School of Medicine Nephropathology Laboratory: Safety Plan

Title

School of Medicine Nephropathology Laboratory: Safety Plan

I. Introduction

The UNC Nephropathology Laboratory Safety Plan outlines the steps taken to ensure that laboratory employees and visitors are provided with an environment free from unnecessary hazards. In addition it describes specific staff activities designed to reduce the risk of injury and includes references to specific policies and procedures required by McLendon Clinical Laboratories and the University of North Carolina at Chapel Hill (UNC-CH) Environment, Health and Safety Office (EHS).

The UNC Nephropathology Laboratory functions both as a clinical laboratory and research laboratory in which both sections occupy adjoining space in a building maintained by the University of North Carolina at Chapel Hill. Because the clinical section of the laboratory shares a Clinical Laboratory Improvement Amendments (CLIA) laboratory registration certificate with McLendon Clinical Laboratories, it must follow their safety requirements and work closely with the McLendon Clinical Laboratories Quality Management (QM) Safety Team members. In addition, the entire UNC Nephropathology Laboratory must follow the UNC-CH EHS rules and regulations.

The UNC Nephropathology Laboratory Safety Plan describes processes for the following:

1. Review of safety policies, plans, and procedures (Section II);
2. Location and availability of safety manuals and Safety Data Sheets (SDS) (Section III);
3. Environmental safety (Section IV);
4. Review of employee incidents and accidents (Section V);
5. Safety training and continuing education for new and current employees (Section VI);
6. Safety inspections (Section VII); and
7. Annual evaluation of the effectiveness of the UNC Nephropathology Safety Plan (Section VIII).

The UNC Nephropathology Laboratory Director is responsible for the review and implementation of this Safety Plan.

The UNC Nephropathology Laboratory Safety Plan is designed to meet the requirements of the College of American Pathologists (CAP), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Occupational Safety and Health Administration (OSHA), the NC Office of State Personnel, and other governmental and professional agencies.

II. Review of Safety Policies, Plans, and Procedures

Specific UNC Nephropathology Laboratory safety documents are written as a necessary supplement to McLendon Clinical Laboratories and UNC-CH EHS policies and procedures. The following documents found in the UNC Nephropathology Laboratory Safety Manual will be reviewed annually by the UNC Nephropathology Laboratory Director:

1. Safety Plan
2. Chemical Hygiene Plan
3. Procedure for Shipping Diagnostic Specimens
4. Procedure for Disposal of Regulated Medical Waste and Infectious Sharps
5. Evacuation Plan
6. General Lab Safety
   1. Smoking, eating, drinking, application of cosmetics and lip balm, manipulation of contact lenses, and mouth pipetting in all technical work areas is prohibited.
7. Disaster Preparedness
   1. Emergency Response Procedures (Hospital Procedures) can be found online and include:
      • Tornado Warning (Code Weather)
      • Active Shooter
      • Hostage Situation (Code Silver)
      • Infant of Child Abduction (Code Pink)
      • Security Alert (Code Gray)
      • Bomb Threat (Code Yellow)
      • Fire (Code Red)
      • Evacuation
      • Biological Incident (Code Green)
      • Utility Failure (Code Black)
      • Mass Casualty Incident (Code Triage)
      • Radiation Incident (Code White)
      • Major Chemical Spill (Code Orange)

Review, revisions, and additions to McLendon Clinical Laboratories, and UNC-CH EHS manuals are the responsibility of that specific department and office, respectively.

McLendon Clinical Laboratories QM Safety Team members are responsible for distributing changes to the McLendon Clinical Laboratories Safety Manual.

III. Location and Availability of Safety Manuals and SDS

Because the UNC Nephropathology Laboratory must follow safety policies and procedures developed by the McLendon Clinical Laboratories and UNC-CH EHS, there is more than one safety manual available to UNC Nephropathology Laboratory personnel. Many similarities are found in the safety policies and procedures between the two departmental safety offices. Personnel directly involved with clinical testing must also strictly adhere to those policies and procedures developed by McLendon Clinical Laboratories in order to adhere to CAP and JCAHO requirements.

Hard copies of the safety manuals and SDS are located in room 408/412 Brinkhous-Bullitt Building. Since all laboratory personnel have access to personal computers with internet access, the following Safety Manuals can also be found on line at:

IV. Environmental Safety

A. Ergonomics

All new employees must take the New Employee Orientation, which includes ergonomic training. As of September 2011, all employees must also take the online ergonomics evaluation through UNC-CH EHS. McLendon Laboratory also has a quiz that must be taken once per an employee’s employment. Nephropathology employees can take either one to fulfill the ergonomics requirement.

B. Excessive Noise

Personnel are protected from excessive noise levels. The laboratory will provide protection against the effects of noise exposure when sound level equal or exceed an 8-hour time-weighted sound level of 85 decibels. The laboratory will monitor noise exposure if there is an indication that excessive noise levels are present.

