MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012
XXX County.

StandardFacility: _____________________SOP No: LGEN.

Operating Procedure.
Version: 1.
Supercedes: N/A.
Effective Date:XXX

Title: Laboratory General Safety Procedure

NAME. SIGNATURE. DATE.

PREPARED BY.

QA UNIT
AUTHORITY.

APPROVAL
AUTHORITY.

1.0 PURPOSE / INTRODUCTION:

1.1 The establishment of standard policies and procedures are necessary for safe
laboratory conduct, handling laboratory hazards, and contingency planning for
safety issues as part of the department safety program.
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 MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

1.2 Laboratory personnel must have knowledge of safe laboratory procedures and an
awareness of potential hazards. Adherence to appropriate safety practices will
prevent serious laboratory accidents.

2.0 SCOPE / RESPONSIBILITY:

2.1 This SOP applies to all laboratory personnel and other departments that use the
laboratories services.
2.2 It is the responsibility of the designated of the County Leads, Quality Assurance
and Quality Control (QC/QA) personnel, Laboratory Supervisors to ensure that the
current SOP is available to the laboratory personnel and the procedure is followed
as documented.

3.0 SAFETY/RISK ASSESSMENT:

3.1 Refer to procedure

4.0 DEFINITIONS:

5.0 SPECIMEN:
5.1 All specimen

6.0 EQUIPMENT/ MATERIALS/ REAGENTS:

6.1 Equipment.
6.1.1 Personal Protective Equipment
6.1.2 Safety equipment
6.2 Materials.
NA

6.3 Reagents.
NA

7.0 METHODOLOGY:
7.1 General Laboratory Safety Standards, Practices and General Requirements
for Personnel on Laboratory Safety:
7.1.1 Become familiar with the location and proper use of emergency exits, fire
equipment and first aid stations.
7.1.2 Follow all outlined safety instructions/policies.
7.1.3 Read all labels carefully.

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 MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

7.1.4 Post appropriate warning signs within the laboratory

7.1.5 Read all posted signs.
7.1.6 Label reagents, materials, and storage containers legibly and according to
regulations.
7.1.7 Inform co-workers of any potential health hazard associated with the work
performed
7.1.8 Report all unsafe conditions or equipment to the director(s)/designee and/or
safety officer/designee.
7.1.9 Treat all materials as toxic until they are adequately identified or
characterized.
7.1.10 Do not use laboratory equipment for non-laboratory procedures.
7.1.11 Place “not in use” signs on equipment awaiting repair or installation and
commissioning.
7.1.12 Cover and store all cutting or capping instruments used in the laboratory
when they are not in use.
7.1.13 Label defective laboratory equipment and remove it from the laboratory
area.
7.1.14 To improve laboratory safety and efficiency, store materials and equipment
in their proper places.
7.1.15 Store bottles of caustic materials, i.e., bleach in a secondary container that
will contain any possible leakage.
7.1.16 Store no more than 500mL of ethanol or isopropyl alcohol on the bench top.
Additional amounts kept in the laboratory must be kept in a locked
"flammable liquids" cabinet.
7.1.17 Treat carefully all systems under vacuum or positive pressure.
7.1.18 Do not move equipment between laboratories unless absolutely necessary.
7.1.19 Never smell or taste any substance used in the laboratory.
7.1.20 Do not eat or drink in laboratory areas.
7.1.21 Do not smoke anywhere in the building.
7.1.22 Do not store food or drink of any kind in the laboratory refrigerators or
freezers.
7.1.23 Do not put laboratory materials, including pencils and pens into your
mouth.
7.1.24 Keep hands away from mouth and face.
7.1.25 Never mouth pipette anything in any area of the laboratory.
7.1.26 Wash hands frequently when in the laboratory and always before leaving
the laboratory, this is essential to avoid becoming exposed to chemical
irritants and infectious agents.
7.1.27 Cover all cuts or abrasions on the hands with adhesive bandages before
entering the laboratory area.
7.1.28 Do not apply cosmetics or lip balm while in the laboratory area.
7.1.29 Do not manipulate contact lenses while in the laboratory area.

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 MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

7.1.30 If possible avoid wearing contact lenses in areas where dust, abrasives,
corrosives, acids, caustics, chemical vapors or fumes are present. These
materials can get under the lenses and damage the eyes.
7.1.31 All personnel - wear hair and/or beards such that they will not come in
contact with working surfaces, specimens or laboratory equipment.
7.1.32 Do not wear loose or dangling jewelry in the laboratory if there is a chance
that it may come in contact with work surfaces, specimens, or moving parts
of equipment.
7.1.33 Do not wear sandals or open-toed shoes or go barefoot in the laboratory to
avoid injuries from falling objects, broken glass or toxic spills.
7.1.34 Use universal precautions while in the laboratory. Handle all laboratory
specimens as if they are potentially infectious.
7.1.35 Decontaminate work surfaces with bleach and/or alcohol before and after
use and immediately after any spill.
7.1.36 Keep laboratories clean and free of material not pertinent to the procedures
being performed.
7.1.37 Always keep laboratory doors closed when performing procedures.
7.1.38 Remove personal protective equipment when leaving the laboratory area.

