipment. it should fit the wearer correctly and adjustments can be made. . spectacles for employees with prescriptive eyewear. taking into account the ergonomic requirements and state of health of the person wearing it. then employers should ensure that such clothing and equipment are available to visitors.workplace safety and health guidelines 125 Protective Clothing and Equipment All healthcare employees who are engaged in any process or activity that involves a risk of bodily injury or danger to health should be provided with suitable and appropriate protective clothing and / or equipment. Appropriate personal protective clothing and equipment should then be selected based upon the hazard(s) identified. the healthcare facility should implement a Personal Protective Equipment Programme. should be provided to ensure effective protection for all. Protective clothing and equipment should be considered as the last option where engineering or administrative controls cannot completely eliminate or isolate the hazard at source. e. • What PPE is necessary. useful life. .126 healthcare Maintenance and Use of PPE There should be provisions for issuing these protective clothing and equipment to new employees. adjust. and wear PPE (The proper sequence and methods of donning and removing the various combinations of protective clothing and equipment should be included as part of the training). Recordkeeping Records of hazard assessments. Regular monitoring The effectiveness of PPE provided should be assessed through monitoring employees’ health and safety in relation to the hazard. replacing them when they are defective and proper storage areas to ensure hygiene and accessibility. and disposal of PPE. Training of Employees All employees should be trained in the proper use and maintenance of any protective clothing and equipment they use. PPE assignments to individual employees and training on usage of PPE and training materials should be properly documented and kept. take off. maintenance. Protective clothing and equipment of a personal nature such as anti-splash goggles or safety shoes should be provided on an individual basis. • The limitations of PPE. • How to properly don. This training must include the following: • When PPE is to be worn. • The proper care. • half. • Singapore Standard: SS 98: 2005 Specification for Industrial Safety Helmets. Like other PPE. This will ensure that the . Use. • Singapore Standard: SS 473: Part 2: 1999 Part 2: Specification for Personal EyeProtectors Part 2: Selection. • powered air purifying respirators (PAPR).or full-face elastomeric respirators. • Singapore Standard: CP 76: 1999 Code of Practice for Selection. Types of respiratory devices used in healthcare includes: • particulate respirators (N95. include the following: respirator chosen for the user provides the maximum level of protection. employees should have been medically evaluated to determine that if it is safe for them to wear it. Use and Maintenance. on top of those generic elements mentioned above. Further information can be obtained from our references: • Singapore Standard: CP 74: 1998 Code of Practice for Selection. the selection of a respirator type must consider the nature of the exposure and risk involved. such as Mycobacterium tuberculosis. It should be performed on an annual basis following approved procedures. Care and Maintenance of Hearing Protectors. Training All employees should be trained to conduct fit checking (both positive and negative pressure mode) before each use. Fit Testing Fit testing is a check on whether there is a tight seal between the face and the facepiece. Use and Maintenance of Respiratory Protective Devices. • Singapore Standard: SS 513: Part 1: 2005 Specification for Personal Protective Equipment – Footwear.workplace safety and health guidelines 127 Respiratory Protection Programme The selection of respiratory protection in healthcare is of special importance as respiratory devices are used to protect healthcare workers’ from hazardous or infectious aerosols. Medical Evaluation Before using a respirator. The elements of an effective respiratory protection programme should. N99 & N100). refer to the publication ‘A Guide to the Workplace Safety and Health (First Aid) Regulations’ which is available at the Ministry of Manpower’s website: www. Provisions should be made to enable first aid delivery to any person who is injured or becomes ill while at work and emergency procedures developed and practiced regularly. The appropriate personal protective equipment (PPE) such as impervious gloves. For more information. needle stick injuries. If there is exposure to these substances. slips. suitable facilities for emergency treatment. contact with