Russell County Hospital
1610 Dowell Road
Russell Springs, KY 42642
270-866-4141
DEPARTMENT:
Laboratory
POLICY/PROCEDURE TITLE
Laboratory Chemical Hygiene Plan
POLICY/PROCEDURE NUMBER:
400-EC -801
Issued: Unknown
Revised: 6/30/02, 7/21/04, 5/10/06
Supercedes:
Prepared by: R. Johnson
Approved:
Reviewed:
Medical Director
Approved:
Reviewed:
Laboratory Director
_________________________________________________________________________________________________
I.
II.
POLICY:
A.
Russell County Hospital maintains an employee “Right-To-Know” center, located outside the
Maintenance Department. Notebooks containing information on the on the Hospital and Laboratory
Emergency Preparedness Plan, Infection Control, and Materials Safety Data Sheets (MSDS), are
located in the laboratory office area on the bookshelf and are available for all employees to read.
B.
The Laboratory Administrative Director, under the direction of the Medical Director, is responsible for the
Chemical Hygiene Plan in the laboratory.
C.
The Laboratory Administrative Director is the Laboratory Safety Officer. She will educate employees as
to general safety measures, possible exposure to hazardous chemicals, procedures for handling, using,
and disposal of such chemicals, and use of engineering controls available.
D.
When there is a potential for occupational exposure, the Laboratory will provide at no cost to the
employees, personal protective equipment (PPE) to minimize exposure to toxic substances. MSDS’ are
used to determine which substances may require special protection and what that should be. The
employer will enforce the consistent use of PPE by employees.
E.
The Laboratory Safety Officer will continuously evaluate the volume of hazardous chemicals used in the
laboratory and will seek ways to reduce on-hand amounts whenever possible. When possible,
appropriate substitutes should be made as they become available.
PROCEDURES:
A.
B.
Material Safety Data Sheets (MSDS):
1.
The Laboratory will maintain an inventory of its in-use hazardous chemicals and reagents as
defined by federal, state, and local ordinances, and hospital-wide waste management programs.
2.
An MSDS will be provided for each hazardous substance. These MSDS are kept in labeled
notebooks, located in the laboratory office area on the bookshelf.
3.
Chemical disposal will be in accordance with the Hospital HAZMAT program, which always uses the
information contained in the MSDS as a definitive guide.
Hazardous Substance Identification.
1.
Procurement of chemicals/reagents. No chemicals will be accepted into the Lab without a label
containing the following information:
a.
Chemical identity/ brand name.
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RUSSELL COUNTY HOSPITAL
Policy/Procedure Title: Laboratory Chemical Hygiene Plan
Policy/Procedure Number: 736-EC-801
b.
c.
Issued: 3/05/02
Revised: 5/10/06
Hazard warning.
Name and address of manufacturer/distributor.
NOTE: Whenever a hazardous chemical is received into the laboratory, the MSDS should be
reviewed to ensure the substance is being handled in compliance with the standards.
2.
3.
Classification of dangerous chemicals.
a.
Caustic or corrosive: Acids and alkalis that may cause burns to the skin, mouth or eyes.
b.
Poisons: A poison is classified as a substance that may cause death or serious injury when
inhaled, ingested or allowed to come into contact with the skin.
c.
Carcinogens: Substances designated by OSHA as carcinogenic require special handling.
Consult the MSDS for specific instructions. Example: Chloroform.
d.
Flammables: such materials that easily ignite, burn, or serve as a fuel to fire such as acetone
or xylenes.
e.
Explosives: Materials that may cause violent eruptions if special safety precautions are not
followed. Example: Acids.
Distribution of hazardous chemicals and reagents.
a.
Acids, alkalis, carcinogens, and corrosives will be transported one container at a time and a
plastic safety carrier will be used when bottles are larger than 500ml.
b.
Handling of materials.
1)
2)
3)
4)
5)
4.
C.
Avoid contact with skin. Wear protective clothing, gloves, and eye protection.
Avoid breathing fumes. Always work under a hood.
Avoid getting any material in your mouth. Never pipette by mouth!!
When working with quantities of acids or alkalis, use a shield or barrier or work in a sink so
that breaks or spills can be controlled.
Use great care when diluting acids or alkalis by adding reagents slowly and carefully.
Always add acid to water, never add water to acid!! Allow the acid to run down the
inside of the container and to mix slowly with the water while swirling the container gently.
Storage of hazardous chemicals and substances.
a.
Label refrigerators to identify if they are safe for storing flammable materials.
b.