7.2 Personal protective equipment (PPE)

7.2.1 Wear full-length solid front disposable gowns or full-length laboratory coats
completely fastened or buttoned while working in the laboratory area.
7.2.2 Do not wear laboratory coats or disposable gowns outside the laboratory.
7.2.3 Wear fitting gloves while processing specimens or performing laboratory
tests.
7.2.4 Change gloves immediately they become contaminated with blood, serum,
plasma or any other body fluids or if they tear.
7.2.5 Use safety goggles or other eye or face protection when handling specimens
or performing procedures where there is an eye-impact hazard.
7.2.6 Use full-face shields (worn or mounted) if there is a possibility of being
exposed to aerosols, splashes from blood products, corrosives, acids,
caustics or other chemicals.
7.2.7 Become familiar with the use of the emergency eye rinsing facilities
available at designated sinks in the laboratory. Become familiar with the use
of emergency shower
7.2.8 Personal protective equipment are provided for the protection of laboratory
personnel; PLEASE USE THEM.
7.3 General Policies
7.3.1 The Laboratory director/designee appoints safety Officers.
7.3.2 The Ministry of Health provides safe working conditions as follows:
7.3.2.1 Employees who work in biohazard areas should have adequate
protective equipment and clothing.
7.3.2.2 Accident prevention as an integral part to safe laboratory functions.
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 MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

7.3.2.3 No job shall be initiated without implementing appropriate safety

measures.
7.3.2.4 Access to laboratories limited to authorized laboratory personnel
only.
7.3.2.5 Review of safe work practices and monthly documentation and
annotated in the Quality Improvement program minutes.
7.4 Procedures for Reporting and Documenting Incident/Accident
7.4.1 Supervisors at all levels review accident prevention measures, analyze any
accident that occur and take appropriate corrective actions. These reviews
are documented and the documentation is placed in the laboratory safety
file.
7.4.2 The laboratory manager or designee reviews and signs off on all incident
reports as part of the laboratory Quality Improvement Program.
7.4.3 The laboratory director or designee conducts an Annual Review of all safety
policies, records and work practices and document such reviews in the QI
annual appraisal reports
7.4.4 All guest shall be briefed on laboratory safety standards before being
allowed to work in any of the laboratory areas.
7.4.5 Accidents resulting in fatalities or in hospitalization of any employee(s) will
be reported to the lab director or designee immediately where possible or
within 24 hours.
7.4.6 A Safety Checklist will be completed at the end of each week.
7.5 Reporting Incident/Accident
7.5.1 Contact the first line supervisor/designee immediately.
7.5.2 Within one hour, if possible
7.5.3 Report the exposure event to the PEP designate; if he is not available inform
one of the coordinators. Phone numbers are posted on the lab notice board.
7.6 Guideline for an exposure event
Refer to SOP LGEN 0023 –Post Exposure Prophylaxis Procedure

7.7 Biohazard Control Procedures

7.7.1 Use universal precautions standards as required at all times.
7.7.2 Decontaminate laboratory work surfaces when work is finished and after
any splash or spill of biological material using 10% bleach solution or 70%
alcohol.
7.7.3 Place biohazard waste in appropriately marked containers for biohazard
waste.
7.7.4 Liquid biohazard waste may be decontaminated by dispensing them into a
10% bleach solution or 70% alcohol as applicable.
7.7.5 Decontaminate reusable supplies such as trays, racks and pipettes by
soaking in a 10% bleach solution or wiping surface with 10% bleach, or by
wiping with 70% alcohol.
7.7.6 Replace gloves if they become contaminated, punctured, or torn.
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 MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

7.7.7 Remove gloves when using the laboratory telephones/general computers to

avoid contaminating the person who might be using the phone/computer.
7.7.8 Perform all procedures with potential for aerosol formation in biological
safety cabinet, e.g. Opening of containers of whole blood, serum, plasma,
performing aliquoting procedures.
7.7.9 Use the appropriate safety cabinet or chemical hood when working with
materials that are infectious, toxic, corrosive, dusty, or irritating to skin or
eyes.
7.7.10 Dispose of all sharps, e.g. pipette tips and pipettes, into appropriate sharps
containers.
7.7.11 Wash hands thoroughly before leaving the laboratory.
7.8 Biological Safety Cabinets
7.8.1 Determine the biological safety level of the laboratory, type of infectious
agents or biochemical hazard that may be present, and the nature of the
work performed.
7.8.2 Use total exhaust safety cabinets for operations that utilize hazardous
chemicals and volatile toxins.
7.8.3 Use a biological safety cabinet when performing procedures that may create
an inhalation or aerosol hazard.
7.8.4 Use biological safety cabinet when working with infectious agents
classified as Biosafety Level-2 (BSL-2) or greater
7.8.5 Biological Safety Cabinets MUST be inspected and certified when
installed or relocated and annually thereafter.
7.8.6 Documentation of certification consists of a sticker with the certification
date affixed to each BSC.
7.9 Use of the Biological Safety Cabinet
7.9.1 Place safety cabinets in an area of low traffic and low draft if possible.
7.9.2 Wear protective clothing (PPE).
7.9.3 Minimize the amount of supplies and equipment inside the hood.
7.9.4 Do not place objects over the ventilation grills in the front of the hood or
block the grills in the back of the hood. This will interfere with the laminar
airflow in the hood.
7.9.5 Keep to a minimum the amount of traffic past the face of the hood.
7.9.6 DO NOT use heating devices or Bunsen burners inside the cabinet unless
absolutely necessary.
7.10 Procedures for Handling Hazardous Spills
7.10.1 Infectious Spills
7.10.2 STOP work immediately and ASSESS the extent of the danger.
7.10.3 ALERT other personnel in the immediate area.
7.10.4 Remove contaminated gloves, discard, and replace with clean
gloves.
7.10.5 Immediately DECONTAMINATE all body areas that may have
been exposed to infectious material as follows (Ask for the help of a
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 MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

