The purpose of this course is to update employees on the 2004 NIOSH recommendations for exposure to neoplastic and hazardous drugs, to raise employee awareness of safety, and to promote safe work practices.
After completing this course, the learner will be able to:
Few workplaces are as complex as a healthcare facility. Such complex situations provide a lot of potential health and safety hazards. 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 (DHHS, 1998). The list of potential hazards includes radiation, toxic chemicals, biological hazards, heat, noise, dusts, and stress. 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.
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). 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. Chemicals may exert either acute or chronic effects on workers. The effects depend on the:
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. 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 area not and may be excreted unchanged or stored in the fatty tissues (solvents), lungs (dusts and fibers), bone (lead and radium), or blood (soluble gases).
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. 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. Exposures routes for antineoplastic and other hazardous drugs are inhalation, skin absorption, ingestion, and injection.
The National Institute of Occupational Health and Safety (NIOSH) released new guidelines, in 2004, about the handling of antineoplastic and other hazardous drugs. NIOSH warns that exposure to hazardous drugs may occur to clinical and non-clinical workers in the following settings (NIOSH, 2004):
NIOSH defines the healthcare workers’ responsibilities in relation to antineoplastic and other hazardous drugs as the following (NIOSH, 2004):
Nearly half of all compensation claims for hospital workers involved back injuries. The most common causes of all work-related back pain are (DHHS, 1998):
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 injury 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 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 (DHHS, 1998):
Patient transfers are particularly hazardous for hospital workers. The following special points should be emphasized to prevent back injuries during transfers.
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.
Hospital fires and disasters are especially dangerous because workers must protect themselves and evacuate large numbers of patients. Almost one-third of hospital fires originated in patient rooms or worker quarters, with matches and smoking as the most frequent cause. Other causes are malfunctioning or misused electrical equipment such as hot plates, coffeepots, and toaster ovens (DHHS, 1998).
Deaths during hospital fires were overwhelmingly due to inhaling the toxic products of combustion rather than to direct exposure to the fire. Another obvious fire hazard is the use of oxygen in 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 in patient areas where oxygen is used. 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.
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 you call the switchboard, be sure to stay on the phone long enough to assure they got the correct information.
Healthcare units are separated by heavy fire doors that close automatically when the alarm is sounded, to keep the fire from spreading. To confine a fire, close 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 someone in supervision is designated to decide when to turn of oxygen supplies.
If a fire is small and confined, you may be able to extinguish it. If a patient's cloths 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.
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.
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.
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 task to workers. Workers are responsible for knowing the alarm code for a disaster and the exit routes.
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.
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.
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.
Violations of standards governing the use of electrical equipment are the most frequently cited causes of electrical fires. 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 include (DHHS, 1998):
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. Common risk factors for hospital violence include the following (DHHS, 2002):
Violence may occur anywhere in the hospital, but it is most frequent in psychiatric wards, emergency rooms, waiting rooms, and geriatric units (DHHS, 2002). 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 (DHHS, 2002). Patients with a condition that causes confusion and impaired judgment are more likely to become violent than a patient with normal mentation. Confusion and impaired judgment may be caused by neurologic conditions, seizures, hypoglycemia, or dementia (Doody, 2003).
Watch for signals that may be associated with impending violence (DHHS, 2002):
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 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 him. Let security know if you feel threatened or if you find or suspect that he's carrying a weapon. And notify your manager if you suspect a patient is going to be violent. Keep your patient informed. Help relieve his tension and anxiety by keeping him informed about when he'll be examined or treated and what's going on (Doody, 2003).
Be alert (DHHS, 2002):
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 patient or co-worker, avoid areas of the room that does not have 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. Observe your surroundings and note anyone who's not wearing staff ID and is lingering where he shouldn't. Ask politely if you can help him and notify security if you aren't satisfied with his 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 (Doody, 2003).