Daily Allowable Exposure Times to Noise

The table below shows noise levels and how long a person can be exposed without hearing protection before there is damage to the ear:

For an 8-hour Time-weighted Average (TWA): no more than 90 decibels.

V. Review of Employee Incidents and Accidents

Refer to chapter IX.A of the McLendon Clinical Laboratories Safety Manual, Incidents and Accidents, for information on reporting and investigating employee incidents and accidents to UNC Hospitals’ employees. Refer to chapter 1 of the University of North Carolina Laboratory Safety Manual, Reporting Injuries and Illnesses, for those employees working for the University of North Carolina at Chapel Hill. All employees injured on the job should report the incident to their direct supervisor as soon as possible to assure that prompt treatment of the injury occurs and proper documentation is performed. All laboratory accidents resulting in property damage or involving spillage of hazardous substances, as well as all occupational injury/illnesses that require medical treatment (except for first aid), will be documented in "Problem Log" and assessed yearly by the director.

The UNC Nephropathology Laboratory Director will evaluate each employee incident/accident report as part of the laboratory’s Quality Improvement Plan (see the UNC Nephropathology Laboratory Procedure Manual) to determine what can be done to avoid future recurrence.

VI. Safety Training and Continuing Education for New and Current Employees

A. New Employees

1. New UNC-CH Employees Performing Clinical Laboratory Testing and Analysis Under the McLendon Clinical Laboratories CLIA Number (i.e. Clinical Technologists and Technicians).
   1. The McLendon Clinical Laboratories QM Safety Team requires all technologists, technicians and lab assistants involved with clinical testing to participate in online UNC-CH EHS training modules in the following areas:
      • Bloodborne Pathogens
      • Tuberculosis and Infection Control
      • Healthcare Worker/Joint Commission (JCAHO)
      • Laboratory Hazardous Waste Management
      • Fire Extinguisher
      • Latex Allergy
      • Formaldehyde Safety
      • Laboratory Worker registration
      • HIPAA training
      • Biological Safety Training (BSL 2) if applicable
      • Laboratory Orientation
      • UNC Nephropathology Laboratory Safety Manual Review
   2. Documentation of all safety training is on the UNC-CH EHS website and can be accessed using PID number.
   3. Refer to McLendon Clinical Laboratories Safety Manual II.A. McLendon Clinical Laboratories Safety Plan for additional information on new employee training.
2. New UNC-CH Employees with Clinical Responsibilities (i.e. Individuals Performing Clinical Laboratory Testing and Analysis, Pathologists and Office Support Staff).
   1. UNC-CH EHS requires all University employees involved with laboratory testing and clinical activities to attend a safety orientation with training in the following areas:

      New Employee Clinical Training Table

      New Employee Training - Clinical	Required For:
      Orientation for Clinical Environment (includes OSHA Bloodborne Pathogens & Tuberculosis Standards, Infection Control and JCAHO Training)	All clinical staff members and anyone required to have a UNC Hospitals ID badge.
      Orientation for Laboratory Environment (includes OSHA Laboratory Standard & EPA Hazardous Waste Management)	All
      Orientation for Office Environment	Office Support Staff
      UNC Nephropathology Laboratory Safety Manual Review	All
      Immunization Review Annual TB Screening Annual Respiratory	Clinical Staff

   2. Documentation of safety training will be kept by UNC-CH EHS and is also accessible to the employee on the EHS Training History website.
   3. Refer to the UNC-CH Laboratory Safety Manual Chapter I Information and Training for additional information on new employee training.
3. New UNC-CH Employees Involved Only With Research Activities.
   1. UNC-CH EHS requires all University employees involved with laboratory research activities to attend a safety orientation with training in the following areas:

      New Employee Research Training Table

      New Employee Training - Research	Required For:
      Orientation for Laboratory Environment (includes OSHA Laboratory Standard & EPA Hazardous Waste Management)	All
      Orientation for Clinical Environment (includes OSHA Bloodborne Pathogens & Tuberculosis Standards, Infection Control and JCAHO Training))	Must be taken by anyone required to have a UNC Hospitals ID badge.
      Bloodborne Pathogens	Those working with or around blood, tissue, or other body fluids.
      UNC Nephropathology Laboratory Safety Manual Review	All

   2. Documentation of safety training will be kept by UNC-CH EHS and is also accessible to the employee on the EHS Training History website.
   3. Refer to the UNC-CH Laboratory Safety Manual Chapter I Information and Training for additional information on new employee training.
4. All New UNC Nephropathology Laboratory Employees.
   1. As soon as possible, new employees are given an Individual Lab Safety Tour of the UNC Nephropathology Laboratory by the supervisor or designee. This tour will include location and use of fire safety equipment, evacuation routes, chemical safety equipment, SDS and safety manuals, PPE, and biohazard waste containers.
   2. New employees will also need to fill out a "Glove Use 101."
   3. A “Worker Registration” form should be completed for each new employee, and submitted to UNC-CH EHS prior to starting laboratory duties.

