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13 steps to prevent bloodborne infection and liability

OSHA Bloodborne Pathogens: A 13 step compliance game plan

Protecting employees from bloodborne infection isn’t just a medical imperative but a legal one under Occupational Safety and Health Administration (OSHA) rules. In case you don’t have the time or inclination to read the entire OSHA regulation, here’s an explanation of what it requires and a 13-step game plan for complying with it.

What the law requires

The OSHA Bloodborne Pathogens standard requires employers, including medical offices, to protect employees who have “occupational exposure” to “blood” or “other potentially infectious materials.” There are three terms you need to understand to comply with the standard:

  • Occupational exposure, which is defined as an employee’s risk of skin, eye, mucous membrane, or parenteral, i.e., the piercing of mucous membranes or the skin via needlesticks, human bites, cuts and abrasions, contact with blood or other potentially infectious materials;
  • Blood, which includes human blood, components of human blood and products made from human blood, including plasma derived products; and
  • Other potentially infectious materials (OPIM), defined as:

(1) Human body fluids such as semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood;

(2) Any unfixed tissue or organ (other than intact skin) from a human; and

(3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

How to comply


Step 1: Perform an exposure determination

Phase 1 of compliance is to assess the hazard by carrying out a so called exposure determination listing:

  • Job classifications in which all employees have occupational exposure;
  • Job classifications in which some employees have occupational exposure; and
  • Job tasks performed by employees in the above categories that involve occupational exposure.

Tip: In determining if occupational exposure occurs, you must assume that employees are not using personal protective equipment (PPE) like gloves.

Step 2: Use “Universal precautions” to control infection hazards

Phase 2 is to implement measures to keep exposed employees from getting infected. Start by using a method of infection control called “universal precautions” to prevent employees from making contact with blood or OPIM.

Step 3: Implement engineering controls to control infection hazards

The next line of defense is the use of “engineering controls,” i.e., devices that eliminate or reduce the risks of infection.

Explanation: OSHA lists different engineering controls that you need to consider and adopt to the extent you determine it’s feasible to use at your medical office, including:

  • Needleless systems;
  • Self-sheathing or other safety engineered needles;
  • Containers for safely disposing of contaminated needles; and
  • Readily accessible hand washing facilities.

Step 4: Implement work controls to control infection hazards

OSHA also requires you to use work controls, i.e., measures that make the work safer, in combination with engineering controls, including:

  • Making employees wash their hands right after handling contaminated needles;
  • Banning employees from bending, recapping or removing infected sharps; and
  • Banning eating, drinking, smoking, and handling of contact lenses in work areas where occupational exposure can occur.

Step 5: Use PPE to control infection hazards

The last line of defense is to provide at no cost to employees and require employees to use PPE to protect them from becoming infected via contact with blood and OPIM. Such PPE may include:

  • Gloves;
  • Gowns;
  • Lab coats;
  • Face shields or masks; and
  • Safety goggles or other eye protection.

Step 6: Keep the workplace clean and sanitary

Your medical office also has to take housekeeping measures to keep the workplace clean and sanitary including:

  • Implement cleaning and decontamination methods according to a written schedule;
  • Cleaning and decontaminating equipment and working surfaces after contact with blood or OPIM;
  • Regularly inspecting any bins, pails, cans, and other receptacles that may become infected with blood or OPIM that you intend to reuse; and
  •  Implementing safe work procedures for disposing of contaminated needles and handling contaminated laundry.

Step 7: Offer employees hepatitis B vaccine

OSHA requires you to take medical measures to protect employees with occupational exposure, including offering them the hepatitis B vaccine at no cost at a reasonable time and place within 10 days of initial assignment to a position that involves occupational exposure. Employees can decline the vaccination but you need to get them to sign a written declination form.

Step 8: Provide employees medical evaluation after exposure incidents

Although the goal is to prevent them, if employees have “exposure incidents,” i.e., make contact with blood or OPIM while doing their job, you must immediately offer them a confidential medical evaluation and follow-up by a doctor or qualified healthcare professional.

Step 9: Use warning labels and signs

The OSHA regulation requires you to use labels and signs to warn employees about blood or OPIM hazards, including:

  • Affixing orange biohazard warning labels to containers of regulated waste, refrigerators, and freezers containing blood or OPIM;
  • Posting orange biohazard warning signs at the entrance of HIV and HBV research lab and production facilities;
  • Putting labels on containers of blood, blood components, or blood products listing their contents;
  • Labeling or color-coding contaminated waste;

Step 10: Provide employees information and safety training

You must train each employee with occupational exposure at the time of initial assignment and at least once a year after that (or more frequently if their duties change in a way that affects their occupational exposure). Training must be provided by a knowledgeable person and, at a minimum, cover:

  • What the OSHA regulation requires;
  •  A general explanation of the epidemiology and symptoms of bloodborne diseases and how they’re transmitted;
  • A description of the Exposure Control Plan (ECP) that we’ll discuss in the next section;
  • The engineering controls, work controls, and PPE used to prevent infection at your medical office;
  • Information about the hepatitis B vaccine;
  • What to do after contact with blood or OPIM;
  • The procedures your medical office follows after an exposure incident, including information about the post-exposure medical evaluation;
  • An explanation of warning signs, labels, and color-coding; and
  • Responses to questions employees want to ask.

Step 11: Implement an exposure control plan (ECP)

The centerpiece of complying with the OSHA regulation is to implement a written ECP that incorporates all of these required measures. You must ensure that a copy of the ECP accessible to employees. Just make sure your ECP includes at least the following elements:

  • The results of the exposure determination, i.e., the job-specific hazard assessment described in Step 1 above;
  • The schedule and method of implementing engineering and work practice controls and PPE used to control identified hazards;
  • The schedule and method of implementing the hepatitis B vaccination and post-exposure evaluation and follow-up requirements;
  • The schedule and method of compliance with training, communication and recordkeeping requirements; and
  • The procedure for evaluating circumstances of exposure incidents.

Step 12: Monitor and review your ECP

The ECP is a work in progress that you must update and reviewed at least once a year to deal with:

  • Any new or changed tasks and procedures affecting occupational exposure;
  • Any new or revised employee positions with occupational exposure;
  • Potential changes in technology that eliminate or reduce exposure to bloodborne pathogens.

You must document this annual consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure. You also must solicit input from non-managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls and document the solicitation in the ECP.

Step 13: Keep records

The final phase in compliance is to maintain specific records, including:

  • Medical records for each employee with occupational exposure, including name, social security number, hepatitis B vaccination status, and results of any medical exams or post-exposure incident evaluations;
  • Training records listing training dates, content of sessions, names and qualifications of trainers, and names and job titles of attendees—which you must retain for at least 3 years; and
  • A sharps injury log documenting injuries from contaminated sharps, including:
    • The type and brand of device involved;
    • Department or work area where the incident occurred; and
    • An explanation of how the incident occurred.

Related Tools

Model Policy: Exposure control

Safety Briefing: Prevent needlestick injury and exposure to bloodborne pathogens

Model Form: Hepatitis B vaccine declination

Model Tool: Exposure Control Plan Checklist









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