NTC Safety Manual
Northern Michigan University School of Nursing
Rettig Nursing Technology Center (NTC)
____________________________________________________________________________
Table of Contents
Purpose, Policy and References
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Employee and Student Exposure Determination
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Compliance Methods .
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General
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Handwashing Facilities
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Needles and Sharps .
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Containers for Sharps .
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NTC Environmental Restrictions
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Housekeeping and Contaminated Equipment
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Personal Protective Equipment (PPE)
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General
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Gloves .
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Laundry Procedures .
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Invasive Procedure Policy
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Exposure to Blood Borne Pathogens Procedure
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Incident Reporting
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Latex Allergy Policy .
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Response to Active Shooter .
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Employee Information and Training Requirements .
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Record Keeping
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Review of Plan
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Attachment 1 NMU Incident Report .
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Attachment 2 Documentation of Refusal to Accept Referral
Attachment 3 SON Latex Response Plan .
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Attachment 4 Response Guideline to Active Shooter
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NTC Safety Manual
Initiated:
Updated:
Revised:
January 2, 2002
May 21, 2009, January 2010
August 2013
Purpose
The purpose of this safety plan is to identify and protect employees and students who are at risk for exposure
to blood-borne infectious diseases in the Rettig Nursing Technology Center (NTC) environment, to comply with
Northern Michigan University (NMU) and Michigan (MI) OSHA standards, and to provide health related
procedures and policies to be followed in the NTC.
Policy
It is the policy of the School of Nursing (SON) and the NTC to comply with NMU and (MI)OSHA Blood-Borne
Pathogens Standards. All employees and students who may incur exposure to blood or other potentially
infectious materials (OPIM) are covered by this policy.
References
NMU blood Borne pathogens Exposure Control Policy (REV: August 21, 1998)
Michigan Department of Community Health Bureau of Laboratories, Health and Safety (APP: January 19,
2000)
Management of Exposure to Blood-Borne Diseases NMU Health Center Accidental Needle Stick Policy (REV:
November 2001)
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Employee and Student Exposure Determination for School of Nursing
Job Classification
Tasks/Procedures
Associate Dean/Director
All listed job classifications names:
Nursing Support & Simulation Specialist
 Handling of sharps
Faculty Simulation Specialist
 Handling of sharps containers
Professors
 Collecting and boxing sharps
Associate Professors
containers for biohazard pickup
Adjunct Faculty
 Managing soiled linens
Overload Faculty
 Performing invasive procedures
AAUP Faculty
Graduate Assistants
NTC Supervisor
NTC Clerks, SLAs, & Techs
NTC Bulk Stores Assistant
Student Nurses
Compliance Methods
Universal Precautions will be observed in all NTC learning labs to prevent contact with blood or OPIM. All
blood and all other human bodily fluids will be considered infectious regardless of the perceived status of the
source individual.
The following work practices will be utilized to eliminate or minimize exposure. Should risk of exposure remain
after institution of these controls, PPE shall also be utilized.
1. HAND WASHING FACILITIES-are readily accessible to those who incur exposure. The NTC
Supervisor is responsible for ensuring maintenance and accessibility of all related hand washing
equipment and items.
2. NEEDLES AND SHARPS-Uncontaminated or contaminated needles and other sharps will not be bent,
recapped, removed, sheared or purposely broken.
a. Needles and Sharps:
i. Disposable needles and sharps are placed into appropriate sharps containers that are
puncture resistant, closeable, leak proof, red, and have a red biohazard label.
ii. Sharps are not to be passed from hand to hand.
iii. Mechanical recapping devices or one-handed techniques may be used in some
situations, however two-handed recapping and using the mouth to hold the cap are
strictly forbidden.
3. CONTAINERS FOR SHARPS-will be located in all NTC lab areas where sharps and needles are used.
a. Containers must be closeable, puncture resistant, leak proof on sides and bottom, and are red
and have red biohazard labels applied to them.
b. Containers will be easily accessible and as close as feasible to immediate area where sharps
and needles are used.
c. Containers are not to overflow, are to be maintained in the upright position, be kept closed and
routinely replaced.
d. Location for Sharps Containers:
i. WS 1609 A & B- one container mounted in each exam room.
ii. WS 1613, 1615, 1702, 1704- one container mounted at each bedside.
iii. WS 1617- storage room for empty containers, partially filled containers and biohazard
collection box for full containers.
iv. WS 1532- one container mounted on wall by birthing bed.
v. WS 1534- one container mounted on wall by ICU bed.
vi. WS 1701, 1703, 3618- containers provided in rooms as needed.
e. Sharps containers will not be opened, emptied or cleaned manually.
