General Lab Safety

A laboratory audit is an assessment performed to demonstrate that the laboratory’s operations are according to regulatory standards and accreditation regulations. It ensures that the laboratory has quality systems in place, follows good laboratory practices, and generates data of integrity and quality. The audit allows the laboratory to understand how well it is performing when compared to a benchmark or standard, and any gaps or nonconformities in performance can show if the policies and procedures that the laboratory has set require revision or are not being followed.

• Lab audits are conducted at least annually for basic laboratory safety, covering general safety and health hazards as well as the proper handling and disposal of hazardous materials. Additional audits may occur if a laboratory uses materials that represent a high risk to workers or to the environment, such as any radiation or select agent use.
• It is the responsibility of the principal investigator or responsible party assigned to each space to respond to lab audit findings within in a timely manner. Failure to comply with this expectation may affect the approval of future protocols.
• Results of the laboratory audits will be shared with the Principal Investigator and the Department Chair.

Laboratory signs and labels communicate critical safety information about hazards, protective measures, emergency stations, and prohibited actions to ensure a safe working environment in labs.

Lab Safety Information Door Sign

Lab Safety Poster

No Food or Drink

All Refrigerators, Freezers, and Microwaves within the laboratory space should be labeled to indicate that they are not to bu used for food or drink. For Example:

Biohazard

And, if biological materials are stored in the unit, that should be indicated as well:

Ice Machines

Ice machines should also be labeled:

NOTE: These are examples of labels that could be used, there are many different labels that could be used to accomplish this requirement.

PPE (Personal Protective Equipment) is equipment worn to minimize exposure by creating a barrier between you and a hazard. Personal protective equipment is not a substitute for good engineering, administrative controls, or good work practices. PPE is used in conjunction with these controls to ensure safety and health. Examples of PPE include respirators, gloves, aprons, as well as fall, head, eye and foot protection. PPE does not reduce the hazard itself, nor does it guarantee permanent or total protection. PPE is merely used to reduce or minimize the exposure or contact to injurious physical, chemical, or biological agents.

Responsibility

Each department is responsible for assessing work areas to determine if hazards are present that would necessitate the use of personal protective equipment. When such hazards exist, the department is responsible for defining what PPE is required and for communicating the requirements to those who are affected.

If you need any assistance regarding PPE, consult your supervisor, instructor, or contact Office of Safety at 701.777.3341.

• Types of PPE Protection
• PPE Hazard Assessment

A Lab Specific Safety Manual  is a tailored document that combines general safety policies with laboratory-specific hazard information, procedures, and training requirements to ensure regulatory compliance and protect all lab personnel.

Lab Specific Safety Manual

Sharps are any object capable of penetrating the skin, including, but not limited to: needles, scalpels, broken glass, broken capillary tubes, razor blades, saw blades, and exposed ends of dental wires. Dispose of sharps in impervious, puncture resistant, rigid containers to eliminate the potential of physical injury. Label all sharps containers that are disposed of in building waste receptacles (e.g., broken glass, sharps, etc.). It is each department's responsibility to assure that sharps are not put into the regular garbage, or other regular waste receptacles, in a loose or unprotected state.

When the disposal of sharps is complicated by the presence of radioactive, hazardous chemical, or bio-hazardous contamination, the proper disposal steps for each must be taken once the sharps have been placed in the proper container and labeled. Sharps containers contaminated with radioactive, hazardous, chemical, or bio-hazardous materials must be labeled with the appropriate hazard symbol (e.g., radioactive, bio-hazardous, corrosive, etc.).

For further information on the disposal of sharps, please contact the Office of Safety at 701.777.3341

Sharps Injury Form

A laboratory risk assessment is a systematic process for identifying hazards, evaluating risks, implementing control measures, and monitoring the risks and risk control measures to ensure safety in laboratory settings.

Step 1. Gather Information

• What biological agents will be handled and what are their pathogenic characteristics?
• What type of laboratory work and/or procedures will be conducted?
• What type(s) of equipment will be used?
• What type of laboratory facility is available?
• What human factors exist (for example, what is the level of competency of personnel)?
• What other factors exist that might affect laboratory operations (for example, legal, cultural, socioeconomic, public perception)

Step 2. Evaluate the Risks

• How could an exposure and/or release occur?
• What is the likelihood of an exposure and/or release?
• What information gathered influences the likelihood the most?
• What are the consequences of an exposure and/or release?
• Which information/factor influences the consequences the most?
• What is the overall initial risk of the activities?
• What is an acceptable risk?
• Which risks are unacceptable?
• Can unacceptable risks be controlled, or should the work not proceed at all?

