OSHA and Hazard Communication for Healthcare Professionals

Professional healthcare workers (HCWs) face a myriad of hazards in our workday world. Although we are the carers of others by profession, we don’t do a very good job of caring for ourselves. Like other occupations in our country, we have hazardous jobs. Biological, chemical, and physical hazards are indoors and outside healthcare facilities. According to OSHA’s 2020 report, more workers are injured in the healthcare workplace than in any other occupational sector, and this number is increasing yearly. While healthcare hazardous communication has improved, safety gaps and laws are still designed to protect HCWs. Additionally, as medical facilities proliferate, HCWs multiply, both in and outside the patient-facing positions. Therefore, there will always be more newly trained employees and more experienced, complacent ones who will get injured. Workplace injury costs to the worker can be life-changing and challenging for everyone around the injured, including co-workers, family, and friends.  The costs to insurance companies for injuries sustained in healthcare and social agencies are staggering at approximately two billion dollars annually. This course will enumerate the hazard and preventative strategies outlined by OSHA with links to this important information throughout. These preventative safety standards cover the provision and safety of your PPE and protection from toxic substances, including biological ones and chemicals, in every aspect of health care. Overall, we must know the rules for hazard communication to remain safe in the workplace. It is amazing how much OSHA covers in your workplace that only a few professionals know everything about. From musculoskeletal injuries caused by hazardous ergonomic conditions, hazard communication signage, bloodborne pathogens, and workplace violence, OSHA has most of us covered. The exception is the self-employed HCW. OSHA has over 7 million workplaces to regulate worker safety, so they must triage reports and in-person inspections. Worker complaints and industries with high severe hazard rates that may cause injury or death are the highest on the list. Some lower-priority inspections are done by telephone with the complainant’s permission. Employers have five working days to reply in writing regarding the safety hazard and what they have done to mitigate it. For more on this, go here.

Drs. Rosner and Markowitz (2020) state that manufacturers have fought against worker safety regulations due to rising financial costs. The manufacturing owners have fought repeatedly to be allowed to set their own less restrictive (and less expensive) rules concerning working conditions regarding worker safety. This struggle goes back to the safety rules of mining (such as hours, ventilation, fire exits, etc.) in the 40s and 50s, child labor, the sewing sweatshops, and basement bakeries of the era. Whenever our country changes political hands, the anti-regulationists fight with the social justice protectionists to either keep worker safety rules or dismantle them. OSHA has been partially dismantled over the years, along with other regulating agencies like the Environmental Protection Agency (EPA) and the Centers for Disease Control and Prevention (CDC), with every anti-regulation election winner to the white house since these regulatory safety agencies were established.

Alarm Fatigue:

• Alarm Fatigue “occurs when clinicians become desensitized and nonreactive to the sensory overload created by an overwhelming number of alarms” (NACNS, 2014)

Body mechanics:

• Applying physical principles to achieve maximum efficiency and limit the risk of bodily stress or injury…(Medical Dictionary, 2012)

Ergonomics:

• The applied science of equipment design, as for the workplace, intended to maximize productivity, reducing operator fatigue and discomfort (American Heritage, 2011)

Hazmat:

• Hazardous material

HCS/GHS:

• The HCS Hazard Communication Standard. The GHS is an acronym for The Globally Harmonized System of Classification and Labeling of Chemicals (UNECE, 2023)

LD50:

• 50% of experimental animals (rabbits, rats, mice, etc.) were killed when this dose (of chemical or drug) was orally ingested, dermally applied, or inhaled. It is measured in mg/kg of body weight. 

NIOSH:

• The National Institute for Occupational Safety and Health, an organizational component of the CDC, works with OSHA to keep healthcare and other workers safe.

OSHA:

• The Occupational Safety and Health Administration, an arm of the US Labor Bureau, was established in 1970 by the United States Congress to provide employee safety regulations for nearly every occupation.

PPE:

• Personal protective equipment includes gloves, masks, gowns, shoe covers, and reinforced clothing such as hazmat suits.

PASS:

• A fire safety training memory tool for Pull, Aim, Squeeze, and Sweep

RACE:

• A fire safety training memory tool for Remove, Alert, Confine, and Extinguish

Standard Precautions:

• Infection prevention practices in the healthcare workplace and anywhere patients are cared for, regardless of a patient’s diagnosis and possible status of contagion. (Farlex, 2012)

Universal Precautions:

• (Universal Blood and Body Fluid Precautions). CDC rules were made 1987 to prevent exposure to human body fluids, such as infectious material from HIV and other bloodborne pathogens (Farlex 2012).

So, what is meant by hazard communication? The first thing that may come to mind is the pictogram showing a stick figure worker slipping on a wet surface. That is a form of hazard communication, but there is so much more to it. What about the hospital color codes for announcements such as “code blue” and “red bags” for biohazard, bloodborne pathogens, radiation danger, needlestick injury signage on sharps containers, slip and fall signs, electric shock warnings, medical gas danger, explosion symbols, the list seems endless! We will sort through and discover potential hazards, learn to spot problems, internalize safety issues, and work to create safer workplaces for us, our co-workers, and our patients.

“Healthcare workers (HCWs) are at high risk of occupational injuries, and approximately 10–15% of patients are affected by an adverse event during their hospital stay” (Strid et al., 2021).

Prevention is the key to a safer workplace. Below are two examples of hazardous communication for fire safety.

