Safety Self-Study Packet

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University of Kansas Hospital Authority
and
University of Kansas Medical Center
Safety
Self-Study PacketSeptember 2002 revision

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Introduction
All employees of the University of Kansas Medical Center and Hospital are required to
participate in ten safety training modules upon initial employment, and on an annual basis
thereafter. This self-study packet has been developed to provide employees with another
medium by which annual refresher requirements can be fulfilled.
Directions
Please follow the directions listed below when completing this training:.
1. Do not make marks in the self-study booklet.
2. Read through the self-study booklet carefully.
3. Complete the written examination at the end of this packet using a separate
answer sheet, or go the http://search.kumc.edu/cgi-bin/exam/self1 and take
the test on line.
4. Return your answer sheet, or on-line certificate of completion, and the
self-study packet to the person who provided this packet to you.
To achieve full compliance, persons participating in this training must have access to
professionals who can answer questions as related to this material. Below is a list of contact
persons, one for each module, who can answer such questions if they arise.
Module Contact
Accident Prevention Safety Office, 588-6126 or email
cwarholi@kumc.edu
Disaster Preparedness Safety Office, 588-6126 or email
cwarholi@kumc.edu
Equipment Management Biomedical Engineering, 588-2195 or email
dcobb@kumc.edu
Electrical Safety Safety Office, 588-6126 or email
cwarholi@kumc.edu
Fire Safety Safety Office, 588-6126 or email
cwarholi@kumc.edu
Hazard Communication (Chemical
Safety)
Safety Office, 588-6126 or email
cwarholi@kumc.edu
Infection Prevention and Control Infection Prevention and Control Office,
588-2779, Page at 917-1909 or email at
nshik@kumc.edu
Personal Protective Equipment Safety Office, 588-6126 or email
cwarholi@kumc.edu
Radiation Safety Safety Office, 588-6126 or email
cwarholi@kumc.edu
Violence in the Workplace Safety Office, 588-6126 or email
cwarholi@kumc.edu

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Alternatives
Other methods by which training requirements can be fulfilled are as follows:
 On-Line Training at http://www2.kumc.edu/safety
 Annual classroom training sessions conducted by the Safety Office (Call 588-6126
for schedule)
If you have any other questions or comments, please feel free to call the Safety Office.
Table of Contents
Module Page #
Accident Prevention 4
Disaster Preparedness 9
Electrical Safety 13
Equipment Management 16
Fire Safety 21
Hazard Communication 26
Infection Prevention and Control 31
Radiation Safety 48
Personal Protective Equipment 56
Violence in the Workplace 58

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Accident Prevention
Objectives
Upon completion of Accident Prevention Training, participants will be able to
accomplish the following:
1. Name three hazard categories.
2. List three hazards that are found in their work area.
3. Describe how to properly lift things from floor level.
4. Describe the proper technique for lifting objects overhead.
5. Describe the proper position for standing.
6. Describe the proper posture for sitting.
7. Identify three safety policies or procedures.
8. List three hazard warning labels.
9. List three phone numbers that can be utilized in the event of an emergency, or
to eliminate hazards.
Introduction
There are many hazards associated with medical, research, and educational facilities such
as those found at KUMC. Many of these hazards can probably be found in your
workplace and can lead to accidents, injuries, or illnesses. This training is designed to
provide you with information to help you recognize and eliminate such hazards.
Identification of Hazards
Our first goal should always be to identify hazards before they lead to an adverse effect.
To make this easier, we place hazards into the following hazard categories:
 Kinetic/Mechanical - crushing, cutting, lifting, slips, trips, and falls,
ergonomics,…..
 Thermal - burns, frost bite, heat exhaustion or stroke, …..
 Electrical - shock, burns, …..
 Acoustic - noise induced hearing loss, …..
 Radioactive – cancer, reproductive, …..
 Biological - bloodborne pathogens, airborne pathogens, …..
 Chemical Hazards - acids, bases, flammable, reactive, …..
When you are in your workplace you should always be on the lookout for hazardous
conditions or situations. If you recognize such conditions or situations, you should take
immediate action to eliminate them.

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Ergonomics
Since many of the hazards categories listed above are addressed in other training sessions
provided by the Safety Office, they will not be covered in this training module. In this
training session, special emphasis will be placed on ergonomics. Fundamentally
speaking, ergonomics is the manner in which the human body interacts with the
workplace. It is the body mechanics of how work is done, and how these mechanics can
cause trauma to the body. Several key points to remember which will help protect you
from ergonomic hazards are as follows:
When Lifting
Do’s Don’ts
 Lift with Legs
 Keep object
close
 Keep feet apart
 Use teamwork
 Pivot feet
 Tuck chin
 Bend from waist
 Keep feet close
 Lift heavy
objects
 Twist while
lifting
 Hold object
away
 from body
When Reaching
Do’s Don’ts
 Get a step stool
for
 objects slightly
out of reach
 Get close to
object
 Maintain proper
posture when
reaching
overhead
 Stretch and
strain to reach
overhead objects

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When Standing
Do’s Don’ts
 Maintain good
posture
 Keep chin
tucked
 Keep knees
relaxed
 Keep shoulders
back
 Put one foot up
when standing
for long periods
 Maintain
excessive flat or
sway back
 Maintain
forward head
posture
 Stand with
rounded
 shoulders
 Stand with
locked knees
When Sitting
Do’s Don’ts
 Have good
posture
 Use a chair that
provides back
support and
allows hips and
knees to be bent
at 90 degrees
 Keep feet flat on
floor
 Sit it in slouched
position
 Lean forward or
downward to
reach your work
 Sit for long
periods of time
without getting
up
Safety Information
KUMC has numerous methods to protect its employees from accidents, injuries and
illnesses. Many policies and procedures have been developed to help educate employees
and help them work more safely and can be found on the KUMC Safety web site at
http://www2.kumc.edu/safety. Some of the specific safety policies and procedures are as
follows:
 Radioisotope Use
 Use of Hazardous Drugs
 Hearing Conservation
 Chemical Hygiene

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KUMC has other information resources available to help keep you safe such as chemical
safety sheets or Material Safety Data Sheets (MSDSs), training programs, labels, placards
and warning signs. Below are some other hazard warning symbols that you might
recognize or encounter at KUMC.
Biohazardous Flammable Liquids Chemical Hazards
Control / Elimination of Hazards
Once hazards have identified, steps should be taken to minimize the affect on you or your
co-workers. This can be done with engineering controls, administrative controls, and/or
personal protective equipment.
The preferred way to reduce or eliminate exposure to a hazard is to use engineering
controls. Engineering controls may include substitution, ventilation, isolation, separation,
guarding, or substitution. Substitution involves replacement of a hazardous material or
activity with a less hazardous material or procedure. Ventilation acts to reduce the
concentration of the hazardous substance thus make it less harmful. Isolation, separation,
and guarding places a barrier between the hazard and the employee.
Administrative controls use job rotation, work assignment, time limits or specific training
to reduce exposure to a hazard. An example of job rotation is trading off exposure to
radiation while holding patients during X-Rays. A pregnant worker should not be
assigned certain work activities that may harm the unborn child. And also, one should
always minimize the exposure time to any hazard, especially radiation.
Personal protective equipment should always be the last resort in control of hazards. This
is because the worker may be exposed to a hazard if the personal protective equipment is
of the wrong type, is insufficient for the concentration of the hazard, fails or is defective,
and, finally, may not be always used when needed.

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Accident/Injury/Illness Response
If you were to have an accident or injury while at work at KUMC you should make sure
that you take appropriate actions. Notify your immediate supervisor or the NAC who
will direct you in obtaining appropriate treatment where indicated. Complete the
Employee Incident/Exposure Report. Your supervisor’s signature on the Form is
necessary authorization for you to be seen. Generally, if you need assessment or
treatment for a work related accident, you will be referred to Occupational Health and
Environmental Medicine Clinic, G572 KU Hospital Building.
KUMC system of Code Alerts – Also refer to Disaster Preparedness and Fire Protection
training. An alert may be announced during certain emergencies. Your supervisor will
instruct you in your duties or actions during the following alerts.
Red - Fire
Blue - Cardiac/respitory arrest
Yellow - Multiple trauma patients
Gray - Severe storm/tornado
Pink - Abduction of baby or child
KUMC has recently obtained certification as a level 1 Trauma Center. As a part of this
effort the Code Yellow Protocol has recently been implemented. Code Yellow Protocol
has three levels:
Level 1 - Seven or more patients
Level 2 - Five or Six patients
Level 3 - Three or Four patients
KUMC has an incident response plan to prevent or respond to infant abduction. As a part
of this effort the Code Pink Protocol has been implemented. Code Pink Protocol has
Four levels:
Level 1 - Code Alert Alarm
Level 2 - Suspected Abduction (Code Pink Announced)
Level 3 - Presumed Abduction
Level 4 - Evaluation
KUMC also has phone numbers that you can call to report hazardous conditions,
emergencies, and accidents/incidents.
 Emergencies 911
 Code Blue x 8-5656
 Police Department x 8-5030
 Facilities Management x 8-7928
 Safety office x 8-6126

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Conclusion
Finally, it should always be remembered that the most important element in the
prevention of workplace injuries, illnesses, and accidents/incidents is you the worker.
Make sure that you are constantly aware of your surroundings and the hazards therein.
Once you have recognized a hazardous situation or condition, make sure that you take all
actions necessary to control or eliminate these hazards.
Disaster Preparedness
Objectives:
Upon completion of the disaster preparedness training, participants will be able to
accomplish the following tasks.
1. Describe the Incident Command System (ICS).
2. List the name and location of the 5 key disaster response locations at KUMC.
3. State the meaning of the three levels of disaster alert.
4. State the goal of the KUMC Disaster Response Program.
5. List three functions of the Emergency Operation Center (EOC).
6. Name three types of natural disasters and three types of man made disasters.
7. List the five principal activities of the Incident Command System.
Introduction
There is an ever-present possibility that a disaster will strike KUMC or one of the
surrounding communities. It is imperative that we, as a medical institution, are prepared
to respond to any disaster scenario that could present itself.
Goal and Responsibilities
The purpose of our Disaster Plan is to outline how we will respond in the event of a
disaster in our community. The goal of the response will be to 1) save lives and limit
casualties, 2) limit damage, and 3) restore normalcy ASAP.
We, the KUMC community have the responsibility to respond to disaster by organizing
all available resources to be deployed in the most efficient and effective manner. Each
department and employee has a responsibility to cooperate and extend their services to
prevent, minimize and repair damage/injuries resulting from disasters.

