Laboratory Safety Assessment Policy

Policy

Assessments of environmental health and safety conditions in the �Ƽ��Ӱ�ԭ�� laboratories will be conducted on a regular and continuing basis in order to evaluate compliance with regulatory requirements and other recognized laboratory safety practices. Results of these assessments will be documented, and noted deficiencies will be resolved.

Responsible Authority

Vice President, Research and Innovation; Environmental Health and Safety Department

Scope

This policy applies to all teaching and research laboratories, and laboratory stockrooms and storerooms maintained by the �Ƽ��Ӱ�ԭ�� that possess chemical, biological, or physical hazards.

Background

Regulatory, moral, and legal obligations require the University to implement an effective laboratory safety program. Inherent in these obligations is the expectation that recognized hazards are identified, evaluated, and managed to an acceptable level of risk. These hazards must be communicated to laboratory personnel, and personnel must be trained in safe work practices that minimize the risks associated with these hazards.

As an educational institution, the University has a unique obligation to teach and promote safe laboratory practices and regulatory compliance, and to provide safe laboratory facilities for teaching and research. The importance of laboratory safety in academia is highlighted by reports that accident rates in academic laboratories are significantly higher than in industrial research and development laboratories with well-developed laboratory safety programs in place (1, 2).

Many of the regulatory requirements and prudent laboratory safety practices applicable to laboratories are outlined in the University Chemical Hygiene Plan (CHP), and the Biological Safety Manual (BSM).

Reference Regulations

29 CFR 1910.1450 “Occupational Exposure to Hazardous Chemicals in Laboratories”
29 CFR 1910.1030 “OSHA Bloodborne Pathogen Standard”
National Institutes of Health “NIH Guidelines for Research Involving Recombinant DNA Molecules” (latest edition)
Centers for Disease Control and Prevention/National Institutes of health, “Biosafety in Microbiological and Biomedical Laboratories” (latest edition)
42 CFR subpart 73 “Possession, Use and Transfer of Select Agents and Toxins”

Definitions

Laboratory

The physical space for which a laboratory supervisor is responsible and which is used for the purpose of conducting scientific research, storage of research materials, or teaching laboratory techniques and scientific experimental procedures.

Laboratory Safety Assessment

An assessment of the laboratory with regard to regulatory compliance, the University health and safety policy, recommended industry standards, and recognized prudent practices.

Laboratory Supervisor

Person who has been assigned responsibility for a particular laboratory space or activity. Principal investigators assume this responsibility for laboratory space assigned to them for research activities. Teaching faculty assume this responsibility for academic laboratory courses for which they are the designated course instructor.

Responsibilities

Deans, Department Chairs, and Directors

Ensure that laboratory supervisors are aware of the responsibilities and procedures contained in this policy, provide administrative enforcement, and ensure compliance with this policy.

Promote laboratory self-inspections and departmental laboratory inspections.

Environmental Health and Safety (EH&S)

The Environmental Health and Safety Department is responsible for providing guidance to laboratory personnel with regard to regulatory compliance and implementation of safe and prudent work practices in the laboratory. EH&S performs laboratory assessments of each laboratory within the time frames discussed in the “Procedures” section, prepares a report describing the results of each assessment, transmits this report to the laboratory supervisor, discusses solutions for the given deficiencies with the responsible laboratory supervisor, and tracks the resolutions of these deficiencies.

Laboratory Supervisors

Laboratory supervisors are responsible for ensuring a safe work environment in the laboratory. This must be demonstrated during the EH&S laboratory safety assessment through the following action items:

Ensure that the employees and students receive all mandatory training (training provided by EH&S, as well as laboratory-specific training provided by the laboratory supervisor), and implement preventative measures to control hazards and minimize risks to personnel as stated in the Laboratory Supervisor Safety Responsibilities Policy.
Evaluate laboratory operations and prepare Standard Operating Procedures (SOPs) for higher risk activities. Chapter three of the University Chemical Hygiene Plan further discusses SOP preparation. The SOPs must provide clear guidance on performing the particular activity safely so that risks to personnel, facilities, and the environment are minimized, and facilitate compliance with all government regulations.
Ensure that all University laboratory safety policies are adhered to during teaching laboratory sessions. Responsibility for the supervision of individual laboratory sessions can be delegated to the qualified Teaching Assistants (TAs) or other laboratory instructors.
The laboratory supervisor must have available for review by EH&S during the laboratory assessment all SOPs, training records, and administrative paperwork (i.e. MOUA) required by the University laboratory safety program.
The laboratory supervisor must work with the EH&S representative to remedy deficiencies found during the lab assessment within the prescribed time frame.