R.A.C.E for Fire Safety

The procedure will vary among facilities and establishments.

Consult your safety departments for further details.

• R=RESCUE
  • Remove anyone in immediate danger from the fire if it does not endanger your life.
• A=ALARM
  • Activate the nearest pull station. Call 911 or your local emergency number and provide the location and type of the fire.
• C=CONTAIN
  • Confine/Contain the fire by closing all doors and windows.
• E=EXTINGUISH
  • If the fire is small enough, extinguish the fire with a fire extinguisher using the PASS method.
    • PULL pin
    • AIM extinguisher
    • SQUEEZE the lever or handle
    • SWEEP nozzle or hose side to side

Figure 1. P.A.S.S. mnemonic for fire extinguisher use

Signs and signage in the workplace

• Health And Safety Signs Examples.
• Signs show things that must be done, such as wearing safety goggles, helmets, hearing protection, and respiratory protection.
• To indicate workplace hazards such as a trip, slip, or fall hazard.
• Risk-to-life signs such as electricity voltage, poison symbols, or deep-water signs.
• Directional signs to show where to go in an emergency, such as Fire Exit or First Aid location signage.
• Warning signs to tell people not to do something, (e.g., No Parking, No Smoking, etc.).
• Signs highlighting hygiene compliance, such as in food preparation areas and bathrooms.
• COVID-19 signs to remind staff and the public of the ongoing risks.
• Waste & Recycling Signs.
• Fire Safety Signs.
• First Aid Signs.
• Mandatory Signs.
• OSHA poster.
• Can you think of others?

Figure 2.  Safety/Hazard Signs

“These symbols provide essential safety information that could prevent injury – or save a life. Every worker should know them and what they mean” (Barrett, 2024).

The Occupational Safety and Health Administration (OSHA) is a federal and state government program created in 1970 to protect workers from known work hazards in mostly manufacturing industries(Rosner & Markowitz, 2020). OSHA inspects workplaces for various programmed and unprogrammed themes, such as multidrug-resistant organism safety, exposure to hazardous chemicals, and other things like waste gases, lasers, and radiation. According to OSHA, every worker has the right to work in a safe environment. As a governmental agency, OSHA can fine companies for workplace safety rule infractions. Also, as a government agency, the strictness of policy enforcement is contingent on the changing political ideology in the country's administration and agency. OSHA publishes compliance information, safety training materials, and extensive occupational safety articles on the website here. OSHA regulates workplace hazard communication signs, caution, safety, and biohazard signs. The OSHA standard includes sign colors, shapes, wording rules, accuracy, and even the tone of the message on the signs (positive rather than negative)(Nemmers, 2022). Why are HCWs getting hurt despite the hazardous communications all around them in every room, department, and corridor?

The problem with hazard communications is that multiple signs create a condition similar to alarm fatigue. Dr. Green (2024) said that workers fatigued by warning signs began performing their jobs riskier due to the warning insensitivity. When healthcare workers see the same WARNING signs in the same places day after day, they become habituated to them and become as good as invisible. A fascinating study by Kim et al. (2023) reported that virtual reality (VR) accident training helped to decrease this sign fatigue, providing safer outcomes. Students who were tested for warning sign fatigue by Vance et al. (2017) forgot which signs they had been seeing regularly. They report that polymorphic signage, signs that create a small visual variation, reduce sign fatigue, and sustained novelty over time. They also found that if the signs were moved up or down or closer to the actual risk, they were noticed more. The study by Vance et al. (2023) also enumerated that although the students spoke the language of the signs, they did not always understand the hazard’s significance, such as why a particular area was a no-smoking area. Pictograms showing an explosion combined with the no smoking sign were more effective with fewer words. Signage may be adjusted in some types of signs, such as color, size, and orientation, according to the OSHA Standards, if they are not mandated (Nemmers, 2022). All the hazard communication in the world will not help a person stay safe unless they are motivated to obey them and avoid the warned action. Dr. Green (2024) makes an interesting point about whether or not the danger or warning sign will be obeyed depending on each person’s psychological approach. His point is that many calculations are going on when someone decides to deliberately ignore a warning sign, based on that person’s thinking process goals, the costs to attain them, their perception of the danger, and “personal and social and cultural decision-making factors” (Green, 2024). To follow this through, think of the person who sees a 55-mph sign while driving. Whether to obey it will be subject to automatic thoughts and calculations. First, what is the goal (getting somewhere at the best speed and safety, being a good driver, etc.), and how important (getting to a wedding or a convenience store for a snack)? Then, what is the cost of obeying the sign (the trip will take longer)? If they disobey, the price could be a ticket or a severe accident. Finally, how does this person view a speed limit culturally and socially (as an unnecessary restriction, or a part of the law, and therefore “good” or “bad”)? This holds in the healthcare workplace as well. Suppose a healthcare worker walks past the same sign daily that reports DO NOT ENTER, and the sign has a huge active magnet picture. They may decide that the sign indicates a danger unlikely to be important at the current time of day and want to cut through to reach the other side of the unit quicker. They have a goal and have decided how important it is and how serious the warning is. They will finally obey the signs in their previous mental calculations and social/ cultural experiences. As an experienced healthcare worker familiar with the building and the various warnings, they may decide to continue through the door despite the warning, which they have determined is irrelevant since MRIs are not performed until 8 am and because they are in a hurry. This example will be investigated further in Case Study #3.

