LMGT211: LABORATORY MANAGEMENT

WEEK 15: MANAGEMENT OF LABORATORY OPERATION

1ST SEMESTER | S.Y 2023-2024
Instructor: PROF. PAMELA SENGSON RMT, MLS, (ASCPI)

OBJECTIVE OF POLICY AND PROCEDURE MANUAL ROTATION PLAN OF THE STAFF

POLICIES - Determine the day-off schedule
- Narrative of rules and regulations* - Be aware of the schedule of leave:
• Sick leave
- Are general statements of understanding which guide, or channel
• Maternity leave
thinking and action in decision making.
• Vacation leave
PROCEDURES • Emergency leave
- Step by step action where we can abide those policies* • Absence without leave (AWOL)
- Note: availability of the reliever
- are plans that establish a required method of handling future o Some institutions have on-call reliever. They are asked to
activities, materials, equipment or machines where it is written in work if the laboratory is understaffed*
detailed exact manner in which a certain activity would be
accomplished. - Determine the rotation

STAFFING PROCESS SAFETY MANAGEMENT

- the setting of a long-term goals and objectives for the number and
type or quality of personnel you need
- Getting the right number of staff, right type of personnel that is
needed to meet the labor requirements of laboratory*
- You need them to do a specific requirement or job inside the
laboratory*
- Once you have the right number and right criteria of staff already,
proceed now with scheduling*
Occupational Health and Safety
• A cross-disciplinary area concerned with protecting the health
and safety of people engaged in work or employment.
o Take note of chain of infection*
• As secondary effect, it may also protect coworkers, family
members, employers, customers, suppliers, nearby communities,
and other members of the public who are impacted by the
workplace environment
**We cannot have a safe and healthy environment without the
collaboration of the employer and the employees

The role of the individual

1. Must always be responsible for his/her safety

2. Must follow the rules and use equipment properly
3. Ensure that the workplace is safe

SCHEDULING PROCESS The role of the employer

- Matching the people presently working in the laboratory with 1. Make sure that employees have proper training, support, right
current workload requirements. equipment should be available, workload, resources, environment
STEPS IN MAKING SCHEDULE 2. Ensure that the workplace is safe
1. Plan a schedule management
STRUCTURAL REQUIREMENT
• Not all laboratory schedules are handled by only the chief
medical technologist. Some chief MT designate this task to Safety factors should be considered in the design and layout of the
other staff of the laboratory. Personnel assigned to plan building.
schedule is the person you are going to tell if you have
request like day-off, etc.* 1. Entrance and exit route
• Plotting of schedule can be every 15 days or every month* 2. Blockage of hallways and doors
2. Define activities 3. Location of sprinklers and fire extinguishers
3. Sequence activities 4. Storage of flammable materials
4. Estimate activity resources • should be away from direct heat*
5. Estimate activity durations 5. Ventilation system
• Whether the personnel will just be assigned in one section or
he/she will be assigned to other sections of the laboratory*
6. Develop schedule The following must be considered in the floor plan layout and
• Once consolidated, you may now develop a schedule* workplace design
• Completely plotted schedule is subject for approval and
1. Separate clinical and administrative offices from areas with
signature of the heads and to also cross-check if the
hazardous materials
laboratory personnel is still working (or pumapasok pa ba) in
• To break the chain of infection*
the laboratory*
2. There should be a system in the delivery and storage of
potentially hazardous materials
GENERAL COMMENTS ON STAFFING AND SCHEDULING
• Proper transporting*
- Based on the practice 8-hour shifts which depend upon the
• Send out of materials or tests if not available on your own
demand and the availability of personnel
laboratory*
o Standard and recommended hours of shift by the DOH*
- Largest number of personnel is assigned during the first 8-hour • Your send out laboratory will be the one to pick up the specimen
shifts or material on your own laboratory*
o Increased number of patients in the morning due to certain 3. There should be a proper ventilation system
preparations of every test like fasting, patients from other 4. Accessibility of special safety equipment fume hoods and first aid
hospitals, people coming in for check up that are subjected stations
for lab tests, etc.* • Should have a big label so that it can be easily seen
- Provision is made to increase staff during the night shift especially
in times of emergency HAZARD vs RISK
o Mostly until 5pm only*
o Caters patient inside the hospital that are admitted in wards*
 • Healthy lifestyle

Methods Of Compliance / Protective Measure and Procedure

1. Adoption of universal precaution policy

2. Engineering and work practice controls
3. Personal protective equipment
4. Housekeeping techniques
• Keep your workplace clean
Universal Precaution

