Insert Agency’s Name &
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OHS Policy Statements
Policy #:
Subject:
Personal Protective Equipment (PPE) – Universal Precautions
POLICY STATEMENT:
In order to reduce the risk of transmission of micro-organisms, staff shall use Standard/Universal
Precautions that require hand hygiene and the use of personal protective equipment (PPE) (e.g.
gloves, gown, mask, and eye/face protection) if there is a potential for contact with blood and body
fluids.
PURPOSE:
The use of PPE is one method of protecting a worker from a hazard. Other control measures should
be used first, such as eliminating the risk, designing engineering controls, and developing and
implementing safe work practices.
This policy applies to the following types of personal protective equipment:
 Gloves
 Respiratory protection
 Eye protection (goggles, face shields, etc.)
 Protective clothing (aprons, gowns, etc.)
 Protective footwear (boots, shoes, etc.)
STATEMENT OF RESPONSIBILITIES:
Employer
 Ensure PPE is provided for workers in sufficient quantity and quality in accordance with
occupational health and safety (OH&S) legislation.
 Ensure training is provided to workers regarding the required use, care, and maintenance of
PPE provided.
Supervisor
 Assess the hazards to workers in the workplace with regard to the need for PPE that may be
required to protect the health and safety of workers. All reasonably practicable alternative
strategies will be implemented prior to recommending the use of PPE.
 Before work begins, provide sufficient quantity and quality of PPE to the workers.
 Ensure that PPE provided to the worker is:
 suitable, adequate, and properly fitted for the worker.
 maintained and kept in a sanitary condition.
 removed from use or service when damaged.
 Ensure that the PPE is stored in a clean, secure location that is readily accessible to workers.
 Ensure that workers are trained in the appropriate use, care, and maintenance of PPE
provided.
 Inform each worker of the reasons why the PPE is required, its uses, and limitations of
Approved by:
Signature:
Original Date:
Date Revised:
Page 1 of 6
Insert Agency’s Name &
Logo Here
OHS Policy Statements
Policy #:
Subject:
Personal Protective Equipment (PPE) – Universal Precautions


protection.
Ensure that workers use the PPE provided, and understand that non-compliance is
unacceptable.
Immediately repair or replace damaged PPE that has been identified by the worker.
Worker
 Must use PPE where directed and provided by his or her employer and in accordance with
safe work practices and procedures.
 Take reasonable steps to prevent damage to the PPE.
 Must follow safe work practices, including all safety precautions while performing his or her
tasks.
 Inform his or her supervisor of any concerns regarding suitability and/or fit of PPE.
 Inform his or her supervisor of any defects or damage to PPE.
PROCEDURE:
A. Gloves
1. Glove use is NOT a substitution for proper Hand Washing!
 Remove gloves after each procedure has been completed.
 Discard gloves and then wash hands.
 Never use the same gloves for more than one individual or procedure.
2. Gloves shall be used:
 To provide a protective barrier and prevent contamination of hands of care givers.
 When touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin.
 To protect the participant from micro-organisms present on the hands of the care giver. In
the absence of gloves these micro-organisms will be transmitted to the participant during
invasive procedures, and procedures that involve touching a person’s mucous membranes
and non-intact skin.
 To reduce the possibility that the hands of the care giver will become contaminated with
micro-organisms.
3. Gloves shall be changed:
 Between participant contacts.
 If a leak is suspected or a glove tears.
 Between care activities and procedures on the same participant, when there has been
contact with materials that may contain high concentrations of micro-organisms.
4. Selection of Gloves
Approved by:
Signature:
Original Date:
Date Revised:
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OHS Policy Statements
Policy #:
Subject:
Personal Protective Equipment (PPE) – Universal Precautions