hazardous chemicals and burns can occur. They should practice Standard Precautions and be aware of the ways to protect themselves when administering assistance or first aid to the injured persons. such as emergency showers for quick drenching and eye wash for flushing of eyes should be available.mom. trips and falls.128 healthcare First Aid Accidents can occur to anyone and in the healthcare industry. gowns and face masks can be used if there is a risk of exposure to the bloodborne pathogens and other infectious materials. Some workplaces may use hazardous or toxic substances. The appropriate first aid given to the injured person is important in saving lives and preventing further injury and pain. These facilities for emergency use should be readily accessible and be properly maintained.gov. they should also be aware of safe clean-up procedures of body fluids and soiled surfaces.sg . Those giving first aid should be aware of the associated hazards as they may come into contact with bloodborne pathogens. such as hepatitis and human immunodeficiency virus (HIV) and other potentially infectious materials. In addition. workplace safety and health guidelines 129 appendices . pitch.130 healthcare Appendix A – Occupational Diseases Reportable under Workplace Safety and Health Act and its Subsidiary Legislation • Aniline poisoning • Anthrax • Arsenical poisoning • Asbestosis • Barotrauma • Beryllium poisoning • Byssinosis • Cadmium poisoning • Carbamate poisoning • Carbon Bisulphide poisoning • Chrome ulceration • Chronic benzene poisoning • Compressed air illness • Cyanide poisoning • Epitheliomatous ulceration (due to tar. mineral oil or paraffin or any compound. product or residue of any such substance) • Hydrogen Sulphide poisoning • Repetitive strain disorder of the upper limb • Silicosis • Toxic anaemia • Toxic hepatitis • Occupational skin diseases • Lead poisoning • Liver angiosarcoma • Manganese poisoning • Mercurial poisoning • Mesothelioma • Noise-induced deafness • Occupational asthma • Organophosphate poisoning • Phosphorous poisoning • Poisoning from halogen derivatives of hydrocarbon compounds . bitumen. coli O157 Salmonella typhi Clostridium difficile Campylobacter jeujuni Hepatitis A Skin and soft tissue infections Staphylococcus aureus (including MRSA) Ringworm Orf Viral respiratory tract infections Droplet: large particles that do not remain airborne for very long and do not travel far from source Respiratory tract infections Respiratory syncytial virus Bordetella pertussis Mumps Infectious rashes Meningitis Airborne: small particles that can remain airborne and travel considerable distances Respiratory tract infections Varicella zoster Neisseria meningitidis Mycobacterium tuberculosis Mycobacterium bovis Avian flu Chlamydia psittaci Infectious rashes Bloodborne: either direct contact with blood or body fluids (or via skinpenetrating injury) or indirect via contaminated articles. e.g. dressings Hepatitis Rubella Hepatitis B Hepatitis C Immune system disease HIV HTLV * From HSE’s Biological Agents: Managing the risks in laboratories and healthcare .workplace safety and health guidelines 131 Appendix B – Examples of Infections and Routes of Transmission Route of Infection Contact: either direct via hands of employees. or indirect via equipment and other contaminated articles Type of disease Gastrointestinal disease Organisms E. glutaraldehyde.g. peracetic acid.132 healthcare Appendix C – Summary of Hazards in Healthcare by Location Location Central supply (CSSU) Hazard • Sterilising gases (if ethylene oxide is used) • Sterilising / disinfecting agents (e. hydrogen peroxide and orthophthaldehyde) • Flammable gases • Hazardous wastes (chemical and bio-hazardous) Dialysis units • Formaldehyde • Bloodborne pathogens • Infectious diseases • Hazardous wastes (chemical and bio-hazardous) • Bloodborne pathogens • Heat from steam/hot water • Sharps • Manual handling • Standing for long hours • Noise • Splashes during washing of equipment • Sharps • Manual handling • Splashes during washing of equipment • Needling of patient Dental surgery • Waste anaesthetic gases (WAGs) • Mercury • Methyl methacrylate • Bloodborne pathogens • Infectious diseases • Hazardous wastes (chemical and bio-hazardous) • Awkward postures • Noise • Ionizing radiation • Sharps • Aerolisation during dental treatment • Chemical allergy during cold sterilisation of equipment . g. falls • Infectious specimens • Infectious/chemical aerosols (during processing) • Allergy to PPE (latex allergy) • Skin chaffing due to prolonged use of occlusive PPE and repeat handwashing • Hazardous wastes (chemical. chlorine based products. detergents. bio-hazardous and radioactive) • Manual handling • Noise • Sharps • Slips and trips . soaps. radioactive. etc. ethylene oxide) • Mutagens • Cryogenic hazards • Bloodborne pathogens Laundry • Bloodborne pathogens • Sharps (e. detergents. caustic cleaners.g.workplace safety and health guidelines 133 Location Kitchen service Hazard • Disinfectants and cleaning agents (e. soaps. chlorine based products.g. etc.) • Manual Handling • Noise • Sharps • Heat • Slips and trips • Electrical hazards Housekeeping • Disinfectants and cleaning agents (e. infectious) • Electrical hazards • Slips. needle punctures) • Hazardous wastes (chemical. radioactive.g. caustic cleaners.g.) • Bloodborne pathogens (from soiled linen. benzene and formaldehyde) • Teratogens (e. solvents. solvents. misplaced used needles or waste disposal) • Manual handling • Sharps • Hazardous wastes (chemical. infectious) • Radiation • Sharps Laboratory • Toxic chemicals • Solvents • Flammable and explosive agents • Carcinogens (e. g. machinery • Noise • Welding fumes • Asbestos • Flammable liquids • Solvents • Mercury • Pesticides • Cleaners • Ammonia • Carbon monoxide • Ethylene oxide • Freons • Paints.134 healthcare Location Maintenance and engineering Hazard • Electrical hazards • Tools. glutaraldehyde.g. ethylene oxide) • Ozone Operating rooms • Sterilising / disinfecting agents (e. adhesives • Water treatment chemicals • Sewage • Heat stress • Cold stress (refrigeration units) • Work at heights • Confined spaces • Manual handling • Strains and sprains Nuclear medicine • Bloodborne pathogens • Radionuclides (e. hydrogen peroxide and orthophthaldehyde) • Bloodborne pathogens • Infection diseases • Manual handling . peracetic acid. technetium) • X-irradiation • Lifting Office areas and data processing • Video display terminals • Indoor air quality • Waste anaesthetic gases (WAGs) • Antiseptics • Methyl methacrylate • Compressed gases • Sterilising gases (e.g. g. falls • Abuse from patient and relatives • Hazardous wastes (e.g. formaldehyde) • Solvents • Phenols Patient care • Waste anaesthetic gases (WAGs) (delivery rooms and recovery rooms) • Bloodborne pathogens • Infectious diseases • Manual handling • Standing for long periods • Radiation • Sharps (e. falls • Pushing. pulling Pathology • Sterilising / disinfecting agents (e. peracetic acid. cytotoxics and chemotherapeutic agents) Radiology • Radiation • Lifting .g. cytotoxics and chemotherapeutic agents) • Slips. glutaraldehyde.g. cytotoxics and chemotherapeutic agents) • Hazardous wastes (chemical and bio-hazardous) • Psychosocial • Electrical hazards • Slips. hydrogen peroxide and orthaphthaladehyde) • Fixative agents (e.g. needle punctures) Pharmacy • Mercury • Hazardous medication handling (e.g.workplace safety and health guidelines 135 Location Hazard • Awkward / Static postures • Sharps • Hazardous wastes (chemical and bio-hazardous) • Electrical hazards • Flammable substances • Freons • Bloodborne pathogens • Infectious diseases • Sharps • Hazardous wastes (chemical and bio-hazardous) • Hazardous medication handling (e. gov.au Health and Safety Laboratory – United Kingdom www.sg National University of Singapore www.osha.osha.gov.spb.sda.gov The National Institute for Occupational Safety and Health (USA) www.cdc.gov.uk Japan International Center for Occupational Safety and Health www.gov.sg Ministry of Manpower www.com .sg Singapore Medical Council www.singaporestandardseshop.sg Singapore Nursing Board www.gov/SLTC/etools/hospital/ World Health Organisation www.moh.jp/english Joint Commission Resources www.smc.gov.jcrinc.cdc.mom.gov.hsa.snb.sg Health Sciences Authority www.sg OSHA Hospital e-Tool http://www.edu.vic.sg Singapore Standards eShop www.gr.gov.gov.hsl.org Occupational Safety and Health Administration (USA) www.gov.jicosh.ilo.workcover.136 healthcare Appendix D – Useful Links Workplace Safety and Health Council www.nus.nea.sg Ministry of Health www.gov Victorian Workcover Authority www.gov/niosh Centers for Disease Control and Prevention (USA) www.gov.who.wshc.int International Labour Organisation www.sg Singapore Pharmacy Board www.gov.sg National Environment Agency www.sg Singapore Dental Council www. mom. . Ministry of Health http://www.gov.gov.The Workplace Safety and Health Act Subsidiary Legislations.Guidelines on Noise and Vibration Control.sg . Ministry of Manpower Occupational Safety and Health Division Workplace Safety and Health Legislation: http://www. .The Workplace Safety and Health Act. 2008. 2007.wshc.moh.mom.html . .sg/legislation/wsh. . 2003.Workplace Safety and Health Council (WSHC): Workplace Safety and Health Guidelines Hotels.The Workplace Safety and Health (Noise) Regulations. .The Work Injury Compensation Act.The Workplace Safety and Health (Incident Reporting) Regulations.Hearing Conservation Programme Guidelines.html . . .Guidelines on Design.Guidelines for Preventing Transmission of Bloodborne Infections in a Healthcare Setting. 