Policy and Procedure Title:

Lab Safety Program and Standard Precautions

Ownership: Effective Date: Code:
Hospital Administration June 2018 AQWCH/Clin/060
Revision Due Date: Type of Policy and procedure:
June 2021  Administrative
By:  Technical (Clinical)
Task Force
Applies to:

Al Qassimi Women’s & Children’s Hospital

1. Purpose & Scope:

1.1. To provide directions for all AQWCH Health Care providers to do their part to ensure a safe and
healthy work environment.
1.2. To describe universal safety measures, good laboratory practices that must be understood
and observed by all laboratory staff to protect them from potential biological, chemical and
physical hazards.

2. Policy Statement:

2.1. The relevant manager/supervisor of laboratory services shall orient and train all staff on the
safe work practices and procedures in compliance with established AQWCH policies and
procedures.

2.2. Specific policies and procedures shall be developed by the Head of Laboratory when it is
appropriate and needed for hazards beyond the scope of manual.

2.3. Safety Committee or equivalent shall act as a resource for the knowledge and guidance
regarding the transportation of dangerous goods, spills, waste management, designated
substances, MSDS sheets, accident investigation, hazard assessment, air quality, ergonomic
assessments, physical demands studies, special investigation and first aid kits.

2.4. The laboratory safety program in AQWCH is integrated within the hospital safety program
through membership in the safety committee or equivalent and through sharing information
about the same.

3. Definitions:

3.1. MSDS: Material Safety Data Sheets are written or printed material concerning a hazardous

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 chemical. They contain basic information needed to insure the safety and health of the user
(storage, handle, and disposal).
3.2. AQWCH: Al Qassimi Women’s & Children’s Hospital

4. Procedure and Responsibility:

Procedures Sequence Responsibilities

4.1 Ensure the availability of the effective safety program Head of Laboratory
through a documented safety manual or equivalent.
4.2 Establish and maintain adequate standards,
policies & procedures, hazard communication
program, respiratory protection program, chemical
hygiene plan, work practice and maintenance o f
buildings and equipment to ensure a safe
working environment as appropriate to the scope of the Head of Laboratory
laboratory.
4.3 Ensure that of all safety policies & procedures, safety
programs, and the laboratory safety manual, is reviewed
as per AQWCH policies and Procedures.
4.4 Participate in internal responsibility system by
supporting activities of Safety committee
4.5 Provide the Safety committee with the results of any
written reports respecting Health and Safety, and
advice employees of the results of any such reports.
4.6 Orient new staff to safety in the laboratory.
4.7 Develop annual plan for training staff in safe work
practices and procedures in compliance with established
AQWCH policies and procedures, including Fire Safety,
First Aid, Good Lab Practice, Hazard Communications and
Respirators Protection Program.
4.8 Take appropriate action to correct any actual or potential
health or safety hazard in the laboratory of the AQWCH as
appropriate to MOHAP policies and procedures. Head of Laboratory
4.9 Update Chemical Inventory List (CIL) & MSDS.
4.10 Implement recommendations of Safety committee.
4.11 Insure staff are practicing their safety code and know
what to do if there is fire, equipment fault, specimen or Laboratory Safety
chemical spillage, or other accident in the laboratory. Coordinator
4.12 Make sure test methods are safe, specimens and
reagents are benign handled and deposed of safely and
specimen containers are benign decontaminated and
cleaned correctly in case of spillage.
4.13 Check that all hazardous chemicals and reagents are
marked or labeled with the correct hazard label and are
being stored and handled safely by staff.
4.14 Observe whether protective clothing is being worm
and kept fastened when in the laboratory and removed
when leaving the laboratory.

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4.15 Make sure that there is no mouth-pipetting.
4.16 Note whether other safety regulations are being kept
such as no smoking, eating, drinking, chewing gum, or
applying cosmetics in the laboratory.
4.17 Laboratory fridges should be inspected for food and
drinks as well as temperature.
4.18 Check whether safety equipment such as first aid box,
eye wash station, head shower, eye goggles, fire blanket,
and fire extinguishers are in good order and that staff
knows the locations and how to use the equipment as
applicable to the laboratory.
4.19 Make sure corridors and exits from the lab are not
being obstructed and fire doors are being kept closed.
4.20 Check whether the laboratory is being kept clean
and that benches are free of unnecessary
equipment, materials and personal property.
4.21 Examine equipment for defects and observe whether
equipment is being used correctly and electrical
connection with compliance with written policy and
procedure, and regulations.
4.22 Observe w h e t h e r s a f e t y r e g u l a t i o n s r e g a r d i n g
p a t i e n t s a n d visitors to the laboratory are being
followed.
4.23 Check for any structural defects in the laboratory or
infestation by insects or rodents.
4.24 Verification that all safety members received appropriate
instruction and that they are aware of all hazards, and
they are competent to handle infectious materials.
4.25 Provision of continuing instruction in safety for all
personnel.
4.26 Investigation of all accidents and incidents involving
the possible escape of potentially infected or toxic
material, even if there has been no personal injury or
exposure, and reporting of the findings and
recommendations to the head of health and safety unit.
4.27 Observe established hospital policies and procedures and
practices regarding safety.
4.28 Participate in safety training, including fire safety, All AQWCH and Visitors
good lab practices, hazard communication, PPE and
respirator protection program, laminar flow benches and
biosafety cabinets, and working safely with chemicals as
scheduled.
4.29 Use personal protective equipment as required.
4.30 Work in a safe & prudent manner.
4.31 Report a n y a c t u a l or potential safety hazards to
his/her Supervisor and Laboratory Safety Coordinator as
per incident reporting system.
4.32 Promote educational programs to increase health and Safety committee

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 safety awareness at work. &
4.33 Conduct risk assessment at least once per year Head of Laboratory
4.34 Orient new staff to infection control policies and
procedures.
4.35 Review new protocols for treatment of needle stick Infection control committee
injuries.
4.36 Act as resource for issues related to infection control and
prevention.
4.37 Ensure the implementation of hospitals/ centers related Head of Laboratory
infection control policies and procedures

5. Tools/Attachments Forms: N/A

6. References:

7. History:

New Policy
Remarks (if any)

Revised Policy Date of Revision: June 2021

Date of 1st Edition: June 2018 Revision Number:

Policy and Procedure

Change Reference Section
Status

8. Performance Indicator: N/A

9. Search Words: Lab Safety Program And Standard Precautions,

AQWCH/Clin/060

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Prepared by: Designation: Head of Laboratory department
Dr. Soria Sari
Signature: Date:

Reviewed & Approved by: Designation: Assistant Director of Medical Affairs

Dr. Khalid Khalfan
Signature: Date:

Reviewed & Acknowledged by: Designation: Head of Quality & Excellence Department
Mrs. Fatima Al Marzooqi
Signature: Date:

Authorized by: Designation: Hospital Director

Dr. Safiya Saif
Signature: Date:

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