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Fire, Safety, and OSHA Requirements for Healthcare Professionals

4 Contact Hours
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), 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), Respiratory Therapist (RT)
This course will be updated or discontinued on or before Saturday, May 28, 2022
Course Description
This course will update healthcare professionals on the NIOSH, CDC and DHHS recommendations for exposure to dangerous situations, hazardous chemicals and neoplastic. Users will be instructed on how to prevent back injury--one of the number one compensation claims among healthcare workers (who often lift patients) actions to take if a fire occurs, and avoiding instances of violence within your organization.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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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:    Jeanna Winchester (PhD)

Outcomes

≤90% of participants will understand the contents and applicability of the Occupational Safety and Health Administration standards.

Objectives

After completing this continuing education course, the participant will be able to meet the following objectives:

  1. Discuss the fundamental components of the anitineoplastic and other hazardous drugs.
  2. Identify key aspects of OSHA’s mission that are present in everyday clinical practice.
  3. Identify the steps of RACE in Fire Hazard and Safety Information.
  4. List the steps for OSHA incident reporting.

An Introduction to OSHA

With the Occupational Safety and Health Act of 1970 (OSH Act), Congress created the Occupational Safety and Health Administration (OSHA) to ensure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education, and assistance.1

OSHA is part of the United States Department of Labor. The administrator for OSHA is the Assistant Secretary of Labor for Occupational Safety and Health. OSHA's administrator answers to the Secretary of Labor, who is a member of the cabinet of the President of the United States.1

The OSH Act covers most private sector employers and their workers, in addition to some public sector employers and workers in the 50 states and certain territories and jurisdictions under federal authority. Those jurisdictions include1:

  1. The District of Columbia
  2. Puerto Rico
  3. Virgin Islands
  4. American Samoa
  5. Guam
  6. Northern Mariana Islands
  7. Wake Island
  8. Johnston Island
  9. The Outer Continental Shelf Lands as defined in the Outer Continental Shelf Lands Act

Employers must also comply with the General Duty Clause of the OSHA Act of 1970. This clause requires employers to keep their workplaces free of serious recognized hazards and is generally cited when no specific OSHA standard applies to the hazard. OSHA covers most private sector employers and workers in all 50 states, the District of Columbia, and other U.S. jurisdictions either directly through Federal OSHA or through an OSHA-approved state program (as listed above). State-run safety and health programs must be at least as effective as the Federal OSHA program. State and local government workers are not covered by Federal OSHA, but they do have protections in states that operate their programs.1

It is essential to understand what Employers must follow according to OSHA standards1:

  • Follow all relevant OSHA safety and health standards
  • Find and correct safety and health hazards
  • Inform employees about chemical hazards through training, labels, alarms, color-coded systems, chemical information sheets, and other methods
  • Notify OSHA within 8 hours of a workplace fatality or within 24 hours of any work-related inpatient hospitalization, amputation, or loss of an eye. Contact information for notifying OSHA is 1-800-321-OSHA or www.osha.gov/report_online
  • Provide required personal protective equipment (PPE) at no cost to workers
  • Keep accurate records of work-related injuries and illnesses
  • Post OSHA citations, injury and illness summary data, and the OSHA Job Safety and Health, “It’s the Law” poster where they are visible to all employees
  • Not retaliate against any worker for using their rights under the law
A Note About Employer Responsibility & Personal Protective Equipment (PPE) in the New Viral Outbreak Era

With the emergence of novel viral outbreaks, such as COVID-19 from the coronavirus category of viruses, it is important to know that employers must pay for most types of required personal protective equipment (e.g., PPE), under American law. 1

There is No Such Thing as an Accident, only a Failure to Recognize the Hand of Fate,” Napoleon Bonaparte.2

There are risks every time an individual decides to leave the comfort and control of their home environment and enter the work sphere. Every American needs to know their rights under American law. Employees have the right to1:

  • Working conditions that do not pose a risk of serious harm
  • Receive information and training (in a language that the workers can understand) about chemical and other hazards, methods to prevent harm, and OSHA standards that apply to their workplace
  • Review records of work-related injuries and illnesses
  • Obtain copies of test results performed to find and measure hazards in the workplace
  • File a complaint asking OSHA to inspect their workplace if they believe there is a serious hazard or that their employer is not following OSHA rules
  • Request that identity remains confidential
  • Use their rights under the law without retaliation. If an employee is fired, demoted, transferred, or retaliated against in any way for using their rights under the law, they can file a complaint with OSHA. This complaint must be filed within 30 days of the alleged retaliation

While OSHA may not be able to protect every worker from every possible accident or scenario, OSHA standards are created in order to establish a system from which risk, hazard and responsibility may or may not be applicable.

Specifically, OSHA standards are rules that describe the methods employers are legally required to follow to protect their workers from hazards.1 Before OSHA can issue a standard, it must go through a very extensive and lengthy process that includes substantial public engagement, notice, and comment.1 The agency must show that a significant risk to workers exists and that there are feasible measures employers can take to protect their workers.1

Construction, General Industry, Maritime, and Agriculture standards protect workers from a wide range of serious hazards. These standards limit the amount of hazardous chemicals workers can be exposed to, require the use of certain safe practices and equipment, and require employers to monitor certain workplace hazards.1

Examples of OSHA standards include1:

  • Requirements to provide fall protection
  • Prevent trenching cave-ins
  • Prevent exposure to some infectious diseases
  • Ensure the safety of workers who enter confined spaces
  • Prevent exposure to such harmful substances as asbestos and lead
  • Put guards on machines
  • Provide respirators or other safety equipment
  • Provide training for certain dangerous jobs

Few workplaces are as complex as a healthcare facility. Such complex situations provide a lot of potential health and safety hazards.1 When compared with the total civilian workforce, hospital workers have a greater percentage of workers’ compensation claims for sprains and strains, infectious and parasitic diseases, dermatitis, hepatitis, mental disorders, eye diseases, influenza, and toxic hepatitis.1

The list of potential hazards includes radiation, toxic chemicals, biological hazards, heat, noise, dust, and stress.1 The risks and exposures for blood and body fluids are important, but not included in this course. Information about the risks and exposures to blood and body fluids are available in a separate course entitled OSHA: Occupational Exposure to Blood and Body Fluids, at www.CEUFast.com.

Antineoplastic & Other Hazardous Drugs for the Healthcare Professionals

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 Material Safety Data Sheet (MSDS).3

The Material Safety Data Sheet (MSDS)

A typical MSDS will include the following sections3:

  1. Product and Company Identification
  2. Hazards 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 Information
  13. Disposal Considerations
  14. Transport Information
  15. Regulatory Information
  16. Other Relevant Information for that chemical

The MSDS should be readily available to every worker. Access to the MSDS allows every worker to educate himself about the chemicals at the worksite.3

Chemicals may exert either acute or chronic effects on workers. The effects depend on the extent (concentration and duration) of exposure, the route of exposure and the physical and chemical properties of the substance.3

The 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.3

The exposure dose is the amount of a substance that actually enters the body during the period of exposure.3 The substance continues to be present in the body until it is metabolized or eliminated. Although some chemicals metabolize rapidly, others are not and might be excreted unchanged or stored in the fatty tissues (solvents), lungs (dust and fibers), bone (lead and radium), or blood (soluble gases).3

Toxic substances can enter the body through several routes, including the intact skin, the respiratory system (inhalation), the mouth (inhalation and ingestion), the eyes, and by accidental needle punctures.3 Inhalation and skin exposure are the most likely.3

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.3

Exposures routes for antineoplastic and other hazardous drugs are inhalation, skin absorption, ingestion, and injection.3