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Disaster Types
There are numerous types of natural and man-made disasters that could occur in our area
to which we must be prepared to respond. Some of them are listed in the table below:
Natural Technology and Man Made
 Tornadoes
 Damaging winds
 Storms (winter and summer)
 Earthquakes
 Fires
 Public Health Emergencies
 Utility failure and loss of
communication
 Structural collapse
 Industrial accidents involving toxic,
caustic, radioactive, explosive,
and/or biological hazards
 Civil disturbance (includes terrorist
activities)
 Transportation accident
Notification
In the event of a disaster, KUMC will probably be notified through the HEAR Radio
System, which is a citywide alert or “emergency broadcast” system.
KUMC has HEAR radios in the ER, Police Dispatch, and at the Switchboard. In the event
of a disaster, these three locations will notify each other and the Switchboard will make
an overhead announcement about the level of severity of the disaster. Each of the three
levels is described below:
Level I – This is the most critical and indicates that there are possible and/or actual
confirmed Mass Casualties, numbering 50 or greater. In the event of a level I disaster,
the switchboard will also call the *primary callback list and department directors and
administrators will call the **secondary callback lists to ensure adequate staffing is
available for the response.
Level II – This indicates that there are possible, but unconfirmed multiple casualties
numbering 50 or less, and that they will probably be coming to KUMC. At this point, the
switchboard will call all personnel on the *primary callback lists to return to KUMC to
participate in response. At this point it is a judgement call for those persons in charge of
**secondary callback lists as to whether these need to be initiated.
Level III – When this is announced overhead, it indicates that there is a weather alert
and/or warning (such as a code gray), or an incident with unknown, if any, casualties.
*The primary callback list is a list of phone numbers or pager numbers provided
to the switchboard to enable them to contact personnel that are critical to
coordinating response efforts (i.e. department directors, administrators, etc.).

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**The secondary callback lists is a list of phone numbers which the departments
maintain to contact critical response personnel in the event of a disaster to notify
them to return to KUMC to aid in response.
It is very important that all responding departments maintain up to date callback lists, and
that all employees who are on this list have adequate training. When callback lists change
it is very important that all lists are updated. Employees who are on a callback list must
always be prepared to return to KUMC to assist in response. Those employees, who are
off duty and are not on a call list, can report to the human resources pool to assist in
response.
Incident Command System
In the event of a disaster KUMC would utilize the Incident Command System (ICS) to
coordinate the most effective response possible. The ICS is based on the principal
activities of; 1) command, 2) operations, 3) medical, 4) logistics, and 5) planning.
According to this system, during a disaster, all response activities will be coordinated by
the Emergency Operation Center (EOC).
The EOC will be coordinating the efforts of responding departments to maximize their
effectiveness. They will also maintain communications between all response and
treatment locations to allow them to gather and process information. They will then
allocate the necessary resources to those response areas needing them. The EOC will be
located in the Police Dispatch room and will consist of the individuals listed below.
 Incident Commander (IC) is the Director of Police
 Top Nursing Administrator
 Chief of Staff
 Ranking Administrator (Hospital, and Central Admin.)
 Director of Public Relations & Marketing
 As needed, the IC will call in additional personnel
Response Locations
Many areas of the hospital will be utilized for disaster response efforts. Some of the key
response locations are as follows:
 Triage – Patients will enter the KU Hospital through the triage area, which will be
located at the ER entrance. In the event that we receive a large number of patients, or
the weather conditions will not allow the primary triage to be utilized, a secondary
triage will be set up in the Hixon Atrium in the Lied Building. At this point, a
tracking document is initiated for each patient.
 Emergency Care Area – All emergency care will be conducted in the emergency
room.
 Press Briefing Area – If members of the press are encountered they should be
instructed to go to Battenfeld Auditorium or the Blue Parking lot North of Applegate
Energy Center.

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 Victim Family Area – Patient family members should be sent to the Wyandotte
Room in the Hospital Main Cafeteria. KUMC will have representatives available to
brief them on the conditions of their affected family members.
 Human Resources Pool – Employees, who are off work and would like to assist in
the response efforts, can report to Lied Auditorium. In this location, Human
Resources professionals, based on the recommendations of the EOC, will send
personnel to areas where they are most needed.
Medical Response
In terms of the patient care, the following individuals will coordinate response activities:
Chief of Staff - conduct overall coordination of medical response
Emergency Dept. Director - oversee triage phase
Chairman of Dept. of Surgery - coordinate patient treatment after triage
Communications
Communications during disaster response could be handled through any of the following
methods: telephone, fax, pager, radio, person to person, news media, etc. The EOC can
be reached at the following phone numbers during disaster response: 588-5035, 5036,
5037, 5040, fax 5039, and Station 32 Emergency Backup Phone.
The EOC has Radio Communication with various KUMC, KU, KCKS, Wyandotte
County, and State agencies who may participate in immediate response. Outside
assistance could also include Wyandotte County Emergency Management, Kansas
Division of Emergency Preparedness, Kansas Highway Patrol, Kansas National Guard,
U.S. Military, and various state agencies.
Employees should not communicate with the media during a disaster response except to
instruct them to report to Press Briefing area, where Public Relations personnel will brief
them. This will ensure patient privacy and prevent the communication of inaccurate
information.
Conclusion
It is imperative that KUMC is prepared to respond to any disaster scenario that could
present itself. It is the responsibility of each employee at KUMC to understand their role
during a disaster response, and that they be ready to assist in such response when called
upon to do so.

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Electrical Safety
Objectives:
Upon completion of Electrical Safety training, participants will be able to accomplish the
following:
1. Know what a ground wire is and how it protects you.
2. List two things to look for when inspecting electrical cords.
3. Identify the safest multiple receptacle adapter devices for use in non-patient care
areas.
4. State the only time an extension cord can be used in a patient care area.
5. Identify the source of emergency power in your patient care area.
6. State at least two precautions to take to avoid electrical shock.
7. Identify the HEM Control Number on a piece of equipment in your patient care
area.
Introduction
Electricity makes our lives much easier. It is all around us, running our air conditioners,
heaters, lights, stereos, and much more. Electricity is easy to use and convenient, but it
must also be remembered that electricity can be very DANGEROUS. Electricity can
cause electrical burns or electrocution, and overheated electrical equipment can cause
fires. Also, electrical sparks can cause explosions.
Electrical Shock
Electrical current is brought into the hospital by two wires
that we see as electrical receptacles. One slit is “hot”, the
other neutral. The “round” opening is the ground or safety
wire. Electricity always tries to reach the ground and if
you remove the third prong from a plug it is possible that
if electricity “leaks”, it will reach the ground through you
rather than go through the ground wire. It is also very
important that you always keep an insulator between you
and electricity. This could be the plastic covering to a
wire, dry wood, rubber or glass.
Macroshock
Electrical current that “leaks” from a broken cord or piece of equipment can produce
electrical shock known as macroshock. The effects of macroshock can range from a
slight tingling sensation to stopping the heart. Individuals experiencing macroshock must
be removed from the electricity source quickly and safely. This can be accomplished by
performing the following:

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1. Eliminating the power source by pulling the plug
if possible or shutting off the power supply to the
building or room
2. Knocking the chord away or pushing the person
away from the power source using something
non conductive (Never use hands or metal
objects)
3. After the victim and power source have been
separated, immediately check for a pulse and
initiate emergency care and activate the
emergency medical system
Microshock
Microshock is another type of electrical shock that can not be felt but is dangerous for
what is called an “electrically sensitive” patient. Normally our skin acts as insulation to
low levels of electrical current. Patients who have breaks in their skin throng abrasions,
wed dressings, pacemakers or monitoring lines connected to a transducer (arterial lines,
pulmonary artery catheters) would be considered electrically sensitive. The patient at
greatest risk is probably the patient with an external pacemaker because the wires go
directly to the heart. The electricity then travels directly to the heart.
Things to do to prevent microshock include:
1. Wear rubber gloves when handling pacemaker leads.
2. Place the pacemaker box in a rubber glove if any wires are exposed.
3. Don’t touch any electrical equipment and the patient at the same time.
4. Instruct the patient with an external pacemaker not to touch the bed frame or
any electrical equipment including electrical radios, razors, etc.
5. Remember 60 cycle interference on the cardiac monitor indicates electrical
current leakage.
If you think a piece of equipment has the potential to or has caused macroshock or
microshock, contact Biomed (x2194) immediately.
GFCIs
One specific safety measure found throughout the hospital to prevent shock is the use of
ground fault circuit interrupters (GFCIs). These are special outlets use near sinks or wet
areas which will discontinue the flow of electricity if it starts free flowing into you or
another conductor.

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Risk Categories
Each piece of equipment in the hospital is categorized into one of two different risk
categories which are as follows:
Risk II - General Patient Care Equipment. Not covered by the Risk III category.
Risk III – High probability of compromising patient safety.
All risk II and III devices will be assigned a “HEM Control Number”. The Hospital
BioMed Department will keep an inventory of this equipment and shall check risk II
equipment annually, and risk II equipment every six months.
Extension Cords/Multiple Receptacle Adapters
Extension cords are PROHIBITED except in emergency situations. You can obtain
approved 1 to 1 hospital grade extension cords from Facilities Management (x7928).
In non-patient care areas like lounges and offices, in some instances there are not enough
electrical outlets. Many multiple receptacle adapters are available for purchase. The
only acceptable adapter for use is a multiple receptacle surge protector with an in line
circuit breaker. All other adapters are unacceptable including 3 in 1 extension cords and
prong adapters.
Safe Work Practices
The following are some of the Do’s and Don’ts of electrical safety.
Do’s  Properly Label all electrically hazardous equipment
 Treat all wires as "live" or "hot ".
 Use properly insulated tools
 Unplug appliances before cleaning or removing
anything from them
 Always use surge protectors
 Keep all areas dry when working.
 Pull plug with plug not cord
 Report all frayed cords or damaged equipment
 Inspect cords and equipment frequently

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 Never overload electrical circuits or cords – if the
circuit or cord is warm it is usually overloaded.
 Never place electrical equipment near flammable
 Never use electrical equipment while touching
metal or other conductors
 Never use extension chords unless they are 1 to 1
hospital grade
 Never remove the third prong from plugs
 Never string electrical cords together
 Never run over cords
Don’ts
Additional Safety Precautions
Red electrical outlets in the work area are supplied by emergency power sources. Only
critical equipment shall be plugged into these outlets. Blue outlets are connected to
battery backup systems.
Conclusion
It is critical that safe work practices be utilized when working with, or in close proximity
to, sources of electricity. It is the responsibility of each KUMC employee to understand
the possible electrical hazards associated with their jobs, and to ensure that all necessary
steps are taken to ensure that electricity does not cause death, injury or illness.
Equipment Management
Objectives
Upon completion of Equipment Management training, participants will be able to
accomplish the following:
1. Describe the purpose of the KUMC Equipment Management Program.
2. Describe the incident reporting process.
3. Differentiate between patient and non-patient care equipment.
4. List three pieces of equipment that could be categorized as Risk II.
5. List three things that Biomedical Technologies does during an equipment safety
check.
6. Identify the types of events that would require the initiation of an incident
report.
7. Name two responsibilities that KUMC employees have as related to equipment
management.
8. Know how to identify 60 cycles on a heart monitor.

