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OSHAPROGRAMM A N UA Lfor Medical FacilitiesAbout the AuthorSheila Dunn, DA, MT (ASCP), holds a doctoral degree in clinical laboratory science from the CatholicUniversity of America in Washington, DC. She has helped thousands of outpatient medical facilities complywith federal regulations such as CLIA and OSHA through her presentations at a nationwide seminar series.She has written more than 150 articles about regulatory issues and healthcare delivery systems and servesas an advisor to numerous companies.10GHCPro, Inc.P.O. Box 1168Marblehead, MA 01945Tel: 800/650-6787Fax: 800/639-8511www.hcmarketplace.com 2005–2010. HCPro, Inc. All rights reserved, including right of reproduction. The author(s) and their agent(s) havemade every reasonable effort in the preparation of this publication to ensure the accuracy of the information. However,the information in this book is sold without warranty, either expressed or implied. The authors, the editors, their agents,and the publishers will not be liable for any damages caused or alleged to be caused directly, indirectly, incidentally, orconsequentially by the information in this publication. This publication cannot and does not provide specific informationfor a user’s exact situation. Users of this publication should exercise their own judgment and, where appropriate, seek theassistance of legal counsel regarding their particular situation.
OSHA Program Manual for Medical Facilities is published by HCPro, Inc.Copyright 2010 HCPro, Inc.All rights reserved. Printed in the United States of America.5 4 3 2 1ISBN: 978-1-60146-743-0No part of this publication may be reproduced, in any form or by any means, without prior written consentof HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please notify us immediately if you havereceived an unauthorized copy.HCPro, Inc., provides information resources for the healthcare industry.HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and JointCommission trademarks.Sheila Dunn, DA, MT (ASCP), AuthorDavid A. LaHoda, Managing EditorMichael Briddon, Executive EditorEmily Sheahan, Group PublisherMike Mirabello, Senior Graphic ArtistMatt Sharpe, Production SupervisorJean St. Pierre, Director of OperationsAdvice given is general. Readers should consult professional counsel for specific legal, ethical, orclinical questions.Arrangements can be made for quantity discounts. For more information, contact:HCPro, Inc.P.O. Box 1168Marblehead, MA 01945Telephone: 800/650-6787 or 781/639-1872Fax: 781/639-2982E-mail: customerservice@hcpro.comVisit HCPro at its World Wide Web sites:www.hcpro.com and www.hcmarketplace.com07/201021793
OSHA PROGRAM MANUALContentsFront Pocket OSHA Poster 3165: IT’S THE LAW!Laminated Eyewash Station Sign4 Sample Biohazard Self-Adhesive LabelsCD-ROM (MS Word for Windows 2000) with Master Record Forms (Tab 11) from this Manualfor Customization.PageIntroductionImportant Information About the Use of This Program. iHow to Customize This Program . . iiWhat Is Included in This Program. viTAB 1: What Is OSHA?A Quick Look at OSHA. 1-1States with OSHA-Approved Plans.1-1OSHA Consultative Services Division.1-2OSHA’s Jurisdiction.1-2OSHA’s General Duty Clause.1-2Employee or Employer?. 1-3Employers’ Responsibility Under OSHA.1-4Overview of OSHA Standards. 1-5OSHA Inspections. 1-5Employee Complaints.1-6If an On-site OSHA Inspection Occurs.1-6During the Inspection.1-7What OSHA Inspectors May Ask Employees.1-8The Typical OSHA Inspection.1-8The Closing Conference.1-9OSHA Sanctions. 1-10Whistleblower Protection. 1-12Students and Volunteers. 1-13ix
