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Mac’s Safety Space: Transporting blood and urine samples

Q: A question about transporting blood and urine samples. Do the samples need to be in a biohazard bag when transported either by hand, on a cart, or via a tube system that can go both to the lab and the pharmacy?

Steve MacArthur: I think the simple response to your question is yes, based on the requirements in the Bloodborne Pathogens Standard. First off, we start with the section on specimens on OSHA’s website:


Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping.

Now we could certainly discuss the merits of urine as a function of “other potentially infectious materials”, but in these days of Standard Precautions, the assumption we make is that it is presumed infectious until proven otherwise. We could also discuss the merits of the zip lock plastic bag as a function of leakage prevention, which will clearly depend on what the specimen is in; plastic would nominally be OK, while glass is probably a little less safe, depending on the method of transport, which would be another consideration.

So moving on to labeling, it seems pretty clear that some sort of unique identifier is in order and since the “standard” for that would be the biohazard symbol, I think we can safely identify that combination as the way to go.


The container for storage, transport, or shipping shall be labeled or color-coded according to paragraph (g)(1)(i) and closed prior to being stored, transported, or shipped. When a facility utilizes Universal Precautions in the handling of all specimens, the labeling/color-coding of specimens is not necessary provided containers are recognizable as containing specimens. This exemption only applies while such specimens/containers remain within the facility. Labeling or color-coding in accordance with paragraph (g)(1)(i) is required when such specimens/containers leave the facility.

In the interest of full disclosure, I’m including the items under paragraph (g)(1)(i) below, just in case there is something than clicks with your particular situation:


Labels and Signs –




Warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material; and other containers used to store, transport or ship blood or other potentially infectious materials, except as provided in paragraph (g)(1)(i)(E), (F) and (G).


Labels required by this section shall include the following legend:


These labels shall be fluorescent orange or orange-red or predominantly so, with lettering and symbols in a contrasting color.


Labels shall be affixed as close as feasible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal.


Red bags or red containers may be substituted for labels.


Containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clinical use are exempted from the labeling requirements of paragraph (g).


Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal are exempted from the labeling requirement.


Labels required for contaminated equipment shall be in accordance with this paragraph and shall also state which portions of the equipment remain contaminated.


Regulated waste that has been decontaminated need not be labeled or color-coded.

Hopefully, that helps answer your question; I think as long as you have something that is specifically identifiable to all who would be handling the specimens, you should be fine.

Nurses outraged over emergency room security switch up

A change in emergency room security staff has nurses up in arms at St. Josephs Hospital in St. Paul, MN. The hospital has replaced off-duty police officers on the night shift with security guards, reports

The hospital’s nurses union says hospital workers are put at risk by this change. The hospital says that switching is perfectly safe and hospital security guards work longer shifts than off-duty police officers. Off-duty police officers will still secure the emergency room Thursday, Friday, and Saturday nights.

How do you think the hospital should handle the nurse’s opposition? Is this an issue of worker safety if the hospital still employs security guards? Let us know in our comment section.

Patient dies at Napa State Hospital from alleged attack

A patient died April 11 at Napa (CA) State Hospital, Napa while being subdued after attacking a fellow patient.

This event comes after a string of security issues at Napa State Hospital.

The incident, which occurred in a high security area of the hospital, has staff worried about how patients will respond, according to KGO-TV of San Francisco.

Kathleen Thomas-Morris, a Service Employees International Union steward, told KGO that patients and staff are scared of what might happen because of the death of a patient.

An autopsy was scheduled for April 13 because it was unclear how the patient died.

How do you think Napa State Hospital should be handling these ongoing situations? Let us know in our comment section.

Mac’s Safety Space: Crash carts

Q: Is there a regulation that states you can’t store crash carts behind locked doors? We have kept our crash carts in our clean holding rooms for as long as I can remember. We had a Joint Commission consultant tell us we could not store them behind locked doors.

Steve MacArthur: Unfortunately, there are any number of consultants who get too involved in “thou shalts” and “thou shalt nots.” The fact of the matter is there is no standard or performance element that specifically prohibits any particular practice. When you look at the medication management standards–and just to be clear, the only reason we have to take extra precautions is because of the medications in the crash carts–the “requirement” is limited to:

MM.03.01.01, EP 6 – Unauthorized individuals are prevented from obtaining medications in accordance with hospital policy, law, and regulation.

And that’s all there is from The Joint Commission, as far as the standards go, but there is additional information in the FAQ section of the Joint Commission website that provides some instruction in how it would expect an organization to implement a risk strategy based on the requirement. This FAQ refers to medications in anesthesia carts, but I think there are more than enough parallels to be able to extend this to crash carts: (Here is the link to the webpage)

Where the rubber meets the road, so to speak, in your situation depends very much on who has access to the clean holding room (I’m going to intuit that the clean holding room is in a location that would not be considered to be under constant observation, which I suspect is the vulnerability identified by your consultant).

