Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Safety Management
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Who is responsible for the hospital safety program?
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What is the title of the person responsible for the safety program?
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Are there other personnel that has responsibilities for portions of the hospital safety program?
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List other persons responsible for the safety program.
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Has the person responsible for the safety program been given authority in writing by the CEO and the board?
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Has the person responsible for the safety program had training or experience in healthcare safety?
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Is Security part of Safety Management or a separation function/department?
Safety Committee/Environment of Care (EOC) Committee
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What is the name and title of the safety committee/Environment of Care (EOC) committee chairman?
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What is the frequency of meetings of the Safety/EOC committee?
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Who maintains the committee minutes?
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Are committee minutes or summaries of the meetings shared with other functions or committees?
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Who are the minutes shared with?
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Are follow up actions included and documented in old business items within the minutes?
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What departments are represented on the committee?
- Nursing
- Plant operations
- Physical Therapy
- Administration
- Human Resources
- Medical Staff
- Dietary
- Environmental Services
- Security
- Others
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Are attendance of members included in the minutes?
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Are incident trending data included within the minutes that address frequency of incidents and categorized by severity and frequency by departments/units?
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If trending data is included in the committee minutes, what areas does it include?
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Are there sub-committees developed on focused safety issues that report to the Safety/EOC committee?
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If sub-committees are used, what areas do they address? (employee or WC, security, fire safety)
Education-safety and security
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For NEW EMPLOYEE orientation, is the hospital safety program addressed that includes hazards identification and accident reporting?
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Is annual education provided for ALL EMPLOYEES that include accident trends, accident reporting and follow up?
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For specific issues for types of accidents such as needle sticks, proper lifting to reduce muscle strains/sprains, investigation of accident causes provided to ALL STAFF MEMBERS as well as problem areas for high risk departments provided?
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Is the education position responsible for hospital education programs included on the hospital safety/EOC committee?
Human Resources/Employee Health
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Does the employee health function report to Human Resources?
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Is the Human Resources department responsible for workers compensation?
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Is there a specific policy for workers compensation that addresses safety, accident prevention, accident/illnesses reporting, claims processing?
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What role, if any, does the Human Resources department play in the hospital safety program?
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If Human Resources manages the workers compensation program, are REPEAT ACCIDENTS by employees monitored and a summary provided to the Safety Officer?
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How are department directors held accountable for accidents within their department (annual evaluations)?
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Is there a job description for EACH EMPLOYEE that includes the physical requirements including lifting, patient transfer, material movement, etc.?
Life Safety and Fire Protection Issues
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Are fire drills conducted once per shift per quarter in each building?
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Are fire extinguishers checked monthly and dated?
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Are critiques conducted on all fire drills to evaluate fire safety equipment, building features and staff responses to the fire drill?
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Are there any dead-end corridors in the hospital, not exceeding 30 feet and the area at the end marked "Not an Exit"?
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Is the hospital totally sprinklered or partially?
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Are there laundry or trash chutes used in the facility?
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If laundry or trash chutes used, are the collection rooms sprinkled and the chute doors equipped with fusible fire links to close?
Emergency Management
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Are external disaster drills conducted semi annually?
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Are internal disaster drills conducted?
Hazardous Material Issues
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Who is responsible for managing the hazardous communication requirements?
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Are MSDS available to the staff in all areas?
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Is training provided on the Hazardous Material program and the use of MSDS to all employees?
Medical Equipment Issues
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Is there a policy that prohibits the use of outside equipment or personally owned equipment from being use in the facility?
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Is there a medical equipment inventory of all equipment that categorizes the device as high risk or life-support or non-high risk?
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Is all medical equipment calibrated and checked for risk of use to the employees and patients performed at least annually or more often according to the manufactures recommendations?
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Is there a biomedical department responsible for checking medical equipment?
Utilities Issues
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Does the facility utilize Hyperbaric services?
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Are all requirements of NFPA 99-2012 Chapter 14 for Hyperbaric Chambers met?