In the presence of a potentially violent person (Doody, 2003):
Take these steps if you cannot defuse the situation quickly (DHHS, 2002:
In the presence of a weapon, maintain behavior that helps diffuse anger (DHHS, 2002):
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 (NIOSH, 2002). Studies do support more general associations between employment in hospitals or laboratories and an increased risk of adverse reproductive effects, primarily spontaneous abortion. The following tables outline the hazards and effects (NIOSH, 2002, p 1).
|Agent||Observed effects||Potentially exposed workers|
|Cancer treatment drugs (e.g., methotrexate)||Infertility, miscarriage, birth defects, low birth weight||Healthcare workers, pharmacists|
|Certain ethylene glycol ethers such as
2-ethoxyethanol (2EE) and
|Miscarriages||Electronic and semiconductor workers|
|Carbon disulfide (CS2)||Menstrual cycle changes||Viscose rayon workers|
|Lead||Infertility, miscarriage, low birth weight,
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 cancers||Healthcare workers, dental personnel, atomic workers|
labor (e.g., prolonged standing, heavy lifting)
|Miscarriage late in pregnancy, premature delivery||Many types of workers|
|Agent||Observed effects||Potentially exposed workers||Preventive measures|
|Birth defects, low birth weight, developmental disorders||Healthcare workers, workers in contact with infants and children||Good hygienic practices such as handwashing|
|Hepatitis B virus||Low birth weight||Healthcare workers||Vaccination|
|Low birth weight, childhood
|Healthcare workers||Practice universal precautions|
workers, workers in contact with infants and children
|Good hygienic practices such as handwashing|
|Birth defects, low birth weight||Healthcare workers, workers in contact with infants and children||Vaccination before pregnancy if no prior
|Toxoplas-mosis||Miscarriage, birth defects,
|Animal care workers,
|Good hygiene practices such as handwashing|
zoster virus (chicken pox)
|Birth defects, low birth weight||Healthcare workers, workers in contact with infants
|Vaccination before pregnancy if no prior
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 chicken pox. But 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 (NIOSH, 2002).
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 an allergic sensitization. Physical agents can also damage the skin, and skin that has been chemically or physically damaged is vulnerable to infection.
The most common and often the most easily preventable of all job-related health problems are skin reactions (dermatitis.) 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.
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.
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 may be much more severe than the direct irritation described in the previous subsection.
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 (NIOSH, 1998).
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.
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, substitution of less irritating chemicals, use of non-powdered gloves, and the institution of a good hygiene program.
Hospital work often requires coping with some of the most stressful situations found in any workplace. 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. Other important stress factors include job specialization, discrimination, concerns about money, lack of autonomy, work schedules, ergonomic factors, and technological changes. The increasing size and bureaucracy of many hospitals may depersonalize the environment and leave many workers feeling isolated, fatigued, angry, powerless and frustrated. 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. Factors commonly mentioned as causes of stress by all categories of hospital workers are (NIOSH, 199b):
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.
DHHS. (2002). Violence: Occupational Hazards in hospitals. DHHS (NIOSH) publication no. 2002-101. Retrieved August 15, 2004 from The CDC.
DHHS. (1998). Guidelines for Protecting the Safety and Health of Healthcare Workers, Retrieved August 15, 2004 from The CDC.
Doody, L. (2003). Defusing workplace violence. Nursing 33(8) 32. Retrieved August 15, 2004 from ProQuest.
NIOSH (2004). Occupational exposures to antineoplastic and other hazardous drugs in healthcare settings. Retrieve August 15, 2004 from The CDC.
NIOSH. (2002). The effects of workplace hazards on female reproductive health. Retrieved August 15, 2004 from The CDC.
NIOSH. (1999). Stress at work. Retrieved August 15, 2004 from The CDC.
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), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Registered Nurse (RN), Respiratory Therapist (RT)
Administration & Leadership, CPD: Preserve Safety, Legal & Regulatory