Although exposure to hazardous drugs and antineoplastics can put the healthcare worker at risk, there are guidelines for handling these drugs safely.3

The National Institute of Occupational Health and Safety’s (NIOSH) New Guidelines

The National Institute of Occupational Health and Safety (NIOSH) released new guidelines, in 2016, about the handling of antineoplastic and other hazardous drugs.3

NIOSH warns that exposure to hazardous drugs may occur to clinical and non-clinical workers in the following settings4:

  • During reconstitution of powdered or lyophilized drugs and further dilution of either the reconstituted powder or concentrated liquid forms of hazardous drugs
  • When aerosols are generated by expelling air from syringes filled with hazardous drugs or during the administration of drugs by intramuscular, subcutaneous, or intravenous routes
  • When dust is generated through counting out individual uncoated oral doses and tables from multi-dose bottles or unit-dosing uncoated tables in a unit-dose machine, presenting a possible inhalation hazard
  • When crushing tablets to make oral liquid doses, thus presenting potential inhalation and dermal exposure
  • When compounding potent powders into custom dosage capsules
  • When measurable levels of drugs are present on drug vial exteriors, work surfaces, floors, final drug products (bottles, bags, cassettes, and syringes), and when airborne droplets of the drug are generated during reconstitution
  • When aerosols are generated during the administration of drugs, either by direct IV push or by IV infusion
  • When handling body fluids, clothing, dressings, linens, and other materials contaminated with body fluids by hospital or home health personnel working with patients treated with hazardous drugs
  • Through the handling of contaminated waste generated at all steps of the preparation and administration process
  • When specialized procedures (intraoperative intraperitoneal chemotherapy) are performed in the operating room
  • When handling unused hazardous drug waste, hazardous drug-contaminated waste, decontaminating and cleaning drug preparation or clinical areas, and transporting infectious, chemical, or hazardous waste containers
  • When removing and disposing of PPE used during the handling of hazardous drugs or waste

NIOSH defines the healthcare workers’ responsibilities in relation to antineoplastic and other hazardous drugs as the following4:

  • Review guidance documents (e.g., the MSDSs) 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
  • Prepare these agents within a ventilated cabinet designed to protect workers and adjacent personnel from exposure and to provide product protection for all drugs that require aseptic handling
  • Use two pairs of powder-free, disposable chemotherapy gloves with the outer one covering the gown cuff whenever there is the 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, 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 the 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 PPE unless the spill is large enough to require an environmental services specialist

Following these guidelines and understanding a healthcare worker’s responsibilities may be the difference between an injury or fatality, and a safe employee experience. In the next section, a fictional case study is describing how a healthcare worker might decide to implement these guidelines in their everyday clinical practice.

A Case Study in Nursing Safety Protocols, PPE & Handling Hazardous Drugs

Ms. Marvel, a night Nursing Supervisor, was responsible for preparing any IV medications until a new night pharmacist was hired. She was instructed on how to prepare these agents within a ventilated cabinet designed to protect workers and adjacent personnel from exposure and to provide product protection for all drugs that require aseptic handling. Prior to preparing these medications, she had to dress the part and double glove while protecting her hands and wrists. If there was a chemical spill, she had to immediately use appropriate safety precautions and PPE, unless the spill was large enough to require an environmental service specialist. She also had to educate the ICU nurses and medical-surgical nurses on how to administer these medications safely and their side effects. Working with the nursing educators, she prepared written instructions for all units where this information was needed to prevent dangerous workplace injuries. When making hospital rounds, she made sure that the nurses knew where the MSDs’ information book was located and that it was up to date.

This is a great example of how OSHA guidelines and effective safety protocols can be implemented in everyday nursing practice! In the next section, we continue our discussion of safety, hazardous and other important concerns for the healthcare professional by looking further, and the types of injuries a healthcare professional may expect.

Musculoskeletal Disorders (MSDs)

The Injuries We Do and Those We Suffer Are Seldom Weighed in the Same Scales,” Aesop6

In 2010, nursing aides, orderlies, and attendants had the highest rates of musculoskeletal disorders (MSDs). There were 27,020 cases, which equates to an incidence rate (IR) of 249 per 10,000 workers, more than seven times the average for all industries. This compares to the all-worker days-away from work rate of 34 per 10,000 workers. In 2010, the average incidence rate for MSD cases with days away from work increased 4 percent, while the MSD incidence rate for nursing aides, orderlies, and attendants increased ten percent.3,5,6

These injuries are due in large part to overexertion related to repeated manual patient handling activities, often involving heavy manual lifting associated with transferring, and repositioning patients and working in extremely awkward postures.3,5,6

Nearly half of all compensation claims for hospital workers involved back injuries.3,5,6

The most common causes of all work-related back pain are3,5,6:

  1. Job performance by a worker who is unfit or unaccustomed to the task
  2. Postural stress
  3. Work that approaches the limit of a worker's strength

Factors that contribute to these causes of back pain are understaffing, the lack of regular training programs in proper procedures for lifting and other work motions, and inadequate general safety precautions. Written guides and programs for preventing back injuries are available for all workers. 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.3,5,6

To prevent back injury, workers should3,5,6:

  • Use proper lifting techniques
  • Request help. When in doubt whether a task may strain the back, a worker should request help rather than taking a chance
  • Use back exercises to strengthen the back muscles and help prevent back injuries. A physician or physical therapist should be consulted.

Patient transfers are particularly hazardous for hospital workers. The following fundamental points should be emphasized to prevent back injuries during transfers3,5,6:

  • Communicate the plan of action to the patient and other workers to ensure that the transfer will be smooth and without sudden, unexpected moves
  • Position equipment and furniture effectively (for example, move a wheelchair next to the bed) and remove obstacles
  • Ensure good footing for the workers and patient (patients should wear slippers that provide good traction)
  • Maintain eye contact and communication with the patient. Be alert for trouble signs
  • If help is needed, request that a co-worker stand by before attempting the transfer
  • Record any problems on the patient’s chart so that other shifts will know how to cope with difficult transfers. Note the need for any special equipment, such as a lift

Accident hazards such as wet floors, stairway obstructions, and faulty ladders should be reduced. 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. Workers should be instructed to use the handrail on stairs, to avoid undue speed, and to maintain an unobstructed view of the stairs ahead of them, even if that means requesting help to manage a bulky load.3,5,6

The consequences of work-related musculoskeletal injuries among nurses are substantial. Along with higher employer costs due to medical expenses, disability compensation, and litigation, nurse injuries also are costly in terms of chronic pain and functional disability, absenteeism, and turnover. Approximately 20% of nurses who leave direct patient care positions do so because of risks associated with the work. Many healthcare workers, who experience pain and fatigue, may be less attentive, less productive, more susceptible to further injury, and may be more likely to affect the health and safety of others. Direct and indirect costs associated with only back injuries in the healthcare industry are estimated to be $20 billion annually.3,5,6

A Case Study in Preventing Back Injuries in the Workplace

David, a float CNA, was educated on how to use the newest lift equipment and techniques to use when transferring patients from their wheelchairs to their beds and visa-versa. He constantly encouraged the staff he worked with to ask for assistance when handling residents who were unable to help themselves or required more than one person to assist them in moving. Prior to using any lift - equipment, he made sure all lines and hooks were secure, and the equipment functioned safely and properly. Especially in the secured units where many of the patients suffered from dementia or Alzheimer’s disease, he instructed the staff to always work as a cohesive team. The individual at the head of the patient was to be in charge, and they would discuss ahead of time the process they would use. Patients were told what was going to be done and why before staff transferred them. Questions were answered at the patient’s level of understanding. David was always in demand!