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Introduction
The University of Kansas Hospital is responsible for assuring patients that all equipment,
which may directly affect their stay, is safe and functioning properly. For this reason, an
extensive Equipment Management Program has been established and implemented by the
Biomedical Technologies Department. This program outlines the policies and procedures
to be utilized by hospital personnel to ensure that all medical equipment is in safe
working condition and that equipment found to be deficient is taken out of service and
repaired immediately. This program also outlines equipment incident/user error reporting
and makes provisions for required record keeping as related to medical equipment.
Definition of Risk
All equipment is categorized based on the potential for it to cause harm to a patient. All
non-medical equipment is categorized as risk I. All patient care equipment is categorized
as one of the following risk categories:
Risk II - General Patient Care Equipment. Not covered by the Risk III category.
Risk III - Any device which has a realistically high probability (projected or
evaluated) of directly compromising the patient's safety or recovery time due to
breakdown, electrical hazard, user error, abuse, or false diagnostic information
governed by Hospital Equipment Management Committee (HEM).
Safety Evaluations
All equipment will have an electrical and performance test performed by the Department
of Biomedical Technologies prior to use. This test will include at least the following:
 Evaluated for inclusion into the proper risk category
 Visually Inspected
 Categorized as Risk II or III
 Must be checked for electrical safety annually
Equipment Management Reporting
Certain events, as related to equipment safety, are required to be reported and
investigated when they occur at KUMC. Such events, or equipment incidents, are
defined as equipment malfunction or user-error causing death, injury, potential risk or a
delay in patient care. It should be noted that user-error causes more equipment related
incidents than do specific equipment malfunctions.

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The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
requires formal attention to user-error as well as to equipment malfunction. More
specifically, JCAHO requires that all such events be properly documented via a formal
report. If such an event would occur in your area you must report this user-error or
equipment malfunction using the KUMC Incident Report Form. This process serves to
achieve the following:
 Provides confidential information regarding the incident.
 Protects KUMC and its employees.
 Provides information as to the cause of the incident so that appropriate corrective
action may be taken.
 Provides information to assess the need for more equipment in-services and to
justify need for purchasing new equipment.
When completing the Incident Report Form, you must:
 Report the matter to the nurse manager, charge nurse, or area supervisor.
 Prepare the Incident Report using following guidelines:
-Fill in patient's name in the upper right hand corner.
-Use addressograph plate if available.
-Fill in appropriate information at top of form as requested.
-Check appropriate box: Type of event, location, and nature of injury.
 Sign the report.
 Give all copies to your immediate supervisor.
NOTE: Only factual information should be recorded on this form. Do not recommend
corrective action or give opinions. The supervisor will review and sign the report and
forward the reports to the Risk Manager. The supervisor will follow-up with the "Follow-
up" Form within the designated time frame.
Safe Medical Devices Act
In 1990 a new regulation was enacted by the Food and Drug Administration (FDA) know
as the Safe Medical Devices Act (SMDA). Under this act, KUMC is required to report
medical device errors to the manufacturer and/or the FDA within 10 days if specific
criteria are met. Liabilities not to exceed $15,000 for each violation, and not to exceed
$1,000,000 for all such violations adjudicated in a single proceeding.
This Act also mandates that the actions described below must be taken in the event a
piece of equipment causes serious illness, injury, or death:
 Immediately retain all packaging materials and disposable supplies.
 Impound equipment immediately with all accessories attached.
 Impound, tag, bag and sequester the device. Include identifying number and date.
 Log device into an impound log with all pertinent data recorded.
 Do not adjust knobs, controls, or any other controlling indicator.

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 Note control setting, and any observed physical damage would be noted.
 Do not clean, process, or change settings.
 Immediately notify the supervisor, and fill out an incident report.
 The supervisor must complete an incident report and forward it to the Risk
Manager within (24) hours
 The supervisor should then notify Hospital BioMed at extension 2195 to
investigate immediately. BioMed will want the following information from you
for the investigation.
Patient's Name
Room and bed number
Name of attending physician
Product name
Location of product
Equipment ID number
Serial number of product
Model number
Name of manufacturer, if known
Brief description of incident
Medical Device User's Report Criteria
For further clarification, the medical device user’s report criteria is based on the
probability that a medical device has caused or contributed to the death of a patient,
serious injury or illness of a patient. An illness or injury is defined as an event which is:
 life threatening
 results in permanent impairment of bodily function
 permanent damage to a bodily structure
 necessitates immediate medical or surgical intervention
 to preclude permanent impairment of a bodily function or
Medical Device Types
When working in patient care areas, you must keep in mind that virtually all pieces of
equipment are considered to be medical. For example, medical devices include but are
not limited to:
Ventilators
Monitors
Dialyzers
Accessories
Components/parts
Implants
Thermometers
Catheters
Syringes
Patient restraints
In vitro test kits
Disposables
Electronic equipment
Related software

20. 20
Current Leakage
All electrical medical equipment has the potential to leak electricity that could cause an
adverse health affect to patients. When working with patients who are on heart monitors,
it is very important to know that 60 cycles is a flag that there is current leakage in the
environment. Under normal operating conditions (no equipment is leaking electricity),
heart monitors will provide a signal that looks like the following picture:
When a piece of equipment in the patient environment is leaking electricity, the heart
monitor will detect this leak and the signal will look like the following picture:
If such a signal is ever noted on the monitor, start unplugging equipment one piece at a
time (you must ensure that by doing so, you do not further compromise patient safety).
When the signal goes back to normal, you have found the piece of equipment that is
leaking. You must then take the equipment out of service immediately and contact
Biomedical technologies.
Conclusion
It is critical to the safety of our patients that all medical equipment is properly maintained
and kept in safe working order. It is each employee’s responsibility to use this equipment
in the manner for which it was intended. It is also each employee’s responsibility to
report all user error and/or equipment incidents, and to initiate corrective actions where
equipment deficiencies are discovered.

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Fire Safety
Objectives
Upon completion of Fire Safety training, participants will be able to accomplish the
following:
1. Identify guidelines that can help prevent fires.
2. Identify life safety measures.
3. Describe the conditions that require implementation of interim life safety measures.
4. Describe the procedures for a Code Red response (R-A-C-C-E-E).
5. Locate fire extinguishers and alarm pull stations in the work area.
6. Describe patient evacuation procedures.
7. Identify primary and secondary evacuation routes from the work area.
8. Differentiate among the types of fires and fire extinguishers in the work area.
Introduction
The University of Kansas Medical Center is responsible for protecting patients, visitors,
students, and employees from the potential adverse affects resulting from fire emergencies.
To fulfill this responsibility, KUMC has developed extensive fire safety (life safety)
policies, procedures, and education programs.
Fire Prevention
Whether at home or here at KUMC, our first priority should always be fire prevention. The
following are some guidelines or tips on how to prevent fires.
 Never overload electrical circuits. Use heavy duty surge
protectors with in-line circuit breakers in areas where multiple
receptacles are needed.
 Never leave open flames unattended.
 Store flammable/combustible materials in appropriate containers
and away from heat and ignition sources.
 Dispose of trash (paper, cardboard and other combustible
materials) promptly. Maintain good housekeeping.
 All space heaters are to be Underwriter's Laboratory (UL) listed
and equipped with a tip-over cut-off switch.
 Observe the no smoking policy within the institution.

22. 22
Life Safety
The following guidelines have been provided to ensure personal safety during a fire
emergency.
 Keep fire exits and stairwells free from any obstruction.
 Identify the primary and secondary evacuation routes and keep those routes
unobstructed.
 Understand the use and know the location of fire extinguishers and fire alarm pull
stations.
 Participate in fire drills at least annually.
Interim Life Safety
The University of Kansas Medical Center shall implement Interim Life Safety Measures
during times of renovation or construction or when significant Life Safety Code deficiencies
exist. Construction and renovation activities may disrupt the normal level of life safety
measures. For example, smoke detectors and alarm systems may be disabled or evacuation
routes may be blocked during construction or renovation activities. Additional training,
drills and daily surveillance will be conducted within areas affected by these activities.
Code Red Procedures (R-A-C-C-E-E)
If a fire emergency would occur at KUMC employees should initiate the R-A-C-C-E-E
procedure to minimize the adverse effects which could result. It is the responsibility of each
and every employee to know how to perform this procedure as outlined below:
Remove those in immediate danger. Close door to the room where the fire is
located.
Activate fire alarm. Alarms are generally located near stairwells and exits.
Call 911 and report the following information:
- Your name, Code Red, Building name, Floor, Room number if known,
Telephone extension number
Close all doors and windows in the surrounding areas. Shut off oxygen zone valves
after patients requiring oxygen have been transferred to portable oxygen
cylinders.
Extinguish the fire if possible.
Evacuate if imminent harm is present. Otherwise you will be informed if evacuation
is needed.

