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Annual Regulatory Requirements, Current Practice

5 Contact Hours
MDR, HIPAA, TJC, OSHA, Patient Rights, and Biohazard
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Dietetic Technicians, Registered (DTR), Dietitian/Nutritionist (RDN), Licensed Nursing Assistant (LNA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Registered Nurse Practitioner, Respiratory Care Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Sunday, March 24, 2024

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

CEUFast, Inc. is an AOTA Provider of professional development, Course approval ID#04077. This distant learning-independent format is offered at 0.5 CEUs Intermediate, Categories: Professional Issues. AOTA does not endorse specific course content, products, or clinical procedures. AOTA provider number 9757.

FPTA Approval: CE23-510227. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.

This course updates and reviews annual training topics required for the Healthcare Insurance Portability and Accountability Act (HIPAA), the Joint Commission on Accreditation of Healthcare Organizations (TJC), and the Occupational Safety and Health Administration (OSHA). It also includes medical device reporting, patient’s rights, Medical Safety Data Sheets (MSDS), and workplace safety. This course does not address facility-specific information.


After completing this course, the learner will be able to:

  1. Identify the patient’s rights.
  2. Discuss Joint Commission on Accreditation of Healthcare Organizations (TJC) national patient safety goals.
  3. Discuss Healthcare Insurance Portability and Accountability Act (HIPAA) regulations.
  4. Identify components of a safe workplace.
  5. Consider the importance of infection prevention focus.
  6. Discuss the environment of care safety.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    David Tilton (RN, BSN)


Quality healthcare includes the responsibility to many masters, of which the client is number one. Have you ever wondered, though, who looks out for the client? Who makes sure everything is up to date, running smoothly, and for goodness sakes, how do they accomplish the massive task of ensuring the best possible care is given?

The answer is we all do. All healthcare professionals work toward the goal of quality care, and to help us on this mission, we look for help from outside regulatory agencies and accreditation organizations who can lend an impartial eye toward how well we are doing and the degree to which we are accomplishing the goal of quality we all desire. One of the most important tools provided to each of us by these regulatory partners during this age of rapid change and information overload is lists of topics for which annual training is required.

Please be mindful that regulatory agencies are not an enemy, nor are they choosing to unduly burden you with repetitive classwork through which you can nap. The viewpoint across the horizon of healthcare, comparing desired outcomes to reality on regional, national, and even international levels, show vulnerabilities and the need for improvements that we may not be aware. That broader view also can identify real-to-us skills that need honing or information deficits that we are unaware.

Annual mandated training is an opportunity to be current with important topics and polish skills we may not have had a call to use recently. So, take the opportunity to benefit from the work put in by the various regulatory agencies that labor to identify key areas needing focus. Let us look at the annual review topics that help us provide the excellent quality of care we crave to give.

Agency Regulation (TJC, 2019)Ongoing Required Training
TJC HR.01.05.03 EP.1Ongoing education and training for competency with documentation of training and competency.
TJC HR.01.05.03 EP.4Ongoing education and training related to responsibilities and any change in responsibilities, with documentation.
TJC HR.01.05.03 EP.5Ongoing education, specific for patient population needs, with documentation of training.
TJC HR.01.05.03 EP.6Ongoing education and training on teamwork, including communication, collaboration, and coordination of care. (All of which needs documenting, so just mentally add that phrase after each regulatory mandate, okay?)
TJC HR.01.06.01Competency to perform duties is assessed at orientation and once every three years.

Patient's Rights

It is all about the patient, the client. It should be no surprise that several regulatory agencies bring clients’ rights to the forefront of annual required training for healthcare professionals. Definitions and concepts of a client's rights and even the very idea that a client might possess any rights at all have dramatically changed over the last few decades. Be warned that client rights, privileges, and clients' duties and obligations remain in a state of societal flux. The anticipation is that changing perspectives will continue for some time, making this a smart topic requiring regular updates.

In its broadest sense, client rights define the basic rules of conduct between healthcare personnel and their clients. This includes institutions and health systems and those employed in any capacity to serve them. Details concerning client rights can be found anchored in federal regulatory documents such as the Emergency Medical Treatment and Active Labor Act (EMTALA), the current most commonly cited hospital deficiency (e.g., substandard function), as well as in every health profession’s defining articles, such as the American Medical Association (AMA) Code of Medical Ethics (Calloway, 2019). Concepts and details concerning client rights abound in state and federal legal statutes and, if broken, may result in professional suspension, fines, or even prison.

EMTALA Updates (PHC, 2019)

Expect frequent updates of the regulatory guidelines directly influencing annual training requirements. Current trends and findings result in updates and guideline changes in every accrediting body.

For example, CMS published new EMTALA guidelines in the QSO memo (Quality Safety Oversite memo) 19-14, June 4, 2019. In response to an upswing of patient death reports coinciding with the use of external restraints.

Frequent updates are not an enemy; they are simply the result of diligence regarding trends happening across the spectrum of healthcare and can help keep you and your organization out of hot water!

When discussing client rights training, it seems easier to ask, who does not require healthcare professionals to update their knowledge on this topic? Two of the major regulatory and accreditation organizations that do require frequent and annual patient rights training are;

  • CMS (Center for Medicare/Medicaid Services)
  • TJC (The Joint Commission)

Multiple accrediting organizations or regulatory agencies duplicate or overlap required training topics because each will have its sphere of vision as to what a specific topic must include. As a general guide concerning client rights, the following key areas are taken from the Advisory Commission on Protection and Quality in the Health Care Industry. The Federal Department of Health and Human Services developed the Consumer Bill of Rights provides a strong guiding framework (DHHS, 2019).

  1. Information Disclosure
    1. You have the right to receive accurate information that you can understand about your health, treatments, health plan, health care providers, and health care facilities. If you speak another language, have a physical or mental disability, or don't understand something, you will be helped to make informed health care decisions.
  2. Choice of Providers and Plans
    1. You have the right to choose your health care provider within your health plan.
  3. Access to Emergency Services
    1. If you have severe pain, an injury, or sudden illness and you are concerned that you could be seriously ill, hurt, or could die, you have the right to get emergency services whenever and wherever needed, to be seen by a doctor, and get services, even if you do not ask your health plan first, and you will not be charged a penalty.
  4. Participation in Treatment Decisions
    1. You have the right to know all your treatment options, even if your health plan does not cover them, and make decisions about your care. Parents, guardians, family members, or others that you choose can represent you if you cannot make your own decisions.
  5. Respect and Nondiscrimination
    1. You have the right to considerate, respectful care and not be discriminated against by your doctors, other health care providers, or health plan representatives.
  6. Confidentiality of Health Information
    1. You have the right to talk in private with health care providers and to have your health care information protected. You also have the right to review and copy your medical records and ask your doctor to make corrections to your record if it is inaccurate, incomplete, or has information that does not relate to your health care.
  7. Complaints and Appeals
    1. You have the right to a fair, fast, and objective review of any complaint you have against your health plan, doctors, hospitals, or other health care personnel. This includes complaints about waiting times, hours available, health care facilities, and the conduct of health care personnel.

Additional consumer benefits include (DHHS, 2019):

  • Insurance must accept you even if you have a pre-existing condition.
  • Health plans must provide free basic preventive care.
  • Adult dependents have the right to stay on their parent’s health plans until 26.
  • Health plans may not limit yearly or lifetime coverage of essential benefits.
  • You have the right to receive easy-to-understand information about your health benefits.
  • Protections exist from unreasonable insurance rate increases.
  • You have the right to appeal a health insurance company decision.

Consumer Responsibilities (Torrey, 2019).

  • Do your best to get well and stay healthy, with healthy habits, such as exercising, not smoking, and eating a healthy diet.
  • It’s imperative to communicate what you want and need clearly.
  • Be involved with your health care providers when making your health care decisions.
  • Work with health care providers in developing and carrying out treatment plans you all agree upon.
  • Use the health plan's internal complaint and appeal process to address concerns that may arise.
  • Avoid knowingly spreading disease.
  • Recognition of risks and limits of the science of medical care and that health care providers are human and can make mistakes.
  • Be aware of a healthcare provider's need to provide care fairly to other patients and the community.
  • Learn about your health plan coverage and options (when available), including all covered benefits, the limits, what isn’t covered, the rules regarding the use of information, and how to appeal coverage decisions.
  • Show respect for other patients and health care workers.
  • Make a good-faith effort to pay your health care bills.
  • Follow procedures of the health plans and health care providers.
  • Report wrongdoing and fraud to the right resources or legal authorities.

Confidentiality of Health Information and HIPAA

Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC IM.01.01.03 EP.3Education and ongoing training on managing interruptions in the information process, with a focus on when electronic systems are unavailable.
TJC IM.03.01.01 EP.1Education and ongoing training on providing access to information resources, 24/7.

Information about both clients and staff must be kept secure and confidential. Specific staff should be designated to ensure this, and any staff member working in the presence of client information must know how to maintain and secure protected information. This is not the job of medical records staff; it is everyone’s duty.

Agency Regulation (ClickSafety, 2019)Annual Required Training
OSHA 29.CFR.1910.1020(g)Annual Exposure and Medical Records Training

Let’s face it; you simply cannot talk about patient rights without serving up a side of HIPAA. The Joint Commission, CMS, and a plethora of state and federal agencies require all healthcare staff from pathologist to plumber be regularly versed on relevant aspects of the Health Insurance Portability and Accountability Act (HIPAA).

The HIPAA privacy rule is a federal regulation that was designed to address public concerns about managed care, insurance availability, and insurance affordability. However, this course only addresses the privacy, confidentiality, and security aspects of the legislation.

The rule sets standards for patient privacy and confidentiality. It also sets severe civil and criminal penalties for people who violate a patient’s privacy. In order to comply with HIPAA, protected patient information must only be shared with people who are directly involved in that patient’s care. This is especially important when talking in public areas (elevators, restrooms, hallways, cafeterias, etc.). Charts or documents should not be left out where they might be seen by unauthorized persons; computer screens should not be angled in such a way as to allow unwanted viewing. It is vitally important to observe surroundings when discussing patient care.

The privacy rule standards address the use and disclosure of individuals’ health information called “protected health information.” All facilities must limit access to protected health information only to those who have a need to know. A nurse who seeks information about a patient not under his/her care is violating the HIPAA rules. Protected health information can only be used for health purposes. Employers cannot use health history information to screen candidates for hire or promotion. Financial institutions may not use it to determine lending practices. Only the individual can explicitly authorize employers, banks, and individuals to have access to his/her medical information.

Agency Regulation (Mercuri, 2017)Annual Required Training
CMS 45 C.F.R. § 164.308(a)(3) & (4)Train workforce members who work with e-PHI.
CMS 45 C.F.R. § 164.308(a)(5)(i)Train ALL workforce members regarding HIPAA security policies and procedures.
The HIPAA Privacy Rule protects individually identifiable personal health information, called PHI, held or transmitted by a covered entity or its business associate, in any form, whether electronic, paper or verbal. PHI includes information that relates to the following:
  • The individual’s past, present, or future physical or mental health or condition
  • The provision of health care to the individual
  • The past, present, or future payment for the provision of health care to the individual
PHI includes many common identifiers, such as name, address, birth date, and Social Security Number.

HIPAA also established the “minimum necessary rule,” which stipulates that only the minimum necessary information may be shared, even with the patient authorization. A classic example would involve treatment for a case of child or domestic abuse; the professional would, rather than providing an entire medical record, share the pertinent data furnished in the form of an abstract, outlining the information that is necessary to provide treatment and protect the victim. The abstracted information could be provided to legal and law enforcement entities.

Health professionals who are directly involved in the treatment of patients are not subject to the minimum necessary rule and can have full access to all information that is needed to provide care. Health information that has implications for public health and safety can be shared without consent. There are several situations where medical information can be shared:

  • Emergency 911 situations
  • When communicable diseases are involved
  • When law enforcement agencies participate
  • If national defense or security is a factor

The public health department is deemed a legitimate recipient of certain personal health information, and professionals may, in fact, in some instances, must report certain findings to the proper public health agency. Included are the cause of death even when the patient dies at home, reportable communicable diseases, child abuse, reporting an adverse drug reaction to the Federal Drug Administration, occurrence of cancer in a state with a cancer registry, meningitis, and immunizations for children.

HIPAA privacy regulations also mandate specific patient rights that include the following:

  • Right to privacy notice requires disclosure and reasonable effort to ensure that the patient understands the agency’s policy concerning privacy of information.
  • Right to request restrictions - patients may specify health information that cannot be released and/or they may restrict to whom information can be released.
  • Right to access of personal health information - patients must be allowed to inspect and copy information contained in the agency’s record.
  • Right to know what disclosures have been made - the agency must track all information released and be able to provide documentation to the patient.
  • Right to amend the personal health information - while patients may request amendments and the agency must allow amendments, the agency may deny some requests.

Electronically generated, stored, or transferred information also falls firmly under HIPAA privacy rules. Both individuals and facilities are responsible for defending electronic protected health information (ePHI).

Agency Regulation (GovRegs, 2019)Annual Required Training
CMS 45 C.F.R. § 164.530(b)A covered entity must train ALL members of its workforce on the policies and procedures with respect to protected health information.
The Security Rule specifies safeguards that covered entities and their business associates must implement to protect the confidentiality, integrity, and availability of ePHI. Covered entities and business associates must develop and implement policies and procedures to protect the security of PHI and electronic (aka) ePHI that they create, receive, maintain, or transmit. Each entity must analyze the risks to the ePHI in its environment and create solutions appropriate for its own situation.

Protected information that does get shared, either by accident or with purpose, must immediately be reported using the facilities established procedures. Depending on the extent of the information breach, the federal agency overseeing HIPAA accountability and/or local media may need to be notified.

Agency Regulation (GovRegs, 2019)Annual Required Training
CMS 45 CFR 164.530(b)(2)(ii)ALL employees will receive regular training in HIPAA policies and procedures, PHI, ePHI, and Privacy breaches.

While the Privacy Breach Notification Rule does not specifically require annual training, many experts in the field of compliance heartily recommend annual ALL staff training due to the risks and penalties associated with security and privacy violations (Lowman, 1218). A privacy breach requires covered entities to notify affected individuals, the Department of Health and Human Services (HHS), and in some cases, the media of a breach of unsecured PHI. Most notifications must be provided without unreasonable delay and no later than 60 days following the discovery of a breach. Notifications of smaller breaches affecting fewer than 500 individuals may be submitted to HHS in a log or other documentation annually. The Rule also requires business associates of covered entities to notify the covered entity of breaches at or by the business associate.

The HHS Office for Civil Rights enforces the HIPAA Privacy, Security, and Breach Notification Rules. For more information on the enforcement process, visit here on the HHS website. Violations may result in the imposition of civil monetary penalties. In some cases, criminal penalties may apply, enforced by the Department of Justice.

Access to Emergency Services Training

Several regulatory agencies require annual training regarding the ability of clients to access emergency care; this is especially important to CMS. The right to care is reflected in the 1986 Emergency Medical Treatment and Labor Act (EMTALA) and ensures the public has access to emergency services regardless of lack of insurance or ability to pay.

Emergency Medical Treatment & Labor Act of 1986 (EMTALA) (CMS, 2019)
Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay (CMS, 2019). Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a client within its capability, or if the patient requests, an appropriate transfer should be implemented.

EMTALA is often called the anti-dumping law and was passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA). Insurance companies are now obligated to use a standard definition for the need for emergency room (ER) services. This definition uses the concept of a prudent layperson. Under this definition, a person has a need for ER services if he or she has signs or symptoms that a reasonable non-medical person would consider an emergency.

If the client has severe pain, an injury, or a sudden illness that convinces him/her that their health is in serious jeopardy, they have the right to receive screening and stabilization emergency services whenever and wherever needed without prior authorization or financial penalty. The client has the right to request transfer to another institution, providing it is medically permissible, and the other facility will accept the transfer.