A major point to remember is that the better a healthcare worker takes care of their own body and protects themselves from diseases and injuries, the more patients they are able to help, every day! Taking care of yourself is just as important as taking care of your patients. There are many ways to be injured in the healthcare workspace and the savvy healthcare professional knows how to navigate those risks while protecting their own health & safety! Next, this course will explore the risks due to fire in healthcare.

Hospital Fires & Other Fire-Related Disasters

Hospital fires and disasters are especially dangerous because workers must protect themselves and evacuate large numbers of patients.7 Almost one-third of hospital fires originated within patient rooms or worker quarters, with matches and smoking as the most frequent cause.7 Other causes are malfunctioning or misused electrical equipment include hot plates, coffeepots, and toaster ovens.7

Deaths during hospital fires were overwhelmingly due to inhaling the toxic products of combustion rather than direct exposure to the fire. Another obvious fire hazard is the use of oxygen within patient areas. Fires can occur in an oxygen-enriched atmosphere because of patient smoking, electrical malfunctions, and the use of flammable liquids. Procedures should be developed and strictly enforced to prevent fire hazards within patient areas where oxygen is used. When entering a new work area, look around and find fire alarms, fire extinguishers, exit signs and oxygen cut off valves.7

One way to remember fire safety is the acronym, RACE7:

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

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. Do not ever hesitate to sound the alarm with any suspicion of fire, but never yell fire. That will only create panic. Call out the facilities code for fire. Call the switchboard to report the fire and pull the fire alarm. When calling the switchboard, be sure to stay on the phone long enough to assure they got the correct information.7

Healthcare units are separated by heavy fire doors that close automatically when the alarm is sounded, to keep the fire from spreading. Additional measures to take to confine a fire include:

  • Closing doors, windows, and all vertical openings like the laundry chute
  • Stuffing wet towels under doors to keep smoke out
  • Shutting off oxygen supplies if directed to do so

Usually, someone in supervision is designated to decide when to turn off oxygen supplies.7

If a fire is small and confined, you may be able to extinguish it. If a patient's clothes are on fire, wrap the patient 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.7

If a fire cannot be extinguished and smoke, fumes or flames threaten patient safety, you may have to evacuate. Evacuate ambulatory patients first. Stay calm and give clear directions. Evacuate horizontally 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 trapped inside the elevator.7

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, pull the pin; aim the nozzle at the base of the fire, and squeeze the trigger, while you make sweeping strokes.7

A Case Study of Fire Safety in Acute Care

Max, an educator and environmental engineer, was responsible for ensuring that staff from all departments knew what to do in case of a fire. He worked on all shifts and reviewed the emergency plan and made sure the Charge Nurse knew he/she was responsible for turning off the oxygen in the units and assigning roles to her healthcare team. They all had to know what the number/code was to announce a fire and its location. Exits to be taken were reinforced, and the healthcare team had to make sure they worked together as a cohesive team without causing people to panic. Staff had to demonstrate to Max that they knew where the fire alarms and extinguishers were located and had to explain how to use them. Staff had to practice using the emergency sleds located on the beds to transport disabled patients. Special mandatory hands-on workshops were held during the day. Max did this on a quarterly basis and provided documentation to the key administrators that this was completed.

For anyone at a healthcare site, having clear and explicit directions for fire safety as well as disseminating that knowledge to other colleagues at that site is critical to everyone’s safety. Fires can get out of control very quickly. The more informed the staff is, and the more frequently the staff practices important fire safety protocols, the more lives will be saved should a terrible situation occur!

Flammable and Combustible Liquids, Vapors, and Gases

A major hazard in all hospitals is the widespread use and storage of flammable and combustible liquids. 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.7

Compressed gases are under pressure and are flammable, so they must be handled with extreme care. An exploding cylinder can have the same destructive effect as a bomb. The proper handling of compressed gas cylinders requires training. 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 properly labeled. The valve protection cap should not be removed until the cylinder is secured and ready for use.7

Compressed gases used in hospitals include7:

  • Acetylene
  • Ammonia
  • Anesthetic gases
  • Argon
  • Chlorine
  • Ethylene oxide
  • Helium
  • Hydrogen
  • Methyl chloride
  • Nitrogen
  • 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.7

In the next section, we will explore how fire safety standards at the risks in Acute Care are truly, global. Lessons from studies conducted in other countries have applicability here at home!

Case Study in India of Fire Safety Hazards: How Safe Are Our Hospitals?

Globally, every fifth fire-related death in 2017 took place in India. Fire can occur to anyone, at any time, and at anywhere, including health-care facilities. Hospital fires can be devastating in terms of loss of life, injuries to patients/ staff, and loss of property/equipment, more so because hospitals house a large number of vulnerable people (old/sick/disabled/pregnant/children, immune-compromised, on life support, and incapable of moving).8

People losing lives at the altar of cure is a saddening tragedy leading to several health, economic, and social ramifications. In the recent past, several fire incidents have been reported all over India. Some of them involved considerable loss of human life and therefore drew wide media attention. Fire-related disasters in hospitals, including near-to-miss events, humanmade, or sequel to natural events, are more frequent than assumed and emerge from external or internal threats. The external threat is exemplified by a bomb blast in Civil Hospital, Ahmedabad.8

There were 21 simultaneous bomb blasts in the entire city within 70 min, followed by another bomb blast in the trauma center of Civil Hospital, timed in a way to cause bigger damage when the victims of earlier blasts arrived at the hospital.8

The affected people included two doctors and several volunteers who gathered to donate blood for the blast victims. Internal threats account for most instances of fires, for example, the accidental fire in a corporation-run public hospital of Ahmedabad, where patients were trapped on the top floor. As the building was centrally air-conditioned, there was no channel for the smoke to come out. It was tough even for firefighters to smash the glass windows to let the fumes out. According to some patients, there were no announcements on the public address system, and the staff abandoned them.8

It was observed that regular fire drills were not conducted, and several fire extinguishers were past the expiration date.8 The 1500-bed GTB Hospital, Delhi, did not have a no-objection certificate from the fire department. In Odisha, too, only four of the 1700 odd hospitals had statutory fire safety clearances.8

In Nellore, 80%–90% of government hospitals still do not have NOC from the Fire Services Department. A compilation of 19 events since 2011 found (90%) in government hospitals. Internal errors responsible for the fire accidents were due to short-circuits except for one, which was due to inappropriate use of the hospital basement. Basement, meant for parking, was used as a storehouse for liquefied petroleum gas cylinders, torn mattresses, and wooden boxes. It also housed a pharmacy, a central storeroom, and a biomedical department, all containing inflammable articles. Five hospitals reported repeated event and that too due to the same reason (electric short-circuit).8

Overloaded electricity point, improper uninterrupted power supply load and acids in the battery, false ceiling panel lined with thermo coal, faulty electric wirings, and overheating leading to burning of wires were some of the causes of electrical fires reported.8 Safety in health-care institutions is not just a matter of poor planning/ regulation but also reflects deeper malaise prevalent in all sectors, including health care, as safety does not necessarily sell.8

Most of the short-circuit-related fire gutted the air-conditioning unit in areas such as intensive care unit (ICU) receiving ventilator support, X-ray room, an incubator of neonatology unit, pediatric ICU, children’s ward, dialysis ward, operation theater, and biomedical equipment’s storeroom. Sometimes, these places have equipment such as ventilators with heavy and fluctuating power load, making them vulnerable for short-circuiting. Oxygen enrichment of air is primarily responsible for many fires. The amount of ignition energy needed to initiate fire reduces in the presence of higher oxygen concentration, and any heat/spark may be the source of ignition.8