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Fire Suppression Systems
Many areas have been equipped with fire suppression systems in addition to the fire
extinguishers.
 The water sprinkler suppression systems fan water to the walls to reduce heat that causes
combustion. All storage in sprinkled buildings or areas must be kept a minimum of 18
inches below the ceiling.
 The halon suppression system floods the area with an inert gas displacing the oxygen to
stop the burning process. The Clendening Library is equipped with this type of system.
 The CO2 suppression systems function in the same manner as the halon systems. This
system is usually local, that is, protecting a single piece of equipment like the cooking
surface of a grill.
 The dry chemical suppression systems are also used to protect a single piece of
equipment or an infrequently occupied room. The dry chemical smothers the fire.
Fire Triangle
There are three elements needed to start a fire. When you have all three elements together
you will complete the fire triangle and a fire will occur.
1. The first element needed is fuel, or something that
will burn. There are many different types of fuel
such as paper, wood, gasoline, drapery and
furniture.
2. The second element needed is adequate amount of
oxygen. Air is the most common source of oxygen
during a fire.
3. The final element needed to complete the "Fire
Triangle" is a source of heat to ignite the flames.
Once a fire has started you must remove one of these elements to put the fire out.
Fire Extinguishers
All fire extinguishers at KUMC are ABC extinguishers, which means that they will put
out all types of fires. Most of these extinguishers contain dry powder that leaves a
residue after use. In areas where expensive electrical equipment is found halon
extinguishers are provided since they will not leave a residue that can ruin electrical
equipment.

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During fire emergencies that require the use of a fire extinguisher, the P-A-S-S method
should be utilized.
P - Pull the pin
A - Aim the nozzle at the base of the fire
S - Squeeze the handle
S - Sweep the base of the fire with the spray in a back and
forth motion until the fire is out
Classes of Fires
Fire can be classified based the type of fuel being consumed. These are class A, B, and C
fires.
A class "A" fire involves
common solid combustables
such as wood or paper products
that are being burned.
A class "B" fire involves liquid
or gas phase fuels that are
being burned.
A class "C" fire involves either
class "A" or "B" fuels that are
burning with a live electrical
current present.

25. 25
Evacuation Procedures
It is also very important that employees understand their responsibilities and know all
evacuation routes in the event that an evacuation is necessary as a result of a fire emergency.
Listed below are some of the key points to remember:
 The senior administrative authority (Fire Chief, Code Red Team, etc.) in the affected
area will determine the immediate necessity of evacuation.
 If patients are evacuated from their rooms, check to ensure that the room is vacant then
close the door and mark it (i.e., white tape, or tie a towel on the door handle).
 Moving the patient in a bed is the last resort. Non-ambulatory patients may be
evacuated by cart, wheelchair or a bed sheet.
 Do not use elevators during a fire emergency.
 Use primary or secondary evacuation routes to vacate the premises.
 Avoid stairwells; first try to evacuate using connecting corridors.
 Additional personnel can gather patient charts following patient evacuation.
Oxygen Valves
As mentioned above, oxygen is one of the three elements necessary to support a fire. As a
result, it is very important that during a fire event, all sources of oxygen have been
eliminated. Listed below are several key points to remember if a fire emergency occurs in
an area where oxygen valves are present:
 All oxygen zone valves are marked to indicate which rooms are served.
 Transfer patients requiring oxygen to portable oxygen cylinders prior to closing an
oxygen zone valve.
Conclusion
It is critical to the safety of everyone who enters KUMC that we are compliant with all fire
safety regulations. It is also critical that KUMC employees know how to respond in the
event of a fire emergency. By achieving these goals, we can minimize the potential for the
occurrence of, and adverse effects resulting from, fire emergencies.

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Hazard Communication
(Chemical Safety)
Objectives
Upon completion of Hazard Communication training, participants will be able to
accomplish the following:
1. Identify the three components of the hazard communication program.
2. Identify the required components of a label.
3. Interpret the markings on the National Fire Protection Association (NFPA)
label for secondary containers.
4. Identify the three methods of protection (hazard controls) against the effects
of hazardous chemicals.
5. Describe three hazards associated with the chemicals in the work area.
6. List five hazardous chemicals in the work area.
7. Locate the Material Safety Data Sheets (MSDSs) for the chemicals in the
work area.
8. Identify the four routes of entry.
9. Determine appropriate actions to take and protective equipment to wear
when handling hazardous chemicals.
Introduction
The hazard communication, or “Right to Know”, program is designed to provide
pertinent hazard information to employees who work with or around hazardous
chemicals. There are three components to the hazard communication program:
 Labels
 Material Safety Data Sheets (MSDSs)
 Training

27. 27
Labels
The first component deals with label requirements. The manufacturer, importer or
distributor must provide the following information on the label:
1. Identity of the hazardous chemical(s).
2. Appropriate hazard warnings.
(Physical & Health Hazards)
ACETONE
DANGER! EXTREMELY FLAMMABLE LIQUID. CAN
CAUSE CENTRAL NERVOUS SYSTEM DEPRESSION,
CHARACTERIZED BY HEADACHE, DROWSINESS,
DIZZINESS AND POSSIBLE NARCOSIS IF INHALED OR
SWALLOWED. CAUSES IRRITATION TO EYES, SKIN
AND RESPIRATORY TRACT. PROLONGED OR
REPEATED SKIN CONTACT MAY PRODUCE
DERMATITIS. TOXIC EFFECTS ARE ENHANCED BY
ETHANOL.
TARGET ORGANS: Central Nervous System.
FIRST AID: EYE-Flush eyes with plenty of water. Get
medical aid.
SKIN-Flush skin with plenty of soap and water.
INHALATION-Remove from exposure to fresh air. If not
breathing, give artificial respiration. Get medical aid
immediately. INGESTION-Give 2-4 cupfuls of milk or water,
then induce vomiting by giving Syrup of Ipecac. Get medical
aid immediately.
REFER TO THE MSDS FOR FURTHER INFORMATION
Ace Manufacturing
12345 Mfg. Ave.
Anytown, USA 00000
(123) 456-7890
3. Name and address of the manufacturer.

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The second type of label used at the Medical Center is the National Fire Protection
Association (NFPA) diamond label. This label is used on secondary containers. Any
time a chemical is taken out of the original product container and placed into another
(secondary) container the NFPA label is to be used.
As illustrated below, each colored section on the label provides information on various
types of hazards presented by a chemical.
Additionally, this label must contain the name of the chemical and the manufactur of the
chemical. It is also a good idea to list the types of personal protective equipment to be
used.
Blank labels can be obtained from the KUMC storeroom and must be marked with the
appropriate information. The numerical and specific hazard labeling information may be
obtained from the original product label, the Material Safety Data Sheet (MSDS), or by
contacting the Safety Office.
MATERIAL SAFETY DATA SHEETS (MSDSs)
The second component of hazard communication involves MSDSs. A MSDS is a
document provided by the manufacturer, importer or distributor of the hazardous
chemical(s). It provides information on the hazards associated with a hazardous chemical
and recommendations for safe use, handling and disposal. The MSDSs are available
within the work area. MSDSs are also available through Pulse at the safety office home

29. 29
page (http://www2.kumc.edu/safety/), on computer database in Dykes Library, in the
Safety Office or by contacting the manufacturer.
The MSDS is divided into sections. Each section is dedicated to a specific topic (i.e.
Reactivity, Fire & Explosion Data, Health Hazards, etc.) Some of the sections are listed
below:
 Name of Chemical
 Manufacturer
 Chemical Components
 Associated Hazards
 Physical Characteristics
 First Aid/Emergency Response
 Spill and Leak Handling
 Reactivity
 Disposal Practices
 Personal Protective Equipment
It is also important to know the hazards (symptoms of overexposure) of the chemicals in
the work area in order to work safely with the chemical(s) or to make determinations
regarding overexposure. This information is also available on the MSDS.
All manufacturers of hazardous chemicals are required to provide one of these sheets for
all products which they sell It is the area supervisors responsibility to ensure that MSDSs
and inventories are immediately available to employees, and that they are updated when
necessary.
Exposure Routes
Knowing the primary route of entry will provide insight into how to protect against
chemical exposure. There are four ways in which chemicals can enter the body:
 Inhalation
 Ingestion
 Absorption through the skin
 Injection
Hazard Controls
The University of Kansas Medical Center utilizes three different types of hazard controls
to protect employees from possible exposure.
 Engineering Controls - These are controls built into the facility to protect against
chemical exposure (i.e. laboratory fume hoods, lead lined walls where X-ray s are
administered). Some areas are equipped with monitoring devices that alarm when
there is a chemical release. The Safety Office monitors areas periodically where
there is a higher risk of overexposure.
 Administrative Controls - These controls limit time and quantity of chemical
exposure through work practices (i.e. working with smaller quantities in a shorter
time period).

30. 30
 Personal Protective Equipment (PPE) - Personal protective equipment can provide
additional protection from chemical exposure. This requires using the appropriate
type of PPE for the hazard presented (i.e. latex gloves are not appropriate protection
for many chemical contact hazards). It should be noted that the use of PPE is only
necessary where it is not technically or economically feasible to utilize either
engineering or administrative controls.
It is also important to know that chemical exposures can be categorized into either acute
or chronic exposures.
 An acute exposure is one which is a brief exposure, and the effects are immediate.
Effects can range from mild irritation to death. Generally speaking, if it doesn’t kill
you, you will recover completely.
 A chronic exposure is persistent, prolonged, and repeated. If you are exposed in this
manner, usually, by the time you recognize the symptoms of an adverse effect, it is
too late. You already have some type of permanent systemic damage.
Employee Responsibilities
It is the responsibility of every employee to know:
 The hazards associate with the chemicals in the work area.
 How to interpret the markings on the NFPA label.
 The location of the MSDSs for the chemicals in the work area.
 How to find information on the MSDS.
 Physical and health hazards associated with the chemicals in the work area.
 How to identify the presence (symptoms/odor) or release (monitoring) of
chemicals in the work area.
 How to work with the chemicals that they have in their work area safely.
 The type of personal protective equipment available and how to use it.
Hazardous Drugs
There has been increasing use of hazardous drugs (HD’s) in health care and growing
evidence of potential hazards of handling, preparation, administration, and disposal of
these agents. KUMC has established specific guidelines for the protection of all
personnel involved in the handling of HD's from the time the drugs arrive at the hospital
until their wastes are transported for disposal.
The mutagenic, teratogenic, and carcinogenic potential of many of the hazardous drugs
have been well established, and represent possible health hazards for exposed individuals.
Determining the magnitude of the degree of risk to any potentially exposed individual or
group is still very difficult due to the limited number of exposure studies performed to