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Med/Surg Units
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Are all corridors free from storage and Equipment?
- Yes
- No
- N/A
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Are med/surg unit storage rooms kept in an orderly fashion to access equipment and reduce falling items?
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Is patient lifting equipment properly storage and accessible?
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Are ALL patient bathrooms equipped with a locking device accessible by the staff ?
Dietary Issues
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Are automatic fire-extinguishing systems within the kitchen inspected every six months (discharge of the fire-extinguishing system is NOT required)?
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Are floors free from water accumulation with emphasis on dish washing areas?
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Are all hot water pipes insulated to protect dietary staff
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Are food storage areas well maintained with proper storage of heavy items at floor level and no storage above 18 inches to the sprinkler heads?
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All all walk-in freezer or cooler units equipped with emergency door handle latches?
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Are knives or other cutting items stored properly?
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Are protective gloves provided and used for dietary employees that cut food items?
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Are head covers required and worn by all persons within the food preparation areas for proper sanitation?
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Are floor matts provided for slippery areas within the kitchen?
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Are proper clothing properly worn by dietary workers that includes proper aprons, non-slip foot wear, head covering, etc.?
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Are cleaning supplies used for ovens/stoves properly stored and labeled and protective clothing worn when cleaning that includes protective eye wear, gloves, etc.?
Imaging Issues
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Is there a policy regarding pregnant employees working within the department where radiation may cause harm to the unborn fetus?
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Are dosimeter badges worn by ALL employees and evaluated regularly for excessive exposure?
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Is annual education on proper techniques proved to all employees responsible for patient transfer or patient movement to and from tables or other equipment where body mechanics are needed?
Outside Issues
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Is weather, such as snow and ice, a risk to slippy conditions?
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Is there a contract for ice and snow removal?
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Are parking lots for visitors and employees well maintained with no tripping hazards such as uneven pavements, pot holes, etc.?
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Are sidewalks maintained with level walking surfaces and proper marking?
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Are there outside stairs provided with required handrails?
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Are perimeter doors properly marked and locked except for designated entrances?
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Are walkways between buildings in good order with no tripping hazards?
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Are emergency call stations available in employee and visitor parking lots?
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Are CCTV's used for parking lots?
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Is the Emergency entrance well marked and easily identified?
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Are oxygen and other piped in gas areas kept locked and secured?
Security Issues
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Who is responsible for hospital security?
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What type of security personnel are available in the hospital?
- In-house security staff
- Contract Security staff
- Off-duty police
- Combination of hospital staff and off-duty policy
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Are security issues/incidents reported to the appropriated person (risk management, Human Resources, Quality, and safety) involving employees, patients, visitors and physicians?
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Are "near miss" incidents, such as verbal abuse, threats, spitting, etc., reported?
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Is deescalation training provided to ALL employees of the hospital include temporary staff?
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Is there an outside source or a staff person certified to provide deescalation training?
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Is there 8 hour crisis prevention and deescalation training provided to the following?
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Are overnight guest allowed that are identified as such with identification of areas accessible to the visitor?
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Are all outside doors locked that prohibits entry into the hospital during non-visitor hours except for the emergency unit?
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Are security rounds conducted throughout the hospital during the evening and night shifts?
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Does the hospital use off-duty police personnel stationed at the Emergency department during the evening and night shifts?
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Are security personnel equipped with personal protective devices and properly trained on the use of these devices?
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What security protective devices are used by the security staff?
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If firearms are used by security personnel, is annual training and certification obtained by all personnel?
Surgery/Obstetrics
Behavioral Health
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Is the behavioral health unit secure going-in and going-out of the unit with audio and visual alarms?
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Are there metal detectors or hand held wands available and used prior to entry into the unit?
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Is there 8 hours of deescalation training to ALL behavior health staff, including temporary staff and hospital staff that may visit the unit for work purposes (housekeeping, dietary, ancillary, etc.)?
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Are behavioral health security isolation rooms totally free of material or objects that create potential harm to patient and staff?