Split air conditioners in ICUs, neonatal ICU, and operating rooms are the source of many such fires, though several other equipment in hospitals have similar vulnerability.8

In air-conditioned buildings with no natural ventilation, most victims die due to inhaling carbon monoxide from smoke; smoke in the building also hampers rescue efforts. The electricity load on the day of commissioning a hospital almost doubles from when the facility is designed, and it further goes up nearly 25% annually.8

No hospital or authority ever estimates correctly, at the time of licensing, the patient load, how many machines it will have, and the required safety checks. The situation is worse in government hospitals where a sheer number of people overwhelm the resources in no time. Over a period of time, minor repairs, haphazard extensions, and replacements might cause some wires to come in contact with each other or create a short-circuit, which may cause a very high current flow through wires and cause fire.8

Because of this, the following suggestions can be made8:

  • Intelligent building design to assure hazard prevention, risk mitigation, assurance of life safety, property protection, and continuity of operations and functioning
    • No hospital building should be put to function unless a building utilization certificate is obtained from a competent authority
      • Similar certificates should be obtained for electrical fittings, lifts, etc.
    • Regulations as per the National Building Code should be adhered to and NOC from the concerned Fire Department should be obtained before operationalizing the hospital and should be renewed annually
    • An effective fire safety program should be in place which addresses and monitors the four important parameters namely means of access through approach roads and open spaces and means of escapes such as external staircases and firefighting equipment
    • In high-rise hospitals, escape chutes may be installed which ensure rapid and safe shifting of everyone including the bedridden patients
  • A disaster action plan, including four points based on rescue, alarm, confine, and extinguish, for firefighting procedures with standard operating procedures, should be prepared and prominently displayed with assigned roles to different persons, with their contact details
    • Regular/periodic training of all the staff and mock drills for rapid, safe evacuation should be carried out
    • An alarm system with a public address system in the hospital to inform everyone about the emergency/disaster must be in place
    • It may not work in case of electricity failure
      • Hence, it must have a power backup
    • Suitable linkage with nearby hospitals is a must to avoid delay for the treatment of critical patients
  • A simple solution for electrical accidents leading to fire is to estimate proper load and keeping some buffer before operationalizing, not to make too many changes to the electrical circuiting
    • If any alternation is done, the capacity of the wire used should be kept in mind
    • Indian hospitals need to make several changes in the arrangement of equipment and practice of handling O2 gas, as well as create awareness among hospital staff, doctors, and administrators

While it is shocking that nearly 1 in 5 fire-related deaths, globally, will occur in India, it is important to evaluate this situation and take lessons from it. Much of what this case study concludes is that there are many reasons why a healthcare facility may begin to lax standards, but once it happens it is a quick downward trend until an accident happens. Due to many flammable chemicals, pressurized tanks and other flammable substances present at healthcare facilities, fires can sweep through an area faster than one could think is possible! Being prepared is key. In the next section, we will look further at how all that medical equipment may be an increased safety risk.

Electrical Equipment: The Likely Culprit

Violations of standards governing the use of electrical equipment are the most frequently cited causes of electrical fires.1,8 Thorough electrical maintenance records should be kept, and considerable effort should be devoted to electrical safety, particularly in areas where patient care is involved. Equipment and appliances that are frequently ungrounded or incorrectly grounded include1,8:

  • 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

As a healthcare professional, you can be the eyes and ears of the facility! If you are in a patient’s room and something just does not look right, it is more important to ask and have it have been nothing than to remain silent, and then a fire breaks out! Whenever possible, take a look at your patient’s room and report anything suspicious, in terms of electrical equipment or wiring, to your supervisor! Electrical fires and other hazardous events are largely out of our control, but we can be on the lookout in the hopes of preventing a terrible situation from occurring.

In the next sections, we will explore natural disasters, reproductive system-related risks, dermatological hazards, and other risks to the healthcare worker.

Bodily Safety Concerns for the Healthcare Professional

I am Oz, the Great and Terrible.” L. Frank Baum9

Disaster plans should be prepared for natural events (e.g., tornadoes, earthquakes, and hurricanes), gas leaks, and bomb threats. The plans should be written and readily available. Supervisory workers will initiate the disaster plan and designate tasks to workers. Workers are responsible for knowing the alarm code for a disaster and the exit routes.

Reproductive Hazards

Up to 4 million women employed in hospitals may be exposed to reproductive hazards. However, there is no clear evidence that exposure conditions in hospitals have resulted in an excess rate of birth defects among the offspring of hospital workers.10

Studies do support more general associations between employment in hospitals or laboratories and an increased risk of adverse reproductive effects, primarily spontaneous abortion. Workers with immunity through vaccinations or earlier exposures are not generally at risk from diseases such as hepatitis B, human parvovirus B19, German measles, or chickenpox. However, pregnant workers without prior immunity should avoid contact with infected children or adults. Workers should also use good hygienic practices such as frequent handwashing to prevent the spread of infectious diseases and universal precautions.10 

In addition to many of these drugs being cytotoxic, the majority are hazardous to males or females who are actively trying to conceive, women who are pregnant or may become pregnant, and women who are breastfeeding, because they may be present in breast milk. These drugs represent an occupational hazard to healthcare workers and should always be handled with the use of recommended engineering controls and PPE, regardless of their formulation (intravenous, subcutaneous, topical, tablet, or capsule). Unopened, intact tablets and capsules may not pose the same degree of occupational exposure risk as injectable drugs, which usually require extensive preparation. Cutting, crushing, or otherwise manipulating tablets and capsules will increase the risk of exposure to workers.10

Table 1: Chemical and Physical Agents that are reproductive hazards in the workplace10
AgentObserved effectsPotentially exposed workers
Cancer treatment drugs (e.g., methotrexate)Infertility, miscarriage, birth defects, low birth weightHealthcare workers, pharmacists
Certain ethylene glycol ethers such as
2-ethoxyethanol (2EE) and
2-methoxyethanol (2ME)
MiscarriagesElectronic and semiconductor workers
Carbon disulfide (CS2)Menstrual cycle changesViscose rayon workers
LeadInfertility, miscarriage, low birth weight,
developmental
disorders
Battery makers,
solderers, welders, radiator repairers, bridge repainters,
firing range workers, home remodelers
Ionizing radiation (e.g., X-rays and gamma rays)Infertility, miscarriage, birth defects, low birth weight, developmental disorders, childhood cancersHealthcare workers, dental personnel, atomic workers
Strenuous physical
labor (e.g., prolonged standing, heavy lifting)
Miscarriage late in pregnancy, premature deliveryMany types of workers
Table 2: Additional Chemical and physical reproductive hazards for women in the workplace10
AgentObserved effectsPotentially exposed workersPreventive measures
Cytomegalo-
virus
(CMV)
Birth defects, low birth weight, developmental disordersHealthcare workers, workers in contact with infants and childrenGood hygienic practices such as handwashing
Hepatitis B virusLow birth weightHealthcare workersVaccination
Human
immuno-deficiency
virus (HIV)
Low birth weight, childhood
cancer
Healthcare workersPractice universal precautions
Human
parvovirus B19
MiscarriageHealthcare
workers, workers in contact with infants and children
Good hygienic practices such as handwashing
Rubella
(German
measles)
Birth defects, low birth weightHealthcare workers, workers in contact with infants and childrenVaccination before pregnancy if no prior
immunity
Toxoplas-mosisMiscarriage, birth defects,
developmental disorders
Animal care workers,
veterinarians
Good hygiene practices such as handwashing
Varicella-
zoster virus (chicken pox)
Birth defects, low birth weightHealthcare workers, workers in contact with infants
and children
Vaccination before pregnancy if no prior
immunity