31. 31
date. Until more extensive information is available, the KUMC guidelines are and will
remain reasonably conservative in nature. They will be updated or modified as necessary.
Included in the guidelines is a brief summary of the known hazards of the drugs;
procedures and equipment necessary for the safe handling, use, and disposal of the drugs;
and a list of hazardous drugs currently in use. A copy of the guidelines can be obtained
from the KUMC Safety Office web site at http://www2.kumc.edu/safety, or call 588-
6126.
Conclusion
In medical/research facilities such as KUMC, the potential for exposure to hazardous
chemicals is almost always present. Employees who work with such chemicals have the
“Right to Know” how these chemicals can adversely effect them, and how to protect
themselves from such effects. The KUMC Hazard Communication Program provides
employees with the tools they need to ensure that they have the information necessary to
perform work with or near hazardous chemicals in a safe manner.
INFECTION PREVENTION AND CONTROL STUDY GUIDE
All employees who are employed in a Category 1 position at KU MED are required to
receive Infection Control education upon employment and annually. Category 1 employees
are those whose jobs require anticipated contact with blood and other potentially infectious
body fluids during the performance of their job duties.
This study guide is designed to educate employees about measures to prevent the spread of
infections. Topics included in this study guide are Bloodborne Pathogens, Tuberculosis, and
Transmission-Based Isolation Precautions.
There is an Infection Control Manual that contains additional information about Infection
Control practices at KU Med. This manual is located in the Safety and Health Policy and
Procedure Manual. If you have any questions, please refer to the manual or contact the
Infection Control Office at 588-2779.

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BLOODBORNE PATHOGENS
EXPOSURE CONTROL PLAN
KU MED has an Exposure Control Plan that describes the steps taken to prevent the
transmission of bloodborne pathogens. This plan includes a copy of the OSHA Bloodborne
Pathogens Standard. A copy of this plan is located in each Infection Control Manual. If you
would like a copy, please contact the Infection Control Office at 588-2779.
STANDARD PRECAUTIONS
It is not always known when patients or associates are infected with Human
Immunodeficiency Virus (HIV), Hepatitis B (HBV), Hepatitis C (HCV) or other infectious
agents. Therefore, standard precautions must always be taken when handling potentially
infectious body fluids to prevent the risk of infection. Standard precautions require that the
blood and potentially infectious body fluids of every patient, regardless of known illnesses
and risk factors, be handled as if infectious, and that barrier precautions such as gloves be
worn to protect associates from coming into contact with them.
Infectious body fluids include:
 Blood, blood components and products made from blood
 Semen
 Vaginal fluids
 Breast milk
 Cerebrospinal fluid
 Synovial fluid
 Pleural fluid
 Pericardial fluid
 Peritoneal fluid
 Amniotic fluid
 Saliva in dental procedures
 Any body fluid visibly contaminated with blood
 All body fluids in situations where it is difficult to differentiate between body fluids
ENGINEERING CONTROLS
Engineering controls are systems or devices that isolate or remove the bloodborne pathogen
hazard from the workplace. The engineering controls presently in use at KU MED are:
Sharps Containers
 Sharps containers are disposable, leakproof, and puncture resistant, and are located as
near as feasible to all areas where contaminated needles and sharps are generated or may
be reasonably anticipated to be found. The containers are red or labeled with the
biohazardous symbol.

33. 33
 Sharps containers are inspected at least daily, and are replaced when they are no more
than 3/4 full.
 Sharps containers containing contaminated items are not to be reached into for any
reason.
 Sharps containers on medicine carts, in IV trays, in nurses stations, examining or
treatment rooms or operating areas are replaced as needed by Environmental Services or
Nursing staff.
 Sharps containers in patient rooms are replaced as needed by Environmental Services or
Nursing staff.
 Sharps containers in other areas (i.e., laboratory) are replaced by associates assigned to
fulfill this task.
 When a sharps container is replaced, the lid is locked in place and the filled container is
placed in or next to a biohazardous trash receptacle.
 Reusable contaminated sharps are stored and transported in puncture resistant leakproof
containers, and are decontaminated prior to being handled.
Engineering Controls to Prevent Splashing
 Closed container sampling lab analysis equipment
 Plexiglas splash guards in the laboratory
Safety Devices to Prevent Needlesticks
 Retractable fingerstick lancets
 IV catheters with retractable needles
 Needleless IV connecting system for piggyback and IV push medications
 Phlebotomy system with self-sheathing needles
 Self-sheathing hypodermic needles
Safety Device Exemptions
There may be situations where an appropriate and effective safer device may not be
available. Appropriate devices are those whose use, based on reasonable judgment in
individual cases, will not jeopardize patient or employee safety or be medically
contraindicated. An effective safer medical is a device that, based on reasonable
judgment, will make an exposure incident involving a contaminated sharp less likely to
occur in the application in which it is used.

34. 34
Safety Product Clinical Exemptions allowed at KU MED include:
Procedure Product Reason for Exemption
Aspiration of
pneumothorax
18 and 24 g Baxter Quick Cath;
Abbott IV Catheter
Appropriate safety device for
this procedure not available
Insertion of arterial or
external/internal jugular
line
16, 18, 20, 22, 24 and 26 gauge
IV Catheters
Appropriate safety device for
this procedure not available
Placement of peripherally
inserted central catheter
(PICC)
Several products are being
evaluated
Effective safety device not yet
identified
Nuclear Medicine injection Interlink Injection Cap Effective safety device to
prevent accidental leakage not
available
Nuclear Pharmacy and
Clyclotron injections
25 gauge 5/8 needle Appropriate safety device that
will fit through metal sleeves
not available
Accessing hemodialysis
fistula
Several products have been
evaluated
Effective safety device to
prevent fistula associated
needlesticks not available
Obtaining arterial blood
gases
Several products have are being
evaluated
Effective safety device to
prevent ABG associated
needlesticks not yet identified
Materials Management has an ongoing process to evaluate safety devices when
available, and to adopt them for use if they are determined to be effective in
reducing the risk of occupational exposure. Input into the selection of safer
devices includes non-managerial employees responsible for direct patient care.
Safety devices to prevent needlesticks are evaluated and recorded as to:
a) a description of and type of device
b) brand name
c) justification for selection
SAFE WORK PRACTICES
Sharps Handling
 Safety needles or needleless systems are used when appropriate and/or effective.
 Contaminated needles are discarded as soon as feasible after use, and are not
recapped, bent or broken.
In settings where the removal of a contaminated needle from a syringe is necessary
(i.e., surgery), the needle will be removed with a mechanical device such as a
hemostat. Some situations require the recapping of contaminated needles. In these
situations a mechanical recapping device or a one-handed recapping technique will
be used.
 Steps are taken to avoid hand-to-hand passing of sharps.
 Needles that are not contaminated with blood or other potentially infectious
materials may be recapped.

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Specimen Handling
 All specimen containers are recognized as containing potentially infectious
materials. A separate biohazardous label for each specimen is not needed.
 All specimen containers that may be contaminated or leak are placed in a secondary
leakproof container.
 Secondary containers used to transport specimens, such as phlebotomy trays, are
labeled with a biohazardous symbol.
Other Safe Work Practices
Hands will be washed with soap and water or alcohol-based waterless hand cleanser
after removing personal protective equipment, and after contact with potentially
infectious materials. Handwashing facilities are reasonably accessible to employees. In
situations where soap and running water are not accessible, antiseptic alcohol-based
waterless hand cleanser is available.
 Eating, drinking, smoking, applying of cosmetics or lip balm, or handling of contact
lenses are not allowed in work areas where blood or body fluids are likely to be
present.
Food and drink are not stored in refrigerators, freezers, shelves, cabinets or on
counter tops where blood or other potentially infectious materials are present.
 Employees perform procedures that may cause splashing or spraying of blood or
potentially infectious body fluids in a manner that reduces risk of exposure.
Mouth pipetting or suctioning of blood or other body fluids is forbidden.
PERSONAL PROTECTIVE EQUIPMENT
Personal protective equipment (PPE) to prevent contact with blood and body fluids is
readily accessible to employees and is cleaned, repaired or replaced when necessary by the
hospital. PPE is provided at no cost to employees, and is removed prior to leaving the work
area. Disposable PPE is disposed of in trash containers.
Types of PPE available at KU MED include gloves, gowns, lab coats, aprons, face shields,
masks, protective eyewear and resuscitation devices.
These devices are available in proper sizes, are appropriate for the tasks performed, and are
effective in preventing the penetration of blood and other potentially infectious body fluids.
The employee uses protective equipment unless there are rare and extraordinary
circumstances in which the employee believes the use of the barriers would prevent the
delivery of Healthcare or increase the risk to the worker or coworker.
Scrub uniforms are available from Linen Service if the associate’s clothing becomes
contaminated with blood or other body fluids. KU MED Environmental Services will
provide for the laundering of personal articles of clothing if they become contaminated and
the associate chooses not to launder them at home.

36. 36
Gloves
 Gloves are worn when there is reasonable likelihood of hand contact with blood or other
potentially infectious materials, mucous membranes, or non-intact skin, when
performing vascular access procedures, or when handling contaminated items or
surfaces.
 Hypoallergenic gloves are provided for those employees who are allergic to gloves
normally provided.
 Disposable gloves are changed when contaminated, torn, or punctured, and hands are
washed after gloves are removed. For infection control purposes, gloves are changed
between patients, or during the care of a single patient when moving from a
contaminated to a clean body site. Disposable gloves are not washed or reused.
 Utility gloves may be decontaminated for reuse if the gloves are not cracked, peeling,
punctured or deteriorating so that their ability to function as a barrier is compromised.
Protective Clothing (i.e., gowns)
 Proper protective clothing is provided that prevents blood or other potentially infectious
materials from passing through to the clothing or skin beneath.
 Protective clothing is laundered or replaced by the hospital as needed, and is removed
prior to leaving the work area or when penetrated by blood or other potentially
infectious materials. When contaminated, items are placed in a designated container for
reprocessing or disposal.
 Surgical caps, hoods or shoe covers are worn when gross contamination of the head or
feet are reasonably anticipated.
Face Shields, Masks, Protective Eyewear
 Face and eye protection are required when there is a potential for splashing, spraying, or
splattering of blood or other potentially infectious materials into the eyes, nose, or
mouth.
 During microsurgery, when it is not reasonably anticipated that there will be splashing
or splattering of blood, protective eyewear may not be necessary.
HOUSEKEEPING
Disinfectants approved by the Infection Control Committee are used to decontaminate
environmental and work surfaces. These surfaces are cleaned and decontaminated routinely
and as soon as feasible after contact with blood and other potentially infectious materials.
All reusable bins, pails, and similar receptacles that have a reasonable likelihood for being
contaminated with blood or other potentially infectious materials are inspected and
decontaminated by Environmental Services on a regular basis, and as soon as feasible upon
visible contamination.
Broken glassware or other sharps that may be contaminated are cleaned using mechanical
means such as a brush and dustpan, tongs, or forceps.