Under EMTALA, a hospital must screen all incoming clients. The screening must be complete enough to find out whether that person has an emergency medical condition. The medical screening exam must be performed by a physician or qualified individual who is designated by the facility to provide the medical screening exam.

Agency Regulation (CMS, 2019)Ongoing Required Training
TJC HR.01.05.03 EP.13Education and training on how to identify and respond to changes in a patient’s condition.

NOTE: Training frequency is not specified in this requirement; however, compliance professionals tend to advise annual training of designated personnel with good record keeping.

Please note all training involving EMTALA must clearly state that a triage exam does not constitute a medical screening exam.

If the client does not have an emergency condition, the hospital has no further obligation under EMTALA. If the client does have an emergency condition, the hospital must provide stabilizing treatment. This treatment must be provided without considering the client’s ability to pay. Before the client is stabilized, the hospital may transfer the client out only if another facility is better equipped to treat the client and their condition. A hospital may not transfer an unstable client for purely economic reasons.

Information Disclosure

Clients in healthcare facilities have the right to accurate and easily understandable information about their health plan, healthcare professionals, and the facility itself. Should English not be their primary language, or they have physical or mental disabilities, then appropriate information must be provided in a manner that allows them to make informed healthcare decisions.

Clients have the right to know about the facility itself. This information can cover a wide topic range such as:

  • How to file a complaint
  • The facility’s position on withholding and withdrawing life-sustaining care and treatment
  • Experience with specific procedures and services
  • Accreditation status, quality, and consumer satisfaction ratings – Note: this information is already available through the internet
  • Their healthcare team – who is responsible for their care – names and professional status, team members education and board certification status, years of practice, experience, quality, and consumer satisfaction ratings
  • Their rights and responsibilities as clients. Remember they must understand the information they are given about their rights

While auditing agencies understand that each facility will have its own methods for making sure clients know and understand their rights, regulatory agencies require proof that facilities are indeed providing this information to clients. Inspection of expectations comes both by undertaking direct observation and examination of facility policies or records.

Most facilities display information on client rights at intake points to the facility. Many also provide clients with a written form of rights at intake during the admission process in client handbooks. Rights and responsibilities may also be posted in waiting areas; be aware; however, a written list of rights is not enough. The facility must make sure that all clients understand their rights well enough to exercise them. In fact, this is true of all information. All information must be presented so that the person can understand it. This means that clients may need special help if they do not speak English, cannot see or hear well, or have other mental or physical barriers to understanding. Examples of special help include:

  • Translation services
  • Sign-language interpreters
  • Social workers or case managers
  • Large print or Braille materials
  • Magnifying glass or large print documents

Participation in Treatment Decisions Training

Clients have the right to participate in decisions about their care and to set the course of their treatment. This means that they must be given accurate information. They have the right to know their diagnosis, prognosis, and treatment options. Healthcare providers must discuss all treatment options with their clients, which includes the option of no treatment. Further, they need to know the risks, benefits and potential medical consequences for each treatment option.

Informed Consent

Discussing clinical information with a client is part of informed consent. Informed consent is an ongoing process of communication between a healthcare provider and the client. It allows the person to make intelligent decisions about a proposed course of treatment. Remember, information is useful to a client only if he or she can understand it. When discussing diagnosis and treatment options with the client, avoid the use of medical jargon and terminology, seek the services of a translator or interpreter if necessary, and assist the patient in obtaining a second opinion if requested.

After receiving all pertinent information, a client may give informed consent for treatment or refuse treatment. Signing as a witness on the informed consent document is witnessing that the client signed the document. It does not mean that the witness participated in providing informed consent.

Except in an emergency, a client must give his or her informed consent prior to the start of any procedure or treatment. Informed consent or the reason for a client’s inability to provide informed consent must be documented in the medical record. The informed consent document must:

  • Be clearly worded in simple terms without abbreviations.
  • Indicate the specific procedure to be performed.
  • Include a list of possible complications.
  • Be written as stated in physician orders.
  • Be signed by the client before receiving pre-op meds that induce sedation or amnesia or reduces anxiety.
  • Contain the client’s dated signature, if the client is of age and competent.
  • Contain the signature of the physician performing the procedure.
  • Ensure that the consent has date and time.
  • Include a witness’ signature affirming the client signed.

Please note that two witnesses are required for:

  • Person signing for an incompetent patient
  • Telephone consent
  • Signature of “X” if the client cannot write
  • When there is a clause for photographs and blood transfusion if applicable

If the client cannot give consent, laws vary from state to state, and policy varies from facility to facility. The following are generally accepted practices. If the client is a minor, the legal guardian must sign the consent. An emancipated minor can sign consent. An emancipated minor is usually recognized as one who is not subject to parental control, as in the following situations:

  • Married minor
  • In military service
  • College student under legal age but living away from home
  • Minor who has a child
  • Court-ordered emancipated minor

If the client is incompetent or incapacitated, permission can be sought from a patient representative who is usually a family member or Power of Attorney. An incompetent client is any client who is mentally or physically incapacitated, as determined by physicians, such that the client cannot communicate treatment preferences. The client does not have to be adjudicated incompetent by a court of law for the purposes of consenting for a procedure. Facility policy usually dictates the process and how many physicians must be involved in the decision.

In an emergency, where the physician feels that delaying a procedure would be an immediate threat to the client’s life or limb, and the client cannot give consent, the physician may proceed with the procedure without consent. This process requires extensive documentation and often a consultation with other physicians. Check your facilities policy.

Clients have the right to refuse treatment. Even after giving informed consent, the client may change their mind at any time. If the client decides to withdraw consent, the treatment must be stopped. When a client refuses treatment, he or she has the right to know what will happen. They should receive information on the possible medical and other consequences of refusing treatment. Parents, guardians, family members, or other individuals that are designated as the representative of the client if he cannot make his/her own decisions must be provided the same information.

Advanced Directives

The Patient Self Determination Act became effective December 1991 (Govtrack, 2019). This federal law requires that all hospitals receiving Medicare or Medicaid funding provide information to all adult clients upon admission about advanced directives and to ask whether they have an advanced directive. In accordance with Federal and State regulations, clients should receive information regarding advanced directives if they do not present with this information at admission. Advanced directives can be used from admission to admission; however, they should be reviewed with the client at each admission to verify accuracy.

If the client is incompetent at the time of admission, the information should be provided to the surrogate or proxy. If the client is temporarily incapacitated, the information should be provided when decisional capacity returns. A client’s right to make decisions about his/her care is true even after they are no longer able to communicate those decisions directly. Advance directives can protect people who may be unable to communicate due to a condition such as irreversible brain damage or brain disease that affects the ability to think as well as communicate.

Advanced directives can limit life-prolonging measures when there is little or no chance of recovery. For example, advanced directives may enable clients to make their feelings known about cardiopulmonary resuscitation (CPR), intravenous (IV) therapy, feeding tubes, ventilators respirators, and dialysis. Advanced directives can address pain relief, either requesting or refusing it.

Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC PC.02.01.11 EP.4Education and training on resuscitation equipment and techniques, as well as proper need and use for.
TJC PC.02.02.01 EP.2Education and training on the needs of dying patients and their families.
CMS 482.13(b)(3)All staff trained on orientation and whenever policy/procedure changes on advance directives.

An advanced directive is a legal document that allows a client to participate in future healthcare decisions. There are two forms of advanced directives:

  • Living Will: a client documents his/her wishes for future treatment in the event of a terminal illness. A living will goes into effect when a client develops a terminal condition that makes it impossible to communicate healthcare decisions directly. They are called living wills because they take effect while a client is still alive.
  • Durable Power of Attorney for Healthcare: in this document, the client appoints a representative to make healthcare decisions. A power of attorney goes into effect when the client loses the ability to communicate his/her own decisions. The client names a person called a surrogate or proxy to make decisions.

An additional tool for participating in future healthcare decisions is the do-not-resuscitate (DNR) order. A DNR order states that a client does not want CPR if he/she goes into cardiac or respiratory arrest. A client may request a DNR order; however, only a physician can approve and give the order.

To be clear, an advanced directive takes effect only after the client is no longer able to communicate directly. Until that time, the client’s direct communication is the only thing that matters. A competent client may change his/her advanced directive at any time. If a client wishes to change a directive, the healthcare professional must make it possible. Care must never be based on whether or not the client has an advanced directive and the decisions in the directive. All clients must be treated fairly and equally, regardless of advanced directives.

Power of attorney, drafted by a licensed attorney, is when one person authorizes another person to act on one’s behalf. Some important points regarding a power of attorney include signatures of the principal party, two adult witnesses, and the notary public. It may be used immediately. A power of attorney does not need to be filed in court except for real estate transactions. A power of attorney is in effect until revoked by the principal, participant’s death, or revoked by the court. A power of attorney may have more than one agent. If so, all agents must concur when making decisions. There are several types of power of attorney.

  • General: an agent acts on behalf of the person in a variety of situations
  • Limited: limited to a specific transaction
  • Healthcare: to make decisions when incapacitated
  • Springing: in effect at some future time – illness, disability of the principal
  • Durable: all of the above can be made “durable” by adding text – enables the agent to act when the principal is incompetent and physically unable to make decisions

A healthcare surrogate is any competent adult expressly designated in writing by a client to make healthcare decisions on his or her behalf when incapacitated. This surrogate has no authority to act until the primary care physician determines that the principal lacks the capacity to make informed healthcare decisions. A proxy is a competent adult, who has not been expressly designated to make healthcare decisions for a particular incapacitated individual but who nevertheless is authorized to make healthcare decisions. A healthcare proxy is appointed by the hospital when there is no power of attorney or surrogate, and healthcare decisions need to be made. Potential representatives for an incapacitated patient may include:

  • Guardian
  • Adult child
  • Domestic partner
  • Brother or sister
  • Close friend

When a client loses the ability to communicate directly often, he/she does not have an advanced directive. The hierarchy of healthcare decision-makers for a client without an advance directive depends upon state law.

Research Participation

Clients have the right to be part of research studies or educational activities. If a client refuses experimental treatment, this should not have any effect on his/her regular care. If the client wants to be part of a research study, he/she must sign a written consent, which explains that the proposed treatment is experimental. The consent form for participation in experimental treatment must include the nature of the experimental treatment, procedures involved, risks and benefits, other available options, and confirmation of any interruption in client care.

Organ Donation

Agency Regulation (GovRegs, 2019b)Annual Required Training
CMS 42 CFR § 482.45Organ, tissue, and eye procurement training for physicians and designated personnel.

Clients have the right to choose organ donation. They must give informed consent if they want to donate their organs. Notify the organ procurement agency affiliated with the facility, as described in the facilities policy. The organ procurement agency will determine if the potential donor is medically suitable.

Agency Regulation (TJC, 2019c)Ongoing Required Training
TJC TS.01.01.01 EP.4,5Education and training on organ donation issues for physicians and any involved personnel. Issues include such as organ procurement organizations (OPO), the need for discretion, and sensitivity to beliefs and circumstances in regard to the family of potential organ donors.

Respect and Nondiscrimination

Clients have the right to considerate, respectful, nondiscriminatory, and compassionate care from doctors, health plan representatives, and other healthcare professionals. Respect means valuing the clients’ needs, desires, feelings, and ideas. Treat clients with common courtesy. For example: knock and wait before entering a client’s room; respond politely to clients; listen to clients; and remain compassionate. Clients have the right to fair and equal healthcare services, regardless of:

  • National origin
  • Political affiliation
  • Level of education
  • Place of residence or business
  • Marital status
  • Personal appearance
  • Mental or physical disability
  • Sexual orientation
  • Genetic information
  • Source of payment

Cultural and Spiritual Needs

Culture is the way of life of a population, including shared knowledge, beliefs, values, attitudes, rules of behavior, language, skills, and world view among members of a given societal group. Culture shapes human behavior because it is the foundation of conscious and unconscious beliefs about "the proper" way to live. Cultures change constantly. Different members of a society internalize and express different parts of their shared culture. Subcultures are also always present and can reflect differences by geographic region or other subgroups within a larger shared society.

Religion, faith, and spirituality have significant cultural and spiritual roles at the end of life customs. When discussing advanced directives or hospice, ethnic and cultural beliefs greatly influence the conversation as well as the decision.

It is important to remember that simply because a person is identified as a member of a particular ethnic group or religion does not necessarily mean that the person or their family has the standard set of beliefs that may be associated with that ethnicity or religion. Within ethnic groups are characteristics that define the use of language, the role of family, religion, spirituality, the definitions of illness, the use of healing practices in healthcare, and health-seeking behaviors. For every case, an assessment must be made of how acculturated a person and their family are, their language skills, and whether an interpreter is needed. An assessment requires both the knowledge and the skills of the clinician.

Client perception of their condition is sometimes referred to as “acceptance.” Rather than asking the client if they accept their diagnosis, a better format can be asking open-ended questions that elicit a cultural response. A client may be taking herbal remedies, employing traditional healing methods, or believe their illness is in direct response to past behaviors, a punishment of some sort. The following questions should be considered.

  • Do you think that there are ways to get better that your physician may not be aware of?
  • What do you think is wrong or causing your health problem?
  • Is there anyone else helping you get better?

This approach is likely to provide a more authentic response to the client’s acceptance of illness. The healthcare professional must also take into consideration cultural beliefs on terminal diseases and death and dying practices. Be aware; there are cultures that believe it is better to withhold terminal news.

Each facility should have a standardized assessment form that will include cultural, religious, and spiritual assessments. Communication is probably the most important aspect of the assessment. The client may have limited English proficiency (LEP) that creates a language barrier. A family member may not be the best interpreter.

Remember that inadequate interpretation is a form of discrimination. Also, cultural beliefs held by the person interpreting may result in misinformation. For instance, a Hispanic woman may not want her son interpreting in a discussion of gynecological issues and may give false information to avoid that situation. An unbiased interpreter should be used for discussions of informed consent and dying.

Cultural competence is the ability to give healthcare in ways that are acceptable and useful to patients because it is congruent with their cultural background and expectations. National cultural competency standards for healthcare professionals include (OMH, 2018):

  1. The Principal Standard
    1. Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
  2. Governance, Leadership, and Workforce
    1. Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.
    2. Recruit, promote, and support a culturally and linguistically diverse governance, leadership and workforce that are responsive to the population in the service area.
    3. Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.
  3. Communication and Language Assistance
    1. Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
    2. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally, and in writing.
    3. Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
    4. Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.
  4. Engagement, Continuous Improvement and Accountability
    1. Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organizations’ planning and operations.
    2. Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities.
    3. Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.
    4. Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.
    5. Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
    6. Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.
    7. Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

Complaints, Grievances, and Appeals

Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC PC.01.02.09 EP.2Employees at all levels need to know about assessment and care of suspected victims of abuse and neglect, such as human trafficking. Staff should be educated on any mandating reporter obligations as well as any specialized resources such as local task forces and authorities that are specially trained to respond to such situations.
TJC PC.01.02.09 EP.3The organization educates staff about how to recognize signs of possible abuse, neglect, and exploitation, and about their roles in follow-up, including reporting.
CMS 482.13(a)(2)(i)All patient care staff trained in orientation and whenever policy/procedures change on the grievance process.

Consumers of health services have the right to question, complain about, file grievances, or appeal decisions made concerning their health care. CMS, TJC, and many state and federal agencies request and require healthcare professionals to be trained on this subject annually.

Every client has the right to a fair, fast, and objective review of any complaint that they have concerning the health plan, doctors, hospital, or other healthcare personnel. This includes complaints about waiting times, operating hours, the conduct of healthcare personnel, and the adequacy of healthcare facilities. Many facilities have a client care representative to deal specifically with complaints or grievances. Many client complaints can be addressed quickly. For example, if a client complains about getting the wrong items on her lunch tray, make sure she gets the right items next time. The sooner the issue is resolved at the lowest level possible, the better client compliance and satisfaction with the healthcare provider. The client may need to have access to the ethics committee for issues regarding his/her care. They should expect that issues related to end-of-life care be treated with respect and sensitivity. The client should be able to examine and receive an explanation of his/her bill regardless of the source of payment.