• Given by the WHO, CDC, and OSHA*

• Defined as approach to infection control. Treat all human blood
HAZARD and body fluids as if they contain the blood borne pathogens
• You know it can cause harm to an individual regardless where it is from*
• Ex. Electricity, biohazard, sharps, stress, noise, chemicals, etc.
• Barrier protection
• Gloves
RISK • Face Protection
• Likelihood or probability that the hazard will really cause • Protective Body clothing
somebody harm • Wash hands
• Ex. Needle without cap • Avoid accidental injuries
o Low likelihood of harm if you will not touch that needle • Proper disposal
o High likelihood of harm if the place is busy

HAZARDS IN THE LABORATORY

I. Biological Hazards
II. Sharp Hazards
III. Chemical Hazards
IV. Radioactive Hazards
V. Electrical/Fire Hazard
VI. Physical Hazard

Personal Protective Equipment

Gloves
- usually have separate sheaths or openings for each finger and the
thumb.
- Latex, nitrile rubber or vinyl disposable gloves are often worn by
health care professionals as hygiene and contamination.
protection measures.
- Garment that covers the whole hand. Use what fits your hands.
Cross contamination may happen if gloves is too loose and it is
difficult to palpate vein. Use non-powdered gloves as much as
possible*

I. BIOLOGICAL HAZARD
• Infectious materials
• Caused by microorganisms
• To prevent infection, you must know how the organisms are
transmitted* Eye And Face Protection
1. Source - Location of the potentially harmful organism* - Since the goal is to provide protection of the eyes, nose and
Prevention mouth, protection may consist of one of two choices:
• Hand washing 1. Chin length face shield only
• Biohazardous waste disposal 2. Eye protection + face mask
• Decontamination
2. Transmission - Ingestion, fecal-oral route, direct contact,
inhalation (droplet or airborne [vectors or fomites]), etc.*
Prevention
• Hand washing
• Personal protective equipment
• Aerosol prevention
• Sterile equipment
Mask
3. Host – can become another source - It is designed to prevent infections in patients and treating
Prevention personnel by catching bacteria shed in liquid droplets and
• Standard precaution aerosols from the wearer's mouth and nose.
• Immunization - Intended to be worn by all healthcare professionals during health
• OSHA guidelines care procedures*

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- It should be fit. To test if the mask fits perfectly, blow air and the you and roll it inside out into a bundle, then dispose of it in the
air coming out will be warm. * biohazard waste container.

Layers of the mask 5. Next, remove your safety glasses by grasping the frames at the
temples. This is an area where there is less potential for
a. Outer Fluid-repellent Layer – outermost colored layer. This contamination. Place them in a designated area to be disinfected
layer will reduce the chance that viruses and bacteria will attach at the end of the shift.
to the mask*
b. High-efficiency filter middle layer – If ever may nakapasok pa 6. Remember to use gloves and cleaning products that meet the
rin na microorganism, this layer will do the hard work in capturing EPA’s approval to clean your safety glasses and follow the
the virus and bacteria that get passed outside that repellent layer* manufacturer’s recommendations for contact time.
c. Absorbent Layer - innermost layer. Absorbs moisture. If the 7. Last, wash your hands with soap and water. Lather the backs of
wearer is sick, it is designed to keep things coming in and keep your hands between your fingers and under your nails and scrub
things from coming out* for at least 20 seconds. An alcohol -based hand sanitizer
containing at least 60 % ethanol or 70 % isopropanol can be used
as a temporary solution until soap and water are available.
8. Additional considerations. Closed -toed shoes with solid and
impermeable uppers should be worn in the laboratory. PPE will
vary based on laboratory specific and procedure -specific risk
assessments.
9. Donning and doffing areas should be physically separated from
Personal Protective Equipment
each other to avoid contamination of clean PPE and personal
- disposable clothing worn to create a barrier between blood, bodily belongings with potentially contaminated PPE. Donning and
fluids, or respiratory secretions. doffing procedures vary per institution. Follow your institutional
- Hazmat suit (white one)* policies and procedures.
**end of video
II. SHARP HAZARD

**video attachment
Donning and Doffing of PPE

1. Remove jewelries, watches, coats, jackets, cell phones, pens and Possible injuries
bags. Place them in a location outside the laboratory
- cuts, puncture or blood borne exposure
2. Tie back any long hair if present - Never recap with two hands*