The National Institute for Occupational Safety and Health is the occupational health research arm of the Centers for Disease Control. Through research and prevention, NIOSH ensures the safety and health of all people in the workplace. For more specific information, visit the website (CDC, 2023). NIOSH and OSHA work together to prevent hazardous drugs and chemicals from harming healthcare workers.

NIOSH has updated its list of hazardous drugs in healthcare settings every two years since 2010. The list includes FDA-approved drugs for humans and those human drugs used for animals that are hazardous to anyone who handles, prepares, administers, or disposes of them. These drugs may cause reproductive, genetic, and developmental in-utero toxicity and carcinogenic harm. Thankfully, NIOSH also produced a 76-page treatise on what they are and how to avoid, eliminate, or reduce injury. Information includes what PPE to use, storage directions, equipment, and how to clean up spills. Home healthcare and veterinary use exposure are also covered. Since we cannot do without chemotherapy drugs and other medications such as antivirals and analgesics, risks must be reduced or eliminated by limiting exposure through administrative, engineering controls, and PPE. Therefore, training in storing, preparing, administering, and disposing of these medications should occur annually. HCWs can consider the complete picture of the hazardous drug, including every time the drug itself or the bodily waste from the patient or animal using the drug is handled. In section 16 of every drug package insert, a manufacturer’s particular handling information (MSHI) should be read before handling drugs that are considered hazardous. This information is essential to people who are or may be pregnant, as well as others, because injury can occur to the egg and the sperm, organs, and blood (Hodson et al., 2023). Many drugs designed to kill cells, such as cancer cells, can and do kill healthy cells. Sadly, no known limits exist on how long a worker can safely be exposed to a carcinogen.

According to OSHA and NIOSH, the hierarchy of controls graph below shows how to eliminate hazardous chemical injuries in the workplace.

Figure 3. Hierarchy of Controls

Let’s imagine a hazardous chemical we work with, such as a fentanyl patch. Notice that the PPE is at the bottom of the chart, indicating it is the least effective measure, but we will wear gloves and a mask to administer or dispose of a used patch. We will wash our hands and discard the patch in a sharps container or a biohazard bag. Here, the hazard is accidental exposure of the HCWs or patients and families to the used fentanyl patch. The patch retains enough fentanyl to overdose anyone or any animal that ingests the gel, which is stronger than the proposed actual dose delivered. As we look up the hierarchy, we can see that we don’t need to change the PPE or how we work, which is how we isolate people from danger (Engineering Controls). In substitution, which is considered a much better way to prevent exposure, could the patient use a less dangerous pain medication? Finally, we use the most effective way to avoid exposure: we eliminate the used patch by disposing of the sharps container or the “red bag” by incineration. This hierarchy of controls may be used in all healthcare professions regardless of the hazard to be prevented.

According to OSHA, manufacturers of hazardous chemicals, including drugs, must have signage of danger. Hazardous pharmaceuticals must follow Hazardous Communication Standards (HCS) 29 CFR 1910.1200. The manufacturer and the importer are the primary ones responsible for labeling and Safety Data Sheets (SDSs). The HCS provides the workers who deal with these hazardous chemicals or drugs with the right to have all the information in the workplace for their safety. Suppose the manufacturer fails to provide SDS for the chemical. In that case, the employer is held responsible for obtaining them but not for incorrect information if they act in good faith. Chemicals in the healthcare environment may cause acute toxicity or result in small and continuing damaging exposures over time. There are many hazardous chemicals used in laboratories and pharmacies. Those HCWs are trained to use a vent hood and various forms of PPE to protect them from accidental inhalation or topical exposure. OSHA's recommendations for Respiratory Protection Standards are found here(OSHA, n.d.a). OSHA also requires recertification of the vent hoods and cabinets every six months, and whenever they are maintained or replaced. Many drugs are dangerous to handle. Fentanyl (liquid, gel, or solid) in tiny amounts is deadly to breathe or ingest. Fentanyl gel or liquid and other opiates are dangerous to handle without gloves as well.  “Anticancer drugs can be inhaled or absorbed through the skin; cutaneous absorption has been observed for cyclophosphamide, 5-fluorouracil, and methotrexate, also after the use of Personal Protective Equipment (PPE)” (Charlier et al., 2021). PPE, such as gloves, must be rated for chemical exposure.  Many chemical cleaners produce dangerous or even deadly gases when mixed with others. For instance, chlorine bleach and ammonia produce chloramine gas, and chlorine bleach and acid mixed produce deadly chlorine gas. “According to the American Association of Poison Control Centers, accidental exposures to chlorine gas from mixing bleach and acid happened 2,284 times in 2017 … “ (Boerner. 2019). Various chemicals are often combined to create cleaners that will dissolve different types of soils, wax, grease, blood, bacteria, and other contaminants. The danger lies in mixing the different cleaners. Chemists who conceive the cleaners do not expect a completely different chemical mixture to be added to the one they have designed. This can and does kill people.