2000.sg/managing_workplace_hazards .The Workplace Safety and Health (First Aid) Regulations. .sg/pub_guidelines.The Workplace Safety and Health (Construction) Regulations.The Workplace Safety and Health (Risk Management) Regulations. Food and Beverage. Operation and Maintenance of Local Exhaust Ventilation Systems. .gov.workplace safety and health guidelines 137 Appendix E – Resources Local references Workplace Safety and Health Council Guidelines to managing workplace hazards: http://www. . 2003.gov. Guidelines to managing workplace hazards: http://www. 2005.Radiation Protection Act.CP 531-1: Code of Practice for Lighting of Work Places – Indoor. http://app.asp?pid=1439 .Guidelines for Good Indoor Air Quality in Office Premises. 1999. . Assessed 15 March 2008. Assessed 15 December 2007.singaporestandardeshop. . 2002.nea.nea.CP 92: Code of Practice for Manual Handling.gov.sg/cms/htdocs/article.Radiation Protection (Ionising Radiation) Regulations. 2006. 2006. Codes of Practice . .138 healthcare National Environment Agency .sg/cms/htdocs/article. .CP 84: Code of Practice for Entry Into and Safe Working in Confined Spaces.gov.asp?pid=2885 Academy of Medicine . Use and Maintenance. Use and Maintenance of Respiratory Protective Devices. http://app.CP 76: Code of Practice for Selection. Care and Maintenance of Hearing Protectors.asp?pid=1531 . 2004. 2005.CP 100: Code of Practice for Hazardous Waste Management.Control of Toxic Wastes.gov. 2007.sg Singapore Standards . .SS 98: Specification for Industrial Safety Helmets.SS 506: Occupational Safety and Health Management System. .SS 513: Part 1: Specification for Personal Protective Equipment – Footwear.sg/cms/htdocs/article. . Productivity and Innovation Board (SPRING) http://www.SS 508: Part 3: Specification for Graphical Symbols – Safety Colours and Safety Signs. 2003. http://app. Singapore Standards. 1998.SS 473: Part 2: Specification for Personal Eye-Protectors Part 2: Selection. . 2004. . Use. 1996.CP 99: Code of Practice for Industrial Noise Control.CP 74: Code of Practice for Selection. . 1999. . .Control of Hazardous Substances. 2000. .nea. Assessed 15 December 2007.Disposal of Radioactive Waste. .Guidelines on the Use of Ultrasound in Medicine. OSHA Technical Manual. .Guidelines for Infection Control in Dental Healthcare Settings. 1989. Centers for Disease Control and Prevention.Glutaraldehyde – Occupational Hazards in Hospitals. Occupational Safety and Health Administration (OSHA) http://www. . 1997.osha. Current as of 15 December 2007.NIOSH Alert: Preventing Allergic Reactions to Natural Rubber Latex in the Workplace. 2001. . World Health Organisation http://www. National Institute for Occupational Safety and Health (CDC.WHO Laboratory Biosafety Manual 3rd edition. NIOSH) .workplace safety and health guidelines 139 Overseas references International Labour Organisation http://www. .Waste Anesthetic Gases . 2003. 2007.Occupational Hazards in Hospitals.Current Intelligent Bulletin 52: Ethylene Oxide Sterilizers in Health Care Facilities – Engineering Controls and Work Practices.The Global Occupational Health Network Newsletter. 2006. . 2001. .Anaesthetic Gases: Guidelines for Workplace Exposures. . .Hospital E-tool.int .Safety in the Use of Anaesthetic Gases.gov/SLTC/etools/hospital/index.Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Section VI Chapter 2: Controlling Occupational Exposure to Hazardous Drugs. 10: Psychosocial Factors and Mental Health at Work. 2004.html . . 2001. US Department of Labor.Control of Nitrous Oxide in Dental Operatories. 2006. . 2000.who.Guidelines on Occupational Safety and Health Management Systems. 2004. Issue No.gov/ . http://www.ilo. . 1996. .org . 1999.Best Practices for Safe Use of Glutaraldehyde in Health Care.Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers. 2007. International Social Security Association (ISSA) . 1998.osha.Hazard Controls – Control of Smoke from Laser / Electric Surgical Procedures. Society of Gastroenterology Nurses and Associates.gov/sharpssafety . Monica Lagerström: .hse. Allan Toomingas. including fire safety signs Part 5: Signs with specific safety meanings.Tackling Stress: The Management Standards Approach. Department for Labour.icrp. Assessed 15 December 2007. .org/Publications/ .BS OHSAS 18001 : 1999 standard (superseded by BS OHSAS 18001 : 2007).Workbook for Designing. .uk/healthservices/violence/ . 2003. 