3. Gather laboratory coat with tight cuffs, gloves, and safety glasses.
4. Make sure you have the right size laboratory coats and gloves.
5. Make sure to visually inspect PPEs for rips, tears, or missing
snaps
6. Put on laboratory coat and snap it completely, then put on safety
glasses and finally, put on gloves.
** Remove PPE from most contaminated to least contaminated III. CHEMICAL HAZARD

DOFFING
1. The first step is to slowly and gently remove your gloves. Start by
making an L with your thumb and first finger. Then place your
fingers perpendicular to your wrist and pinch. Be careful to not
touch the cuff of the coat with your dirty glove.
2. Next, pull the glove completely off. It should now be inside out.
Grab the inside out glove with your bare hand, the one the glove
just came off of, and then pinch the other glove at the wrist. Then
pull the pinched glove up high and away from the wrist. Pull the
glove off, making sure the gloved hand is flat and you do not
- Right to know regulations
touch the outside of the contaminated glove with your clean hand.
3. And last, discard the gloves into the biohazard waste container. 1. OSHA - the agency responsible for developing and enforcing
Remember, do not reuse the gloves. Take care to not touch the regulations governing safety in the workplace.
potentially contaminated outside surfaces of your laboratory coat 2. Material Safety Data Sheets – a document required by OSHA
with your bare hands. The cuffs of the coat should be clean, detailing safety information about each hazardous about each
however, as the gloves extended over them during your work. hazardous substance.
4. Next, unsnap your laboratory coat and grasp the sleeve cuff of • Included here is the type of hazard, composition of the
one of the arms and pull off the laboratory coat. Do the same for chemical, first aid measure, etc.*
the other arm. If you are reusing the laboratory coat, hang it in a
designated area. Please note, if there is visible contamination or it
is determined that the laboratory coat should be disposed of, with
the inside of the coat facing towards you, fold the coat away from

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 IV. RADIOACTIVE HAZARDS

- the amount of radioactivity present in the laboratory is very small

and not dangerous, however the effects of radiation are
Chemical Spills cumulative related to the amount of exposure
- Uses radioisotopes in their procedure*
1. If there’s skin contract - don't attempt to neutralize it.
- Filmbadge - they wear this to monitor the amount of exposure
• Flush the area with large amount of water*
and to avoid excessive amounts of radiation despite them being
2. Remove contaminated clothing
exposed to radioisotopes such as gamma rays, x-rays, and beta
• If part of the clothing has spill, remove it* particles*
Chemical Labeling

1. Poisonous
• (w/ skull in the photo) any material or reagent that will V. ELECTRICAL/FIRE HAZARDS
cause someone illness or eventually kill the individual if they
ingested inhaled or come in contact with mucus membrane,
eyes, or skin*
2. Corrosive
• (w/ test tube in the photo) can cause irreversible alteration,
visible destruction to the part of the body that comes in to
contact with the chemical*
• Ex. Acids such as hydrochloric acid, sulfuric acid*
2 Major Hazards in The Laboratory
3. Carcinogenic
• Any substance that can cause cancer such as benzene* 1. Physical harm from shocks or burns
4. Flammable • Whenever a person comes into contact with an electrical
• Substances that are capable of ignition or igniting* source*
2. Dangers from fire caused by heat and sparks
• Usually generated from malfunctioning wiring or equipment*
Recommended Safeguards from NFPA

NFPA - national fire protection association

1. Extension cords adapters should not be used
2. Equipment should not be operated with wet hands.
3. Report dangerous conditions such as frayed cords and overloaded
circuits to the appropriate persons
4. Circuit breakers should be labeled and conveniently located
5. Electrical equipment should not be used in areas with flammable
materials
6. There should be a constant electrical safety check
Chemical Handling • To check if the following are followed, there is constant audit
and investigation coming from internal and external
a. Chemicals should never be mixed sources*
b. Chemicals should be added in the order specified in the
instruction. Recommended Procedures in Dealing With Electrical Accidents
c. Prepare reagents under fume hood
d. Do not pipette by mouth. 1. Never directly touch a person who is in contact with a live wire or
• This was an old practice* equipment
2. Unplug the electrical source
Chemical Storage 3. Separate the victim from the live wire by using nonconductors like
wood and plastic
Never store the following types of wastes near each other 4. Protect victim from electrical shock by covering him with coat
• Acids and bases until help arrives
• Cyanide, sulfide, or arsenic compounds and acids
What to do in case of the:
• Alkali or Alkali earth metals, alkyllithiums etc. and aqueous waste
• Powdered or reactive metals and combustible material Rescue - anyone in immediate danger of the fire
• Mercury or silver and ammonium containing compounds Alarm – pull the nearest fire alarm and call fire response
• Organics and acids Contain – fire by closing all doors in the fire area
• Storing chemicals should be compatible with each other. If Extinguish – small fires. If not, leave the area and close the door
incompatible, it should be stored separately *