Step 3. Develop a Risk Control Strategy

• What resources are available for risk control measures?
• What risk control strategies are most applicable for the resources available?
• Are resources sufficient to obtain and maintain those risk control measures?
• Are proposed control strategies effective, sustainable and achievable in the local context?

Step 4. Select and Implement Risk Control Measures

• Are there any national/international regulations requiring prescribed risk control measures?
• What risk control measures are locally available and sustainable?
• Are available risk control measures adequately efficient, or should multiple risk control measures be used in combination to enhance efficacy?
• Do selected risk control measures align with the risk control strategy?
• What is the residual risk after risk control measures have been applied and is it now acceptable?
• Are additional resources required and available for the implementation of risk control measures?
• Are the selected risk control measures compliant with national/international regulations?
• Has approval to conduct the work been granted?
• Have the risk control strategies been communicated to relevant personnel?
  Have necessary items been included in the budget and purchased?
• Are operational and maintenance procedures in place?
• Have personnel been appropriately trained?

Step 5. Review Risks & Risk Control Measures

• Have there been any changes in activities, biological agents, personnel, equipment or facilities?
• Is there any new knowledge available of biological agents and/or the processes being used?
• Are there any lessons learned from incident reports and investigations that may indicate improvements to be made?
• Has a periodic review cycle been established?

UND Laboratory Risk Assessment Tool

Performing Risk Assessment

IBC Protocol Risk Assessment and Determination of NIH Guidelines

Laboratory Move-Ins

Lab Move-In Checklist

Laboratory Close-Outs

Laboratories within the University of North Dakota must be left in a state suitable for new occupants or for renovation activities. The vacating Principal Investigator (PI) and Department are responsible for ensuring the cleaning and disinfection of equipment and counters, movement of equipment from the lab as surplus, repair, or relocation, and disposal of chemical, biological, and radioactive waste materials prior to vacating the space.
If disposal of hazardous materials at closeout requires removal services from an outside contractor, the responsible department will be charged for this service. Any regulatory action or fines resulting from improper management or disposal of hazardous materials will accrue to the responsible department. Additionally, if cleaning or disinfection of the vacated laboratory requires university resources atypical of ordinary processes, costs of the processes may be brought forward to the responsible department.

Lab Close-out Checklist

Responsibilities

• Office of Safety will provide proper guidance for laboratory closeout. The Office of Safety will do a final walk through of the laboratory to be vacated to ensure all items were taken care of. This walk-through may include the Departmental Chair and/or another Departmental Representative.
• Departments are responsible for ensuring that all Principal Investigators are aware of and follow these guidelines to ensure laboratory clearance by the Office of Safety. Departments are ultimately responsible for the proper clearance of laboratory space and equipment that was assigned to the individual PIs. If items are left behind and the responsible PI cannot be determined, the Department Chair will assume responsibility for the proper closeout of the laboratory. Departments need to notify the Office of Safety of moves and close outs as soon as this information is known to allow them to coordinate the lab close out with the PI.
• Principal Investigator(s) are responsible for the safe operation of their laboratory or laboratories. This includes leaving any and all of these facilities in a clean and safe condition when the premises are vacated. The PI needs to inform their Department Chair and the Office of Safety of the impending move at least one month before the date.

Chemicals

• Ensure that all containers of chemicals are labeled with the name of the chemical.
• Confirm that all containers are securely closed.
• Empty beakers, flasks, evaporating dishes, etc.
• Check refrigerators, freezers, fume hoods and bench tops as well as storage cabinets for chemical containers.
• Hazardous chemical wastes must not be sewered or trashed; they must be collected for disposal by the Office of Safety.
• Determine which chemicals are usable and transfer responsibility for these materials to another party who is willing to take charge of them. Ensure the transfer is properly documented by transferring the chemical to the recipient’s chemical inventory.
• If a new user cannot be found, the materials should be disposed of as hazardous waste by submitting a Chemical Waste Manifest form to the Office of Safety. This process requires a particular time allotment and should be started at least one (1) month before departure from the laboratory. Chemical pickup must be completed before the laboratory is vacated.
• Remove all contaminants from fume hood surfaces, chemical cabinets, and counter tops.

Controlled Substances

• Dispose of controlled substances following federal guidelines and the UND Use of Controlled Substances Policy. Keep the substances locked appropriately until they are picked up for disposal.
• The Registrant must send a letter to the Minneapolis DEA office requesting cancellation of the DEA registration and informing them of the drug disposal. Include in the letter the name of the Registrant, DEA registration number and expiration date, lab/building address, effective date of the cancellation, and Social Security Number of the Registrant.
• If applicable, send unused DEA Form 222 to the Minneapolis DEA office via certified or registered mail. In your cover letter to the DEA, list the unique numbers on Form 222 and save a copy of the letter in your controlled substances records.