37. 37
Spills of blood or other potentially infectious body fluids are cleaned by removing the
infectious substance, then disinfecting the area with hospital-approved disinfectant.
Environmental Services is contacted to clean large spills. In non-clinical areas, ES is
contacted to clean following all spills. In clinical areas, small spills can be cleaned by ES or
clinical staff.
DISPOSAL OF REGULATED WASTE
Regulated waste is defined as:
 Liquid or semiliquid blood or other potentially infectious materials;
 Contaminated items that would release blood or other potentially infectious
materials in a liquid or semiliquid state if compressed;
 Items that are caked with dried blood or other potentially infectious materials and
contaminated sharps; and
 Pathological and microbiological waste containing blood or other potentially
infectious materials.
Regulated waste is stored in leakproof red bags. These bags are closed prior to removal to
prevent spillage during handling and transporting of waste. Disposal of all regulated waste is
in accordance with State and Federal regulations.
Note: KUMC has three major waste streams; regular waste, radioactive waste, and
infectious waste. The descriptions in this section apply to infectious waste.
MEDICAL EQUIPMENT
All used medical equipment is considered potentially contaminated, and is handled using
standard precautions. All technicians who service medical equipment in the hospital setting
are to follow this policy. Potentially contaminated equipment sent out of the hospital for
repairs or service is to be labeled with the biohazard symbol.
LAUNDRY
Contaminated laundry is not sorted or rinsed in patient care areas.
All laundry from patient care areas is handled as little as possible and is bagged at location
of use. Blue leakproof bags are used to contain and transport contaminated laundry, to
prevent soak through and leakage of fluids to the exterior.
At KU MED and Hospital Linen Service, all laundry from patient care areas is considered
contaminated and is handled using standard precautions.
Employees who have contact with contaminated laundry wear personal protective
equipment and receive annual training on the proper use of protective equipment.

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COMMUNICATION OF BIOHAZARDS
Specific labeling with the use of the Biohazard Symbol followed by the term
"BIOHAZARDOUS" or the use of red bags or containers, is required to warn employees of
potential hazards. The biohazard label is fluorescent orange or orange-red with lettering or
symbols in a contrasting color, and is an integral part of a container or is affixed as close as
feasible to the container by a string, wire or adhesive to prevent its loss or unintentional
removal.
Labeling is required for:
 Refrigerators and freezers containing blood or other potentially infectious materials.
 Containers used to store, transport or ship blood or other potentially infectious materials.
 Contaminated equipment sent for service or repair.
 Phlebotomy trays.
Labeling is not required for:
 Containers of blood, blood components, and blood products labeled as to their contents
and released for transfusion or other clinical use because they have been screened for
HBV and HIV prior to their release.
 Individual containers of blood or other potentially infectious materials that are placed in
secondary labeled containers during storage, transport, shipment, or disposal.
 Specimen containers, since standard precautions are used when handling all specimens.
 Laundry bags or containers, since standard precautions are used when handling all
laundry.
 Regulated waste that has been decontaminated.
COMPLIANCE MONITORING
The purpose of compliance monitoring is to ensure that employees follow the protective
practices outlined in the OSHA Bloodborne Pathogens Standard. Compliance monitoring is
done during routine Safety Rounds. Following Safety Rounds, a report is provided to
Managers outlining variances. The manager is responsible for following up.
EXPOSURE PROPHYLAXIS, TREATMENT AND FOLLOW-UP
Medical evaluation, prophylaxis, treatment and follow-up will be provided by
Occupational Health and Environmental Medicine Services at a reasonable time and
place and at no cost to the employee.
Exposure Prophylaxis
HBV vaccination (and other prophylactic measures as they become available) will be
made available within 10 working days of initial assignment to all employees at risk for
occupational exposure unless the employee has previously received the complete HBV
vaccination series, antibody testing has revealed that the employee is immune, or the
vaccine is contraindicated for medical reasons.

39. 39
If the employee initially declines HBV vaccination s/he shall sign a declination form. At
any time in the future the employee may request and receive HBV vaccination provided
they are still at risk for occupational exposure.
Exposure Evaluation and Follow-up
With the occurrence of an occupational bloodborne exposure, the employee shall
immediately decontaminate the area of the body that incurred the exposure, report the
incident to their supervisor, and complete the agency appropriate incident report form. If
the incident occurs after normal working hours or on the weekend, then the employee
shall report to Emergency Services only for conditions listed in the Bloodborne Pathogen
risk assessment. All Bloodborne pathogen exposure follow-up will be conducted through
Occupational Health and Environmental Medicine. Follow-up includes employee testing
for Hepatitis B, Hepatitis C and HIV and determination of risk status of the source patient
for Hepatitis B, Hepatitis C and HIV
POST-EXPOSURE CHEMOPROPHYLAXIS
Employees who are exposed to an individual who is HIV positive or at high risk for
HIV, may be a candidate to receive chemophylaxis. The employee must immediately
report to Occupational Health and Environmental Medicine Services (Department of
OHEM) during normal business hours or to the Emergency Department after hours,
to determine if the exposure falls within the recommended guideline for
chemoprophylaxis treatment. Chemoprophylaxis should be administered within 1-2
hours after a high risk HIV exposure.

40. 40
RISK ASSESSMENT FOR BLOODBORNE PATHOGEN EXPOSURE
Verify that an actual blood or body fluid exposure occurred (penetrating injury with
contaminated item, mucosal/conjunctival exposure or exposure to non-intact skin - i.e.
open wound).
Did such an exposure occur?
Yes No Stop
Does the situation require immediate attention? To assess, answer the next 4 questions:
1. Does the wound need to be sutured or debrided? Yes No
2. Did the splash occur to the eye, mucous membrane or non-intact skin (open wound)?
Yes No
3. Is the source patient high risk for Hepatitis B or know to be positive for HbsAg?
Yes No
4. Is the source patient high risk for HIV, HIV infected or have AIDS? Yes No
If “YES” to any of the previous 4 questions the employee will report IMMEDIATELY
to Occupational Health and Environmental Medicine Services during regular business
hours, (M - F 8:00am - 4:30pm) or the KU Emergency Department after hours for
treatment. Evaluation and Management of Bloodborne Pathogen exposures are covered
under Worker’s Compensation.
If the exposure does not meet the above criteria for emergent care, the employee will
report to Occupational Health and Environmental Medicine Services as soon as possible
during regular business hours for evaluation and management.
Please Note: Exposures that occur from needles or sharp objects found in patient rooms,
sharp containers, or in the trash and the exact source is unknown, the employee will
report to Occupational Health and Environmental Medicine Services as soon as possible
during regular business hours for evaluation and management.
Work Status: Personnel may return to work. The department of OHEM or the ED
physician will give specific work restrictions if needed.
For any questions please page 913-917-9044 the on-call person for
Employee/Occupational Health.

41. 41
HEPATITIS B, HEPATITIS C AND HIV
Some of the bloodborne diseases that hospital employees can be exposed to on the job
include:
 Hepatitis B (HBV)
 Hepatitis C (HCV)
 Human Immunodeficiency Virus (HIV), the virus that causes AIDS
Hepatitis B (HBV)
Hepatitis B is virus that infects the liver and can lead to cirrhosis and death. Hepatitis B
(HBV) is a major risk for Healthcare workers. The infection rate in the United States is
3.3 cases per 100,000. Hepatitis B affects about 8,500 healthcare workers each year.
Studies show the infection rate for Hepatitis B from a contaminated needle, a common
mode of transmission, is as high as one in six. Symptoms include weakness, fatigue,
anorexia, nausea, abdominal pain, jaundice (yellow skin), fever, headache, vomiting,
diarrhea, decreased appetite, and generalized muscle aches. Hepatitis B virus may be
transmitted when a person’s mucous membranes or breaks in the skin are exposed to an
infected person’s blood, semen, vaginal secretions, or other potentially infectious
materials.
Of those who are infected with hepatitis B, one-third will have no signs, one-third will
have mild, flu-like illness, and the rest will have severe symptoms of the illness. The
signs of severe clinical hepatitis B include: jaundice (yellowing of the skin and eyeballs),
dark urine, extreme fatigue, loss of appetite, nausea, abdominal (belly) pain, joint pain,
rash and fever.
The Hepatitis B virus may be spread by sexual or other contact with semen, vaginal
secretions, blood, and other body fluids of an infected person. Hepatitis B can also be
spread from a pregnant woman to her unborn child.
Human Immunodeficiency Virus (HIV)
A person who is HIV positive (HIV+) is infected with the human immunodeficiency
virus. This virus causes Acquired Immune Deficiency Syndrome (AIDS). Being HIV+
does not mean that the person has AIDS, or that they will become seriously ill soon. The
virus may be inactive for periods of time, sometimes for several years. During this time,
an infected person may have no signs of disease. In 2001, 40 million people around the
world were infected; 48% of people worldwide with ADIS are women.
The HIV virus attacks the immune system. It eventually affects the body’s ability to fight
off “opportunistic infections” which are caused by organisms that usually do not cause
disease in people who have healthy immune systems. People infected with the HIV virus
are also more likely to develop contagious diseases such as tuberculosis, because the
immune system is not able to fight them off.
A person infected with HIV may have the following characteristics:
 carry the virus for years without developing any signs