co-worker if necessary):
7.10.5.1.1 Initially soak clothing or exposed body areas with 70%
alcohol.
7.10.5.1.2 Wash thoroughly with soap and warm water - a
minimum of three minutes. Do not abrade skin during the
washing process.
7.10.5.1.3 Use the eyewash if eyes were exposed.
7.10.6 Change gloves again and take any FIRST AID measures necessary.
7.10.7 RESTRICT ACCESS to the area, cover the spill with absorbent
material and thoroughly soak with freshly prepared 10% household
bleach.
7.10.8 Allow the spilled material to stay in contact with the disinfectant for
30 minutes and then clean up the area.
7.10.9 Do not pick up any containers until they have been decontaminated
7.10.10 Remove protective clothing and discard.
7.10.11 NOTIFY the Safety officer and supervisor as soon as
possible. Do not leave the area until this is done.
7.10.12 Prepare a REPORT of Incident or Accident with the help of
the supervisor.
7.10.13 Chemical Spills
7.10.13.1 Immediately FLUSH any exposed body areas and clothing
with large volumes of water.
7.10.13.2 Request the help of a co-worker, if necessary.
7.10.13.3 Use emergency body shower or eye showers as needed.
7.10.13.4 Put on protective clothing (PPE) - Laboratory coat, gloves,
Safety goggles, glasses, or face shield.
7.10.13.5 Retrieve the Chemical Spill clean-up materials
7.10.13.6 Place absorbent NEUTRALIZING material over the spill
area. Use enough material to absorb the entire spill.
7.10.13.7 Place the used absorbent material in the CLEAR plastic bags
provided and close securely with the fastener.
7.10.13.8 REFER to the MSDS for proper DISPOSAL or contact the
Safety officer for directions.
7.10.13.9 NOTIFY the Safety Officer or Laboratory director/designee
of the incident within one hour.
7.10.13.10 Prepare a REPORT of Incident or Accident with the help of
the supervisor/designee.
7.11 Hazardous Waste Disposal
7.11.1 Infectious or Pathological Waste (Soft Waste)
7.11.1.1 Includes any solid or liquid biological material that may
contain or be contaminated with potentially communicable disease
agents.
7.11.1.2 Locate red infectious/biohazard waste disposal containers in
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 MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

each area of the laboratory where infectious waste may accumulate.

7.11.1.3 Line containers with disposable bright orange/red biohazard
bags before placing infectious waste into them to prevent leakage.
7.11.1.4 Included in this category are:
7.11.1.4.1 Used gloves
7.11.1.4.2 Transfer pipettes (In burn up bins)
7.11.1.4.3 Test tubes
7.11.1.4.4 Specimen containers
7.11.1.5 Fill infectious waste bag/containers no more than three-
quarters full.
7.11.1.6 Remove biohazard bags from the hoods after each day's use
or as needed.
7.11.1.7 Transport bags and containers to the biohazard storage room.
7.11.1.8 Biohazard wastes bags are incinerated
7.11.2 Sharps Disposal
7.11.2.1 Sharps are pipette tips, pipettes, needles, syringes, broken
glassware, blood collection tubes, microwell plates or any object
that can puncture the skin.
7.11.2.2 All sharps must be prepackaged in puncture resistant
containers.
7.11.2.3 Dispose of sharps in appropriate biohazard sharps containers
provided for this purpose.
7.11.2.4 Do not dispose of any other trash into these containers.
7.11.2.5 Do not overfill sharps disposal containers. Fill to 3/4
capacity.
7.11.2.6 Needles should not be recapped, bent, or broken prior to
disposal.
7.11.2.7 Do not remove needles from disposable syringes.
7.11.2.8 Expel excess liquid from syringes or pipettes.
7.11.2.9 Dispense infectious liquid into a 10% bleach solution prior to
disposal.
7.11.2.10 Lock filled containers.
7.11.2.11 Dispose off sharps containers in biohazard containers.
7.11.3 Chemical Waste
7.11.3.1 All chemical containers must be labeled with the name of
the chemical, name and address of the manufacturer and
specific hazard warnings.
7.11.3.2 Material Safety Data Sheets (MSDS) must be readily
available for each chemical or reagent used in the laboratory.
7.11.3.3 Non-hazardous chemical waste can be disposed of by
pouring down the sink:
7.11.3.4 Hazardous chemical waste includes toxic, corrosive,
ignitable, reactive, and explosive materials.
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 MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

7.11.3.5 Store corrosive chemicals in an approved corrosive

container.
7.11.3.6 Store flammables in a flammable cabinet separate from
corrosives and oxidizers.
7.11.3.7 Store oxidizers separately.
7.11.3.8 Store organic acids separate from mineral acids.
7.11.3.9 Store concentrated acids and bases in a fume hood with a
barrier between them.
7.11.3.10 Do not store hazardous chemicals on shelves above eye level
(approx. five feet).
7.11.3.11 Label chemical storage areas according to National Fire
Protection Association (NFPA) standards.
7.11.3.12 Handle any material that is not infectious or radioactive and
whose risk to public safety is in doubt, as hazardous chemical waste
until clarification can be obtained.
7.11.3.13 Dispose of chemical waste according to Safety Guidelines.
Also refer to MSDSs.
7.11.3.14 Do not dispose of hazardous chemicals by pouring them
down the sink.
7.11.3.15 If in doubt as on how to dispose of hazardous chemicals
consult with the Safety Officer, laboratory director/designee and
MSDS.
7.11.3.16 NOTE: All laboratory generated hazardous wastes will be
disposed of according to the local and state regulations.