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Fire Fighting Strategies

- Construction
a. Building structure
o It should be calamity proof*
b. Fire resistant construction material
c. Layout plan of entrance and exits
o It should be strategically located*
• B for basa
d. Storage of flammable materials.
• C for kuryente
• It should placed in a explosion proof container* • Class K or Class F (same lang)
• Gas cylinders and oxygen tank should be away from direct
heat to avoid explosion*

• There are some incidents that safety pin can't be pull right
away because there is safety seal*
• That's why twisting motion to break the safety seal is done
before proceeding with PASS*

VI. Physical Hazard

1. Avoid running in the workplace.
2. Watch for wet floors
3. Keep long hair pulled back
4. Avoid dangling jewelry
5. Use closed-toe shoes.
Fire Fighting Equipment

a. Fire resistant building materials

b. Automatic sprinklers
c. Self-closing doors
d. Fire hydrants
e. Fire extinguisher
f. Fire blankets
g. Materials that can be used to prevent fire
• Sand can also extinguish fire *
Types of Fire and Fire Extinguisher

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 CHEMICAL WASTE
A. If the chemical waste is not hazardous, dispose directly in the
trash or if it is liquid it can be disposed in the sink and flushed
with large amount of water.
B. Regulated hazardous waste
1. If the waste can be neutralized or destroyed – neutralized
then dispose directly in the trash or if it is liquid, after
MANAGEMENT OF SAFETY LABORATORY neutralizing dispose it in the sink.
2. If the waste cannot be neutralized – collect then contact the
A. Responsibility licensed disposal company
Safety committee
• Assigned to the overall development and monitoring of
RADIOACTIVE WASTE
safety management program which are governed by
safety officers* If the half-life of the radioactive is <90 days
Safety officers • Allow it to decay in storage
• In charge for all the policies and procedures of the safety • Dispose in trash or in sink
committee has talked about should be implemented on Half life >90 days
a daily basis and should be communicated to all • Contact the licensed disposal company
departments and staff involved*
B. The safety management program BIOLOGICAL WASTE
1. Policy and procedures
A. Sharps - collected by the disposal company
2. Communications
B. Animal carcasses – incinerated
3. Disaster plans.
C. Infectious waste - collected by the disposal company
• Draft the policy and the chronological order of the
procedures*
Healthcare waste management manual
• Communicate the standard policy and procedures to all
Color-coding Scheme for Containers
employees and employers*
Color of container bag Type of Waste
• Draft disaster plan also called as disaster and risk
management plan* Black Non-infectious dry waste
4. Safety audits and inspections Green Non-infectious wet waste (kitchen,
• To check if you are ready and safe practices dietary, etc,)
inside the laboratory* Yellow Infectious and pathological waste
• Internal – own entities inside the hospital will go Yellow with black band Chemical waste including those with
to the laboratory to inspect* heavy metals
• External – DOH will do the audit. They will Orange Radioactive waste
check for materials, building structures, etc. They Red Sharps and pressurized containers
also bring their assessment tool and see what
category your laboratory belongs (primary,
secondary, or tertiary)*
5. Accident investigation and accident prevention
• Corrective action - action to prevent the accident that
happened from happening in the future

• Safety equipment should be available in the laboratory

• The following items should be available
o Fume hood
o Fire extinguisher
o Fire alarm
o Shower
o Eye wash fountain
o First aid kit
o Chemical control spill kit
o PPE
o Scrub suit and lab coat

Solid waste

• Any solid, liquid, semi-solid, or contained gaseous material

that is discarded, abandoned, recycled, or is an inherently
waste-like material
Non-hazardous wastes

• Are those that pose no immediate threat to human health

and the environment ( Ex. household garbage)
Biodegradable waste
• Originates from plant or animal sources, which may be
broken down by other living organisms
Non-biodegradable
• Cannot be broken down by other living organisms
Hazardous waste

• Potential threat to human health or the environment when

improperly treated, stored, transported, and disposed
PROPER DISPOSAL OF LABORATORY WASTES

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