More than 50% of the clients who sue do so because of miscommunications, anger, and lack of information between physicians, hospital staff, and clients/families. Grievance management is everyone’s responsibility. Handling grievances effectively from the start benefits everyone involved, helps keep small grievances from becoming big ones, and reduces the risk of liability. When complaints cannot be resolved quickly and easily, clients have the right to file a grievance. A grievance is a formal written or verbal complaint. If a client wants to file a grievance, the healthcare professional must:

  • Explain the grievance process at the facility. This includes the name of the staff person the client should contact for the assistance of with resolution of their grievance.
  • Explain that grievances may be filed with state agencies. This is true whether or not the client has already used the facility’s internal grievance process.
  • Give the client the phone number and address for filing a grievance with the state.

Healthcare facilities must review, investigate, and resolve all grievances within a reasonable period. If the grievance has to do with the client’s safety, it should be reviewed immediately. Examples include grievances about abuse or neglect. To complete the grievance process, the facility must give the client a written report. This report should explain how the facility investigated the grievance and the facility’s decision about the grievance.

Bills and Bill Examination

On a somewhat related note to HIPAA and grievances, clients possess the right to question their bills. They have the right to request and receive a detailed explanation of every item on a bill, and training on this subject is expected either separately or as a component of client rights training.

Workplace Safety

Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC APR.09.02.01 EP.1,2Staff concerns about safety and quality of care, reporting ongoing training.

Did you know that The Joint Commission is one of five hospital and health services accrediting agencies accepted by CMS for the United States; The Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP), Accreditation Association for Hospitals Health Systems Inc. (AAHHS), the Center for Improvement in Healthcare Quality (CIHQ) and Det Norske Veritas Healthcare Inc. (DNV). TJC is the big dog, providing oversight for more than 5000 hospitals and 10,000 other types of healthcare facilities. All accreditors serve the same function of inspection and accreditation of quality in health facilities so as to assure CMS that the health care provided meets or exceeds conditions of payment for services participation set by the federal government. This allows the approved health provider to receive payments and other monies from Medicare and Medicaid.

Please remember that although accrediting organizations serve a vital link between tax dollars and health care, these organizations are not part of the federal government. They are independent contractors serving the function of assuring federal and state authorities and in turn, private insurers and citizens, that each healthcare facility they accredit provides a high level of quality care. The process of approval is often referred to as the health services provider gaining a “deemed” status, as in deemed worthy to receive payments. For the purpose of this course, we will focus on The Joint Commission annual training requirements due to TJC’s size, standing, close working relationship with CMS, and the history of comprehensive observation and inspection of its expectations.

TJC 2019 Hospital National Patient Safety Goals (CMS, 2018)
Goal 1Identify Patients Correctly
NPSG.01.01.01Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.
NPSG.01.03.01Make sure that the correct patient gets the correct blood when they get a blood transfusion.
Goal 2Improve staff communication
NPSG.02.03.01Get important test results to the right staff person on time.
Goal 3Use medicines safely
NPSG.03.04.01Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups, and basins. Do this in the area where medicines and supplies are set up.
NPSG.03.05.01Take extra care with patients who take medicines to thin their blood.
NPSG.03.06.01Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines being given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.
Goal 4Use Alarms Safely
NPSG.06.01.01Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
Goal 5Prevent Infection
NPSG.07.01.01Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.
NPSG.07.03.01Use proven guidelines to prevent infections that are difficult to treat.
NPSG.07.04.01Use proven guidelines to prevent infection of the blood from central lines.
NPSG.07.05.01Use proven guidelines to prevent infection after surgery.
NPSG.07.06.01Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.
Goal 6Identify Patient Safety Risks
NPSG.15.01.01Find out which patients are most likely to try to commit suicide.
Goal 7Prevent Mistakes in Surgery
UP.01.01.01Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.
UP.01.02.01Mark the correct place on the patient’s body where the surgery is to be done.
UP.01.03.01Pause before the surgery to make sure that a mistake is not being made.
UP.01.03.01Pause before the surgery to make sure that a mistake is not being made.

The Joint Commission national patient safety goals provide a clear map of which areas will be the target of interest and inspection during accreditation surveys or inquiries. Be certain to address the topics found in the TJC safety goals in your annual training.

By the way, communication between health professionals and accrediting bodies is meant to flow both ways. Should you have concerns about client safety or quality of care, both CMS and Joint Commission have avenues of communication open to hear your concerns.

National Patient Safety Goals

Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC APR.09.02.01 EP.1,2Staff concerns about safety and quality of care, reporting ongoing training.

Did you know that The Joint Commission is one of five hospital and health services accrediting agencies accepted by CMS for the United States; The Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP), Accreditation Association for Hospitals Health Systems Inc. (AAHHS), the Center for Improvement in Healthcare Quality (CIHQ) and Det Norske Veritas Healthcare Inc. (DNV). TJC is the big dog, providing oversight for more than 5000 hospitals and 10,000 other types of healthcare facilities. All accreditors serve the same function of inspection and accreditation of quality in health facilities so as to assure CMS that the health care provided meets or exceeds conditions of payment for services participation set by the federal government. This allows the approved health provider to receive payments and other monies from Medicare and Medicaid.

Please remember that although accrediting organizations serve a vital link between tax dollars and health care, these organizations are not part of the federal government. They are independent contractors serving the function of assuring federal and state authorities and in turn, private insurers and citizens, that each healthcare facility they accredit provides a high level of quality care. The process of approval is often referred to as the health services provider gaining a “deemed” status, as in deemed worthy to receive payments. For the purpose of this course, we will focus on The Joint Commission annual training requirements due to TJC’s size, standing, close working relationship with CMS, and the history of comprehensive observation and inspection of its expectations.

TJC 2019 Hospital National Patient Safety Goals (CMS, 2018)
Goal 1Identify Patients Correctly
NPSG.01.01.01Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.
NPSG.01.03.01Make sure that the correct patient gets the correct blood when they get a blood transfusion.
Goal 2Improve staff communication
NPSG.02.03.01Get important test results to the right staff person on time.
Goal 3Use medicines safely
NPSG.03.04.01Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups, and basins. Do this in the area where medicines and supplies are set up.
NPSG.03.05.01Take extra care with patients who take medicines to thin their blood.
NPSG.03.06.01Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines being given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.
Goal 4Use Alarms Safely
NPSG.06.01.01Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
Goal 5Prevent Infection
NPSG.07.01.01Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.
NPSG.07.03.01Use proven guidelines to prevent infections that are difficult to treat.
NPSG.07.04.01Use proven guidelines to prevent infection of the blood from central lines.
NPSG.07.05.01Use proven guidelines to prevent infection after surgery.
NPSG.07.06.01Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.
Goal 6Identify Patient Safety Risks
NPSG.15.01.01Find out which patients are most likely to try to commit suicide.
Goal 7Prevent Mistakes in Surgery
UP.01.01.01Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.
UP.01.02.01Mark the correct place on the patient’s body where the surgery is to be done.
UP.01.03.01Pause before the surgery to make sure that a mistake is not being made.
UP.01.03.01Pause before the surgery to make sure that a mistake is not being made.

The Joint Commission national patient safety goals provide a clear map of which areas will be the target of interest and inspection during accreditation surveys or inquiries. Be certain to address the topics found in the TJC safety goals in your annual training.

By the way, communication between health professionals and accrediting bodies is meant to flow both ways. Should you have concerns about client safety or quality of care, both CMS and Joint Commission have avenues of communication open to hear your concerns.

Recognizing and Reporting Abuse

All clients should be screened for abuse. Facilities must have procedures for identifying, reporting and treating victims of abuse. Clients have the right to expect access to protective services in the case of abuse.

Agency Regulation (CMS, 2018)Ongoing Required Training
CMS 482.13(c)(3)The hospital, during its orientation program, and through an ongoing training program, provides ALL employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection.

Abuse can take many forms. It may include emotional abuse, economic abuse, sexual abuse, threats, using the threat of removing children, using privilege, intimidation, isolation, and other behaviors used to maintain fear, intimidation, and power. There are many theories as to why some people are abusers. However, the reason abusers use this behavior is that violence is an effective method for gaining and keeping control over another person.

Sexual abuse is an unwanted sexual activity with perpetrators using force, making threats or taking advantage of victims not able to give consent. Most victims and perpetrators know each other. Immediate reactions to sexual abuse include shock, fear or disbelief. Long-term symptoms include anxiety, fear or post-traumatic stress disorder. While efforts to treat sex offenders remain unpromising, psychological interventions for survivors, especially group therapy, appear effective.

Psychological abuse occurs when a person tries to control information available to another person with the intent to manipulate that person’s sense of reality or their view of what is acceptable and unacceptable. Psychological abuse often contains strong emotionally manipulative content and threats designed to force the victim to comply with the abuser’s wishes and can include constant verbal abuse, harassment, excessive possessiveness, isolating the person from friends and family, deprivation of physical and economic resources, and destruction of personal property.

Physical abuse is physical force or violence that results in bodily injury, pain, or impairment. It includes assault, battery, and inappropriate restraint. It often begins with what is excused as trivial contact that escalates into more frequent and serious attacks.

Child abuse and neglect are at a minimum, any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; and an act or failure to act which presents an imminent risk of serious harm. Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include acts of violence like striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. This abuse may not have been intended to hurt the child, but an injury may have resulted from over-discipline or physical punishment. Neglect is the failure to provide for the child’s basic needs.

Child abuse or neglect is defined by the child welfare branch of the U.S. Department of Health and Human Services (DHHS) as:

  • Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or
  • An act or failure to act which presents an imminent risk of serious harm.
Mandatory Reporters of Child Abuse and Neglect
Agency Regulation (Findlaw, 2018)Ongoing Required Training
Public Health and Welfare U.S. Code

Title 42 U.S.C. § 5106a(b)(2)(B)(i)
Training to be provided under the grant (in order to receive federal grant monies) to support direct line and supervisory personnel in report taking, screening, assessment, decision making, and referral for investigating suspected instances of child abuse and neglect.
The Federal Child Abuse Prevention and Treatment Act (CAPTA) requires each State to have provisions or procedures for requiring reports of known or suspected instances of child abuse and neglect.

To find statute information for a particular State or Territory, go here.

Any suspicion of abuse involving minors requires consideration of cultural values and standards of care as well as recognition that the failure to provide the necessities of life may be related to poverty.

Elder abuse can take many forms. It also may include physical, emotional, psychological, sexual abuse, neglect, abandonment, or financial and material exploitation. With the frail elderly, neglect is a major problem. Neglect is the refusal or failure to fulfill any part of a person's obligations or duties to an elderly person. Most laws concerning elder abuse are state laws and can be found in a variety of state legal codes such as criminal, probate, welfare, business, and professional codes. Please be aware of your own states’ regulations and guidelines.

Many victims of abuse are seen in healthcare settings. Healthcare professionals often fail to identify victims because there is a lack of training on what to look for and how to ask about abuse. Opportunities for intervention are missed, and victims continue to suffer the adverse health consequences of physical and emotional abuse. For example, physically battered victims seek assistance in healthcare settings, often repeatedly.

Staff should question whether abuse might have occurred if a client’s explanation of the injury does not match the actual injury. For example, a child’s x-rays may show an unexplained broken bone.

Screening for abuse must be done. The healthcare professional should document abuse in the medical record; safeguard evidence; provide medical advice, referrals, and safety planning; and show empathy with compassion. Each facility must maintain a list of private and public community agencies that provide help for abuse victims. Staff should make appropriate referrals for victims.

Screening questions should always be asked in a private room, away from the suspected batterer, and preceded by assurances of all the confidentiality allowed by law. Healthcare professionals should find ways to separate the client from the possible abuser if the abuser demands to accompany the potential abuse victim into the examining room.

Use of Restraints

Sometimes clients need to be kept safe from their own actions. While we always encourage individuals to exercise internal control, at times, there may be a need for external measures of restraint. The decision to use physical or chemical restraints is a medical decision. Restraints must never be used for the purpose of discipline or convenience. When a client requires external restraint, it is important to protect that person’s safety, rights, comfort, and dignity.

Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC PC.03.03.01 EP.2Education and training on the use of restraint and seclusion
TJC PC.03.03.07 EP.1,3Education and training on minimizing the use of restraint and seclusion for behavioral purposes
TJC PC.03.03.07 EP.4Education and training on safe use of physical holding techniques, procedures for “take-downs,” and the application and removal of mechanical restraints
CMS 483.13(e)(10-11) CMS 482.13(f)Periodic ongoing restraint and seclusion policy training for any staff involved in the process
TJC PC.03.03.07 EP.5,6 TJC PC 03.05.17 EP.2,4,5Qualifications, education, and training of staff allowed to initiate restraint or seclusion, and perform 15-minute assessments of patients in restraint or seclusion. Demonstration of staff competence to perform these duties

Review the equipment, policies, and documentation tools for each facility where you practice, as there may be some variation in both practice and definition of restraints. Restraint standards for medical/surgical purposes apply when the primary reason for use directly supports medical healing. Please note that slightly different standards are used for behavioral management, such as in a psychiatric setting and long-term care (TJC, 2019b).

Medical vs. Behavioral Restraint Use
According to The Joint Commission:The decision to use restraints for medical/surgical reasons or for behavioral health care reasons is not based on the treatment setting but on the situation the restraint is being used to address. The simplest way to determine what is a behavioral health reason is first to determine what it is not. When restraints must be applied to directly support medical healing - this is not a behavioral health reason.

Behavioral use of restraints is a last-used option and should be considered only when a client is imminently at risk of harming themselves or others with their behaviors. Less intrusive methods of regaining safety must be attempted before restraint is applied.

Medication to control behavior should be used only as part of a therapeutic plan, after appropriate assessment by professionals. Chemical restraint is a term used to describe the use of medications for purposes unrelated to the client’s medical condition. An example is the use of a sedating psychotropic drug to manage or control behavior.

It is the intended use of a device or method that classifies the device or method as a restraint. For instance, IV arm-boards, postural support devices, orthopedic appliances, protective devices like helmets, are not restraints when used to promote healing or protect an easily injured tissue or surgical site.

This is Restraint vs. This is Not Restraint
According to The Joint Commission:Technically, a bed enclosure or side rails are neither purely a restraint nor a form of seclusion, based on the definitions that accompany the Joint Commission standards. However, a bed enclosure (e.g., net bed) and likewise a side rail could potentially restrict a patient's freedom to leave the bed and as such, would be restraint. If, for example, a bed rail is used to facilitate mobility in and out of bed, it is not a restraint. If the patient/client can release or remove the device, it would not be a restraint.

Restraints or seclusion are to be used as a last resort after alternatives have proven to be unsuccessful. Restraints should not cause harm or be used as a form of punishment. Examples of alternatives to restraints include, but are not limited to:

  • Interaction on 1:1 basis with staff
  • Redirection
  • PRN medication with client consent
  • Staff or client-initiated time out in a quiet room with the door unlocked. It should be presented as a way for a client to regain control, not as a threat
  • Staff presentation of limits where consequences are presented for client to choose
  • Removal of stimuli from the client or vice versa. Keep in mind that moving a client close to a busy nurses' station so you can keep a close eye on him/her could over stimulate and worsen symptoms
  • Relaxation exercises
  • Calming music
  • Distraction tactics

If lesser interventions are not successful, and you need to apply a physical restraint as a last resort, use the least-restrictive device possible. For example, a lap buddy is a soft vinyl device that attaches to the wheelchair rather than the client. Although the client can remove it when they are oriented, it serves as a reminder that he/she should not get up without assistance and protects in the event that he/she becomes confused again. Another alternative is a geriatric chair set in a reclining position or with a lapboard. This is less restrictive than a safety belt or roll belt. And a roll belt, in turn, is less restrictive than a vest restraint. Mitts are generally more suitable than wrist restraints because they are less restrictive and allow the client to move their arms freely. Another option is elbow restraints that keep the arm straight but allow free arm movement.