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f.
If the sharps container has been contaminated on the outside, with donned gloves, it must be
put in a biohazard bag and placed into a biohazard collection box.
g. Responsible persons for collecting and boxing containers: NTC Supervisor and NTC Clerks.
4. NTC ENVIRONMENTAL RESTRICTIONS: In areas where there is a possibility of exposure to blood or
OPIM it is not permitted to eat, drink, apply cosmetics or lip balm or handle contact lenses.
5. HOUSEKEEPING AND CONTAINED EQUIPMENT: Equipment that has become contaminated with
blood or OPIM shall be examined prior to prepping for pickup and shall be decontaminated as
necessary:
a. All equipment and environmental and working surfaces shall be cleaned and decontaminated if
contact with blood or OPIM using a solution of 1 part bleach to 8 parts water. Decontamination
shall be done immediately after the procedure or as soon as feasible after any spill of blood or
OPIM.
b. Broken glass will not be picked up directly with the hands. A broom and dust pan must be used,
located in WS1611, and the materials placed in a puncture proof container. Vacuum cleaners
are not to be used to pick up broken glass.
c. Tools used to clean up must be decontaminated or properly disposed of after use.
6. PERSONAL PROTECTION EQUIPMENT (PPE):
General:
 PPE will be provided by the NTC without cost.
 PPE will be chosen based on anticipated exposure to blood or OPIM.
 PPE is considered appropriate if it does not permit blood or OPIM to pass through or
reach clothing, skin, eyes, mouth or other mucus membranes under normal conditions of
use and for the duration of the time in which the PPE will be used.
 All garments, which are penetrated by blood, shall be removed immediately or as soon
as possible and placed in appropriate receptacles.
 All PPE will be removed before leaving NTC lab rooms.
Gloves:
 Gloves will be used when it is reasonably anticipated that hand contact will be made with
blood or OPIM, mucus membranes or non-intact skin or when handling or touching
contaminated surfaces or items.
 Gloves must be worn for the following procedures:
o Oral care
o Administering blood glucose checks
o Administering TB skin tests
 Disposable gloves will not be re-used, washed or decontaminated.
 Disposable gloves will be replaced when their ability to function as a barrier has been
compromised, or if they become contaminated.
 Hypoallergenic gloves, powderless gloves or other similar alternatives will be provided to
those allergic to gloves normally provided.
 Handwashing after glove removal is required. Studies have shown that although gloves
provide a barrier they are not completely impermeable.
 Utility gloves may be decontaminated for re-use if the integrity of the glove is not
compromised.
 Utility gloves will be discarded if they are cracked, peeling, torn, punctured or if ability to
function is compromised.
7. LAUNDRY PROCEDURES:
a. Laundry contaminated with blood or OPIM will be handled as little as possible. Such laundry will
not be sorted or rinsed in the area of use.
b. Gloves are to be worn to place contaminated laundry in the clear plastic and red labeled
biohazard laundry bags.
c. Home laundering is not permitted.
d. College Laundry and Rentals is the vendor used for laundry services. This agency uses
universal precautions.
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Invasive Procedure Policy in the NTC
1. No student shall perform an invasive procedure on another student or volunteer.
2. Invasive procedures are any nursing procedure that involves entry into any body cavity and/or invades
the integrity of the skin or body cavity, unless identified as an exception to this policy.
3. Only mannequins or other instructional aides shall be used for such practice.
4. Exceptions to the policy include the following procedures:
a. Oral and ear assessments
b. Oral and tympanic temperatures
c. Oral feeding
d. Nasal exams
e. Vaginal exams
f. TB skin test administration with supervision
g. Glucose checks with supervision
Exposure to Blood-Borne Pathogens
Procedure for Management of Accidental Exposure to Blood-Borne Diseases
1. Significant exposure is defined as percutaneous, ocular, or mucous membrane exposure to blood or
other body fluids containing visible blood.
2. If possible, the wound or exposed area shall be immediately and thoroughly washed with soap and
water, or irrigated with tap water for eyes or other mucous membrane.