OSHA ensured we have Safety Data Sheets (SDS). These were formerly known as material safety data sheets (MSDS). What is found on every SDS for the occupation sectors. Firstly, the SDS for each hazardous chemical should be provided by the supplier of the products that manufacture the dangerous chemical. For example, suppose a supplier sends cases of ammonia floor cleanser or antiseptic hard surface wipes to your workplace. In that case, they are responsible for providing the SDS for the hazardous ingredients to the employers. The employer is then responsible for making those available to the employees. Secondly, it is mandated that all employees have easy access to SDS for every hazardous chemical that is in their work areas. This requires employee language training to access the materials if stored on paper or electronically. Thirdly, the contents of the SDS are also mandated. The SDS sheets must include 16 specific areas of information to comply with the internationalized Global Harmonized System (GHS) version.

SDS contents include (in part):

• The name of the hazardous chemical signature and the health effects of product exposure.
• Risk assessment for the product's usage, storage, and handling must appear. What precautions should personnel at risk of exposure take?
• Emergency protocols include what to use to counteract the chemical if it is contacted, ingested, on fire, or spilled.
• How to safely dispose of the chemical, and other areas covered might be when it was last printed and reviewed.

SDSs should be reviewed every three years to be kept up to date.

Out of 16 sections, the SDS sheets have nine sections that would be most directly helpful to the (non-chemist) worker:

• Section 1. Identification/ name of the chemical or product:
  • For example,” Floor Cleaner.” Name and address of the manufacturer.
• Section 2. Hazards Identifications:
  • These include eye, lung, or skin irritation, hazard prevention, and exposure-response. Instructions on storing and disposing of the product are also found here.
• Section 4. First Aid Measures:
  • Whether poison control is needed for skin exposure, ingestion, and first aid Facilities.
• Section 5. Firefighting Measures:
  • This section covers which type of extinguisher will be used with this or these chemical(s), whether toxic fumes will be released if heated, whether a Hazchem number is applied, and particular firefighter advice.
• Section 6. Accidental Release:
  • This section includes information on what PPE should be used, environmental considerations, and what to use to clean up. It may also refer to other pertinent sections.
• Section 7. Handling and Storage:
  • Substance handling and storage, as well as “specific end uses,” are listed here.
• Section 8. Exposure Controls and Personal Protection:
  • Which PPE is needed for each part of the worker's body, e.g., Eyes, skin, respiratory, etc.? How much chemical exposure is expected with the constituents, what are the limits, and what precautions must be taken?
• Section 10. Stability and Reactivity:
  • The stability and reactivity of the product (chemical or chemical mixture) in various conditions like high or low temps. Conditions to avoid, like sparks or fire, salt water, etc. Finally, what should you expect as this product undergoes decomposition, such as in a fire or freeze?
• Section 11. Toxicological Information:
  • This will be where you can find the constituents' Lethal Dose 50 (LD50) orally, dermally, and via inhalation.
• Section. 13. Disposal Consideration:
  • This is where you find the directions for treating the product's waste in small or large quantities, such as putting it down the sewer, soaking it up with perlite, or placing it in a landfill.

For a sample of an SDS of a chemical floor cleaner, go to MSDS Power Fresh Bleach Hospital Grade.

Daniqia and Hassan are patient care assistants working to get all the residents at the rehab facility weighed for the week. Mr. Williams is a 64-year-old male patient who was ambulatory but has had recent knee surgery and is a 2+ max assist patient. Mr. Williams’s last weight was 397 pounds (180.5 Kg). Hassan remembers that the last time he weighed Mr. Williams, he and the patient almost fell. Because of this previous near fall, he and Daniqia planned to use the lifting equipment with a scale kit. This safety equipment makes it possible to weigh very heavy patients without injuring them or employees. Back injuries to patient care assistants in the healthcare workplace were the specific cause of an average of ten days away from work among HCWs, according to the Bureau of Labor; therefore, OSHA mandates safety equipment. Although Daniqia and Hassan find it time-consuming and, frankly, they don’t like using the lift, they both understand that they or the patient could be seriously injured if they don’t. It would take them as much time to get more helpers to weigh Mr. Williams than to use the conveniently located lift. Recently, they both had the OSHA training module on body mechanics and were trained to use the safety equipment properly. As certified healthcare workers, they have required training to maintain their certification. Their state also requires them to have a certain number of CEUs to renew their certifications. Their workplace has made these things available so the company administrators can easily maintain OSHA safety regulations. Fewer healthcare workers and patient injuries also represent fewer financial and human resource losses to the medical facility.

Both employees don nonsterile gloves and explain the lift scale apparatus's purpose and how they will use it. Moving the sling apparatus to the bedside, they plug it in and unhook the sling straps. First, Daniqia checks the max weight allowance to ensure the lift apparatus is strong enough to lift the patient safely. They instruct Mr. Williams to roll to one side as they slide the sling across the bed to his back. Rolling him over it and to the other side, they straightened out the sling behind him. Hassan lowers the lifting arm with the attached scale to the straps and fastens them securely. Daniqia zeroes out the scale, sets it for kilograms, and turns it on. Explaining what they are doing at every step, she lifts the patient with the machine enough to swing him out to the bedside and records his weight. Hassan moves Mr. Williams back over the bed and lowers him down to the bed surface, removing the sling by asking Mr. Williams to roll over and back again. The entire process took about eight minutes. At first, Mr. Williams was a little afraid of the sling and the lift; however, when he saw how well it worked and how comfortable it was, he reported he was willing and able to do that again.