Gas Cylinders (if no other user available)

• Remove gas connections and replace cylinder caps.
• Return gas cylinders, whether empty or partially filled, to the manufacturer or distributor through which they were purchased/rented. Ensure that you receive a return receipt from the vendor and retain this receipt in Department records.
• If possible, use all remaining gas in a cylinder to render it empty.. Empty cylinders should be clearly marked as empty to avoid confusion when it comes to return or disposal of the cylinder. Do not vent full or partially used cylinders into fume hoods as a means of disposal.
• In the event it is not possible to return the cylinders as specified above, contact the Office of Safety.
  

Human and Animal Tissue

• If samples must be saved, locate an appropriate researcher to take responsibility for them and notify your Department Head and the UND IBC as to who is taking responsibility for them.
  
• Remove fixed tissue from preservative before disposal.
  
• Dispose of chemical preservatives as hazardous chemical waste (see Chemical Disposal above).
  
• Dispose of animal tissue and remains appropriately by submitting as biological waste to the Office of Safety or by contacting the Center for Biomedical Research as appropriate.
  
• Defrost, clean, and disinfect refrigerators and freezers.
• If appropriate biological waste disposal is uncertain, contact the Lab & Research Safety Officer at 7-2444.

Microorganisms/Cultures, Recombinant DNA, and Toxins of Biological Origin

• If samples or stocks must be saved, locate an appropriate researcher to take responsibility for them and notify your Department Head and the UND IBC as to who will take responsibility.
  
• If microorganism stocks/cultures, recombinant DNA, or biologically derived toxins are moved or destroyed, notify the Lab & Research Safety officer at 7-2444.
  
• If an autoclave is available to decontaminate biological waste, place all microorganism stocks and culture plates in an autoclavable bag and proceed with decontamination under appropriate autoclave conditions. If no autoclave is available, place material in a red biohazard bag and submit a Biological Waste Manifest form to initiate pick up by the Office of Safety.
  
• For toxins of biological origin, contact the Biological Safety Officer for proper disposal.
  
• Decontaminate liquid biological wastes and disinfect all potentially contaminated surfaces.
  
• Clean and decontaminate incubators, drying or curing ovens, refrigerators and freezers. If providing equipment for moving or surplus, attach the required Decontamination Statement (UND Form 205a) to the equipment.
  
• If appropriate biological waste disposal is uncertain, contact the Lab &  Research Safety Officer at 7-2444.
  

Radioactive Materials

Prior to closeout of a radioactive materials use area and/or a radioactive materials use permit, it is the responsibility of the department and the authorized permit holder to assure that the following steps have been completed:

• Package all radioactive materials (stock vials, sealed sources, lead containers/shields, and wastes) per UND’s Radiation Safety Program Manuel for pickup.
  
• Prior to transferring radioactive materials to a new location, notify the Radiation Safety Officer (RSO 7-5931) to obtain authorization for the transfer and to assure that the new use area is properly posted and permitted.
  
• Arrange for pickup of all radioactive wastes through the RSO. Complete a Waste Disposal Form/Manifest for pickup.
  
• Contact the RSO to discontinue radiation badge dosimetry.
  
• Following removal of all radioactive wastes and stock materials, perform a contamination survey (and if appropriate a GM instrument survey) of all former storage and use areas within the laboratory or under the permit to be closed out. NOTE: Areas of potential residual contamination include refrigerators/ freezers, centrifuges, water baths, hoods, sinks, floor areas under waste containers, etc. Also, if there are contaminated areas or equipment in the laboratory, they must be decontaminated. A follow-up survey must be made of the decontaminated areas and the results included in the above survey.
  
• Provide the Department Head and the RSO with a copy of the final contamination survey.
  
• Schedule the Radiation Safety closeout survey with the RSO. Do not allow further use of room until the closeout survey is complete and the radiation caution door posting is removed by the RSO.
• If the permit holder fails to satisfactorily complete the above steps, the Department will be responsible for the completion of (or payment of costs to complete) the required closeout steps. The Department is responsible for immediate notification of the RSO if the above steps have not been completed.

Mixed Hazards

Occasionally it is necessary to dispose of materials that contain more than one of these hazards (chemical, radioactive or biological agent) Contact the Office of Safety.

Equipment

• If laboratory equipment is to be left for the next occupant, clean and/or decontaminate it before departing the laboratory.
  