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Are cameras used to monitor day rooms or multi-purpose rooms viewable at the nursing stations?
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Are monitors available at the nursing station that views patients in security isolation rooms?
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Is the behavior health unit nursing station secure and protected for patients?
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Are there duress alarms available at the nursing station to call for assistance from agitated or unruly patients?
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Are the hospital staff responding to a security code from the behavior health unit trained for deescalation and physical threats?
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Are all patient rooms in the behavioral health unit equipped for suicide prevention?
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Is there a hospital code specific to elopement from the behavioral health unit?
Special Care Unit
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Is security provided that limits visitors within the unit?
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Is equipment maintained in an orderly fashion to allow treatment and reduce tripping from cords and other equipment?
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Are waiting areas provided that is separate from the special care units and limits the number of visitors allowed?
Emergency Services
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Is the outside of the Emergency Department well lighted and signs
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Is the signage proper for ambulatory and ambulance entrances?
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Are the entrances into the ED well secured and employees protected from intruders?
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Are duress alarms available within the emergency department to call for assistance for unruly patients/visitors?
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Is the emergency department provided with "safe rooms" for treatment of patients that are deemed a potential threat to themselves or the staff and located next to or adjacent to the nurses stations and equipped with cameras?
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Are decontamination facilities and supplies available to treat patients exposed to chemical, biological, radiological or nuclear agents?
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Are off-duty police officers or in-house security staff stationed nearby or immediately available for threats to the hospital staff?
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Is the triage area of the Emergency department well protected from patient threats with barriers or bullet proof glass?
Plant Operations/Maintenance
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Is the emergency power generator tested monthly?
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Do all subcontractors performing work both inside and outside the facility provide evidence of insurance with a minimum of $1M/$3M?
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Does all subcontractors or contractors working inside and outside the facility provide evidence of workers compensation?
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Is there any asbestos currently in the hospital construction?
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If asbestos is within the facility, is there a current O&M plan (operations and maintenance) available?
OSHA Record keeping & requirements
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Who maintains OSHA records?
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Is the OSHA log 300 current within 7 days of every recordable incident and up-to-date?
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Is there a incident report or OSHA Form 301 available with the OSHA case # for each 300 log entry?
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Is the OSHA Form 300A summary dated, signed and posted February through April each year?
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Is there a system available for employees to communicate identified hazards or safety issues?
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Is there a safety incentive program to recognize employees or department that excel in reducing workplace injuries/illnesses?
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Are emergency phone numbers readily available to contact in-house or outside agencies in emergency situations, e.g., poison control, local police, decontamination issues, bomb or terrorist threat, etc.?
Central Sterile Supply
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Is ETO use for sterilization?
Laboratory
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Is there a eye wash station or a eye wash device available?
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Is the eye wash station or flushing device checked for proper function and documented?
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Is there a safety shower available and periodically tested (annually) with documentation?
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Are chemical stared properly with required labeling for identity and appropriate warning for corrosive, flammable or caustic materials?
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Are PPE's (personal protective equipment available and used at all lab work stations?
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Is eating and drinking prohibited in work areas and a break area separated from the lab working areas?
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Are Lab coats provided and properly stored to minimize contamination to other parts of the hospital?
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Are face shields and/or eye protection provided and used at work stations where spills or splashes might occur?
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Are spill kits readily available in all areas of the lab where chemicals are used or stored?
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Are fume hoods provided for working with flammable and toxic materials and ventilation tested?
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Are protective gloves worn at all times at laboratory work stations?
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Is there a written Chemical Hygiene Plan (CHP) current and available in the lab?
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Is there a policy prohibiting mouth pipetting of blood or Other Potentially Infectious Material (OPIM)?
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Is there a current written Exposure Control Plan addressing all employees who come in contact with blood-borne pathogens?
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Does the hospital laboratory have a policy for waste disposal and prohibits pouring chemicals down the drains?
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Are Material Data Safety sheets current an readily available to lab employees?
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