BCG, although classified as a vaccine, is used in the treatment of certain cancers. BCG should be prepared with aseptic techniques. To avoid cross-contamination, parenteral drugs should not be prepared in areas where BCG has been prepared. A separate area for the preparation of BCG suspension is recommended. All equipment, supplies, and receptacles in contact with BCG should be handled and disposed of as biohazardous. If preparation cannot be performed in a containment device, then respiratory protection, gloves, and a gown should be worn to avoid inhalation or contact with BCG organisms.10

NIOSH performs a hazard identification for each of the drugs listed based on its criteria, as described above. The actual risk to healthcare workers depends on the toxicity of the drugs, how the drugs can enter the body (e.g., dermal, inhalation, or ingestion), and how the drugs are handled/manipulated and how often; as well as the exposure controls in place, such as the type of engineering controls and PPE. For example10:

  1. Dispensing a single tablet to a patient may pose a relatively low risk to the healthcare worker. A single pair of gloves may be adequate.
  2. Repeatedly counting, cutting, or crushing tablets may pose a higher risk for worker exposure than dispensing a single tablet and contamination to the workplace if exposure controls are not in place.
  3. If a containment device such as a BSC (Class II biological safety cabinet) or CACI (compounding aseptic containment isolator) is not available, then double gloves, a protective gown, respiratory protection, and a disposable pad to protect the work surface should be used.
  4. Preparing several intravenous doses of an antineoplastic drug typically poses a higher potential risk to the worker. In addition to double gloving and a protective gown, an engineering control such as a BSC or CACI, possibly supplemented with a CSTD (closed system drug transfer device), is necessary to protect the drug, environment, and healthcare worker.

Group 1: Antineoplastic drugs, including those with the manufacturer’s safe-handling guidance (MSHG).10

Abbreviations10

  • AHFS: American Hospital Formulary Service
  • MRHD: Maximum Recommended Human Dose

NIOSH ‘s updated list of the newest 2016 drugs is noted below and meet one or more of the NIOSH criteria for a hazardous drug. In addition to many of these drugs being cytotoxic, the majority are hazardous to males or females who are actively trying to conceive, women who are pregnant or may become pregnant, and women who are breastfeeding, because they may be present in breast milk.

These drugs represent an occupational hazard to healthcare workers and should always be handled with the use of recommended engineering controls and PPE, regardless of their formulation (intravenous, subcutaneous, topical, tablet, or capsule). Unopened, intact tablets and capsules may not pose the same degree of occupational exposure risk as injectable drugs, which usually require extensive preparation. Cutting, crushing, or otherwise manipulating tablets and capsules will increase the risk of exposure to workers.10

The manufacturer’s safe-handling guidance (MSHG) is typically in Section 16 of the DPI. See Table 6 for safe-handling recommendations.10

Table 3: Group 1 - Anineoplastic drugs, including those with the manufacturer's safe-handling guidance (MSHG) 2016 added drugs10
DrugAHFS classificationMSHGSupplemental information
afatinib10:00 antineoplastic agents Special warnings on contraception for females while taking and 2 weeks post-treatment; FDA Pregnancy Category D
axitinib10:00 antineoplastic agents Teratogenic, embryotoxic and fetotoxic in mice at exposures lower than human exposures; FDA Pregnancy category D
belinostat10:00 antineoplastic agentsyesMay cause teratogenicity and/or embryo-fetal lethality because it is a genotoxic drug and targets actively dividing cells; FDA Pregnancy Category D
bosutinib10:00 antineoplastic agents 

FDA Pregnancy

Category D
cabozantinib10:00 antineoplastic agents 

agents

Embryolethal in rats at exposures below the recommended human dose; FDA Pregnancy category D
carfilzomib10:00 antineoplastic agents 

agents

Special warnings on contraception while taking and 2 weeks post- treatment; FDA Pregnancy category D
dabrafenib10:00 antineoplastic agents Special warnings on contraception for females while taking and 2 weeks post-treatment; FDA Pregnancy Category D
enzalutamide10:00 antineoplastic agents Embryo-fetal toxicity in mice at exposures that were lower than in patients receiving the recommended dose; FDA Pregnancy Category X
histrelin10:00 antineoplastic agents Can cause fetal harm when administered to a pregnant patient, with the possibility of spontaneous abortion; FDA Pregnancy Category X
ixazomib10:00 antineoplastic agentsyesMale and female patients of childbearing potential must use effective contraceptive measures during and for 3 months following treatment
panobinostat10:00 antineoplastic agentsyesSpecial warnings on contraception for females while taking and 1 month post-treatment
pertuzumab10:00 antineoplastic agents Black Box warning on embryo-fetal death and birth defects; FDA Pregnancy Category D
pomalidomide10:00 antineoplastic agentsyesFemales of reproductive potential must use two forms of contraception or continuously abstain from heterosexual sex during and for 4 weeks after stopping treatment; FDA Pregnancy Category X
ponatinib10:00 antineoplastic agents FDA Pregnancy Category D
regorafenib10:00 antineoplastic agents Black Box warning on severe and sometimes fatal hepatotoxicity; total loss of pregnancy at doses lower than recommended human dose; FDA Pregnancy Category D
trametinib10:00 antineoplastic agents Embryotoxic and abortifacient at doses less than recommended human dose; FDA Pregnancy Category D
trifluridine/tipiracil (combination only)10:00 antineoplastic agentsyesEmbryo-fetal lethality and embryo-fetal toxicity at doses lower than or similar to exposures at the recommended human dose
vismodegib10:00 antineoplastic agents Black Box warning on embryo-fetal death or severe birth defects; recommend effective contraception for females during therapy and for 7 months after treatment; present in semen; no sperm donation during and 3 months posttreatment; FDA Pregnancy Category D
ziv-aflibercept10:00 antineoplastic agents Embryotoxic and teratogenic in rabbits at exposure levels lower than human exposures at the recommended dose, with increased incidences of external, visceral, and skeletal fetal malformations; FDA Pregnancy Category C
Table 4: Group 2- Non-antineoplastic drugs that meet one or more of the NIOSH criteria for a hazardous drug, including those with the manufacturer's safe-handling guidance (MSHG)10
DrugAHFS classificationMSHGSupplemental information
methimazole68:36:08 antithyroid agents Appears in human breast milk; FDA Pregnancy Category D
mipomersen24:06:92 antilipemic agents, miscellaneous Black Box warning on hepatotoxicity; FDA Pregnancy Category B
ospemifene68:16:12 estrogen agonists-antagonists Black Box warning on increased risk of endometrial cancer in certain populations; risk of adverse outcomes during pregnancy and labor; FDA Pregnancy Category X
paliperidone28:16:08:04 atypical antipsychotics Metabolite of risperidone; excreted in human breast milk; FDA Pregnancy Category
teriflunomide92:20 immunomodulatory agents Black Box warning on severe hepatotoxicity and teratogenicity, including major birth defects; FDA Pregnancy Category X