3. A NMU Incident Report for Accident/Injury/Illness shall be completed and returned to the NTC
Supervisor. Incident Report forms are in a hanging file located at the NTC Clerk’s desk. (For online
link see Attachment 1).
4. The Exposed Person will be referred to the NMU Health Center. A physician’s visit is not needed, but a
scheduled nurse visit and lab draws must be done on the same day as the incident.
5. The nurse will administer Tetanus toxoid 0.5ml IM if no Tetanus booster within 10 years.
6. If the Exposed Person has not received Hepatitis B vaccine, the initial immunization will be offered. For
greatest effectiveness, Hepatitis B immune globulin (HBIG) should be given as soon as possible after
exposure, preferably within 24 hours. Its value beyond seven days after exposure is unclear. The dose
is 0.06ml/kg, to a maximum of 5ml, IM. BILLING: The patient will be responsible for this charge.
7. The Exposed Person will have the following labs drawn:
a. Rapid HIV antibody
b. HCV
c. ALT (SGPT)
d. Hepatitis B surface antibody (HBsAB)
e. Hepatitis B surface antigen (HBsAg)
f. BILLING: The Exposed Person’s bill is submitted to the patient’s health insurance first, then to
the department where the incident occurred. At no time should anyone be denied testing.
8. REFUSAL OF TREATMENTa. If the Exposed Person refuses to accept referral to the Health Center a Documentation of
Refusal to Accept Referral form shall be completed and returned to the NTC Supervisor
(Attachment 2).
b. The NMU Health Center is to be notified of the Exposed Person’s refusal to accept referral.
c. If the Exposed Person accepts referral but does not give consent for HIV testing the Health
Center will draw an extra tube and tell the patient is will be saved for 90 days. They can elect to
have testing up to that time. Otherwise the sample will be discarded.
9. If the SOURCE PATIENT is identifiable, they shall be informed of the incident and requested to report
to the Health Center to have the following labs drawn:
a. HIV antibody
b. Hepatitis B surface antigen – unless patient has had 3 Hepatitis B shots,
then a Hepatitis
BsAB test will be done instead.
c. HCV
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d. BILLING: The cost will be paid by the Health Center as incentive for the source patient to be
tested.
10. If any tests are positive, the physician will make recommendations for prophylaxis based on the latest
available guidelines.
11. The physician may advise the Exposed Person to return for additional HIV testing depending upon the
nature of the exposure.
12. NTC Supervisor is responsible for assuring SON required paperwork is completed regarding exposure
in the NTC.
Incident Reporting
Any accident or incident occurring in the NTC shall be reported immediately to supervising faculty and NTC
Supervisor. An NMU Incident Report form is to be filled out and submitted per NMU protocol. (Attachment 1)
Latex Allergy Management
Students who have been identified as having a latex allergy/sensitivity or have been medically advised to avoid
latex should coordinate with each clinical instructor and the NTC Supervisor to plan for his/her safety. It is
incumbent for the student to monitor their environment for possible risk of exposure. Student may request latex
allergy carts at clinical sites.
1. For management of known allergies and procedure for exposure see Nursing Latex Response Plan
(Attachment 3).
Response to Active Shooter
In the event of an ACTIVE SHOOTER on campus:
1. Refer to Response Guidelines for an Active Shooter (Attachment 4).
Employee Information and Training Requirements
1. All NTC employees will be trained prior to initial assignment to NTC exposure and safety policies and
procedures.
2. NTC Supervisor will schedule and keep record of NTC staff safety training.
3. NTC Supervisor will be responsible for refresher training as needed.
Record Keeping
1. The NTC Supervisor will maintain and update the following nursing student records:
a. MMR – (for Rubella record)
b. Tetanus – (within 10 years)
c. Hepatitis B
d. TB skin test results
e. TB Questionnaires and/or chest x-ray results
f. CPR
g. Flu Shot
h. Criminal Background Checks
2. Incident reports will be maintained by the NTC Supervisor.
Review of Plan
This plan will be reviewed and updated by the NTC Supervisor and approved by the SON Safety Committee.