Points for Consideration:

• If OSHA had not mandated the company to supply safety equipment to assist with a known safety hazard, what might have happened?
• If OSHA had not directed the safety equipment (in this case, a Hoyer lift with scale apparatus) to be kept in a convenient place, what might the employees have done?
• If OSHA had not compelled employees to train in the safe use of the equipment and correct body mechanics, what might have happened to the patient or the employees?

Healthcare industry workers continue to have a high rate of workplace injuries; more than half of them are musculoskeletal injuries.According to OSHA, these injuries are partly caused by repeated straining of the musculoskeletal system, overstraining, and slips or falls during patient care. According to Oakman et al., (2022)

“WMSDs (Workplace musculoskeletal disorders) are complex disorders which require identification and control of relevant physical and psychosocial workplace hazards, yet findings from the current study suggest that tools are not being effectively used to support mitigation of workplace physical and psychosocial hazards.”

Safety equipment is mandated; however, employers and employees must use it to prevent injury. Unfortunately, OSHA cannot mandate the availability of time to use safety measures, as this concerns employee-to-customer ratios. More reasonable (given time constraints) mandated employee-to-customer ratios have been hard fought, with employer profit/loss margins and politics being the main culprits.

Organizations and agencies have not mandated the nurse-to-patient ratio to date except in two states, MA and CA, and partially in a few other states (ANA, 2023). A well-planned and informative study by Lasater et al. (2021) encompassed 116 hospitals and 417,861 Medicare medical and surgical patients all over New York. In the study, 2,747 Registered nurses for two years were asked, “How many patients did you have on your last shift”? The responses varied from as little as 4.3 to 10.5 patients per nurse, with an average of 6.3 patients per nurse (6.9 in New York City proper). Then, Lassater et al. (2021) studied statistics from the Centers for Medicare and Medicaid Services, MEDPAR, and Services Impact Files. These data sources incorporated Medicare Claim Data, mortality, length of stay, and readmissions within 30 days of all 417,861 patients. This study concluded that higher nurse-to-patient ratios save lives, reduce readmissions, and lower hospital costs. It is generally known and accepted that higher staff-to-patient ratios produce greater safety from staff musculoskeletal injuries (Lee et al. 2021). There was a bill in Congress and the Senate to make the nursing ratios a matter of law nationwide. A supporting statement released by the ANA stated,

“ The American Nurses Association (ANA) supports the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act (H.R.2530 and S.1113), which would establish minimum nurse-to-patient ratios for every hospital…and provide whistleblower protections for nurses who choose to advocate for the safety of their patients” (ANA 2023).

However, the bills were introduced and did not come into consideration. OSHA has not mandated nurse-patient ratios due to the lack of legislative support.

For the complete ANA press release, go here

Go here for the OSHA Safe Patient Handling publication (OSHA, 2014).

How can healthcare employees spot risks that should be covered by OSHA or need reporting? Workers know they can clean up tripping, slipping, and fall hazards.

What are the red flags?

• Tripping or falling hazards that are not easy to fix, for instance, an unprotected drop-off or a heavy apparatus in a precarious position close to employees or patients.
• Is there a risk of an electrical fire or an explosion? Can you smell fumes?
• Are there sources of radiation that are not shielded? How would you know?
• Are gases being vented near patients or employees that aren’t safe? Are workers exposed to waste gases in poorly ventilated areas?
• Are there extension cords in work areas that are overloaded? Are there frayed cords or low-power lines?
• Is a patient too heavy or unable to help in a transfer? Is the equipment up to date and safe for use?
• Are sterile supplies stacked on the floor? Are pieces of equipment stored against exit doors?

The employee sometimes finds an unsafe condition by almost being injured. Sometimes, a worker may discover a danger by injury (see case study 3). Healthcare workers can request to see all safety reports for their workplace facility. Online, you can check your company’s record of violations. Employees can call OSHA or go online to report safety violations or new risks in their workplace anonymously. Employees can request an OSHA inspection anonymously and be assured that OSHA will “check it out.” OSHA also protects the employee from retribution for reporting what may be safety violations.

Contact information for notifying OSHA is 1-800-321-OSHA, or you can find it online here(OSHA, n.d.c).

You can get involved in the safety culture of your workplace, state, or nation by joining work committees and healthcare worker’s associations such as the ANA, which has four million members nationally. Many are lobbying Congress for safer workplaces. Those workers using the same equipment and safety guidelines that are nevertheless not protected by OSHA standards should consider getting involved in the attempt to encourage legislative support for increased, inclusive worker safety regulation in our country. Employees not covered by OSHA regulations are:

• Self-employed workers
• Independent contractors
• Volunteers
• Interns
• Family members of farm owners
• Employees of state and local governments (Individual and local governments are responsible for them)

In an article in the National Institutes of Health Library, Wizner (2021) explains that in 2018, California's Worker's Compensation cost was $23.5 billion. Because of the extensive database the Wizner study used, the data may apply to all HCWs nationally (2021). These graphs show the injury rate across the four healthcare settings and the eight job types injured in those four settings over ten years.