7.12 Infection Control/Blood borne Pathogens Exposure Control Plan

7.12.1 The Blood borne Pathogens Standard was issued to reduce the occupational
transmission of infections caused by microorganisms sometimes found in
human blood, body fluids, or other materials.
7.12.2 Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV), as
well as a variety of other infectious agents, have been shown to be
responsible for infecting workers handling/exposed to human blood and
other body fluids containing these viruses.
7.12.3 Routes of infection have been by needle-stick injuries and by direct contact
of mucous membranes and non-intact skin with contaminated blood or body
fluids and other materials.
7.12.4 Occupational transmission of Hepatitis B Virus occurs much more often
than transmission of Human Immunodeficiency Virus. However, the lethal
nature of HIV requires that all possible measures be used to prevent the
exposure of workers to the HIV virus.

7.12.5 Scope and Procedures

7.12.5.1 The Ministry of Health has established an infection control
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 MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

plan to minimize and prevent, when possible, employee exposure to

disease causing microorganisms transmitted through human blood,
body fluids and other potentially infectious materials.
7.12.5.2 The plan involves all employees who are or may be exposed
to blood and other potentially infectious materials as part of their
duties.
7.12.5.3 Review the plan at least annually and update as necessary.
7.12.5.4 A copy of the laboratory infection control plan is available to
be read and as for reference by employees, as part of the
SOP/policy. Keep the copy in the main laboratory areas accessible
by all lab personnel.

7.12.6 Basic components of this exposure control plan include:

7.12.6.1 Exposure determination.
7.12.6.2 Methods of compliance.
7.12.6.3 Procedures for evaluation and follow-up of exposure
incident.
7.12.6.4 Employee training.
7.12.6.5 Record keeping procedures
7.12.6.6 Exposure Determination.

7.12.7 The exposure control plan includes all job categories in which there is a
possibility that an employee will have skin, eye, mucous membrane, or
potential contact with blood or other potentially infectious materials.

7.12.8 Job categories with a definite risk of exposure

7.12.8.1 Phlebotomists
7.12.8.2 Laboratory supervisors and managers
7.12.8.3 Laboratory technologists and technicians
7.12.8.4 QA/QC technologists and technician

7.12.9 Job categories with a possible risk of exposure

7.12.9.1 Clerical staff - accidental spills in sample receiving areas.
7.12.9.2 Department Directors, supervisors, QA Officers - accidental
spills or aerosols while observing testing.

7.12.10 Potentially infectious materials include:

7.12.10.1 Blood and blood products
7.12.10.2 Cerebrospinal fluid
7.12.10.3 Semen
7.12.10.4 Vaginal secretions
7.12.10.5 Pleural fluid
7.12.10.6 Pericardial fluid
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 MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

7.12.10.7 Peritoneal fluid

7.12.10.8 Any body fluid visibly contaminated with blood
7.12.10.9 Unfixed tissues or organs (other than intact skin) from
human, living or dead.
7.12.10.10 Blood, organs, or other tissues from experimental animals
infected with HIV or HBV.
7.12.10.11 Cell or tissue cultures, organ cultures, and culture media
containing HIV or HBV virus.

7.12.11 Methods of Compliance (Universal precautions)

7.12.11.1 Always handle all blood or other body fluids as potentially
infectious materials capable of transmitting an infectious disease.
7.12.11.2 Use engineering and work practice controls to minimize or
eliminate employee exposure by:
7.12.11.2.1 Maintain or replace faulty parts/instruments on a
regular basis:
7.12.11.2.2 Hand washing facilities
7.12.11.2.3 Sharps containers
7.12.11.2.4 Personal protective equipment
7.12.11.2.5 Waste removal
7.12.11.2.6 Absorbent material for spills (Spill Removal Kits)
7.12.11.2.7 Laundry/housekeeping procedures
7.12.11.2.8 Biohazard labels

7.12.11.3 General hygiene measures

7.12.11.3.1 Practice appropriate hand washing, it is the primary
protective infection control measure.
7.12.11.4 Sharps management
7.12.11.4.1 Do not bend, recap, reuse, remove or share
contaminated needles or other contaminated sharps.
7.12.11.4.2 Throw them without manipulation into sharps’
container while maintaining their integrity.

7.12.12 Precautions when handling, procuring, and transporting

specimens
7.12.12.1 Wear PPE as needed at all times. Follow Universal
Precautions.
7.12.12.2 Place blood specimens or other potentially infectious
material in a container that prevents leakage during collection,
handling, processing, storage, transport, or shipping.
7.12.12.3 Seal specimen containers before storing, transporting or
shipping.
7.12.12.4 Use the following containers in the laboratory:
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SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

7.12.12.4.1 Tubes with screw caps that is leak-proof.

7.12.12.4.2 Test tube racks of a size to hold the types of tubes
used in the laboratory.
7.12.12.4.3 Red-orange or red plastic biohazard bags with seals.
7.12.12.5 Seal the primary specimen container and place it in a
secondary container if specimens are to be transported or shipped.
7.12.12.6 Follow all state and local regulations for shipping potentially
infectious materials.
7.12.12.7 Consult with supervisors and carefully handle shipments that
are not submitted or received in appropriately labeled sturdy
containers that prevent leaks/spills or exposures.
7.12.12.8 Reject and discard shipments that show obvious signs of
leaks/spills. Document and ensure the director or designee is
notified of the occurrence. The director or designee will notify the
submitting facility of the incident.