Say someone from materials, when dropping off supplies, would have unobserved, unfettered access to the crash cart–the plastic lock would tell you that someone had gotten in, but remember, the standard requires you to prevent unauthorized people from accessing medications. Securing something effectively is not the same as being able to tell whether someone had actually gained access. But that does not mean that you can’t, under any circumstances, store the crash cart in the clean holding room.

You have to ensure that there is an effective means of preventing someone from accessing the medications without compromising the requirements of MM.03.01.03, EP 2, which requires hospitals to make emergency medications and their associated supplies readily accessible in patient care areas. Most facilities have done this by placing the carts in very close proximity to the nurses’ station, but in clear line of sight.

Ultimately, it becomes an assessment with one axis representing the continuum of least secure to most secure, and the other axis representing the continuum of least accessible to most accessible. Somewhere in that matrix is a strategy in which the medications are sufficiently secure and sufficiently accessible. If you can demonstrate that your current practice meets those criteria, then you should be able to defend your strategy during a survey.

Fear of radiation exposure cause pediatric clinic relocation

Employee concern about possible radiation exposure from the radiology department has prompted Sutter Amador Hospital, Jackson, CA, to temporarily relocate its pediatric clinic.

Clinic employees expressed their concerns about potential radiation exposure and recent health issues to hospital officials, but hospital spokeswoman, Jody Boetzer, told The Sacramento Bee that she couldn’t confirm those health issues.

Sutter Amador Hospital hired an independent health physicist to perform a full risk assessment of the building to test it for radiation. The final report is expected to be delivered by the end of this week. The health physicist also performed radiation testing on March 30 in the radiology department and in the pediatric clinic, but found readings to be normal, reports The Sacramento Bee.

How does your facility handle fears of radiation exposure? What is your plan of action?

Mac’s Safety Space: Greetings From the Survey Zone…

A few items have been popping up in surveys over the last couple of weeks; two require a homework assignment for you, the other I offer as general information. So here goes:

LS.01.02.01 – I thought this one would have gone away forever, but it would seem that there have been a few folks who have lost sight of a very important aspect of the Interim Life Safety Standards and that is the practical application of the risk assessment to determine whether or not the LSC deficiencies you are managing as plan for improvements (PFI’s) (and that’s anything that you are measuring as a PFI) require implementation of any Interim Life Safety Measures (ILSM). Now, every once in a while I get some pushback from folks because this requirement is not necessarily the most explicit in the world; a point with which I do not totally disagree. The key concept here is the phrase “covers situations when Life Safety Code deficiencies cannot be immediately corrected.” I think you’ll agree with me that anything you are managing as a PFI is a deficiency that cannot be immediately corrected, and the surveyors recognize this very clearly. So, homework assignment #1: make sure you have an ILSM assessment for your PFI’s. Pretty simple, so done, done, and on to the next one…

LS.02.01.20 EP #1 – Doors are unlocked in the direction of egress. Now I’m sure you’re all up to snuff on delayed egress doors and the like, but this one is a little, if you’ll excuse the use of the term, funky. Every once in a while, there are exterior doors (and even more rare, interior doors) that have dead bolt locking mechanisms on them. I’ve seen ‘em, you’ve seen ‘em, they are definitely out there. However, if you have dead bolt locking mechanisms on any of the doors in any of your egress paths, you need to make sure that the breakaway features of those doors will still work if the deadbolt is engaged. While this is valuable from a survey standpoint, it makes a great deal of sense to ensure folks can get out in an emergency—and some dead bolt locking arrangements will prevent folks from doing that. So, homework assignment #2: go check all your perimeter doors (and keep an eye out on the interior egress route doors, you don’t want to lock folks in there either).

The information you may very well have figured out—there are more survey days for the LSC surveyors, so they have more time to find stuff and they are finding more stuff. They have more time to look at documents, more time to find penetrations, more time to find corridor clutter, more time to find doors that don’t close and latch, more time to ask to see the ILSM assessments for your PFIs. I do know of at least one survey in which the LSC surveyor arrived a week or so after the rest of the survey team; I don’t know if we should consider that an anomaly or if there are already some scheduling challenges in the mix. Much too early to tell. But if I hear anything more on that point, I’ll be sure to share.

Ok – now get to that homework!

Do your emergency exercises truly test the capabilities of staff to protect your patients?

I wanted to share with our readers an exciting opportunity for those in charge of emergency exercises and drills in healthcare facilities.

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In the first part of the program, Marge McFarlane, PhD, CHSP, HEM, MEP, CHEP, a safety consultant currently serving the Wisconsin Hospital Emergency Preparedness Program as the Department of Homeland Security Exercise and Evaluation Program coordinator, identifies the wealth of resources already out there to help you design meaningful drills for all types of situations and accreditation requirements.