Figure 4. HCW injury by setting
(Wisner et al., 2021)

Healthcare workers in hospitals and nursing/residential care were the most injured on the job, with nurses' and nurses’ aides being the highest. Back pain was the highest musculoskeletal disorder. HCWs and administrators have to work together to help prevent injuries (AlJabri et al., 2020)

Fig. 5. Medical and occupational injuries by position
(Wisner et al., 2022)

It should be assumed that any employer would be morally, financially, and logically on board with employee safety and, by extension, customer safety. However, there is a continuing need for OSHA inspections of healthcare workplaces and other occupational sectors. Employers, in turn, are offered training materials and safety advice on request for free without penalty. OSHA’s Section 5(a)(1) of the Occupational Safety and Health Act, also known as The General Duty Clause, requires employers to furnish a workplace free from recognized hazards that may cause or are likely to cause death or serious physical harm.Healthcare workplaces that are “Magnet” facilities also have requirements similar to those of OSHA, based on the Joint Commission requirements for “Magnet” status.

Employers are required by OSHA Safety and Health Management Systems Standards to provide safety and prevention training regarding known and common likely workplace dangers. In healthcare, there are many, such as needle sticks, exposure to toxic drugs, violence, infection, chemical contact reactions, body mechanics failures, slips and falls, and others. Workplaces must have emergency response plans and specific training in place in case of known unlikely danger possibilities, such as fires, explosions, unsafe weather events, or major catastrophes. Records of any injuries or deaths must be kept. Employers are required by law (OSHA) to report workplace deaths within 8 hours and any severe injury within 24 hours.

OSHA can fine noncompliant employers with the full weight of the US government behind the agency. For “Willful” (intentionally, knowingly) safety violations, the fine can be as much as $160,323.00 per violation. If they have already been warned or fined for a violation and have not abated the issue, they can be fined up to a maximum of $16,131 per day for up to thirty days. If a violation is repeated in the future, there will be another $161,323.00 fine. If a company commits a “Serious” violation, this could be up to $16,131 per violation. States with their own OSHA entity must have max fines at least as “effective” as OSHA’s Federal fines. State and local government employers are not required to be fined for citations, although they can.

According to Emily Mibach of The Daily Post, in October of 2023, a Bay Area nurse who works for Kaiser Healthcare System was moving a metal bed in the interventional radiology department anteroom for Magnetic Resonance Imaging (MRI) after preparing the patient to have an MRI. The MRI has a magnetic force that is 300 times stronger than that of a refrigerator magnet. To do this, she passed by where the door to the MRI room was inadvertently left open during the operation. Unfortunately, the MRI machine was in use at the time. The powerful magnets of the MRI pulled the metal bed abruptly, crushing the nurse between the metal bed and the MRI machine. OSHA reported, “She suffered injuries to her pelvis, right leg, and abdomen, according to documents the Post obtained from the California Occupational Safety and Health Administration. She spent several days in the hospital recovering (Mibach, 2023).”

OSHA reported that the nurse also had a severe laceration that required surgery. The nurse reported in a KTVU article, “Basically, I was running backward; if I didn’t run, the bed would smash me underneath."(Jaroz, 2023). OSHA fined Kaiser $18,000.00 for the safety violation of not having a plan to keep the door shut when the machine was in use. Kaiser reported that hazard communication signage and training on MRI safety were in place. As you might expect, multiple meetings occurred within hours of the incident to attempt to prevent such an accident in the future. The spokesperson for the Kaiser Healthcare System reported that they cooperated with investigators from the U.S. Department of Health & Human Services, Centers for Medicare and Medicaid Services (CMS), and Cal/OSHA. Multiple control areas were adjusted, such as personnel training, policy and procedure changes, and ensuring the system was aligned with the American College of Radiology Safety Guidelines. Ultimately, the Centers for Medicare and Medicaid approved the action plans. For a KVTU interview (Jaroz, 2023) with the nurse and a photo of the bed trapped in the MRI machine, go here.

Points to consider:

• What if, in the sudden magnetic pull, the nurse who was running backward trying to escape the bed had fallen, and her head had come between the metal bed and the MRI machine?
• What could the nurse have done to prevent the injury?
• If the patient (who did fall out of the bed, uninjured) had been sitting in a wheelchair at the time of the incident, what might have been the result for the patient and the nurse?

Figure 6. MRI Patient Safety Poster
(PA Patient Safety Authority, 2018)

A multitude of strategies exist to prevent healthcare worker injuries. Many studies have been written and reviewed to determine what is needed to avoid direct patient care and non-direct healthcare worker injuries. The World Health Organization (2022) has written a comprehensive e-book to help companies organize their occupational health and safety programs. Any worker can read these for free online. See “Resources” below. A quick review of the number of articles written since 2020 from Google Scholar produces 17,600 using the term “Healthcare workers injury in the workplace.” Various injury prevention strategies noted are:

• Have a well-thought-out occupational health and safety program.
• Increased HCW training and knowledge of infectious pathogens’ mode of infection and the use of universal precautions (Alhumaid, 2021).
• A supervisor with a positive safety attitude and a whole team approach to “unit” safety (NIH n.d.).
• The belief of workers that safety is a serious issue and that their company cares about their safety (Shaw et al.,2020).
• A “no blame” environment for reporting safety issues in the workplace (WHO 2022).

The creation of OSHA over 50 years ago was initially meant to help protect specific workers in an industrialized, for-profit America from literally dying on the job (Rosner & Markowitz, 2020). Over the years, OSHA has become more generalized, covering Americans with a few exceptions. OSHA involves hazard identification, warning, training, record-keeping, and punitive measures for non-compliant companies with known safety hazards. Hazard Communications, which OSHA specifically mandates, are many, and there are also non-mandated hazard communications in the healthcare worker’s daily environment. Like “alarm fatigue,” HCWs can become so accustomed to all the hazard signs around them that the “hazard communications” might as well have become invisible. We tend to grow desensitized and overconfident about the many dangers around us on every shift, and this causes at least some workplace injuries. Another main reason for workplace injury is the need for speed. Due to decreasing staff and increasing responsibilities, some HCWs skip safety protocols to complete them in time.