Laboratory Personnel

It is the responsibility of laboratory personnel to attend training and obey all laboratory safety policies as well as prudent laboratory practices while working in the laboratory, and to report any safety, policy, or regulatory compliance problems to their supervisor. Laboratory personnel must be proactive in providing a safe work environment, must be fully aware of the hazards associated with their work, and know how to reduce the risks of these hazards. The laboratory supervisor may designate laboratory personnel to be responsible for carrying out the above-mentioned supervisory responsibilities; however, the laboratory supervisor always maintains responsibility for overall safety in the laboratory. Laboratory personnel may be present during the laboratory assessment, especially if requested by the laboratory supervisor. They may also be requested to present the above-mentioned tasks to EH&S representatives.

Procedure

The laboratory safety assessment process conducted by EH&S is a general review of laboratory safety, including implementation of prudent laboratory safety practices, government regulations, and recommendations and requirements stated in the University safety manuals. Any unsafe conditions or work practice will be noted, and training documentation and SOP preparation will be checked. EH&S will then enter the assessment data into an online database (SafetyStratus) and will assign resolution dates based on the level of risk posed by the deficiencies. Depending on the condition of the laboratory, or the severity of the noted deficiencies, a follow-up visit may be scheduled.

Should this visit be the initial visit for a new researcher at the University, the meeting will be an introduction to the University laboratory safety program, and the requirements of this program will be discussed with the investigator.

Laboratory supervisors can ask for more time or assign their findings to another person, but must ultimately mark their assigned deficiencies as “resolved” within SafetyStratus. This completes the assessment procedure for the current period. Department Chairs will be able to view open and closed findings within their department, but may also request reports from EH&S that outline various safety metrics such as severity of findings, time to resolution, and most common corrective actions. Email reminders are automatically sent to the laboratory supervisor, and the Environmental Health and Safety representative will follow-up to ensure that deficiencies have been resolved. As described above, the follow-up time will depend on the severity and type of deficiency noted. If a laboratory supervisor fails to address their assigned deficiencies after multiple reminders, they will be referred to the Chair of their respective departments, and/or the Dean of their respective College. Should a laboratory supervisor feel that a given deficiency is not valid, the laboratory safety committee can be consulted as to whether or not the cited deficiency is valid.

All laboratory assessment records will be maintained by EH&S and SafetyStratus for at least three years.

Every laboratory at the �Ƽ��Ӱ�ԭ�� will be assessed by EH&S annually as resources permit, unless the current state of research necessitates a more- or less-regular schedule (to be determined by EH&S in consultation with the laboratory supervisor). Depending on the amount and severity of deficiencies, additional follow-up may be done via phone or email, a “pop in” visit, or a scheduled second laboratory assessment.

Laboratory supervisors are required to internally monitor laboratory safety conditions by conducting documented laboratory safety self-assessments at least annually. EH&S recommends that these self-assessments are conducted approximately 6-8 months after EH&S assessments in order to provide more regular evaluation through a given year. Such self-assessments can be conducted by individuals or teams of laboratory workers, including undergraduate and graduate students, postdoctoral associates, and teaching assistants. Laboratory supervisors, instructors, and stockroom supervisors are encouraged to tailor assessment checklists to suit conditions in their own facilities. Refer to the Chemical Hygiene Plan appendix for a sample laboratory assessment checklist.

References

The Laboratory Safety Institute, LSI web site: http://www.labsafety.org.
Furr, Keith A. (ed.). 1995. CRC Handbook of Laboratory Safety, 4th Edition, pg. 218, Boca Raton: CRC Press.

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