Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry of Health ‫وزارة الصحة‬

Directorate of Health Affairs - Najran ‫ نجران‬- ‫مديرية الشؤون الصحية‬
Maternity & Children’s Hospital ‫مستشفى الوالدة واألطفال‬

Department: LABORATORY Original Date: 02.01.2018

Policy Code Number: DPP LB-017 Revised Date:
Version number: 1 Effective Date: 02.02.2018
TITLE: LABORATORY SAFETY PROGRAM Review due: 02.02.2021

1. STATEMENT OF PURPOSE
1.1. To provide a thorough understanding of safety procedures, and to ensure a safe
environment for all of Laboratory sections .

2. APPLICABILITY
2.1 All laboratory staff

3. DEFINITION
SAFETY PROGRAM: A program applies to all activities in the laboratory where there exists the
potential for personal hazard or property damage and to minimize the risks associated with
operations in the laboratory

4. POLICY
It is the policy of the laboratory and blood bank that all staff shall participate regularly in the
Safety Program to ensure a safe work environment

5. PROCEDURE
5.1 The basic elements of the program are:
5.1.1Chemical hygiene plan
5.1.2Mechanism of compressed gases control.
5.1.3 Biological safety procedures and use of standard precautions
5.1.4 Tuberculosis and other biological hazards exposure plan.
5.1.5 Electrical safety plan.
5.1.6 Fire prevention and control plan.
5.1.7 Provision and use of personal protective equipment.
5.1.8 Provision and control of negative pressures in sections dealing with highly
infectious materials
5.1.9 Provision, use and control of biological safety cabinets.
5.1.10 Provision of safety equipment.
5.1.11 Waste disposal plan.
5.1.12 Provision and use of first aid kits.
5.1.13 Reporting of infection and safety incidents.
5.1.14 Training is an integral part of this program. MCH laboratory have a
moral, professional and legal responsibility to train laboratory workers in
safe laboratory practices. Laboratory supervisors must ensure that
training occurs before an individual begins working in the laboratory the
training and education of laboratory workers; Initial training and annual
refresher training and competency testing thereafter is required for all
employees who work in the laboratories

DPP LB-17.1.4 (3) Page 2 of 2

Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Directorate of Health Affairs - Najran ‫ نجران‬- ‫مديرية الشؤون الصحية‬
Maternity & Children’s Hospital ‫مستشفى الوالدة واألطفال‬

Department: LABORATORY Original Date: 02.01.2018

Policy Code Number: DPP LB-017 Revised Date:
Version number: 1 Effective Date: 02.02.2018
TITLE: LABORATORY SAFETY PROGRAM Review due: 02.02.2021

5.1.14.1 All laboratory workers must be trained in emergency procedures, the

proper use of appropriate safety equipment (e.g. eyewash units, showers, fire
extinguishers).

5.1.14.2 All laboratory workers must be familiar with appropriate procedures for
dealing with fires that might break out in their laboratory, spillages of the
substances handled in their laboratory and other accidents that have the
potential for property damage and/or personal injury.
5.1.14.3 the use of personal protective equipment where there is the potential
for exposure to or contact with chemical, biological or physical agents;
5.1.14.4 Regular safety audits should conducted by laboratory safety officer,
to assess effectiveness of the program.

6. RESPONSIBILITIES
6.1 Chief of laboratory
6.2Laboratory Safety officer
6.3 FMS Director

7. REFERENCES
7.1 CBAHI reference standard LB 17.1.3
7.2 Safety in Health-Care Laboratories (WHO)

8. FORMS / EQUIPMENTS
8.1 Accident form (OVR)
8.2 Personal Protective Equipment ( PPE)

9. REVISION
9.1 Will be reviewed after 2 years or revised as needed according to APP LD - 001.

10. APPROVALS
10.1 Prepared by:
10.1.1 Eng. Saleh AL Sharmah Signature:______________Date:__________
Facility Management & Safety Director
10.1.2Mr. Mohammad Al Abbas Signature:__________ Date:__________
Infection Control Director
10.1.3 Dr. B.P.RudramuneswaraSwamy Signature :____________ Date : _________
Laboratory Infection control Officer
10.1.4Dr. Ahmed Mahmoud Signature:____________ Date : _________

DPP LB-17.1.4 (3) Page 2 of 2

Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصحة‬
Directorate of Health Affairs - Najran ‫ نجران‬- ‫مديرية الشؤون الصحية‬
Maternity & Children’s Hospital ‫مستشفى الوالدة واألطفال‬

Department: LABORATORY Original Date: 02.01.2018

Policy Code Number: DPP LB-017 Revised Date:
Version number: 1 Effective Date: 02.02.2018
TITLE: LABORATORY SAFETY PROGRAM Review due: 02.02.2021

Laboratory Safety Officer

10.1.5 Dr. SyedTanweer Iqbal Signature :_____________Date : _________
Laboratory Medical Director
10.1.6Mr Ali Abdullah AlBesher Signature :_____________Date : _________
Chief of Laboratory &Blood Bank
10.2 Reviewed by
10.2.1Mr Ali Hussein AlMehthal Signature :_____________Date : _________
Quality and Patient Safety Director
10.3 Approved by:
10.3.1Dr.Mamdouh Al OthmanyMohd Signature :_____________Date : _________
Medical Director.
10.3.2 Mr. Ali Mohammad Ghraban Signature :_____________Date : _________
Hospital Director.

DPP LB-17.1.4 (3) Page 2 of 2