Thanks to OSHA, we have mandates for SDS for all the hazardous chemicals we might encounter within our workplaces. We have personal protective equipment we don’t have to pay for to do our jobs. We are trained (in a language we can understand) to find the safety data sheets and how to read them. The SDS is now compliant with the rest of the world (GHS) in the 16 areas of chemical property information. We know to look at section number 16 (MSHI) of drug package inserts for hazards of drug handling. We have hazard communication regarding fire safety training, such as RACE and PASS, to help us remember what to do in a fire emergency. We have hazardous communication in every area of the healthcare worker’s environment, such as radiation, lasers, dangerous machinery, gases, and chemicals. While study after study shows conclusively that the safety of HCWs and patients depends on staffing ratios, healthcare administrative buy-in, and OSHA compliance, we still have no OSHA mandate for nurse-to-patient ratios. Bipartisan legislative support for further OSHA measures in healthcare staffing has been lacking. Companies with a positive safety culture reduce their financial losses due to lost productivity and legal and medical costs for employee injuries. As employees of American companies fulfilling OSHA regulations, we are expected to internalize the training and warnings, notice the dangers to ourselves and others, and report dangers not sufficiently safeguarded against. Consider getting involved in the safety culture of your work environment and that of the rest of the country.

• OSHA’s Workers Rights and Protections, go here(OSHA, n.d.c).
• OSHA’s home website, go here(OSHA, n.d.d).
• Contact information for notifying OSHA is 1-800-321-OSHA or online here(OSHA, n.d.b).
• For information on how political environments affect OSHA power, go here(Rosner & Markowitz, 2024).
• For all OSHA training requirements in OSHA standards, go here (OSHA, 2015).
• For more specific information,  visit the NIOSH website here(NIOSH, 2023).
• For the complete ANA press release, go here(ANA, 2023).
• Go here for the OSHA Safe Patient Handling publication (OSHA, 2014).
• For the World Health Organization’s guide for developing and implementing Occupational Health and Safety programs for health workers, go here(WHO, 2022).
• OSHA Hospital eTool here For Hospital Hazards Prevention (OSHA, 2023).
• OSHA’s Hospital Worker Safety go here(OSHA, n.d.e).