tofacitinib

92:36 disease modifying antirheumatic drugs
 
Black Box warning for lymphoma and other malignancies; FDA Pregnancy Category C
Table 4: Group 3 -Non-antineoplastic drugs that primarily have adverse reproductive effects10
DrugAHFS classificationMSHGSupplemental information
clomiphene68:16:12 estrogen agonist-antagonists FDA Pregnancy Category X
eslicarbazepine28:12:92 anticonvulsants, miscellaneous Fetal malformations, fetal growth retardation, embryolethality, and reduced body weights observed in animal studies; excreted in human breast milk; FDA Pregnancy Category C
lomitapide24:06:92 antilipemic agents, miscellaneous FDA Pregnancy Category X
macitentan48:48 vasodilating agents Black Box warning for embryofetal toxicity; special warnings on contraception for females while taking and 1 month post-treatment; FDA Pregnancy Category X
pamidronate92:24 bone resorption inhibitors Embryo-fetal toxicities at doses below the recommended human dose; FDA Pregnancy Category D
pasireotide68:29:04 somostatin agonists Increased implantation loss and decreased viable fetuses, corpora lutea, and implantation sites at doses less than the human recommended dose; FDA Pregnancy Category C
peginesatide20:16 hematopoietic agents Adverse embryo-fetal effects, including reduced fetal weight, increased resorption, embryofetal lethality, and cleft palate, observed in doses below the recommended human dose; FDA Pregnancy Category C
riociguat48:48 vasodilating agents Exclude pregnancy before the start of treatment, monthly during treatment, and 1 month after stopping treatment; FDA Pregnancy Category X
temazepam28:24:08 benzodiazepines Increased risk of congenital malformations associated with treatment during the first trimester of pregnancy; FDA Pregnancy Category X
Table 5 would list drugs that were deleted from the 2014 NIOSH hazardous drug list for the 2016 update; however, there are no deletions to report.10
Table 6: Personal Protective Equipment (PPE) and engineering controls for working with reproductive-hazardous drugs in healthcare settings10
FormulationActivityDouble chemo-therapy glovesProtective gownEye/face protectionRespiratory protectionVentilated engineering control
All types of hazardous drugsReceiving, unpacking, and placing in storageNo (single glove can be used, unless spills occur)Yes, when spills and leaks occurNoYes, when spills and leaks occurNo
Intact tablet or capsuleAdministration from unit-dose packageNo (single glove can be used)NoNoNoN/A
Tablets or CapsulesCutting, crushing, or manipulating tablets or capsules; handling uncoated tabletsYesYesNoYes, if not done in a control deviceYes
AdministrationNo (single glove can be used)NoYes, if vomit or potential to spit upNoN/A
Oral liquid drug or feeding tubeReceiving, unpacking, and placing in storageNo (single glove can be used, unless spills occur)Yes, when spills and leaks occurNoYes, when spills and leaks occurNo
Topical drugCompoundingYesYesYes, if not done in a control deviceYes, if not done in a control deviceYes, BSC or CACI (Note: carmustine and mustargen are volatile)
AdministrationYesYesYes, if liquid that could splashYes, if inhalation potentialN/A
Subcutaneous/ intra-muscular injection from a vialPreparation (withdrawing from vial)YesYesYes, if not done in a control deviceYes, if not done in a control deviceYes, BSC or CACI
AdministrationYesYesYes, if liquid that could splashNoN/A

Withdrawing and/or mixing intravenous or intramuscular solution from a vial or ampoule
CompoundingYesYesNoNoBSC or CACI; use of CSTD re-commended
Administration of prepared solutionYesYesYes; if liquid that could splashNoN/A; CSTD required per USP 800 if the dosage form allows

Solution for irrigation
CompoundingYesYesYes, if not done in a control deviceYes, if not done in a control deviceYes, BSC or CACI; use of CSTD re-commended
Administration (bladder, HIPEC, limb perfusion, etc.)YesYesYesYesN/A

Powder/solution for inhalation/ aerosol treatment
CompoundingYesYesYes, if not done in a control deviceYes, if not done in a control deviceYes, BSC or CACI; use of CSTD recommended
Aerosol administrationYesYesYesYesYes, when applicable

Administration
YesYesYes, if liquid that could splashYes, if inhalation potential
N/A
Drugs and metabolites in body fluidsDisposal and cleaningYesYesYes, if liquid that could splashYes, if inhalation potentialN/A
Drug-contaminated wasteDisposal and cleaningYesYesYes, if liquid that could splashYes, if inhalation potentialN/A
SpillsCleaningYesYesYesYesN/A

This course has presented, here, many chemical and physical agents that may be a reproductive risk for men and women in the healthcare workplace. Further, we provided a detailed list of antineoplastic drugs that have documented reproductive maladaptive side effects as well as lists of PPE and other engineering controls to handle these drugs. Next, we will continue our safety standards discussion by exploring possible dermatological hazards for healthcare professionals.

Dermatological Hazards

Skin injuries and diseases account for a large proportion of all occupational injuries and diseases. Skin injuries in the hospital environment include cuts, lacerations, punctures, abrasions, and burns. Skin diseases and conditions of hospital workers include dermatitis, allergic sensitization, infections such as herpes, and skin cancer. Chemicals can directly irritate the skin or cause allergic sensitization. Physical agents can also damage the skin, and skin that has been chemically or physically damaged is vulnerable to infection.11

The most common and often the most easily preventable of all job-related health problems are skin reactions (dermatitis).11 The skin is the natural defense system of the body: it has a rough, waxy coating, a layer of protein, keratin, and an outer layer of dead cells to help prevent chemicals from penetrating the tissues and being absorbed into the blood.11

Many chemicals cause irritation on contact with the skin, irritant contact dermatitis, by dissolving the protective fats or keratin protein layer, dehydrating the skin, or killing skin cells. Symptoms of this kind of irritation are red, itchy, peeling, dry, or cracking skin. Some chemicals are not irritants under normal conditions, but they will irritate skin that has already been damaged by sunburn, scratching prolonged soaking, or other means. Tars, oils, and solvents can plug the skin pores and hair follicles, causing blackheads, pimples, and folliculitis.11

Some persons become sensitized to chemicals days, months, or even years after their first exposure. This allergic reaction does not occur in every worker who contacts the chemical. Symptoms are red, itchy, and blistering skin, like a poison oak or ivy reaction, and maybe much more severe than the direct irritation described in the previous subsection.11

The association between basal and squamous cell carcinomas and ultraviolet radiation has been well established. The association between skin cancer and exposure to other agents is less well documented, but ionizing radiation and antineoplastic drugs have been implicated. Other evidence indicates that malignant transformation of cells damaged by chronic allergic contact dermatitis may occur.11

The skin can be damaged by a variety of microorganisms, including bacteria, fungi, viruses, and parasites. Herpes simplex is the most common dermatologic infection among dentists, physicians, and nurses.11

Relatively simple precautions can considerably reduce skin hazards. Effective measures include work practices and engineering controls that limit solvent exposure, the use of personal protective equipment, the substitution of less irritating chemicals, use of non-powdered gloves, and the institution of a good hygiene program.11

Next, we explore a fundamental safety issue not only in the workplace but in our everyday lives: Stress!

Stress!

