Accreditation

See what standards caught an OSHA inspector's attention

Accreditation Connection, May 3, 2004

In June 2003, an inspector from the Occupational Safety and Health Administration (OSHA) showed up without warning at Frankford Hospital in Philadelphia. The inspector walked into the administrator's office and announced that he was there to review injury logs-and then some.

Over the next three weeks, the inspector returned four more times, says John Osgood, vice president of Frankford Hospital, who is responsible for safety.

"A 'wall-to-wall' is what [the inspector] called it-a wall-to-wall, comprehensive inspection," explains Osgood, who is also chair of the hospital's safety committee.

The inspection was completed August 4, 2003, with five "other than serious" citations on the record but no fines. "Other than serious" violations are those that OSHA believes would probably not cause death or serious physical harm, but that do have a direct impact on staff safety.

"I think we got through it pretty well. Unfortunately, it took some time," says Osgood.

Here are the standards the inspector focused on:

  • Bloodborne pathogens (1910.1030)

Nineteen pages from OSHA explain the inspector's findings at Montefiore, and almost all of the concerns stem from the bloodborne pathogens requirements.

The citation showed the inspector was extremely knowledgeable about safety needles and other safety devices available on the market.

As a result, OSHA listed a citation under the bloodborne requirements because Montefiore allegedly didn't annually review technology changes to safety devices.

Items the inspector pointed out include attached guarded needle injection systems used with prefilled glass medication cartridges, prefilled medications with attached guarded safety needle delivery systems, needleless catheter and tube anchoring systems that don't require the use of suture needles, and hypodermic safety needles.

  • OSHA injury log (29 CFR Parts 1904 and 1952)

An error in Frankford Hospital's injury log precipitated the visit by OSHA. Its OSHA 200 Log for 2000 (now known as the 300 Log) showed an injury rate of 13 per 100 full-time employees, which automatically flagged the site for a possible inspection by the agency.

As it turned out, Frankford's documentation was off. "Through a double counting error we committed in 2000, our rate was a 13," Osgood says.

Due to confusion on the hospital's part about the definition of an injury, Frankford inadvertently counted certain injuries twice, when those incidents should have only gone into a column once, he adds.

  • HAZWOPER (1910.120)

Under the hazardous waste and emergency operations response (HAZWOPER) standard, hospitals must develop an emergency plan for hazardous materials spills, including the role of workers and related training, as well as prevention techniques.

The inspector who visited Frankford became confused by the hospital's various policies that interconnected to its HAZWOPER plans, Osgood says.

"He had a lot of trouble understanding what our exact procedure was because it was in several manuals," he says.

Specifically, OSHA cited the hospital for not having enough information on the roles of employees in HAZWOPER activities-specifically, what types of events they will handle.

  • Respiratory protection (1910.134)

OSHA requires hospitals to develop a written respiratory protection program that includes specific procedures and training.

Again, the inspector had difficulty grasping Frankford's policy for the use of full-face respirators. He didn't doubt that the hospital's staff members were versed in respiratory procedures, but there was no singe documentation of it.

"He knew that we knew what we were talking about, but he wanted to relate it to what we had in writing," Osgood says. "He couldn't put his arms around it." OSHA cited the hospital for not having written procedures for the use of respirators in routine situations and otherwise foreseeable emergencies.

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