7.12.13 Management of contaminated equipment

7.12.13.1 Assess equipment and decontaminate before servicing or
shipping.
7.12.13.2 If equipment cannot be fully decontaminated attach a label
stating which parts remain contaminated.
7.12.13.3 Decontaminate with 10% bleach solution or 70% alcohol
unless otherwise stipulated by the manufacturer.

7.12.14 Personal protective equipment

7.12.14.1 The employer will provide personal sanitary and reliable
protective equipment for the employees to use when exposure is
likely to occur. Employees will be trained in and know where this
equipment is located so that it is used by them in technical areas in
situations where exposure is likely to occur.
7.12.14.2 Employees will be trained to recognize these instances.
7.12.14.3 Gloves, laboratory coats, hood, hood sleeves, safety glasses,
and full safety face shields must be available.
7.12.14.4 Wear protective equipment whenever there is a possibility of
exposure of the skin, eyes, mouth, or other mucous membranes to
infectious, biohazardous or chemical materials.
7.12.14.5 Wear properly fitting gloves. Small, medium, large and
extra-large sizes are available. Let the lab director/designee know
when your particular size is running low.
7.12.14.6 Hypoallergenic gloves and cotton glove liners are available
for employees who have allergies to latex gloves or the powder in
gloves.
7.12.14.7 Remove and dispose of coats, gowns, or gloves as soon as
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 MINISTRY OF HEALTH

SOP Title: Laboratory General Safety Procedure. Version 1

SOP No: LGEN. 0012

possible whenever they become contaminated with potentially

infectious material or they tear as the employee is working with
potentially infectious material.
7.12.14.8 Place disposable lab coats, gowns, etc. in biohazard waste
container after use. Use a disposable lab coat for no longer than two
weeks.
7.12.14.9 Remove all personal protective equipment before leaving the
laboratory area.
7.12.14.10 Remove filled biohazard bags from hoods each day when
work is completed or as soon as they are filled up.
7.12.14.11 Disposable gloves:
7.12.14.11.1 Replace immediately when they are contaminated or
their ability to function as a barrier is compromised, i.e.
torn or punctured.
7.12.14.11.2 Do not wash or decontaminate single-use gloves for
re-use.
7.12.14.11.3 Discard all gloves into a biohazard container.
7.12.14.11.4 Always decontaminate and/or wash your hands
whenever you remove gloves
7.12.14.12 Utility gloves
7.12.14.12.1 Decontaminate and reuse utility gloves from spill
removal kits if they are in good condition.
7.12.14.12.2 Discard gloves that show signs of deterioration such
as cracking or peeling or whenever their ability to act as
a barrier is compromised.
7.12.14.12.3 Discard torn or punctured gloves.
7.12.14.13 Use full safety face shields (worn or mounted) if there is a
chance that aerosols of blood or other potentially infectious
materials may contaminate eyes, nose or mouth.
7.12.14.14 Wear safety goggles when the chance of exposure is to the
eyes but not to the mouth or nose.
7.12.14.15 The use of regular eyeglasses in lieu or safety glasses is
permitted if they have side protectors. The wearing of contact lenses
is not considered a form of protection against exposures.
7.12.14.16 Wear laboratory coats, disposable or reusable gowns
7.12.14.16.1 While performing assays.
7.12.14.16.2 While performing quality control duties.
7.12.14.16.3 When opening tubes of blood, serum, plasma, or
other fluids.
7.12.14.16.4 While operating or cleaning laboratory instruments.
7.12.14.16.5 When decontaminating and cleaning up chemical or
biological spills.

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7.13 Housekeeping
7.13.1 Maintain the workplace in a clean and sanitary condition.
7.13.2 Clean equipment and environmental working surfaces with appropriate
disinfectants:
7.13.2.1 After completing any procedure in the laboratory
7.13.2.2 Immediately following any spill of blood or other potentially
infectious material.
7.13.2.3 At the end of each work shift if a work surface has been used
during the day.
7.13.3 Replace protective coverings, e.g. plastic wrap, aluminum foil from
equipment or environmental surfaces if they become contaminated or if
there is a possibility that they may have become contaminated.
7.13.4 Decontaminate pails, cans, and other receptacles that may become
contaminated with potentially infectious materials. If they become visibly
contaminated, decontaminate immediately.
7.13.5 Do not reuse “disposable” containers.
7.14 Regulated Medical Waste
They includes:
7.14.1 Liquid or semi-liquid blood or other potentially infectious materials.
7.14.2 Contaminated items that, if compressed, would release blood or other
potentially infectious materials in a liquid or semi-liquid state.
7.14.3 Items caked with dried blood or other potentially infectious materials that
would release these materials during handling.
7.14.4 Contaminated sharps (properly stored in sharps containers).
7.14.5 Pathological and microbiological waste containing blood or other
potentially infectious materials.
7.14.6 Cultures, stocks, and vaccines.
7.14.7 Animal waste.
7.15 Waste Containers
7.15.1 Place all regulated waste materials into containers that are:
7.15.1.1 Closable
7.15.1.2 Constructed to contain all contents and prevent leakage of
fluids during handling, storage, transport or shipping.
7.15.2 Use red or red-orange primary containers with a biohazard label.
7.15.3 Use rigid secondary containers with biohazard labels.
7.15.4 Seal containers prior to moving or removal from the laboratory to prevent
spillage or protrusion of contents during handling, storage, transport, or
shipping.
7.15.5 Place containers that have become contaminated on the outside into a
second container with the same characteristics as the initial container.
7.16 Labels
7.16.1 Place warning labels on the following:
7.16.1.1 Containers of regulated medical waste.
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7.16.1.2 Refrigerators and freezers containing blood or other