A licensed, independent practitioner must order the restraint or seclusion; however, the facility may authorize qualified staff members, usually registered nurses, to initiate the use of restraints when needed before an order is obtained. The independent practitioner must evaluate the need for restraint or seclusion and assess the client within 1 hour.

The authorized staff member can discontinue restraints or seclusion as soon as the assessment reveals that restraints or seclusion are no longer necessary. The use of restraints for acute medical or surgical purposes must be reviewed and renewed if needed by the licensed, independent practitioner at least every 24 hours. The use of restraints for behavioral healthcare purposes in long term care must be reviewed and renewed if needed by the licensed, independent practitioner at least every 30 days.

Case Study

Case Study: (Based on a real story from Mercy Hospital, Springfield, Missouri) (Porter & Plunkett, 2018)

In 2017 a patient diagnosed with schizoaffective disorder was admitted to the BHU (Behavioral Health Unit) shortly before 5 a.m. and quickly was in a confrontation with a registered nurse.

According to reports and video monitor records, the patient screamed and spat on the nurse’s chest. “Don’t ever spit on me again,” the nurse stated, moving forward to the patient. When the patient raised his right arm between them, the nurse pushed it back down. The patient responded by used his other hand to punch the nurse in the face. The nurse “charged forward and struck the patient in the face/neck area,” relates the report, pushing him up against a wall as the patient continued to strike the nurse’s head and neck. The nurse then “slammed the patient to the floor,” the report states.

“That was a major mistake. I will press charges, guaranteed,” the nurse said. The nurse then pinned the patient to the floor and held him there for several minutes until security officers arrived to stand the patient and escort him to a small windowless room with a lockable door known as the Acute Care Area (ACA).

The nurse involved in the altercation continued to document on the patient in the small locked room for the next two hours, until the end of his shift.

The CMS Inspector reviewing the incident was, it seems safe to say, not amused.

In the CMS ruling finding patients being placed in Immediate Jeopardy, CMS is quoted stating. “The facility used ACA as seclusion to isolate patients because of behavioral acts. The facility did not recognize this action as seclusion, so no orders or other restraint monitoring was put into place”.

Other areas of concern arising from this and other similar situations uncovered during CMS review of Mercy might have included:

  • Not removing and replacing the staff who threatened and laid hands on the patient.
  • Need for staff training in less provoking interventions.
  • Need for staff training in less restrictive interventions.
  • Need for staff training on seclusion and restraint definitions, policy, procedures.
  • Need for a hospital incident reporting system.

Procedures for checking and documenting while a client is in restraints are rigorous. Each facility will have a restraint or seclusion documentation tool that must be completed, which must include the following.

Assessment of clients in restraints in an acute care setting or long-term care setting:

  • Client to be checked at least hourly
  • Restraints removed to allow movement at least every 2 hours
  • Assess, turn, reposition, range of motion exercises, offer nourishment and fluids, and toilet the client at least every 2 hours

Psychiatric setting assessment of clients in restraints or seclusion:

  • Continuous observation is required
  • Vital Signs every hour
  • Ongoing assessment of airway and respiratory status
  • Assess hydration and offer fluids at least every two hours
  • Toileting offered every two hours
  • Nutrition at mealtimes as safety permits
  • Assess circulation and range of motion every fifteen minutes
  • Check for injury associated with the application of restraint or seclusion
  • Assess psychological status including readiness for discontinuation of restraint or seclusion
  • Documentation of all activities
Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC PC.03.05.13 EP.1Education and training on the need for continuous monitoring when a patient is both restrained and secluded.

The written order in the chart must include the justification for restraint or seclusion, the type of restraint used, and the time limit for use. Some facilities will have a template for the physician’s order. The documentation of restraints and seclusion needs to include; the circumstances that led to seclusion or restraint, consideration or failure of non-physical interventions, rationale for intervention used, notification of family if appropriate, criteria for discontinuation as well as informing the client of the behavior criteria, each evaluation, any assistance provided to the client, continuous monitoring, debriefing of client with staff and any injuries that are sustained and treatment received.

Physical restraints should always be fastened for easy release in an emergent situation. The restraint should be attached to a fixed part of the furniture, like the bed frame. Fixing it to a movable part, like a side rail, could inadvertently tighten the restraint causing client injury or loosen the restraint causing it to be ineffective.

Case Study
A Joint Commission surveyor comes to the ward where a client is in behavioral restraint due to an assault and secluded in a corner room due to her loud cursing and continuous verbal threats upsetting other clients. The primary physician is awaiting drug toxicology results before beginning a medication process to calm the client, and a staff member is sitting at the foot of the clients’ bed, observing their vital signs and respiration.

The surveyor asks the observing staff if she can speak to them at the nurse’s station away from the anxious, animated client.

The observing staff refuses, stating this client must have continuous, direct attendance at all times.

What reaction do you anticipate from survey personnel spurned?

This is a WIN! No person in seclusion AND restraint can be left alone at any time, for any reason. The possibilities of things going wrong while in restraints and isolated are mind-boggling, here are a few:
  • Sudden unattended emesis and aspiration
  • Medical emergencies due to heightened adrenal functions and agitation, e.g., stroke, cardiac arrest, panic attack, etc.
  • Self-injury from throwing oneself against restraining devices
  • Another client or person entering the room where the first is tied down and unattended and causing injury
NOTE: Surveyors do not utilize trick questions; they are, however, willing to observe if staff are familiar with their own institutional procedures and policy.

Fall Reduction

Agency RegulationOngoing Required Training
TJC HR.01.05.03Ongoing education and training on fall reduction.

A high falls risk is not an acceptable reason to use restraints. The following are suggestions to reduce falls risk:

  • Check the client at least every hour.
  • Remind the client to call for assistance if he/she wants to visit the bathroom.
  • Use low beds or put the mattress on the floor for high-risk clients who will not call for assistance to get up.
  • Arrange furniture so that it does not block the walkways.
  • Use a nightlight and keep debris and liquids off the floor.
  • Keep the client's personal items, water pitchers, and call light within reach at all times.
  • Make sure the client wears his/her eyeglasses, hearing aid, or other assistive devices.
  • Ask family or friends to stay with him/her at night or at other times when he/she tries to climb out of bed.

Violence Preparation

CDC reports identify the risk of violence to healthcare workers being much higher than for all other private sector industries. The documentation clearly shows that 50 percent of healthcare professionals have been and will be victims of assault in the workplace (Moore & Plaff, 2019). The circumstances of hospital violence differ from workplace violence in other settings such as banks, convenience stores, or taxicabs, where violence most often relates to robbery. Violence in hospitals is usually an outpouring of emotion rather than an attempt at a material gain. With the violence toward others resulting from clients or their family members who feel frustrated, vulnerable, and out of control. Common risk factors for hospital violence include the following:

  • Working directly with volatile people, especially if they are under the influence of drugs or alcohol or have a history of violence or certain psychotic diagnoses
  • Working when understaffed-especially during meal times and visiting hours
  • Transporting clients
  • Long waits for service
  • Overcrowded, uncomfortable waiting rooms
  • Working alone
  • Poor environmental design
  • Inadequate security
  • Lack of staff training and policies for preventing and managing crises with potentially volatile patients
  • Drug and alcohol abuse
  • Access to firearms
  • Unrestricted movement of the public
  • Poorly lit corridors, rooms, parking lots, and other areas

Violence may occur anywhere in a hospital, but it is most frequent in psychiatric wards, emergency rooms, waiting rooms, and geriatric units. Studies indicate that violence often takes place during times of high activity, and during interaction with clients. Assaults may occur when service is denied when a client is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking, tobacco, or alcohol use. Clients with the condition that causes confusion and impaired judgment are more likely to become violent than a client with normal mentation. Confusion and impaired judgment may be caused by neurologic conditions, seizures, hypoglycemia, or dementia. Watch for signals that may be associated with impending violence:

  • Verbally expressed anger and frustration
  • Body language such as threatening gestures
  • Signs of drug or alcohol use

Also, it is important to note how your co-workers behave. If a colleague’s demeanor or behavior has changed for the worse, notify your manager. For example, slamming equipment around is red-flag behavior.

Learn from history. If a client has a history of violent behavior (such as acting combative in the ambulance or waiting room), prepare yourself for potentially violent behavior and warn others who are caring for him/her. Let security know if you feel threatened or if you find or suspect that he’s carrying a weapon. Notify the supervisor if you suspect a client is going to be violent. Help relieve the client’s tension and anxiety by keeping him informed about when he’ll be examined or treated and what’s going on.

Be alert to your environment:

  • Evaluate each situation for potential violence when you enter a room or begin to relate to a patient or visitor.
  • Be vigilant throughout the encounter.
  • Do not isolate yourself with a potentially violent person.
  • Plan your exit. Always keep an open path for exiting. Do not let the potentially violent person stand between you and the door.
  • When you’re with an upset client or co-worker, avoid areas of the room that lacks an accessible exit.
  • If you’re going to an isolated part of your facility, let others know where you’re going and when you expect to return.
  • Consider asking for an escort.
  • Note anyone who’s not wearing staff ID and is lingering where he/she shouldn’t. Politely ask if you can help them and notify security if you aren’t satisfied with the answer. If you’d rather not approach someone, call security and provide a full description.
  • Evaluate the way you wear equipment to be sure it cannot be used as a weapon against you. For example, consider that a stethoscope or ID badge without a breakaway necklace can be used to choke you. Carry your stethoscope in a pocket and use an ID badge necklace that has a breakaway feature.
  • If you wear a necktie, opt for a clip-on style.
  • If your hair is long, wear it in a way that’s not easy to pull, and do not wear dangling jewelry.

In the presence of a potentially violent person:


  • Plan a clear exit route.
  • Keep 5 to 7 feet between you and him. Never turn your back on him or let him get between you and the exit.
  • Keep your voice calm and quiet.
  • Acknowledge that he has a right to his feelings.
  • Assume that he has a valid concern and address it.
  • Try to meet reasonable demands.
  • Offer alternatives when possible. For example, tell an angry patient that although he cannot order take-out pizza, you’ll see if you can get him an early dinner. Tell an angry colleague that you see that she’s angry and that you’d like to work with her and your manager to resolve the situation.
  • Call for backup or security if a situation grows increasingly tense.
  • Ensure access to bathrooms, a phone, TV, and something to read.
  • Track equipment. Return it to its rightful place. When you take an item into a client’s room, dispose of it properly, or take it with you when you leave.

Take these steps if you cannot defuse the situation quickly:

  • Remove yourself from the situation.
  • Call security for help.
  • Report any violent incidents to your management.

Do not

  • Do not ignore the agitated person or avoid him.
  • Do not threaten or demand obedience.
  • Do not argue or become defensive or judgmental.
  • Do not laugh, move suddenly, make threatening gestures, or invade his personal space.
  • Do not try to handle a dangerous situation alone. Call security or initiate your facility’s violence prevention protocol.

In the presence of a weapon, maintain behavior that helps diffuse anger:

  • Present a calm, caring attitude.
  • Do not match the threats.
  • Do not give orders.
  • Acknowledge the person’s feelings (for example, “I know you are frustrated”).
  • Avoid any behavior that may be interpreted as aggressive (for example, moving rapidly, getting too close, touching, or speaking loudly).

Sexual Harassment

Let’s face it, something about the healthcare environment brings out the best and the worst in people and their behaviors. Sexual harassment is not acceptable and can lead to civil prosecution and/or disciplinary action up to termination. Sexual harassment includes unwelcome:

  • Sexual advances
  • Request for sexual favors
  • Verbal, visual, or physical behavior of a sexual nature

State laws and requirements control the mandate for training concerning the prevention of sexual harassment in the workplace. Be assured that training will be required for ALL employees, on a frequency specific to your state laws. National oversite of sexual harassment policies and complaints is provided by the U.S. Office of Civil Rights, and they are proactive in exerting authority when incidents are reported (OCR, 2019).

Sexual harassment becomes unlawful when it becomes a condition of employment, of advancement, unreasonably interferes with work performance, or creates an intimidating, hostile, or offensive work environment.

Work environments vary, and people have varying levels of sensitivity. The worker has a responsibility to inform the people involved that they must stop because he/she/they are offended or feels sexually harassed. If the behavior continues, report it to your supervisor or the human resources department. Do not mistakenly think it will go away on its own. Like a lingering foul stench, harassment requires positive action in order to have it cease.

Radiation Safety

The primary sources of radiation exposure in a healthcare facility are x-rays and radionuclides used in diagnostic tests and therapy. Areas, where radiation is used, are marked with the international tri-foil symbol.

GHS Chemical Hazard Symbol – Radiation (OSHA, 2019)

Ionizing Radiation


Non-Ionizing Radiation

  • Ionizing Radiation = Concentrated energy waves that destabilize atoms such as x-rays, tomography, angioplasty, fluoroscopy, and nuclear medicine. Ionizing radiation poses a risk of tissue damage and other health risks. Damage can accrue with repeated exposures.
  • Non-Ionizing Radiation = Energy waves composed of oscillating electric and magnetic fields such as ultraviolet (UV), infrared (IR), microwave (MW), radio frequency (RF), and extremely low frequency (ELF). Non-ionizing radiation can pose the danger of tissue destruction and health risk if not properly controlled.
More information on radiation and its hazards can be obtained from OSHA here.

Remember, portable x-ray machines may be found tucked in closets, storage rooms, at the side hall of emergency or critical care units, or many other unmarked areas.

Agency Regulation (OSHA, 2015)Annual Required Training
OSHA 29.CFR.1910.1096(f) and (i)Annual Ionizing Radiation Worker Training

During exposure to radiation, you should limit your time as much as possible, move at least six to ten feet from the source, and wear leaded shields. If your job requires routine exposure, you should wear a monitoring device to measure your exposure. When working with radioactive material, wash your hands thoroughly and dispose of trash in the appropriate manner. Do not eat, drink, smoke, or apply products to your skin in an area where radioactive material is being used.

Environment Safety

For most health professionals and virtually every organization in the health industry, the major regulatory authorities expecting targeted annual training are TJC, CMS, and OSHA. Let’s take a look at training topics that focus on safety in the workplace from the perspective of those organizations’ expectations.

Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC EC.03.01.01 EP.1Ongoing training, so staff know how to identify physical risks in the environment of care, and demonstrate how to eliminate them.
TJC EC.03.01.01 EP.2Ongoing training so staff can demonstrate the ability to handle an environment of care incident.
TCJ EC.03.01.01 EP.3Ongoing training so staff can demonstrate the ability to report an environment of care risk.

Injury Prevention

If you are injured or exposed to a dangerous substance on the job, stop what you are doing; report the injury or exposure to your supervisor; seek medical attention if needed; and complete an employee accident report.

Accident hazards such as wet floors, stairway obstructions, and faulty ladders make the environment of care dangerous, eliminate them. Wet-floor hazards can be reduced by proper housekeeping procedures such as marking wet areas, cleaning up spills immediately, cleaning only one side of a passageway at a time, keeping halls and stairways clear, and providing good lighting for all halls and stairwells. Stairway hazards can be minimized by the use of the handrail on stairs, avoiding undue speed, and maintaining an unobstructed view of the stairs ahead, even if that means requesting help to manage a bulky load.


Back injury prevention, safe lifting, and safe movements all fall under the heading of ergonomics. Ergonomics is a science that designs equipment and work tasks to fit the worker. The goal is to prevent worker injury. If you have pain, tingling, or numbness associated with a specific activity, reevaluate how you are performing the task to ensure you are doing it correctly. Consult your supervisor or employee health provider to have an ergonomic evaluation of your work. There may be equipment and methods available to reduce the risk of injury.