Job stress refers to the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker. Job stress can lead to poor health and even injury.12,13 Hospital work often requires coping with some of the most stressful situations found in any workplace.12,13

Hospital workers must deal with life-threatening injuries and illnesses complicated by complex hierarchies of authority and skills, dependent and demanding patients, and patient deaths; all of these contribute to stress.12,13

Other important stress factors include job specialization, discrimination, concerns about money, lack of autonomy, work schedules, ergonomic factors, and technological changes.12,13

The increasing size and bureaucracy of many hospitals may depersonalize the environment and leave many workers feeling isolated, fatigued, angry, powerless and frustrated.12,13

These feelings may be expressed as apathy, loss of self-confidence, withdrawal, or absenteeism. Failure to recognize and treat the sources of stress results in workers who suffer burnout.12,13

Factors commonly mentioned as causes of stress by all categories of hospital workers are12,13:

  • Understaffing
  • Role conflict and ambiguity
  • Inadequate resources
  • Working in unfamiliar areas
  • Excessive noise
  • Lack of control (influence, power) and participation in planning and decision making
  • Lack of administrative rewards
  • Under-utilization of talents and abilities
  • Rotating shift work
  • Exposure to toxic substances
  • Exposure to infectious patients

Stress has been associated with loss of appetite, ulcers, mental disorder, migraines, difficulty in sleeping emotional instability, disruption of social and family life, and the increased use of cigarettes, alcohol, and drugs. Stress can also affect worker attitudes and behavior. Some frequently reported consequences of stress among hospital workers are difficulties in communicating with very ill patients, maintaining pleasant relations with coworkers, and judging the seriousness of a potential emergency.12,13

Understanding stress in the healthcare workplace could be vital in preventing a harmful, dangerous or violent situation from erupting. In the final sections of this course, we look at violence in the workplace, environmental safety standards, and how OSHA is going to handle reporting and recordkeeping of safety incidents.

Workplace Violence

Nonviolence Doesn’t Always Work, But Violence Never Does,” Isaac Asimov6

Workplace violence is a serious concern for the approximately 15 million health care workers in the United States.14 OSHA is the federal agency responsible for protecting the safety and health of the nation's workers, although states may assume responsibility under an OSHA-approved plan. OSHA does not require employers to implement workplace violence prevention programs, but it provides voluntary guidelines and may cite employers for failing to provide a workplace free from recognized serious hazards.14

The circumstances of hospital violence differ from the circumstances of workplace violence in general. In other workplaces such as convenience stores and taxicabs, violence most often relates to robbery. Violence in hospitals usually results from patients and occasionally from their family members who feel frustrated, vulnerable, and out of control.14

Common risk factors for hospital violence include the following14:

  • 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 mealtimes and visiting hours
  • Transporting patients
  • 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 the 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 interaction with patients. Assaults may occur when service is denied, when a patient is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking, or tobacco or alcohol use.14

Patients with a condition that causes confusion and impaired judgment are more likely to become violent than a patient with normal mentation.14

Confusion and impaired judgment may be caused by neurologic conditions, seizures, hypoglycemia, or dementia. Watch for signals that may be associated with impending violence14:

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

Note how your co-workers behave. If a colleague’s demeanor or behavior has changed for the worse, notify your manager.14 For example, slamming equipment around is red-flag behavior. Learn from their history. If a patient 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 this patient. Let security know if you feel threatened or if you find or suspect that the patient is carrying a weapon. Notify your nursing supervisor, manager, and hospital security or police if you suspect a patient is going to be violent. Keep your patient informed. Help relieve patient’s tension and anxiety by keeping him/her informed about when examinations/treatments will be performed and what is going on.14

Be Alert14:

  • 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
  • Watch your surroundings

Always keep an open path for exiting. Do not let the potentially violent person stand between you and the door. When you are with an upset patient or co-worker, avoid areas of the room that do not have an accessible exit. If you are going to an isolated part of your facility, let others know where you are going and when you expect to return. Consider asking for an escort. Observe your surroundings and note anyone who is not wearing staff ID and is lingering where they should not be. Ask politely if you can help and notify security if you are not satisfied with the answer. If you would 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 is not easy to pull, and do not wear dangling jewelry.14

Healthcare Worker DOs & DON'Ts in Violent Situations in the Healthcare Workplace

In the presence of a potentially violent person, DO14:

  • Plan a clear exit route
  • Keep 5 to 7 feet between you and him/her, never turn your back, or let him/her get between your and the exit
  • Keep your voice calm and quiet
  • Acknowledge that he/she has a right to his/her feelings
  • Assume that he/she 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/she cannot order take-out pizza, you will see if you can get him/her an early dinner
    • Tell an angry colleague that you see that he/she is angry and that you would like to work with him/her and your manager to resolve the situation
  • Call for backup or security if a situation grows increasingly tense
  • Ensure that he/she has access to bathrooms, a phone, a TV, and something to read
  • Track equipment
    • Return it to its rightful place
    • When you take an item into a patient’s room, dispose of it properly or take it with you when you leave

In the presence of a potentially violent person, DO NOT:

  • Do not ignore the agitated person or avoid him/her
  • 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/her personal space
  • Do not try to handle a dangerous situation alone
    • Call security or initiate your facility's violence prevention protocol

    Take these steps if you cannot defuse the situation quickly14:

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

    In the presence of a weapon, maintain behavior that helps diffuse anger14:

    • 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)

    You can make all the difference in violent situations! Staying calm and following these quick tips just might diffuse a violent situation from deteriorating into a worse one. Let us finish up our safety and hazards discussion by looking at a case study of the types of hazards experience by home health workers, overall.

    A Case Study in Environmental Health & Safety Hazards Experienced by Home Health Care Providers15

    The demand for home health care services is escalating in step with the aging population, resulting in an ever-growing number of paid caregivers providing in-home services for individuals with illnesses and disabilities. The number of home health aides and personal attendants is expected to increase by about 50% between 2008 and 2018, substantially more than the average increase for all other occupations. The unique physical environment of each home offers significant challenges when providing health care to clients while protecting caregivers’ health and safety. Data from the Oregon Home Care Commission (2008-2010) indicated that HHC providers in publicly funded programs incurred 352 lost-time injuries per 10,000 full-time workers.15

    Multiple types of home hazards have been identified by diverse types of HHPs, including nurses, aides and technicians, administrators, social workers, physical therapists, and occupational therapists.15 Homes can harbor a variety of hazards, including throw rugs, pests, tobacco smoke, mold, sharps, inadequate lighting, cluttered hallways and rooms, and inaccessible bathrooms.15

    Despite high rates of work-related injuries and the identification of a variety of hazards, scant research describes hazards by specific locations in the home. Hazards also negatively affect job performance, job satisfaction, and health.15 In the only published study describing specific locations in the home of injuries incurred by HHC providers, researchers found that 60% of home health aide injuries occurred inside client homes, with the most common locations being the bedroom (24%), bathroom (18%), and kitchen (9%).15

    Half of the injuries were associated with client handling, 8% with specific objects (e.g., needles, pets), 8% with cleaning, 4% with lifting objects, 2% with trash disposal, and 28% were unspecified. Client handling tasks that resulted in injury included moving clients in bedding, bathing, and transferring clients.15

    This case study explored environmental health and safety hazards encountered by HHPs in clients’ homes and specific rooms within those homes.15 Consistent with other studies, trip/slip/lift hazards were the most commonly identified hazards, and the specific sources for these types of hazards varied, a key finding with implications for enhanced HHP training.15 Sprains and strains, commonly attributable to lifts, slips, and trips, have previously been documented to be the most frequent lost-work-time injuries to HHC providers, resulting in almost one month of lost work time.15

    Recommendations to reduce exposure to trip/slip/lift hazards include making changes in the work environment, (e.g., removing throw rugs, securing cords, providing adequate lighting), using assistive devices such as transfer or gait belts, participating in ergonomics training, and wearing sturdy shoes with slip-resistant soles.15

    These and other recommendations can be incorporated into specific training for HHPs on how to assess and manage trip/slip/lift hazards, especially for home health aides who have the most exposure. Exposures to potential biohazards, such as human or pet waste and blood-borne pathogens, were commonly expressed concerns in this study as well as by other researchers.15