potentially infectious material.
7.16.1.3 Containers used to store, transport, or ship blood or other
potentially infectious materials.
7.16.1.4 Contaminated equipment-include on the label parts that
cannot be cleaned and so remain contaminated.
7.16.2 Labels must have the biohazard symbol and the text “Biohazard”.
7.16.3 Use fluorescent orange or red-orange labels with lettering and symbols in a
contrasting color.
7.16.4 Labels must be an integral part of the container or affixed as close as
feasible to the container. Place them on opposite sides of the containers.
7.16.5 Affix labels so that they cannot be lost or unintentionally removed.
7.16.6 No label is required on individual containers of blood or other potentially
infectious material if they are placed in labeled containers during storage,
transport, shipment, or disposal.

7.17 Hepatitis B Vaccination

7.17.1 All staff who have risk of exposure to blood borne pathogens should receive
Hepatitis B vaccine.
7.17.2 Any staffs who routinely works in the lab (non-administrative personnel) is
identified as having a risk for exposure to blood borne pathogens.
7.17.3 Post exposure evaluation and follow-up are offered if there is an exposure
incident on the job.
7.17.4 Medical evaluations and vaccination series are performed by, or under the
supervision of, a licensed physician, physician’s assistant, or nurse
practitioner as per recommendations by ministry of health guidelines.
7.17.5 Hepatitis B vaccination will be administered as recommended by the
manufacturer of the vaccine being administered.
7.17.6 Currently no routine booster dose is recommended
7.17.7 Vaccinations are not available to the following:
7.17.7.1 Employees who have previously received the complete
Hepatitis B vaccination series.
7.17.7.2 Employees for whom the vaccine is medically
contraindicated.
7.17.7.3 Employees with potential exposure risk who choose not to
take the Hepatitis B vaccination. Those employees must sign a
declination statement

7.18 Employee Training

7.18.1 All employees will be trained regarding blood borne pathogens and all other
laboratory safety issues.
7.18.2 Train annually during working hours.
7.18.3 Provide additional training whenever there are changes in tasks or
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procedures that affect occupational exposure. Limit this training to the new
exposure situation.
7.18.4 Tailor the training approach to the educational level, literacy, and language
of the employees.
7.18.5 Training is given by the Safety Officer Procedures to use in an emergency
involving exposure to blood or other potentially infectious materials.

7.19 Emergency First Aid Procedures

7.19.1 First aid is the treatment of a sick or injured person before regular medical
or surgical attention can be obtained.
7.19.2 Procedures should never supersede nor take the place of proper medical
attention.
7.19.3 Notify emergency personnel promptly.
7.19.4 Never administer first aid beyond one’s training/qualifications.
7.19.5 Restrict procedures to approved methods of artificial respiration, oxygen
administration, control of bleeding, and treatment for shock or burns
7.19.6 Keep calm and use common sense.
7.19.7 Under most circumstances, no more than two persons are needed to attend
to an injured person.
7.19.8 Give the injured person room to breathe.
7.19.9 Do not move an injured person unless fumes, fire, or other hazards exist.
Moving may cause additional harm in case of broken bones or head, spinal
column, or internal injuries.

7.19.10 Artificial Respiration/Cardiopulmonary Resuscitation

procedures are the methods of choice. Only perform these procedures if
certified to do so!

7.19.11 Minor Injuries

7.19.11.1 Provide a first aid kit for treatment.
7.19.11.2 Notify the Safety Officer, QA Officer or Laboratory Director
if materials are used from the kit so that the kit can be stocked with
used materials.
7.19.12 Burns
7.19.12.1 Smother flames on a person’s clothing by rolling the victim
in a coat or blanket.
7.19.12.2 Do not attempt to remove clothing that adheres to the skin.
7.19.12.3 Submerge a localized burn in cold/ ice water.
7.19.12.4 Do not open blisters.
7.19.12.5 For chemical burns flush contaminated skin areas with
copious amounts of water for at least fifteen (15) minutes.
7.19.13 Bleeding
7.19.13.1 Stop arterial or other copious bleeding before giving any
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other treatment.
7.19.13.2 Hold a clean compress directly on the wound and apply hand
pressure.
7.19.13.3 If the wound is on an extremity, apply pressure to the points
as well.
7.19.13.4 Tourniquets are not recommended, except as a final resort.
7.19.13.5 If bleeding is not profuse, carefully wash any foreign
material from the wound with soap and water.
7.19.13.6 Apply antiseptic to all parts of the wound.
7.19.13.7 Cover lightly with a clean dressing such as sterile gauze.
7.19.13.8 Puncture wounds must always receive prompt medical
attention since antiseptic may not reach the bottom of the wound.
7.19.14 Fractures
7.19.14.1 Do not move the victim unless there is an immediate hazard.
7.19.14.2 Leave splinting of broken bones to a physician.
7.19.14.3 Treat for shock and bleeding.
7.19.15 Shock
7.19.15.1 Shock is present in all injuries to some degree.
7.19.15.2 Shock may kill a victim even when other injuries have been
treated.
7.19.15.3 Shock Symptoms
7.19.15.3.1 Paleness
7.19.15.3.2 Cold, moist skin with or without sweating
7.19.15.3.3 Nausea
7.19.15.3.4 Shallow breathing
7.19.15.3.5 Trembling
7.19.15.4 Treatment
7.19.15.4.1 Keep the victim warm.
7.19.15.4.2 Lower the head or raise the feet.
7.19.15.4.3 Keep the airway open.
7.19.15.4.4 Give liquid stimulants such as hot coffee or tea, if
possible. (This is not possible in the laboratory.)
7.19.15.4.5 Do not attempt to give liquids if the victim is
unconscious.
7.19.15.4.6 Never give victims alcoholic liquids.
7.19.16 Electrical Shock
7.19.16.1 Shut off the current, if possible.
7.19.16.2 Using heavy insulated or rubber gloves, carefully remove the
victim from the source.
7.19.16.3 Give artificial respiration if necessary.
7.19.16.4 Keep the victim warm.
7.19.17 Poisons
7.19.17.1 Attempt to determine the kind of poison involved.
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7.19.17.2 Observe the victim for shock.