Agency Regulation (Subach, 2019)Ongoing Required Training
The rules around OSHA ergonomics training are tricky. Currently, there are no direct federal regulations mandating ergonomics training for employees. However, OSHA mandates for safe and healthy work practices include interpretations that might have well been entitled ergonomics. This means that in practice, since 2001, OSHA ergonomic focused rules apply to all general industry, including workers involved with healthcare.
  • Training on initial hire.

When a work injury occurs that meets the standard for an “Action Trigger,” the employer has 90-days to alter the ergonomic design of the work being done for injury prevention. Action Triggers include:

  • Repetitive motion tasks – same movements for at least 2 hours at a time, using a high repetition device (i.e., keyboard or mouse) more than 4 hours a day.
  • Force involved – lifting more than 75 pounds, push/pull more than 20 pounds more than 2 hours per day.
  • Posture – deviated body position (e.g., bent back, uplifted arms, etc.) more than 2 hours per day.
  • Contact stress – body contact (using hand/knee as a hammer) more than 10 times per hour for 2 or more hours per day.
  • Vibration – using high vibration tools more than 30 minutes per day, or moderate vibration tools more than 2 hours per day.

If prevention changes do not occur or two injuries of the same type have occurred within the last 18 months, then OSHA requires a Full Ergonomics Program to be implemented, which means training!

  • Within 45 days of any significant injury, all employees doing similar tasks must be retrained.
  • Within 90 days of a significant injury, all employees, supervisors, and managers must receive preventive training.
  • Every three years, comprehensive refresher training must be provided.

Injuries and illnesses that affect muscles, nerves, tendons, ligaments, joints, or spinal discs are known as musculoskeletal disorders (MSD). Injuries can result from cumulative trauma and repetitive strain, where small injuries over time build up until one more injury triggers a debilitating MSD. The following tasks have a high risk of cumulative trauma and repetitive strain:

  • Repetitive activity (typing)
  • Contact stress (hammering)
  • Twisting while lifting or carrying
  • Pulling or dragging
  • Sitting or standing in one position for a long time
  • Reaching above your shoulder
  • Lifting
  • While stooping low
  • Heavy objects
  • Unwieldy objects
  • An object that is positioned far from your body
  • Frequent lifting without rest between lifts

The primary approach to preventing back injury involves reducing manual lifting and other load-handling tasks that are biomechanically stressful. The secondary approach is to train workers on how to perform stressful tasks while minimizing the biomechanical forces on their backs and how to maintain flexibility and strengthen the back and abdominal muscles. To prevent back injury, workers should:

  • Use tools to avoid lifting when possible
  • Lifting devices
  • Slide boards
  • Shower chairs
  • Gait belts
  • Use proper lifting techniques
  • Keep your back in its normal upright position when lifting
  • Keep your head and shoulders up, and tighten your abdominal muscles when lifting
  • Bend at the knees, not at the waist
  • Get a good grip and slightly bend your elbows
  • Lift with your legs in a smooth, even motion, not with your back
  • Bear the weight with your arms and legs, not your back
  • Bear the weight as close to your body as possible
  • Pivot on your feet to change direction, do not twist
  • Lower an object by widening your stance and bending your knees
  • Don’t reach higher than your shoulders to lift
  • Limit the number of lifts per day
  • Request help. When in doubt about whether a task may strain the back, a worker should request help rather than taking a chance
  • Back exercises can be used to strengthen the back muscles and help prevent back injuries. A physician or physical therapist should be consulted
  • The benefit of using back belts is undetermined. The belt may lead to a false sense of security and a failure to use proper lifting techniques. This can lead to injuries

Client transfers are particularly hazardous for healthcare professionals. The following special points should be emphasized to prevent back injuries during transfers (Cluett, 2019).

  • Obtain lifting equipment as applicable
  • Do not do a manual transfer alone
  • Position equipment and furniture effectively (for example, move a wheelchair next to the bed) and remove obstacles
  • Communicate the plan of action to the client and other workers to ensure that the transfer will be smooth and without sudden, unexpected moves
  • Use a wide, balanced stance
  • Ensure good footing for the client if applicable (clients should wear slippers that provide good traction)
  • Maintain eye contact and communication with the client. Be alert for trouble signs
  • Record any problems on the client’s chart so that other workers will know how to cope with difficult transfers. Note the need for any special equipment, such as a lift.

Chemical Hazards

All healthcare facilities are required to have detailed information about the chemicals that are at the worksite. This information is in a standard format called a Safety Data Sheet (SDS). A Safety Data Sheet (SDS) is basically an updated format for the material safety data sheet (MSDS). Manufacturers’ transition from MSDS to SDS should have been completed by December 2015. The reason for this transition is the mishmash of different MSDS styles and formats in use in the United States, which was simply bad news and confusion for all of us end users. The new rules require a standardized format of 16 sections in a strict ordering.

Agency Regulation (UVA, 2018)Annual Required Training
OSHA 29.CFR.1910.1200Annual Hazard Communication Training.

If no relevant information is found for any given subheading within one of the numbered sections, the SDS must clearly indicate that no applicable information is available. Sections 12-15 of the new SDS are not currently mandatory, while sections of the SDS 1-11 and section 16 are. SDS sections contain the following:

  1. Product identification
  2. Hazard(s) identification
  3. Composition/ information on ingredients
  4. First-aid measures
  5. Fire-fighting measures
  6. Accidental release measures
  7. Handling and storage
  8. Exposure controls/personal protection
  9. Physical and chemical properties
  10. Stability and reactivity
  11. Toxicological information
  12. Ecological impact information (Non-mandatory)
  13. Disposal considerations (Non-mandatory)
  14. Transport information (Non-mandatory)
  15. Regulatory information (Non-mandatory)
  16. Other information, including date of preparation or last revision of the SDS or the last change to it.

Chemicals may exert either acute or chronic effects on workers. The effects depend on the:

  • Extent (concentration and duration) of exposure
  • Route of exposure
  • Physical and chemical properties of the substance

Did you know that all of the hazard pictograms used in the United States have already been replaced with international symbols? Tsk, tsk. That was a nationwide training mandate for 2013, and you had better be on guard for questions related to the new SDS and hazard symbols during surveys.

The new worldwide visual warning system is part of the Globally Harmonized System of Classification and Labeling of Chemicals (GHS) and uses two sets of warning pictograms. One set is for the transporting of chemicals, and a second set for workplace use and storage.

Let’s take a look at a new pair of warning symbols that have replaced the retired poison pictogram commonly found in medical closets and work areas.

GHS Chemical Hazard Symbol (OSHA, 2018)
Health HazardSkull and Crossbones
Access the full list of new warning pictograms from OSHA here.
  • Carcinogen
  • Mutagenicity
  • Reproductive Toxicity
  • Respiratory Sensitizer
  • Target Organ Toxicity
  • Aspiration Toxicity
  • Acute Toxicity (Fatal or Toxic)

Effects exerted by a substance may also be influenced by the presence of other chemicals and physical agents or by an individual’s use of tobacco, alcohol, or drugs. The exposure dose is the amount of a substance that actually enters the body during the period of exposure. The substance continues to be present in the body until it is metabolized or eliminated. Although some chemicals are rapidly metabolized, others are not and maybe excreted unchanged or stored in the fatty tissues (solvents), lungs (dust and fibers), bone (lead and radium), or blood (soluble gases).

Agency Regulation (OSHA, 2018b)Annual Required Training
OSHA 29.CFR.1910.1001(j)(7)Annual Airborne Asbestos Training
OSHA 29.CFR.1910.120(e)

OSHA 29.CFR.1910.120. AppC
Annual Hazardous Waste Training

Annual Hazardous Waste Emergency Response Training
OSHA 29.CFR.1910.1045(o)(1)Annual Hazardous Substance Training – Acrylonitrile
OSHA 29.CFR.1910.1028(j)(1)Annual Hazardous Substance Training – Benzene
OSHA 29.CFR.1910.1003(e)Annual Hazardous Substance Training – Carcinogens
OSHA 29.CFR.1910.1047(j)(3)Annual Hazardous Substance Training – Ethylene Oxide
OSHA 29.CFR.1910.1048(n)(1)Annual Hazardous Substance Training – Formaldehyde

Toxic substances can enter the body through several routes, including intact skin, the respiratory system (inhalation), the mouth (inhalation and ingestion), the eyes, and by accidental needle punctures. Inhalation and skin exposure are the most likely. Some substances can also damage the skin or eyes directly without being absorbed. Not all substances can enter the body through all routes. Inorganic lead, for example, can be inhaled or swallowed, but it does not penetrate the skin. Exposure routes for antineoplastic and other hazardous drugs are inhalation, skin absorption, ingestion, and injection.

Not every toxic substance annual training requirement should be on your individual training list. You should not be handling asbestos, for instance. Someone in the hospital or at the care site does, however, as many of the buildings used for offices, clinics, and hospitals fall into the timeframe during which asbestos was used in flooring, ceiling products, building insulation, and a plethora of other practical products. Take the time to find out which specific substances are used and handled in your work setting and whether you need any of the annual training concerning them.

Fire Prevention

Agency Regulation (OSHA, 2018b)Annual Required Training
TJC EC.02.03.03 EP2Annual Fire Drill Training
OSHA 1910.156(c)(2)Annual Fire Brigade Training
OSHA 1910.157(g)(2,4)Annual Portable Fire Extinguisher Training
OSHA 1910.158(b)(10)Annual Fixed Fire Extinguisher Training

Training on fire safety is not only required by the major regulatory agencies; it is common sense. Any health professional who has lived through a fire in a care setting knows and most likely has night terrors about the complexity of moving ill clients out of harm’s way in an emergency.

In healthcare, we are all expected to render assistance during situations that place our clients at risk. We, therefore, all require a working understanding of fire response, small fire suppression, and tactics to slow the spread of larger fires. A fire brigade designation such as found in OSHA regulations does not pertain to every health worker, but rather to those who have received additional instruction on fire suppression and rescue. If you have the floor or unit staff designated as “safety officers” or “fire wardens” please review the OSHA Fire Brigade definitions to make sure they receive correct training before an inspection or cross your fingers before you are called on to perform in an actual emergency.

Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC EC.02.02.03 EP.3,4Quarterly unannounced fire drills, all shifts, varying conditions, with staff participation.

For all of us, when you enter a new work area, look around and find fire alarms, fire extinguishers, exit signs, and oxygen cut off valves. One way to remember fire safety is the acronym, RACE.

  • R: rescue
  • A: alarm
  • C: contain the fire (if possible)
  • E: extinguish or evacuate

Never hesitate to sound the alarm with any suspicion of fire, yet also never “yell fire.” Yelling “fire” creates panic. Instead, call out the facility's verbal code for fire. Call the switchboard to report the fire and pull the fire alarm. When you call the switchboard, be sure to stay on the phone long enough to ensure they have received the correct information such, where you are!

If a fire is small and confined, you may be able to extinguish it. If a client’s garments are on fire, wrap them tightly in a large blanket to extinguish the flames. If a piece of equipment catches fire, pull the plug, or cut the electricity as soon as possible.

OSHA is very clear if you place hand-held portable fire extinguishers for staff to use in emergencies, you must train every staff annually how to use them. Portable fire extinguishers come in different classes for use on fires of different sources. The extinguisher has small pictures on the label that help you identify the type of fire source material they should be used on. Class A puts out fires involving ordinary combustibles. Class B extinguishers smother fires involving flammable liquids or gases. Class C extinguishers put out fires in or near electrical equipment. Type ABC extinguishers can be used to fight all three types of fires. To use an extinguisher, remember PASS:

  • Pull the pin
  • Aim the nozzle at the base of the fire
  • Squeeze the trigger while making
  • Sweeping strokes with the extinguisher plume

If a fire cannot be extinguished and smoke, fumes or flames threaten client safety, you may need to evacuate. Evacuate ambulatory clients first. Stay calm and give clear directions. Evacuate horizontally for as long as you can. Then evaluate vertically down to a lower level. Never use an elevator to escape during a fire. A sudden loss of power could leave you and your client trapped inside the elevator.

Healthcare units are required to be separated by heavy fire doors that close automatically when the alarm is sounded, to keep the fire from spreading. To confine a fire, close the doors, windows, and all vertical openings like the laundry chute. Stuff wet towels under doors to keep smoke out. Shut off oxygen supplies if directed to do so. Usually, facility policy designates someone in supervision to decide when to turn of oxygen supplies.

When rescuing anyone in immediate danger, remember to stay low. Smoke rises to the ceiling and forms a heavy, dense cloud that slowly descends. This cloud is deadly because it contains toxic gases.

Staff responsible for inspecting, maintaining, or repairing fixed fire extinguishing equipment such as sprinklers or fire hose reels must be trained annually concerning these essential safety items.

Emergency Management Disaster Preparedness

Katrina, Joplin Missouri, the Twin Towers; the list of disasters affecting hospitals, all of us in the health professions, are limitless due to the fact that emergencies come to us, either physically or by proxy in the form of waves of injured.

Agency Regulation (OSHA, 2018b)Annual Required Training
TJC EM.03.01.03 EP.1,2,3,4Annual Emergency Response Training
OSHA 29.CFR.1910.120(q)Annual Emergency Response Training
CMS 40.CFR.311Annual Emergency Response Training

Joint Commission requests and requires annual training for emergency responses specific to healthcare facilities, including twice-yearly live emergency scenarios (e.g., bomb threat, hostage situation, facility fire, plane crash into the building, etc.). At least one of these annual training must involve the community around the organization, such as fire department, search, and rescue, police, etc. Be aware that TJC requires an assigned designee at these exercises to monitor performance and document deficiencies, with staff training following up to correct anything found lacking. Don’t be tempted to take emergency response training lightly; not only will it be “graded” by regulatory agencies, but it could also very well save the lives of those precious to you.

Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC EM.03.01.03 EP.5Evaluation of disaster exercises and scenarios specific to communications, resources, assets, security, staff, utilities, and patients.
TJC EM.03.01.03 EP.17Evaluate disaster scenarios, then change the EOP Emergency Operations Plan to include changes in further ongoing training.

Supervisors, you must know how to initiate the disaster plan and designate tasks to workers.

Each worker must be trained to:

  • Locate the disaster plan on each unit where he/she works
  • Know the alarm codes for each type of disaster
  • Know the exit routes
  • Know how to use any evacuation equipment

Alarm System

As of January 1, 2016, the Joint Commission began expecting ongoing training on the purpose and correct operation of medical device alarm systems. This is now an expectation for every health care professional who uses in any device that possesses alarms.

Agency Regulation (TJC, 2019c)Annual Required Training
TJC NPSG.06.01.01 EP.4Purpose and Correct Operation of Alarm Systems

Nearly every medical device possesses an audible or visual alarm these days, and the wild cacophony that is heard, and often ignored, in health settings is a cause of “alarm fatigue” to both the public and to regulatory agencies. Knowing when to set the alarm, how to set it, how to respond to it in a timely manner are all matters requiring proper training and accountability (Gaines, 2019).

As health systems move further into the age of electronic health records and systems, expect digital monitoring of essential medical equipment. In other words, should equipment alarms sound consistently without being attended to, the marvelous mechanism of the Joint Commission Tracer System is likely to stumble upon and take notice. So, train appropriately, staff accordingly, work intelligently, or practice how to respond to accreditation surveyor queries.

Infection Prevention

Every health professional knows the drill; Infection = Bad, Prevention = Good. It is a shame it is not that easy, what with new organisms and changing drug resistances cropping up all the time. CMS, Joint Commission, OSHA, and every state have expectations concerning annual training of health workers on infection prevention, and that failing, infection control.

Agency Regulation (TJC, 2019c)Annual Required Training
TJC NPSG.07.03.01 EP.2Healthcare-associated infections, multidrug-resistant organisms, and prevention strategies.
TJC NPSG.07.04.01 EP.1Central line-associated bloodstream infections and the importance of their prevention.
TJC NPSG.07.05.01 EP.1Surgical site infections and the importance of their prevention.
OSHA 29 CFR 1910.1030(g)(2)Bloodborne Pathogens Annual Training.
CMS 482.42(a)(1)Ongoing infection prevention training for all staff.