ContentsTAB 2: OSHA Program AdministrationInjury & Illness Prevention Plan Flowchart. Reverse Side of TOCInjury & Illness Prevention Plan. 2-1Management Leadership and Employee Involvement.2-1Key Contacts for the OSHA Program Manual.2-2Location of the OSHA Program Manual.2-2Duties of the OSHA Safety Officer. 2-2Accident/Incident Investigation & Reporting Procedure. 2-3Definition of an Accident and/or Incident.2-4When to Investigate an Accident or Incident.2-4How to Document an Accident/Incident.2-4Correcting Unsafe Conditions.2-4Recordkeeping Requirements. 2-5Workplace Hazard Analysis. 2-7Practical Ideas for Involving Employees. 2-8Organizing OSHA Compliance Duties. 2-9Weekly Facility Review Checklist (Form 4-A).2-10Monthly Facility Review Checklist (Form 4-B).2-11Annual Facility Review Checklist (Form 5).2-12Annual OSHA Program Manual (Exposure Control Plan) Review Form (Form 3).2-15TAB 3: General Facility SafetyKeeping Employees Safe. 3-1Important Phone Numbers & Contacts.3-1Emergency Phone List.3-2Fire Safety. 3-3Automatic Sprinkler Systems.3-3Fire Alarms.3-3Fire Procedures: Immediate Actions.3-3Building Evacuation.3-4Fire Extinguishers.3-4Purchase the Right Extinguisher.3-5How Many Fire Extinguishers to Have & Where to Put Them.3-6How to Use a Fire Extinguisher: The “PASS” Technique.3-6When to Extinguish Fires with a Portable Fire Extinguisher.3-7When NOT to Extinguish Fires and to Evacuate.3-7Fire Extinguisher Inspections.3-7Fire Extinguisher Maintenance.3-7Fire Risks During Surgery.3-8Fire Drills.3-8Fire Extinguisher Supplement. Supplementx
ContentsAnnual Employee Retraining. 10-5Bloodborne Pathogens Annual Training Contents.10-6Respiratory Protection Annual Training.10-6Hazard Communication Annual Training Contents.10-7New Employee Orientation. 10-7New Employee OSHA Orientation Checklist (Form 26).10-8Sample Tests with Answer Keys. 10-10OSHA Yearly Retraining: Sample Essay Test Questions (Form 28).10-11OSHA Yearly Retraining: Sample Essay Test—Answer Key.10-12OSHA Yearly Retraining: Sample Multiple Choice Test Questions (Form 29).10-13OSHA Yearly Retraining: Sample Multiple Choice Test—Answer Key.10-15OSHA Yearly Retraining: Sample True/False Test Questions (Form 30).10-16OSHA Yearly Retraining: Sample True/False Test—Answer Key.10-17Documenting Employee Training. 10-17Annual Safety Training Record (Form 27). 10-18TAB 11: Master Record FormsGeneral Equipment and Facility RecordsSafety Report.Form 1Autoclave Log.Form 2Eyewash Station Weekly Check Log.Form 2-AAnnual OSHA Program Manual Review.Form 3Weekly Facility Review Checklist.Form 4-AMonthly Facility Review Checklist.Form 4-BAnnual Facility Review Checklist.Form 5Fire Drill Evaluation Form.Form 5-AEmployee Fire Drill Participation Sign-up Sheet.Form 5-BRisk Assessment for Workplace Violence.Form 6Housekeeping Schedule.Form 7Emergency Telephone List.Form 7-ABloodborne Pathogens RecordsBloodborne Pathogens Exposure Determination List #1.Form 8Bloodborne Pathogens Exposure Determination List #2.Form 9Bloodborne Pathogens PPE Checklist.Form 9-ABloodborne Pathogens Compliance Checklist: ECP, Training, and Records.Form 9-BSafety Needle/Syringe Evaluation.Form 10Phlebotomy Device Evaluation.Form 11Generic Safety Device Evaluation.Form 12Sharps Disposal Container Locations.Form 12-ASharps Evaluation
OSHA Yearly Retraining: Sample Essay Test—Answer Key.10-12 OSHA Yearly Retraining: Sample Multiple Choice Test Questions (Form 29).10-13 OSHA Yearly Retraining: Sample Multiple Choice Test—Answer Key .10-15 OSHA Yearly Retraining: Sample True/False Test Questions (Form 30) .10-16 OSHA Yearly Retraining: Sample True/False .