7.19.17.3 Refer for immediate medical attention
7.19.18 Industrial Safety
7.19.18.1 Use and storage of flammable/combustible liquids
7.19.18.2 Store/place only enough of a flammable chemical to meet
daily requirements at the workbench.
7.19.18.3 Use approved safety containers for storage of flammable
materials.
7.19.18.4 Store no more than five litres of flammable liquids on open
shelves.
7.19.18.5 Store flammable materials in excess of five litres in metal
safety cabinets and mark the cabinets accordingly.
7.19.18.6 Do not place flammable liquid storage cabinets in corridors,
stairways, or hallways.
7.19.18.7 Use only explosion-proof refrigerators for storing flammable
materials that require refrigeration. Ensure that the refrigerator is
labeled.
7.19.18.8 Keep flammable liquids, acids, and corrosives segregated
from one another and display appropriate signs for each.
7.19.18.9 Keep flammable liquids stored inside buildings at least
eighteen (18) inches away from electric lights, steam pipes, and
ceilings.
7.19.18.10 Maintain at least an 18 inch clearance between stored
flammable materials and combustible interior partition walls of
buildings, except where otherwise approved by the Primary Fire
coordinator.
7.19.18.11 Do not use gasoline, naphthalene, benzene or other highly
flammable volatile liquids for cleaning purposes.
7.19.19 Chemical Hygiene Plan
7.19.19.1 The Laboratory Director is responsible for the overall
implementation of the chemical hygiene plan.
7.19.19.2 The Laboratory Director will review the annual Chemical
Hygiene Plan effectiveness.
7.19.19.3 Plan will describe policies and procedures for all operations
that involve hazardous chemicals.
7.19.19.4 The Designee for the Department under the scope of the lab
director will ensure the use of personal protective equipment.
7.19.19.5 The Lab Director and designee will assure exposure
monitoring when permissible levels are exceeded.
7.19.19.6 The Laboratory Safety Officer is responsible for
implementing the chemical hygiene plan.
7.19.19.7 After the initial Safety Orientation, employees are
responsible for using PPE when handling corrosive or flammable
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materials.
7.19.19.8 Thick gloves or double gloving, in addition to protective
eyewear and lab coats should be used when handling corrosives.
7.19.19.9 Gloves, eyewear and a lab coat should be used when
handling flammable materials.
7.19.19.10 The role of supervisors is to enforce the use of PPE, monitor
for chemical use safety and provide recommendations to the
Chemical Hygiene Plan officer.
7.20 Duties of the Safety Officers
7.20.1 Oversight of lab safety policies and procedures.
7.20.2 Continuing staff education of these policies
7.20.3 Management of employee injuries and exposures. This would include
following up with occurrences, looking for trends and making engineering
or work practice control changes if necessary
7.20.4 Regular safety audits which include fire and electrical safety, ergonomics,
chemical hygiene, housekeeping, waste management, PPE, and infection
prevention.
7.20.5 Act as the laboratory Chemical Hygiene Officer
7.20.6 Maintenance of an inventory of all hazardous materials and all hazardous
waste.
7.20.7 Ensure that there are precautionary labels posted on the containers of all
hazardous chemicals indicating type of hazard (for example corrosive,
carcinogen) and immediate reminders if what to do if accidental contact
occurs.
7.20.8 Ensuring that the Department’s hazardous waste is kept at a minimum
7.20.9 Ensuring that all personnel are properly trained in hazard communications, ,
use of proper protective equipment, and storage and waste disposal, and
maintain records of, laboratory safety trainings
7.20.10 Ensuring that appropriate Material Safety Data Sheets (MSDS) are
available in each work area or in a central area and that MSDS guideline for
exposure monitoring and use of protective equipment are followed.
7.20.11 Investigating all hazardous material spills and exposures.
7.20.12 Ensuring that chemical fume hood, laminar flow hoods, and other
protective equipment as needed (respirators if used) are inspected and
certified as functioning correctly on an annual basis.
7.21 Evacuation Plan and Procedures
7.21.1 Responsibilities for the primary evacuation of the laboratory in case of an
emergency lie with the laboratory personnel.
7.21.2 Evacuation route maps are posted next to each fire exit route.
7.21.3 To prevent injury and limit the spread of the emergency situation the
following steps take precedence over firefighting or damage control:
7.21.4 Alert personnel in the immediate vicinity of the emergency incident, of the
nature and extent of the emergency.
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7.21.5 Activate the fire alarm.