Selection of gloves should be based on:
o proper fit for the worker;
o the type of procedure being done; and,
o the likelihood of exposure to body fluid.
5. Gloves shall be worn:
 When exposure to potentially infectious material such as blood, body fluids, secretions,
excretions, mucous membranes, and non-intact skin is anticipated.
 For handling items or surfaces soiled with blood or body fluids.
 By care givers who have cuts, scratches, or other breaks in the skin.
6. Single-use Disposable Gloves
 Single-use disposable gloves must not be washed or reused.
7. Procedure for Removing Soiled Gloves
 The outside of gloves is considered contaminated.
 Grasp outside of glove with opposite gloved hand and peel off.
 Hold removed glove in gloved hand.
 Slide fingers of un-gloved hand under remaining glove at wrist.
 Peel glove off over first glove.
 Discard gloves in waste container.
B. Gowns/Aprons
1. Gowns/aprons are to be used to prevent soiling of clothing with infectious secretions and/or
excretions when caring for participants.
2. Gowns/aprons are recommended for care workers who are caring for participants who are
infected with specific micro-organisms (e. g. antibiotic resistant organisms). The use of
gowns/aprons decreases the transmissions of organisms from the infected individuals and the
environment.
3. Long sleeve gowns serve to protect the forearms and clothing of the care worker from
splashing and soiling with body substances.
4. Gowns/aprons should have all ties done up to maximize coverage of the care worker.
5. Gowns that are impermeable to liquids provide greater protection to the skin when splashes
of large quantities of blood or body fluids are anticipated. Leg coverings and boots may also
be used in these situations.
6. Disposable gowns/aprons may be used if a shortage is occurring (e.g. outbreak conditions).
Approved by:
Signature:
Original Date:
Date Revised:
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OHS Policy Statements
Policy #:
Subject:
Personal Protective Equipment (PPE) – Universal Precautions
7. Gowns/aprons are to be used for a single contact with the participant and his or her
environments; gowns/aprons are to be discarded immediately after use into the appropriate
container.
8. Hands must be washed before and after gowning.
9. Procedure for removing of contaminated gowns:
 Gown front and sleeves are considered contaminated.
 Unfasten ties.
 Pull away from neck and shoulders, touching inside of gown only.
 Turn gown inside out.
 Fold or roll into a bundle and place in designated receptacle for reprocessing or in waste
container.
C. Eye Protection
1. Eye Goggles
 Eye goggles will be worn when there is risk of blood and body exposure to the eyes of
the care worker. This may be required when a participant is on precautions for a severe
respiratory illness.
 To be effective, there must be coverage on all sides of the goggles to prevent splashing.
Prescription eye glasses do not meet this need.
2.
Removal of Eye Goggles
 The outside of eye goggles is considered contaminated.
 To remove, handle by head band or ear pieces.
 Place in designated receptacle for reprocessing or in waste container.
 Wash hands after removal.
D. Face Protection
1. Face protection includes such items as:
 eye goggles plus a respiratory mask
 a face shield
2. Face protection must be worn during procedures in which blood or blood contaminated body
fluids may be splashed onto the mucous membranes, nose, mouth, or eyes. Face protection
must be used when:
 dressing fresh burns or major open wounds.
 for the protection of care workers from the transmission of infectious microorganisms (e.g. cleaning bedpans or commodes).
Approved by:
Signature:
Original Date:
Date Revised:
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OHS Policy Statements
Policy #:
Subject:
Personal Protective Equipment (PPE) – Universal Precautions
3. Face shields are an alternative to eye goggles providing protection from blood and body
fluids to other facial areas. They are available in disposable and non-disposable versions.
4. Removal of Face Shields
 The outside of the face shield is considered contaminated.
 To remove, handle by head band or ear pieces.
 Place in designated receptacle for reprocessing or in waste container.
 Wash hands after removal.
E. Respiratory Protection
1. Where a worker is likely to be exposed to dust, fumes, gas, mist, aerosol, vapours, or any
contaminant that may be present in amounts that are harmful or offensive to the worker, the
employer will provide the worker with suitable, approved, and adequate respiratory
protection.
2. The worker must use the respiratory protective equipment provided.
3. The use of a respiratory mask is recommended to prevent the worker from being infected by
micro-organisms that are transmitted through the air. Masks protect the wearer from inhaling
both large particle aerosols (droplets) that are transmitted by close contact and generally
travel short distances (1 meter or 3 feet) or small particle aerosols (droplet nuclei) that remain
suspended in the air and thus travel longer distances.
4. In general:
 Masks are for single use only.
 Masks must completely cover the nose and mouth.
 Do not touch the mask when in use.
 Change the mask when wet.
 Discard all used masks into the wastebasket immediately after removing them.
 Masks must not dangle around the neck.
 Wash hands after removing the mask.
 Masks should be worn with nose piece on top, pleats open downward.
Surgical Face Masks
1. Surgical face masks provide a physical barrier between the wearer and the environment.
These types of masks are flexible and paper-like and provide a barrier for large air borne
particles.
2. In general, a surgical face mask is:
 Worn by care givers and visitors to protect the wearer from large infectious air drops
(such as for influenza).
Approved by:
Signature:
Original Date:
Date Revised:
Page 5 of 6
Insert Agency’s Name &
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OHS Policy Statements
Policy #:
Subject:
Personal Protective Equipment (PPE) – Universal Precautions


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Worn by care givers to protect them from body fluids when performing procedures that
may generate splashing and aerosols.
Worn by care givers to protect the participant from infectious organisms present in the
care giver’s nose and mouth.
Worn by the infectious participant who goes to public places (e.g. physician’s office).
High Efficiency (95%) Particulate Respirators - N95 Masks
1. N95 masks:
 Have the ability to filter particles 1 micron in size and are required for protection against
diseases transmitted through the air.
 Must be worn by care givers attending to an infectious participant (e.g. chicken pox,
measles, and severe respiratory illness as recommended by Public Health).
 To be effective, the N95 mask must be fitted to the wearer such that there are no gaps
where air may bypass the mask and be inhaled by the wearer.
2. Removal of Disposable Mask/Respirator
 Front of mask/respirator is considered contaminated.
 Grasp bottom, then top ties or elastics and remove.
 Discard in waste container.
 Wash hands.
EVALUATION:
This policy shall be reviewed every three years by the Licensee/Board of Directors as part of the
safety program review and/or whenever there is a change of circumstances that may affect the health
and safety of workers, or a change in Legislation.
REFERENCE:
Saskatchewan Employment Act, PART III.
Occupational Health and Safety Regulations, sections 85, 86, 87, 88, 89, 472, 473, and 474.
Labour Relations and Workplace Safety (LRWS) and Workers’ Compensation Board.
Approved by:
Signature:
Original Date:
Date Revised:
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