1997.Guideline for the Use of High-Level Disinfectants and Sterilants for Reprocessing of Flexible Gastrointestinal Endoscopes. Occupational Safety and Health Service. British Standards Institution . Accessed 20 October 2007.cdc. New Zealand . Hans-Martin Hasselhorn.gov. 2005.Occupational Health for Healthcare Workers: A Practical Guide. 2004.Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Healthcare Settings. Health and Safety Executive (HSE).BS 5499-5: 2002 Graphical Symbols and Signs .hse. 2007.Medical Surveillance for Healthcare Workers Exposed to Hazardous Drugs. 1999. Safe Handling of Cytotoxic Drugs.org International Atomic Energy Agency http://www.140 healthcare .Violence: Occupational Hazards in Hospitals. http://www. 2005. . INC (SGNA) . UK . http://www.Stress at Work.uk/latex/ . http://www. .Guidelines for the provision of facilities and general safety and health in the healthcare industry. 1999.Biological agents: Managing the Risks in Laboratories and Healthcare Premises.iaea.HSE Information Sheet. 2003.gov.Workplace Violence. and Evaluating a Sharps Injury Prevention Program. 2002. . Accessed 1 July 2007. The International Commission on Radiological Protection (ICRP) http://www. Implementing. 2004.Latex allergies.Safety signs. . http://hss. Accessed 15 March 2008.org/ .gov/nuclearsafety/techstds/standard/standard.workplace safety and health guidelines 141 United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR) http://www. Safety and Security.gov.cfm US Department of Energy (DOE).htm Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) Radiation Health Series.au/publications/Codes/rhs. Accessed 15 March 2008.html National Council on Radiation Protection and Measurements (NCRP) http://www.europa.arpansa.ncrponline. Accessed 15 March 2008. Office of Health.org/ European Commission Energy – Nuclear Issues. Nuclear Safety and Environment Online Approved DOE Technical Standards. http://www.unscear.energy. http://ec.eu/energy/nuclear/radioprotection/publication_en. 142 healthcare acknowledgements . Theresa Liew Lee Lin.Tong Tee Hui. Pollution Control Department Health Sciences Authority . OSH Specialist Department ParkwayHealth . OSH Specialist Department . Head.Prof Bosco Chen Bloodworth. Specialist.Yap Tien Siang. Senior Specialist. OSH Specialist Department .Colleen Low. System Safety. Centre for Radiation Protection and Nuclear Science . OSH Specialist Department . Construction and Equipment Safety.Yeong Chark Sung. System Safety.Dr Yim Kok Kean. Deputy Director. Occupational Health and Safety Division Ministry of Health . Specialist. Health Risk Control. Senior Specialist.Dr Ong Bee Ping. (Acting) Head. Executive Engineer. Manager (Quality) We would like to thank SingHealth for their assistance in providing images for this publication.Jamie Lim Yin Yin.Jeanne Lim.Chow Chee Kiong. Occupational Medicine.Dr Tay Ee Guan. OSH Specialist Department .Dr Lucy Leong.Dr Anthony Goh Singapore Health Services ( SingHealth) . Quality Division . Senior Specialist. . OSH Specialist Department . Director. Director (Quality) . Group Assistant Vice President. Construction and Equipment Safety.Ivan Goh. Education & Research National Environment Agency .workplace safety and health guidelines 143 Acknowledgements Contributors Ministry of Manpower Occupational safety and Health Division . System Safety. Senior Specialist. OSH Specialist Department . Medical Director. Health Regulation Division Singapore Dental Association .Dr Jason So. USA • Centers for Disease Control and Prevention (CDC). UK • International Social Security Association (ISSA) • Swedish Work Environment Authority • Society of Gastroenterology Nurses & Associates • Global Occupational Health Network • Hasselhorn et al. USA • Health and Safety Executive (HSE). USA • The National Institute for Occupational Safety and Health (NIOSH). • World Health Organisation (WHO) • British Standard Institute (BSI) .144 healthcare The Workplace Safety and Health Council would also like to acknowledge contributions from the following agencies: • SPRING Singapore • Ministry of Health (MOH) • Singapore Medical Association • Occupational Safety and Health Administration (OSHA). . As a guide. The Ministry of Manpower and the Workplace Safety and Health Council do not accept any liability or responsibility to any party for losses or damage arising from following the guidelines. this booklet has no legal standing. . without prior written permission.Published in April 2008 by the Workplace Safety and Health Council in collaboration with the Ministry of Manpower. This publication may not be reproduced or transmitted in any form or by any means. The information provided in this guidebook is accurate as at time of printing. These guidelines are co-developed by the Workplace Safety and Health (WSH) Council and the Ministry of Manpower. in whole or in part. All rights reserved.