Hand Washing Guidelines

Under the current Center for Disease Control (CDC) handwashing guidelines, washing hands with soap and water is to be done whenever the hands are visibly dirty. If not visibly soiled, rubbing hands with an alcohol hand rub is the primary means of hand hygiene for routinely decontaminating the hands during routine client care. Alcohol-based hand rubs increase compliance with hand hygiene because hand rubbing requires less time, results in less skin irritation, and does not require proximity to a sink. Hand hygiene is indicated before (Mennella & Kornusky, 2018):

  • Client contact
  • Donning gloves when inserting a central venous catheter (CVC)
  • Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don’t require surgery

Hand hygiene is also indicated after:

  • Contact with a client’s intact skin
  • Contact with body fluids or excretions, non-intact skin, or wound dressings
  • After removing gloves


Standard Precautions

Standard precautions are strategies for protecting healthcare workers from the occupational transmission of organisms. The premise is that all pre-existing client infections cannot be identified; therefore, barrier precautions should be used routinely to protect from all sources of potential infection. Standard precautions apply to blood, all body fluids, secretions, and excretions except sweat regardless of whether or not they contain visible blood, non-intact skin, and mucous membranes. Additional precautions are based on highly transmissible or epidemiologically important pathogens. Transmission Based Precautions (isolation) are airborne, droplet, and contact.

Agency Regulation (CMS, 2018)Ongoing Required Training
TJC IC.01.05.01 EP.7

TJC IC.02.01.01 EP.7
Training and education on responsibilities related to preventing and controlling infections.
CMS 482.23(c)(1)Ongoing training and competency for administration of drugs and biologicals.

Personal Protective Equipment (PPE)

The appropriate use of personal protective equipment (PPE) is an important element of standard infection prevention precautions. Gloves provide a protective barrier between the client and the healthcare worker and prevent gross contamination of the hands. Gloves do not replace the need for handwashing because gloves may have small defects, may be torn during use, and hands may become contaminated during glove removal.

Agency Regulation (OSHA, 2016)Ongoing Required Training
OSHA 1910.132 (f)(1)(i-v);(2),(3)(i-iii);(4)PPE training ongoing and as needed.

Masks, goggles, or face shields should be used to protect the mucous membranes of the eyes, nose, and mouth during situations where there is a likelihood of splashes or sprays. A surgical mask is worn by healthcare workers to provide protection against large-particle droplets during close client contact. When tuberculosis is known or suspected, healthcare workers should wear an N95 respirator, a high-efficiency particulate air (HEPA) filter respirator, or a powered air-purifying respirator (PAPR).

Gowns are worn to prevent contamination of clothing and protect the healthcare worker’s skin from blood and body fluid exposure. Impermeable gowns, leg coverings, boots, or shoe covers provide more protection when large quantities of blood or body fluids may be splashed. Gowns are also worn as a part of some transmission-based precautions. Mouthpieces, resuscitation bags, or other ventilation devices should be used instead of mouth-to-mouth resuscitation.

Needlestick Prevention

Needles should never be recapped, bent, broken, or removed from contaminated syringes. Sharps should be disposed of in a puncture-proof container and then transported to a reprocessing area. Improved engineering controls are among the most effective approaches to reducing occupational hazards and therefore are an important element for a needlestick prevention program. Such controls include eliminating the unnecessary use of needles and implementing devices with safety features. Most injuries from hollow bore needles can be prevented with the use of safer sharps devices, and a number of sources have identified the desirable characteristics of such safety devices. These characteristics include the following:

  • The device has no needle.
  • The safety feature is an integral part of the device.
  • The device preferably works passively (i.e., it requires no activation by the user). If the user action is necessary, the safety feature should be engaged with a single-handed technique and allows the worker's hands to remain behind the exposed sharp.
  • The user can easily tell whether the safety feature is activated.
  • The safety feature cannot be deactivated and remains protective through disposal.
  • The device performs reliably.
  • The device is easy to use and practical.
  • The device is safe and effective for client care.

Although each of these characteristics is desirable, some are not feasible, applicable, or available for certain healthcare situations. For example, needles will always be necessary where alternatives for skin penetration are not available. Also, a safety feature that requires activation by the user might be preferable to one that is passive in some cases. Each device must be considered on its own merit and, ultimately, on its ability to reduce workplace injuries. The desirable characteristics listed here should serve only as a guide for device design and selection.

Transmission Based Precautions (Isolation)

Transmission based precautions and protective environment (PE) are terms used to describe protective measures that need to be employed for specific groups of clients. An older term for this was isolation. Clients requiring transmission-based precautions require a private room. Clients infected with the same organism can share a room. This is referred to as cohorting.

Contact Precautions

Contact precautions are used for clients with known or suspected infections, or who are colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact. Examples include:

  • Presence of stool incontinence (may include norovirus, rotavirus, or Clostridium difficile), draining wounds, uncontrolled secretions, pressure ulcers, or presence of ostomy tubes and/or bags draining body fluids.
  • Presence of generalized rash.

Contact precaution clients should be in a private room. Standard precautions should be used, and a gown should be worn if there is likely to be direct contact with the client or environmental surfaces.

Airborne Precautions

Airborne precautions are implemented for diseases that are transmitted by microorganisms in airborne droplet nuclei. Droplet nuclei are tiny particle residues left when droplets evaporate. Droplet nuclei remain suspended in the air and can be widely dispersed by air currents. Early identification and triage of suspected cases of airborne transmitted diseases should be done, and possibly infectious clients should be separated from others and asked to wear a surgical mask.

Airborne precautions require a specially ventilated room with at least 6 air changes per hour, negative air pressure relative to the hallway, and outside exhaust or HEPA-filtered recirculation. The door to the room must be kept closed. The negative air pressure should be monitored. An N-95 mask or a powered air-purifying respirator (PAPR) is used by health workers in airborne precaution settings:

  • These masks and respirators should be labeled and stored in a paper bag between uses.
  • These masks and respirators should be discarded if soiled or if it no longer maintains its structural or functional integrity.
  • The N-95 mask should also be discarded at the end of each work shift.
  • The disposable respirator should be discarded at the end of 2 weeks.

Each employee who may work in an airborne precautions setting must be fit tested to assure that the N-95 mask or PAPR fit the employee’s face so that droplet nuclei cannot get in gaps between the mask and the face. Be aware, employees with beards will not pass fit testing.

When a client in airborne precautions needs to be moved or transported, the client should wear a surgical mask from the time he/she leaves the isolation room, until they return.

Tuberculosis (TB) is a current high-interest topic for training due to nearly (in 2017, according to WHO, the World Health Organization) 10 million new TB cases and nearly 1.6 million TB-related deaths. Over one billion lives have been claimed by TB in the past 200 years. More than all the deaths from smallpox, malaria, influenza, HIV/AIDs, cholera and plague during that time frame combined (NIAID, 2019). TB symptoms are cough lasting for more than 2 weeks, loss of appetite, weight loss, night sweats, hemoptysis, and fever. Clients presenting with these symptoms should be asked to put on a surgical mask until a physician can make the determination to use airborne precautions. If an acid-fast bacillus (AFB) test is ordered, TB is suspected, and airborne precautions should be implemented.

Droplet Precautions

Droplet precautions are used for clients known or suspected to be infected with microorganisms transmitted by droplets generated during coughing, sneezing, talking, or performance of procedures. These microorganisms include, yet are not limited to:

  • Respiratory viruses (e.g., influenza, parainfluenza virus, adenovirus, respiratory syncytial virus, human metapneumovirus)
  • Bordetella pertussis
  • For the first 24 hours of therapy: Neisseria meningitides, and group A streptococcus

Droplet precautions require a private room, but no special ventilation is necessary, and the door may remain open. Masks should be donned upon entering the room and especially if working within three feet of the client. The client should be masked if transported.

Neutropenic Precautions

Neutropenic precautions (aka., reverse isolation) are implemented to protect immunocompromised clients. Neutropenia is a condition that causes low neutrophils in the blood. Neutrophils are a type of white blood cell made in the bone marrow that aids the body in fighting infection. Examples of conditions that might warrant neutropenic precautions include:

  • Acquired immunodeficiency syndrome
  • Agranulocytosis
  • Burns, extensive noninfected type
  • Dermatitis, noninfected vesicular, bullous, or eczematous disease (when severe and extensive)
  • Immunosuppressive therapy, until the patient’s immunity, is adequate
  • Lymphomas and leukemia, especially late stages of Hodgkin’s disease or acute leukemia

Neutropenic precautions require a private room with positive air pressure relative to the air pressure in the hall. Other precautions may range from standard precautions and limitation of traffic to extensive precautions using gloves, gowns, and masks. This varies depending on the reason for the precautions and the degree of the client’s immunosuppression.

Central Line and Surgical Infections

Central Line-Associated Bloodstream Infection (CLABSI), along with Surgical Site Infection (SSI) prevention are critical areas of concern. Annual training is a focus for any health care staff whose job duties place them in contact with central venous catheters (CVCs) or surgical wounds and dressings. CVCs play an important role in support of the client, allowing for the administration of intravenous fluids, medications, blood products, and parenteral nutrition, as well as providing hemodialysis access and hemodynamic monitoring. CVCs have also been identified as one of the most frequent causes of heath care related bloodstream infections. SSIs are estimated to account for 31% of all Hospital Acquired Infections (HAIs), leading to longer hospital stays (Boev & Diss, 2016). We must say estimated due to the lack of accurate, voluntary hospital reporting on SSIs. A trend that has not gone unnoticed and will inevitably lead to more regulations and oversight should healthcare organizations not be willingly forthcoming concerning important public safety issues.

Infectious Waste Management

In healthcare, it is everyone’s responsibility to dispose of biohazardous material properly. One negligent act can result in a biohazardous exposure. Biohazard materials include blood and body fluids. If you are in doubt, use a biohazard container to dispose of the material. All biohazardous containers should be red and have the following biohazard symbol.



Biohazard sharps containers are to be red and come in varied sizes. Biohazardous sharps containers are made to store small glass objects and anything capable of piercing or puncturing the skin, whether it is contaminated or not. This includes sharps with protective devices like retractable sheaths. Even if a sharp is not contaminated, if it is put in the regular garbage, someone may be stuck with that sharp and not know if it was contaminated or not. The typical examples are needles, sutures, scalpels, disposable instruments, and lancets. Replace sharps containers when they are three-quarters full. Failure to do so may result in someone being contaminated because sharps are close to the top, or the closure device does not swing freely.

Biohazardous bags are red and are to be used for biohazardous material that is not sharp and may be contaminated with blood or body fluid. These bags are also used for the disposal of chemotherapy drugs and chemicals, even though they are not infectious.



General waste bags are used for general trash and some body fluids and equipment if there is no visible blood: urine, feces, disposable pads or chux, PPE, used gloves, respiratory care items, and suctions canisters. However, if in doubt, use a biohazardous bag.

Case Study

Case Study
Earl from housekeeping is tidying the hematology section of the clinical laboratory at the end of a bustling day. He notices fragments of glass tucked under the counter edge next to the microscopy station. He carefully dons heavy gloves and disposes of the glass shards in the clearly marked sharps container.

General cleaning done, he changes to vinyl gloves for better dexterity and grabs onto a partially filled general use garbage bag. As he bends his knees to lift, he feels a sharp pain in the palm of his gloved hand, supporting the bottom of the white plastic bag. Grimacing, he looks at his lacerated palm and the sharp jutting dagger of broken microscope slide poking through the thin material.

All sharps, not just needles, go into the designated red sharps container. Glass shards, metal fragments, empty vials, blood tubes, microscope slides, glass pipettes, everything that is sharp or can become sharp goes into the sharps box.

Recommended Healthcare Worker Immunization

Healthcare worker vaccination is a hot button topic currently, so anticipate frequent training focused on this topic for years to come.

Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC IC.02.04.01 EP.2Education and training on influenza vaccine, non-vaccine prevention and control, diagnosis, transmission, and impact of influenza.

The CDC’s perspective is that health professionals are always at risk for exposure to serious, and sometimes deadly, diseases. Each of us works directly with clients or handle material that could spread infection. Due to these factors, each of us should be appropriately vaccinated to reduce the chance of catching or spreading vaccine-preventable diseases. The CDC hot list of healthcare worker vaccinations include:

CDC Recommendations in Brief
Hepatitis BAbsence of documented evidence of a complete hep B vaccine series, or lack of an up-to-date blood test (i.e., no serologic evidence of immunity or prior vaccination) warrants;
  • Get a 3-dose series of Recombivax HB or Engerix-B (dose #1 now, #2 in 1 month, #3 approximately 5 months after #2) or a 2-dose series of Heplisav-B, with the doses separated by at least 4 weeks.
  • Get an anti-HBs serologic test 1-2 months after the final dose.
Flu (Influenza)Get 1 dose of influenza vaccine annually.
MMR (Measles, Mumps, & Rubella)If born in 1957 or later and have not had the MMR vaccine, or don't have an up-to-date blood test that shows you are immune to measles or mumps (i.e., no serologic evidence of immunity or prior vaccination), get 2 doses of MMR (1 dose now and the 2nd dose at least 28 days later). If born in 1957 or later and have not had the MMR vaccine, or don't have an up-to-date blood test that shows immunity to rubella, only 1 dose of MMR is recommended.
Varicella (Chickenpox)If you have not had chickenpox (varicella), if you haven't had varicella vaccine, or if you don't have an up-to-date blood test that shows you are immune to varicella (i.e., no serologic evidence of immunity or prior vaccination) get 2 doses of varicella vaccine, 4 weeks apart.
Tdap (Tetanus, Diphtheria, Pertussis)Get a one-time dose of Tdap as soon as possible if you have not received Tdap previously (regardless of when the previous dose of Td was received).

Get Td boosters every 10 years thereafter.

Pregnant HCWs need to get a dose of Tdap during each pregnancy.
MeningococcalThose who are routinely exposed to isolates of N. meningitidis should get one dose.

Exposure to Bloodborne Pathogens

OSHA possesses a comprehensive bloodborne pathogen standard for workers in areas of risk, which, of course, includes healthcare, housekeeping, and emergency responders, to name a few. As a healthcare professional be careful to take this topic seriously as some 295,000 hospital-based healthcare workers experience occupational, percutaneous injuries annually, according to reports from the International Health Care Worker Safety Center (Zehnder, 2015). Infectious organisms present in the blood which can cause serious or life-threatening disease in humans include hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

The presence of an exposure control plan is essential in a healthcare setting, and as a healthcare professional, you must know your facilities policies. The exposure control plan must describe how an employer will use a combination of engineering and work practice controls, ensure the use of personal protective clothing and equipment, provide training, medical surveillance, hepatitis B vaccinations, and signs/labels. Engineering controls are the primary means of eliminating or minimizing employee exposure and include the use of safer medical devices, such as needleless devices, shielded needle devices, and plastic capillary tubes.

Should a needlestick or exposure to blood occur: Provide immediate care to the exposure site.

  • Wash wounds and skin with soap and water
  • Flush mucous membranes with water
  • Irrigate eyes with clean water, saline or sterile wash

Please note that no scientific evidence has shown that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended.