• If laboratory equipment is to be transferred to another department, room, or building, ensure appropriate documentation is submitted to the originating department for inventory tracking.
  
• If laboratory equipment is to be discarded or surplussed, be aware that capacitors, circuit boards, transformers, mercury switches, mercury thermometers, radioactive sources and chemicals must be removed before disposal. Contact the Office of Safety.
  
• If exhaust or filtration equipment has been used with extremely hazardous substances or organisms, alert the Office of Safety.
  
• Equipment potentially contaminated with radioisotopes should be surveyed by the RSO.
  

Shared Storage Areas

Of particular concern are shared storage units such as refrigerators, freezers, cold rooms, stock rooms, waste collection areas, etc., particularly if no one has been assigned to manage the unit. Departing researchers must carefully survey any shared facility in order to locate and appropriately dispose of their hazardous materials.

Lab Equipment Decontamination Form

Emergency Drenching and Flushing Equipment

Each new university facility must have emergency drenching and flushing equipment incorporated into it by design whenever injurious corrosive materials are planned for use within it. Installation of such equipment must be as specified in ANSI Z358.1-1998. Only equipment that is certified by the manufacturer as meeting the performance specifications contained in ANSI Z358.1-1998 may be placed in new facilities.

Existing University facilities must be equipped as necessary to include emergency drenching and/or flushing equipment that is readily accessible and can be reached within 10 seconds from the area(s) where injurious corrosive materials are used. Equipment performance specifications, height, and clearance distances should be as stated in ANSI Z358.1 - 1998.

Off-site/remote locations must have drenching/flushing equipment available whenever work involves the use of injurious corrosive materials. Plumbed units that are maintained by the owner/controller of an off-site facility may be used or self-contained units can be purchased. A water hose supplying potable water and equipped with a proper face and body wash nozzle can be used at off-site locations where the possibility of exposure to injurious corrosive materials is very low and when proper personal protective equipment is used.

The temperature of the flushing fluid for emergency drenching and flushing equipment should be lukewarm. A means of controlling the temperature to less than 100 degrees F must be included in tempered flushing fluid systems.

Flushing fluid shut off valves located within branch lines serving emergency drenching and flushing equipment should be tagged to indicate that turning off the valve would turn off the supply to the emergency equipment.

Emergency drenching and flushing equipment must be identified by highly visible signage whenever the equipment cannot be readily seen by its potential users.

The following are the key specifications from ANSI Z358.1 - 1998.

1. Plumbed and self-contained emergency showers:
   1. Plumbed and self-contained emergency showers must supply at least 20 gallons per minute (gpm) of flushing fluid at a velocity low enough to be non-injurious to the user.
   2. At least a fifteen minute supply of flushing fluid must be available.
   3. The flushing fluid supply valve must stay open without the use of the operator's hands.
   4. Shower head height must be between 82 and 96 inches (84" is optimal) from the user's standing surface.
   5. Protection from freezing or freeze protected equipment is required where the possibility of freezing exists.
   6. Shower enclosures (if used) require at least a 34-inch diameter unobstructed area to provide adequate space for the user.
2. Plumbed and self-contained eyewash:
   1. Plumbed and self-contained eyewash units must supply at least 0.4 gpm of flushing fluid and at a velocity low enough to be non-injurious to the user.
   2. At least a fifteen minute supply of flushing fluid must be available.
   3. Eyewash units must supply flushing fluid to both eyes simultaneously.
   4. The flushing fluid supply valve must stay open without the use of the operator's hands.
   5. Nozzles must be protected from airborne contaminants. Nozzle protective device removal must be automatic (not require a separate motion by the user) when the unit is turned on.
   6. Eyewash units must be placed between 33 and 45 inches from the user's standing surface and at least 6 inches from the nearest wall or other obstruction.
3. Eye/Face wash equipment:
   1. Plumbed and self-contained eye/face wash units must supply at least 3.0 gpm of flushing fluid and at a velocity low enough to be non-injurious to the user.
   2. At least a fifteen minute supply of flushing fluid must be available.
   3. Eye/Face wash units must supply flushing fluid to both eyes simultaneously.
   4. The flushing fluid supply valve must stay open without the use of the operator's hands.
   5. Nozzles must be protected from airborne contaminants. Nozzle protective device removal must be automatic (not require a separate motion by the user) when the unit is turned on.
   6. Eyewash units must be placed between 33 and 45 inches from the user's standing surface and at least 6 inches from the nearest wall or other obstruction.
4. Hand-held drench hoses:
   1. Hand-held drench hoses provide support for emergency shower and eyewash units but they are not intended to replace them.
   2. Plumbed and self-contained drench hoses must supply at least 3.0 gpm of flushing fluid and at a velocity low enough to be non-injurious to the user.
   3. At least a fifteen minute supply of flushing fluid must be available.
5. Combination units such as an eyewash and shower combination are ideal in many situations. Installation and performance requirements for combination units are as presented for the individual components.
6. Personal eyewash equipment:
   1. Personal eyewash equipment, such as bottles and small portable units, are designed for immediate flushing of the eyes without being injurious to the user. Personal eyewash equipment supports plumbed and self-contained units, but it does not provide adequate replacement.
   2. Operator instructions must be maintained on personal eyewash equipment.
   3. Water must be changed out at least once per week when it is used without a preservative. An expiration date must be maintained according to the manufacturer's specifications on equipment containing flushing solutions or preservatives.