In the second part of the program, Meg Femino, who is Director for Emergency Management at Beth Israel Deaconess Medical Center, Boston, presents a case study for the vertical evacuation drill of large full scale NICU—the drill required first the horizontal evacuation of 34 infants to a smoke zone and then a vertical evacuation within 25 minutes 34.

In addition to the expert advice, participants will receive resource tools including:

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California hospitals will be required to tighten security if new bill passes

Preliminary approval was given by a California legislative committee for a bill to move forward that will increase security in hospitals and require workers to report acts of violence to the state.

Assemblywoman Mary Hayashi (D) and the California Nurses Association sponsored the bill and brought it to the Assembly Committee on Health, arguing that nurses are increasingly exposed to violence in the workplace, reports the Los Angeles Times. The bill comes after the death of a nurse who was bludgeoned in the medical facility she worked at in Northern California.

The California Hospital Association (CHA) opposes the proposed bill, saying it would put an increased burden on hospitals. The CHA says hospitals already have to report incidents of violence to the police, state Department of Public Health, and the Division of Occupational Safety and Health (OSHA).

The bill is waiting to go to the Assembly appropriations committee before going to the full Assembly.

Do you think this bill should pass? What does your facility require in terms of reporting violence? Let us know in our comment section.

Mac’s Safety Space: A visit to the infusion center

Q: Our Chief Operating Officer (COO) is concerned that The Joint Commission may go to our infusion center. We understand that the life safety surveyor will focus his survey on healthcare occupancies, in our case the main hospital and ambulatory surgery center. Should we be concerned that the survey will include a visit to the infusion center?

Steve MacArthur: Generally speaking (and this would need to be validated, though I’m pretty sure), if the infusion center is not designated as a healthcare occupancy, then the Life Safety Code (LSC) surveyor will not need to visit that location. If we have designated it as ambulatory healthcare (sometimes this is something the state would determine), then it is likely that they will, considering they’ll have two days to fill.

I would check on the e-Statement of Conditions to see how we’ve identified the occupancy type and if it’s a business occupancy (and I suspect that it is), then the LSC surveyor will in all likelihood confine themselves to the main hospital and the Ambulatory Surgical Center. That said, it is also more than likely that at least one member of the survey team will pay a visit to that location, so we want to make sure that we’re appropriately managing general safety stuff, as well as the basics of life safety—no corridor obstructions, fire extinguisher checks in order, nothing stored in front of fire extinguishers, fire alarm pull stations, etc.

Mac’s Safety Space: Life Safety Code retractable hooks

Q: I had a Life Safety Code question I was hoping you could help me with when you get a chance. Specifically, our nursing staff wants us to mount retractable stainless steel hooks on the inside of our patient room doors to be used with “gait belts” for physical therapy and for turning patients in their beds. These patient room doors go directly from the patient room into the corridor without any intervening room(s), and the door opens inward (into the patient room). None of these doors are part of a rated smoke or fire wall assembly.

All of our patient room doors are 1 and ¾ inch thick, solid-bonded core wood doors that resist the passage of smoke for up to 20 minutes and have a metal frame. Our hospital is NOT fully sprinkled, which means that some of these doors are in a smoke compartment that is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section of Chapter 19, Existing Health Care Occupancies, of the Life Safety Code of 2000, while some are not.

The hooks are mounted on a 4-inch by 4-inch wide stainless steel platform that stands 1 inch high. The platform would be secured to the door by four sheet metal or wood screws that would extend into the door about 1 inch, but would NOT come out the other side. The hook retracts very easily because it is designed to prevent suicides.

Unfortunately, I do not have a manufacturer name or model number, because our nursing department purchased them without checking with us first and now want us to install them. Again, we have a concern about securing this or any other device to corridor doors, but I can’t find a specific reference to this in the Life Safety Code, which is why I’m asking for your help.

A: Happy to be of service. I ran this by my Greeley colleague Brad Keyes and we are in agreement that as long as the doors in question are not fire rated doors or doors that serve a smoke compartment barrier (which you indicated was the case), then there should be no problem from a Life Safety Code perspective . Corridor doors to patient rooms are only required to resist the passage of smoke, regardless whether the smoke compartment has a sprinkler or not.

That said, whenever I encounter folks who are engaging in these types of modifications, I encourage them to check with the local AHJ to run it by them. You certainly know your AHJ better than I do, so you definitely have a better sense of how to (or even if to) approach this. I’ve just seen too many folks that went ahead with the modification without checking with the locals, only to have to undo everything when someone gets a hair across their posterior because they weren’t consulted (and I suspect you know if you have that type of a personality in the mix).