42. 42
 suffer from flu-like symptoms of fever, diarrhea and fatigue
 develop HIV-related illnesses such as nervous system problems, cancer,
 pneumonia, tuberculosis, and opportunistic infection
 will most likely develop AIDS
HIV is spread through contact with infected blood, semen, and vaginal fluids. HIV is not
spread by casual contact such as touching or working around patients who are infected.
The main behavior that transmits HIV is sexual contact. Sharing of needles during I.V.
drug use also transmits the virus. In an occupational setting, the rate of infection after
being stuck with an HIV contaminated needle is one in 300.
Hepatitis C Virus (HCV)
Hepatitis C Virus is spread mainly through blood transfusions and intravenous drug
abuse. It resembles Hepatitis B in that it attacks the liver. Symptoms of active HCV are
milder than those of HBV - or may not even be present. However, HCV is more likely to
cause a chronic carrier state and more likely to lead to cirrhosis, liver cancer, and death.
TUBERCULOSIS
EXPOSURE CONTROL PLAN
KU MED has an Exposure Control Plan that describes the steps taken to prevent the
transmission of Tuberculosis. A copy of this plan is located in each Infection Control
Manual. If you would like a copy, please contact the Infection Control Office at 588-2779.
TUBERCULOSIS INFORMATION
Tuberculosis (TB) is an infectious disease that occurs most often in the lung.
Tuberculosis is a serious and growing threat to everyone. Most tuberculosis infections are
treatable with drugs. There are some strains of the disease that are resistant to most drugs
now available.
Although anyone can get tuberculosis, there are some groups that are at a greater risk
than others. These high-risk groups include:
 low socio-economic levels without a strong social support system
 the homeless
 the elderly
 those who live in nursing or retirement homes
 IV drug users
 migrant workers
 foreign-born people from areas where the disease is common.
In addition to a positive TB skin test the patient may have one or more of the following
symptoms if infected with tuberculosis:
 productive cough

43. 43
 coughing up blood
 fever and chills
 night sweats
 recent weight loss
Patients who are HIV (AIDS) infected may have tuberculosis without showing these
typical signs.
Tuberculosis is most commonly spread by breathing in the airborne droplet nuclei (<5
microns). Organisms transmitted in this manner can be suspended in the air for long
periods of time and can be dispensed in air currents. Approximately 18,000 new cases of
active TB are reported to the CDC annually. U.S.- Rate, 2000, 6.4 cases per 100,000
(down from 7% in 1997).
An important way to control the spread of tuberculosis is to find out early who has been
exposed to the disease. Persons can have a positive tuberculin skin test without being
infectious with TB. This is why all hospital employees are given either a tuberculin skin
test or chest x-ray at the time of pre-employment health screening.
When a patient is known to have tuberculosis in the stage when it can be spread to others,
all who enter the patient’s room must wear personal protective equipment that is
recommended by the Infection Prevention & Control Committee. If the patient leaves the
room, the patient should wear a surgical mask.
At the Kansas University Medical Center, nurses may generate an order for Transmission
Based Precautions. Discontinuation of isolation requires a physician order and/or a
consult with Infection Control.
TRANSMISSION BASED PRECAUTIONS
Transmission-Based Precautions are used to reduce the risk of transmission of
microorganisms from patients with documented or suspected infections with highly
transmissible or epidemiologically important pathogens for which additional precautions
beyond Standard Precautions are needed.
Handwashing and Gloving: Handwashing is the single most important measure to
reduce the risks of transmitting microorganisms. Hands should be washed promptly and
thoroughly between patient contacts and after contact with blood, body fluids, and
contaminated equipment or articles. When hands are visibly clean, hand hygiene with
alcohol-based waterless handrub is an effective alternative to washing hands with soap
and water.
Encourage patients to wash their hands when visibly contaminated, before meals, after
toileting, and when leaving their room.

44. 44
Gloves are worn for three reasons: 1) to provide a protective barrier and to prevent gross
contamination of hands, 2) to reduce the likelihood that microorganisms will be
transmitted to patients during invasive procedures, and 3) to prevent the transmission of
microorganisms from the hands of the healthcare provider from one patient to another.
Gloves must be changed between patient contacts and hands must be washed after gloves
are removed.
Patient Placement: Appropriate patient placement is an important component of
isolation precautions. When possible, a patient with a highly transmissible or
epidemiologically significant microorganism is placed in a private room with
handwashing and toileting facilities. In addition, patients who consistently soil the
environment with infectious body fluids (stool, infected urine, wound drainage, etc.) are
placed in a private room when possible. When a private room is not available, roommate
selection must be based on the epidemiology and mode of transmission of the infecting
pathogen and the patients’ risk factors for developing infections. If a private room is not
available, Infection Control should be consulted to assist with appropriate patient
placement.
Patient Transport: Patients in isolation should leave the isolation room for essential
purposes only. When patient transport is necessary, the following steps should be taken
to minimize the risk of infection transmission: 1) appropriate barriers (e.g., masks,
impervious dressings) are worn or used by the patient, 2) personnel in the area to which
the patient is being transported are notified if the impending arrival of the patient and of
the needed precautions, and 3) patients are informed of ways by which they can assist in
preventing the transmission of their infectious microorganisms to others.
Visitors: Visitors are encouraged to follow isolation guidelines, but cannot be required to
do so. Visitors should be provided information to help them understand the risks of
spreading a disease, and the benefits of following isolation measures. If a visitor refuses
to wear isolation garb, they should be asked to wash their hands each time they leave the
patient’s room. Please contact Infection Control at 588-2779 if you would like us to
provide information to patients or visitors.
AIRBORNE PRECAUTIONS
In addition to Standard Precautions, use Airborne Precautions for patients known or
suspected to have serious illnesses transported by airborne droplet nuclei. Examples of
such illnesses include:
 Tuberculosis
 Measles (Rubeola)
 Chickenpox (Varicella)
 Smallpox
 Shingles (Zoster): Only when patient is immunocompromised or shingles are
disseminated.
Note: Chickenpox and disseminated Zoster require two types of precautions,
Airborne and Contact, until all lesions are crusted and dry.

45. 45
Airborne Precautions apply to patients known or suspected to be infected with
epidemiologically important pathogens that can be transmitted through the airborne route,
and are designed to reduce the risk of airborne transmission of infectious agents.
Airborne transmission can occur in two ways: 1) by dissemination of airborne droplet
nuclei (5 µm or smaller) of evaporated droplets that may remain suspended in the air for
long periods of time, or 2) by dust particles containing the infectious agent.
Microorganisms carried in this manner can be dispersed by air currents and may be
inhaled by or deposited on a susceptible host. Environmental factors such as airflow can
effect transmission, therefore Airborne Precautions require special air handling and
ventilation measures.
Patient Placement: Private isolation room with negative air pressure and >6 air changes
per hour. The door must remain closed. If a private room is not available, Infection
Control should be consulted to assist with appropriate patient placement.
Isolation Sign: Place the Airborne Precautions sign on the outside of the patient’s door.
Patient Transport: Patient is to leave room for medically essential purposes only. If
transport out of the room is necessary, the patient is to wear a surgical mask to minimize
dispersal of droplet nuclei.
Personal Protective Equipment:
For measles, chickenpox and disseminated shingles: Susceptible persons should not enter
the room of patients known or suspected to have measles, varicella or disseminated
shingles. Persons immune to measles or chickenpox need not wear respiratory protection.
For tuberculosis: A N-95 Respirator or Powered Air Purifying Respirator (PAPR) is to be
worn by persons sharing air space with patients with known or suspected TB. Training
and medical monitoring for use of the N-95 respirator and PAPR is required.
DROPLET PRECAUTIONS
In addition to Standard Precautions, use Droplet Precautions for patients known or
suspected to have serious illnesses transmitted by large particle droplets. Examples of
such illnesses include:
 Invasive Haemophilus influenzae type B disease, including meningitis, pneumonia,
epiglottitis, and sepsis.
 Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis.
Other serious bacterial infections spread through droplet transmission, including:
 Diphtheria (pharyngeal)
 Mycoplasma pneumonia
 Pertussis
 Pneumonic plague

46. 46
 Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children.
Serious viral infections spread by droplet transmission, including:
 Influenza
 Mumps
 Parvovirus B19
 Rubella
Droplet Precautions apply to patients known or suspected to be infected with
epidemiologically important pathogens that can be transmitted through the droplet route,
and are designed to reduce the risk of droplet transmission of infectious agents.
Droplets are generated from the source person primarily during coughing, sneezing, and
talking, and during the performance of certain procedures such as suctioning and
bronchoscopy.
Transmission occurs when droplets containing microorganisms generated from the
infected person are propelled a short distance through the air and deposited on the host’s
conjunctivae, nasal mucosa, or mouth. Because droplets do not remain suspended in the
air, special air handling and ventilation are not required to prevent droplet transmission.
Patient Placement: Private room. If a private room is not available, consult Infection
Control.
Isolation Sign: Place the Droplet Precautions sign on the outside of the patient’s door.
Patient Transport: Limit patient movement. If transport out of the room is necessary,
the patient is to wear a surgical mask to minimize dispersal of droplet nuclei.
Personal Protective Equipment: Wear well-fitting surgical mask when entering patient
room.
CONTACT PRECAUTIONS
In addition to Standard Precautions, use Contact Precautions for patients known or
suspected to have serious illnesses easily transmitted by direct patient contact or by
contact with items in the patient’s environment. Examples of such illnesses include:
 Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-
drug resistant bacteria judged by the infection control program, based on current state,
regional, or national recommendations, to be of special clinical and epidemiologic
significance. The bacteria considered to meet these criteria are Vancomycin Resistant
Enterococcus (VRE), Vancomycin Resistant Staphylococcus aureus (VRSA, VISA),
Methicillin Resistant Staphylococcus aureus (MRSA), Acinetobacter baumanii,
Stenotrophomonas maltophilia, extended spectrum beta lactamase (ESBL) producing
Gram negative organisms, resistant Gram negative bacilli susceptible to <2
antimicrobial agents, and any organism designated by Infection Control.