On sound of alarm, all activities should be stopped immediately
irrespective of their nature and the building evacuated!
7.21.6 Summon the fire department.
7.21.7 Shut all doors to the laboratory as personnel evacuate the building.
7.21.8 The last personnel to leave are the lab supervisors, making sure all have
evacuated/shut doors.
7.21.9 Inspect all labs to make sure no one is inside.
7.21.10 Be available to direct the fire department and emergency vehicles to
the scene of the emergency.
7.22 Safety drills
7.22.1 Conduct evacuation drills at least once a year to evaluate disciplined and
orderly evacuations.
7.22.2 Procedures to follow:
7.22.2.1 Stop working, leave the working stations, and calmly exit the
building as you shut the doors.
7.22.2.2 Congregate approximately 100 feet from the building until the drill
is concluded.
7.23 Electrical Safety
7.23.1 Yearly, facilities maintenance will check each circuit supporting fixed,
electrical receptacles for polarity and ground integrity.
7.23.2 Facilities maintenance will be informed of the arrival of new instruments
and appliances.
7.23.3 They will check for adequate grounding and current leakage before initial
use.
7.23.4 They will also be informed when repair, modification or a problem is
suspected, so this check can also be done.
7.23.5 Facilities will document these checks on their database and/or tags on the
equipment.
7.23.6 Replace damaged or deteriorated cords. Do not attempt to repair them.
7.23.7 Inspect open equipment such as motors for dust and grease accumulation.
7.23.8 Do not overload sockets. Insist that maintenance personnel survey loads on
individual circuits regularly and distribute them so that none has an
excessive load.
7.23.9 Call the safety officer and maintenance officer immediately to examine
circuits with blown fuses or opened a circuit breaker.
7.23.10 Do not store flammable materials in biological safety hoods,
incubators, or refrigerators that have not been fitted with explosion-proof
motors or equivalent shielding.
7.23.11 The facilities manager and/or laboratory supervisor will maintain
documentation of inspections and repairs for each piece of equipment.
7.24 Chemical Toxin Hazard Control (including carcinogens).
7.24.1 Notify all personnel before using any hazardous chemical toxin in the
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laboratory.
7.24.2 Label containers of any chemical toxin used in the laboratory.
7.24.3 Identify the chemical toxin by type of hazard (poison, caustic, skin or eye
irritant),
7.24.4 Precautions to be taken when using the substance, and instructions to follow
in case of accidental exposure or contamination.
7.24.5 Conduct an annual inventory of all chemical toxin materials used in the
laboratory.
7.24.6 Exposure to carcinogens is of particular concern for the laboratory worker.
Classification of carcinogens includes:
7.24.6.1 Class I - chemicals considered to be carcinogenic
7.24.6.2 Class II - chemicals suspected of being carcinogenic
7.24.7 Keep the use of carcinogenic material at the lowest practical volume to
reduce potential hazard.
7.24.8 Take the following safeguards when handling chemical toxins or Class I
carcinogens to avoid accidents:
7.24.8.1 Wear personal protective equipment (PPE), including a fully
fastened laboratory coat or smock and protective gloves.
7.24.8.2 Discard gloves after each use and after overt contact with
any chemical toxin hazard.
7.24.8.3 Do not wear PPE outside the laboratory area.
7.24.8.4 Conduct all procedures involving weighing or working with
large amounts of carcinogenic material in a chemical fume hood.
7.24.8.5 Close the protective glass front as much as possible.
7.24.8.6 Do not eat, drink, smoke, remove or insert contact lenses, or
apply cosmetics in areas where chemical toxin or carcinogenic
material is used or stored.
7.24.8.7 Always use mechanical pipetting aids for all pipetting
procedures. Do not pipette any chemical toxin or carcinogen by
mouth under any circumstances.
7.24.8.8 Wash hands thoroughly immediately after completion of a
procedure in which chemical toxin or carcinogenic substances have
been used.
7.24.8.9 Wash hands thoroughly before leaving the laboratory.
7.24.8.10 Cover work surfaces on which chemical toxins are used with
steel or plastic trays, dry absorbent paper, or other impervious
material.
7.24.8.11 Thoroughly decontaminate or dispose of protective work
surfaces upon completion of procedures involving chemical toxins
or carcinogens.
7.24.8.12 Cover analytical instruments used to measure or weigh
carcinogens with a disposable weight sheet, if possible. If no
covering is used thoroughly decontaminate the instrument after use.
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7.24.8.13 Decontaminate or dispose of contaminated materials in

labeled containers for disposal of these types of materials. Always
refer to MSDS. If necessary consult with the Safety Officers
7.25 Radiation Safety
7.25.1 Refer to the Radiation Protection Act, chapter 243, (Laws of Kenya).

8.0 APPENDICES:

9.0 REFERENCES:

10.0 DOCUMENT CHANGE HISTORY:

10.1 Version Table:
Version 1: Laboratory Safety Dated: SOP No.: No. Pages:
LGEN. 0012 7.

Version 2: Dated: SOP No.: No. Pages:

.
Version 3: Dated: SOP No.: No. Pages:

10.2 SOP Review Log

Date of Changes made. Name of reviewer. Signature.
review.

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SOP AWARENESS LOG.

I, the under named, have read and understand the contents of this SOP. I agree to
contact my supervisor/ designee if I have any query.

NO. DATE NAME SIGNATURE

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NOTE: This is a CONTROLLED document. Any documents that are not stamped in red “APPROVED” are not controlled.
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