A comprehensive exposure prevention plan and strategies play significant roles in decreasing the risk of infection from bloodborne pathogens. The risks of exposure with appropriate precautions are low, yet they are real. Understanding how exposure occurs and the risks of exposure is imperative for both the occupational health clinician and the healthcare worker. After an occupational exposure to a bloodborne pathogen, the risk of infection depends on a number of factors including:

  • Type of body substance involved
  • Route of exposure
  • Volume of blood or body fluid involved
  • Severity of exposure
  • Pathogen suspected
  • Degree of viremia (e.g., viral count or quantity of virus in the blood)
  • Immune status of the healthcare worker at the time of exposure
  • Whether appropriate post-exposure prophylaxis (PEP) was used

Hepatitis B

Hepatitis B virus is one of the chief pathogens of concern. Healthcare workers who have received the hepatitis B vaccine (HBV) and have developed immunity to the virus are at virtually no risk for infection. The risk of HBV infection is primarily related to the degree of contact with blood in the workplace and also the hepatitis antigen (HBeAg) status of the source person. Individuals who are both hepatitis B surface antigen (HBsAg) positive and HBeAg positive have more virus in their blood and are more likely to transmit HBV. The rough risk for a non-vaccinated healthcare worker with an exposure incident is between 6% to 30%. When given within one week of injury, post-exposure prophylaxis (PEP) with multiple doses of hepatitis B immune globulin (HBIG) provides an estimated 75% protection from transmission (Zehnder, 2015).

Although percutaneous injuries are among the most efficient modes of HBV transmission, these exposures probably account for only a minority of HBV infections among healthcare workers. In several investigations of nosocomial hepatitis B outbreaks, most infected healthcare workers could not recall an overt percutaneous injury, although in some studies, up to one-third of infected recalled caring for a client who was HBsAg-positive. Additionally, HBV has been demonstrated to survive in dried blood at room temperature on environmental surfaces for at least 1 week (CDC, 2019).

Hepatitis C

Hepatitis C virus (HCV) has no vaccine. Fortunately, it is not transmitted efficiently through occupational exposures to blood, with a needlestick or sharps exposure to HCV-positive blood showing a risk for contracting HCV infection at approximately 2% (CDC, 2019b). There have been a few instances of HCV transmission from blood splash to the eye; however the risk of such is thankfully low. Do always be sure to utilize standard precautions to minimize the risk of exposure.

The CDC makes no recommendations on restriction of healthcare workers positive for HCV, as the risk of reverse transmission, staff-to-client has been shown to be negligible.

Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV, AIDS)

HIV/ AIDS is a highly visible source of concern. HIV is the pathologic organism, and AIDS is the final terminal stage of HIV infection. No vaccine is available for HIV, so prevention is key to halting its spread. Be very aware that an HIV infected person who has no signs of an infection or illness can still infect others. There are four main ways HIV is transmitted:

  • Sexual intercourse
  • Sharing of needles and syringes
  • Body fluids (blood, semen, vaginal fluid, and breast milk)
  • Babies born of infected mothers and drinking breast milk of infected mothers

HIV infection is most often spread through sexual activities or exposure to infectious blood. Male to male sexual contact, aka “men who have sex with men” or MSM, when combined with injection drug use account for around half of new HIV cases in the United States. In contrast, case numbers from developing countries and resource-limited areas show most new HIV infections arise from vaginal intercourse.

The transmission of the HIV virus is significantly affected by the type of sexual exposure. Receptive anal intercourse has a much greater risk of viral transmission as compared to receptive vaginal intercourse. The use of condoms does not preclude transmission, due to many factors such as holes, tears, improper fitting, etc.; however, condom use lowers the chance of transmission as compared to intercourse sans protection. The presence of other sexually transmitted diseases, such as the ulcerations of genital herpes, can increase the risk of transmission as much as four times.

Incorrect rumors about ease of viral spread have led the CDC to provide a list of ways HIV cannot be spread (CDC, 2019c):

  • HIV cannot be spread in air or water.
  • HIV cannot be spread by insects, including bed bugs, ticks, or mosquitoes.
  • HIV cannot be spread in saliva, sweat, or tears, and no documented case exists of HIV being transmitted by spitting.
  • HIV cannot be spread by casual contact, such as sharing dishes or shaking hands.
  • HIV cannot be spread by closed mouth or social kissing.
  • HIV cannot be spread from toilet seats.

The average risk of HIV transmission after percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.1% (CDC, 2019c). The risk after a mucous membrane exposure is considered to be even lower. Although episodes of HIV transmission after non-intact skin exposure have been documented, the average risk for transmission by this route has not been precisely quantified but is estimated to be less than the risk for mucous membrane exposures. The risk for transmission after exposure to fluids or tissues other than HIV-infected blood is considerably lower than for blood exposures.

Tuberculosis Exposure Prevention

Tuberculosis (TB) infects one-third of the world’s population, according to the World Health Organization (WHO). Active TB infections are very contagious, and several treatment-resistant strands of the bacteria are actively circulating globally. To avoid acquiring TB (Kerkar, 2017):

  • Avoid spending long periods in stuffy, enclosed rooms with anyone who has active TB until that person has been on an effective course of medication for at least two weeks.
  • Utilize protective masks when working with clients with active TB.

The CDC identifies three levels of TB infection control in health-care settings. The first level, administrative controls, should focus on minimizing the number of areas where exposure to Mycobacterium tuberculosis may occur. The second level, environmental controls, focuses on reducing the concentration of airborne TB particles. Because persons entering areas where infected clients may go, the third level of the hierarchy is the use of respiratory protective equipment in situations that pose a high risk for exposure.

Agency Regulation (OSHA, 2011)Annual Required Training
OSHA 1910.134(k)(5)(i-iii)Respiratory Protection for TB training.

Respiratory equipment for TB protection is only as good as the fit of the device and the training of the person wearing it. Particulate filter respirators certified by the Centers for Disease Control and Prevention’s (CDC) National Institute for Occupational Safety and Health (NIOSH) that can be used for protection against airborne TB include:

  • Non-powered respirators with N95, N99, N100, R95, R99, R100, P95, P99, and P100 filters (including disposable respirators)
  • Powered air-purifying respirators (PAPRs) with high-efficiency filter

To be effective and reliable, the CDC and NIOSH have determined that respiratory protection programs must include at least the following elements:

  • Assignment of responsibility to one person with sufficient knowledge who is given the authority and responsibility to manage all aspects of the program.
  • Standard operating procedures that include information and guidance for the proper selection, use, and care of respirators.
  • Screening by a physician or other licensed health-care professional of all healthcare workers (HCWs) who might need to use a respirator for pertinent medical conditions at the time they are hired, and then re-screening periodically.
  • Annual training of HCWs with a specific focus on prevention, transmission, and symptoms.
  • Selection of filtering facepiece respirators approved by CDC/NIOSH.
  • Fit testing performed during the initial respiratory protection program training and periodically thereafter, in accordance with federal, state, and local regulations.
  • Inspection and maintenance of respirators according to manufacturer instructions.
  • Evaluation of the respirator program periodically to ensure its continued effectiveness.

Pain Management

The right to be heard when suffering from pain, to be assessed seriously, to not have their pain minimized, and to have appropriate treatment options presented is an essential right for all humans. Some healthcare organizations and health providers forget this foundational ideal in the search for convenience and profit. Not to worry, your eagle-eyed regulatory agency soars ready to swoop should any of us misplace our first loves.

Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC MS.03.01.03 EP.2Ongoing education and training on the assessment and management of pain.

Pain may be defined as an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage. Pain is always subjective. Pain is whatever the person is experiencing; it says it is, and it exists whenever he/she says it does. Clients may experience acute, chronic, or cancer (e.g., malignant) pain.

Acute pain follows injury to the body and generally disappears as healing takes place. Typically, this is not greater than 6 months. There is an identifiable pathology that accounts for the pain. It may arise from operative procedures or from tissue trauma associated with an inflammatory process, for example. It is often associated with objective physical signs such as increased heart rate, hypertension, and pallor (autonomic nervous system activity), giving a visual appearance we associate with being in pain.

Chronic nonmalignant pain is pain that lasts for an extended period of time, usually greater than 6 months. There may or may not be known active pathology to account for the suffering that the individual is experiencing. Chronic pain, in contrast to acute pain, is rarely accompanied by signs of autonomic nervous system activity, leading to many of us doubting the existence of legitimate pain.

Cancer pain may be acute, chronic, or intermittent. It usually has a definable cause, which is usually related to tumor recurrence or treatment.

The 5th Vital Sign

The failure to routinely assess and document pain impedes change. The American Pain Society promotes the phrase, pain is the 5th vital sign, to increase the visibility of pain among healthcare professionals. Vital signs are taken seriously. For example, practitioners rarely fail to recognize and take action on elevated blood pressure. Blood pressure is routinely measured and recorded in the client’s chart, and standard practice holds that elevated blood pressure requires assessment and action. If pain intensity is assessed routinely with the same zeal as the traditional four vital signs (temperature, heart rate, respiratory rate, and blood pressure) and then documented, pain management would improve. As the 5th vital sign, pain intensity becomes visible and can be used to guide treatment.

Pain Assessment

Basic pain assessment is simple, must be performed regularly, and action is planned based on client reports. It makes no difference whether the client is in the hospital, a long-term care facility, a behavioral health facility, an outpatient clinic, or being cared for by a home care agency. No matter where the client is, the intensity of pain should be assessed and documented:

  1. During the initial evaluation of the client
  2. After any known pain-producing procedure
  3. With each new report of pain
  4. At regular intervals when vital signs are taken
  5. At suitable intervals after pharmacologic intervention (60 minutes after oral; 30 minutes after parenteral), or nonpharmacologic intervention to evaluate the current pain treatment plan.

The most widely used measure to assess intensity is the Numerical Rating Scale (NRS), where the client is asked to rate their pain from 0-to-10, with 0 equaling no pain and 10 equaling the worst possible pain they can imagine. Since we have no instrument to objectively measure pain intensity in the same way that blood pressure is measured by a sphygmomanometer, the only valid measure of pain is the client’s self-report (a subjective measure). Sometimes healthcare professionals may believe that they are the best judges of a person’s pain; however, many studies demonstrate that healthcare professionals either over-estimate or underestimate a client’s pain.


For clients who cannot respond verbally and/or rate their pain numerically, the Faces Pain Scale (FPS) for adults and children can be used. This scale consists of images of faces with various expressions (e.g., smiling, frowning, grimacing). The client selects the face that is consistent with his/her current level of pain.

If a client has cognitive/expressive deficits, observation of nonverbal expression and behavior or report of a family member or significant other needs to be considered when assessing pain intensity.

Each healthcare institution should use a pain intensity rating that will elicit a full assessment. Besides intensity, the complete pain assessment includes the following:

  • Location of pain
  • Character or Quality (throbbing, shooting, sharp, cramping, aching, burning, etc.)
  • Onset, duration, variations, rhythms (is the pain better or worse at certain times, certain hours?)
  • Alleviating factors - what makes the pain better
  • Aggravating factors - what makes the pain worse
  • Effects of pain (impact on daily life, function, sleep, appetite, relationships with others, mood, emotions, concentration, etc.)

Pharmacological Management of Pain

Opioid analgesics are the cornerstone of pharmacological management for acute pain, especially when the pain is moderate or severe. Other agents, such as NSAIDs, may control mild to moderate pain or reduce opioid dose requirements for more severe pain. The intravenous (IV) route is the route of choice with acute pain only until oral intake is tolerated. Once the oral intake is tolerated, the route should be changed to oral. Intramuscular administration of medications is not recommended for the treatment of any type of pain. Absorption of medication is variable with the intramuscular route, and IM injections may hurt!

Medications are the cornerstone of the management of cancer pain because they are effective, relatively low risk, inexpensive, and usually, have a rapid onset. Three major classes of medications are used alone or, more commonly, in combination to manage cancer pain:

  1. NSAIDs, ASA, and acetaminophen
  2. Opioid analgesics
  3. Adjuvant or co-analgesic medications

Adjuvant medications are those medications that are not usually thought of as analgesics but which, when given with known analgesics, have synergistic effects or exhibit analgesic activity of their own. Adjuvant nonopioid pain medications include:

  • Antidepressants
  • Anti-inflammatory
  • Anticonvulsants
  • Muscle relaxants
  • Antihistamines

In the past, clients with chronic nonmalignant pain were excluded from long-term therapy with opioids for fear they would become addicted or psychologically dependent. Although often confused with addiction, tolerance and physical dependence are not equivalent to addiction. Physical dependence is just that; if the opioid is suddenly stopped or an antagonist medication such as naloxone is given, symptoms of withdrawal will occur. Tolerance is a decrease in one or more effects of the opioid, whether it is decreased analgesia, sedation, or respiratory depression. When tolerance to analgesia occurs, clients may need increased doses of opioids to achieve the same pain relief. Although most clients who take opioids several times daily for more than one month develop some degree of tolerance and physical dependence, the risk of addiction can be minimal – in some studies, less than one percent. Recent studies have shown that, along with other modalities, opioids might be a reasonable treatment addition for chronic pain in clients who are not terminally ill. Generally speaking, the oral route of administration is the optimal route for administration of medications for chronic pain (Asher, 2019).

Effective pharmacologic management of all types of pain requires that the regimen be individualized. In addition to choosing a suitable medication or medications, optimal doses must be selected. As with acetaminophen and ASA, all NSAIDs have ceiling (maximum) doses that, if exceeded, may precipitate toxicity without improving analgesia. Opioids, however, have no maximum dose. Generally, with opioids, the goal is to use the smallest dose that relieves the maximum amount of pain with the fewest side effects. Equally important for effective pharmacologic management of pain, the medication should be given:

  • Before pain occurs or increases (e.g., before a painful event such as wound debridement) or
  • Around the clock (ATC) or at regularly scheduled times if the pain is present most of the day

A rule of thumb is if the pain is present 12 or more hours out of 24 hours, ATC dosing should be considered. The analgesics should be routinely scheduled to prevent the recurrence of pain. Along with ATC dosing, supplementary analgesia (rescue dose) should also be available.

Common Side Effects with Long-term Opioid Treatment

All opioid analgesics share common side effects, the most common being constipation, nausea and/or vomiting, sedation and mental clouding, respiratory depression, and dry mouth, which can affect dental, as well as general, health. Although side effects are usually less serious than the under-treatment of pain, they warrant discussion. Tolerance to all the side effects, except constipation, develops with time.

Constipation will not diminish with time and can become a significant clinical problem if preventive measures are not instituted. Opioids reduce the motility of the intestines. Reduced activity and decreased appetite can make the problem worse. Constipation can be alleviated by eating foods high in fiber and by drinking eight to ten glasses of water a day (if not contraindicated by other problems). Exercise can help too. When starting on routine opioids, patients need to start on a stool softener/laxative preparation and be continually reassessed to ensure the current bowel regimen is working.

When clients complain of nausea and/or vomiting after opioid administration has begun, it is often helpful to administer an antiemetic on a fixed schedule for several days until tolerance to this side effect develops. At that point, PRN dosing is usually adequate. Depending on the antiemetic chosen, clients need to be monitored for the possibility of increased sedation.

Transitory sedation and mental clouding are common when opioid doses are increased, but tolerance usually develops rapidly. Persistent drug-induced sedation is usually best treated by reducing the amount of opioids for each dose and increasing the dosage frequency. This strategy will decrease the peak concentrations in the blood while maintaining the same total dose. Central nervous system (CNS) stimulants, such as caffeine or methylphenidate, may be added to increase alertness if the above approach is ineffective in reducing sedation.

Clients receiving long-term opioid therapy usually develop tolerance to the respiratory depressant effects of these agents. Be aware - occasionally, respiratory depression occurs when pain is abruptly relieved, and the sedative effects of opioids are no longer opposed by the stimulating effects of pain. In a client with symptoms, physical stimulation may be enough to prevent significant hypoventilation. The opioid antagonist naloxone should be administered cautiously to those who are receiving opioids on a long-term basis. Symptomatic respiratory depression should be treated cautiously using a dilute solution of naloxone (0.4 mg in 10 ml of saline), administered as 0.5 ml (0.02 mg) boluses every minute. Naloxone should be given in doses to improve respiratory function, but not to reverse analgesia, since a return to full alertness may be accompanied by a severe withdrawal syndrome as well as a return of pain.