47. 47
 Enteric infections with a low infectious dose or prolonged environmental survival,
including:
 For diapered or incontinent patients: Clostridium difficile, E. coli O157:H7,
Shigella, Hepatitis A., or Rotavirus
 Respiratory syncytial virus, parainfluenza virus, or enteroviral infection in infants and
young children
 Skin infections that are highly contagious or that may occur on dry skin, including:
 Herpes simplex virus (neonatal)
 Major abscesses or draining wounds that cannot be covered
 Lice
 Scabies
 Staphylococcal furunculosis in infants and young children
 Chickenpox or Shingles (Zoster) unless lesions are dry.
Note: Chickenpox and disseminated Zoster require two types of
precautions, Airborne and Contact, until all lesions are crusted and
dry.
 Viral/hemorrhagic conjunctivitis
 Viral hemorrhagic infections (Ebola, Lassa, Marburg)
Contact precautions apply to patients known or suspected to be infected or colonized, at
any anatomical site, with epidemiologically important microorganisms that can be
transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs
when performing patient-care activities that require touching the patient’s dry skin) or
indirect contact (touching) the environmental surfaces or patient care items in the
patient’s environment.
Patient Placement: Private room. If a private room is not available, consult Infection
Control.
Isolation Sign: Place the Contact Precautions sign on the outside of the patient’s door.
Patient Transport: Limit the movement and transport of the patient from the room to
essential purposes only. If the patient must leave the room, ensure that precautions are
maintained to minimize the risk of transmission of microorganisms to other patients and
contamination of environmental surfaces or equipment.
Personal Protective Equipment:
Gloves and Hand Hygiene - In addition to wearing gloves as outlined under Standard
Precautions, wear gloves when entering the room. During the course of providing care for
a patient, change gloves after having contact with infective material that may have high
concentrations of microorganisms (fecal material and wound drainage). Perform hand
hygiene after removing gloves. Studies show that, when hands are visibly clean, hand
hygiene with waterless alcohol-based handrub is highly effective in removing bacteria
and viruses from hands. Following hand hygiene, ensure that hands do not touch
potentially contaminated environmental surfaces or items in the patient’s room to avoid
transfer of microorganisms to other patients or environments.

48. 48
Gowns: In addition to wearing a gown as outlined under Standard Precautions, wear a
clean, nonsterile gown when entering the room if you anticipate that your clothing will
have substantial contact with the patient. environmental surfaces, or items in the patient
room, or if the patient is incontinent or has diarrhea, an ileostomy, a colostomy, or wound
drainage not contained by a dressing. Remove the gown before leaving the patient’s
environment. After gown removal, ensure that clothing does not contact potentially
contaminated environmental surfaces.
Having Patients Wear Isolation Gowns: Patients in Contact Precautions will wear
isolation gowns when they are outside of their room and have one of these conditions:
 Draining wounds where the drainage cannot be contained by a dressing or
drainage collection system
 Open colonized or infected wounds that cannot be covered by clothing or
dressings.
 Uncontrolled incontinent diarrhea or stools that cannot be contained
Patient-Care Equipment: When possible, dedicate the use of noncritical patient care
equipment to a single patient to avoid sharing between patients. If use of common
equipment or items is unavoidable, then clean or disinfect them before use with another
patient.
Environmental Cleaning: Since environmental contamination is thought to play a role
in the transmission of resistant organisms, thorough cleaning of all environmental
surfaces must occur on a regular basis, and when surfaces are visibly contaminated.
Radiation Safety for Patient Care Personnel
Objectives
Upon completion of the hazard communication training, participants will be able to
accomplish the following tasks.
1. Understand the ALARA (as low as reasonably achievable) policy at KUMC.
2. Cite examples of work practices which enable workers to keep their exposures to
external radiation ALARA.
3. Cite examples of work practices which enable workers to keep their exposure to
internally deposited radiation ALARA.
4. Discuss regulatory standards which limit the amount of exposure that a radiation
worker may receive; that a fetus/embryo may receive.
5. Identify response actions in the event of an emergency involving radiation.
1.0 INTRODUCTION

49. 49
1.1 Background Radiation
Radiation and radioactive materials occur in nature and can be found in the air we
breathe, the water we drink, the ground we walk on, and in our bodies. Everyone is being
exposed continually to these naturally occurring sources of radiation. The average annual
exposure to background radiation in the United States is 300 mrem. The mrem is a unit
of measure for radiation just as meter is a unit of measure for distance. In many cases,
especially for nurses in the hospital setting, annual occupational exposures are
significantly less than annual exposures from background sources.
1.2 Medical Uses of Radiation
Radiation-emitting equipment and radioactive materials are used at the University of
Kansas Medical Center (KUMC) for diagnostic, therapeutic, and research purposes.
1.3 Risks Associated with Radiation
At levels much greater than those allowed for workers in the work place, radiation is
known to cause cancer. It is unknown whether radiation exposures at the levels
encountered in the work place increase the risk of getting cancer. Therefore, radiation
protection limits, as specified in the Federal regulations, are based on a conservative
assumption that for every increase in radiation exposure there is a linear increase in risk.
The maximum allowed annual occupational exposure is set at a risk level comparable to
the risk associated with other safe occupations.
A philosophy of radiation protection that has been practiced for decades - keeping
exposure to radiation As Low As Reasonably Achievable (ALARA) - has recently been
incorporated into the regulations. As part of the ALARA program for KUMC
institutional investigational levels have been set. This program will be explained in more
detail in Section 4.0.
This study-guide has been prepared to review specific practices implemented at the
University of Kansas Medical Center to keep worker exposure ALARA.
2.0 DIAGNOSTIC USE OF RADIATION
The use of radiation is an important tool in the diagnosis of illness and injury in patients.
X-ray equipment is located in the Radiology Department, the Cardiovascular Laboratory,
nursing units, and some of the clinics. Radioactive materials are used by Nuclear
Medicine for diagnostic purposes.
2.1 Use of X-rays
The Department of Radiology has primary responsibility for most of the x-ray equipment
in use at KUMC. Patients who undergo diagnostic x-ray examinations do not pose a

50. 50
hazard to health care workers. When portable x-ray units are brought to the patient’s
room, specific safety rules must be followed:
 Remain at least 6 feet from the patient, the x-ray tube and the x-ray beam.
 If asked to hold the patient or if closer than 6 feet to the x-ray beam, wear a lead
apron and gloves.
 Hold patients only when necessary and then infrequently
 If pregnant do not hold patients
2.2 Use of Radioactive Materials
The Division of Nuclear Medicine, Department of Radiology, is responsible for the
diagnostic use of radioactive materials in patients. Most patients will be taken to Nuclear
Medicine for their diagnostic examination. However, mobile units may be brought to the
patient room, usually in intensive care.
Radiation can be detected around patients who have received radioactive materials for
diagnostic purposes; However, the radiation levels associated with these patients is within
the limits allowed for members of the general public per current regulations, therefore, no
restrictions are necessary.
2.3 Work Practices to Maintain Exposures to Diagnostic X-rays ALARA
During general radiology exams, no one should be in the room with the patient unless the
patient needs to be held. General radiology rooms are provided with shielded booths
where the technologist and other personnel must stand when x-rays are generated.
In the event that a patient needs to be held, the person holding the patient must be
provided with at least a lead apron and, if the hands are near the beam of radiation, leaded
gloves. Radiology technologists and persons occupationally exposed to radiation should
not be assigned the task of holding patients. Usually, the person assigned the task of
holding the patient should be a family member or someone who is not occupationally
exposed to radiation. No person should be assigned the task of holding patients on a
routine basis.
During fluoroscopic exams it is necessary for personnel (physicians, technologist, and
ancillary personnel) to be near the x-ray tube. Most fluoroscopic equipment is provided
with some, but not sufficient, shielding. It is necessary for personnel in the fluoroscopy
room to be provided with personnel protective equipment (PPE) to maintain exposures
ALARA. This protective equipment, at a minimum, must include a lead apron. In some
instances it may be necessary to use leaded gloves, thyroid shields, wrap around aprons,
and leaded glasses. Usually this added protection is not necessary except during
interventional procedures.
3.0 THERAPEUTIC USE OF RADIATION

51. 51
Radiation is used at KUMC to treat patients who have cancer. Their treatment can be
delivered via teletherapy, brachytherapy, or radiopharmaceutical therapy. The patients
undergoing teletherapy are taken to Radiation Oncology to be treated with either 60
Co
(Cobalt-60) or with high energy x-rays. These patients do not pose a radiation hazard to
nursing staff. Patients being treated using brachytherapy or radiopharmaceutical therapy
can be sources of radiation exposure and/or contamination to the nursing staff, therefore,
staff must adhere to a number of restrictions which will be described in Section 4.0.
3.1 Brachytherapy - 192
Ir and 137
Cs
Brachytherapy is the use of sealed, radiation sources that are implanted or inserted into
the patient. Since these sources are sealed they are not a source of radioactive
contamination but are a source of radiation exposure to persons near the sources. The
sealed sources used at KUMC for therapy purposes are 192
Ir (Iridium - 192) and 137
Cs
(Cesium - 137) both of which emit gamma radiation. Both of these sources have longer
half-lives, therefore, the sources must be removed from the patient before the patient can
leave the assigned room or be dismissed from the hospital. In order to ensure that the
sources do not become lost, specific restrictions must be followed which will be
discussed further in Section 4.0.
3.2 Radiopharmaceutical Therapy - 131
I and 32
P
Radiopharmaceutical therapy is the use of unsealed radioactive materials that are injected
into or administered orally to the patient. This patient can be a source of radiation
exposure for persons near the patient. In some cases, the radioactive material may be
excreted from the body, usually in body fluids, thereby potentially contaminating anyone
or anything in contact with the patient. In order to maintain exposures ALARA and to
limit the spread of contamination, specific restrictions must be followed which will be
discussed in Section 4.0.
3.2.1 131
I (Iodine-131)
The use of 131
I for the treatment of thyroid cancer is managed by Nuclear Medicine.
About 2-3 patients are treated monthly with an average 3 day length of stay.
131
I, a gamma emitter, is a source of external radiation exposure and radioactive
contamination. Initially after ingestion, the 131
I is distributed throughout the body
especially in body fluids (urine, blood, tears, sweat). Approximately 70% is excreted
from the body, primarily in the urine, within 24-hours. Anything the patient comes in
contact with may become contaminated.
3.2.2 32
P (Phosphorous-32)
The use of 32
P for the treatment of cancer is managed by Radiation Oncology and
Obstetrics and Gynecology. It is used infrequently with an average of 1 patient or less
per year.