B. Current Employees

1. Current UNC-CH Employees Performing Clinical Laboratory Testing and Analysis Under the McLendon Clinical Laboratories CLIA Number (i.e. Clinical Technologists and Technicians).
   1. On an annual basis, current employees are retrained in the same areas as the new employees. This will include updates to the McLendon Clinical Laboratories Safety Manual and applicable sections of Hospital-wide safety documents as requested by McLendon Safety Team members.
   2. Refer to McLendon Clinical Laboratories Safety Manual II.A. McLendon Clinical Laboratories Safety Plan for additional information on current employee retraining.
2. Current UNC-CH Employees with Clinical Responsibilities (i.e. Individuals Performing Clinical Laboratory Testing and Analysis, Pathologists and Office Support Staff).
   1. UNC-CH EHS requires all University employees involved with laboratory testing activities to attend or complete on-line the following for annual retraining:

      Annual Training Clinical Update Table

      Annual Training Update - Clinical	Required For:
      Bloodborne Pathogens	All
      Tuberculosis and Infection Control	All
      Healthcare Worker/JCAHO	All
      HIPAA Training	All
      UNC Nephropathology Laboratory Safety Manual Review	All
      Annual TB Screening	All

3. Current UNC-CH Employees Involved Only with Research Activities.
   1. UNC-CH EHS requires all University employees involved with laboratory research activities to attend or complete on-line the following for annual retraining:

      Annual Training Research Update Table

      Annual Training Update - Research	Required For:
      Bloodborne Pathogens	Those working with or around blood, tissue, or other body fluids.
      Tuberculosis	Must be taken by anyone required to have a UNC Hospitals ID badge.
      Healthcare Worker/JCAHO	Must be taken by anyone required to have a UNC Hospitals ID badge.
      HIPAA Training	All
      UNC Nephropathology Laboratory Safety Manual Review	All

4. All Current UNC Nephropathology Laboratory Employees.
   1. An annual UNC Nephropathology Laboratory safety meeting is held each year to discuss changes or additions to laboratory safety. Topics include laboratory safety plan review, safety policies review, safety procedures review, laboratory safety inspection reports, employee training and testing, and health and safety memorandums.
   2. All employees are asked to participate in firedrills arranged by the building/department administrator, as well as any mock firedrills that may take place. Fire extinguisher training is provided through the Fire Safety section of UNC-CH EHS as well as UNC Hospitals Environment Health and Safety Department.

VII. Safety Inspections

A. McLendon Clinical Laboratories Safety Inspections

1. The UNC Nephropathology Laboratory will participate in an annual inspection by the McLendon Clinical Laboratories QM Safety Team. These inspections will be coordinated and scheduled by the McLendon Clinical Laboratories QM Safety Team. Inspection records are kept with McLandon Clinical Laboratory.
2. In addition, an annual safety inspection will be conducted in association with CAP self-inspection or in advance of a CAP inspection.
3. Refer to McLendon Clinical Laboratories Safety Manual II.A. McLendon Clinical Laboratories Safety Plan for additional information on safety inspections.

B. UNC-CH EHS Laboratory Inspections

1. UNC-CH EHS will inspect the laboratory at least annually. The Collaborative Laboratory Inspection Program (CLIP) is used which includes key-indicator reviews, referral inspections, announced inspections, and self-inspections.
2. Inspection reports are sent from UNC-CH EHS to the UNC Nephropathology Laboratory Director or Principal Investigator following the inspection. All non-compliant issues must then be corrected in a timely manner.

VIII. Annual Evaluation of the Effectiveness of the UNC Nephropathology Safety Plan

1. The UNC Nephropathology Laboratory follows safety policies, plans and procedures developed by the McLendon Clinical Laboratories and UNC-CH EHS. Annual evaluation of the effectiveness of individual safety plans will be the responsibility of that specific laboratory or office. Refer to individual safety manuals for further information on annual evaluation of the effectiveness of those safety plans.
2. The UNC Nephropathology Laboratory will be responsible for annual evaluation and review of the effectiveness of its Safety Plan, which has been written to satisfy requirements of McLendon Clinical Laboratories and UNC-CH EHS. The version of the Laboratory Safety Plan, titled Appendix 2-A. University of North Carolina Laboratory Safety Plan, is required by the University and supplements this document.

IX. History

Created: 3/15/02 LKC/DBT

Replaces: 1/30/98

Revisions:

• 7/12/18 LHR
• 5/8/14 LHR
• 11/6/13 LHR
• 9/22/11 LHR
• 2/4/11 LHR
• 3/8/07 LKC
• 3/11/04 LKC