Far more common than acute respiratory depression is a sub-acute overdose, in which sedation gradually builds and is followed by a slowing of respiratory rate and then by respiratory failure. The degree of sedation, rather than the respiratory rate, is a better indicator of impending respiratory depression. This complication is best managed by withholding one or two doses and then reducing the standing dose by 25% of its current level.

Opioids may also occasionally cause other side effects such as urinary retention, pruritus, myoclonus, seizures, hallucinations, confusion, sexual dysfunction, and sleep disturbances.

Nonpharmacologic Techniques of Pain Management

Nonpharmacologic techniques of pain management are once again gaining popularity. It is estimated that Americans spend $30.2 billion annually out-of-pocket on complementary and alternative medicine (CAM), the greatest proportion going to alternative methods of pain control (NCCIH, 2016). Health professionals need to know about these approaches in order to assist clients in making educated decisions. Analgesics are the mainstay of pain relief; however, even with the optimal use of analgesics, most pain is best treated with a combination of analgesic and non-analgesic approaches. For some types of mild pain, non-analgesic approaches alone may provide sufficient relief. Non-analgesic techniques are a supplement for but do not replace, pharmacologic interventions for moderate to severe pain.

Cognitive-behavioral interventions are methods that are thought to influence feelings, and if thought (and behaviors) can be changed, so can feelings and even sensations, such as pain. Cognitive-behavioral methods require the client’s active participation.

Relaxation is a state of relative freedom from both anxiety and skeletal muscle tension, a quieting or calming of the mind and muscles. Although relaxation is a learned technique, it can be achieved quickly in a motivated client.

Distraction from pain is the focusing of attention on stimuli other than the pain sensation. The stimuli focused upon can be auditory, visual, or tactile-kinesthetic (hearing, seeing, touching, and moving). By focusing attention and concentration on stimuli other than pain, pain is placed on the periphery of awareness. Distraction does not make the pain go away, nor does the effectiveness of the use of distraction indicate the absence of pain. Music and humor are an extremely effective means of distraction.

Imagery/visualization involves mentally creating a picture by using one’s imagination. This may be a focus on a close person, a place of enjoyment, a past event, or anything that is thought to bring pleasure. Since the mind is occupied, the pain is reduced in focus.

Non-invasive Mechanical Interventions for Pain

Massage is soothing and relaxing, both physically and mentally. Massage may decrease pain by relaxing muscle tension and increasing capillary circulation, thereby improving general circulation.

Vibration is a form of electric massage. When vibration is applied lightly, it may have a soothing effect similar to massage. Vibration applied with moderate pressure may relieve pain by causing numbness, paresthesia, and/or anesthesia of the area stimulated.

Heat/Cold – Heat reduces inflammation and promotes relaxation. It can be in the form of hot tub baths, heating pads, or heat packs. Cold is often more effective in relieving pain than heat. Applications of cold reduce muscle spasms secondary to underlying skeletal muscle spasm, joint pathology, or nerve root irritation. Methods of cold application include ice massage, ice bags, and gel packs. Alternating heat and cold may be more effective than the use of heat or cold alone.

Transcutaneous Electrical Nerve Stimulation (TENS) provides low voltage electricity to the body via electrodes placed on the skin. TENS may help with acute or chronic pain. Electrical stimulation of sensory nerves helps block pain signals going to the brain.

Acupuncture is a neuro stimulatory technique that treats pain by the insertion of small, solid needles into the skin at varying depths. Various theories exist to offer an explanation of how acupuncture works.

Invasive Therapies for Pain

With rare exceptions, less invasive analgesic approaches should precede invasive approaches. If drug therapy, cognitive-behavioral interventions, and/or non-invasive mechanical interventions do not alleviate pain, invasive therapies such as nerve blocks and neurosurgery may be useful.

Latex Sensitivity

While we are talking about skin absorption, the first thing each of us reaches for when the ick hits the emesis basin is a pair of disposable gloves. Remember that latex is a high reactivity substance for some individuals, both staff and clients. The American College of Allergy, Asthma, and Immunology classify allergic reaction to latex as type I, type IV, and irritant reaction:

  • Type I reactions are also known as Immunoglobulin E (IgE) reactions. They are systemic reactions that are generally immediate and possibly life-threatening. Type I reactions occur due to skin contact or inhalation of latex proteins. The symptoms may include facial flushing, rhinitis, vomiting, diarrhea, wheezing, dyspnea, facial or laryngeal edema, bronchospasm, and anaphylaxis.
  • Type IV reactions are delayed hypersensitivity or dermatological symptoms. They may not appear for several days after exposure. The symptoms include pruritus, edema, erythema, and vesicles.
  • Irritant reactions are the most common type of latex reaction. It is a non-allergenic condition due to latex gloves. The back of the hands may have a dry, itchy rash. Be discerning as irritant reactions may also have other causes, such as irritation from soaps or detergents, other chemicals, or incomplete hand drying.

A wide variety of products contain latex: medical supplies, personal protective equipment, and numerous household objects. Most people who encounter latex products only through general home use have no health problems from the use of these products.

Latex allergy should be identified during the initial assessment of allergies. When a latex-sensitive client is admitted, follow the facility policy. This usually involves extra signage, requesting non-latex equipment and perhaps even moving to a private room.

Workers should take the following steps to protect themselves from latex exposure and allergy in the workplace:

  • Use non-latex gloves for activities that are not likely to involve contact with infectious materials, like food preparation, routine housekeeping, and maintenance.
  • If you choose latex gloves, use powder-free gloves with reduced protein content. So-called hypoallergenic latex gloves do not reduce the risk of latex allergy. However, they may reduce reactions to chemical additives in the latex.
  • When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove deterioration) unless they have been shown to reduce latex-related problems and maintain glove barrier protection.
  • After removing latex gloves, wash hands with mild soap and dry thoroughly.
  • Use good housekeeping practices to remove latex-containing dust from the workplace.
  • Learn to recognize the symptoms of latex allergy: skin rashes; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and shock.
  • If you develop symptoms of latex allergy, avoid direct contact with latex gloves and other latex-containing products until you can see a physician experienced in treating latex allergy.

Hazardous Flammable Combustible - Liquids, Vapors, and Gases

A major hazard in all hospitals is the widespread use and storage of hazardous, flammable, and/or combustible liquids and gases. Many liquids have vapors that are flammable or combustible and can be ignited by a spark from a motor, friction, or static electricity. Handling and storage directions must be followed and are located on the SDS for that material. All flammable liquids should have the following label(s);

GHS Chemical Hazard Symbol





Compressed Gas

Compressed Gas

Harmful / Irritant

Harmful Irritant

Access the full list of new warning pictograms from OSHA here.

OSHA HCS HazCom 2012 Final Rule

Compressed gases are under pressure and flammable, so they must be handled with extreme care. An exploding cylinder can have the same destructive effect as a bomb. Storage areas for compressed gas cylinders should be well ventilated, fireproof, and dry. Cylinders should not be stored near steam pipes, hot water pipes, boilers, highly flammable solvents, combustible wastes, unprotected electrical connections, open flames, or other potential sources of heat or ignition. Cylinders should be labeled appropriately. The valve protection cap should not be removed until the cylinder is secured and ready for use.

Compressed gases used in hospitals include acetylene, ammonia, anesthetic gases, argon, chlorine, ethylene oxide, helium, hydrogen, methyl chloride, nitrogen, and sulfur dioxide. Acetylene, ethylene oxide, methyl chloride, and hydrogen are flammable, as are the anesthetic agents’ cyclopropane, diethyl ether, ethyl chloride, and ethylene. Although oxygen and nitrous oxide are labeled as nonflammable, they are oxidizing gases that will aid combustion.

Antineoplastic Drugs, Hazardous Drugs, Toxic Substances

Pharmaceuticals are chemicals. Certain pharmaceuticals have a higher risk of toxicity, both when taken as directed and/or during incidental exposure. It is important to be aware of high alert medications such as those identified in the 2016 NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, which includes such classifications as; insulins, opioids, antithrombotic agents, antiarrhythmics, chemotherapeutic agents, chemicals that slow or prevent the formation of clots in the blood (e.g., anticoagulants), and many more.

Exposure to hazardous drugs may occur to clinical and non-clinical workers in the following settings (Connor, 2016):

  • When reconstituting of drugs or further dilution
  • When expelling air from syringes filled with hazardous drugs or during the administration of drugs
  • When dust is generated through counting out oral doses and tablets from multi-dose bottles or unit-dosing uncoated tablets in a unit-dose machine
  • When crushing tablets to make oral liquid doses
  • When compounding powders into custom dosage capsules
  • When drugs are present on drug vial exteriors, work surfaces, floors, and final drug products (bottles, bags, cassettes, and syringes)
  • When handling body fluids, clothing, dressings, linens and other materials contaminated with body fluids or hazardous drugs
  • When handling contaminated waste at any step of preparation or administration process
  • When specialized procedures (intraoperative intraperitoneal chemotherapy) are performed
  • When handling unused hazardous drug waste, hazardous drug-contaminated waste, decontaminating and cleaning drug preparation or clinical areas
  • When transporting infectious, chemical or hazardous waste containers
  • When removing and disposing of PPE used during the handling of hazardous drugs or waste
Agency Regulation (TJC, 2019b)Ongoing Required Training
TJC NPSG.03.05.01 EP.7Education and training on anticoagulant therapy.
OSHA 1910.1450(f)(2)Training to ensure that employees are apprised of the hazards of chemicals present in their work area.

Healthcare workers’ responsibilities in relation to antineoplastic and other hazardous drugs include (Connor, 2016):

  • Review guidance documents, safety data sheets (SDS) and other information resources for hazardous drugs handled
  • Be familiar with and be able to recognize sources of exposure to hazardous drugs
  • Prepare these agents in a dedicated area where access is restricted to authorized personnel only
  • Use two pairs of powder-free, disposable chemotherapy gloves with the outer one covering the gown cuff whenever there is a risk of exposure to hazardous drugs
  • Avoid skin contact by using a disposable gown made of a low-lint and low permeability fabric. The gown should have a closed front, long sleeves and elastic or knit closed cuffs and should not be reused
  • Wear a face shield to avoid splash incidents involving eyes, nose, or mouth when adequate engineering controls are not available
  • Wash hands with soap and water immediately before using and after removing personal protective clothing, such as disposable gloves and gowns
  • Use syringes and IV sets with Luer-lock fittings for preparing and administering these agents and place drug-contaminated syringes and needles in chemotherapy sharps containers for disposal
  • When an IV line must be primed with a solution containing hazardous medication, it should be done in a pharmacy
  • When additional protection is necessary, use closed-system, drug-transfer devices, glove bags, and needle-less systems within the ventilated cabinet
  • Handle hazardous wastes and contaminated materials separately from other trash
  • Decontaminate work areas before and after each activity with hazardous drugs and at the end of each shift

Clean up spills immediately while using appropriate safety precautions and personal protective equipment (PPE) unless the spill is large enough to require an environmental services specialist.

While having current information on all high-risk therapeutics is important, take special care to be familiar with any specifically called out in regulatory statutes.

Electrical Safety

TJC’s environment of care guidelines, as well as OSHA, mention the electric needs found in today’s health environment. Health workers need to pay special attention to electrical hazards because they work with tools comprised of electrical circuits. Coming in contact with an electrical voltage can cause current to flow through the body, resulting in electrical shock and burns. Serious injury or even death may occur.

All equipment brought into a facility must be safety checked by the engineering department. Violations of standards governing the use of electrical equipment are the most frequently cited causes of electrical fires. Equipment and appliances that are frequently ungrounded or incorrectly grounded include:

  • Three-wire plugs attached to two-wire cords
  • Grounding prongs that are bent or cut off
  • Ungrounded appliances resting on metal surfaces
  • Extension cords with improper grounding
  • Cords molded to plugs that are not properly wired
  • Ungrounded, multiple-plug spiders that are often found in office areas and at nurses’ stations
  • Personal electrical appliances brought by the workers from home (radios, coffeepots, fans, electric heaters) that are not grounded, have frayed cords, poor insulation, or are otherwise in poor repair

Waived Testing

Waived tests are on the Joint Commission hot sheet at the moment, so have your staff prepared. Waived testing is the technical term now used for simple to use tests that have a low risk for error. What is being “waived” is the on-location clinical laboratory oversight requirements for certain simple tests, not the test itself. Don’t worry if the new term used for these point-of-care (POC) tests seems confusing, it is!

CDC on Waived Testing (CDC, 2018)
Under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), simple, low-risk tests can be waived and performed with no routine regulatory oversight in physicians' offices and various other locations”.

Tests can be waived under CLIA if they are determined to be "simple tests with an insignificant risk of an erroneous result.”

Those testing sites performing without regulatory oversight must hold a certificate of waiver (CW or COW) from CLIA. A valid CLIA certificate is required for Medicare reimbursement.

Certain point-of-care tests such as glucose, dipstick urinalysis, fecal occult blood, urine human chorionic gonadotropin (hCG), and group A streptococcal antigen (the direct test from throat swabs) are examples of commonly used waived tests.

Agency Regulation (Woten, 2018)Annual Required Training
TJC WT.03.01.01.EP.6Annual training and competence for Waived Testing

CLIA regulates laboratory testing and requires clinical laboratories to be certified, and believe me, medical laboratories require a basket full of certificates in order to do business. Waived testing is also overseen by CLIA, and by three federal agencies who work together with CLIA in making sure accuracy and high standards are met (CDC, 2018):

  • FDA – the Food and Drug Administration
  • CMS – Combined Medicare Medicaid Services
  • CDC – Centers for Disease Control

Clear documentation of the training each person performing a waived test has completed must be readily available to auditors. This means training for each individual waived test (e.g., documentation for a blood glucose meter, documentation for fecal blood strips, etc.), not a one size fits all “they had waived test training.” Please don’t shrug this off as there are currently over forty different tests in the waived category, and if you are the “person Friday” in a physician’s clinic, you will need to train and have documentation for each of the tests you use and show a fresh test completion for every update the manufacturer makes to each specific waived test.

Agency Regulation (Woten, 2018)Ongoing Required Training
TJC WT.03.03.01 EP.1,3,4Education, training, and documented competency for every staff performing waived testing, every test they do, and for every update to that test.

Some waived test helpful suggestions:

  • Use the manufacturer’s instructions, from the most current lot. Instructions change over time, and you are responsible for what is current now, not then.
  • Quality control and/or calibration, as specified by the kit manufacturer, is a must, do it, and document it clearly. Keep those records for two years to meet CLIA requirements.
  • When the manufacturer supplies reagents or test kits, do not tamper with them. Health personnel are notorious for doing cost-saving tricks such as cutting a test strip in half lengthwise to get two uses.
  • Never use outdated strips or reagents.
  • Handle all test kits, as the manufacturer recommends. No tucking temperature-controlled reagents in that space alongside the wheezing over-heated refrigerators’ coils, for instance.
  • Be sure to follow all regulations that pertain to laboratory testing, such as bloodborne pathogen and hazardous waste handling.


The public sleeps better at night, knowing that healthcare has regulatory guardians assuring quality is being given to them, the client.

While each and every one of us in the health professions work to give the best care possible, we sometimes get distracted. It is good that we have authorities, regulatory agencies, and accreditation organizations looking on from outside the fuss and flurry. They help us stay on the path of evidence-based care and give guidance when we stray.

Annual required training, not from our employer, but from organizations with a more global viewpoint, aid us in keeping a solid foundation in our practice of quality client care.

Required annual mandated training changes on a frequent basis, so it is necessary that each of us stay current with what areas are the focus of state, federal, and independent organizations to which we owe diligence. This year’s topics may differ to a small degree from the previous year, or by a great extent. Whichever it may be, we know that proof of training will be required on inspection, accreditation visit, or in our employer’s annual evaluation of our performance and readiness.

Don’t fear the audit, accreditation, inspection, or survey. Be ready for each and every surprise visit by giving quality care and having those annual required training completed and safely documented.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


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