Use of Flushing Equipment

Immediate and proper use of emergency drenching and flushing is essential to minimizing injury upon injurious corrosive chemical contact. The following guidelines should aid in minimizing injury due to contact with corrosive materials:

1. Flush eyes and/or skin for at least 15 minutes. Never use home-made neutralizing solutions to flush chemicals from the body.
2. Immediately remove contaminated clothing. Do this while under the shower when gross contamination has occurred. Have someone assist with clothing removal when possible.
3. Hold eyelids open with fingers so flushing fluid can fully irrigate the eyes. Note: People may not always be able to flush their eyes on their own because of intense pain. Nearby helpers should be prepared to assist with holding the eyelids open. Other helpers may need to assist with keeping the person under the flushing fluid for at least 15 minutes.
4. Seek medical attention after flushing the areas of contact for at least 15 minutes.
5. Notify supervisor as soon as the emergency has subsided.
6. An assistant may use a fire blanket or uncontaminated article of clothing as a shield to provide privacy for someone who needs to remove their clothes while under an emergency shower, and for body coverage while seeking medical attention.

Equipment Inspections

Each department is responsible for making sure that flushing, inspection, and repair of the emergency drenching and flushing equipment within its area(s) occurs. This responsibility includes changing flushing fluid in portable units at the frequencies recommended by the manufacturer. Departments may request assistance from the Office of Safety or the Facilities Department to fulfill these requirements. Minimum flushing and inspection requirements are presented below.

Weekly Flushing Requirements

Plumbed eyewash and eye/face wash stations must be activated and flushed at least once per week for at least three minutes.

• Inspect eyewash and eye/face wash stations while flushing to make sure that water rises to approximately equal heights, and that fluid flow is sufficient to flush both eyes simultaneously while at a velocity low enough to be non-injurious to the user.
• Water in self-contained eyewash and eye/face wash stations must be replaced with fresh potable water at least once per week or upon manufacturer's expiration when a preserved solution is used in these units.
• Each personal eyewash station/unit must be reviewed weekly to make sure components are in place and the station/unit is readily accessible. Also verify that bottles with seals/tamper indicators are sealed, replacing those that are not.

Monthly Flushing Requirements

• Plumbed emergency showers and drench hose stations must be activated and flushed at least once per month.
• Each eyewash, shower, or drench hose unit not passing inspection or requiring repair, must be signed to warn people that the emergency flushing station is not functioning properly. Repair of defective units must be expedited.
• Records of each flush/inspection must be kept. These records may be recorded on tags that are attached to drenching and flushing equipment, by means of a checklist, or by both. Copies of flush/inspection records must be forwarded to the Office of Safety at least once per year. Forward the filled tag to the Office of Safety when tags are used as the only means of tracking the inspections. If tag sent to the Office of Safety, a new tag must be attached to the equipment.

Repairs

• Whenever an eyewash station is non-functional, a portable eyewash station or equivalent must be available if work with injurious corrosive materials cannot be delayed.
• Each department is responsible for ensuring that drenching and flushing equipment that do not pass inspection is repaired in a priority manner. When emergency drenching and flushing equipment is non-functional, it must be clearly tagged/signed as being out-of-service.
• Anyone removing emergency drenching and flushing equipment from service must notify the Office of Safety and the affected department beforehand. This requirement includes those periods when main or branch water lines that serve drenching and flushing equipment are turned off.

References

• OSHA Standard, 29 CFR 1910.151
• OSHA Standard, 29 CFR 1926.50
• ANSI Standard, Z358.1-1998, American National Standard for Emergency Eyewash and Shower Equipment
• Laboratory Health and Safety Handbook, R. Scott Stricoff and Douglas B. Walters, John Wiley & Sons, Inc., 1990

Eyewash Inspection Checklist