Small amounts of flammable and other hazardous chemicals for current use may be stored at
the bench. Store the rest in the appropriate cabinet or area as indicated by the MSDS sheet.
c.
Large cylinders of compressed gases must be securely chained to a stationary wall or object.
Maintenance personnel will move and connect these cylinders.
Containment and clean up of chemical spills.
1.
Vacate area and contain spill, if possible.
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RUSSELL COUNTY HOSPITAL
Policy/Procedure Title: Laboratory Chemical Hygiene Plan
Policy/Procedure Number: 736-EC-801
D.
Issued: 3/05/02
Revised: 5/10/06
2.
Follow Hazardous Waste Management Plan, to include referring to the appropriate MSDS.
3.
Dial 0 on the telephone and notify operator, who will contact the hospital Safety Officer or
designee.
Engineering controls and Laboratory safety equipment. Engineering controls will be used to eliminate
or minimize employee exposure. The following is a list of Laboratory safety equipment and
instructions as to its proper use and maintenance.
1.
Eye-Wash Stations: A permanent “plumbed-in” eyewash station is well marked and is located in
the main Lab, by the chemistry section, and next to the emergency shower.
a.
b.
2.
To use this eyewash
1)
Push the lever on the right side marked “PUSH” until the water flows freely.
2)
Lower face into running water, holding eyelids open with hands if necessary, and rinse
eyes completely.
3)
Report to the Emergency Department for further treatment and complete an “Occurrence
Report”.
Maintenance: Monthly. Flush the eyewash station by allowing the water to run for at least
one minute to ensure fresh water remains in the pipes. Scour the bowl with cleanser and
wipe out with bleach then rinse well to ensure the bowl is clean. Document the maintenance
on the logsheet.
Fire Extinguishers.
a.
There is one extinguisher for the Laboratory. It is located in the main laboratory room next to
the phone.
b.
Maintenance:
1) Inspected annually by a contracted company.
2) Inspected monthly by the Maintenance Department.
3) Inspection documentation is kept in the Maintenance department and on each
extinguisher’s log.
3.
Fire Blanket:
a.
The fire blanket is located just inside the door leading to microbiology.
b.
Should a person’s clothes catch fire, do the following:
1) WALK to the fire blanket.
2) Pull the blanket from the container, drop to the floor, and roll up in the blanket.
3) Report immediately to the Emergency Department for treatment and complete an
Occurrence Report.
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RUSSELL COUNTY HOSPITAL
Policy/Procedure Title: Laboratory Chemical Hygiene Plan
Policy/Procedure Number: 736-EC-801
4.
D.
III.
Issued: 3/05/02
Revised: 5/10/06
Emergency Shower:
a.
The shower is located in the main Lab near the Chemistry department, next to the eyewash
station.
b.
Use when a person’s face or clothing is badly splashed with a large quantity of acid or caustic
material.
c.
To use: Stand under the shower, face up, and pull the ring to allow water to flow over face and
body.
d.
After showering, report immediately to the Emergency Department for treatment. If still
shedding hazardous chemicals after showering, go to the ER by exiting out the door by the
Information Services department and entering the ER through the outside entrance into the
decontamination room.
e.
File an Occurrence Report.
f.
Notify the RCH Safety Officer if the shower was used to wash off a hazardous chemical.
Contain but do not attempt to clean up the contaminated area.
g.
Maintenance: Monthly: Flush the shower, using a large plastic trash can to catch the water, to
ensure fresh, clean water remains in the pipes. Document on the maintenance logsheet.
5.
Heat Resistant Gloves: Use when handling any hot material/equipment.
6.
Fluid Resistant Lab Coats: Always worn when working with chemicals or any bio-hazardous
material. Must be buttoned at all times.
7.
Aprons: Plastic disposable aprons may be worn as an adjunct to the Lab coats for particularly
messy jobs.
8.
Safety face-shields. Use a barrier when working with hazardous or infectious material that may
aerosolize or spray.
9.
Safety Goggles: Every employee is issued or has access to these. Used when performing tasks
that may result in a splash or spray from a hazardous or infectious material.
Reduction of hazardous materials. The type and volume of hazardous materials used within the
laboratory must be continuously monitored and evaluated. Whenever feasible, hazardous chemicals
should be replaced with substances that are less hazardous provided the substitute substances give
acceptable performance. Devices containing mercury should be replaced with devices that do not
contain mercury if and when they become available. Only minimal amounts of hazardous chemicals
should be stocked at any given time, although an adequate inventory must be kept to ensure there are
no compromises to laboratory services.
REFERENCES: RCH Environment of Care Plan, 2001.
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