Initiated: 1/02; Rev. 5/09, 1/10, 5/13
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Attachment 1
NMU Incident Report for Accident/Injury/Illness Forms
1. NMU Public Safety Link for Incident Reporting. Options of online PDF Format for completion of current
form and sending via email or for Microsoft Word Format for printing copies and filling out with pen.
http://www.nmu.edu/publicsafety/node/7
Initiated: Spring 2008, Rev. May 2009, Rev. January 2010, Rev. 5/2013
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Attachment 2
Northern Michigan University
School of Nursing
Rettig Nursing Technology Center
Documentation of Refusal to Accept Referral
Date: _____________________________________ Date of Birth: _______________________
Name: ______________________________________________________________________
Address: ____________________________________________________________________
Reason for Referral: ___________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
I have been advised to go to the NMU Health Center or affiliate employee health services immediately for
counseling and testing because of the above-mentioned reason(s). Even though it has been recommended
that I do so, I do not plan to go now for the following reason(s):
____________________________________________________________________________
___________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
The following possible risks of not accepting or acting upon the referral have been explained to me:
___________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
I hereby release Northern Michigan University and NMU School of Nursing from any and all liability arising out
of or connected with my decision not to follow the above medical recommendation.
Signature: ____________________________________ Date: __________________________
I witness the fact that the individual signed the above and said he/she read and understood the same.
Witness Signature: ____________________________________ Date: ___________________
c: NMU Health Center
Initiated: January 2002, Rev. May 2009
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Attachment 3
School of Nursing Latex Response Plan
When working in the clinical setting or nursing skills labs, students may be exposed to latex and other
allergens.
Procedure:
For students with known sensitivity/allergy to latex or any other element in the skills lab or clinical
environment, it is recommended that you:
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Obtain consultation from your health care provider about your sensitivity/allergy, risks and
treatment.
Inform the NTC Supervisor, skills lab faculty and your clinical instructor of your sensitivity.
o Latex-free gloves can be provided. However, the lab environment and clinical facilities are
not latex free.
Inform the faculty member of your plan to handle a reaction.
In case of a life-threatening reaction in a nursing clinic or skills lab, an ambulance is to be summoned.

Any faculty member or student may dial 911 on the phone. State that you have a life threatening
“Latex emergency” and need an ambulance. Epinephrine will be needed.
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Do not handle the victim with any latex products.
Victim will be transferred to a hospital in the community by ambulance. It is helpful for the
ambulance personnel to know the victim’s allergies, current medications and any medical
conditions.
If a student or faculty member has a reaction requiring medical attention, a SON Incident Report is to be
completed and forwarded to the NTC Supervisor. I have reviewed the above policy and understand that
questions regarding this policy are to be directed to the NTC Supervisor.
Student/Faculty Signature: __________________________________________________
Printed Name: ___________________________________________________________
Date: ___________________________________________________________________
Initiated: 7/02, Rev. 5/09
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Attachment 4
Response Guidelines for an Active Shooter
Secure Immediate Area
 Lock and barricade doors
 Turn off lights
 Close blinds
 Block windows
 Turn off radios and computer monitors
 Keep occupants calm, quiet, and out of sight
 Keep yourself out of sight and take adequate cover/protection (i.e. concrete walls, thick desks, filing cabinets),
which may protect you from bullets
 Silence cell phones
 Place signs in exterior windows to identify the location of injured persons
Contacting Authorities
 Use 911 (dialing 911 from a campus phone will connect you with NMU Public Safety)
 Dialing 911 from a cell phone will connect with Marquette County Central Dispatch. Make sure to give the
dispatcher your exact location
 Dialing 227-2151 will contact you with central dispatch at NMU Public Safety (the non-emergency line)
 Be aware that the 911 system will likely be overwhelmed
 Program the NMU Public Safety and Police Services administrative line (227-2151) into your cell phone for
emergency use
What to Report:
 Your specific location, in particular the building name and the office or room number
 The number of people at your specific location
 The number of injured persons and what types of injuries have been suffered
 Provide as much of the following information as is known
o Assailant’s location
o Number of suspects
o Race
o Gender
o Clothing description
o Physical features
o Type of weapons (long gun or hand gun)
o Backpack type
o Shooter’s identity
o Type of incident – i.e. shooting or explosion
Un-securing an Area
 Consider risks before un-securing rooms
 Remember, the shooter will not stop until they are engaged by an outside force
 Attempts to rescue people should only be made if they can be accomplished without further endangering the
persons inside a secured area
 Consider the safety of masses vs. the safety of a few
 If doubt exists for the safety of the individuals inside the room, the area should be secured.
Initiated: Spring 2008, Rev. 5/2009
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