• Alhumaid, S., Al Mutair, A., Al Alawi, Z., Alsuliman, M., Ahmed, G. Y., Rabaan, A. A., Al-Tawfiq, J. A., & Al-Omari, A. (2021). Knowledge of infection prevention and control among healthcare workers and factors influencing compliance: a systematic review. Antimicrobial Resistance & Infection Control, 10(1), 86. Visit Source.
• Aljabri, D., Vaughn, A., Austin, M., White, L., Li, Z., Naessens, J., & Spaulding, A. (2020). An investigation of healthcare worker perception of their workplace safety and incidence of injury. Workplace health & safety, 68(5), 214-225. Visit Source.
• American Heritage® Dictionary of the English Language, Fifth Edition. (American Heritage). (2011). Ergonomics. Visit Source.
• American Nurses Association, (ANA). (2023). American Nurses Association supports the nurse staffing standards for hospital patient safety and quality care act. American Nurses Association (ANA). Visit Source.
• Barrett, J. (2024). Safety symbols and their meanings. Safeopedia. Visit Source.
• Blackley, B. H., Nett, R. J., Cox‐Ganser, J. M., Harvey, R. R., & Virji, M. A. (2023). Eye and airway symptoms in hospital staff exposed to a product containing hydrogen peroxide, peracetic acid, and acetic acid. American Journal of Industrial Medicine, 66(8), 655-669. Visit Source.
• Boerner, L.K. (2019). Accidental Mix of Bleach and Acid Kills Buffalo Wild Wings Employee, Chemical and Engineering News, vol. 97(45). Visit Source.
• Centers for Disease Control and Prevention. (CDC). (2023). National institute for occupational safety & health (NIOSH). Centers for Disease Control and Prevention (CDC). Visit Source.
• Charlier, B., Coglianese, A., De Rosa, F., De Caro, F., Piazza, O., Motta, O., ... & Izzo, V. (2021). Chemical risk in hospital settings: Overview on monitoring strategies and international regulatory aspects. Journal of Public Health Research, 10(1). Visit Source.
• Complete Office Supplies. (2021). Safety Data Sheet- Power Fresh Bleach-Hospital Grade. Visit Source.
• Ecolab. (2019). Safety Data Sheet- Oxycide Daily Disinfectant Cleaner. Visit Source.
• Evans, G. (2016). Protect Patients, Harm Workers? Cleaning Agent Raises Concerns: Healthcare dilemma: Kill the bugs but spare the workers. Relias Media. Visit Source.
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• Fearn, S. (2023). Mystery of ‘toxic lady’ who made medics around her sick. Unilad. Visit Source.
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• Grant, P. M., Haas, J. S., Whipple, R. E., & Andresen, B. D. (1997). A possible chemical explanation for the events associated with the death of Gloria Ramirez at Riverside General Hospital. Forensic Science International, 87(3), 219-237. Visit Source.
• Green,M. (2024). The Psychology of Warnings. Human Factors and Science. Visit Source.
• Hodson L, Ovesen J, Couch J, Hirst D, Lawson C, Lentz TJ, MacKenzie B, Mead K. (2023). Managing hazardous drug exposures: information for healthcare settings. National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2023-130. Visit Source.
• Jaroz, B. (2023).  Bay Area nurse crushed in MRI accident highlighting safety concerns. FOX KTVU. Visit Source.
• Kim, N., Grégoire, L., Razavi, M., Yan, N., Ahn, C. R., & Anderson, B. A. (2023). Virtual accident curb risk habituation in workers by restoring sensory responses to real-world warning. Iscience, 26(1). Visit Source.
• Lasater, K. B., Aiken, L. H., Sloane, D. M., French, R., Anusiewicz, C. V., Martin, B., Reneau, K., Alexander, M., & McHugh, M. D. (2021). Is hospital nurse staffing legislation in the public's interest?: An observational study in New York State. Medical Care, 59(5), 444–450. Visit Source.
• Lee, S. J., Stock, L., Michalchuk, V., Adesoye, K., & Mullen, K. (2021). Impact of California safe patient handling legislation: Health care workers’ perspectives. Workplace Health & Safety, 69(3), 124-133. Visit Source.
• Medical Dictionary for the Health Professions and Nursing. (2012) Body mechanics. (2012). Visit Source.
• Medical Dictionary for the Health Professions and Nursing. (2012). Standard precautions. Visit Source.
• Mibach, E. (2023). Kaiser Redwood City fined after MRI machine injures nurse. The Daily Post. Visit Source.
• National Association of Clinical Nurse Specialists (NACNS). (2014). Alarm Fatigue. Visit Source.
• National Institutes of Health. (NIH). (n.d.) Safety, health and wellness, responsibilities for supervisors. National Institutes of Health. Visit Source.
• National Institute for Occupational Safety and Health. (NIOSH). (n.d.). Hierarchy of controls (infographic). Centers for Disease Control. Visit Source.
• National Institute for Occupational Safety and Health. (NIOSH). (2023). Managing hazardous drug exposures: Information for healthcare settings. Centers for Disease Control and Prevention (CDC). Visit Source.
• Nemmers, P. (2022).OSHA Safety Signs: Compliance, National Association of Safety Professionals. Visit Source.
• Oakman, J., Kinsman, N., Weale, V., & Stuckey, R. (2022). A qualitative exploration of tools used by WHS professionals for the prevention of musculoskeletal disorders. Safety Science, 149, 105685. Visit Source.
• Occupational Safety and Health Administration. (OSHA). (n.d. a). Respiratory Protection Standards.Visit Source.
• Occupational Safety and Health Administration. (OSHA). (n.d.b). Report a Fatality or Severe Injury. Visit Source.
• Occupational Safety and Health Administration. (OSHA). (n.d.c). Workers Rights and Protection. Visit Source.
• Occupational Safety and Health Administration. (OSHA). (n.d.d). Occupational Safety and Health Administration Homepage. Visit Source.
• Occupational Safety and Health Administration. (OSHA). (n.d.e). Worker Safety in Hospitals. Visit Source.
• Occupational Safety and Health Administration. (OSHA). (2014). Safe Patient Handling. Visit Source.
• Occupational Safety and Health Administration. (OSHA). (2015). Training requirements in OSHA standards. Occupational Safety and Health Administration (OSHA). 2254-09R 2015. Visit Source.
• Occupational Safety and Health Administration. (OSHA). (2020). Worker safety in hospitals: caring for our caregivers. United States Department of Labor. Visit Source.
• Occupational Safety and Health Administration. (OSHA). (2023). Hospitals eTools. Visit Source.
• PA safe patient advisories. (2018). MRI patient safety poster (infographic). Visit Source.
• Rosner, D., & Markowitz, G. (2020). A short history of occupational safety and health in the United States. American journal of public health, 110(5), 622-628. Visit Source.
• Saling, J. (2023). DMSO. WebMd. Visit Source.
• Shaw, A., Flott, K., Fontana, G., Durkin, M., & Darzi, A. (2020). No patient safety without health worker safety. The Lancet, 396(10262), 1541-1543. Visit Source.
• Strid, E. N., Wåhlin, C., Ros, A., & Kvarnström, S. (2021). Health care workers’ experiences of workplace incidents that posed a risk of patient and worker injury: a critical incident technique analysis. BMC health services research. 21 (511). Visit Source.
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• Vance, A., Kirwan, B., Bjornn, D., Jenkins, J., & Anderson, B. B. (2017). What do we really know about how habituation to warnings occurs over time? A longitudinal fMRI study of habituation and polymorphic warnings. Proceedings of the 2017 CHI Conference on Human Factors in Computing Systems. Visit Source.
• Wizner, K., Gaspar, F. W., Biggio, A., & Wiesner, S. (2021). Occupational injuries in California's health care and social assistance industry, 2009 to 2018. Health science reports, 4(2), e306. Visit Source.
• World Health Organization. (WHO). (2022). Caring for those who care: guide for the development and implementation of occupational health and safety programs for health workers. World Health Organization (WHO). Visit Source.