    OSHA regulations require agencies to have an exposure control plan and annual blood-borne pathogen training, but neither a control plan nor training is required for other biohazards.15 Most participants in this study (73%) indicated they received training on standard precautions and were supplied with gloves, but not other forms of PPE, such as face shields, goggles, or protective clothing. These findings highlight the need for an agency- and policy-level changes to assure that HHPs have the PPE necessary for personal safety.15

    Air quality and allergen exposures from tobacco smoke, mold, and inadequate ventilation were considered highly hazardous by participants with asthma and allergies. Several participants commented that their agency had a tobacco smoking policy in which clients agreed not to smoke (nor allow others to smoke in their home) while the HHP was there.15

    Although helpful, not all agencies have this type of policy, and not all HHPs insist their agencies’ policies be followed. Although the consequences of exposure to secondhand tobacco smoke are well known, the NIOSH does not include this hazard in its 2010 Occupational Hazards in Home Care publication. The findings of this study highlight the need for policy- and individual-level interventions to reduce the risk of exposure to secondhand tobacco smoke.15

    The U.S. Surgeon General has stated that no risk-free level of exposure to tobacco smoke exists, so it is imperative that NIOSH and OSHA develop a standardized smoke-free policy template that can be adapted and implemented by home health agencies to protect their workers. Participants in this study identified the most hazards in the kitchen, followed by the bedroom and the bathroom. These locations were also the primary locations where studies report that injuries occurred to home health aides. Although trip/slip/lift hazards were the most common hazard type reported in each room in the present study, with the exception of throw rugs, which pose a hazard in every room, the specific types of risks differed.15

    Water and grease spills were described frequently on kitchen floors; tight spaces and missing equipment in bathrooms; clutter, tight spaces, and lifting hazards in the bedroom; electrical cords and oxygen tubing in the living room; and clutter in the hallway. Similar differences in the types of biohazards encountered in each room were identified.15

    Pet droppings were key biohazards in the kitchen and living room; human waste was commonly noted as bathroom and bedroom hazards.15 The rooms in clients’ homes in which HHPs work varied by type of HHP and clients’ needs. For example, nurses may not go into a client’s bedroom or kitchen if client care is provided in the living room.15

    By contrast, home health aides are often in all rooms if they provide cleaning, meal preparation, and personal care services. A key implication of these findings is that health care agencies should provide tailored training that addresses the different hazards HHC providers are likely to encounter by room, also taking into account HHC provider job descriptions and client needs.15

    A Summary of Fire & Safety Environmental Hazards reported for HHC Providers:

    • Fire/Burn Hazards
      • Smoking with Oxygen in Use. Especially risk in smaller apartments with heavy smokers
      • Using Stove for Heat. Sometimes individuals will leave their burners on for heat
      • 8% of HHC Providers report incidents with fire or a burn
    • Poor/Dim lighting (can cause falls and other risks)
    • Electrical Hazards
      • Inadequate outlets
      • Faulty outlets
      • 3% of HHC Providers report incidents with electrical hazards
    • Illicit Drugs that involved lighters, matches, or other combustible products
    • Unsafe furniture, unsafe objects, and/or penetrating objects
    • Inadequate, unclean or contaminated areas, especially if this area contains forms of gasoline or other combustible products
    • The trip, slip or lift hazards due to clutter, unsafe objects or addressing patient needs. Nearly 40% of HHC providers reports incidents with trip, slip, or lift hazards
    • Chemical or other biohazards that can include sharps, human or animal waste, and combustible products. 17% of HHC Providers report incidents with chemical or biohazards
    • Air quality due to lack of appropriate ventilation or possibly due to a patient’s chronic smoking habits. Other air quality hazards can occur if there is inappropriate ventilation in the setting during a fire incident
    • Allergens

    OSHA Injury & Illness Recordkeeping and Reporting Requirements

    Up to this point, this course has largely been reporting to you, the participant, the OSHA guidelines, requirements and standards that are important to the healthcare professional. Equally as important, is the process for reporting and the records that are kept of safety violations. Without detailed recordkeeping and nationwide collaboration, the safety and quality of care of the healthcare community might diminish. OSHA standards protect the patients, the employees, as well as the employers and, are vital to our healthcare system.

    OSHA published a Final Rule to amend its recordkeeping regulation to remove the requirement to electronically submit to OSHA information from the OSHA Form 300 (Log of Work-Related Injuries and Illnesses) and OSHA Form 301 (Injury and Illness Incident Report) for establishments with 250 or more employees that are required to routinely keep injury and illness records. Covered establishments are only required to electronically submit information from the OSHA Form 300A (Summary of Work-Related Injuries and Illnesses). The requirement to keep and maintain OSHA Forms 300, 300A, and 301 for five years is not changed by this Final Rule.1

    Through this, OSHA continues to evolve into the digital landscape. Previously, paperwork was handled in a more physical manner, but this could increase wait times and delay important changes to be made. Through revising its recordkeeping system, and providing more digital options for submission and review, OSHA claims can be filed, recorded and evaluated more efficiently. This reduces overall waste, financial cost and wait times for individuals who have safety concerns.

    Recordkeeping Requirements

    Many employers with more than ten employees are required to keep a record of serious work-related injuries and illnesses. Minor injuries requiring first aid only do not need to be recorded. This information helps employers, workers, and OSHA evaluate the safety of a workplace, understand industry hazards, and implement worker protections to reduce and eliminate hazards, preventing future workplace injuries and illnesses.1

    Maintaining and Posting Records

    The records must be maintained at the worksite for at least five years. Each February through April, employers must post a summary of the injuries and illnesses recorded the previous year. Also, if requested, copies of the records must be provided to current and former employees, or their representatives.1

    Severe Injury Reporting

    Employers must report any worker fatality within 8 hours and any amputation, loss of an eye, or hospitalization of a worker within 24 hours.1

    Contact OSHA!

    For questions or to get information or advice, to report an emergency, report a fatality or catastrophe, order publications, sign up for OSHA's e-newsletter, or to file a confidential complaint, contact your nearest OSHA office, visit www.osha.gov or call OSHA at 1-800-321-OSHA (6742), TTY 1-877-889-5627.1

    Conclusions

    Many healthcare workers must constantly deal with exposures to neoplastic and hazardous drugs. Every year new drugs are developed, and each has certain side effects. Fortunately, organizations such as NIOSH, CDC, and DHHS are constantly updating important information telling us how to be safe, along with the side effects of new chemical agents. Healthcare workers in all departments need to know where their MSDS book is located and have easy access to it. Educators must constantly up-date their safety manuals, educate works on all shifts, and in all departments. In today's volatile world, healthcare workers and others need to stay informed of how to handle fires and to be prepared for disasters, both man-made and natural. Knowing how to use equipment that can prevent injuries, along with practicing using this equipment is imperative. Workplace violence is everybody’s concern. The key to success is to learn to listen effectively, know when to speak and what to say, respect everybody’s personal distance, and show genuine concern for all those you are in contact with. People need to feel valued and appreciated and know what the consequences are for their actions. Administrators have the responsibility of making sure healthcare workers are protected from injuries while at work and enforce the consequences when a worker is physically or mentally abused by a patient, relative, or co-worker. Healthcare facilities should be safe havens for all!!

    Select one of the following methods to complete this course.

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

    References

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    14. Occupational Safety and Health Administration. Workplace Violence. 2020. Visit Source.
    15. Polivka BJ, Wills CE, Darragh A, Lavender S, Sommerich C, Stredney D. Environmental health & safety hazards experienced by home health care providers. Workplace Health Saf. 2015; 63:512-522. doi: 1177/2165079915595925.