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Joint Commission focuses on biohazard container labeling


February 8, 2018

Double-check the inventory of your hazardous waste and materials on site, ensure that biohazard containers have the correct labeling available for whatever chemicals are inside and ensure new staff are trained on the hazardous materials used in their departments.

The Joint Commission (TJC) standard requiring hospitals to minimize risks related to hazardous waste and materials is often among the top most challenging standards for hospitals. Now with TJC’s use of the Survey Analysis for Evaluating Risk (SAFER) matrix, the commission is also gathering data on which standards are more likely to be cited with an immediate threat to life, or to the lesser degree of high likelihood for harm.

EC.02.02.01 was third on a list presented at last fall’s Executive Briefing that isolated the top Environment of Care and Life Safety standards most often cited with a high likelihood to harm, behind the more well-known problems of ligature risk (cited under EC.02.06.01) and air pressure relationships (cited under EC.02.05.01).

With that kind of data-crunching available, you can expect such areas to be a focus of surveyors. And if they do find a problem, it’s likely to cause the most headaches to resolve.

Eyewash, labeling top concerns
Problems under EC.02.02.01 in the first six months of last year were cited under EP 5, requiring hospitals to minimize risks associated with hazardous chemicals, and under EP 12, which covers the labeling of hazardous materials and waste, according to the briefing by then-acting engineering director John Maurer.

Look toward your eyewash stations -- or in some cases the lack of eyewash stations -- for the first set of problems and to biohazard containers for the second, says Steven A. MacArthur, a senior consultant with The Greeley Company in Danvers, Mass.

Eyewash station concerns, says MacArthur, generally fall into two areas: Whether an eyewash station is located where a surveyor believes one should be located and if it is available, is it being maintained properly.

“Either there’s a missing inspection, the access to the eyewash station is obstructed during the survey, or there is clearly something wrong with the eyewash -- usually the protective caps are missing,” says MacArthur. “All of those scenarios have the potential for being serious -- if someone needs an eye-wash and the thing doesn’t work properly or it’s been contaminated, etc., someone could definitely be harmed.”

Assess locations of eyewash stations
However, the question of where eyewash stations are required often leads to what MacArthur terms “over interpretation” by some surveyors.

“OSHA only requires emergency eyewash equipment when there is a risk of occupational exposure to a corrosive chemical,” says MacArthur.

OSHA standard 1910.151 covers medical and first aid requirements and says:

  • The employer shall ensure the ready availability of medical personnel for advice and consultation on matters of plant health.
  • In the absence of an infirmary, clinic, or hospital in near proximity to the workplace that is used for the treatment of all injured employees, a person or persons shall be adequately trained to render first aid. Adequate first aid supplies shall be readily available.
  • Where the eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use.

OSHA guidance on eyewash stations also makes reference to American National Standards Institute (ANSI) standard, ANSI/ISEA Z358.1, which “goes a bit further by indicating eyewash equipment should be available for caustic chemicals as well as corrosives,” notes MacArthur.

“A lot of the findings I’ve seen have been generated by the clinical surveyors, who are frequently in the company of staff that aren’t really clear on what the requirements are,” observes MacArthur. The surveyor may ask to see the safety data sheet (SDS) for the product in use “and if the SDS indicates that the first aid for eye exposure is a 15- or 20-minute flush with water, then they equate that with an eyewash station.”

Do a risk assessment
But an eyewash station is not always required, and some experts, including the former TJC Engineering Director George Mills, have said that unnecessary eyewash stations lead to problems with regular maintenance, which leads to more RFIs. Mills has often noted that TJC standards themselves do not specifically require eyewash stations, but in general do require OSHA adherence.

An online TJC frequently asked question (FAQ) on eyewash stations references ANSI Z358-1, but also notes that a “proactive, defensible, documented risk assessment process that may deviate from Z358.1 is acceptable provided OSHA criteria is not compromised.” It also notes that eyewash bottles are acceptable, provided the use is backed by an acceptable risk assessment process. (Note that surveyors also check expiration dates on eyewash bottles just as they do other medical supplies.)

Survey citations under EP 12 are often related to the labeling of secondary containers, says MacArthur, “usually the containers that are used to transport soiled [medical] instruments.”

Medical devices such as endoscopes must be pretreated immediately after use with a pre-cleaning agent, predetermined by hospital policy, and put into a biohazard transport container to be taken to central services for complete cleaning. Those chemicals must be identified on the outside of the container.

In terms of actual risk to whoever transports that container for cleaning, “these conditions are not particularly ‘scary,’ but you can’t completely negate the potential,” and the harm level is sometimes elevated on survey, says MacArthur.

Use these tips
To avoid problems on survey, MacArthur offers these tips:

Update your inventory. Have a complete “working knowledge of what corrosive chemicals are in use in the organization and where those chemicals are being used. I would be inclined to include caustic chemicals as well.” EP 1 of EC.02.02.01 requires a written -- and current -- inventory of hazardous materials.

Evaluate those products to see if there are safer (i.e., not corrosive or caustic) alternatives to be used. “The classic finding revolves around the use of chemical sprays to soak instruments awaiting disinfection and sterilization -- if you don’t soak them, then the bioburden dries and it’s a pain to be sure it’s all removed,” says MacArthur. “Generally, some sort of enzymatic spray product is used -- but not all of them are corrosive and require an eyewash station.”

Ensure eyewash is where it is needed. Once you know where you have corrosive or caustic chemicals, “you need to make sure you have properly accessible eyewash equipment,” which is generally within 10 seconds of unimpeded travel time from the area of exposure risk to the eyewash.

Educate your staff. That includes other accreditation officers who might be accompanying clinical surveyors. “You need to make sure that staff understand what products they have and why an eye-wash is not required -- strictly speaking, there really aren’t that many places in a hospital for which an eyewash station would be required -- if that is the case.” Make sure they know to reach out to the safety team if a question comes up to ensure there really is a problem. “Every once in a while there’s a truly legit finding,” says MacArthur, usually because some product “found its way someplace where it didn’t belong.” But more often than not, the eyewash station is not necessary.

Make labels available and educate when something must be labeled. “Be absolutely relentless when it comes to the labeling of secondary containers,” warns MacArthur. “If there’s something of a biohazard nature and you put it in a container, then that container must be properly identified as a biohazard; if you put a chemical in a spray bottle, bucket, or other container, then there needs to be a label.”

“Anything that is not in its original container has to be labeled, regardless of what the container is, the reason for doing it, etc. The hazard nature of the contents must be clear to anyone and everyone that might encounter the container.”

OSHA information sheet on eyewash station maintenance: https://www.osha.gov/Publications/OSHA3818.pdf
ANSI/ISEA Z358.1-2014, “American National Standard for Emergency Eyewash and Shower Equipment:” https://webstore.ansi.org/RecordDetail.aspx?sku=ANSI%2FISEA+Z358.1-2014
Joint Commission FAQ on eyewash station design criteria: https://tinyurl.com/y7gvyr6f

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